U.S. court allows state bans on gender-affirming care for adults in unprecedented ruling

While bans on trans youth’s care have been numerous in recent years, this is the first to restrict care for transgender adults.

By Desiree Guerrero Mar 11, 2026

On Tuesday, the U.S. 4th Circuit Court of Appeals went a step further in the ongoing attacks on gender-affirming care for transgender individuals in this country.

While more than a dozen U.S. states currently prohibit or limit Medicaid coverage for gender-affirming care, the 4th Circuit became the first federal appeals court to enforce this type of law, according to a report by Reuters. The decision follows last year’s Supreme Court ruling in the United States v. Skrmetti case, which rejected a challenge to a Tennessee ban on gender-affirming treatment for minors.

The unanimous decision came from a three-judge panel of the 4th U.S. Circuit Court of Appeals in Richmond, Virginia, overturning a prior judge's ruling in 2024 that the statute violated anti-discrimination protections under federal law as well as the Constitution. In defense of the first-of-its-kind ruling, the 4th Circuit panel stated that since the law applies to specific procedures, not specific individuals, it does not illegally discriminate against transgender people.

The three judges on the panel — who’d all been appointed by Republican presidents (two by Trump and one by George Bush Sr.) — had dissented in 2024 when the majority of the 4th Circuit declared the West Virginia law invalid. In the 35-page documentation of the ruling, the panel expressed similar justifications for the decision as they had in the 2024 case.

"It is not irrational for a legislature to encourage citizens to appreciate their sex and not become disdainful of their sex by refusing to fund ⁠experimental procedures that may have the opposite effect," wrote Judge Julius Richardson, a Trump appointee.

The specific types of surgeries that the West Virginia law seeks to remove from Medicaid coverage include altering physical characteristics in order to align with one's gender identity, including chest reconstruction, genital alteration, and facial procedures. This is the first time that such restrictions have been enforced on Medicaid coverage for any transgender individuals, not just minors.

Republican West Virginia Attorney General John McCuskey added that the state should not have to foot the bill for "unproven, non-essential medical procedures."

"Every dollar spent on these unproven procedures takes away funding that could be used to treat cancer, heart disease, and diabetes," stated McCuskey.

Official legal opposition to this decision has yet to be filed in the courts, but is certainly expected. The Advocate will continue to follow this story as it unfolds.