The 4th U.S. Circuit Court of Appeals in Richmond, Virginia, issued a unanimous decision Tuesday upholding West Virginia’s 2004 statute banning Medicaid coverage for gender-transition surgeries. The three-judge panel overturned a previous ruling that had declared the law violated federal anti-discrimination statutes and the Constitution’s guarantee of equal protection.

The appeals court said the law targets specific medical procedures rather than individuals, and therefore does not unlawfully discriminate against transgender people. The decision comes as Republican-led states, backed by former President Donald Trump’s administration, continue efforts to limit gender-transition treatments and broader transgender rights.

The 4th Circuit’s ruling marks the first time a federal appeals court has upheld a state law restricting Medicaid coverage for gender-transition care. The court’s decision follows the Supreme Court’s rejection last year of a challenge to a Tennessee law banning gender-transition treatments for minors.

Judge Julius Richardson, a Trump appointee writing for the panel, stated, “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.” The panel frequently cited the Supreme Court’s prior rulings to support its analysis.

The procedures at issue include surgeries that alter physical characteristics to align with gender identity, such as chest reconstruction, genital surgery, and facial procedures. West Virginia Attorney General John McCuskey argued the state should not fund “unproven, non-essential medical procedures,” noting that funds could be used for treatments addressing cancer, heart disease, and diabetes.

The law had initially been struck down in 2024 by the full 4th Circuit, but the Supreme Court directed the panel to reconsider it in light of the Tennessee case. The plaintiff, Shauntae Anderson, is represented by Lambda Legal, an LGBT rights group that has not yet responded to the latest ruling.

Other states, including Florida, Georgia, and Arizona, face ongoing lawsuits over similar bans or limits on insurance coverage for gender-transition procedures. The Trump administration has also issued executive actions affirming a binary definition of sex and barring transgender individuals from military service, while proposing restrictions on Medicaid and Medicare funding for providers performing gender-transition care for minors.

The appeals court ruling reinforces the position of states seeking to limit gender-transition procedures through Medicaid, while ongoing legal and federal regulatory challenges continue.