On September 9, 2025, the U.S. Court of Appeals for the Eleventh Circuit issued a decision in Anna Lange v. Houston County, Georgia, et al., holding that denying coverage for gender-affirming surgery does not amount to sex discrimination under Title VII of the Civil Rights Act of 1964. This ruling reverses a previous decision by a three-judge panel from 2024 and diverges from other recent federal court opinions that have found similar exclusions to be unlawful.
The case involved a transgender woman who has worked as a deputy with the Houston County Sheriff’s Office since 2006. After she began presenting as female at work in 2017, she received hormone therapy and psychological care covered by her employer’s health insurance plan. However, when she sought coverage for gender-affirming surgery, her request was denied due to an explicit exclusion in the plan for “[d]rugs for sex change surgery” and “[s]ervices and supplies for a sex change and/or the reversal of a sex change…”
Following this denial, the plaintiff filed a discrimination charge with the Equal Employment Opportunity Commission before suing in federal court. The district court initially ruled in her favor, finding that excluding gender-affirming care constituted unlawful sex discrimination under Title VII and issued an injunction against enforcing the exclusion.
Houston County appealed. Although a three-judge panel affirmed the lower court’s decision in 2024, the full Eleventh Circuit later reheard the case en banc. The central question was whether excluding coverage for sex reassignment surgery violated Title VII on its face.
In its published opinion, which spans over one hundred pages, the majority concluded that such exclusions do not constitute sex discrimination because they are applied uniformly regardless of an individual’s sex or gender identity.
The majority cited United States v. Skrmetti (145 S. Ct. 1816 [2025]), where the Supreme Court upheld Tennessee’s ban on gender-affirming care for minors based on uniform application rather than targeting transgender status specifically. Applying similar reasoning to Title VII claims, the Eleventh Circuit found no violation.
The court also chose not to rely on Bostock v. Clayton County—a Supreme Court decision interpreting Title VII protections as extending to sexual orientation and gender identity—as persuasive authority in this context.
Recent changes at the federal level were noted as part of broader context: An executive order requiring interpretation of Title VII protections to include gender identity (Executive Order 13988) was rescinded in January 2025 by Executive Order 14168, which restricts recognition of sex and gender to immutable characteristics assigned at conception or biological “binary.”
Legal observers point out that this ruling stands apart from other decisions such as Fletcher v. Alaska (443 F. Supp 3d 1024 [D. Alaska 2020]), Doe v. City of Philadelphia (No. 24-0468), and L.B. v. Premera Blue Cross (781 F. Supp 3d 1128 [W.D.Wash.2025]), where courts have found exclusions on gender affirming care to be discriminatory.
“Consult with your benefits counsel to evaluate whether there are any express protections or exclusions in employer-sponsored benefit plans relating to gender identity and gender affirming care to then determine the best path forward.”
“Stay informed about evolving state laws and regulations, which may require changes to applicable health and benefit plans.”
“Review current employment policies to assess whether any provisions conflict with your organization’s initiatives regarding equity and/or equal treatment in the workplace.”