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The Fifth Circuit Court of Appeals unanimously struck down a Biden administration mandate on Friday that forced doctors and medical facilities to provide “gender-transition” procedures and abortions against their religious beliefs and health insurers to cover them.

In Franciscan Alliance, Inc. et al. v. Xavier Becerra, the three-judge panel upheld a lower court’s permanent injunction against the Department of Health & Human Services (HHS) mandate which protected Christian Medical and Dental Associations and Specialty Physicians of Illinois, along with Franciscan Alliance, a Catholic hospital system. Now the HHS cannot take action against them under the Affordable Care Act’s (ACA) anti-discrimination provision, known as Section 1557, for refusing to perform the procedures which violate their religious freedom under the federal Religious Freedom Restoration Act.


The court wrote, “As the district court persuasively reasoned, the district court injunctions, the 2020 Rule, and the 2021 Interpretation combined to threaten Franciscan Alliance in the same way that the challenged portions of the 2016 Rule did. Since that time, it has become even clearer that Franciscan Alliance’s RFRA claim is not moot. Just months ago HHS issued the 2022 Notice, which warned covered entities like Franciscan Alliance that refusing to offer gender-reassignment surgeries violates Section 1557. HHS has also repeatedly refused to disavow enforcement against Franciscan Alliance. In its brief on appeal, HHS simply says it ‘has not to date evaluated’ whether it will enforce Section 1557 against Franciscan Alliance—in other words, it concedes that it may.”

In March, the HHS issued guidance declaring that it “stands with transgender and gender nonconforming youth and their families—and the significant majority of expert medical associations—in unequivocally stating that gender affirming care for minors, when medically appropriate and necessary, improves their physical and mental health” and that “federally-funded covered entities restricting an individual’s ability to receive medically necessary care, including gender-affirming care, from their health care provider solely on the basis of their sex assigned at birth or gender identity likely violates Section 1557” of the Affordable Care Act.

In 2016, the Obama administration implemented a regulation via Section 1557 of the Affordable Care Act, known as Obamacare, that sought to require health care providers to perform gender transition procedures, including on minors, despite any sincere religious objections. The Obama administration interpreted the federal ban on sex discrimination to include discrimination based on sexual orientation and gender identity, even though neither term is found in federal civil rights law passed by Congress.

Although President Trump moved to repeal the 2016 Rule, the Biden administration revived it.

The “sex reassignment” surgery market in the United States was valued at $1.9 billion in 2021 and is expected to expand at a compound annual growth rate of 11.23 percent from 2022 to 2030. Despite “the minimum age of 18 as eligibility” to undergo these procedures, anecdotal reports show that surgeons have performed them on children younger than 18 years.

Liberty Counsel Founder and Chairman Mat Staver said, “This unanimous ruling is a major victory to protect the religious freedom and conscience rights of medical professionals. The first rule of medicine is to do no harm. The federal government should never force people to violate that or their faith, especially if they are required to perform harmful, irreversible procedures against their conscience and medical judgment.”

Author: Liberty Counsel

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