Splitting Equality: Access to Gender-Affirming Care in the Fourth Circuit.

This Note critically examines the evolving legal landscape surrounding transgender individuals' access to gender-affirming care in the United States, focusing on two pivotal cases before the Fourth Circuit: Kadel v. Folwell (North Carolina) and Fain v. Crouch (West Virginia). These cases present a constitutional and statutory challenge to the exclusion of medically necessary gender-affirming care from state health plans, under Title VII of the Civil Rights Act of 1964 and the Equal Protection Clause of the Fourteenth Amendment. The Note contextualizes these lawsuits within a broader historical trajectory of transgender rights, highlighting legal and cultural milestones that have shaped access to care and recognition. Drawing on precedent, including Grimm v. Gloucester County School Board and Bostock v. Clayton County, the analysis explores how gender identity is legally understood through the lens of sex discrimination. It further considers the persuasive value of medical consensus on the necessity of gender-affirming care, as endorsed by major health organizations. The paper identifies the legal inconsistencies and discriminatory rationales employed by states to deny this care and critiques the sociopolitical underpinnings of such exclusions. By comparing the different factual and legal circumstances of Kadel and Fain, the Note argues that the Fourth Circuit has an opportunity to affirm constitutional protections for transgender persons. It proposes a legally and politically viable middle ground: requiring states to provide coverage for non-surgical interventions such as medication and psychotherapy, thereby upholding basic standards of care while navigating judicial restraint. Ultimately, the Note underscores that the outcome of these joined en banc proceedings will significantly influence future litigation, legislative efforts, and the lived realities of transgender individuals. In doing so, it advocates for a legal framework rooted in equality, medical necessity, and the dignity of all persons under the law.