Franciscan Alliance v. Becerra

Becket Role:
Case Start Date:
August 23, 2016
Deciding Court:
U.S. Court of Appeals for the Fifth Circuit
Original Court:
U.S. District Court for the Northern District of Texas
Practice Area(s):

Case Snapshot

A federal mandate issued in 2016 required doctors to perform gender transition procedures on any patient, including a child, even if the doctor believed the procedure would be harmful. An agency rule imposing the mandate was struck down in court after it was challenged by nine states, several religious organizations, and an association of over 19,000 healthcare professionals. The religious organizations and doctors continue to fight to obtain full protection for their consciences and medical expertise from this unlawful requirement.


On October 15, 2019, the district court ruled that the government's 2016 rule imposing the transgender mandate is unlawful, concluding that doctors must be free to practice in their field of medicine without being forced to perform these controversial procedures that violate their faith. The court did not, however, issue an order permanently stopping the government from imposing this unlawful mandate on religious hospitals and doctors. On April 15, the Fifth Circuit Court of Appeals ruled that the district court should reconsider whether to provide that lasting protection.
Franciscan Alliance

Case Summary

In May 2016, the federal government issued a mandate that would require a doctor to perform gender transition procedures on any patient, including a child, even if the doctor believed the procedure could harm the patient. The mandate required virtually all private insurance companies and many employers to cover gender reassignment therapy or face severe penalties and legal action. 

But there were two major insurance plans exempted from HHS’s mandate—the plans run by HHS itself: Medicare and Medicaid. Why? Research shows that not only are there significant risks with gender reassignment therapy – especially in childhood – such as heart conditions, increased cancer risk, and loss of bone density, but most children with gender dysphoria grow out of it naturally without these invasive procedures. The government’s own panel of medical experts concluded that these procedures can be harmful and advised against requiring coverage of these medical and surgical procedures under Medicare and Medicaid. 

An association of over 19,000 healthcare professionals, nine states, and several religious organizations filed two lawsuits against the mandate, and in December 2016, two different federal courts issued preliminary decisions ruling that the policy was an unlawful overreach by a federal agency and a likely violation of religious liberty. The decision to undergo gender reassignment therapy is a difficult and deeply personal one, and it is especially complicated and sensitive in the case of children. Doctors should not be forced to perform procedures that according to their medical judgment, expertise, and conscience they believe to be harmful. 

Following the initial court rulings, the government issued a new rule that said it was aimed at fixing the legal problems. That rule was itself blocked in other courts, however, and the new Administration has indicated an intent to consider changing or discarding it. 

Meanwhile, on October 15, 2019, a federal judge confirmed his earlier ruling that the transgender mandate is unlawful, explaining that doctors must be free to practice in their field of medicine without being forced to perform these controversial procedures that violate their faith. The court did not, however, issue an order permanently stopping the government from imposing this unlawful mandate on religious hospitals and doctors. Becket therefore appealed on behalf of the challengers. On April 15, 2021the Fifth Circuit Court of Appeals ruled that the district court should consider further whether to grant the hospitals and doctors that lasting protection. 

More information can be found at  

Importance to Religious Liberty:

  • Individual Freedom: The freedom of conscience is the human right to believe, express beliefs, and act according to the dictates of an individual’s conscience. Becket defends the right of all individuals to live according to their consciences without government coercion.