Sisters of Mercy v. Azar

Becket Role:
Case Start Date:
November 7, 2016
Deciding Court:
District Court for the District of North Dakota
Original Court:
District Court for the District of North Dakota
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. That rule was struck down in court after it was challenged by nine states, several religious organizations, and an association of over 19,000 healthcare professionals. In May 2019, HHS proposed bringing its regulations into compliance with those decisions and ensuring that the personal decision to undergo gender transition procedures is kept between patients and their doctors, free from government interference.


On May 24, 2019, HHS proposed a new rule that follows a court ruling, complies with accepted medical research and protects both the medical judgment of the doctor and the unique, individual needs of the patient.

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 studies show that children with gender dysphoria found that fewer than 1-in-4 children referred for gender dysphoria continued to experience that condition into adulthood. Some grew out of it, but many of the children ended up realizing that they were not transgender but instead gay. The government’s own panel of medical experts concluded that these therapies can be harmful and advised against requiring coverage of these medical and surgical procedures under Medicare and Medicaid.

Becket filed the lawsuit in federal court in November 2016 on behalf of the Sisters of Mercy, the University of Mary, and SMP Health System. The State of North Dakota also joined Becket’s legal challenge. In December 2016, two different federal courts ruled 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. It is a healthcare decision that should be left between a family and their doctor, and not decided by politicians and government bureaucrats.

The government is now proposing to fix the unlawful rule by protecting patients and preserving the integrity of the doctor-patient relationship. Issued in May 2019, the new rule would fix the transgender mandate to align with medical research and keep the federal government out of decisions that should fall squarely in the space between patients and their doctors.

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.