(Radio Iowa) — The Iowa Supreme Court heard oral arguments Thursday in the Department of Human Services appeal of a district court ruling that said the state Medicaid program has to pay for sex-change surgery for two transgender individuals. The lower court ruling says the state violated the Iowa Civil Rights Act and the equal protection clause of the Iowa Constitution by refusing payment, but lawyer Matthew Gillespie argued that is not the case. “This case is not about whether transgender Iowans have suffered and continue to suffer from pernicious discrimination. This case is not about whether transgender Iowans have legitimate medical needs related to gender dysphoria,” Gillespie says. ” In fact, this case is not about transgender Iowans at all.”

He says the case centers on the rules followed by the state. “This case is about whether Iowa Medicaid appropriately denied coverage for surgeries performed primarily for psychological. For the reasons outlined in our brief, and I will discuss here today, the answer should be ‘yes’,” according to Gillespie. He says the rules were not specifically written to discriminate against transgender Iowans. “The petitioners have argued that transgender Iowans seeking coverage for procedures to treat gender dysphoria are similarly situated to non-transgender Iowans seeking treatment for the same procedures to address non-physiological conditions,” according to Gillespie. “And in doing so, it reveals the true nature of the crux of the issue is not gender identity — but is instead focused on psychological versus non-psychological health.” Gillespie also disputes the idea that the issue violates the Iowa Civil Rights Act. “Had the Iowa Civil Rights Act been intended to apply in circumstances such as this, there would have been a more clear indication that it was meant to. Again, the application of that act to policy decisions of the executive is a massive expansion unprecedented in the state and contrary to both federal and other state law,” Gillespie argued.

The attorney for the other side, John Knight, says the state has tried to move the target. “The state in challenging the district court’s ruling has in a sense taken on the role of medical expert. And they’ve proposed a different set of facts with respect to the regulation,” Knight says. He says the state is wrong about the need for the surgery. “In a sense they have recharacterized the nature of this surgery here as cosmetic by their use of the language psychological services. The record evidence however shows that this surgery is medically necessary, and that it is really life-saving treatment for a number of individuals — including my clients,” Knight says. He says the state also has it wrong when it comes to the denial of payment violating the Iowa Civil Rights Act. “Section B of the public accommodations definition talks about units of government and it talks about services provided by a unit of government. There’s nothing that limits those services to on-site services. So I think you’d have to be basically writing an exception in that isn’t there,” according to Knight.

Knight was asked about how big an impact this would have. “Everyone with gender dysphoria does not need surgery. My clients do, and so there would certainly be medical people involved — both a surgeon and a mental health professional, at least one and sometimes two who are assessing the necessity of the coverage,” according to Knight. “And the reality is, this is a very small population, so we are not talking about a about significant number of people.”

The Supreme Court will issue a ruling on the case at a later date.