The chief judge of the U.S. District Court for the Middle District of Georgie, Marc Treadwell, writes in his opinion that the exclusion for the surgery, which is complicated and can cost tens of thousands of dollars, "plainly discriminates because of transgender status." Enacted in 1964, the Civil Rights Act prohibits employment discrimination based on race, color, religion, sex, and national origin.

In a 33-page ruling issued last week Treadwell compares the county's health insurance excluding "all treatment for gender dysphoria" (including sex-change surgery and drugs related to the procedure) to surgery for breast cancer and hormone therapy for menopausal women. "The fact of the matter is, for example, that the plan pays for mastectomies when medically necessary for cancer treatment but not when mastectomies are medically necessary for sex change surgery," the judge writes. "And the plan pays for hormone replacement therapy medically necessary for the treatment of menopause, but not hormone replacement therapy medically necessary for "sex change." The undisputed, ultimate point is that the Exclusion applies only to transgender members, and it applies to Lange [the plaintiff] because she is transgender."