The death of a transgender woman in Cleveland has been ruled a homicide, making it the 23rd reported murder of a trans person in the U.S. this year.

Brandi Bledsoe, 32, died of a gunshot wound to the chest, the Cuyahoga County medical examiner ruled Thursday, The Plain Dealer of Cleveland reports. She was found dead Saturday around 10 a.m. in a driveway behind a house, with plastic bags over her head and both hands, according to the paper. She had also suffered head trauma. Her body was discovered by a young boy riding his bike.

Initial reports misgendered Bledsoe, but then members of her family came forward to say she was a trans woman, having come out to them two years ago. Bledsoe, a Home Depot employee and animation artist, was much happier once she began presenting as her authentic self, relatives said.

"She wasn't very outgoing before she told us," her cousin John Craggett told The Plain Dealer."She just wasn't happy with who she was. When she told us, she was honestly a lot better as Brandi. She was happy."

"She was really beautiful," Craggett added. "She was really sweet and nice. That's what bugs the crap out of me about this. Whoever did this can rot in hell."

Bledsoe had grown up in Nebraska and moved to Cleveland several years ago, family members said. She had lived with her grandfather in Cleveland for a time, but she recently got a place of her own.

"We got along great when she lived with me," Johnnie Ledbetter, her grandfather, told The Plain Dealer. "I wish she was around more after she moved out."

She is at least the fourth transgender woman killed in Cleveland since 2012, the paper reports. Police said they are taking her identity into consideration in investigating the crime, but they have yet to determine a motive or make an arrest.

The nationwide count of reported murders of trans people has already made 2016 the deadliest year on record, and Bledsoe's death puts it two above 2015's total of 21. The actual number is likely much higher, as many trans people are misgendered in death, or their murders are not reported by media.

The New York State Health Department has signaled it intends to allow transgender youth to receive Medicaid coverage for hormones that forestall puberty, wiping away prohibitions that have been criticized by lesbian, gay, bisexual and transgender groups.

The move, announced on Wednesday in a proposed rule in the State Register, would allow minors who are being treated for gender dysphoria to receive Medicaid payment for pubertal suppressants and cross-sex hormone therapy, which mimic the biological chemistry of the opposite gender. Previously, the state had covered such hormone treatments for adults, a change that took effect last year.

In the proposed rule, the department stated that its concerns about the safety and efficacy were supplanted after it “had the opportunity to talk to a number of practitioners who treat minors” with gender dysphoria, who uniformly agreed that hormone therapies were medically justifiable for young people who feel that their birth sex is not their true gender.

“The proposed changes therefore would make Medicaid coverage of transgender care and services available, regardless of an individual’s age, when such care and services are medically necessary to treat the individual’s gender dysphoria,” the rule reads.

The change will not take effect immediately; the rule has a 45-day comment period, and the state can formally adopt it after that time.

New York is not the only state to allow Medicaid — a joint federal and state program — to cover such hormone treatments, said Sasha Buchert, a staff lawyer with Transgender Law Center in California, which has long had such coverage.

But Ms. Buchert said New York’s move was a “significant step forward” in providing care for transgender people of all ages.

“These decisions,” she said, “should be made by physicians.”

The decision in New York came during a legal battle — and after victories — for advocates for transgender rights, both in New York and in other parts of the nation.

“Puberty is traumatic, or can be, for all people, but it’s incredibly traumatic for transgender people,” said Belkys Garcia, a staff lawyer with the Legal Aid Society, one of several groups that filed a federal suit against New York’s restrictions on payments for transgender treatments. She added that puberty suppressants, in particular, allow some young people grappling with gender dysphoria “time to figure themselves out,” even if they do not eventually transition to the opposite sex.

New York was among a handful of states that had enacted prohibitions on Medicaid payments for such treatments, a policy that dated back to the administration of Gov. George E. Pataki, a three-term Republican who left office in 2006. Since then, there were several failed legal attempts to overturn those rules.

But advocates have been emboldened in recent years by both a broader cultural acceptance of transgender people as well as actions by Gov. Andrew M. Cuomo, a Democrat, including in late 2014 when he instructed the Department of Financial Services to guarantee insurance coverage for gender dysphoria. Last fall, the governor also announced Anti-discrimination measures for transgender people in housing and other areas, using his executive power to overcome a legislative logjam in the Republican-led State Senate.

In March 2015, the Health Department, already facing legal action, adopted rules that allowed for some coverage, including gender reassignment surgery for adults displaying “a persistent and well-documented case of gender dysphoria,” but stopped short of covering minors as well as certain treatments the state considered cosmetic, rather than medically necessary.

In July, however, a federal judge in Manhattan, Jed S. Rakoff, of United States District Court, ruled that such restrictions on the so-called cosmetic procedures were not legally defensible, but wanted a trial for the issue of whether treatment for youth was medically necessary. More legal arguments are planned for this month, but though the proposed rule on youth coverage could satisfy the court.

The state’s action on Wednesday also would appear aimed at addressing the judge’s concerns, by clarifying the state’s intent to allow Medicaid coverage for a wide variety of treatments including mastectomy,hysterectomy and breast augmentations, as well as electrolysis — which is often expensive — in certain cases.

The legal team pushing for the changes — including Legal Aid, the Sylvia Rivera Law Project, and Willkie Farr & Gallagher — says it will continue to push the state for fast action on the proposed rule. “Without a judgment from the court, there’s nothing to say the state can’t make another change,” Ms. Garcia said.

Health Department officials characterized the change as another sign of Mr. Cuomo’s “commitment to equality in all areas.”

“These proposed regulations build upon existing science to ensure that youths who have been diagnosed with gender dysphoria receive medically necessary care,” said James Plastiras, a spokesman for the department. “And render moot any claim that current standards don’t provide that care.”

Many surgical procedures would not necessarily be appropriate for minors — “It’s rare that people are getting surgery under 18,” Ms. Garcia pointed out — though they could be covered in some cases under the department’s proposed rule.

But the major benefit for transgender youth would primarily be the hormone treatments, according to medical professionals.

Dr. Carolyn Wolf-Gould, a family practitioner at the Gender Wellness Center in Oneonta, N.Y., part of Bassett Healthcare Network, said that blocking the physical characteristics of puberty could offset the need for difficult surgeries, particularly for “youth that are assigned male at birth.”

“Once male puberty has occurred it’s very hard to reverse those changes,” Dr. Wolf-Gould said, noting the genital and facial changes and hair growth that occur usually during that period, along with physical bulking.

She added that for birth-females intending to transition to male, mastectomies can cause “painful and unsightly scars.”

There is also, however, a major emotional benefit to allowing “a youth to go through puberty in their affirmed gender,” she said.

“It provides tremendous psychological relief,” she said, adding that delaying puberty can provide “a sense that they suddenly have some control going on with their body.”

The Human Rights Campaign Foundation — in partnership with the AAP and the American College of Osteopathic Pediatricians — today released a comprehensive support guide for the parents, allies and health care providers of transgender children.

Developed in association with AAP/ACOP physicians and mental healthprofessionals who have worked extensively with transgender children, the support guide, Supporting and Caring for Transgender Children, is intended to detail what it means for children to be transgender and why medical experts now embrace a “gender-affirming” approach.

“We know more than ever before about what transgender children need to grow up safe and healthy, and a large part of that is being accepted, nurtured and supported in their gender identity by their family, physicians and community,” Karen Remley, MD, MBA, MPH, FAAP,executive director and CEO of the AAP, said in the press release. “We hope this new guide will become a useful tool for anyone who has a transgender child in their life.”

While the guide provides easy to understand explanations of gender identity, fluidity, exploration and how identity differs from sexual orientation, it also is intended to help dispel misinformation that has provided a platform for North Carolina’s discriminatory HB2 law that denied transgender people access to public restrooms and facilities based on their gender identity.

Portions of HB2, also known as the Public Facilities Privacy and Security Act, directly addressed children in public schools, and stated that, “in no event shall that accommodation result in the local boards of education allowing a student to use a multiple occupancy bathroom or changing facility … for a sex other than the student’s biological sex.”

“The ACOP is excited to be a part of this guide providing pediatricians, otherprimary care physicians, allied health staffs, patients, families and caretakers with this vital information for transgender youth,” ACOP President, Carl R. Backes, DO, FACOP, said in the release. “We suggest all efforts ensuring transgender young people be respected and valued.”

In addition to its backing of the support guide, the AAP is developing a policy statement on caring for transgender youth that it plans to publish in 2017.

In the landmark case, Katharine Prescott argues the Rady Children's Hospital-San Diego (RCHSD) in California discriminated against her transgender son based on his sex.

The civil complaint filed in a federal court in the state of California comes amid a raging debate in the United States about the rights of the lesbian, gay, bisexual and transgender (LGBT) community.

The 14-year-old transgender boy, Kyler Prescott, committed suicide about five weeks after staying at the hospital in 2015 where he was treated for having suicidal thoughts and self-inflicted wounds.

The suit claims the hospital violated anti-discrimination provisions in federal and state laws, including the Affordable Care Act, President Barack Obama's signature healthcare law.

The plaintiff's attorney, Alison Pennington, with the Oakland-based Transgender Law Center, said she believed it was the first case to claim an underage transgender person had suffered sex-based discrimination under the Affordable Care Act.

Less than half a dozen similar suits have claimed discrimination against adult transgender people since the law was enacted in 2010, she said.

In a telephone interview, the mother said filing the lawsuit was painful, but she hoped it would ensure no other parents or child go through the same ordeal.

"I believed that they would be able to help him feel better," she told the Thomson Reuters Foundation.

"They really just made things worse."

According to the suit, RCHSD said on its website that it was competent in caring for transgender children and teens.

But the complaint claims that the hospital's nursing and other staff "repeatedly addressed and referred to Kyler as a girl, using feminine pronouns."

The transgender boy, who had legally changed his name and gender, subsequently called his experience at the hospital "horrible," the complaint said.

A spokesman for RCHSD said that while he could not comment on pending legal matters, "any allegations of wrongdoing, including discrimination, are investigated thoroughly and followed up on."

Court documents did not list a defense attorney.

The Affordable Care Act is the first federal healthcare law to explicitly ban discrimination against transgender people, said Dru Levasseur, a spokesman at Lambda Legal, a New York City-based LGBT rights group.

A ruling by a Minnesota federal court last year became the first to recognize discrimination against a transgender person under the healthcare law, Levasseur said.

The mother is seeking damages and restitution, as well as an injunction that would force the hospital to institute policies preventing the discrimination of transgender youth based on sex.

In 2011, the National Transgender Discrimination Survey found that 41 percent of transgender and gender non-conforming U.S. respondents said they had attempted suicide.

A Cincinnati woman today sued the Cincinnati public library and the corporate parent of Anthem Blue Cross and Blue Shield for refusing to cover her sex-reassignment surgery.

The insurer's refusal violates the Affordable Care Act's guarantee of coverage for medically necessary treatment, and the employer's requirement under federal law to treat employees equally, regardless of gender, says Rachel Dovel's lawsuit, filed in U.S. District Court in Cincinnati.

If the case proceeds, it could be the first establishing or denying an insurer's requirement to cover transgender surgery under the Affordable Care Act, better known as Obamacare.

There has been other litigation over other transgender rights, however. Those include a legal settlement that established a right for some California inmates to get state-paid gender-conversion surgery. Local government-based requirements for schools to honor students' gender identity in bathroom choice are working their way through courts across the country.

"We may be the first because most insurers and most employers cover the service," said Jennifer Branch, a partner at Gerhardstein & Branch, a Cincinnati law firm that handles civil liberties cases exclusively. The firm's other clients have included Jim Obergefell, whose demand that his gay marriage be legally recognized helped establish gay marriage rights across the country with a landmark 2015 U.S. Supreme Court decision.

Chris Rice, a representative of the Public Library of Cincinnati and Hamilton County, declined comment, saying he had not seen the court filing and could not discuss a matter in litigation. But Anthem Blue Cross and Blue Shield said in a statement late Monday that the company fully complies with Obamacare's requirements, suggesting any denial of coverage for Dovel's surgery was a result of the library's insurance-buying decisions.

"We're sensitive to the issues raised by Ms. Dovel in this case," said Anthem spokesman Jeff Blunt. "All of Anthem's health plans are fully compliant with the Affordable Care Act and they have been reviewed and approved by appropriate state regulators.  As is the industry standard, coverage for transgender surgery is available as an optional rider, or add-on coverage, that employers may purchase."

Here's what the case is about.

The background:

Dovel, 34, was born male and had the name Nathan until after a diagnosis in 2014 of gender dysphoria, or severe and unremitting emotional pain due to incongruity with the sex assigned or assumed at birth, according to the lawsuit.

She began hormone therapy, which was covered by insurance, and started changing her outward appearance. In 2015, she changed her name from Nathan Bradley Dovel to Rachel Katrina Dovel.

To that point, the library treated her well, said Dovel, a 2005 University of Toledo graduate who works in the library's catalog and processing department. But the library, where she has worked nearly 11 years, balked when it came to the next stage of Dovel's treatment.

The insurer's and employer's decision:

Her doctors said sex-reassignment surgery was medically necessary to treat her gender dysphoria, the lawsuit says. But Anthem Blue Cross Blue Shield, the public name of the corporate entity Community Insurance Company, said sex-reassignment surgery is not covered under the library's group policy.

Dovel learned "that the library's insurance policy allows coverage for surgical procedures when medically necessary but categorically excludes "[s]ervices and supplies related to sex transformation and/or the reversal thereof . . . regardless of origin or cause," the lawsuit says. 

Dovel appealed to the library's board of trustees and asked the board to update its coverage with a rider to its insurance policy. The board's minutes show that in June, the trustees voted not to.

The medical rationale:

If Dovel had needed foot surgery instead, the insurer and employer would have covered it, Dovel said in a phone interview from her lawyers' offices. 

And the library's policy would cover an orchiectomy for a non-transgender male employee who was diagnosed with testicular cancer, or a vaginoplasty for a non-transgender female employee who was diagnosed with Mayer-Rokitansky-Kuster-Hauser syndrome, the lawsuit says.

Surgery to treat gender dysphoria is necessary too, Dovel and her lawyers said. "The sex reassignment surgery is a procedure that is both medically necessary and consistent with well-established standards of care for the treatment of gender dysphoria," the lawsuit says.

Dovel told cleveland.com that "I just want the library to support its queer employees. Specifically, I would like the library to support its trans employees by recognizing that we have legitimate medical needs and they should be treated fairly."

The alleged rights violations:

Failing to do so violates federal employment anti-discrimination law, the lawsuit says, because the law forbids discrimination in compensation, terms, conditions, or privileges of employment.

It also violates Dovel's constitutional right to equal protection under the 14th Amendment, and it violates the Affordable Care Act, the lawsuit says. That's because Obamacare prohibits discrimination in any health program that receives federal money.

Anthem sells Obamacare health insurance policies in Ohio and receives federal compensation. Therefore, its treatment of patients under employer-provided policies is covered under that law, the lawsuit says.

What's next:

Dovel has scheduled surgery in November at the Pappillon Gender Wellness Center near Philadelphia. She said the costs of her surgery will be about $21,000, not counting travel and room and board, and she'll face considerable debt if the insurer and library don't change their minds.

They have 60 days to respond to the lawsuit.

Dovel wants a jury trial, compensatory damages and a court order than bans the library from maintaining insurance coverage that denies transition-related care. She also wants the court to ban Anthem from selling such coverage.

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