Sept. 1 had been circled on Aiden Vasquez’s calendar since a spring Iowa Supreme Court decision ruled Medicaid funds could be used on transition-related care, including surgeries.

September marked the first month that a surgeon suggested by his doctor, Dr. Nicole Nisly of the University of Iowa LGBTQ Clinic, would be performing phalloplasties, the scientific name for what is commonly referred to as “bottom surgery” for transgender men.

In September, he will finally become himself, Vasquez, 51, said Monday from his Davenport home.

“Well, that was the plan,” he said, correcting himself through tears.

Legislation passed just before the session ended would allow government entities to opt out of using public insurance dollars, including Medicaid, to pay for transition-related surgeries. If signed, the law would effectively overrule the Iowa Supreme Court’s March decision that said the state should pay for transition care, throwing Vasquez and other transgender Iowans into limbo for surgeries long desired.

“I had been in a dark depression for about six months, but when I left Dr. Nisly’s office with that referral, it felt like she had taken my hand and pulled me out of this hole I had been living in,” Vasquez said. “Now, it’s like they shoved me back in and threw dirt over top of me. It just feels like I've been kicked in the face.”

Added to the health budget bill, the Legislature's language would allow any state or local government unit or tax-supported district to decline using public funds for “sex reassignment surgery” or “any other cosmetic reconstructive or plastic surgery procedure related to transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder."

Despite passing the GOP-majority Iowa House and Senate, the new law doesn’t go into effect unless Gov. Kim Reynolds signs it. The governor, who can use a line-item veto to block the provision, did not return request for comment Monday.

The ACLU of Iowa, which originally brought the Supreme Court case on behalf of two transgender Iowans, can sue again. On Monday, the ACLU of Iowa declined to comment on their plans, instead sending a statement from Mark Stringer, their executive director, that said the amendment “risks people’s health and lives to score political points.”

The provision's wording is very similar to the language in the Iowa Code that the Supreme Court already found to be discriminatory, said Sharon Malheiro, a local lawyer and activist who filed an amicus brief in the case.

"This particular section just picks out one class of citizens to deny access to service for and I believe that violates the equal protection clause of the Iowa Constitution," she said.

Malheiro also called the move a direct attack on the “tripartite system of government,” pointing to the legislators' expressed desire to overturn the court decision. In defending the provision during floor debate Friday, Sen. Mark Costello, R-Imogene, said he added the amendment to change the administrative code back to the way it was for years before the lawsuit.

“They don't care about the judiciary and what the judiciary says,” Malheiro said.

At the LGBTQ Clinic, Nisly said some of her patients who had been clinically depressed, even suicidal, were beginning to feel hopeful after the decision was announced. They were making goals for the first time in a long time: quit smoking, lose weight, get themselves healthy enough to start working again.

Now — despite all major medical groups agreeing that transition-related care, including surgeries, is medically necessary — her patients again fear they will never be able to align their bodies with how they see themselves.

“These people have waited so long and worked so hard to get to a space of positive thinking and healing and moving forward and to see this happen, I find it cruel,” she said. “I don’t think the people making these decisions understand their choices affect real people, and not only that, they affect their families, kids and spouses."

How we got here

After years of dealing with denials and headaches regarding their health coverage, Carol Ann Beal, 43, of northwest Iowa, and EerieAnna Good, 29, of southwest Iowa, sued the Department of Human Services in 2017. They alleged that the state's blanket ban denying their use of public funds for doctor-prescribed surgery singled them out solely because of their gender identity.

The Iowa Supreme Court agreed, ruling that the "express ban on Medicaid coverage for gender-affirming surgical procedures" contradicted the gender-identity protections in the Iowa Civil Rights Act.

In their unanimous decision, the justices struck down the administrative code governing Medicaid in Iowa that classified transition-related surgeries as "cosmetic, reconstructive or plastic surgery" and explicitly banned "surgeries for the purpose of sex reassignment."

At the time, advocates heralded the decision as the first by any state's highest court holding that transgender people have the right to use public money for transition-related surgeries. They hoped the decision would open the door for challenges to similar bans in at least 20 states.

Gender identity — or the deeply held sense of who one is, which may differ from the sex organs with which one was born — and sexual orientation were added to the Iowa Civil Rights Act as protected classes in 2007.

Under the civil rights law, transgender Iowans have legal protections against discrimination in education, employment, housing and public accommodations. Medicaid, a state and federally funded health insurance program, is considered a public accommodation.

In his district court ruling invalidating the ban of taxpayer-funded "gender-affirming surgical procedures," Polk County Chief District Judge Arthur Gamble wrote that the state did not "rebut the medical evidence that gender affirming surgery is medically necessary treatment."

"The agency acted in the face of evidence upon which there is no room for difference of opinion among reasonable minds," he wrote.

The state appealed, arguing the ban is not discriminatory because the department denies all surgeries performed primarily for psychological reasons.

"We are covering these surgeries in the same instances when the primary purpose is to address a non-psychological purpose," Assistant Attorney General Matthew Gillespie said during oral arguments before the Supreme Court.

The Supreme Court stopped short of ruling that the code violated the equal protection clause in the Iowa Constitution — as Gamble held in his June ruling. Justice Susan Christensen wrote that answering that question wasn't necessary to resolve this case, leaving the door open for laws like the one added late last week.

As the Legislature drew to a close, the “Costello amendment” edited Chapter 216 of the Iowa Civil Rights Act to add a clause allowing certain entities to essentially opt out of covering transition-related care. That portion of the code already contains a religious exemption.

The Republican-controlled House voted for the proposal Saturday afternoon, one day after the GOP-majority Senate advanced it. No Democrat voted for the plan.

If Reynolds signs the bill into law, the restrictions would go into effect immediately.

Before that happens, LGBTQ rights groups, including the Washington D.C.-based Human Rights Campaign, are hoping to convince her to use a line-item veto on the language.

“As a native Iowan, it’s disturbing to see lawmakers in my home state trying to roll back the clock on progress and discriminating against transgender people at the eleventh legislative hour,” JoDee Winterhof, a senior vice president with the Human Rights Campaign, said in a statement urging the governor not to approve the amendment.

Transition care affordable and cost-effective, study says

The Supreme Court verdict ended an almost two-year legal battle that hinged on whether transition-related surgery was "medically necessary" or a procedure provided solely for psychological purposes.

As the Iowa Senate briefly debated the added provision, lawmakers focused little on the question of necessity and more on the cost.

Costello defended the provision during floor debate Friday, saying the surgeries were “not a proper use of our state monies.”

The Family Leader, a conservative, Christian organization in Des Moines, agreed that “taxpayers should not be compelled to fund potentially harmful procedures that seek treatment options outside of God’s design,” said Drew Zahn, the group’s spokesperson.

For transgender people, transitioning can be a spectrum. While some transgender people might want surgeries, others find alignment simply by dressing in gender-specific clothing.

Transition surgeries can range from $20,000 to $100,000, putting it out of reach of individuals who qualify for public assistance. Despite what may seem like a high cost, a recent study published in the Journal of General Internal Medicine found the “expenses hold good value for reducing the risk of negative endpoints — HIV, depression, suicidality, and drug abuse."

Vasquez had hoped to be the first transgender man in Iowa to get a phalloplasty, even going so far as to schedule a dog sitter for September and putting in a campsite reservation for his wife to stay near him during his post-operative recovery.

Since starting his transition a few years ago, Vasquez has lost more than 100 pounds and dedicated his life to helping transgender people. He hosts a live question and answer session on Facebook about once a month with parents of transgender kids and tries to make himself available to anyone seeking information.

Now, Vasquez said he will lean on his Christian faith to get him through.

“I have a relationship with God and I know that he has led me to this,” Vasquez said. “He revealed to me that this is my calling, so I am going to have to do a whole lot of praying and trust he will work this out.”