An Obama-appointed federal judge is forcing Wisconsin taxpayers to provide costly sex reassignment surgery and hormonal procedures for low-income transgender residents who get free medical care from the government. In a recently issued ruling U.S. District Judge William M. Conley writes that Medicaid, the publicly funded insurance that covers 65.7 million poor people, cannot deny the medical treatment needs of those suffering from “gender dysphoria.” Officials estimate it will cost up to $1.2 million annually to provide transgender Medicaid recipients in the Badger State with treatments such as “gender confirmation” surgery, including elective mastectomies, hysterectomies, genital reconstruction and breast augmentation. The intricate operations are typically done by plastic surgeons.

The ruling culminates a lawsuit filed more than a year ago by two transgender Wisconsinites, who accuse the federal and state-funded insurance program of providing them with disparate and inferior health care on the basis of sex. Cody Flack of Green Bay and Sara Makenzie of Baraboo say they suffer from severe gender dysphoria that requires costly surgery. Flack, a woman, claims to be ashamed of her breasts and wants to have them surgically removed as she transitions into a man’s body. To make a case for the government to pay for her surgery, she claims that she engages in “binding,” which flattens her breasts and causes sores, skin irritation and respiratory distress. Flack also has difficulty binding her breasts due to a disability, according to court documents. Makenzie, a man who legally changed his name to Sara and wears women’s clothing, says his “male-appearing genitalia” causes him “great distress” and negatively affects his sexuality and social life. Showering and seeing his body in a mirror is “painful,” court records state, and Makenzie fears someone will be able to see his “male genitals” through his clothing.

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