The future of the Biden administration’s efforts to prohibit LGBTQ discrimination in health care is at stake after a Trump-appointed judge ruled that the Affordable Care Act defines sex narrowly.

The decision weakens protections for LGBTQ people who believe they were discriminated against because of gender identity or sexual orientation, while the Biden administration still works on a final rule that would guarantee those protections remain.

The issue has been debated since the Obama administration and the ruling adds to the uncertainty.

“There’s no question that this has created a mess for the agency,” Karen Loewy, senior counsel and director of constitutional law practice for civil rights group Lambda Legal, said of the opinion by Federal District Judge Matthew J. Kacsmaryk.

Kacsmaryk, a judge in Texas who has criticized the constitutional right to same-sex marriage, recently held that discrimination on the basis of gender identity and sexual orientation isn’t barred under Section 1557 of the ACA. The ruling rejected a Biden administration notice that it would enforce protections for LGBT Americans.

The ruling “purports to basically shield all health-care entities across the country from having to comply with a federal statute to which they are subject,” Loewy said. “The statute itself makes clear that sex discrimination in federally funded health programs...

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