Sterling Misanin knew from a young age that he was a boy. His transition began in earnest after he moved to Charleston three years ago. But when a new South Carolina law halted a crucial step in his gender-affirming care, he decided to fight back.
Misanin, 32, is the lead plaintiff in a federal lawsuit against the state of South Carolina and the Medical University of South Carolina over a ban on transgender care that he and others allege discriminates against those seeking gender-affirming care.
While 26 states have banned such care for minors, South Carolina's is "one of the most restrictive in the country" because it also denies care to adults, said Jace Woodrum, executive director of the ACLU of South Carolina, which is representing Misanin and the other plaintiffs.
The plaintiffs are seeking a preliminary injunction to keep what they contend is an unconstitutional law from continuing to deny them care.
No hearing on that request in the federal court case has yet been scheduled.
A spokesman for the South Carolina Attorney General's office said it does not comment on pending litigation.
The U.S. Supreme Court will later this year take up a case United States v. Skrmetti, challenging a ban on gender-affirming care for minors enacted in Tennessee, along with a similar case challenging a ban in Kentucky.
In those cases — and in challenges to bans on gender-affirming care for minors in Arkansas, Alabama, Florida, Georgia and Indiana — district courts blocked the laws from going into effect only to later have those decisions reversed by appellate courts that reinstated them.
The Supreme Court will have the ultimate say in those cases, but that decision is unlikely to take up the question of adult access, which affects Misanin and at least dozens, if not hundreds, of others across the state, Woodrum said.
A few states have restricted access to public funding, such as Medicaid, for gender-affirming care in a similar way to which abortion opponents blocked access to that care, said Gabriel Arkles, senior legal counsel for Advocates for Trans Equality, which has filed an amicus curiae brief in the Skrmetti case. That has "profoundly impacted a lot of adults' access to care," he said.
While the Supreme Court case may not directly impact adults, the court's decision could determine "what level of scrutiny does government discrimination against trans people get?" Arkles said.
Cutting off gender-affirming care for minors was one of the first major pieces of legislation the South Carolina House of Representatives took up this year, holding a hearing on the bill on its first day of session. The bill barreled through committees and onto the floor for a full vote despite the pleas and tears from dozens of families who showed up to testify about the devastating effect it would have on their children.
It followed a similar process in the Senate, where one doctor after another testified that providing the care was supported by every mainstream medical group in the country, including the American Medical Association and the American Academy of Pediatrics.
It was signed into law by Gov. Henry McMaster in May, where it was proclaimed to be one of the "landmark child safety bills" passed by the Legislature this year.
But there was little discussion about other provisions of the bill that prohibited public funds or Medicaid funds from being used to pay for gender-affirming care. Many were then surprised in June when MUSC Health decided that provision meant it had to end all transgender care.
"The law prohibits the use of public funds directly or indirectly for gender transition procedures," MUSC Health CEO Patrick Cawley said at the time. "MUSC Health funds are public funds, we are prohibited from providing gender transition services to all patients."
MUSC will receive around $121 million in state funding this year, according to budget documents. That would be 12 percent of the university's budget but about 2 percent of MUSC Health's projected $6 billion budget, according to an analysis by The Post and Courier.
The abrupt cutoff was a shock to most of the MUSC patients, who include some of its own employees, and it hit Sterling Misanin just days before he was scheduled to take the next step in his transition.
John
Misanin knew he was a boy early on, and around age 5 adopted the name John, apparently in honor of a beloved lifeguard at the pool where his family went. His mother thought it was a crush, but, Misanin said, "it was more like I wanted to be him, which is a very different feeling."
Running around the grocery store with his bowl cut, telling people his name was John and having them recognize him instantly as a boy was gratifying, he said.
Sterling Misanin stands in Hampton Park, Sept. 12, 2024, in Charleston. Misanin, a transgender man, is suing MUSC for refusing to perform his scheduled hysterectomy because it was gender-affirming care.
While that was allowed for a while, he said he eventually felt pressured by his family to give it up. But Misanin persisted, preferring to hang out with boys and play tackle football and jump into pickup basketball games. It gave him a comfortable feeling he didn't have around girls and the typical feminine things expected of them, he said.
Misanin said he "truly felt like I was one of guys, like I was a guy." Misanin was the one to go hunting and fishing with his father and truly enjoyed those pursuits. They went backpacking on the Appalachian Trail, and his dad taught him to drink and smoke cigars. He would say with a wink that Misanin "was his favorite son" even though there was an older brother who went to boarding school and apparently did not share their interests.
Late in high school and into college, he began to hear about transgender identity, but it remained an abstract concept. There wasn't anyone on TV or anyone he had come across that could help him understand what that meant.
It was only after college, when he met a couple of transgender women, that he could hear about their process of transitioning. That "really started to connect some of the dots in my mind" about what might be possible for him, Misanin said.
Then the pandemic hit. Outside of a few Zoom calls from family, he was alone. And Misanin was forced to look inward.
"And that's really when I realized that lying to myself was exhausting," he said. "And honestly, what was the point of lying when it's just me by myself?"
So, little by little, he began to accept himself and to move forward. His wardrobe didn't have to change much, and Misanin started therapy to help him work through how his life was evolving. Each of those steps "was giving me more of a feeling of myself than anything else I had experienced before," he said.
His position at work was being phased out. He found a new job at a company based in Charleston, so he moved from Madison, Wis. That was another step.
"I used that opportunity, honestly, to have a fresh start," Misanin said.
He was hesitant about being himself in the general public, but was welcomed by friends and members of the LGBTQ+ community. And it gave him the courage to come out out as a transgender man, first to longtime friends, then to family and, finally, at work, as well. (He had yet to change his name and gender on his identification, so work required him to continue with his deadname.) Because he deals with a lot of employees as a national manager involved in training, it was very public, but "thankfully, (they were) very, very supportive," Misanin said.
With therapy and support, he felt comfortable starting a medical transition. He didn't want to wait months for the endocrinology appointment he wanted at MUSC, where his other care was provided, so he began taking testosterone through another provider. It required going back to see the provider every three months for lab work, and then every six months, so he was continuously monitored as his body adapted.
Observing how his body and voice was changing was "euphoric," Misanin said, "to be able to start to see myself in a way that really aligned with how I've always seen myself in my head, and now people outwardly are going to be seeing the same thing."
The call
Next was top surgery, which reshaped the chest and nipples to create a more masculine appearance and alleviated the need for painful binding. Misanin said it was an "immediate relief" not to have to hide anything and "just being able to see myself as I am."
After that would be a hysterectomy, which also can facilitate further transition surgeries. It became an arduous process for Misanin of getting pre-approval from his insurance company, letters from his mental health providers certifying his gender dysphoria and arranging the schedule with the surgeon at MUSC.
He plans his work schedule out a year in advance, so he had to arrange for his time off after the surgery and for others to take his place and adjust their schedules. There were a lot of things that had to be lined up precisely.
The surgery, originally scheduled for March, had to be postponed because of a glitch with his insurance. It required redoing some things all over again. But the new date became June 28.
Everything was on track in the weeks and days leading up to it. He messaged back and forth with doctors' offices and completed routine lab work.
On June 24, just days before surgery was scheduled, he was messaging with MUSC offices about labs and post-surgical instructions when his phone rang. It was an 843 area code but a number he didn't recognize. It was a woman who didn't identify herself, he said, but asked if he was Sterling Misanin. Then she asked if he had a surgery at MUSC scheduled.
"Is it related to gender-affirming care?" she asked. He said it was.
"Just letting you know that effective immediately the surgery has been canceled." If he had questions, she instructed him to call his providers.
"I thought it was spam at first," Misanin said. "Like maybe MUSC's records had been leaked or something."
He immediately messaged his surgeon, who was able to call him within an hour to let him know she had received an email from MUSC's leadership that gender-affirming care was no longer allowed.
When contacted by The Post and Courier, MUSC declined to comment, citing active litigation.
Sterling Misanin stands in Hampton Park, Sept. 12, 2024, in Charleston. Misanin, a transgender man, is suing MUSC for refusing to perform his scheduled hysterectomy because it was gender-affirming care.
Misanin was left in disbelief, thinking it might be "a cruel joke." He got his hopes up twice for the surgery, only to see them dashed. He was left dismayed and frustrated. But not one to just stew in frustration, Misanin began to think about what he could do about his situation.
He filed an ethics complaint with MUSC, citing their policy of commitment to diversity and inclusion, but that ultimately went nowhere.
He also reached out to the ACLU.
A big part of the lawsuit is the way that Misanin and transgender patients and families have been discriminated against, said Woodrum of the ACLU of South Carolina. Other patients can receive hysterectomies, but transgender man cannot. Other children can receive hormone therapy and puberty blockers, for those going through puberty prematurely, but transgender children get that same treatment — even when that treatment is recommended and supported by the child's doctor, Woodrum said.
"Some parents can make decisions for their children and some can't," he said. "And some doctors can follow the medical standard of care and some can't." Rather than doctors or parents, Woodrum contends, those decisions are "being made by politicians."
That is at the heart of the allegation of discrimination: "This question of equal protection under the law. When we give something in this country, in this state, to one group of people and not to another, that is discrimination," Woodrum said.
Some of the plaintiffs in the lawsuit are transgender families and their children who are scrambling to find care, including by leaving the state. Others are adults whose care was also abruptly terminated. They appear under pseudonyms as transgender people face being fired from jobs, evicted from housing or worse, Woodrum said.
Misanin has chosen to make his fight public.
It was something he had to think about. But he also recognized he is fortunate — to be secure in his job, in his place, among his friends and where he is in his life — in a way that others who are in the same fight might not be.
"It was truly a decision of wanting to fight for myself, for sure, but then also for the people that I know that can't fight for themselves," at least not publicly, Misanin said. Not in the way he can, and is.