Abstract
This study analyzes how U.S. healthcare organizations implemented legal requirements to treat patients in a manner consistent with their gender identity under Section 1557 of the Affordable Care Act. The ways that healthcare organizations determine gender and track complaints constitute socio-technical systems for compliance, and they shape what discrimination protections look like on the ground. We interviewed grievance handlers about how they use information technologies to process possible civil rights claims from patients and argue that their work demobilizes and erases civil rights, especially claims such as transgender harassment. Mobilized physician-led implementation groups, by contrast, enacted a version of gender identity recognition by tracking identities and bodies in electronic medical records and material objects such as specimen labels. Default structures—the dropdown menus of healthcare software—both shape and are shaped by professional norms, financial incentives, and conceptions of justice and deservingness. These socio-technical structures allow conflicting stories of transgender rights to continue on in different parts of the healthcare organization, making it difficult for law to transform healthcare delivery.
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