Florida health officials circumvented traditional regulatory channels to draft a report recommending gender-affirming health care be excluded from coverage under Medicaid, a state employee alleges in an exchange included in new court filings.

Florida’s Agency for Health Care Administration (AHCA), which controls most of the state’s Medicaid program, wrote in a June report that available medical literature provides “insufficient evidence” that puberty blockers, hormones and gender-affirming surgeries are safe and effective treatments for gender dysphoria and therefore excluded them from Medicaid coverage because they are “experimental and investigational.”

The ensuing state rule, which took effect in August, bars transgender youth and adults in Florida from using Medicaid to help pay for any “procedures that alter primary or secondary sexual characteristics” when those procedures are used to treat gender dysphoria, stripping more than 9,000 transgender Floridians of access to critical health care.

But new court documents filed late Friday by plaintiffs in a case challenging Florida’s Medicaid exclusion include allegations from an AHCA employee that state health officials did not follow customary procedures for developing generally accepted professional medical standards (GAPMS) in creating the June report.

Documentation of an email exchange between Christopher R. Cogle, the chief medical officer of Florida Medicaid, and Jeffrey English, an AHCA employee, show evidence of tension within the agency over the GAPMS recommendation on treatments for gender dysphoria.

Cogle in the June correspondence inquires whether the AHCA has a standard operating procedure for GAPMS recommendations, to which English responds in the affirmative, adding: “If you will excuse me, I feel obligated to include this information: I was not informed or consulted, did not in any way participate, and did not write the GAPMS concerning gender dysphoria treatment.”

“That particular GAPMS did not come through the traditional channels and was not handled through the traditional GAPMS process,” English wrote.

“I do not cherry pick data or studies and would never agree to if I were so asked,” he continued. “All I can say about that report, as I have read it, is that it does not present an honest and accurate assessment of the status of the current evidence and practice guidelines as I understand them to be in the existing literature.”

Most major medical organizations including the American Medical Association (AMA) and the American Academy of Pediatrics (AAP) agree that gender-affirming health care for transgender youth and adults is medically necessary, and have denounced government efforts to insert politics into medicine.

The AHCA report in June acknowledged that groups like the AMA and AAP support the use of puberty blockers, hormones and surgeries to treat gender dysphoria, but said “none of those organizations rely on high-quality evidence.”

“Their eminence in the medical community alone does not validate their views in the absence of quality, supporting evidence,” the report said.

English in his message to Cogle says he apologizes “if I come across as a bit agitated about it, but as the ‘GAPMS guy’ around here, lots of assumptions have been made by those who do not know me well.”

“I’m a different sort of person than the author of that report,” English wrote. “I can’t speak for them. I conduct myself and my work with integrity and I do not play favorites, yay or nay. Full stop, period.”

English did not immediately respond to The Hill’s request for comment. The AHCA did not respond to The Hill’s questions about how it developed its GAPMS recommendation for gender dysphoria treatment or why the report was not drafted using the agency’s standard operating procedure.

Court documents filed Friday also show the AHCA determined as recently as 2016 that it cannot “categorically exclude” the prescription of puberty blockers to treat gender dysphoria in transgender youth under Medicaid, though the agency admitted at the time that it was unable to determine “whether puberty suppression therapy is considered a health service that is consistent with generally accepted professional medical standards.”

The filings further revealed that the court denied a state request to compel two of the plaintiffs in the case challenging the Medicaid exclusion to submit to psychological testing, finding the state failed to provide evidence that its selected medical expert is not a “transgender denier or skeptic.” The request applied only to plaintiffs Susan Doe and K.F., both of whom are transgender youth under 18, and not to the case’s two other transgender plaintiffs, who are in their early to mid 20s.

Florida health officials have been broadly accused by medical professionals and LGBTQ advocates of publishing intentionally misleading and false information about gender-affirming health care for transgender youth and adults to push a conservative political agenda.

In addition to instituting a state Medicaid policy explicitly excluding coverage for gender-affirming health care, Florida’s Board of Medicine — whose membership consists of doctors appointed by Gov. Ron DeSantis (R) — in October voted to begin drafting a rule to ban puberty blockers, hormone therapy and surgeries for transgender youth under 18.

In April, the state Health Department issued a guidance suggesting gender-affirming health care — including social transition, which can include changes as simple as using new pronouns — should not be accessible to minors. At least 10 medical experts whose research was cited in the guidance told Vice News in August that their work was being misrepresented.

In a study published Wednesday in the New England Journal of Medicine, transgender adolescents and young adults reported increased life satisfaction and fewer symptoms of depression and anxiety after receiving gender-affirming hormone therapy for two years.