A federal appeals court on Wednesday heard arguments in a major religious liberty case that could determine whether Christian doctors and religious hospitals can be forced to perform sex-reassignment surgery and treat gender dysphoria under Obamacare.

At issue is a 2016 Obama-era interpretation of the Affordable Care Act (Obamacare) that prohibits doctors and healthcare facilities from discriminating on the basis of gender identity, which is defined as an individual’s “internal sense of gender, which may be male, female, neither, or a combination of male and female.” Under the rule, doctors and healthcare facilities are required to treat gender dysphoria and perform gender-transition procedures in children and adults or be liable for discrimination.

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