The state of North Dakota is now the sixth state to sue the Obama administration over rules that some believe might require doctors to aid patients who desire to undergo gender transition treatments—from hormone therapy to mastectomies—despite their convictions or belief that the procedure would not be beneficial for the person.

“The regulation … undermines the longstanding sovereign power of states such as North Dakota to regulate healthcare, ensure appropriate standards of medical judgment, and protect its citizens’ constitutional and civil rights,” the suit, filed on Monday by the Becket Fund for Religious Liberty, reads.

“Under this rule, states are now required to force all healthcare professionals at state-run facilities to participate in medical transition procedures (including hormone therapy, plastic surgery, hysterectomies, and gender reassignment surgery), and to cover those procedures in the states’ health insurance plans, even if a doctor believes such procedures are harmful to the patient,” it states.

Several Roman Catholic entities—Sisters of Mercy, the University of Mary and SMP Health System—also joined the suit.

As previously reported, Texas, Wisconsin, Kentucky, Nebraska and Kansas all filed suit in August, as well as the Christian Medical and Dental Association and the Roman Catholic Franciscan Alliance.

The states challenged a rule released by the Department of Health and Human Services (HHS) that “builds on prior federal civil rights laws to prohibit sex discrimination in health care.”

“The final rule requires that women be treated equally with men in the health care they receive and also prohibits the denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping,” the document released by HHS outlines.

The Becket Fund for Religious Liberty notes that the preamble to the rules outlines that doctors who accept Medicare or Medicaid will be required to provide the same services to transgendered individuals that they would normally offer to others, if those services are considered “medically necessary to treat gender dysphoria.”

“The rule requires covered employers, and their healthcare providers and professionals, to perform (or refer for) medical transition procedures (such as hysterectomies, mastectomies, hormone treatments, plastic surgery, etc.), if a physician or healthcare provider offers analogous services in other contexts,” it wrote in its brief.

“For example, in the preamble, HHS stated, ‘A provider specializing in gynecological services that previously declined to provide a medically necessary hysterectomy for a transgender man would have to revise its policy to provide the procedure for transgender individuals in the same manner it provides the procedure for other individuals,'” the organization noted.

Therefore, as North Dakota “oversees and controls several agencies and a healthcare facility that receive federal funding administered by HHS,” officials are concerned how the new rule will lord over physicians in the state. Sisters of Mercy, the University of Mary and SMP Health System are apprehensive that the rule will mandate that they violate their religious beliefs in order to obey the government.

“SMP Health System must now choose between (a) following its faith and its best medical judgment, or (b) following the regulation,” the suit states. “If it follows its faith and medical judgment, SMP Health System will be subject to financial penalties and lawsuits.”

The entities are seeking a declaration that the rule violates the U.S. Constitution, as well as the Administrative Procedure Act and the Religious Freedom Restoration Act, and that the government be permanently enjoined from enforcing the regulation on all states.

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