United States District Court, D. Idaho
FINDINGS OF FACT, CONCLUSIONS OF LAW, AND
Lynn Winmill Chief U.S. District Court Judge
more than forty years, the Supreme Court has consistently
held that consciously ignoring a prisoner's serious
medical needs amounts to cruel and unusual punishment in
violation of the Eighth Amendment. See Estelle v.
Gamble, 429 U.S. 97, 103 (1976). After all, inmates have
no choice but to rely on prison authorities to treat their
medical needs, and “if the authorities fail to do so,
those needs will not be met.” Id. Prison
authorities thus treat inmates with all manner of routine
medical conditions - broken bones are set; diabetic inmates
receive insulin; inmates with cancer receive chemotherapy;
and so on. This constitutional duty also applies to far less
routine, and even controversial, procedures - if necessary to
address a serious medical need. And so it is here. Plaintiff
Adree Edmo alleges that prison authorities violated her
Eighth Amendment rights by refusing to provide her with
gender confirmation surgery. For the reasons explained below,
the Court agrees and will order defendants to provide her
with this procedure, a surgery which is considered medically
necessary under generally accepted standards of care.
Court will explain its reasoning below but will first pause
to place this decision in a broader context. The Rule of Law,
which is the bedrock of our legal system, promises that all
individuals will be afforded the full protection of our legal
system and the rights guaranteed by our Constitution. This is
so whether the individual seeking that protection is black,
white, male, female, gay, straight, or, as in this case,
transgender. This decision requires the Court to confront the
full breadth and meaning of that promise.
Edmo is a male-to-female transgender prisoner in the custody
of the Idaho Department of Correction (“IDOC”).
She has been incarcerated since April 2012. In June 2012,
soon after being incarcerated, an IDOC psychiatrist diagnosed
Ms. Edmo with gender dysphoria. An IDOC psychologist
confirmed that diagnosis a month later.
dysphoria is a medical condition experienced by transgender
individuals in which the incongruity between their assigned
gender and their actual gender identity is so severe that it
impairs the individual's ability to function. The
treatment for gender dysphoria depends upon the severity of
the condition. Many transgender individuals are comfortable
living with their gender identity, role, and expression
without surgery. For others, however, gender confirmation
surgery, also known as gender or sex reassignment surgery
(“SRS”), is the only effective treatment.
treat Ms. Edmo's gender dysphoria, medical staff at the
prison appropriately began by providing Ms. Edmo with hormone
therapy. This continued until she was hormonally confirmed -
meaning she had the same circulating sex hormones and
secondary sex characteristics as a typical adult female. Ms.
Edmo thus achieved the maximum physical changes associated
with hormone treatment. But, Ms. Edmo continued to experience
such extreme gender dysphoria that she twice attempted
self-castration. For her second attempt, Ms. Edmo prepared
for weeks by studying the anatomy of the scrotum and took
steps to diminish the chance of infection by boiling a razor
blade and scrubbing her hands with soap. She was successful
in opening the scrotum and exposing a testicle. But because
there was too much blood, Ms. Edmo abandoned her second
self-castration attempt and sought medical assistance. She
was transported to a hospital where her testicle was
already noted, an inmate has no choice but to rely on prison
authorities to treat their medical needs. For this reason,
the United States Supreme Court has held that deliberate
indifference to a prisoner's serious medical needs
constitutes cruel and unusual punishment in violation of the
Eighth Amendment to the United States Constitution. See,
e.g., Estelle v. Gamble, 429 U.S. 97, 103 (1976). To
show such deliberate indifference, Ms. Edmo must establish
two things. First, she must show a “serious medical
need” by demonstrating that failure to treat a medical
condition could result in significant further injury or the
“unnecessary and wanton infliction of pain.”
Second, she must show that the prison officials were aware of
and failed to respond to her pain and medical needs, and that
she suffered some harm because of that failure.
Edmo's case satisfies both elements of the deliberate
indifference test. She has presented extensive evidence that,
despite years of hormone therapy, she continues to experience
gender dysphoria so significant that she cuts herself to
relieve emotional pain. She also continues to experience
thoughts of self-castration and is at serious risk of acting
on that impulse. With full awareness of Ms. Edmo's
circumstances, IDOC and its medical provider Corizon refuse
to provide Ms. Edmo with gender confirmation surgery. In
refusing to provide that surgery, IDOC and Corizon have
ignored generally accepted medical standards for the
treatment of gender dysphoria. This constitutes deliberate
indifference to Ms. Edmo's serious medical needs and
violates her rights under the Eighth Amendment to the United
States Constitution. Accordingly, for the reasons explained
in detail below, IDOC and Corizon will be ordered to provide
Ms. Edmo with gender confirmation surgery. Thus, the Court
will grant in part Plaintiff's Motion for Preliminary
Injunction (Dkt. 62).
ruling, the Court notes that its decision is based upon, and
limited to, the unique facts and circumstances presented by
Ms. Edmo's case. This decision is not intended, and
should not be construed, as a general finding that all
inmates suffering from gender dysphoria are entitled to
gender confirmation surgery.
Transgender and Gender Dysphoria
Transgender is an umbrella term for a person whose gender
identity is not congruent with their assigned gender. Tr.
50:5-11. A transgender person suffers from gender dysphoria
when that incongruity is so severe that it impairs the
individual's ability to function. Tr. 50:12-14.
American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (“DSM-5”)
sets forth specific criteria which must exist before a
diagnosis of gender dysphoria is appropriate. Specifically,
two conditions are required:
a. First, there must be marked incongruence between one's
experienced/expressed gender and assigned gender, of at least
six month's duration, as manifested by at least two of
i. A marked incongruence between one's
experienced/expressed gender and primary and/or secondary sex
ii. A strong desire to be rid of one's primary and/or
secondary sex characteristics because of a marked
incongruence with one's experienced/expressed gender.
iii. A strong desire for the primary and/or secondary sex
characteristics of the other gender.
iv. A strong desire to be of the other gender.
v. A strong desire to be treated as the other gender.
vi. A strong conviction that one has the typical feelings and
reactions of the other gender.
b. Second, the individual's condition must be associated
with clinically significant distress or impairment in social,
occupational, or other important areas of functioning. Exh.
1001 at 3-4.
“Clinically significant distress” means that the
distress impairs or severely limits the person's ability
to function in a meaningful way and has reached a threshold
that requires either medical or surgical interventions, or
both. Tr. 51:3-8.
every person who identifies as transgender has gender
dysphoria. Tr. 50:5-11.
World Professional Association of Transgender Health
(“WPATH”) Standards of Care for the Health of
Transsexual, Transgender, and Gender Nonconforming People
were first promulgated in 1979 and are the internationally
recognized guidelines for the treatment of individuals with
gender dysphoria. Tr. 42:6-20; Exh. 15. WPATH Standards of
Care are “flexible clinical guidelines.” Tr.
118:16-24, 119:1-7, 8-25, 288:7-23, and “are intended
to be flexible in order to meet the diverse health care needs
of transsexual, transgender, and gender nonconforming
people.” Exh. 15 at 8.
WPATH Standards of Care have provided treatment guidelines
for incarcerated individuals since 1998. Tr. 54:11-21; Exh.
15 at 73. The current WPATH Standards of Care apply equally
to all individuals “irrespective of their housing
situation” and explicitly state that health care for
transgender people “living in an institutional
environment should mirror that which would be available to
them if they were living in a non-institutional setting
within the same community.” Tr. 54:11-21; Exh. 15 at
73. The next update to the WPATH Standards of Care will also
apply to an individual regardless of where that person is
housed, including in a prison setting. Tr. 54:25-55:12.
WPATH Standards of Care indicate that options for
psychological and medical treatment of gender dysphoria
a. changes in gender expression and role,
b. hormone therapy to feminize or masculinize the body,
c. surgical changes of primary or secondary sex
d. psychotherapy. Exh. 15 at 15-16.
WPATH Standards of Care suggest options for social support
and changes in gender expression, including:
a. offline and online peer support resources, groups, or
community organizations that provide avenues for social
support and advocacy;
b. offline and online support resources for families and
c. voice and communication therapy to help individuals
develop verbal and non-verbal communication skills that
facilitate comfort with their gender identity;
d. hair removal through electrolysis, laser treatment, or
e. breast binding or padding, genital tucking or penile
prostheses, padding of hips or buttocks; and
f. changes in name and gender marker on identity documents.
Exh. 15 at 16.
WPATH Standards of Care provide that the purposes of
psychotherapy include “exploring gender identity, role,
and expression; addressing the negative impact of gender
dysphoria and stigma on mental health; alleviating
internalized transphobia; enhancing social and peer support;
improving body image; or promoting resilience.” Exh. 15
Cross-sex hormone therapy results in development of secondary
sex characteristics of the other sex and provides an increase
in the overall level of well-being of a person with gender
dysphoria. Tr. 60:8-22. For a transgender woman, hormone
treatment has physical effects such as breast growth,
thinning of facial hair, redistribution of fat and muscle,
and shrinkage of the testicles. Tr. 246:7-20. The maximum
physical effects of hormone therapy will typically be
achieved within two to three years. Exh. 15 at 42; Tr.
Surgery - particularly genital surgery - is often the last
and the most considered step in the treatment process for
gender dysphoria. Exh. 15 at 60.
Many transgender individuals find comfort with their gender
identity, role, and expression without surgery. Exh. 15 at
60. For many others, however, surgery is essential and
medically necessary to alleviate their gender dysphoria. Exh.
15 at 60. For the latter group, relief from gender dysphoria
cannot be achieved without modification of their primary or
secondary sex characteristics to establish greater congruence
with their gender identity. Exh. 15 at 60.
individuals with severe gender dysphoria, where hormone
therapy is insufficient, gender confirmation surgery is the
only effective treatment and is medically necessary. Tr.
168:23-169:15; see also Ettner Decl. ¶ 51.
WPATH criteria for genital reconstruction surgery in
male-to-female patients include the following:
a. Persistent, well documented gender dysphoria;
b. Capacity to make a fully informed decision and to consent
c. Age of majority in a given country;
d. If significant medical or mental health concerns are
present, they must be well controlled;
e. 12 continuous months of hormone therapy as appropriate to
the patient's gender goals; and
f. 12 continuous months of living in a gender role that is
congruent with their gender identity. Exh. 15 at 66.
Regarding the first criterion, “persistent, well
documented gender dysphoria” is deemed to exist when
the person has a well-established diagnosis of gender
dysphoria that has persisted beyond six months. Tr.
Regarding the fourth criterion, the WPATH Standards of Care
make clear that the presence of co-existing mental health
concerns does not necessarily preclude possible changes in
gender role or access to feminizing/masculinizing hormones or
surgery. Exh. 15 at 31. But these concerns need to be
optimally managed prior to, or concurrent with, treatment of
gender dysphoria. Exh. 15 at 31.
a. It is often difficult to determine whether coexisting
mental health concerns are a result of gender dysphoria or
are unrelated to that medical condition. Tr. 171:1-14, 24-25,
172:1-5; 387:20-25, 388:1, 398:2-18, 601: 11- 602: 2;
Campbell Decl., Dkt. 101-4, ¶¶ 30-33. Co-existing
mental health issues directly tied to an individual's
gender dysphoria should not be considered in assessing
whether an individual meets the fourth WPATH criterion that
significant medical or mental health concerns must be well
controlled. Tr. 387:6 to 388:6.
Regarding the sixth criterion - a twelve-month experience of
living in an identity-congruent role - the WPATH Standards of
Care provide that this is intended to ensure that the
individual has had the opportunity to experience the full
range of different life experiences and events that may occur
throughout the year (e.g., family events, holidays,
vacations, season-specific work or school experiences).
During this time, patients should present consistently, on a
day-to-day basis and across all settings of life, in their
desired gender role. This includes coming out to partners,
family, friends, and community members (e.g., at school,
work, and in other settings). Exh. 15 at 67.
individual in prison can satisfy the criterion of living in a
gender role congruent with their gender identity. Tr.
Ettner is one of the authors of the WPATH Standards of Care,
version 7. Tr. 42:21-24. Dr. Ettner has been a WPATH member
since 1993 and chairs its Committee for Institutionalized
Persons. Tr. 43:2-16; Exh. 1003.
a. Dr. Ettner has treated approximately 3, 000 individuals
with gender dysphoria, including evaluating whether gender
confirmation surgery is necessary for certain patients. She
has referred approximately 300 patients for gender
confirmation surgery and assessed approximately 30
incarcerated individuals with gender dysphoria. Tr.
b. Dr. Ettner has extensive experience treating patients who
have undergone gender confirmation surgery. Tr. 44:2-8.
c. Dr. Ettner is an author or editor of numerous
peer-reviewed publications on treatment of gender dysphoria
and transgender healthcare. Dr. Ettner is an editor for the
textbook, “Principles of Transgender Medicine and
Surgery, ” which was revised in 2017 and is the
textbook used in medical schools. Tr. 44:14-45:1; Exh. 1003.
d. Dr. Ettner also trains medical and mental health providers
on treating people with gender dysphoria, including assessing
whether gender confirmation surgery is appropriate, through
the global education initiative of WPATH and other
presentations. Tr. 41:8-16, 45:17-46:18.
e. Dr. Ettner has been appointed by a federal court as an
independent expert related to evaluation of an incarcerated
patient for gender confirmation surgery. Tr. 46:19-22.
f. However, Dr. Ettner is not a Certified Correctional
Healthcare Professional, and she has not treated inmates with
gender dysphoria. Tr. 106:21-24, 107:11-18.
Gorton is an emergency medicine physician who practices at a
federally qualified healthcare center that primarily services
uninsured patients or those with Medicare or Medicaid. Exh.
1004; Tr. 234:24-235:2. Dr. Gorton also works with Project
Health, which has provided training for numerous clinics
regarding the provision of transgender health care in
California. Tr. 233:5-21. Dr. Gorton is a member of WPATH and
is on WPATH's Transgender Medicine and Research Committee
and its Institutionalized Persons Committee. Tr. 238:4-6;
a. Dr. Gorton has been the primary care physician for
approximately 400 patients with gender dysphoria and is
currently the primary care physician for approximately 100
patients with gender dysphoria. Exh. 1004; Tr. 237:4-12. Dr.
Gorton currently provides follow-up care for about thirty
patients who have had vaginoplasty. Exh. 1004; Tr.
b. Dr. Gorton has published peer-reviewed articles regarding
treatment of gender dysphoria. ...