Tom Hill | Deliberate Indifference: Does the Eighth Amendment Guarantee Access to Gender Confirmation Surgery For Transgender Prisoners?

BACKGROUND

The Eighth Amendment explicitly prohibits cruel and unusual punishment, but what are the parameters of this protection? In Estelle v. Gamble, the Supreme Court expanded the definition to include “deliberate indifference to serious medical needs of prisoners.” This 1976 decision proscribes a form of inhumane treatment that extends beyond physical punishment: 

“(D)enial of medical care may result in pain and suffering which no one suggests would serve any penological purpose… The infliction of such unnecessary suffering is inconsistent with contemporary standards of decency as manifested in modern legislation codifying the common law view that “it is but just that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.” 

However, it is not the case that every prisoner’s claim for inadequate medical treatment necessarily involves an Eighth Amendment violation. Under Kolisek v. Spencer, to prevail on such a claim, a plaintiff must prove that: (1) a serious medical need exists, and (2) prison administrators’ acted with deliberate indifference to that need.

THE ISSUE

The aforementioned two-prong test comes into play when deciding whether an inmate can receive treatment for gender dysphoria. According to the World Professional Association for Transgender Health, gender dysphoria is defined as “distress that is caused by discrepancy between a person’s gender identity and that person’s sex assigned at birth.” In the recently decided case, Edmo v. Corizon, the Ninth Circuit went on to recognize that, if left untreated, gender dysphoria can lead to “debilitating distress, depression, impairment of function, substance use, self-surgery to alter one’s genitals or secondary sex characteristics, self-injurious behaviors, and even suicide.” Despite this, the question of whether gender dysphoria is a serious medical issue for inmates is not at issue here. 

With regard to gender dysphoria, treatment ranges from changes in gender expression to gender confirmation surgery (GCS). The latter is politically controversial, but a growing body of evidence demonstrates that it is an effective treatment for gender dysphoria. The Fifth Circuit, in Gibson v. Collier, expressed concern that transgender prisoners are not guaranteed “the best treatment for gender dysphoria, only that which prevents their medical well-being from dropping below ‘society’s minimum standards of decency.’”

The legal controversy at issue here involves the definition of “adequate treatment,” specifically the standard for “deliberate indifference” to an inmate’s medical need in the context of transgender prisoners. The question becomes whether a transgender inmate’s Eighth Amendment right against cruel and unusual punishment is violated when GCS is denied and substituted with less invasive treatment.

THE SPLIT

The Fifth and Ninth Circuits diverge in their interpretation of the First Circuit’s opinion in Kosilek v. Spencer, which held that Michelle Kosilek, an anatomically male prisoner who identified as female, was not entitled to GCS. The Court reasoned that, although her gender dysphoria was severe, it was unclear whether GCS would provide significantly greater relief than the non-surgical treatment she was already receiving. The prison was found not deliberately indifferent, and the claim was denied.

The Fifth Circuit has interpreted Kosilek as creating a de facto, blanket ban on GCS on the grounds that there exists controversy about whether the procedure is ever medically necessary. In Gibson v. Collier, Vanessa Gibson (who the Fifth Circuit insists on calling Scott Gibson), is a male-to-female transgender inmate who has been presenting as female since the age of fifteen. Despite receiving hormonal therapy from the prison, Vanessa showed signs of depression, attempted to castrate herself, and even attempted suicide three times. The Court, however, held that withholding GCS from her is not “deliberate indifference” because there exists controversy about the efficacy of the procedure, finding that an Eighth Amendment violation did not occur. The Court granted summary judgment against Gibson for failing to provide sufficient evidence of medical indifference, and reaffirmed the prison policy that denied the inmate’s right to be evaluated as a candidate for GCS in the first place. 

In contrast, in Edmo v. Corizon, the Ninth Circuit has interpreted the Kosilek decision by holding that the medical necessity of GCS must be determined on a case-by-case basis. In this case, Adree Edmo had received non-invasive treatment for her gender dysphoria as an inmate in Idaho. Despite these efforts, Edmo continued to suffer from suicidal ideations, depression, and attempts to self-castrate. Citing the district court’s lengthy discussion of the latest research on gender dysphoria and the efficacy of GCS, the Court determined that it was medically necessary for Edmo to receive the surgery. Due to the increased social awareness of transgender healthcare and significant advancement in treatment, the Ninth Circuit held: where an inmate’s health record shows medical necessity in treating gender dysphoria, and prison officials deny such treatment, those officials are in violation of the Eighth Amendment.

LOOKING FORWARD

In concluding his opinion in Gibson, Judge Ho argued that “it cannot be deliberately indifferent to deny in Texas what is controversial in every other state.” It is, however, this exact controversy that highlights the need for certiorari. It is clear that the lack of access to ever evolving and effective treatment causes severe medical harm, as was the case with Michelle, Vanessa, Adree, and several other transgender inmates. This predictable and preventable harm falls well below the “minimum standards of decency” the Eighth Amendment aims to preserve.