Adree Edmo v. Corizon, Inc.
935 F.3d 757 (2019)
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Rule of Law:
When the record demonstrates that gender confirmation surgery is the medically necessary treatment for a prisoner's severe gender dysphoria, and responsible prison officials deny that treatment with full awareness of the prisoner's suffering, their actions constitute deliberate indifference to a serious medical need in violation of the Eighth Amendment.
Facts:
- Adree Edmo, a transgender woman incarcerated by the Idaho Department of Correction (IDOC), suffers from severe gender dysphoria, a condition she has experienced since childhood.
- Since 2012, prison medical staff, including Corizon psychiatrist Dr. Scott Eliason, diagnosed Edmo with gender dysphoria and provided her with hormone therapy.
- Despite hormone therapy, Edmo continued to experience profound psychological distress due to her male genitalia, leading her to attempt self-castration with a razor blade in September 2015.
- In April 2016, Dr. Eliason formally evaluated Edmo for Gender Confirmation Surgery (GCS) but concluded it was not medically necessary, applying his own personal criteria that were inconsistent with the professionally recognized WPATH Standards of Care.
- In December 2016, Edmo attempted self-castration a second time, successfully removing one testicle before stopping due to severe bleeding.
- Following the second, nearly successful self-castration attempt, Dr. Eliason and other prison officials did not re-evaluate Edmo for GCS or alter their conclusion that the surgery was medically unnecessary.
- Edmo continued to experience severe mental anguish and engaged in other self-harm behaviors, such as cutting her arms, to cope with her ongoing thoughts of self-castration.
Procedural Posture:
- Adree Edmo filed a pro se complaint in the U.S. District Court for the District of Idaho against the Idaho Department of Corrections, its private medical provider Corizon, Inc., and various officials.
- After counsel was appointed, Edmo filed an amended complaint asserting claims under the Eighth Amendment and other laws, and later moved for a preliminary injunction to compel defendants to provide her with gender confirmation surgery.
- The district court held a three-day evidentiary hearing, treating it as a final trial on the merits for the requested injunctive relief.
- On December 13, 2018, the district court granted a permanent injunction, finding that defendants had been deliberately indifferent to Edmo's serious medical need in violation of the Eighth Amendment and ordering them to provide her with GCS.
- Defendants-Appellants, including IDOC and Corizon, filed a timely notice of appeal to the U.S. Court of Appeals for the Ninth Circuit.
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Issue:
Does the denial of gender confirmation surgery to a transgender prisoner, for whom the surgery has been determined to be medically necessary to treat severe gender dysphoria, constitute deliberate indifference to a serious medical need in violation of the Eighth Amendment's prohibition on cruel and unusual punishment?
Opinions:
Majority - Per Curiam
Yes. The denial of medically necessary gender confirmation surgery to a prisoner with severe gender dysphoria constitutes deliberate indifference to a serious medical need, violating the Eighth Amendment. The court affirmed the district court's finding, reasoning that Edmo demonstrated a serious medical need and that the prison officials' response was deliberately indifferent. The court credited the district court's factual findings, which established that GCS was medically necessary for Edmo based on the testimony of her highly qualified expert witnesses who followed the World Professional Association for Transgender Health (WPATH) Standards of Care. In contrast, the court found that the State's experts lacked relevant experience and that the treating physician, Dr. Eliason, based his denial on 'inexplicable criteria' that were 'invented out of whole cloth' and medically unacceptable. Dr. Eliason demonstrated deliberate indifference by knowing of Edmo's extreme suffering and two self-castration attempts, yet continuing an ineffective treatment plan and failing to provide the necessary surgery. The court explicitly rejected the Fifth Circuit's contrary holding in Gibson v. Collier, stating it was based on an outdated premise that there is no medical consensus on the necessity of GCS.
Analysis:
This decision solidifies that gender confirmation surgery can be a medically necessary treatment for gender dysphoria, and its denial can constitute an Eighth Amendment violation. The court strongly endorses the WPATH Standards of Care as the controlling benchmark for determining medically acceptable treatment, thereby limiting the discretion of prison doctors to deviate from established professional guidelines without a credible medical basis. By creating a direct circuit split with the Fifth Circuit's categorical ruling in Gibson v. Collier, this case significantly increases the likelihood of Supreme Court review to resolve the constitutional standard of care for transgender prisoners nationwide. The ruling provides a clear, fact-intensive framework for evaluating such claims based on individualized medical necessity rather than blanket policies.
