Edmo v. Corizon, Inc.

935 F.3d 757

Adree EDMO, aka Mason Edmo, Plaintiff-Appellee,

v.CORIZON, INC.; Scott Eliason ; Murray Young; Catherine Whinnery, Defendants-Appellants,andIdaho Department of Corrections; Al Ramirez, in his official capacity as warden of Idaho State Correctional Institution;

Henry Atencio; Jeff Zmuda; Howard Keith Yordy; Richard Craig ; Rona Siegert, Defendants.

Adree Edmo, aka Mason Edmo, Plaintiff-Appellee,

v.Idaho Department of Corrections; Al Ramirez, in his official capacity as warden of Idaho State Correctional Institution; Henry Atencio; Jeff Zmuda; Howard Keith Yordy; Richard Craig ; Rona Siegert, Defendants-Appellants,andCorizon, Inc.; Scott Eliason ; Murray Young; Catherine Whinnery, Defendants.

No. 19-35017

No. 19-35019

United States Court of Appeals, Ninth Circuit.

Argued and Submitted May 16, 2019 San Francisco, California

Filed August 23, 2019

Brady J. Hall (argued), Special Deputy Attorney General; Lawrence G. Wasden, Attorney General; Office of the Attorney General, Boise, Idaho; Marisa S. Crecelius, Moore Elia Kraft & Hall LLP, Boise, Idaho; for Defendants-Appellants Idaho Department of Corrections, Henry Atencio, Jeff Zmuda, Howard Keith Yordy, Richard Craig, and Rona Siegert.

Dylan A. Eaton (argued), J. Kevin West, and Bryce Jensen, Parsons Behle & Latimer, Boise, Idaho, for Defendants-Appellants Corizon, Inc.; Scott Eliason; Murray Young; and Catherine Whinnery.

Lori Rifkin (argued), Hadsell Stormer & Renick LLP, Emeryville, California; Dan Stormer and Shaleen Shanbhag, Hadsell Stormer & Renick LLP, Pasadena, California; Craig Durham and Deborah Ferguson, Ferguson Durham PLLC, Boise, Idaho; Amy Whelan and Julie Wilensky, National Center for Lesbian Rights, San Francisco, California; for Plaintiff-Appellee.

David M. Shapiro, Sheila A. Bedi, and Vanessa del Valle, Roderick & Solange MacArthur Justice Center, Chicago, Illinois; Molly E. Whitman, Akin Gump Strauss Hauer & Feld LLP, Dallas, Texas; for Amici Curiae Andrea Armstrong, Sharon Dolovich, Betsy Ginsberg, Michael B. Mushlin, Alexander A. Reinert, Laura Rovner, and Margo Schlanger.

Molly Kafka and Richard Alan Eppink, ACLU of Idaho Foundation, Boise, Idaho; Devon A. Little and Derek Borchardt, Walden Macht & Haran LLP, New York, New York; Amy Fettig and Jennifer Wedekind, ACLU National Prison Project, Washington, D.C.; Gabriel Arkles and Rose Saxe, ACLU LGBT & HIV Project/ACLU Foundation, New York, New York; for Amici Curiae Former Corrections Officials.

Devi M. Rao and Jason T. Perkins, Jenner & Block LLP, Washington, D.C., for Amici Curiae Medical and Mental Health Professional Organizations.

Sharif E. Jacob, Ryan K. M. Wong, Kristin E. Hucek, and Patrick E. Murray, Keker Van Nest & Peters LLP, San Francisco, California, for Amicus Curiae Jody L. Herman.

Alan E. Schoenfeld, Wilmer Cutler Pickering Hale and Dorr LLP, New York, New York; Michael Posada, Wilmer Cutler Pickering Hale and Dorr LLP, Washington, D.C.; Richard Saenz, Lambda Legal Defense & Education Fund Inc., New York, New York; A. Chinyere Ezie, Center for Constitutional Rights, New York, New York; for Amici Curiae Civil Rights & Non-Profit Organizations.

Before: M. Margaret McKeown and Ronald M. Gould, Circuit Judges, and Robert S. Lasnik,^** District Judge.

PER CURIAM:

The Eighth Amendment prohibits "cruel and unusual punishments." U.S. Const. amend. VIII. "The Amendment embodies broad and idealistic concepts of dignity, civilized standards, humanity, and decency ...." Estelle v. Gamble , 429 U.S. 97, 102, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976) (quotation omitted). Our society recognizes that prisoners "retain the essence of human dignity inherent in all persons." Brown v. Plata , 563 U.S. 493, 510, 131 S.Ct. 1910, 179 L.Ed.2d 969 (2011).

Consistent with the values embodied by the Eighth Amendment, for more than 40 years the Supreme Court has held that "deliberate indifference to serious medical needs" of prisoners constitutes cruel and unusual punishment. Estelle , 429 U.S. at 106, 97 S.Ct. 285. When prison authorities do not abide by their Eighth Amendment duty, "the courts have a responsibility to remedy the resulting ... violation." Brown , 563 U.S. at 511, 131 S.Ct. 1910. We do so here.

Adree Edmo (formerly Mason Dean Edmo) is a male-to-female transgender prisoner in the custody of the Idaho Department of Correction ("IDOC"). Edmo’s sex assigned at birth (male) differs from her gender identity (female). The incongruity causes Edmo to experience persistent distress so severe it limits her ability to function. She has twice attempted self-castration to remove her male genitalia, which cause her profound anguish.

Both sides and their medical experts agree: Edmo suffers from gender dysphoria, a serious medical condition. They also agree that the appropriate benchmark regarding treatment for gender dysphoria is the World Professional Association of Transgender Health Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People ("WPATH Standards of Care"). And the State¹ does not seriously dispute that in certain circumstances, gender confirmation surgery ("GCS") can be a medically necessary treatment for gender dysphoria. The parties’ dispute centers around whether GCS is medically necessary for Edmo—a question we analyze with deference to the district court’s factual findings.

Following four months of intensive discovery and a three-day evidentiary hearing, the district court concluded that GCS is medically necessary for Edmo and ordered the State to provide the surgery. Its ruling hinged on findings individual to Edmo’s medical condition. The ruling also rested on the finding that Edmo’s medical experts testified persuasively that GCS was medically necessary, whereas testimony from the State’s medical experts deserved little weight. In contrast to Edmo’s experts, the State’s witnesses lacked relevant experience, could not explain their deviations from generally accepted guidelines, and testified illogically and inconsistently in important ways.

The district court’s detailed factual findings were amply supported by its careful review of the extensive evidence and testimony. Indeed, they are essentially unchallenged. The appeal boils down to a disagreement about the implications of the factual findings.

Crediting, as we must, the district court’s logical, well-supported factual findings, we hold that the responsible prison authorities have been deliberately indifferent to Edmo’s gender dysphoria, in violation of the Eighth Amendment. The record before us, as construed by the district court, establishes that Edmo has a serious medical need, that the appropriate medical treatment is GCS, and that prison authorities have not provided that treatment despite full knowledge of Edmo’s ongoing and extreme suffering and medical needs. In so holding, we reject the State’s portrait of a reasoned disagreement between qualified medical professionals. We also emphasize that the analysis here is individual to Edmo and rests on the record in this case. We do not endeavor to project whether individuals in other cases will meet the threshold to establish an Eighth Amendment violation. The district court’s order entering injunctive relief for Edmo is affirmed, with minor modifications noted below.

Our opinion proceeds as follows. In Part I, we provide background on gender dysphoria, the standard of care, and the evidence considered and factual findings made by the district court. Part II explains why this appeal complies with the Prison Litigation Reform Act ("PLRA") and is not moot. In Part III, we turn to the gravamen of the appeal: Edmo’s Eighth Amendment claim and showing of irreparable injury. Part IV addresses the State’s challenges to the injunction’s scope and narrows the injunction as to certain defendants. Part V rejects the State’s objections to the procedure employed by the district court. We conclude in Part VI.

I. Background²

A. Gender Dysphoria and its Treatment

Transgender individuals have a "[g]ender identity"—a "deeply felt, inherent sense" of their gender—that does not align with their sex assigned at birth.³ Am. Psychol. Ass’n, Guidelines for Psychological Practice with Transgender and Gender Nonconforming People , 70 Am. Psychologist 832, 834 (2015). Recent estimates suggest that approximately 1.4 million transgender adults live in the United States, or 0.6 percent of the adult population. Andrew R. Flores et al., The Williams Inst., How Many Adults Identify as Transgender in the United States? , at 2 (2016), http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf.

Gender dysphoria⁴ is "[d]istress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)." World Prof’l Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People 2 (7th ed. 2011) (hereinafter "WPATH SOC"). The Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ("DSM-5") sets forth two conditions that must be met for a person to be diagnosed with gender dysphoria.⁵

First, there must be "[a] marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following":

(1) "a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics";

(2) "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";

(3) "a strong desire for the primary and/or secondary sex characteristics of the other gender";

(4) "a strong desire to be of the other gender";

(5) "a strong desire to be treated as the other gender"; or

(6) "a strong conviction that one has the typical feelings

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