Monroe v. Baldwin

424 F.Supp.3d 526

Janiah MONROE, Marilyn, Melendez, Ebony Stamps, Lydia Helena Vision, Sora Kuykendall, and Sasha Reed, Plaintiffs,

v.John BALDWIN, Steve Meeks, and Melvin Hinton, Defendants.

Case No. 18-CV-00156-NJR-MAB

United States District Court, S.D. Illinois.

Signed December 19, 2019

John A. Knight, Camille E. Bennett, Carolyn M. Wald, Ghirlandi Guidetti, Roger Baldwin Foundation of ACLU, Inc. ACLU of Illinois, Brent P. Ray, Pro Hac Vice, Austin B. Stephenson, Cameron N. Custard, Catherine L. Fitzpatrick, Erica B. Zolner, Megan M. New, Samantha G. Rose, Scott H. Lerner, Sydney L. Schneider, Jordan M. Heinz, Kirkland & Ellis LLP, Chicago, IL, Sarah Jane Hunt, Kennedy Hunt P.C., Thomas E. Kennedy, III, Law Offices of Thomas E. Kennedy, III, L.C., St. Louis, MO, for Plaintiffs.

Lisa A. Cook, Christopher L. Higgerson, Joseph E. Okon, Illinois Attorney General's Office, Springfield, IL, for Defendants.

MEMORANDUM AND ORDER

ROSENSTENGEL, Chief Judge:

Janiah Monroe, Marilyn Melendez, Ebony Stamps, Lydia Helena Vision, Sora Kuykendall, and Sasha Reed are transgender women in the custody of the Illinois Department of Corrections ("IDOC") (Doc. 1). They filed this putative class action under 42 U.S.C. § 1983, alleging IDOC provides transgender inmates inadequate treatment for gender dysphoria, in violation of the Eighth Amendment (Id. ). Plaintiffs bring this suit against the IDOC Director, Chief of Health Services, and Mental Health Supervisor in their official capacities (Id. ).

THE COMPLAINT

According to the Complaint, IDOC utilizes a committee of unqualified officials to oversee the security, placement, and treatment of transgender inmates ("the Transgender Committee") (Doc. 1). Through the Transgender Committee and other flawed policies, IDOC often delays or denies hormone therapy for reasons not recognized by the medical community; fails to provide adequate hormone therapy and hormone monitoring; fails to consider and provide surgery as part of medically necessary treatment for gender dysphoria ; prevents and fails to permit, accommodate, and facilitate social transition necessary to treat gender dysphoria ; and fails to provide access to clinicians competent to treat gender dysphoria, resulting in misdiagnosis and inappropriate treatment.

Plaintiffs seek a preliminary injunction directing Defendants to: (1) cease the policy and practice of allowing the Transgender Committee to make the medical decisions regarding gender dysphoria resulting in denials and delays of treatment; (2) cease the policy and practice of denying and delaying hormone therapy for reasons that are not recognized as contraindications to treatment; (3) cease IDOC's policy and practice of refusing to evaluate and provide surgery to treat gender dysphoria ; and (4) cease the policy and practice of depriving gender dysphoric prisoners of medically necessary social transition, including by mechanically assigning housing based on genitalia.

Plaintiffs also seek medically necessary treatment for Plaintiffs and the putative class members, including: (1) access to clinicians who meet the competency requirements stated in the Standards of Care to treat gender dysphoria ; (2) evaluation for gender dysphoria upon request or clinical indications of the condition; (3) timely medically prescribed treatment for gender dysphoria, including, but not limited to, hormone therapy and monitoring and gender-affirming surgery; (4) medically necessary social transition, including individualized placement determinations, avoidance of cross-gender strip searches, and access to gender-affirming clothing and grooming items; and (5) training for IDOC staff on the importance of social transition, including using proper names and pronouns for transgender inmates. Finally, Plaintiffs request the Court appoint a medical expert in gender dysphoria to oversee IDOC's implementation of the above-referenced relief.

The Court held a two-day hearing on the motion for preliminary injunction and now makes the following findings of facts and conclusions of law (Docs. 155 & 156).

FACTS

Treatment of Gender Dysphoria

Gender dysphoria refers to a condition in which a person experiences clinically significant distress stemming from incongruence between one's experienced or expressed gender and one's assigned gender (Doc. 157, p. 95; Doc. 158, p. 14). Gender dysphoria is considered a medical condition and has been removed from the mental and behavioral disorders in the World Health Organization Classification of Diseases and the Diagnostic Statistical Manual of Mental Disorders (Doc. 158, p. 95). The World Professional Association for Transgender Health ("WPATH") is a professional association dedicated to understanding and treating gender dysphoria (Doc. 157, p. 98). WPATH dictates medically-accepted Standards of Care for treating gender dysphoria (Id. at p. 7). According to WPATH, its Standards of Care are "the highest standards of health care" for transgender people (Doc. 123, Ex. 13, p. 8). IDOC purports to follow the Standards of Care and has updated its mental health standards operating procedure manual to incorporate them (Doc. 143, Ex. 4, pp. 4, 10). According to WPATH, treatment options for gender dysphoria include social role transition, cross-sex hormone therapy, psychotherapy, and surgery (Doc. 158, p. 14).

WPATH lists the minimum qualifications a mental health professional must attain in order to assess and treat gender dysphoria (Id. at p. 25). Specifically, a person must: hold a master's degree in behavioral science; be familiar with the Diagnostic Statistical Manual of Mental Disorders or the International Classification of Diseases; have documented supervision in psychotherapy; understand the variations of gender identities and gender expressions; have continuing education in the assessment and treatment of gender dysphoria ; have cultural competence; and be aware of the growing body of literature in the area (Id. at pp. 25-26). Individuals who are new to the field should work under the supervision of someone with competence who is regarded as an expert in gender dysphoria (Id. at p. 26).

Social Role Transition

Social role transition is living in the role congruent to one's affirmed identity. For instance, in the case of a transgender woman, social transition would include wearing a female hairstyle, female clothing, and makeup, and using a feminine name, female toiletries, and a female bathroom (Doc. 158, p. 16). In a prison setting, social transition would require a transgender woman be afforded the same canteen items that female prisoners can access, have means to safe and effective hair removal, be referred to by a female name, and be permitted to wear makeup or clothing that affirms her gender (Id. at p. 17).

Psychotherapy

Psychotherapy helps individuals become more resilient, deal with stigma, manage family situations, and cope with the social problems that are attendant to gender dysphoria (Id. at p. 14).

Surgery

There are different surgical options for transgender individuals, including reconstruction of the genitalia, also known as gender-affirming surgery (Id. at pp. 20, 90). Reconstruction eliminates the major source of hormones that contribute to and cause gender dysphoria (Id. at pp. 20-21). After reconstruction, the urogenital organs function and appear the same as one's peers (Id. ). In 2014, Medicare declared gender-affirming surgery to be medically necessary and safe (Id. at p. 88). Studies indicate that less than one percent of patients who undergo gender-affirming surgery around the world experience regret (Id. at p. 90). Other studies show suicide and self-harm dramatically decrease following reconstruction surgery (Id. ). Other surgical options include removal of the breasts and chest reconstruction (Id. at p. 21).

Cross-Sex Hormone Therapy

Cross-sex hormone therapy involves taking hormones to masculinize or feminize the body (Id. at p. 14). An individual should not begin hormone therapy unless he or she has well-documented gender dysphoria above the age of majority and has no significant mental health concerns that prevent him or her from giving informed consent (Id. at p. 19). Hormone therapy is often a necessary component of treating gender dysphoria (Id. at p. 156).

The Endocrine Society Guidelines are internationally recognized baseline guidelines for the adequate treatment of gender dysphoria (Doc. 157, p. 91). Hormone therapy that falls below the Guidelines is considered less-than-adequate treatment (Id. at pp. 98-99). The Guidelines state that once a person begins hormone therapy, they should undergo baseline lab testing to monitor hormone levels (Id. at p. 102). Hormone levels need to be checked every two to three months for the first year of treatment, and dosages should be adjusted accordingly until a target hormone level is achieved (Id. ). After this period, hormone levels should be checked once or twice each year (Id. ). An individual who suddenly stops taking hormones is at risk for serious medical or mental health complications (Id. at p. 103).

Spironolactone and Estradiol are the two main agents involved in hormone therapy for transgender women (Id. at pp. 103-04). Spironolactone is a testosterone-blocker, and Estradiol is estrogen (Id. at pp. 104, 109). Estradiol is administered at a starting dose of two milligrams and titrated to four or six milligrams (Id. at p. 104). Four milligrams typically results in target concentrations (Id. at p. 105). For transgender men, hormone treatment involves testosterone injections (Id. at p. 106).

Spironolactone is a diuretic that can elevate potassium levels and cause heart arrhythmias, kidney failure, and death (Id. at p. 107). Estradiol enlarges the pituitary gland, which can cause blindness if the gland gets too big (Id. at pp. 107-08). Thus, monitoring hormone levels is important for efficacy and safety (Id. at p. 108).

There are other forms of estrogen besides Estradiol, but the Endocrine...