Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-19-35019/USCOURTS-ca9-19-35019-1/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 

---

FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

ADREE EDMO, AKA Mason Edmo,

Plaintiff-Appellee,

v.

CORIZON, INC.; SCOTT ELIASON;

MURRAY YOUNG; CATHERINE 

WHINNERY,

Defendants-Appellants,

and

IDAHO DEPARTMENT OF 

CORRECTIONS; HENRY ATENCIO;

JEFF ZUMDA; HOWARD KEITH 

YORDY; AL RAMIREZ, Warden; 

RICHARD CRAIG; RONA SIEGERT,

Defendants.

No. 19-35017

D.C. No.

1:17-cv-00151-

BLW

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2 EDMO V. CORIZON

ADREE EDMO, AKA Mason Edmo,

Plaintiff-Appellee,

v.

IDAHO DEPARTMENT OF 

CORRECTIONS; HENRY ATENCIO;

JEFF ZUMDA; HOWARD KEITH 

YORDY; AL RAMIREZ, Warden; 

RICHARD CRAIG; RONA SIEGERT,

Defendants-Appellants,

and

CORIZON, INC.; SCOTT ELIASON;

MURRAY YOUNG; CATHERINE 

WHINNERY,

Defendants.

No. 19-35019

D.C. No.

1:17-cv-00151-

BLW

ORDER

Filed February 10, 2020

Before: M. Margaret McKeown and Ronald M. Gould, 

Circuit Judges, and Robert S. Lasnik,

* District Judge.

Order;

Statement by Judge O’Scannlain;

Dissent by Judge Collins;

Dissent by Judge Bumatay

* The Honorable Robert S. Lasnik, United States District Judge for 

the Western District of Washington, sitting by designation.

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EDMO V. CORIZON 3

SUMMARY**

Prisoner Civil Rights

The panel denied a petition for panel rehearing and 

denied a petition for rehearing en banc on behalf of the court, 

in a case in which the panel affirmed the district court’s entry 

of a permanent injunction in favor of an Idaho state prisoner, 

but vacated the injunction to the extent it applied to certain 

defendants in their individual capacities, in the prisoner’s 

action seeking medical treatment for gender dysphoria.

Respecting the denial of rehearing en banc, Judge 

O’Scannlain, joined by Judges Callahan, Bea, Ikuta, 

R. Nelson, Bade, Bress, Bumatay and VanDyke, stated that 

with its decision not to rehear this case en banc, this court 

became the first federal court of appeals to mandate that a 

State pay for and provide sex-reassignment surgery to a 

prisoner under the Eighth Amendment. Judge O’Scannlain 

stated that the three-judge panel’s conclusion—that any 

alternative course of treatment would be “cruel and unusual 

punishment”—is as unjustified as it is unprecedented. To 

reach such a conclusion, the court created a circuit split, 

substituted the medical conclusions of federal judges for the 

clinical judgments of prisoners’ treating physicians, 

redefined the familiar “deliberate indifference” standard, 

and, in the end, constitutionally enshrined precise and 

partisan treatment criteria in what is a new, rapidly changing, 

and highly controversial area of medical practice. 

** This summary constitutes no part of the opinion of the court. It 

has been prepared by court staff for the convenience of the reader.

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4 EDMO V. CORIZON

Dissenting from the denial of rehearing en banc, Judge 

Collins stated that whether the defendant doctor was 

negligent or not (a question on which Judge Collins 

expressed no opinion), his treatment decisions did not 

amount to “cruel and unusual punishment,” and the court 

thus strayed far from any proper understanding of the Eighth 

Amendment. 

Dissenting from the denial of rehearing en banc, Judge 

Bumatay, joined by Judges Callahan, Ikuta, R. Nelson, Bade 

and VanDyke, and by Judge Collins as to Part II, stated that 

by judicially mandating an innovative and evolving standard 

of care, the panel effectively constitutionalized a set of 

guidelines subject to ongoing debate and inaugurated yet 

another circuit split. And by diluting the requisite state of 

mind from “deliberate indifference” to negligence, the panel

effectively held that—contrary to Supreme Court 

precedent—medical malpractice does become a 

constitutional violation merely because the victim is a 

prisoner.

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EDMO V. CORIZON 5

ORDER

The full court was advised of the petition for rehearing 

en banc. A judge requested a vote on whether to rehear the 

matter en banc. The matter failed to receive a majority of 

the votes of nonrecused active judges in favor of en banc 

consideration. Fed R. App. P. 35.

The petition for rehearing en banc is DENIED. An 

opinion respecting denial of rehearing en banc, prepared by 

Judge O’Scannlain, and dissents from denial of rehearing en 

banc prepared by Judge Collins and Judge Bumatay are filed 

concurrently with this order.

O’SCANNLAIN, Circuit Judge,* with whom CALLAHAN, 

BEA, IKUTA, R. NELSON, BADE, BRESS, BUMATAY, 

and VANDYKE, Circuit Judges, join, respecting the denial 

of rehearing en banc:

With its decision today, our court becomes the first 

federal court of appeals to mandate that a State pay for and 

provide sex-reassignment surgery to a prisoner under the 

Eighth Amendment. The three-judge panel’s conclusion—

that any alternative course of treatment would be “cruel and 

unusual punishment”—is as unjustified as it is 

unprecedented. To reach such a conclusion, the court creates 

a circuit split, substitutes the medical conclusions of federal 

* As a judge of this court in senior status, I no longer have the power 

to vote on calls for rehearing cases en banc or formally to join a dissent 

from failure to rehear en banc. See 28 U.S.C. § 46(c); Fed. R. App. P. 

35(a). Following our court’s general orders, however, I may participate 

in discussions of en banc proceedings. See Ninth Circuit General Order 

5.5(a).

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6 EDMO V. CORIZON

judges for the clinical judgments of prisoners’ treating 

physicians, redefines the familiar “deliberate indifference” 

standard, and, in the end, constitutionally enshrines precise 

and partisan treatment criteria in what is a new, rapidly 

changing, and highly controversial area of medical practice.

Respectfully, I believe our court’s unprecedented 

decision deserved reconsideration en banc.

I

A

In 2012, Adree Edmo (then known as Mason Dean 

Edmo) was incarcerated for sexually assaulting a sleeping 

15-year-old boy. By all accounts, Edmo is afflicted with 

profound and complex mental illness. She1 suffers from 

major depressive disorder, anxiety, alcohol addiction, and 

drug addiction. At least two clinicians have concluded that 

she shares the traits of borderline personality disorder. She 

abused alcohol and methamphetamines every day for many 

years, stopping only upon her incarceration. A victim of 

sexual abuse at an early age, she attempted suicide three 

times before her arrest for sexual assault—twice by overdose 

and once by cutting.

A new diagnosis was added in 2012: gender dysphoria. 

Two months after being transferred to the Idaho State 

Correctional Institution (a men’s prison), Edmo sought to 

speak about hormone therapy with Dr. Scott Eliason, the 

Board-certified director of psychiatry for Corizon, Inc. (the 

prison’s medical care provider). In Dr. Eliason’s view, 

1 Though Edmo was born a male, Edmo has legally changed the sex 

listed on her birth certificate to female. I therefore use feminine 

pronouns throughout, just as the panel does.

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EDMO V. CORIZON 7

Edmo met the criteria for gender dysphoria.2 After the 

diagnosis was confirmed by another forensic psychiatrist 

and the prison’s Management and Treatment Committee,

Edmo was prescribed hormone therapy. She soon changed 

her legal name and the sex listed on her birth certificate. As 

a result of four years of hormone therapy, Edmo experienced 

physical changes, including breast development, 

redistribution of body fat, and a change in body odor. She 

now has the same circulating hormones as a typical adult 

female.

In April 2016, at Edmo’s request, Dr. Eliason evaluated 

her for sex-reassignment surgery.3 Ultimately, Dr. Eliason 

decided to maintain the current course of hormones and 

supportive counseling instead of prescribing surgery. He 

staffed Edmo’s case with Dr. Jeremy Stoddart (a 

psychiatrist) and Dr. Murray Young (a physician who served 

as the Regional Medical Director for Corizon), as well as 

Jeremy Clark, a clinical supervisor and member of the World 

Professional Association for Transgender Health 

(“WPATH”). He also presented the evaluation and vetted it 

2 Gender dysphoria is a diagnosis introduced in the latest, fifth 

edition of the American Psychiatric Association’s Diagnostic and 

Statistical Manual of Mental Disorders. It replaces the now-obsolete 

“gender identity disorder” used in the previous edition. The gender 

dysphoric patient experiences “clinically significant distress or

impairment in social, occupational, or other important areas of 

functioning” that is associated with the feeling of incongruence between 

perceived gender identity and phenotypic sex. See Am. Psychiatric 

Ass’n, Diagnostic and Statistical Manual of Mental Disorders 453 (5th 

ed. 2013).

3 The panel adopts the question-begging term “gender confirmation 

surgery,” which is preferred by Edmo and her lawyers. I will continue 

to use the neutral “sex-reassignment surgery.”

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8 EDMO V. CORIZON

before the regular meeting of the multidisciplinary 

Management Treatment Committee.

Dr. Eliason, supported by Dr. Stoddart, Dr. Young, and 

Clark, opted not to recommend sex-reassignment surgery for 

several reasons, some of which are described in his chart 

notes and others of which were elaborated in their testimony. 

First, Dr. Eliason noted that Edmo reported that the hormone 

therapy had improved her dysphoria and Eliason “did not 

observe significant dysphoria.” In the absence of more 

severe distress, Dr. Eliason could not justify the risks of 

pursuing the most aggressive—and permanent—treatment 

through surgery. Second, Dr. Eliason observed that Edmo’s 

comorbid conditions—major depressive disorder and 

alcohol use disorder, among others—were not adequately 

controlled. Edmo had refused to attend therapy consistently 

in prison. She also engaged in self harm (including cutting 

and attempted castration) and exhibited co-dependency and 

persistently poor sexual boundaries with other prisoners. In 

Dr. Eliason’s view, Edmo’s other mental health disorders 

were not sufficiently stabilized to handle the stressful 

process of surgery and transition. Finally, Dr. Eliason 

observed that Edmo—who was parole-eligible and due to be 

released in 2021—had not lived among her out-of-prison 

social network as a woman. He noted the high suicide rates 

for postoperative patients and was concerned that Edmo 

might be at greater risk of suicide given the potential lack of 

support from family, friends, coworkers, and neighbors 

during her transition. Dr. Eliason did not rule out the 

possibility of Edmo receiving sex-reassignment surgery at 

some later point. As Dr. Eliason put it in his notes on his 

consultation with Edmo, “Medical Necessity for Sexual 

Reassignment Surgery is not very well defined and is 

constantly shifting.” Citing the changing nature of the 

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EDMO V. CORIZON 9

science and the contingent nature of his evaluation of Edmo, 

his recommendations were merely “for the time being.”

B

About a year after her evaluation, Edmo filed this § 1983 

lawsuit against Dr. Eliason, the Idaho Department of 

Corrections, Corizon, and several other individuals, alleging 

that the prison doctors’ treatment choice violated her right to 

be free from cruel and unusual punishment under the Eighth 

and Fourteenth Amendments. She then moved for a 

preliminary injunction to require the prison to provide her 

with sex-reassignment surgery.

The district court held an evidentiary hearing on the 

motion. At the outset of the hearing, the court commented 

that it was hard “to envision” how a request to mandate sexreassignment surgery could be granted through anything 

other than a permanent injunction. Nonetheless, the district 

court evaluated Edmo’s motion under the preliminary 

injunction standard and, only out of “an abundance of 

caution,” provided a footnote evaluating whether an 

injunction was merited under the more demanding standard 

for a permanent injunction (which the court erroneously 

described as “no more rigorous than that applicable to a 

claim for preliminary mandatory relief”). Edmo v. Idaho 

Dep’t of Corr., 358 F. Supp. 3d 1103, 1122 n.1 (D. Idaho 

2018); see Edmo v. Corizon, Inc., 935 F.3d 757, 784 n.13 

(9th Cir. 2019) (“[T]he standard for granting permanent 

injunctive relief is higher (in that it requires actual success 

on the merits) . . . .”).

In addition to testimony from Edmo, Dr. Eliason, and 

Jeremy Clark, the evidentiary hearing featured testimony 

from four expert witnesses. Edmo presented Dr. Randi 

Ettner, a psychologist, and Dr. Ryan Gorton, an emergency 

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10 EDMO V. CORIZON

room physician. Dr. Ettner is one of the authors of the World 

Professional Association of Transgender Health’s Standards 

of Care for the Health of Transsexual, Transgender, and 

Gender Nonconforming People and chairs WPATH’s 

Committee for Institutionalized Persons. Dr. Gorton serves 

on that committee too. WPATH—formerly the Harry 

Benjamin International Gender Dysphoria Association—

describes itself as a “professional association” devoted “to 

developing best practices and supportive policies worldwide 

that promote health, research, education, respect, dignity, 

and equality for transsexual, transgender, and gender 

nonconforming people in all cultural settings.” World Prof’l 

Ass’n for Transgender Health, Standards of Care for the 

Health of Transsexual, Transgender, and GenderNonconforming People 1 (7th ed. 2011) (“WPATH 

Standards”). One of WPATH’s central functions is to 

promulgate Standards of Care, which offer minimalist 

treatment criteria for several possible approaches to gender 

dysphoria, from puberty-blocking hormones to sexreassignment surgery.

In addition to Dr. Eliason and Mr. Clark, the State 

presented Dr. Keelin Garvey, the Chief Psychiatrist of the 

Massachusetts Department of Corrections and chair of its 

Gender Dysphoria Treatment Committee, and Dr. Joel 

Andrade, a clinical social worker who served as clinical 

director for the Massachusetts Department of Corrections 

and served on its Gender Dysphoria Treatment Committee. 

Each set of experts had gaps in their relevant experience. 

Edmo’s experts had never treated inmates with gender 

dysphoria, while the State’s experts had never conducted 

long-term follow-up care with a patient who had undergone 

sex-reassignment surgery.

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EDMO V. CORIZON 11

Edmo’s experts testified that, in their opinion, Edmo 

needs sex-reassignment surgery. They based their 

conclusion on the latest edition of WPATH Standards of 

Care, which contain six criteria for sex-reassignment 

surgery:

(1) “persistent, well documented gender dysphoria,”

(2) “capacity to make a fully informed decision and to 

consent for treatment,”

(3) “age of majority,”

(4) “if significant medical or mental health concerns are 

present, they must be well controlled,”

(5) “12 continuous months of hormone therapy as 

appropriate to the patient’s gender goals,”

(6) “12 continuous months of living in a gender role that 

is congruent with their gender identity.”

Id. at 60. In the opinion of Edmo’s experts, Edmo met all 

six criteria and was unlikely to show further improvement in 

her gender dysphoria without such surgery.

The State’s experts disagreed on three main grounds. 

First, they did not regard the WPATH Standards as definitive 

treatment criteria, let alone medical consensus. In their 

analysis, the evidence underlying the WPATH Standards is 

not sufficiently well developed, particularly when it comes 

to the treatment of gender dysphoric prisoners. Therefore, 

they opined that a prudent, competent doctor might rely on 

clinical judgment that differs from the (already ambiguous) 

WPATH Standards. Second, the State’s experts testified 

that, even under WPATH, Edmo failed to meet the fourth 

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12 EDMO V. CORIZON

criterion for surgery, which requires that the patient’s other 

mental health concerns be well controlled in order to reduce 

the risks associated with transitioning. In the view of the 

State’s experts, her mental health raised the concern that she 

would have trouble transitioning. For their part, Edmo’s 

experts argued that Edmo’s depression and addiction were 

controlled enough for surgery and that some current 

symptoms (such as self-cutting) stem from her gender 

dysphoria and therefore can be alleviated with surgery. 

Finally, the State’s experts testified that Edmo also failed to 

meet the WPATH Standards’ sixth criterion for surgery, 

which requires that Edmo live as a woman for twelve months 

before surgery. In their view, it was essential that Edmo live 

those twelve months outside of prison—that is, within her 

social network—in order to be adequately sure that she and 

her social network are ready for the challenges posed by 

transitioning. Edmo’s experts disagreed, noting that 

WPATH says treatment in prisons should “mirror” treatment 

outside of prisons.

C

Although this appeal is from a grant of a preliminary 

injunction, at some point the evidentiary hearing on the 

motion for a preliminary injunction was consolidated into a 

final bench trial on the merits. It is hard to know when (or 

if) the parties were given the requisite “clear and 

unambiguous notice” of consolidation. See Isaacson v. 

Horne, 716 F.3d 1213, 1220 (9th Cir. 2013); see also Univ. 

of Tex. v. Camenisch, 451 U.S. 390, 395 (1981).

The district court applied the Supreme Court’s oft-cited 

rule that “deliberate indifference to serious medical needs of 

prisoners constitutes the ‘unnecessary and wanton infliction 

of pain’ proscribed by the Eighth Amendment.” Estelle v. 

Gamble, 429 U.S. 97, 104 (1976) (quoting Gregg v. 

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EDMO V. CORIZON 13

Georgia, 428 U.S. 153, 173 (1976)). The State agreed that 

gender dysphoria is a serious medical need, so the only 

question on the merits is whether Dr. Eliason and his team 

were “deliberately indifferent” as a matter of law.

The district court concluded that the State’s experts were 

“unconvincing” and gave their opinions “virtually no 

weight.” Edmo, 358 F. Supp. 3d at 1125–26. Once such 

expert testimony was set aside, the district court held that 

any decision not to prescribe sex-reassignment surgery 

would be “medically unacceptable under the circumstances” 

and would therefore violate the Eighth Amendment. Id.

at 1127. Accordingly, the district court entered an injunction 

ordering the State to “take all actions reasonably necessary 

to provide Ms. Edmo gender confirmation surgery as 

promptly as possible.” Id. at 1129.

D

The panel has now affirmed the injunction. See Edmo, 

935 F.3d at 803. Concluding that sex-reassignment surgery 

was “medically necessary” and that the prison officials chose 

a different course of treatment “with full awareness of the 

prisoner’s suffering,” the panel holds that Dr. Eliason and 

the other prison officials “violate[d] the Eighth 

Amendment’s prohibition on cruel and unusual 

punishment.” Id.

To reach its conclusion that sex-reassignment surgery 

was medically necessary, the panel spends most of its 

lengthy opinion extolling and explaining the WPATH 

Standards of Care. Because Dr. Eliason failed to “follow” 

or “reasonably deviate from” the WPATH Standards, the 

panel concluded that his treatment choice was “medically 

unacceptable under the circumstances.” Id. at 792. To reach 

the ultimate conclusion—that Dr. Eliason had a deliberately 

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14 EDMO V. CORIZON

indifferent state of mind and was consequently in violation 

of the Eighth Amendment—the panel posited that 

Dr. Eliason’s awareness of the risks that Edmo would 

attempt to castrate herself or feel “clinically significant” 

distress “demonstrates that Dr. Eliason acted with deliberate 

indifference.” Id. at 793. Each conclusion was legal error.

II

“Deliberate indifference is a high legal standard.” 

Toguchi v. Chung, 391 F.3d 1051, 1060 (9th Cir. 2004). It 

is, after all, under governing precedent one form of the 

“unnecessary and wanton infliction of pain” that is the sine 

qua non of an Eighth Amendment violation. Estelle, 

429 U.S. at 104 (quoting Gregg v. Georgia, 428 U.S. 153, 

173 (1976)). Simply put, Edmo must prove that 

Dr. Eliason’s chosen course of treatment was the doing of a 

criminally reckless—or worse—state of mind. Farmer v. 

Brennan, 511 U.S. 825, 839 (1994).

We have stated that a deliberately indifferent state of 

mind may be inferred when “the course of treatment the 

doctors chose was medically unacceptable under the 

circumstances” and “they chose this course in conscious 

disregard of an excessive risk to plaintiff’s health.” Jackson 

v. McIntosh, 90 F.3d 330, 332 (9th Cir. 1996). Yet even 

most objectively unreasonable medical care is not 

deliberately indifferent. “[M]ere ‘indifference,’ 

‘negligence,’ or ‘medical malpractice’” is not enough to 

constitute deliberate indifference. Lemire v. Cal. Dep’t of 

Corr. & Rehab., 726 F.3d 1062, 1082 (9th Cir. 2013) 

(quoting Broughton v. Cutter Labs., 622 F.2d 458, 460 (9th 

Cir. 1980)). “Even gross negligence is insufficient to 

establish deliberate indifference . . . .” Id. Likewise, “[a] 

difference of opinion between a physician and the prisoner—

or between medical professionals—concerning what 

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EDMO V. CORIZON 15

medical care is appropriate does not amount to deliberate 

indifference.” Snow v. McDaniel, 681 F.3d 978, 987 (9th 

Cir. 2012) (citing Sanchez v. Vild, 891 F.2d 240, 242 (9th 

Cir. 1989)), overruled on other grounds by Peralta v. 

Dillard, 744 F.3d 1076, 1083 (9th Cir. 2014) (en banc). 

Although the panel organizes its opinion according to the 

dictum we first articulated in Jackson, it so contorts the 

standard as to render deliberate indifference exactly what we 

have said it is not: a constitutional prohibition on good-faith 

disagreement between medical professionals.

A

The panel first, and fundamentally, errs by 

misunderstanding what it means for a chosen treatment to be 

medically “unacceptable” for purposes of the Eighth 

Amendment. As did the district court, the panel concludes 

that the decision to continue hormone treatment and 

counseling instead of sex-reassignment surgery for Edmo

was “medically unacceptable under the circumstances” 

because, in short, Dr. Eliason failed to “follow” or 

“reasonably deviate from” the WPATH Standards of Care. 

Edmo, 935 F.3d at 792. Yet such an approach to the Eighth 

Amendment suffers from three essential errors. First, 

contrary to the panel’s suggestion, constitutionally 

acceptable medical care is not defined by the standards of 

one organization. Second, the panel relies on standards that 

were promulgated by a controversial self-described 

advocacy group that dresses ideological commitments as 

evidence-based conclusions. Third, once the WPATH 

Standards are put in proper perspective, we are left with a 

“case of dueling experts,” compelling the conclusion that Dr. 

Eliason’s treatment choice was indeed medically acceptable.

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16 EDMO V. CORIZON

1

A mere professional association simply cannot define 

what qualifies as constitutionally acceptable treatment of 

prisoners with gender dysphoria. In Bell v. Wolfish, 441 U.S. 

520 (1979), the Supreme Court rejected the argument that 

prison conditions must reflect those set forth in the American 

Public Health Association’s Standards for Health Services in 

Correctional Institutions, the American Correctional 

Association’s Manual of Standards for Adult Correctional 

Institutions, or the National Sheriffs’ Association’s 

Handbook on Jail Architecture. Id. at 543 n.27. According 

to the Court, “the recommendations of these various groups 

may be instructive in certain cases, [but] they simply do not 

establish the constitutional minima.” Id. After all, even 

acclaimed, leading treatment criteria only represent the 

“goals recommended by the organization in question” and 

the views of the promulgating physicians,4 and so, without 

more, a physician’s disagreement with such criteria is simply 

the “‘difference of medical opinion’ . . . [that is] insufficient, 

as a matter of law, to establish deliberate indifference.” Id.;

Jackson, 90 F.3d at 332 (quoting Sanchez, 891 F.2d at 242); 

accord Snow, 681 F.3d at 987; see also Long v. Nix, 86 F.3d 

761, 765 (8th Cir. 1996) (“[N]othing in the Eighth 

Amendment prevents prison doctors from exercising their 

independent medical judgment.”).

In its discussion of the role of treatment standards, the 

panel fails to cite a single case in which a professional 

organization’s standards of care defined the line between 

medically acceptable and unacceptable treatment. Instead, 

the panel cites two cases, one from the Seventh Circuit and 

4 Although, as we will see, only half of the committee that 

promulgates the WPATH Standards are physicians.

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EDMO V. CORIZON 17

one from the Eighth, for the proposition that professional 

organizations’ standards of care are “highly relevant in 

determining what care is medically acceptable and 

unacceptable.” Edmo, 935 F.3d at 786 (emphasis added). 

That may be. But as those two cases demonstrate, the range 

of medically acceptable care is defined by qualities of that

care (or of its opposite) and not by professional associations. 

Medically unacceptable care is “grossly incompetent or 

inadequate care,” Allard v. Baldwin, 779 F.3d 768, 772 (8th 

Cir. 2015), or care that constitutes “such a substantial 

departure from accepted professional judgment to 

demonstrate that the person responsible did not base the 

decision on . . . [accepted professional] judgment,” 

Henderson v. Ghosh, 755 F.3d 559, 566 (7th Cir. 2014) 

(original parenthetical) (quoting McGee v. Adams, 721 F.3d 

474, 481 (7th Cir. 2013) (stipulating that “medical 

professionals . . . are ‘entitled to deference in treatment 

decisions unless no minimally competent professional 

would have so responded’”)). For its part, the First Circuit 

holds in its own sex-reassignment-surgery case that medical 

care does not violate the Eighth Amendment so long as it is 

“reasonably commensurate with the medical standards of 

prudent professionals.” Kosilek v. Spencer, 774 F.3d 63, 90 

(1st Cir. 2014) (en banc). The panel is alone in its insistence 

that a professional association’s standards add up to the 

constitutional minima.5

5 Far from countering such assertions, the panel’s concession that 

“deviation from [WPATH] standards does not alone establish an Eighth 

Amendment claim” is just a truism that recognizes that the Eighth 

Amendment also contains a subjective element. Edmo, 935 F.3d at 789. 

Moreover, such a statement serves simply to repeat the panel’s faulty 

premise that the WPATH Standards are the appropriate reference point 

in any analysis of medical acceptability.

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18 EDMO V. CORIZON

2

In the words of the panel, speaking for our court, the 

WPATH Standards are “the gold standard,” the “established 

standards” for evaluations of the necessity of sexreassignment surgery, the “undisputed starting point in 

determining the appropriate treatment for gender dysphoric 

individuals.” Edmo, 935 F.3d at 787–88, 788 n.16. But such 

overwrought acclaim is just the beginning of the panel’s 

thorough enshrinement of the WPATH Standards. The 

district court chose which expert to rely on by looking at 

which expert hewed most closely to the WPATH Standards 

of Care. See Edmo, 358 F. Supp. 3d at 1124–26. And the 

panel uncritically approves such an approach, calling the 

WPATH Standards “a useful starting point for analyzing the 

credibility and weight to be given to each expert’s opinion.” 

Edmo, 935 F.3d at 788 n.16. By rejecting any expert not (in 

the court’s view) appropriately deferential to WPATH, the 

district court and now the panel have effectively decided ab 

initio that only the WPATH Standards could constitute 

medically acceptable treatment.6

6 In enshrining the WPATH Standards as the “gold standard” for 

determining when to provide surgery to a prisoner with gender 

dysphoria, the panel makes much of the State’s comment in its opening 

statement before the evidentiary hearing that the WPATH Standards are 

the “best standards out there.” Edmo, 935 F.3d at 769, 788 n.16. The 

panel even goes so far as to insist that “[b]oth sides . . . 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.” Id. at 767. But, contrary to the panel’s 

suggestion, the State’s admission that the WPATH Standards are more 

refined than any alternative hardly means that the State agrees—or the 

Eighth Amendment requires—that a medical provider must base 

treatment decisions on WPATH’s criteria. Indeed, before the district 

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EDMO V. CORIZON 19

One would be forgiven for inferring from the panel’s 

opinion that its bold assertions about the WPATH Standards 

are uncontroverted truths. But, as the Fifth Circuit has 

recognized, “the WPATH Standards of Care reflect not 

consensus, but merely one side in a sharply contested 

medical debate over sex reassignment surgery.” Gibson v. 

Collier, 920 F.3d 212, 221 (5th Cir. 2019). For its part, the 

First Circuit, sitting en banc, has likewise held that 

“[p]rudent medical professionals . . . do reasonably differ in 

their opinions regarding [WPATH’s] requirements.” 

Kosilek, 774 F.3d at 88. Our court should have done the 

same.

The WPATH Standards are merely criteria promulgated 

by a controversial private organization with a declared point 

of view. According to Dr. Stephen Levine, author of the 

WPATH Standards’ fifth version, former Chairman of 

WPATH’s Standards of Care Committee, and the courtappointed expert in Kosilek, WPATH attempts to be “both a 

scientific organization and an advocacy group for the 

transgendered. These aspirations sometimes conflict.” Id. at 

78. Sometimes the pressure to be advocates wins the day. 

As Levine put it, “WPATH is supportive to those who want 

sex reassignment surgery. . . . Skepticism and strong 

alternate views are not well tolerated. Such views have been 

known to be greeted with antipathy from the large numbers 

of nonprofessional adults who attend each [of] the 

organization’s biennial meetings . . . .” Id. (ellipses and 

court and before our court, the State clearly rejected the notion that any 

particular treatment criteria defines what is medically acceptable, stating 

that Dr. Eliason’s choice “should be ratified as long as it is a reasonable 

choice.” The panel erroneously construes the State’s refusal to concede 

that it violated the WPATH Standards as a concession that such 

standards are the “benchmark” of legally acceptable medical care.

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brackets original). WPATH’s own description of its drafting 

process makes this clear. Initially, the sections of the sixth 

version were each assigned to an individual member of 

WPATH who then published a literature review with 

suggested revisions. WPATH Standards, supra, at 109. The 

suggested revisions were then discussed and debated by a 

thirty-four-person Revision Committee, all before a 

subcommittee drafted the new document. Id. at 109–11. 

Only about half of the Revision Committee possesses a 

medical degree. The rest are sexologists, psychotherapists, 

or career activists, with a sociologist and a law professor 

rounding out the group. Id. at 111.

The pressure to be advocates appears to have won the 

day in the WPATH Standards’ recommendations regarding 

institutionalized persons. Recall that one central point of 

contention between the State’s witnesses and Edmo’s was 

over whether Edmo’s time undergoing hormone therapy in 

prison provides sufficient guarantee that she could live well 

outside of prison as a woman without having ever done so 

before. The district court resolved the debate by citing the 

WPATH Standards’ section on institutionalized persons, see 

Edmo, 358 F. Supp. 3d at 1125, which tersely stipulates that 

institutionalized persons should not be “discriminated 

against” on the basis of their institutionalization, WPATH 

Standards, supra, at 67. Such a recommendation is not 

supported by any research about the similarity between 

prisoners’ experiences with sex-reassignment surgery and 

that of the general public. Indeed, as Edmo’s expert witness 

and WPATH author, Dr. Randi Ettner, admits, there is only 

one known instance of a person undergoing sexreassignment surgery while incarcerated—leaving medical 

knowledge about how such surgery might differ totally 

undeveloped.

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EDMO V. CORIZON 21

Instead, WPATH’s recommendation for institutionalized 

persons merely expresses a policy preference. The article 

from which the recommendations are adapted stipulates 

upfront that, because WPATH’s “mission” is “to advocate 

for nondiscriminatory” care, it presumes that treatment 

choices should be the same for all “demographic variables, 

unless there is a clinical indication to provide services in a 

different fashion.” George R. Brown, Recommended 

Revisions to the World Professional Association for 

Transgender Health’s Standards of Care Section on Medical 

Care for Incarcerated Persons with Gender Identity 

Disorder, 11 Int’l J. of Transgenderism 133, 134 (2009). 

Unable to make an evidentiary finding from a sample size of 

one, the article concludes that its presumption should set the 

standard of care and then proceeds to recommend revisions 

with the express purpose of influencing how courts review 

gender dysphoria treatments under the Eighth Amendment. 

Id. at 133, 135. As a later peer-reviewed study by 

Dr. Cynthia Osborne and Dr. Anne Lawrence put it, 

WPATH’s institutionalized-persons recommendations 

follow from an “ethical principle,” not “extensive clinical 

experience.” Cynthia S. Osborne & Anne A. Lawrence, 

Male Prison Inmates With Gender Dysphoria: When Is Sex 

Reassignment Surgery Appropriate?, 45 Archives of Sexual 

Behav. 1649, 1651 (2016).

Even apart from the concerns over WPATH’s 

ideological commitments, its evidentiary basis is not 

sufficient to justify the court’s reliance on its strict terms. 

The WPATH Standards seem to suggest as much. In its own 

words, the WPATH Standards are simply “flexible clinical 

guidelines,” which explicitly allow that “individual health 

professionals and programs may modify them.” WPATH 

Standards, supra, at 2. Indeed, the most recent WPATH 

Standards “represents a significant departure from previous 

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22 EDMO V. CORIZON

versions” in part due to significant changes in researchers’ 

conclusions over the preceding decade. Id. at 1 n.2. 

Moreover, the WPATH Standards lack the evidence-based 

grading system that characterizes archetypal treatment 

guidelines, such as the Endocrine Society’s hormone therapy 

guidelines. Lacking evidence-based grading, the WPATH 

Standards leave practitioners in the dark about the strength 

of a given recommendation. See William Byne et al., Report 

of the American Psychiatric Association Task Force on 

Treatment of Gender Identity Disorder, 41 Archives of 

Sexual Behav. 759, 783 (2012) (concluding that “the level 

of evidence” supporting WPATH’s Standards’ criteria for 

sex-reassignment surgery “was generally low”). For these 

reasons, the Centers for Medicare & Medicaid Services, an 

agency of the United States Department of Health and 

Human Services, decided, “[b]ased on a thorough review of 

the clinical evidence,” that providers may consult treatment 

criteria other than WPATH, including providers’ own 

criteria. Ctrs. for Medicare & Medicaid Servs, Proposed 

Decision Memo for Gender Dysphoria and Gender 

Reassignment Surgery (June 2, 2016); Ctrs. for Medicare & 

Medicaid Servs, Decision Memo for Gender Dysphoria and 

Gender Reassignment Surgery (Aug. 30, 2016).

3

The panel’s disposition results from its failure to put the 

WPATH Standards in proper perspective. Had the district 

court understood that Edmo’s experts’ role in WPATH 

marks them not with special insight into the legally 

acceptable care, but rather as mere participants in an ongoing 

medical debate, they would have acknowledged this case for 

what it is: a “case of dueling experts.” Edmo, 935 F.3d 

at 787. Instead of giving Drs. Garvey and Andrade (to say 

nothing of Dr. Eliason) “no weight” due to their insufficient 

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EDMO V. CORIZON 23

fealty to WPATH, the district court should have recognized 

them as legitimate, experienced participants in that debate. 

And had the State’s experts’ criticisms of and interpretation 

of the WPATH Standards been given proper weight—any 

weight at all—the district court would have had to conclude 

that the State’s disagreement with Edmo’s experts was a 

mere “difference of medical opinion,” not a constitutional 

violation. Jackson, 90 F.3d at 332.

So too with its assessment of Dr. Eliason’s treatment 

choice. It is instructive that the worst the district court can 

say about Dr. Eliason is that he “did not apply the WPATH 

criteria.” Edmo, 358 F. Supp. 3d at 1126. Focusing the 

analysis not on whether Dr. Eliason applied the standards of 

a professional association but rather on whether the 

treatment choice was within that of a prudent, competent 

practitioner, the cautious treatment selected by Dr. Eliason 

is plainly constitutionally acceptable.

As Drs. Garvey and Andrade explain, it is medically 

acceptable to offer Edmo a treatment of hormone therapy 

and psychotherapy but not sex-reassignment surgery. The 

practitioners’ fear that sex-reassignment surgery would 

exacerbate Edmo’s other mental illnesses and increase the 

risk of surgery was a genuine and sound fear. As Dr. Garvey 

put it, “[b]ased on her current coping strategies, I would be 

concerned about her suicide risk after surgery.” Although 

the measured “regret rate,” which refers to the proportion of 

postoperative patients who regret their surgery, is “low,” see 

Edmo, 935 F.3d at 771, the district court and the panel failed 

to acknowledge detailed testimony that those studies 

neglected to follow up with such a high proportion of the 

observed sample that the stated figure does not “represent 

the full picture.” In Dr. Andrade’s opinion, “I think there are 

things she needs to work out in therapy in the short and long 

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24 EDMO V. CORIZON

term before she can make a really well-informed decision 

about surgery.” He raised the concern that Edmo is 

particularly at risk because of “unresolved trauma” that may 

stem, not from gender dysphoria, but instead from past 

sexual abuse.

Dr. Eliason’s view that Edmo needed to have lived as a 

woman outside of prison in order to ensure that she would 

be able to adapt well after the surgery was also legitimate. 

Indeed, under the peer-reviewed treatment criteria 

developed by Drs. Osborne and Lawrence, Edmo was not 

eligible for sex-reassignment surgery for these exact reasons. 

Acknowledging the lack of evidence concerning the effects 

of sex-reassignment surgery on inmates, the unique 

challenges imposed by the correctional setting, and the 

significant risk of patient regret, Drs. Osborne and Lawrence 

proposed criteria that require a prospective patient have “a 

satisfactory disciplinary record and demonstrated capacity to 

cooperate” and “a long period of expected incarceration after 

[surgery],” among others. Osborne & Lawrence, supra, 

at 1661. This latter criterion helps to ensure that male-tofemale patients have “a longer period of time to consolidate 

one’s feminine gender identity and gender role.” Id. at 1660; 

see also id. at 1656 (“[I]nmates with [gender dysphoria] who 

attempt to live in female-typical gender roles within men’s 

prisons . . . could not effectively prepare” for life after 

surgery.) The district court disregarded such additional, 

peer-reviewed treatment criteria because they “are not part 

of the WPATH criteria and are in opposition to the WPATH 

Standards of Care.” Edmo, 358 F. Supp. 3d at 1126. Had 

the district court taken a step back and considered not 

whether Osborne and Lawrence were WPATH-compliant 

but rather whether a competent physician could rely on their 

reasoning, it would have had to conclude that Dr. Eliason’s 

treatment choice was that of a competent, prudent physician.

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EDMO V. CORIZON 25

Perhaps recognizing such problems with the district 

court’s definition of medical unacceptability, the panel 

concludes its medical-unacceptability analysis by changing 

the subject. Instead of considering whether Dr. Eliason’s 

choice of treatment was medically unacceptable, the panel 

fixates on Dr. Eliason’s chart notes, which sets forth three 

general categories in which he believes sex-reassignment 

surgery may be required: (1) “Congenital malformation or 

ambiguous genitalia,” (2) “Severe and devastating dysphoria 

that is primarily due to genitals,” (3) or “Some type of 

medical problem in which endogenous sexual hormones 

were causing severe physiological damage.” According to 

the panel, such categories “bear little resemblance” to the 

WPATH Standards and therefore “Dr. Eliason’s evaluation 

was not an exercise of medically acceptable professional 

judgment.” Edmo, 935 F.3d at 791–92. In the first place, 

Dr. Eliason’s categories are not meant to substitute for 

treatment standards. Such categories describe three broad 

pools of eligible patients; whether a particular patient 

belongs in a certain pool—by having dysphoria sufficiently 

severe to require sex-reassignment surgery, for instance—

would be resolved by more detailed evaluative criteria. In 

the second place, conformity to WPATH is not the test of 

constitutionally acceptable treatment of gender dysphoria. 

But more broadly, the panel simply asks the wrong question. 

Deliberate indifference may be inferred when “the course of 

treatment the doctors chose was medically unacceptable 

under the circumstances,” not when the doctors’ 

contemporaneous explanation of the choice is incomplete. 

Jackson, 90 F.3d at 332 (emphasis added); see also Snow, 

681 F.3d at 988; Toguchi, 391 F.3d at 1058; Hamby v. 

Hammond, 821 F.3d 1085, 1092 (9th Cir. 2016) (all referring 

to the “course of treatment,” not the rationale). It does not 

matter that Dr. Eliason’s testimony justifies his treatment 

choice in ways not explicit in his chart notes such that the 

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26 EDMO V. CORIZON

panel calls his testimony a “post hoc explanation.” Edmo, 

935 F.3d at 791. So long as the ultimate treatment choice

was medically acceptable, our precedents tell us, we cannot 

infer “the unnecessary and wanton infliction of pain” that 

violates the Eighth Amendment.

B

Even were the panel correct that the only medically 

acceptable way to approach a gender dysphoric patient’s 

request for sex-reassignment surgery is to apply the WPATH 

Standards of Care, we still could not infer a constitutional 

violation from these facts. As the Supreme Court has 

explained, the Eighth Amendment simply proscribes 

categories of punishment, and punishment is “a deliberate 

act intended to chastise or deter.” Wilson v. Seiter, 501 U.S. 

294, 299–300 (1991). “[O]nly the ‘unnecessary and wanton

infliction of pain’ implicates the Eighth Amendment.” Id.

at 297 (quoting Estelle, 429 U.S. at 104) (emphasis original).

Hence the commonplace deliberate-indifference inquiry, 

which is a culpability standard equivalent to criminal 

recklessness. Farmer, 511 U.S. at 839–40. Simply put, 

unless the official “knows of and disregards an excessive 

risk to inmate health and safety,” he does not violate the 

Eighth Amendment. Id. at 837.

1

With little explanation, the panel castigates Dr. Eliason 

for having “disregarded” risks that he directly and 

forthrightly addressed. Edmo, 935 F.3d at 793. Far from 

disregarding the risk that Edmo would attempt to castrate 

herself, Dr. Eliason investigated the causes of such a risk and 

took concrete steps to mitigate it. Edmo’s self-harm 

(including her castration attempts) followed closely after her 

disciplinary infractions and other severe stressors. 

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EDMO V. CORIZON 27

Identifying this causal connection, Dr. Eliason prescribed 

and encouraged regular counseling to address Edmo’s acting 

out and her ability to cope. Dr. Eliason also sought to further 

deter self-castration by explaining to Edmo that she will 

need to have intact genitals for any eventual surgery, 

something Edmo now understands and articulated in her 

testimony. Likewise, contrary to the panel’s conclusion that 

he disregarded the risk of continued distress, Dr. Eliason 

opted for a treatment of continued hormone therapy and 

more regular supportive counseling precisely because 

hormone therapy had already substantially ameliorated the 

distress from the dysphoria.

Furthermore, the panel errs by fixating on such 

individual risks. Physicians ministrate to whole individuals 

with whole diseases. Thus, individual risks may—and 

frequently do—persist for the sake of the overall health of 

the person. Dr. Eliason and his staff clearly believed their 

treatment choice would mitigate overall risk, including 

grave risks the panel downplays. Given Edmo’s long-term 

struggles with severe depression and addiction, coupled with 

the fact that she had not lived as a woman within her social 

network, Eliason and the other doctors with whom he staffed 

the evaluation were concerned that she would have trouble 

adjusting after surgery, which could lead to regret, relapse, 

or new mood disorders. Ultimately, they worried that she 

might attempt suicide again. Such risks are not trifling and, 

in light of them, Dr. Eliason’s willingness to accept some 

risk that Edmo would try to castrate herself or would 

continue to feel the distress of gender dysphoria (while 

taking steps to mitigate such risks) is anything but 

deliberately indifferent.

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2

None of this is to acquiesce in the straw-man argument 

set up by the panel: that, so long as officials provide some 

care, they are immunized from an Eighth Amendment claim. 

One may assume that some medical care is indeed so 

obviously inadequate that, without any direct evidence of the 

defendant’s state of mind, we may infer that the defendant 

was deliberately indifferent. See Farmer, 511 U.S. at 842 

(remarking that deliberate indifference is “subject to 

demonstration in the usual ways, including inference from 

circumstantial evidence” and may be inferred “from the very 

fact that the risk was obvious”).7 But that is not this case.

Even in a legal universe in which the WPATH Standards 

define adequate care, Dr. Eliason’s deviations were not 

deliberately indifferent. He selected a course of treatment 

that, in light of the complex of diagnoses, the grave risks, 

and the rapidly evolving nature of the medical research, was 

7 It should, however, be noted that the panel fails to identify a 

precedent of ours in which we have inferred a physician’s deliberate 

indifference solely from the inadequate nature of the treatment and the 

persistence of known risks. In the nearest cases, some other 

circumstantial evidence has suggested the obviousness of the inadequacy 

such that the physician must have been aware of the inadequacy. E.g.,

Snow, 681 F.3d at 988 (non-specialist refused the recommendation of a 

treating specialist); Hamilton v. Endell, 981 F.2d 1062, 1067 (9th Cir. 

1992) (same); Lopez v. Smith, 203 F.3d 1122, 1132 (9th Cir. 2000) 

(same); Hunt v. Dental Dep’t, 865 F.2d 198, 201 (9th Cir. 1989) (refusal 

to replace the dentures prisoner had been prescribed); Jett v. Penner, 

439 F.3d 1091, 1098 (9th Cir. 2006) (prisoner not referred to specialist 

for reasons unrelated to the prisoner’s medical needs and medical records 

were manipulated); Colwell v. Bannister, 763 F.3d 1060, 1070 (9th Cir. 

2014) (reliance on arbitrary prison policy). I do not doubt that mere 

inadequacy may raise the inference of deliberate indifference, but we 

seem to leave such an inference for cases of genuine quackery.

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EDMO V. CORIZON 29

not obviously inadequate. Cf. Lemire, 726 F.3d at 1075 (“A 

prison official’s deliberately indifferent conduct will 

generally ‘shock the conscience’ so long as the prison 

official had time to deliberate before acting . . . .”). He 

subjected his assessment to a review process intended to 

surface any possibility he was not considering, a review

process that included several doctors and a full committee. 

And far from being an “unjustifiable” or “gross” deviation 

from the WPATH Standards, he departed from WPATH by 

raising the Standards’ own concerns for the presence of 

comorbid conditions and the patient’s limited experience as 

a woman. See Farmer, 511 U.S. at 839 (incorporating the 

Model Penal Code’s definition of criminal recklessness); 

Model Penal Code § 2.02(2)(c) (1985) (stating that the 

criminally reckless individual “disregards a substantial and 

unjustifiable risk” and that such disregard “involves a gross 

deviation from the standard of conduct that a law-abiding 

person would observe in the actor’s situation.”). Indeed, the 

panel concludes that his deviations were simply not 

“reasonable”—the test for negligent malpractice, not 

deliberate indifference. Edmo, 935 F.3d at 792. “Eighth 

Amendment liability requires ‘more than ordinary lack of 

due care . . . .’” Farmer, 511 U.S. at 835 (quoting Whitley v. 

Albers, 475 U.S. 312, 319 (1986)).

III

The panel’s novel approach to Eighth Amendment 

claims for sex-reassignment surgery conflicts with every 

other circuit to consider the issue. The panel acknowledges 

such a circuit split with the Fifth Circuit’s opinion in Gibson 

v. Collier, 920 F.3d 212 (5th Cir. 2019), but tries—and 

fails—to distinguish the First Circuit’s en banc opinion in 

Kosilek v. Spencer, 774 F.3d 63 (1st Cir. 2014). See Edmo, 

935 F.3d at 794–95. The panel does not even address a third 

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30 EDMO V. CORIZON

decision: the Tenth Circuit’s opinion in Lamb v. Norwood, 

899 F.3d 1159 (10th Cir. 2018).

Just as in this case, the First Circuit considered an appeal 

of an injunction mandating sex-reassignment surgery. But, 

unlike our court, the First Circuit reversed. Though the panel 

attempts to downplay the direct conflict between its opinion 

and Kosilek by pointing to minor differences between the 

factual circumstances in each case,8 the decisive differences 

are matters of law. As to whether the care was medically 

unacceptable, the First Circuit held that medically acceptable 

treatment of gender dysphoric prisoners is not synonymous 

with the demands of WPATH. Kosilek first reversed the 

district court’s finding that one of the State’s experts was 

“illegitimate” because the district court “made a 

significantly flawed inferential leap: it relied on its own—

non-medical—judgment” and put too much “weight” on the 

WPATH Standards. Kosilek, 774 F.3d at 87–88. With that 

expert now taken seriously, the First Circuit held that the 

denial of Kosilek’s sex-reassignment surgery was medically 

8 The differences between the circumstances in Kosilek and those in 

this case are not substantial enough to distinguish the holdings. The 

clinical judgments in each case were motivated by concerns about 

coexisting mental health conditions and the risk of suicide. Kosilek, 

774 F.3d at 72. Just as in this case, Kosilek surfaced expert opinions that 

the WPATH Standards are best applied flexibly, that in-prison 

experience in the newly assigned gender is not a sufficient guarantee of 

ability to transition, and that practitioners face a “dearth of empirical 

research” on sex-reassignment surgery. Id. at 72–73, 76. The “security 

concerns” over how to house a potential postoperative Kosilek, which 

the panel considers the foremost difference between the two cases, was 

not even essential to Kosilek’s holding. See Edmo, 935 F.3d at 794; 

Kosilek, 774 F.3d at 91–92 (concluding that the officials’ “choice of a 

medical option . . . does not exhibit a level of inattention or callousness 

to a prisoner’s needs rising to a constitutional violation” before even 

analyzing the security concerns).

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EDMO V. CORIZON 31

acceptable because it was within the bounds of “the medical 

standards of prudent professionals.” Id. at 90. On the 

question of deliberate indifference, the First Circuit applied 

a test, which, unlike the panel’s inference from the 

practitioners’ mere knowledge that a course of treatment 

carried risks, asked whether the practitioners “knew or 

should have known” that course of treatment was medically 

unacceptable. Id. at 91.

For its part, the Fifth Circuit has held that good faith 

denial of sex-reassignment surgery never violates the Eighth 

Amendment. Recognizing “large gaps” in medical 

knowledge and a “robust and substantial good faith 

disagreement dividing respected members of the expert 

medical community,” the Fifth Circuit concluded that “there 

can be no claim [for sex-reassignment surgery] under the 

Eighth Amendment.” Gibson, 920 F.3d at 220, 222. Indeed, 

Texas’s refusal to even evaluate the inmate for sexreassignment surgery is, in the words of the Fifth Circuit, not 

“so unconscionable as to fall below society’s minimum 

standards of decency” and permit an Eighth Amendment 

claim. Id. at 216 (quoting Kosilek, 774 F.3d at 96).

Finally, the Tenth Circuit has upheld the entry of 

summary judgment against a prisoner’s Eighth Amendment 

claim for sex-reassignment surgery. See Lamb, 899 F.3d 

at 1163. As in this case, the doctor who evaluated the 

prisoner in Lamb determined that “surgery is impractical and 

unnecessary in light of the availability and effectiveness of 

more conservative therapies.” Id. Adopting Kosilek’s

subjective standard—that an Eighth Amendment violation 

would take place “only if prison officials had known or 

should have known” that “sex reassignment surgery [was] 

the only medically adequate treatment”—the Tenth Circuit 

held that “prison officials could not have been deliberately 

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32 EDMO V. CORIZON

indifferent by implementing the course of treatment 

recommended by a licensed medical doctor.” Id. at 1163 & 

n.11 (citing Kosilek, 774 F.3d at 91).

Although I am not aware of any other circuits to have 

directly addressed the questions posed in this case,9 for its 

part, the Seventh Circuit has held that it is at least not 

“clearly established” that there is a constitutional right to 

gender-dysphoria treatment beyond hormone therapy. 

Campbell v. Kallas, 936 F.3d 536, 549 (7th Cir. 2019). Nor 

is it “clearly established” that a prison medical provider is 

prohibited from denying sex-reassignment surgery on the 

basis of the patient’s status as an institutionalized person. Id.

at 541, 549.

With this decision, our circuit sets itself apart.

IV

I do not know whether sex-reassignment surgery will 

ameliorate or exacerbate Adree Edmo’s suffering. 

Fortunately, the Constitution does not ask federal judges to 

put on white coats and decide vexed questions of psychiatric 

medicine. The Eighth Amendment forbids the “unnecessary 

and wanton infliction of pain,” not the “difference of opinion 

between a physician and the prisoner—or between medical 

9 The Seventh and Fourth Circuits (along with our own circuit) have 

also held that arbitrary blanket bans on certain gender dysphoria 

treatments can violate the Eighth Amendment—an issue not presented 

here because Idaho evaluates prisoner requests for sex-reassignment 

surgery on a case-by-case basis. See Rosati v. Igbinoso, 791 F.3d 1037, 

1040 (9th Cir. 2015); De’lonta v. Johnson, 708 F.3d 520, 526 (4th Cir. 

2013); Fields v. Smith, 653 F.3d 550, 556 (7th Cir. 2011).

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EDMO V. CORIZON 33

professionals.” Snow, 681 F.3d at 985, 987 (quoting Estelle, 

429 U.S. at 104).

Yet today our court assumes the role of Clinical 

Advisory Committee. Far from rendering an opinion 

“individual to Edmo” that “rests on the record,” Edmo, 

935 F.3d at 767, the panel entrenches the district court’s 

unfortunate legal errors as the law of this circuit. Instead of 

permitting prudent, competent patient care, our court 

enshrines the WPATH Standards as an enforceable “medical 

consensus,” effectively putting an ideologically driven 

private organization in control of every relationship between 

a doctor and a gender dysphoric prisoner within our circuit. 

Instead of reserving the Eighth Amendment for the grossly, 

unjustifiably reckless, the panel infers a culpable state of 

mind from the supposed inadequacy of the treatment.

We have applied the traditional deliberate-indifference 

standard to requests for back surgery, kidney transplant, hip 

replacement, antipsychotic medication, and hernia surgery. 

Yet suddenly the request for sex-reassignment surgery—and 

the panel’s closing appeal to what it calls the “increased 

social awareness” of the needs and wants of transgender 

citizens—effects a revolution in our law! Id. at 803. The 

temptation to stand at what we are told is society’s next 

frontier and to invent a constitutional right to state-funded 

sex-reassignment surgery does not justify the revision of 

previously universal principles of Eighth Amendment 

jurisprudence.

Dr. Eliason and the State’s other practitioners were not 

deliberately indifferent—far from it. And they certainly 

were not guilty of violating the Eighth Amendment. They 

confronted the serious risks to Edmo’s health, especially the 

gravest one. They considered the knotty quandary posed by 

her overlapping illnesses and the vicissitudes of her life. 

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34 EDMO V. CORIZON

Mindful of the dictate “first do no harm,” these doctors 

determined that the appropriate treatment would be more 

cautious and more reversible than the one the patient desired. 

And they did so in the shadow of the ongoing debate about 

when the surgical replacement of the genitals is curative and 

when it is not.

Surely this was not cruel and unusual punishment.

COLLINS, Circuit Judge, dissenting from the denial of 

rehearing en banc:

The Supreme Court has held that a prisoner claiming that 

his or her medical treatment is so inadequate that it 

constitutes “cruel and unusual punishment” in violation of 

the Eighth Amendment must make the demanding showing 

that prison officials acted with “deliberate indifference” to 

the prisoner’s “serious medical needs.” Estelle v. Gamble, 

429 U.S. 97, 104 (1976). As judges of an “inferior Court[],” 

see U.S. Const. art. III, § 1, we are bound to apply that 

standard, but as Judge Bumatay explains, the panel here 

effectively waters it down into a “mere negligence” test. See 

infra at 47–48 (Bumatay, J., dissenting from denial of 

rehearing en banc). That is, by narrowly defining the range 

of “medically acceptable” options that the court believes a 

prison doctor may properly consider in a case such as this 

one, and by then inferring deliberate indifference from 

Dr. Eliason’s failure to agree with that narrow range, the 

district court and the panel have applied standards that look 

much more like negligence than deliberate indifference. Id. 

at 45–48. Whether Dr. Eliason was negligent or not (a 

question on which I express no opinion), his treatment 

decisions do not amount to “cruel and unusual punishment,”

and we have thus strayed far from any proper understanding 

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EDMO V. CORIZON 35

of the Eighth Amendment. I therefore join Part II of Judge 

Bumatay’s dissent, and I respectfully dissent from our 

failure to rehear this case en banc.

BUMATAY, Circuit Judge, with whom CALLAHAN, 

IKUTA, R. NELSON, BADE, and VANDYKE, Circuit 

Judges, join, and with whom COLLINS, Circuit Judge, joins 

as to Part II, dissenting from the denial of rehearing en banc:

Like the panel and the district court, I hold great 

sympathy for Adree Edmo’s medical situation. And as with 

all citizens, her constitutional rights deserve the utmost 

respect and vigilant protection. As the district court rightly 

stated,

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.1

Adree Edmo is a transgender woman suffering from 

gender dysphoria—a serious medical condition. While 

incarcerated in Idaho’s correctional facilities, she asked that 

her gender dysphoria be treated with sex-reassignment 

1 Edmo v. Idaho Dep’t of Corr., 358 F. Supp. 3d 1103, 1109 (D. 

Idaho 2018), order clarified, No. 1:17-CV-00151-BLW, 2019 WL 

2319527 (D. Idaho May 31, 2019), and aff’d in part, vacated in part, 

remanded sub nom. Edmo v. Corizon, Inc., 935 F.3d 757 (9th Cir. 2019).

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36 EDMO V. CORIZON

surgery (“SRS”). After consultation with a prison doctor, 

her request was denied. She then sued under the Eighth 

Amendment.2

I respect Edmo’s wishes and hope she is afforded the best 

treatment possible. But whether SRS is the optimal 

treatment for Edmo’s gender dysphoria is not before us. As 

judges, our role is not to take sides in matters of conflicting 

medical care. Rather, our duty is to faithfully interpret the 

Constitution.

That duty commands that we apply the Eighth 

Amendment, not our sympathies. Here, in disregard of the 

text and history of the Constitution and precedent, the 

panel’s decision elevates innovative and evolving medical 

standards to be the constitutional threshold for prison 

medical care. In doing so, the panel minimizes the standard 

for establishing a violation of the Eighth Amendment.

After today’s denial of rehearing en banc, the Ninth 

Circuit stands alone in finding that a difference of medical 

opinion in this debated area of treatment amounts to “cruel 

and unusual” punishment under the Constitution. While this 

posture does not mean we are wrong, it should at least give 

us pause before embarking on a new constitutional 

trajectory. This is especially true given the original meaning 

of the Eighth Amendment.

Because the panel’s opinion reads into the Eighth 

Amendment’s Cruel and Unusual Clause a meaning in 

conflict with its text, original meaning, and controlling 

2 Because Judge O’Scannlain thoroughly recites the relevant facts in 

his opinion respecting the denial of the rehearing en banc, which I join 

in full, I do not reiterate them here.

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EDMO V. CORIZON 37

precedent, I respectfully dissent from the denial of rehearing 

en banc.

I.

In holding that Idaho3 violated the Eighth Amendment, 

the panel opined that the Constitution’s text and original 

meaning merited “little discussion.” See Edmo, 935 F.3d

at 797 n.21. I disagree.

As inferior court judges, we are bound by Supreme Court 

precedent. Yet, in my view, judges also have a “duty to 

interpret the Constitution in light of its text, structure, and 

original understanding.” NLRB v. Noel Canning, 573 U.S. 

513, 573 (2014) (Scalia, J., concurring). While we must 

faithfully follow the Court’s Eighth Amendment precedent 

as articulated in Estelle v. Gamble, 429 U.S. 97 (1976), and 

its progeny, “[w]e should resolve questions about the scope 

of those precedents in light of and in the direction of the 

constitutional text and constitutional history.” Free Enter. 

Fund v. Public Co. Accounting Oversight Bd., 537 F.3d 667, 

698 (D.C. Cir. 2008) (Kavanaugh, J., dissenting), aff’d in 

part, rev’d in part and remanded, 561 U.S. 477 (2010).

Accordingly, the Eighth Amendment’s history and 

original understanding are of vital importance to this case.

A.

The Eighth Amendment provides that “[e]xcessive bail 

shall not be required, nor excessive fines imposed, nor cruel 

and unusual punishments inflicted.” U.S. Const. amend. 

3 For simplicity, I collectively refer to Defendants below and 

Appellants here as “Idaho.”

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38 EDMO V. CORIZON

VIII. Even just a cursory review of the amendment’s 

original meaning shows that Edmo’s claims fall far below a 

constitutional violation as a matter of text and original 

understanding.

At the time of the Eighth Amendment’s ratification, 

“cruel” meant “[p]leased with hurting others; inhuman; 

hard-hearted; void of pity; wanting compassion; savage; 

barbarous; unrelenting.” Bucklew v. Precythe, 139 S. Ct. 

1112, 1123 (2019) (citing 1 Samuel Johnson, A Dictionary 

of the English Language (4th ed. 1773); 1 Noah Webster, An 

American Dictionary of the English Language (1828) 

(“Disposed to give pain to others, in body or mind; willing 

or pleased to torment, vex or afflict; inhuman; destitute of 

pity, compassion or kindness.”)). Even today, “cruel” 

punishments have been described as “inhumane,” Farmer v. 

Brennan, 511 U.S. 825, 838 (1994), involving the 

“unnecessary and wanton infliction of pain,” Whitley v. 

Albers, 475 U.S. 312, 319 (1986) (emphasis added) 

(citations omitted), or involving the “superadd[ition] of 

terror, pain, or disgrace.” Bucklew, 139 S. Ct. at 1124 

(emphasis added) (internal quotation marks and citations 

omitted).

In the 18th Century, a punishment was “unusual” if it ran 

contrary to longstanding usage or custom, or had long fallen 

out of use. Bucklew, 139 S. Ct. at 1123 (citing 4 William 

Blackstone, Commentaries on the Laws of England 370 

(1769); Stuart Banner, The Death Penalty: An American 

History 76 (2002); Baze v. Rees, 553 U.S. 35, 97 (2008) 

(Thomas, J., concurring); John F. Stinneford, The Original 

Meaning of “Unusual”: The Eighth Amendment as a Bar to 

Cruel Innovation, 102 Nw. U. L. Rev. 1739, 1770–71, 1814 

(2008)). This early understanding comports with the plain 

meaning of “unusual,” which has changed little from our 

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EDMO V. CORIZON 39

Nation’s founding. See Harmelin v. Michigan, 501 U.S. 

957, 976 (1991) (comparing Webster’s American Dictionary 

(1828) definition of “unusual” as that which does not 

“occu[r] in ordinary practice” with Webster’s Second 

International Dictionary 2807 (1954) as that which is not “in 

common use.”).

Conversely, customs enjoying a long history of usage 

were described as “usual” practices. Stinneford, supra, 

at 1770. James Wilson, a key contributor to the 

Constitution, stated that “long customs, approved by the 

consent of those who use them, acquire the qualities of a 

law.” 2 James Wilson, Collected Works of James Wilson 

759 (Kermit L. Hall & Mark David Hall eds., Indianapolis, 

Liberty Fund 2007); see also Stinneford, supra, at 1769. 

Likewise, early American courts construing the term “cruel 

and unusual” (generally, as used in state constitutions) 

upheld punishments that were not “unusual” in light of 

common law usage. Stinneford, supra, at 1810–11 (citing 

Barker v. People, 20 Johns. 457, 459 (N.Y. Sup. Ct. 1823), 

aff’d, 3 Cow. 686 (N.Y. 1824); Commonwealth v. Wyatt, 

27 Va. 694, 701 (Va. Gen. Ct. 1828); People v. Potter, 1 

Edm. Sel. Cas. 235, 245 (N.Y. Sup. Ct. 1846)). Thus, 

“[u]nder the plain meaning of the term, a prison policy 

cannot be ‘unusual’ if it is widely practiced in prisons across 

the country.” Gibson v. Collier, 920 F.3d 212, 226 (5th Cir. 

2019).

Finally, various views have been proposed with respect 

to the original meaning of “punishment” in the Eighth 

Amendment. Some view the word as being inapplicable to 

conditions of confinement. See, e.g., Farmer, 511 U.S. 

at 837 (“The Eighth Amendment does not outlaw cruel and 

unusual ‘conditions’; it outlaws cruel and unusual 

‘punishments.’”) (Souter, J.). Some have even suggested 

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40 EDMO V. CORIZON

that “punishment” refers only to sentences imposed by a 

judge or jury. See Hudson v. McMillian, 503 U.S. 1, 18 

(1992) (Thomas, J., dissenting); but see Helling v. 

McKinney, 509 U.S. 25, 40 (1993) (Thomas, J., dissenting) 

(recognizing that the “evidence is not overwhelming” on this 

question). Others believe the term was originally understood 

to encompass more than sentences called for by statute or 

meted out from the bench or jury box, but it required 

deliberate intent. See, e.g., Wilson v. Seiter, 501 U.S. 294, 

300 (1991) (“The infliction of punishment is a deliberate act 

intended to chastise or deter. This is what the word means 

today; it is what it meant in the eighteenth century.”) (Scalia, 

J.) (quoting Duckworth v. Franzen, 780 F.2d 645, 652 (7th 

Cir. 1985)); see also Celia Rumann, Tortured History: 

Finding Our Way Back to the Lost Origins of the Eighth 

Amendment, 31 Pepp. L. Rev. 661, 675, 677 (2004) 

(presenting historical evidence that the word punishment 

was “understood at the time to include torturous 

interrogation”) (citing 4 William Blackstone, Commentaries 

on the Laws of England; 3 Jonathan Elliot, The Debates in 

the Several State Conventions on the Adoption of the 

Federal Constitution 447–48).

B.

While the foregoing overview does not provide the full 

contours of the original understanding of the Cruel and 

Unusual Clause, it demonstrates that Idaho’s actions are far 

from a constitutional violation based on the clause’s text and 

original meaning. Idaho’s actions simply do not amount to 

the “barbarous” or “inhuman” treatment so out of line with 

longstanding practice as to be forbidden by the Eighth 

Amendment.

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EDMO V. CORIZON 41

No longstanding practice exists of prison-funded SRS.4 

Indeed, the medical standards at the heart of Edmo’s claim 

are innovative and evolving. The standards of care relied on 

by Edmo were promulgated by the World Professional 

Association for Transgender Health (“WPATH”) in 2011—

only about five years before Edmo’s lawsuit. WPATH, 

Standard of Care for the Health of Transsexual, 

Transgender, and Gender-Nonconforming People (7th ed. 

2011) (“WPATH standards”). As the standards themselves 

note, this “field of medicine is evolving.” The WPATH 

standards also call for flexibility, individual tailoring, and 

wide latitude in treatment options.

Likewise, as recognized by numerous federal courts, the 

WPATH standards are not accepted as medical consensus. 

The first circuit court to address the issue ruled that the 

WPATH standards did not foreclose alternative treatment 

options, and that a doctor’s decision to choose a nonWPATH treatment did not violate the Eighth Amendment. 

Kosilek v. Spencer, 774 F.3d 63, 90 (1st Cir. 2014). The 

Fifth Circuit also found that the WPATH standards remained 

controversial and did not reflect a consensus. Gibson, 

920 F.3d at 223. Similarly, after reciting the WPATH 

standard’s recommended treatment options for gender 

dysphoria, the Tenth Circuit rejected a claim that prison 

officials acted with deliberate indifference “by 

implementing [an alternative] course of treatment 

recommended by a licensed medical doctor,” rather than 

4 See, e.g., Quine v. Beard, No.14-cv-02726-JST, 2017 WL 

1540758, at *1 (N.D. Cal. Apr. 28, 2017), aff’d in part, vacated in part, 

rev’d in part sub nom. Quine v. Kernan, 741 F. App’x 358 (9th Cir. 

2018); Kristine Phillips, A Convicted Killer Became the First U.S. 

Inmate to Get State-Funded Gender-Reassignment Surgery, Wash. Post 

(Jan. 10, 2017), https://wapo.st/2S21zP3.

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42 EDMO V. CORIZON

SRS. Lamb v. Norwood, 899 F.3d 1159, 1163 (10th Cir. 

2018), cert. denied, 140 S. Ct. 252 (2019).5

The debate about the WPATH standards continues even 

outside prison walls. The Centers for Medicare and 

Medicaid Services (“CMS”) declined to adopt the WPATH 

standards due to inadequate scientific backing, and instead 

gives providers discretion to apply either the WPATH 

standards or their own standards. CMS, Decision Memo for 

Gender Dysphoria and Gender Reassignment Surgery 

(August 30, 2016), available at https://go.cms.gov/36yMrx

X. Similarly, the American Psychiatric Association 

expressed concern about the scientific evidence 

undergirding the WPATH standards. And as recently as 

2017, WPATH requested that Johns Hopkins University 

conduct an evidence-based review of the standards, a review 

that, at the time of Edmo’s lawsuit, was ongoing.

Idaho’s actions reflect the uncertainty regarding the 

WPATH standards throughout the medical field, and do not, 

under the record, reflect a want of compassion. See supra

O’Scannlain, J., dissenting at 22–29. Given the lack of 

medical consensus, Dr. Eliason’s decision to pursue an 

alternative treatment, rather than SRS, cannot constitute the 

“barbarous” or “inhuman” conduct prohibited by the Eighth 

Amendment. See Bucklew, 139 S. Ct. at 1123. Nothing in 

the record reflects that Dr. Eliason’s diagnosis and treatment 

of Edmo was tainted by malice or animosity. Notably, 

Dr. Eliason concluded that Edmo had coexisting mental 

5 In the non-SRS context, the Tenth Circuit also found no Eighth 

Amendment violation where a doctor prescribed lower hormonal 

treatment levels for a gender dysphoric inmate than those suggested by 

the WPATH standards. Druley v. Patton, 601 F. App’x 632, 635 (10th 

Cir. 2015).

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EDMO V. CORIZON 43

health issues that required treatment and counseling prior to 

considering SRS. The district court itself found Edmo’s 

reluctance to address those issues “troubling.” Edmo, 358 F. 

Supp. 3d at 1121. Additionally, Idaho had no blanket policy 

prohibiting SRS, and Dr. Eliason never definitively ruled it 

out. Dr. Eliason committed to monitoring Edmo’s candidacy 

for SRS after deciding that Edmo did not meet the criteria 

for the procedure in 2016. In sum, Dr. Eliason’s decision to 

pursue an alternative treatment to SRS suggests a tailored 

evaluation of potential risks and does not reflect the hardhearted or barbarous treatment proscribed by the text of the 

Constitution.

Given the facts of this case, Dr. Eliason’s treatment 

cannot rise to the infliction of cruel and unusual 

punishment—not in a sense that bears any resemblance to 

the original meaning of that phrase. This is not to say that 

the WPATH standards are not a medically acceptable 

standard. But the innovative, contested, and evolving nature 

of the WPATH standards, the lack of medical consensus, and 

the particular circumstances of this case make clear that no 

constitutional violation occurred under the Constitution’s 

text and original understanding.

II.

In addition to being inconsistent with the original 

understanding of the Eighth Amendment, I, like Judge 

O’Scannlain, believe that the panel decision departs from 

precedent.

A.

Since Estelle v. Gamble, the Supreme Court has 

recognized claims for inadequate medical treatment under 

the Eighth Amendment when prison officials act with 

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44 EDMO V. CORIZON

“deliberate indifference to serious medical needs of 

prisoners.” 429 U.S. at 104. The test for such a claim 

involves “both an objective standard—that the deprivation 

was serious enough to constitute cruel and unusual 

punishment—and a subjective standard—deliberate 

indifference.” Snow v. McDaniel, 681 F.3d 978, 985 (9th 

Cir. 2012), overruled on other grounds by Peralta v. Dillard, 

774 F.3d 1076 (9th Cir. 2014). Under Ninth Circuit 

precedent, if a defendant’s treatment decision was 

“medically acceptable,” then the court need go no further: 

the plaintiff cannot show deliberate indifference as a matter 

of law. Jackson v. McIntosh, 90 F.3d 330, 332 (9th Cir. 

1996) (citing Estelle, 429 U.S. at 107–08).

Deliberate indifference is a high bar, involving an 

“unnecessary and wanton infliction of pain” or conduct that 

is “repugnant to the conscience of mankind.” Estelle, 

429 U.S. at 104, 105–06 (citations omitted). An inadvertent 

failure to provide adequate medical care is neither, so it 

cannot support an Eighth Amendment claim. Id; see also

Farmer, 511 U.S. at 835 (explaining that deliberate 

indifference requires “more than ordinary lack of due care 

for the prisoner’s interests or safety”) (citation omitted).

A prison official acts with deliberate indifference only 

where he “knows of and disregards an excessive risk to 

inmate health or safety.” Farmer, 511 U.S. at 837 (emphasis 

added). As Justice Thomas describes it, this is the secondhighest standard of subjective culpability under the Court’s 

Eighth Amendment jurisprudence—short only of “malicious 

and sadistic action for the very purpose of causing harm.” 

Id. at 861 (Thomas, J., concurring) (internal quotation marks 

and citations omitted). Such a stringent culpability 

requirement “follows from the principle that ‘only the 

unnecessary and wanton infliction of pain implicates the 

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EDMO V. CORIZON 45

Eighth Amendment.’” Id. at 834 (quoting Wilson, 501 U.S. 

at 294).

Our precedent has consistently emphasized the 

challenging threshold for showing deliberate indifference.6 

Rightfully so, too. In the 44 years since Estelle, an unbroken 

line of Supreme Court cases reaffirmed that mere 

negligence, inadvertence, or good-faith error cannot 

establish an Eighth Amendment claim.7

B.

The panel’s decision here dilutes the otherwise stringent 

deliberate indifference standard. The panel begins by

finding Edmo’s gender dysphoria to be a “serious medical 

6 See Hamby v. Hammond, 821 F.3d 1085, 1092 (9th Cir. 2016)

(explaining that “[a] difference of opinion between a physician and the 

prisoner—or between medical professionals—concerning what medical 

care is appropriate does not amount to deliberate indifference,” and 

reiterating the “high legal standard” for showing an Eighth Amendment 

violation) (citations omitted); Toguchi v. Chung, 391 F.3d 1051, 1060 

(9th Cir. 2004); Hallett v. Morgan, 296 F.3d 732, 745 (9th Cir. 2002); 

Wood v. Housewright, 900 F.2d 1332, 1334 (9th Cir. 1990).

7 See Minneci v. Pollard, 565 U.S. 118, 130 (2012) (noting that “to 

show an Eighth Amendment violation a prisoner must typically show 

that a defendant acted, not just negligently, but with ‘deliberate 

indifference’”) (citing Farmer, 511 U.S. at 825, 834); Ortiz v. Jordan, 

562 U.S. 180, 190 (2011) (restating Farmer’s articulation of the 

deliberate indifference standard); Wilson, 501 U.S. at 297 

(“[A]llegations of ‘inadvertent failure to provide adequate medical care,’

or of a ‘negligent . . . diagnosis,’ simply fail to establish the requisite 

culpable state of mind.”) (internal citations and alterations omitted); 

Whitley, 475 U.S. at 319 (“To be cruel and unusual punishment, conduct 

that does not purport to be punishment at all must involve more than 

ordinary lack of due care . . . . It is obduracy and wantonness, not 

inadvertence or error in good faith, that characterize the conduct 

prohibited by the Cruel and Unusual Punishments Clause[.]”).

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need.” Edmo, 935 F.3d at 785. It then determines, based 

solely on the WPATH standards, that Dr. Eliason’s failure to 

recommend SRS was medically unacceptable. Id. at 786–

92. From there, the panel leaps to conclude that Dr Eliason 

was “deliberately indifferent” precisely because it viewed 

his treatment as “ineffective” and “medically unacceptable” 

under the panel’s reading of the WPATH standards. Id. 

at 793. Thus, under the panel’s approach, compliance with 

the court-preferred medical standards (in this case, the 

WPATH standards) is the beginning and the end of the 

inquiry. This is not the deliberate indifference inquiry 

required by precedent.

As an initial matter, and as Judge O’Scannlain aptly 

points out, the panel errs in holding up one medically 

accepted standard, i.e., the WPATH guidelines, as the 

constitutional “gold standard,” thereby precluding any 

further debate on the matter. See supra O’Scannlain, J., 

dissenting at 15–22. As discussed above, the WPATH 

standards do not establish a definitive medical consensus and 

judges applying Eighth Amendment standards should not 

and need not take sides in this debate.

More fundamentally though, the panel’s analysis 

effectively erases the subjective deliberate indifference 

requirement with its circular reasoning. Nowhere does the 

panel consider any direct evidence of Dr. Eliason’s 

subjective mental state. Cf. Jett v. Penner, 439 F.3d 1091, 

1098 & n.2 (9th Cir. 2006) (concluding that a doctor’s 

medical note stating “I reviewed xrays which showed no 

obvious fracture malalignment,” written after reviewing a 

radiology report which specifically indicated a deformity, 

could evidence deliberate indifference) (alteration in 

original). Nor does the panel consider the many reasons 

underlying Dr. Eliason’s decision to decline SRS treatment. 

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EDMO V. CORIZON 47

See supra O’Scannlain, J., dissenting at 15–22. Once those 

reasons are swept aside, the panel circularly infers deliberate 

indifference based on its prior determination that 

Dr. Eliason’s treatment plan was “ineffective” or “medically 

unacceptable” under the WPATH standards. See Edmo, 

935 F.3d at 793–94 (finding Dr. Eliason deliberately 

indifferent because his treatment “stopped short of what was 

medically necessary”).

Such an approach is particularly troublesome because, if 

replicated, deliberate indifference could be inferred solely 

from a finding of a “medically unacceptable” treatment. For 

Eighth Amendment claims like Edmo’s, a plaintiff must first 

show the “medically unacceptable” treatment of a “serious 

medical need[]” and, second, that the doctor’s treatment 

decision reflected “deliberate indifference” to the medical 

need. Jackson, 90 F.3d at 332. The panel’s analysis 

collapses this two-part inquiry into one circular step. If 

courts follow the panel’s reasoning, in every case of 

medically unacceptable treatment, courts could 

automatically infer deliberate indifference.

Worse still, because “medical acceptability” is an 

objective negligence inquiry, the ultimate effect of the 

panel’s analysis is to dilute the heightened, subjective 

culpability required for deliberate indifference, see Farmer,

511 U.S. at 839–40, into mere negligence, which the 

Supreme Court has repeatedly warned falls short of an 

Eighth Amendment violation. See, e.g., Estelle, 429 U.S. 

at 105–06. By denying rehearing en banc in this case, we 

relegate federal judges to the role of referee in medical 

disputes. This is not what the Constitution or precedent 

envisions.

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48 EDMO V. CORIZON

* * *

The Eighth Amendment’s history and text entreat us to 

hold the line on the heightened standards for a constitutional 

deprivation found in our precedent. As Justice Thomas 

rightly observed, “[t]he Eighth Amendment is not, and 

should not be turned into, a National Code of Prison 

Regulation.” Hudson, 503 U.S. at 28 (Thomas, J., 

dissenting). By judicially mandating an innovative and 

evolving standard of care, the panel effectively 

constitutionalizes a set of guidelines subject to ongoing 

debate and inaugurates yet another circuit split. And by

diluting the requisite state of mind from “deliberate 

indifference” to negligence, the panel effectively holds 

that—contrary to Supreme Court precedent—“[m]edical 

malpractice [does] become a constitutional violation merely 

because the victim is a prisoner.” Estelle, 429 U.S. at 106 

(altered). I respectfully dissent from the denial of rehearing 

en banc.

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