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Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

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In the 

United States Court of Appeals 

For the Seventh Circuit ____________________

No. 15‐2043

JAMES E. RIANO,

Plaintiff‐Appellant,

v.

ROBERT A. MCDONALD, Secretary of Veterans Affairs,

Defendant‐Appellee.

____________________

Appeal from the United States District Court for the

Eastern District of Wisconsin.

No. 11‐cv‐939 — Charles N. Clevert, Jr., Judge.

____________________

ARGUED JANUARY 11, 2016 — DECIDED AUGUST 17, 2016

____________________

Before EASTERBROOK, WILLIAMS, and SYKES, Circuit Judges.

WILLIAMS, Circuit Judge. James Riano worked as a regis‐

tered nurse for the Veterans Health Administration, which is

part of the U.S. Department of Veterans Affairs. While exam‐

ining male patients for genital warts, Riano manipulated

their penises with his hands, attempting to induce erections.

He also used words like “pecker” and “balls,” rather than

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medical terms. The agency found his examination technique

and his language to be inappropriate, so he was fired. He

appealed and was given a hearing that included representa‐

tion by counsel, live testimony from medical experts, written

testimony from patients, and a written report from an inves‐

tigator who had interviewed the patients. The appeals board

affirmed his termination.  

Riano sought review in federal district court, and now

appeals to this court, arguing that the agency’s procedures

were constitutionally inadequate. He complains that he was

not allowed to call patients to testify live. Live testimony, he

argues, would have shown that some patients were comfort‐

able with his technique and language, and also might have

shown that complaining patients had ulterior motives. But

the board’s decision to affirm Riano’s termination was based

on its determination that his technique and language were

inappropriate. That was a professional judgment that did not

turn on the patients’ subjective views. And Riano does not

dispute the relevant details about his technique and lan‐

guage. So he has failed to show that he was harmed by the

lack of live patient testimony. We affirm.

I. BACKGROUND

A. Allegations and Initial Termination

In the late 1970s and early 1980s, Riano was a hospital

corpsman in the Navy. As a civilian, he became a registered

nurse. In 2004, he began working as a registered nurse for

the Veterans Health Administration at a medical center in

Milwaukee. In the summer of 2007, he began working in the

center’s new clinic, which specialized in treating genital

warts. In January 2008, a patient accused him of sexual as‐

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No. 15‐2043 3

sault. According to the allegations, Riano told the patient

that it was easier to see genital warts on an erect penis, and

during each visit, Riano used his hands to stimulate the pa‐

tient’s penis until it was erect. Twice, the patient ejaculated.

Joe Cossairt, a Special Agent in the agency’s Office of the

Inspector General, investigated Riano. Cossairt sent ques‐

tionnaires to the forty‐eight patients Riano had treated, and

conducted follow‐up interviews with the twenty‐two who

responded. Cossairt concluded that Riano had manipulated

patients’ penises with his hands (sometimes using over‐the‐

counter moisturizing cream), and had used inappropriate

non‐medical language with patients. After reviewing the re‐

port, the chief of dermatology opined that Riano’s technique

was not standard and not medically necessary.

In December 2009, the manager of the medical division

recommended that Riano be fired because of his inappropri‐

ate language and technique. Riano responded orally and in

writing, arguing that his method of causing erections to

conduct examinations was appropriate and was what he had

learned in the Navy. The center’s associate medical director

of nursing recommended Riano be fired, and the center’s di‐

rector agreed.

B. Appeal Within Agency

1. Appeals Board’s Evidentiary Rulings

Riano appealed and was given a hearing. He had learned

the identities of some (but not all) of the patients who had

submitted written responses to the investigator’s question‐

naire. Riano’s lawyer contacted those patients and some

were supportive of Riano, saying they were comfortable

with his language and technique. Additionally, some were

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critical of the investigator, saying his questions were too

suggestive, he took their answers out of context, and he

raised an inappropriate consideration by asking if they be‐

lieved Riano was gay.  

These supportive patients submitted written statements

to the appeals board. Riano asked the board to let the pa‐

tients testify live, and he also asked for the names of all pa‐

tients who spoke to the investigator. The agency also asked

to present live testimony from some patients. The board de‐

nied these requests, citing patient privacy, potential emo‐

tional harm, and the adequacy of the patients’ written state‐

ments. The board also denied Riano’s request to present tes‐

timony from a former corpsman who had trained and

worked with Riano in the military—the board found this

proposed testimony irrelevant.

2. Riano’s Testimony

Riano testified that he learned his technique in the Navy,

and he described his technique and its justifications in some

detail. He said that he began each examination by applying

moisturizing cream to the penis. He admitted that doing so

was not strictly necessary, but he said that it created a sheen

that made warts easier to see. The cream also combated dry

skin and he applied it over the entire penis, including areas

not being examined. He then “pull[ed] out” on the penis and

applied pressure at the base of the penis to “entrap blood

within the shaft which would provide a firmer surface.”

That caused the penis to become “enlarged.” Riano estimat‐

ed that 75–80% of his patients developed partial or full erec‐

tions. That result was intended because Riano believed the

firm surface—enlargement, erection, or engorgement—made

warts easier to see. (Indeed, he told patients to do self‐

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No. 15‐2043 5

examinations at home when they had “full erection[s].”)

Riano denied wrapping his hand around the penis and

stroking it, denied telling patients to visualize women they

wanted to have sex with, denied telling patients not to mas‐

turbate for a week prior to seeing him for an examination,

and denied conducting examinations in a manner designed

to result in his own personal pleasure.

Concerning his communication with patients, Riano ad‐

mitted to using terms like “cock,” “dick,” “tool,” and “balls,”

and also to identifying himself as a “pecker checker” and

“dick doctor,” but he said he only used such terms if the pa‐

tient did so first. Such language, he said, can put patients at

ease. He denied discussing any patient’s examination with

another patient and denied complimenting patients for hav‐

ing smooth penile skin. But he admitted saying to a patient,

“you hang,” referring to the size and position of the patient’s

flaccid penis. That comment, he said, was relevant to his ad‐

vice to the patient—to cover up a blister so that it did not rub

against the patient’s underwear and cause irritation.

3. Medical Testimony

The agency presented a number of medical witnesses.

William Aughenbaugh, the department’s director of derma‐

tology, testified that he had treated thousands of male pa‐

tients for genital warts. He would sometimes, but not typi‐

cally, gently stretch a patient’s skin, and for small warts he

would sometimes use magnifying lenses. But he testified

that a firm surface is not necessary. He also testified that it

was inappropriate to use crude language with patients, even

to put patients at ease. Blaine Jensen, a certified physician’s

assistant, testified that he had treated about one hundred pa‐

tients and that an erection—even a partial one—was not nec‐

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6   No. 15‐2043

essary, nor would it make treatment easier. He also testified

that crude language was inappropriate but admitted to us‐

ing words like “nuts,” “balls,” and “dick” with younger vet‐

erans to build rapport. Judith Murphy, who was previously

the medical center’s associate director of nursing, testified

that it was not necessary to have an enlarged surface to see

genital warts and that it was unprofessional to use terms like

“pecker” and “dick,” even to put patients at ease.

Riano also presented medical testimony. April Bigelow, a

nurse practitioner in a clinic that specializes in treating sex‐

ually transmitted diseases, testified that she had treated

hundreds of patients, about half of whom became at least

partially erect when their skin was manipulated. She opined

that greater surface area can be beneficial, and she some‐

times told patients that a self‐examination might be easier

with an erect penis. But she also said that an erection was

not medically necessary, that she had never purposefully in‐

duced a patient’s erection, and that she did not think doing

so was an acceptable medical technique. She said that Riano

described his technique to her as “sometimes appl[ying]

pressure at the base of the penis in order to enhance surface

area.” In her opinion, that was “within the scope of practice

for a nurse.” She also said that if a patient used “crude lan‐

guage” to describe body parts, she would use the same lan‐

guage, to facilitate communication. Amber Robbins, a der‐

matologist, testified that she had conducted between twenty

and thirty genital‐wart examinations in the prior three years,

and her patients rarely developed erections. She said that

purposefully causing an erection was not a method that she

would use, nor was it necessary.  

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Jeanine Harvey also testified in defense of Riano. Harvey

was one of the center’s health technicians and, like Riano,

had been a Navy corpsman. Her description of a corpsman’s

training and experience matched Riano’s. Harvey knew

many military providers, herself included, who applied

pressure to the base of a penis to induce firmness when ex‐

amining for genital warts or other conditions. She opined

that doing so was necessary. She had seen frequent erections,

and four ejaculations, during examinations. She also testified

that it was common to use moisturizing cream to create a

sheen that makes warts easier to see.

4. Appeals Board’s Conclusion and Judicial Re‐

view

The appeals board found that Riano failed to distinguish

between language and practices suitable for a corpsman and

those suitable for a registered nurse. The board recognized

that not all patients subjectively felt that they had been as‐

saulted or that Riano’s communication with them had been

inappropriate. But the board found that, objectively, Riano

had used language and an examination technique that was

medically inappropriate. So the board affirmed Riano’s ter‐

mination. He sought review in the district court, which af‐

firmed, and he now appeals to this court.

II. ANALYSIS

The agency brought two “charges” against Riano: (i) in‐

appropriate manual manipulation of male veterans’ genitals;

and (ii) unprofessional comments to veterans during exami‐

nation or treatment. Each charge was made up of numerous

“specifications,” which are individual instances of alleged

misconduct. To sustain a charge, the agency was only re‐

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quired to prove one specification, and only so much of that

specification as necessary to sustain the essence of the

charge. See Burroughs v. Dep’t of the Army, 918 F.2d 170, 172

(Fed. Cir. 1990); Avant v. Dep’t of Air Force, 71 M.S.P.R. 192,

198 (1996).

Riano had a statutory right to appeal his termination,

first within the agency and then to federal court. 38 U.S.C.

§§ 7401(1), 7461(a), 7462(f)(1). In court, he complains about

alleged defects in the agency’s procedures, so we must set

aside the agency’s decision if it was “obtained without pro‐

cedures required by law.” 38 U.S.C. § 7462(f)(2)(B). The

“law” that Riano relies on is the federal constitution and as a

“public employee” who had “a property interest in [his]

job,” the constitution protects him from being fired without

“due process of law.” Carmody v. Bd. of Trs. of the Univ. of Ill.,

747 F.3d 470, 474 (7th Cir. 2014) (citing cases). “The funda‐

mental requirement of due process is the opportunity to be

heard ‘at a meaningful time and in a meaningful manner.’”

Mathews v. Eldridge, 424 U.S. 319, 333 (1976) (quoting Arm‐

strong v. Manzo, 380 U.S. 545, 552 (1965)).

We have said that “the due process clause is flexible and

requires only ‘such procedural protections as the particular

situation demands.’” Ringquist v. Hampton, 582 F.2d 1138,

1140 (7th Cir. 1978) (quoting Morrissey v. Brewer, 408 U.S. 471,

481 (1972)). To determine whether an agency’s procedures

failed to meet the constitutional minimum, courts balance

three factors: “first, the private interest that was affected by

the official action; second, the risk of erroneous deprivation

of such interest through the procedures used, and the prob‐

able value, if any, of additional or substitute procedural

safeguards; and finally, the Government’s interest, including

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No. 15‐2043 9

the function involved and the fiscal and administrative bur‐

dens that the additional or substitute procedural require‐

ment would entail.” Mann v. Vogel, 707 F.3d 872, 879 (7th Cir.

2013) (internal quotation marks and brackets omitted) (quot‐

ing Mathews, 424 U.S. at 335). Riano complains about the ap‐

peals board’s refusal to hear live patient testimony. Riano

wanted to present live testimony from supportive patients,

and wanted to cross‐examine complaining patients. Riano

argues that the balancing analysis prescribed by Mathews

demonstrates that live testimony and cross‐examination

were constitutionally required.  

But a balancing analysis is not required if Riano cannot

explain how live testimony and cross‐examination would

have helped his case. See Clancy v. Geithner, 559 F.3d 595, 601

(7th Cir. 2009) (lack of hearing did not violate due process

where plaintiff did “not identify any material factual dis‐

putes that could have been resolved by an evidentiary hear‐

ing or cross‐examination of witnesses”); Wozniak v. Conry,

236 F.3d 888, 890 (7th Cir. 2001) (“[E]ven for the most im‐

portant decisions, an evidentiary hearing is required only if

there are material factual disputes.”); see also Cleveland Bd. of

Educ. v. Loudermill, 470 U.S. 532, 544 (1985) (noting that the

employees’ terminations involved “arguable issues” and that

their due‐process argument did not require them to show

“certain success”). That rule is well illustrated by Ringquist v.

Hampton, 582 F.2d 1138 (7th Cir. 1978). Ringquist was fired

from his job as an auditor for the IRS. The reason was that on

audits related to seventeen tax returns, Ringquist had

marked certain deductions as “verified” even though the

taxpayers lacked verifying documentation. Ringquist’s de‐

fense was that although the taxpayers lacked documenta‐

tion, Ringquist had, with an innocent state of mind, relied on

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representations made to him by the taxpayers’ tax preparer.

Ringquist’s termination was upheld after a hearing at which

affidavits were received from the seventeen taxpayers but

the taxpayers did not testify live and were not available for

cross‐examination. In federal court, Ringquist argued that

due process required an opportunity to cross‐examine the

taxpayers. We rejected that argument because Ringquist’s

theory of defense—that he had innocently relied on the tax

preparer, and that the deductions were, in a technical sense,

“verified”—would not have been advanced by cross‐

examining the taxpayers. Id. at 1141.

Riano’s case is similar. The appeals board issued a written

opinion explaining its determination that Riano’s language

and examination technique were medically inappropriate.

That decision was not dependent on the subjective feelings

of Riano’s patients. Notably, several patients said—in written

statements or in their interviews with the investigator—that

Riano had manipulated their penises, but not in a way that

made them uncomfortable. A typical statement was that

Riano “never continued to ‘stroke’ or manipulate my penis

beyond what was necessary for him to treat me or find the

warts.” But what is “necessary” in a genital‐wart examina‐

tion is a medical question, and the board heard testimony

that: (i) Riano’s technique was not necessary; and (ii) patients

tend to trust what their medical provider tells them about

what is “necessary.” So, though the board acknowledged the

patients’ statements, it did not find that they supported over‐

turning Riano’s termination.  

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No. 15‐2043 11

Nor was the board’s decision based on Riano’s subjective

intentions.1 In arguing that his intentions were innocent,

Riano stressed that he learned his examination technique in

the Navy, where he also learned to use slang to put patients

at ease. The record shows that the board found those factual

contentions irrelevant. The board denied Riano’s request to

call as a witness a “former corpsman who was trained with

and worked in the same military clinics” as Riano. The board

considered the corpsman’s proposed testimony irrelevant,

noting that “corpsman training is not equivalent to [regis‐

tered nurse].” The board credited Riano’s testimony about

his training but found it “significant” that he was unable “to

distinguish his training and actions as a corpsman (with no

professional licensure or training) from that of the profes‐

sional licensed registered nurse.” The board specifically

found that Riano’s “training as a Navy corpsman in the

treatment of genital warts and the acceptance of the use of

crude slang terms, is not [an] excuse for this behavior to

have continued after he received training as a Registered

Nurse and in his practice as a nurse in the Department of

Veterans Affairs Medical Center.”  

Because the board did not rely on the subjective feelings

of patients, or the subjective intentions of Riano, Riano does

not state a due‐process violation by arguing that live patient

testimony and cross‐examination would have been relevant

to those issues. In Green v. Board of School Commissioners, 716

F.2d 1191 (7th Cir. 1983), a school bus driver was fired for

making “suggestive, lewd, and/or sexual advances” to girls

                                                  1 To be sure, the agency’s lawyer asked Riano questions that were

aimed at his subjective intentions. But we review the board’s decision,

not the lawyer’s examination.

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on his bus. His argument that he was denied due process be‐

cause he could not cross‐examine the girls was rejected, in

part because he admitted to the relevant conduct and dis‐

puted only the irrelevant issue of his state of mind. Id. at

1193 (“Green concedes that he often ‘clowned around’ with

girls on his bus. Maybe Green’s intentions when he touched

these girls were not as bad as the girls believed. That, how‐

ever, is beside the point. Green was charged with having

made ‘suggestive, lewd, and/or sexual advances,’ not with

attempted rape.”). In McNeill v. Butz, 480 F.2d 314 (4th Cir.

1973), a male named McNeill and a female named Canaday

were both fired from the Department of Agriculture for al‐

leged wrongdoing. They were given hearings but not al‐

lowed to cross‐examine their accusers. The court found that

under the particular circumstances, cross‐examination was

constitutionally required. Id. at 325. The court reversed Can‐

aday’s termination. Id. at 326. But it affirmed McNeill’s be‐

cause, though he denied some of the allegations against him,

he admitted enough of them to justify his termination. Id.  

Riano is like Green in Green and McNeill in McNeill (and

not like Canaday in McNeill). That is, the appeals board justi‐

fiably affirmed his termination based on facts that he admit‐

ted. To the extent he disputed very specific details—such as

whether he wrapped his hand around the penis—resolving

those disputes was not necessary to the board’s decision. In

short, we agree with the reasoning and conclusion of the dis‐

trict court:  

Here, Riano is like the male employee in

McNeill. His own testimony provided confir‐

mation or corroboration of his treatment tech‐

nique. Regardless of whether the veteran pa‐

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No. 15‐2043 13

tients were accurate as to lengthy stroking of

their penises and whether Riano manipulated

them to a partial or full erection, Riano’s own

testimony confirmed that he pressed on the

veteran patients’ penises to increase blood flow

and firmness. And he admitted using corps‐

man language with patients. Hence, Riano fails

to persuade this court that confrontation and

examination of the veteran witnesses would

have altered the hearing result in any way.

III. CONCLUSION

The decision of the district court is AFFIRMED.

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