Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-19-35017/USCOURTS-ca9-19-35017-0/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; AL RAMIREZ, in his 

official capacity as warden of Idaho 

State Correctional Institution;

*

HENRY ATENCIO; JEFF ZMUDA;

HOWARD KEITH YORDY; RICHARD 

CRAIG; RONA SIEGERT,

Defendants.

No. 19-35017

D.C. No.

1:17-cv-00151-

BLW

ADREE EDMO, AKA Mason Edmo,

Plaintiff-Appellee,

No. 19-35019

* Al Ramirez is substituted in his official capacity for his 

predecessor, Howard Keith Yordy, pursuant to Rule 43(c)(2) of the 

Federal Rules of Appellate Procedure.

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2 EDMO V. CORIZON

v.

IDAHO DEPARTMENT OF 

CORRECTIONS; AL RAMIREZ, in his 

official capacity as warden of Idaho 

State Correctional Institution; HENRY 

ATENCIO; JEFF ZMUDA; HOWARD 

KEITH YORDY; RICHARD CRAIG;

RONA SIEGERT,

Defendants-Appellants,

and

CORIZON, INC.; SCOTT ELIASON;

MURRAY YOUNG; CATHERINE 

WHINNERY,

Defendants.

D.C. No.

1:17-cv-00151-

BLW

OPINION

Appeal from the United States District Court

for the District of Idaho

B. Lynn Winmill, Chief District Judge, Presiding

Argued and Submitted May 16, 2019

San Francisco, California

Filed August 23, 2019

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

Circuit Judges, and Robert S. Lasnik,** District Judge.

Per Curiam Opinion

** 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***

Eighth Amendment / Prisoner Rights

The panel affirmed the district court’s entry of a 

permanent injunction in favor of Idaho state prisoner Adree 

Edmo, but vacated the injunction to the extent it applied to 

defendants Corizon, Howard Yordy, Rona Siegert, Dr. 

Young, Dr. Craig, and Dr. Whinnery, in their individual 

capacities, in Edmo’s action seeking medical treatment for 

gender dysphoria.

The district court concluded that Edmo had established 

her Eighth Amendment claim. The district court further 

concluded that gender confirmation surgery (“GCS”) was 

medically necessary for Edmo, and ordered the State to 

provide the surgery.

The panel credited the district court’s factual findings as 

logical and well-supported, and held that the responsible 

prison authorities were deliberately indifferent to Edmo’s 

gender dysphoria, in violation of the Eighth Amendment. 

The panel held that the record, as construed by the district 

court, established that Edmo had a serious medical need, that 

the appropriate medical treatment was GCS, and that prison 

authorities had not provided that treatment despite full 

knowledge of Edmo’s ongoing and extreme suffering and 

medical needs. The panel rejected the State’s position that 

there was a reasoned disagreement between qualified 

medical professionals. The panel emphasized that its 

*** 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

analysis was individual to Edmo, and rested on the record of 

this case.

Addressing further aspects of the appeal, the panel 

rejected the State’s contention that the district court did not 

make the Prison Litigation Reform Act’s requisite “neednarrowness-intrusiveness” findings, causing the injunction 

to automatically expire and mooting the appeal. The panel 

held that the district court’s order, considered as a whole, 

made all the findings required by 18 U.S.C. § 3626(a)(1)(A), 

and Ninth Circuit precedent. The panel also held that the 

permanent injunction that the district court entered had not 

expired, and remained in place, albeit stayed. The panel 

accordingly denied the State’s motion to dismiss.

The panel held that the district court did not err in 

granting a permanent injunction. Specifically, the panel 

held, based on the district court’s factual findings, that Edmo 

established her Eighth Amendment claim and that she will 

suffer irreparable harm – in the form of ongoing mental 

anguish and possible physical harm – if GCS is not provided. 

The State did not dispute that Edmo’s gender dysphoria was 

a sufficiently serious medical need to trigger the State’s 

obligations under the Eighth Amendment. The panel held 

that the district court did not err in crediting the testimony of 

Edmo’s experts that GCS was medically necessary to treat 

Edmo’s gender dysphoria and that the State’s failure to 

provide that treatment was medically unacceptable. The 

panel further held that the district court did not err in 

discrediting the State’s experts because aspects of their 

opinions were illogical and unpersuasive. Also, the panel 

held that the record demonstrated that Dr. Eliason acted with 

deliberate indifference to Edmo’s serious medical needs. 

The panel noted that its decision was in tension with the Fifth 

Circuit’s decision in Gibson v. Collier, 920 F.3d 212 (5th 

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EDMO V. CORIZON 5

Cir. 2019), and the panel rejected that decision’s categorical 

holding that denying GCS cannot, as a matter of law, violate 

the Eighth Amendment.

The panel held that the district court did not err in finding 

that Edmo would be irreparably harmed absent an 

injunction. The panel rejected the State’s contentions as to 

why the district court erred in this finding.

The panel next considered the State’s challenges to the 

scope of the injunction. The panel held that the injunction 

was properly entered against Dr. Eliason because he 

personally participated in the deprivation of Edmo’s 

constitutional rights. The panel also held that because Edmo 

may properly pursue her Eighth Amendment claim for 

injunctive relief against Attencio, Zmuda and Ramirez in 

their official capacities, they were properly included within 

the scope of the district court’s injunction. On remand, the 

district court shall amend the injunction to substitute the 

current warden as a party for Yordy. The panel vacated the 

district court’s injunction to the extent it applied to Yordy, 

Siegert, Dr. Young, Dr. Craig, and Dr. Whinnery in their 

individual capacities because the evidence in the record was 

insufficient to conclude that they were deliberately 

indifferent to Edmo’s serious medical needs. The panel 

vacated the injunction as to Corizon, and remanded with 

instructions to the district court to modify the injunction to 

exclude Corizon. Finally, the panel held that the injunctive 

relief ordered was not overbroad.

The panel considered the State’s challenges to the 

procedure used by the district court. The panel rejected the 

State’s contention that the district court erroneously 

converted the evidentiary hearing into a final trial on the 

merits without giving proper notice. The panel held that the 

State did receive notice, and in any event, the State had not 

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6 EDMO V. CORIZON

shown any prejudice. The panel also rejected the State’s 

contention that the district court violated defendants’ 

Seventh Amendment right to a jury trial by converting the 

evidentiary hearing into a trial on the merits. The panel held 

that the State’s conduct waived its right to a jury trial with 

respect to issues common to Edmo’s request for an 

injunction ordering GCS and her legal claims.

COUNSEL

Brady J. Hall (argued), Special Deputy Attorney General; 

Lawrence G. Wasden, Attorney General; Office of the 

Attorney General, Boise, Idaho; Marisa S. Crecelius, Moore 

Elia Kraft & Hall LLP, Boise, Idaho; for DefendantsAppellants Idaho Department of Corrections, Henry 

Atencio, Jeff Zmuda, Howard Keith Yordy, Richard Craig, 

and Rona Siegert.

Dylan A. Eaton (argued), J. Kevin West, and Bryce Jensen, 

Parsons Behle & Latimer, Boise, Idaho, for DefendantsAppellants Corizon, Inc.; Scott Eliason; Murray Young; and 

Catherine Whinnery.

Lori Rifkin (argued), Hadsell Stormer & Renick LLP, 

Emeryville, California; Dan Stormer and Shaleen Shanbhag,

Hadsell Stormer & Renick LLP, Pasadena, California; Craig 

Durham and Deborah Ferguson, Ferguson Durham PLLC, 

Boise, Idaho; Amy Whelan and Julie Wilensky, National 

Center for Lesbian Rights, San Francisco, California; for 

Plaintiff-Appellee.

David M. Shapiro, Sheila A. Bedi, and Vanessa del Valle, 

Roderick & Solange MacArthur Justice Center, Chicago, 

Illinois; Molly E. Whitman, Akin Gump Strauss Hauer & 

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EDMO V. CORIZON 7

Feld LLP, Dallas, Texas; for Amici Curiae Andrea 

Armstrong, Sharon Dolovich, Betsy Ginsberg, Michael B. 

Mushlin, Alexander A. Reinert, Laura Rovner, and Margo 

Schlanger.

Molly Kafka and Richard Alan Eppink, ACLU of Idaho 

Foundation, Boise, Idaho; Devon A. Little and Derek 

Borchardt, Walden Macht & Haran LLP, New York, New 

York; Amy Fettig and Jennifer Wedekind, ACLU National 

Prison Project, Washington, D.C.; Gabriel Arkles and Rose 

Saxe, ACLU LGBT & HIV Project/ACLU Foundation, New 

York, New York; for Amici Curiae Former Corrections 

Officials.

Devi M. Rao and Jason T. Perkins, Jenner & Block LLP, 

Washington, D.C., for Amici Curiae Medical and Mental 

Health Professional Organizations.

Sharif E. Jacob, Ryan K. M. Wong, Kristin E. Hucek, and 

Patrick E. Murray, Keker Van Nest & Peters LLP, San 

Francisco, California, for Amicus Curiae Jody L. Herman.

Alan E. Schoenfeld, Wilmer Cutler Pickering Hale and Dorr 

LLP, New York, New York; Michael Posada, Wilmer Cutler 

Pickering Hale and Dorr LLP, Washington, D.C.; Richard 

Saenz, Lambda Legal Defense & Education Fund Inc., New 

York, New York; A. Chinyere Ezie, Center for 

Constitutional Rights, New York, New York; for Amici 

Curiae Civil Rights & Non-Profit Organizations.

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8 EDMO V. CORIZON

OPINION

PER CURIAM:

The Eighth Amendment prohibits “cruel and unusual 

punishments.” U.S. Const. amend. VIII. “The Amendment 

embodies broad and idealistic concepts of dignity, civilized 

standards, humanity, and decency . . . .” Estelle v. Gamble, 

429 U.S. 97, 102 (1976) (quotation omitted). Our society 

recognizes that prisoners “retain the essence of human 

dignity inherent in all persons.” Brown v. Plata, 563 U.S. 

493, 510 (2011).

Consistent with the values embodied by the Eighth 

Amendment, for more than 40 years the Supreme Court has 

held that “deliberate indifference to serious medical needs” 

of prisoners constitutes cruel and unusual punishment. 

Estelle, 429 U.S. at 106. When prison authorities do not 

abide by their Eighth Amendment duty, “the courts have a 

responsibility to remedy the resulting . . . violation.” Brown, 

563 U.S. at 511. We do so here.

Adree Edmo (formerly Mason Dean Edmo) is a male-tofemale transgender prisoner in the custody of the Idaho 

Department of Correction (“IDOC”). Edmo’s sex assigned 

at birth (male) differs from her gender identity (female). The 

incongruity causes Edmo to experience persistent distress so 

severe it limits her ability to function. She has twice 

attempted self-castration to remove her male genitalia, 

which cause her profound anguish.

Both sides and their medical experts agree: Edmo suffers 

from gender dysphoria, a serious medical condition. They 

also agree that the appropriate benchmark regarding 

treatment for gender dysphoria is the World Professional 

Association of Transgender Health Standards of Care for the 

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EDMO V. CORIZON 9

Health of Transsexual, Transgender, and Gender 

Nonconforming People (“WPATH Standards of Care”). 

And the State1 does not seriously dispute that in certain 

circumstances, gender confirmation surgery (“GCS”) can be 

a medically necessary treatment for gender dysphoria. The 

parties’ dispute centers around whether GCS is medically 

necessary for Edmo—a question we analyze with deference 

to the district court’s factual findings.

Following four months of intensive discovery and a 

three-day evidentiary hearing, the district court concluded 

that GCS is medically necessary for Edmo and ordered the 

State to provide the surgery. Its ruling hinged on findings 

individual to Edmo’s medical condition. The ruling also 

rested on the finding that Edmo’s medical experts testified 

persuasively that GCS was medically necessary, whereas 

testimony from the State’s medical experts deserved little 

weight. In contrast to Edmo’s experts, the State’s witnesses 

lacked relevant experience, could not explain their 

deviations from generally accepted guidelines, and testified 

illogically and inconsistently in important ways.

The district court’s detailed factual findings were amply 

supported by its careful review of the extensive evidence and 

testimony. Indeed, they are essentially unchallenged. The 

appeal boils down to a disagreement about the implications 

of the factual findings.

Crediting, as we must, the district court’s logical, wellsupported factual findings, we hold that the responsible 

1 In addition to IDOC, Edmo sued Corizon, Inc. (a private for-profit 

corporation that provides health care to inmates in IDOC custody) and 

various employees of IDOC and Corizon. The defendants briefed the 

case jointly, and for ease of reference we refer to them collectively as 

“the State.”

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10 EDMO V. CORIZON

prison authorities have been deliberately indifferent to 

Edmo’s gender dysphoria, in violation of the Eighth 

Amendment. The record before us, as construed by the 

district court, establishes that Edmo has a serious medical 

need, that the appropriate medical treatment is GCS, and that 

prison authorities have not provided that treatment despite 

full knowledge of Edmo’s ongoing and extreme suffering 

and medical needs. In so holding, we reject the State’s 

portrait of a reasoned disagreement between qualified 

medical professionals. We also emphasize that the analysis 

here is individual to Edmo and rests on the record in this 

case. We do not endeavor to project whether individuals in 

other cases will meet the threshold to establish an Eighth 

Amendment violation. The district court’s order entering 

injunctive relief for Edmo is affirmed, with minor 

modifications noted below.

Our opinion proceeds as follows. In Part I, we provide 

background on gender dysphoria, the standard of care, and 

the evidence considered and factual findings made by the 

district court. Part II explains why this appeal complies with 

the Prison Litigation Reform Act (“PLRA”) and is not moot. 

In Part III, we turn to the gravamen of the appeal: Edmo’s 

Eighth Amendment claim and showing of irreparable injury. 

Part IV addresses the State’s challenges to the injunction’s 

scope and narrows the injunction as to certain defendants. 

Part V rejects the State’s objections to the procedure 

employed by the district court. We conclude in Part VI.

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EDMO V. CORIZON 11

I. Background2

A. Gender Dysphoria and its Treatment

Transgender individuals have a “[g]ender identity”—a 

“deeply felt, inherent sense” of their gender—that does not 

align with their sex assigned at birth.3 Am. Psychol. Ass’n, 

Guidelines for Psychological Practice with Transgender 

and Gender Nonconforming People, 70 Am. Psychologist 

832, 834 (2015). Recent estimates suggest that 

approximately 1.4 million transgender adults live in the 

United States, or 0.6 percent of the adult population. 

Andrew R. Flores et al., The Williams Inst., How Many 

Adults Identify as Transgender in the United States?, at

2 (2016), http://williamsinstitute.law.ucla.edu/wp-content/

uploads/How-Many-Adults-Identify-as-Transgender-in-theUnited-States.pdf.

Gender dysphoria4 is “[d]istress that is caused by a 

discrepancy between a person’s gender identity and that 

person’s sex assigned at birth (and the associated gender role 

and/or primary and secondary sex characteristics).” World 

Prof’l Ass’n for Transgender Health, Standards of Care for 

the Health of Transsexual, Transgender, and Gender2 The following sections are derived from the district court’s factual 

findings and the record on appeal.

3 At birth, infants are classified as male or female based on visual 

observation of their external genitalia. This is a person’s “sex assigned 

at birth,” but it may not be the person’s gender identity.

4 Until recently, the medical community commonly referred to 

gender dysphoria as “gender identity disorder.” See Kosilek v. Spencer, 

774 F.3d 63, 68 n.1 (1st Cir. 2014).

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12 EDMO V. CORIZON

Nonconforming People 2 (7th ed. 2011) (hereinafter 

“WPATH SOC”). The Fifth Edition of the American 

Psychiatric Association’s Diagnostic and Statistical Manual 

of Mental Disorders (“DSM-5”) sets forth two conditions 

that must be met for a person to be diagnosed with gender 

dysphoria.5

First, there must be “[a] marked incongruence between 

one’s experienced/expressed gender and assigned gender, of 

at least 6 months’ duration, as manifested by at least two of 

the following”:

(1) “a marked incongruence between one’s 

experienced/expressed gender and primary 

and/or secondary sex characteristics”;

(2) “a strong desire to be rid of one’s primary 

and/or secondary sex characteristics because 

of a marked incongruence with one’s 

experienced/expressed gender”;

(3) “a strong desire for the primary and/or 

secondary sex characteristics of the other 

gender”;

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

(5) “a strong desire to be treated as the other 

gender”; or

5 Each expert in the case used these criteria to determine whether 

Edmo has gender dysphoria.

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EDMO V. CORIZON 13

(6) “a strong conviction that one has the 

typical feelings and reactions of the other 

gender.”

Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of 

Mental Disorders 452 (5th ed. 2013) (hereinafter “DSM-5”). 

Second, the person’s condition must be associated with 

“clinically significant distress”—i.e., distress that impairs or 

severely limits the person’s ability to function in a 

meaningful way and has reached a threshold that requires 

medical or surgical intervention, or both. Id. at 453, 458. 

Not every transgender person has gender dysphoria, and not 

every gender dysphoric person has the same medical needs.

Gender dysphoria is a serious but treatable medical 

condition. Left untreated, however, it can lead to debilitating 

distress, depression, impairment of function, substance use, 

self-surgery to alter one’s genitals or secondary sex 

characteristics, self-injurious behaviors, and even suicide.

The district court found that the World Professional 

Association of Transgender Health Standards of Care for the 

Health of Transsexual, Transgender, and Gender 

Nonconforming People (“WPATH Standards of Care”)6

“are the internationally recognized guidelines for the 

treatment of individuals with gender dysphoria.” Edmo v. 

Idaho Dep’t of Corr., 358 F. Supp. 3d 1103, 1111 (D. Idaho 

2018). Most courts agree. See, e.g., De’lonta v. Johnson, 

708 F.3d 520, 522–23 (4th Cir. 2013); Keohane v. Jones, 

328 F. Supp. 3d 1288, 1294 (N.D. Fla. 2018), appeal filed,

6 The WPATH Standards of Care were formerly referred to as the 

“Harry Benjamin Standards of Care” and were promulgated by WPATH 

under its former name, the “Harry Benjamin International Gender 

Dysphoria Association.” Kosilek, 774 F.3d at 70 & n.3.

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14 EDMO V. CORIZON

No. 18-14096 (11th Cir. 2018); Norsworthy v. Beard, 87 F. 

Supp. 3d 1164, 1170 (N.D. Cal.), appeal dismissed & 

remanded, 802 F.3d 1090 (9th Cir. 2015); Soneeya v. 

Spencer, 851 F. Supp. 2d 228, 231–32 (D. Mass. 2012). But 

see Gibson v. Collier, 920 F.3d 212, 221 (5th Cir. 2019) 

(“[T]he WPATH Standards of Care reflect not consensus, 

but merely one side in a sharply contested medical debate 

over [GCS].”); cf. Kosilek, 774 F.3d at 76–79 (recounting 

testimony questioning the WPATH Standards of Care). And 

many of the major medical and mental health groups in the 

United States—including the American Medical 

Association, the American Medical Student Association, the 

American Psychiatric Association, the American 

Psychological Association, the American Family Practice 

Association, the Endocrine Society, the National 

Association of Social Workers, the American Academy of 

Plastic Surgeons, the American College of Surgeons, Health 

Professionals Advancing LGBTQ Equality, the HIV 

Medicine Association, the Lesbian, Bisexual, Gay and 

Transgender Physician Assistant Caucus, and Mental Health 

America—recognize the WPATH Standards of Care as 

representing the consensus of the medical and mental health 

communities regarding the appropriate treatment for 

transgender and gender dysphoric individuals.

Each expert in this case relied on the WPATH Standards 

of Care in rendering an opinion. As the State acknowledged 

to the district court, the WPATH Standards of Care “provide 

the best guidance,” and “are the best standards out there.” 

“There are no other competing, evidence-based standards 

that are accepted by any nationally or internationally 

recognized medical professional groups.” Edmo, 358 F. 

Supp. 3d at 1125.

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EDMO V. CORIZON 15

“[B]ased on the best available science and expert 

professional consensus,” the WPATH Standards of Care 

provide “flexible clinical guidelines” “to meet the diverse 

health care needs of transsexual, transgender, and gender 

nonconforming people.” WPATH SOC at 1–2. Treatment 

under the WPATH Standards of Care must be 

individualized: “[w]hat helps one person alleviate gender 

dysphoria might be very different from what helps another 

person.” Id. at 5. “Clinical departures from the [WPATH 

Standards of Care] may come about because of a patient’s 

unique anatomic, social, or psychological situation; an 

experienced health professional’s evolving method of 

handling a common situation; a research protocol; lack of 

resources in various parts of the world; or the need for 

specific harm reduction strategies.” Id. at 2.

The WPATH Standards of Care identify the following 

evidence-based treatment options for individuals with 

gender dysphoria:

(1) “changes in gender expression and role 

(which may involve living part time or full 

time in another gender role, consistent with 

one’s gender identity)”;

(2) “psychotherapy (individual, couple, 

family, or group) for purposes such as 

exploring gender identity, role, and 

expression[,] addressing the negative impact 

of gender dysphoria and stigma on mental 

health[,] alleviating internalized 

transphobia[,] enhancing social and peer 

support[,] improving body image[,] or 

promoting resilience”;

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16 EDMO V. CORIZON

(3) “hormone therapy to feminize or 

masculinize the body”; and

(4) “surgery to change primary and/or 

secondary sex characteristics (e.g., 

breasts/chest, external and/or internal 

genitalia, facial features, body contouring).”

Id. at 10. The WPATH Standards of Care state that many 

individuals “find comfort with their gender identity, role, 

and expression without surgery.” Id. at 54. For others, 

however, “surgery is essential and medically necessary to 

alleviate their gender dysphoria.” Id. That group cannot 

achieve “relief from gender dysphoria . . . without 

modification of their primary and/or secondary sex 

characteristics to establish greater congruence with their 

gender identity.” Id. at 55; see also Jae Sevelius & Valerie 

Jenness, Challenges and Opportunities for GenderAffirming Healthcare for Transgender Women in Prison, 

13 Int’l J. Prisoner Health 32, 36 (2017) (“Negative 

outcomes such as genital self-harm, including autocastration 

and/or autopenectomy, can arise when gender-affirming 

surgeries are delayed or denied.”); George R. Brown & 

Everett McDuffie, Health Care Policies Addressing 

Transgender Inmates in Prison Systems in the United States, 

15 J. Corr. Health Care 280, 287–88 (2009) (describing the 

authors’ “firsthand knowledge of completed autocastration 

and/or autopenectomy in six facilities in four states”).

The weight of opinion in the medical and mental health 

communities agrees that GCS is safe, effective, and 

medically necessary in appropriate circumstances. See, e.g., 

U.S. Dep’t of Health & Human Servs., No. A-13-87, 

Decision No. 2576, (Dep’t Appeals Bd. May 30, 2014); 

Randi Ettner, et al., Principles of Transgender Medicine and 

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EDMO V. CORIZON 17

Surgery 109–11 (2d ed. 2016); Jordan D. Frey, et al., A 

Historical Review of Gender-Affirming Medicine: Focus on 

Genital Reconstruction Surgery, 14 J. Sexual Med. 991, 991 

(2017); Cynthia S. Osborne & Anne A. Lawrence, Male 

Prison Inmates With Gender Dysphoria: When Is Sex 

Reassignment Surgery Appropriate?, 45 Archives of Sexual 

Behav. 1649, 1651–53 (2016); see also De’lonta, 708 F.3d 

at 523 (“Pursuant to the Standards of Care, after at least one 

year of hormone therapy and living in the patient’s identified 

gender role, sex reassignment surgery may be necessary for 

some individuals for whom serious symptoms persist. In 

these cases, the surgery is not considered experimental or 

cosmetic; it is an accepted, effective, medically indicated 

treatment for [gender dysphoria].”).

The WPATH criteria for genital reconstruction surgery 

in male-to-female patients include the following:

(1) “persistent, well documented gender 

dysphoria”;

(2) “capacity to make a fully informed 

decision and to consent for treatment”;

(3) “age of majority in a given country”;

(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”; and

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18 EDMO V. CORIZON

(6) “12 continuous months of living in a 

gender role that is congruent with their 

gender identity.”

WPATH SOC at 60. The parties’ dispute focuses on 

whether Edmo satisfied the fourth and sixth criteria.

With respect to the fourth criterion, the WPATH 

Standards of Care provide that coexisting medical or mental 

health concerns unrelated to the person’s gender dysphoria 

do not necessarily preclude surgery. Id. at 25. But those 

concerns need to be managed prior to, or concurrent with, 

treatment of a person’s gender dysphoria. Id. Coexisting 

medical or mental health issues resulting from a person’s 

gender dysphoria are not an impediment under the fourth 

criterion. It may be difficult to determine, however, whether 

mental or medical health concerns result from the gender 

dysphoria or are unrelated.

The WPATH Standards of Care explain that the sixth 

criterion—living for 12 months in an identity-congruent 

role—is intended to ensure that the person experiences the 

full range of “different life experiences and events that may 

occur throughout the year.” Id. at 61. During that time, the 

patient should present consistently in her desired gender 

role. Id.

Scientific studies show that the regret rate for individuals 

who undergo GCS is low, in the range of one to two percent. 

See, e.g., Osborne & Lawrence, Male Prison Inmates With 

Gender Dysphoria, 45 Archives of Sexual Behav. at 1660; 

William Byne, et al., Report of the American Psychiatric 

Association Task Force on Treatment of Gender Identity 

Disorder, 41 Archives of Sexual Behav. 759, 780–81 

(2012). The district court found, and the State does not 

dispute on appeal, that Edmo does not have any of the risk 

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EDMO V. CORIZON 19

factors that would make her likely to regret GCS. See Edmo, 

358 F. Supp. 3d at 1121.

The WPATH Standards of Care apply equally to all 

individuals “irrespective of their housing situation” and 

explicitly state that health care for transgender individuals 

“living in an institutional environment should mirror that 

which would be available to them if they were living in a 

non-institutional setting within the same community.” 

WPATH SOC at 67. The next update to the WPATH 

Standards of Care will likewise apply equally to incarcerated 

persons. The National Commission on Correctional Health 

Care (“NCCHC”), a leading professional organization in 

health care delivery in the correctional context, endorses the 

WPATH Standards of Care as the accepted standards for the 

treatment of transgender prisoners.

In summary, the broad medical consensus in the area of 

transgender health care requires providers to individually 

diagnose, assess, and treat individuals’ gender dysphoria, 

including for those individuals in institutionalized 

environments. Treatment can and should include GCS when 

medically necessary. Failure to follow an appropriate 

treatment plan can expose transgender individuals to a 

serious risk of psychological and physical harm. The State 

does not dispute these points; it contends that GCS is not 

medically necessary for Edmo.

B. Edmo’s Treatment

Edmo is a transgender woman in IDOC custody. Her sex 

assigned at birth was male, but she identifies as female. In 

her words, “my brain typically operates female, even though 

my body hasn’t corresponded with my brain.”

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20 EDMO V. CORIZON

Edmo has been incarcerated since pleading guilty in 

2012 to sexual abuse of a 15-year-old male at a house party. 

Edmo was 21 years old at the time of the criminal offense. 

Edmo is currently incarcerated at the Idaho State 

Correctional Institution (“ISCI”). At the time of the 

evidentiary hearing, she was 30 years old and due to be 

released from prison in 2021.

Edmo has viewed herself as female since age 5 or 6. She 

struggled with her gender identity as a child and teenager, 

presenting herself intermittently as female, but around age 

20 or 21 she began living fulltime as a woman.

Although she identified as female from an early age, 

Edmo first learned the term “gender dysphoria” and the 

contours of that diagnosis around the time of her 

incarceration. Shortly thereafter, Corizon psychiatrist 

Dr. Scott Eliason diagnosed her with “gender identity 

disorder,” now referred to as gender dysphoria. Corizon 

psychologist Dr. Claudia Lake confirmed that diagnosis.

While incarcerated, Edmo has changed her legal name to 

Adree Edmo and the sex on her birth certificate to “female” 

to affirm her gender identity. Throughout her incarceration, 

Edmo has consistently presented as female, despite receiving 

many disciplinary offense reports for doing so. For example, 

when able to do so, Edmo has worn her hair in feminine 

hairstyles and worn makeup, for which she has received 

multiple disciplinary offense reports.7

 Medical providers 

have documented Edmo’s feminine presentation since 2012.

7 Before the evidentiary hearing, Edmo tried to receive access to 

female commissary items, such as women’s underwear. Most of her 

requests were denied. On the eve of the evidentiary hearing, IDOC 

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EDMO V. CORIZON 21

Neither the parties nor their experts dispute that Edmo 

suffers from gender dysphoria. That dysphoria causes Edmo 

to feel “depressed,” “disgusting,” “tormented,” and 

“hopeless.”

To alleviate Edmo’s gender dysphoria, prison officials 

have, since 2012, provided hormone therapy. Edmo has 

followed and complied with her hormone therapy regimen, 

which helps alleviate her gender dysphoria to some extent. 

The hormones “clear[] [her] mind” and have resulted in 

breast growth, body fat redistribution, and changes in her 

skin. Today, Edmo is hormonally confirmed, which means 

that she has the hormones and secondary sex characteristics 

(characteristics, such as women’s breasts, that appear during 

puberty but are not part of the reproductive system) of an 

adult female. Edmo has gained the maximum physical 

changes associated with hormone treatment.

Hormone therapy has not completely alleviated Edmo’s 

gender dysphoria. Edmo continues to experience significant 

distress related to gender incongruence. Much of that 

distress is caused by her male genitalia. Edmo testified that 

she feels “depressed, embarrassed, [and] disgusted” by her 

male genitalia and that this is an “everyday reoccurring 

thought.” Her medical records confirm her disgust, noting 

repeated efforts by Edmo to purchase underwear to keep, in 

Edmo’s words, her “disgusting penis” out of sight.

In addition to her gender dysphoria, Edmo suffers from 

major depressive disorder with anxiety and drug and alcohol 

addiction, although her addiction has been in remission 

amended its policy concerning the treatment of gender dysphoric 

prisoners to increase transgender women’s access to female commissary 

items.

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22 EDMO V. CORIZON

while incarcerated. Edmo has taken her prescribed 

medications for depression and anxiety. Prison officials 

have also provided Edmo mental health treatment to help her 

work through her serious underlying mental health issues 

and a pre-incarceration history of trauma, abuse, and suicide 

attempts. Edmo sees her psychiatrist when scheduled. But 

Edmo does not see her treating clinician, Krina Stewart, 

because Edmo does not believe Stewart is qualified to treat 

her gender dysphoria. Edmo has attended group therapy 

sessions inconsistently.

In September 2015, Edmo attempted to castrate herself 

for the first time using a disposable razor blade.8 Before 

doing so, she left a note to alert officials that she was not 

“trying to commit suicide,” and was instead “only trying to 

help [her]self.” Edmo did not complete the castration, 

though she continued to report thoughts of self-castration in 

the following months.

On April 20, 2016, Dr. Eliason evaluated Edmo for GCS. 

At the time, IDOC’s policy concerning the treatment of 

gender dysphoric prisoners provided that GCS “will not be 

considered for individuals within [IDOC], unless determined 

medically necessary by” the treating physician.9 Corizon’s 

policy does not mention GCS.

In his evaluation, Dr. Eliason noted that Edmo reported 

she was “doing alright.” He also noted that Edmo had been 

on hormone replacement therapy for the last year and a half, 

but that she felt she needed more. He reported that Edmo 

8 She had previously reported thoughts of self-castration to 

clinicians.

9 IDOC revised its policy shortly before the evidentiary hearing, but 

its revised policy contains functionally identical language.

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EDMO V. CORIZON 23

had stated that hormone replacement therapy helped 

alleviate her gender dysphoria, but she remained frustrated 

with her male anatomy.

Dr. Eliason indicated that Edmo appeared feminine in 

demeanor and interaction style. He also indicated that Edmo

had previously attempted to “mutilate her genitalia” because 

of the severity of her distress. Dr. Eliason later testified that, 

at the time of his evaluation, he felt that Edmo’s gender 

dysphoria “had risen to another level,” as evidenced by her 

self-castration attempt.

But Dr. Eliason also flagged that he had spoken to prison 

staff about Edmo’s behavior and they explained it was 

“notable for animated affect and no observed distress.” He 

similarly noted that he had personally observed Edmo and 

did not see significant dysphoria; instead, she “looked 

pleasant and had a good mood.”

As to GCS, Dr. Eliason explained in his notes that while 

medical necessity for GCS is “not very well defined and is 

constantly shifting,” in his view, GCS would be medically 

necessary in at least three situations: (1) “congenital 

malformations or ambiguous genitalia,” (2) “severe and 

devastating dysphoria that is primarily due to genitals,” or 

(3) “some type of medical problem in which endogenous 

sexual hormones were causing severe physiological 

damage.” Dr. Eliason concluded that Edmo “does not meet 

any of those . . . criteria” and, for that reason, GCS is not 

medically necessary for her.

Dr. Eliason instead concluded that hormone therapy and 

supportive counseling suffice to treat Edmo’s gender 

dysphoria for the time being, despite recognizing that Edmo 

had attempted self-castration on that regimen. Dr. Eliason 

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24 EDMO V. CORIZON

indicated that he would continue to monitor and assess 

Edmo.

Dr. Eliason staffed Edmo’s evaluation with Dr. Jeremy 

Stoddart, Dr. Murray Young, and Jeremy Clark, who all 

agreed with his assessment. They did not observe Edmo; 

rather, they agreed with Dr. Eliason’s recommended 

treatment as he presented it to them. The record is sparse on 

the qualifications of Dr. Stoddart and Dr. Young, but Clark 

has never personally treated anyone with gender dysphoria 

and was not qualified under IDOC policy to assess whether 

GCS would be appropriate for Edmo.

Dr. Eliason also discussed his evaluation with IDOC’s 

Management and Treatment Committee (“MTC”), a multidisciplinary team composed of medical providers, mental 

health clinicians, IDOC’s Chief Psychologist, and prison 

leadership. The MTC meets periodically to evaluate and 

address the unique medical, mental health, and housing 

needs of prisoners with gender dysphoria. The committee 

“does not make any individual treatment decisions 

regarding” treatment for inmates with gender dysphoria. 

“Those determinations are made by the individual clinicians 

or the medical staff employed by Corizon.” The MTC 

agreed with Dr. Eliason’s assessment.

Although not mentioned in his April 20, 2016 notes, 

Dr. Eliason testified at the evidentiary hearing that he 

considered the WPATH Standards of Care when 

determining Edmo’s treatment. Citing those standards, 

Dr. Eliason testified that he did not believe GCS was 

appropriate for two reasons: (1) because mental health 

issues separate from Edmo’s gender dysphoria were not 

“fully in adequate control” and (2) because Edmo had not 

lived in her identified gender role for 12 months outside of 

prison. He explained that Edmo needed to experience 

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EDMO V. CORIZON 25

“living as a woman” around “her real social network – her 

family and friends on the outside” so that she could 

“determine whether or not she felt like that was her real 

identity.”

Edmo was never evaluated for GCS again, but the MTC 

considered her gender dysphoria and treatment plan during 

later meetings. The MTC continues to believe that GCS is 

not medically necessary or appropriate for Edmo.

In December 2016, Edmo tried to castrate herself for the 

second time. A medical note from the incident reports that 

Edmo said she no longer wanted her testicles. Edmo 

reported to medical providers that she was “feeling 

angry/frustrated that [she] was not receiving the help desired 

related to [her] gender dysphoria. Inmate Edmo’s actions 

were reported as a method to stop/cease testosterone 

production in Edmo’s body. Edmo denied suicidal ideation 

. . . .”

Edmo’s second attempt was more successful than the 

first. She was able to open her testicle sac with a razor blade 

and remove one testicle. She abandoned her attempt, 

however, when there was too much blood to continue. She 

then sought medical assistance and was transported to a 

hospital, where her testicle was repaired. Edmo was 

receiving hormone therapy both times she attempted selfcastration.

Edmo testified that she was disappointed in herself for 

coming so close but failing to complete her self-castration 

attempts. She also testified that she continues to actively 

think about self-castration. To avoid acting on those 

thoughts and impulses, Edmo “self-medicat[es]” by cutting 

her arms with a razor. She says that the physical pain helps 

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26 EDMO V. CORIZON

to ease the “emotional torment” and mental anguish her 

gender dysphoria causes her.

Edmo further testified that she expects GCS to help 

alleviate some of her gender dysphoria. In particular, she 

testified that she expects GCS to help her avoid having “as 

much depression about myself and my physical body. I 

don’t think I will be so anxious that people are always 

knowing I’m different . . . .” Edmo recognizes, however, 

that GCS “is not a fix-all”: “[i]t’s not a magic operation. . . . 

I’m still going to have to face the same stressors that we all 

face in everyday life . . . .”

C. Initiation of this Action

Edmo filed a pro se complaint on April 6, 2017. She also 

moved for a temporary restraining order, a preliminary 

injunction, and the appointment of counsel.

Edmo’s motion for appointment of counsel was granted 

in part, and counsel for Edmo appeared in June and August 

2017. Counsel withdrew Edmo’s pro se motion for 

preliminary injunction shortly thereafter.

On September 1, 2017, Edmo filed an amended 

complaint asserting claims under 42 U.S.C. § 1983, the 

Eighth Amendment, the Fourteenth Amendment, the 

Americans with Disabilities Act, the Affordable Care Act, 

and for common law negligence. She named as defendants 

IDOC, Henry Atencio (Director of IDOC), Jeff Zmuda 

(Deputy Director of IDOC), Howard Keith Yordy (former 

Warden of ISCI), Dr. Richard Craig (Chief Psychologist at 

ISCI), Rona Siegert (Health Services Director at ISCI), 

Corizon, Dr. Eliason, Dr. Young, and Dr. Catherine 

Whinnery (Corizon employee).

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EDMO V. CORIZON 27

Through counsel, Edmo filed a renewed motion for a 

preliminary injunction on June 1, 2018. Among other relief, 

Edmo sought an order requiring the State to provide her with 

a referral to a qualified surgeon and access to GCS.

The State moved to extend the time to respond to Edmo’s 

motion. After a status conference, the district court set an 

evidentiary hearing for October 10, 11, and 12, 2018. The 

court permitted the parties to undertake four months of 

extensive fact and expert discovery in preparation for the 

hearing.

D. The Evidentiary Hearing

At the evidentiary hearing, each side had eight hours to 

present its case. The district court heard live testimony from 

seven witnesses over three days. It also considered 

thousands of pages of exhibits, including Edmo’s medical 

records. With the parties’ agreement, the court also 

permitted the State to submit declarations in lieu of live 

testimony and permitted Edmo to impeach the declarations 

with deposition testimony.

At the outset of the hearing, the district court noted that 

“[w]e’re here on a hearing for a temporary injunction,” but 

it explained that “it’s hard for me to envision this hearing 

being anything but a hearing on a final injunction[,] at least 

as to” the injunctive relief ordering GCS. The court stated 

that it was unsure whether that made a difference, and it 

asked the parties to address at some point whether the 

hearing was for a preliminary injunction or a permanent 

injunction. Notably, the State did not do so.

The district court heard testimony from three percipient 

witnesses: Edmo, Dr. Eliason (the Corizon physician), and 

Jeremy Clark (an IDOC clinician who did not meet IDOC’s 

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28 EDMO V. CORIZON

criteria to assess Edmo for GCS). Their relevant testimony 

is largely recounted above.

It also heard testimony from four expert witnesses, two 

each for Edmo and the State. Dr. Randi Ettner, Ph.D. in 

psychology, testified first for Edmo. Dr. Ettner is one of the 

authors of the current (seventh) version of the WPATH 

Standards of Care. She has been a WPATH member since 

1993 and chairs its Institutionalized Persons Committee. Dr. 

Ettner has authored or edited many peer-reviewed 

publications on the treatment of gender dysphoria and 

transgender health care more broadly, including the leading 

textbook used in medical schools on the subject. She also 

trains medical and mental health providers on treating people 

with gender dysphoria. Dr. Ettner has been retained as an 

expert witness on gender dysphoria and its treatment in 

many court cases, and she has been appointed as an 

independent expert by one federal court to evaluate an 

incarcerated person for GCS.

Dr. Ettner has evaluated, diagnosed, and treated between 

2,500 and 3,000 individuals with gender dysphoria. She has 

referred about 300 people for GCS. She has also refused to 

recommend surgery for some patients who have requested it. 

She believes that not everyone who has gender dysphoria 

needs GCS. Dr. Ettner also has “[e]xtensive experience” 

treating and providing post-operative care for patients who 

have undergone GCS.

Dr. Ettner has assessed approximately 30 incarcerated 

individuals with gender dysphoria for GCS and other 

medical care, but she has not treated incarcerated patients. 

She has not worked in a prison and she is not a Certified 

Correctional Healthcare Professional.

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EDMO V. CORIZON 29

Based on her evaluation of Edmo and a review of 

Edmo’s medical records, Dr. Ettner diagnosed Edmo with 

gender dysphoria, depressive disorder, anxiety, and suicidal 

ideation. In Dr. Ettner’s opinion, GCS is medically 

necessary for Edmo and should be immediately performed. 

She explained that most patients with gender dysphoria do 

not require GCS, but Edmo requires it because hormone 

therapy has been inadequate for her and Edmo has attempted 

to remove her own testicles. Dr. Ettner further explained that 

GCS would give Edmo congruent genitalia, eliminating the 

severe distress Edmo experiences due to her male anatomy.

Dr. Ettner further opined that Edmo meets the WPATH 

criteria for GCS. She explained that Edmo has “persistent 

and well-documented long-standing gender dysphoria”; 

Edmo “has no thought disorders and no impaired reality 

testing”; Edmo is the age of majority in this country; 

although Edmo has depression and anxiety, those conditions 

do not “impair her ability to undergo surgery” because they 

are “as controlled as [they] can be”; Edmo has had six years 

of hormone therapy; and Edmo has lived for more than one 

year “as a woman to the best of her ability in a male prison.”

More specifically, as to the fourth criterion, Dr. Ettner 

opined that Edmo does not have mental health concerns that 

would preclude GCS. She explained that Edmo’s depression 

and anxiety are as “controlled as can be” because Edmo “is 

taking the maximum amount of medication that controls 

depression.” Dr. Ettner noted that Edmo has complied with 

taking her prescribed medications and that psychotherapy is 

not “a precondition for surgery” under the WPATH 

Standards of Care. She also flagged that Edmo has the 

capacity to comply with her postsurgical treatment, as 

evidenced by her compliance with her hormone therapy to 

date.

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30 EDMO V. CORIZON

As to the clinical significance of Edmo’s self-castration 

attempts and cutting behaviors, Dr. Ettner explained that 

neither behavior indicates that Edmo has inadequately 

controlled mental health concerns. Rather, those behaviors 

indicate “the need for treatment for gender dysphoria.” 

Dr. Ettner explained that

when an individual who is not psychotic or 

delusional attempts what we call surgical 

self-treatment – because we don’t regard 

removal of the testicles or attempted removal 

of the testicles as either mutilation or selfharm – we regard it as an intentional attempt 

to remove the target organ that produces 

testosterone, which, in fact, is the cure for 

gender dysphoria.

In Dr. Ettner’s opinion, Edmo’s depression and anxiety “will 

be attenuated post surgery.”

Dr. Ettner opined that Edmo satisfies the sixth criterion 

because she has lived “as a woman to the best of her ability 

in a male prison.” Dr. Ettner based her opinion on Edmo’s 

“appearance . . . , her disciplinary records, which indicated 

that she had attempted to wear her hair in a feminine 

hairstyle and to wear makeup even though that was against 

the rules and she was – received some sort of disciplinary

action for that, and her – the way that she was receiving 

female undergarments and had developed the stigma of 

femininity, the secondary sex characteristics, breast 

development, et cetera.”

Dr. Ettner opined that if Edmo does not receive GCS, 

“[t]he risks would be, as typical in inadequately treated or 

untreated gender dysphoria, either surgical self-treatment, 

emotional decompensation, or suicide.” Dr. Ettner 

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EDMO V. CORIZON 31

explained that Edmo “is at particular risk of suicide given 

that she has a high degree of suicide ideation.” If, on the 

other hand, Edmo receives surgery, Dr. Ettner opined that

[i]t would eliminate the gender dysphoria. It 

would provide a level of wellbeing that she 

hasn’t had previously. It would eliminate 

80 percent of the testosterone in her body, 

necessitating a lower dose of hormones going 

forward, which would be particularly helpful 

given that she has elevated liver enzymes. 

And it would, I believe, eliminate much of the 

depression and the attendant symptoms that 

she is experiencing.

Dr. Ryan Gorton, M.D., also testified for Edmo. 

Dr. Gorton is an emergency medicine physician. He also 

works pro bono at a clinic serving uninsured patients or those 

with Medicare or Medicaid. Many of those patients have 

mental health conditions or have been in prison. He has 

published peer-reviewed articles on the treatment of gender 

dysphoria, and he has been qualified as an expert witness in 

cases involving transgender health care. Dr. Gorton also 

provides training on transgender health care issues to many 

groups, is a member of WPATH, and serves on WPATH’s 

Transgender Medicine and Research Committee and its 

Institutionalized Persons Committee.

Dr. Gorton has been the primary care physician for about 

400 patients with gender dysphoria. At the time of the 

evidentiary hearing, Dr. Gorton was treating approximately 

100 patients with gender dysphoria. Dr. Gorton has assessed 

patients for gender dysphoria, initiated and monitored 

hormone treatment, referred patients for mental health 

treatment, and determined the appropriateness of GCS. At 

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32 EDMO V. CORIZON

the time of the evidentiary hearing, Dr. Gorton was 

providing follow-up care for about 30 patients who had 

vaginoplasty. Dr. Gorton has no experience treating 

transgender inmates and is not a Certified Correctional 

Healthcare Professional.

Based on his review of Edmo’s medical records and his 

in-person evaluation of Edmo, Dr. Gorton opined that GCS 

is medically necessary for Edmo and that she meets the 

WPATH criteria for GCS. He explained that Edmo has 

“persistent well-documented gender dysphoria,” as shown in 

her prison medical records; she has the capacity “to make a 

fully informed decision and to consent for treatment” 

because “she didn’t seem at all impaired in her decisionmaking capacity”; she is the age of majority; she has 

depression and anxiety, “but they are not to a level that 

would preclude her getting [GCS]”; she had 12 consecutive 

months of hormone therapy; and she has been living in her 

“target gender role . . . despite an environment that’s very 

hostile to that and some negative consequences that she has 

experienced because of that.”

Dr. Gorton further opined that if Edmo “is not provided 

surgery, there is a very substantial chance she will try to 

attempt self-surgery again. And that’s especially worrisome 

given her attempts have been progressive. . . . So I think she 

might be successful” on her next attempt. He predicted that 

there is little chance that Edmo’s gender dysphoria will 

improve without surgery. Conversely, Dr. Gorton 

anticipated that Edmo is unlikely to regret surgery because 

“her gender dysphoria is very genital-focused” and regret 

rates among GCS patients are very low.

Dr. Gorton also opined that Edmo’s self-castration 

attempts demonstrate “that she has severe genital-focused 

gender dysphoria and that she is not getting the medically 

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EDMO V. CORIZON 33

necessary treatment to alleviate that.” He elaborated that 

Edmo’s depression and anxiety are not driving Edmo’s selfcastration attempts: “there [are] a lot of people with 

depression and anxiety who don’t remove their testicles.”

Finally, Dr. Gorton criticized Dr. Eliason’s evaluation of 

Edmo. He explained that he disagreed with Dr. Eliason’s 

conclusion that Edmo does not need GCS and he also 

disagreed with the three “criteria” Dr. Eliason gave for when 

GCS would be necessary. Dr. Gorton criticized Dr. 

Eliason’s first criterion—that GCS could be needed where 

there is “congenital malformation or ambiguous genitalia”—

because that situation “isn’t even germane to transgender 

people”; rather, it relates to “people with intersex 

conditions.” As to the second criterion—that GCS could be 

needed when a patient is suffering from “severe and 

devastating gender dysphoria that is primarily due to 

genitals”—Dr. Gorton pointed out that the WPATH 

Standards of Care for surgery require only “clear and 

significant dysphoria.” And even applying Dr. Eliason’s 

higher bar, Dr. Gorton explained that Edmo would still 

qualify for GCS because she has twice attempted selfcastration, demonstrating “severe genital-focused 

dysphoria.” Finally, Dr. Gorton characterized Dr. Eliason’s 

third criterion—that GCS could be needed in situations when 

“endogenous sexual hormones were causing severe 

physiological damage”—as “bizarre.” Dr. Gorton could not 

conjure “a clinical circumstance where that would be the 

case that your hormones that your body produces are 

attacking you . . . . I just don’t understand what [Dr. Eliason] 

is talking about there.”

Dr. Keelin Garvey, M.D., testified for the State. 

Dr. Garvey is a psychiatrist and Certified Correctional 

Healthcare Professional. As the former Chief Psychiatrist of 

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34 EDMO V. CORIZON

the Massachusetts Department of Corrections, Dr. Garvey 

chaired the Gender Dysphoria Treatment Committee. She 

directly treated a “couple of patients” with gender dysphoria 

earlier in her career as Deputy Medical Director, but she has 

not done so in recent years. Prior to evaluating Edmo, Dr. 

Garvey had never evaluated a patient in person to determine 

whether that person needed GCS. Dr. Garvey has never 

recommended a patient for GCS, and she has not done 

follow-up care with a person who has received GCS.

Based on her evaluation of Edmo and a review of 

Edmo’s medical records, Dr. Garvey diagnosed Edmo with 

gender dysphoria, major depressive disorder, alcohol use 

disorder, stimulant use disorder, and opioid use disorder. 

She explained that the latter three are in remission.

Relying on the WPATH Standards of Care, Dr. Garvey 

opined that GCS is not medically necessary for Edmo.10 Dr. 

Garvey first explained that Edmo does not meet the first 

WPATH Standards of Care criterion—“persistent, well 

documented gender dysphoria”—because of a lack of 

evidence in pre-incarceration medical records that Edmo 

presented as female before her time in prison. Dr. Garvey 

acknowledged, however, that Edmo has been presenting as 

female since 2012 and that she has been diagnosed with 

gender dysphoria since that time.

Dr. Garvey then explained that Edmo does not meet the 

fourth criterion—“medical/mental health concerns must be 

well controlled”—because Edmo “is actively self-injuring.” 

Dr. Garvey elaborated that “self-injury in any form is never 

10 Dr. Garvey testified that she relies on the WPATH Standards of 

Care and the NCCHC guidelines adopting those standards when treating 

inmates with gender dysphoria.

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EDMO V. CORIZON 35

considered a healthy or productive coping mechanism” and 

that she would like to see Edmo “develop further coping 

skills that she would be able to use following surgery so that 

she is not engaging in self-injury after surgery.” Dr. 

Garvey’s concern is that GCS is a “stressful undertaking” 

and Edmo lacks “effective coping strategies” to deal with the 

stress.

Finally, Dr. Garvey testified that Edmo does not meet the 

sixth criterion—“12 continuous months of living in a gender 

role that is congruent with gender identity”—because Edmo 

has not presented as female outside of prison and “there [are] 

challenges to using her time in a men’s prison as this reallife experience because it doesn’t offer her the opportunity 

to actually experience all those things she is going to go 

through on the outside.”

Dr. Joel Andrade, Ph.D. in social work, also testified for 

the State. He is a licensed clinical social worker and is a 

Certified Correctional Healthcare Professional with an 

emphasis in mental health. Dr. Andrade has over a decade 

of experience providing and supervising the provision of 

correctional mental health care, including directing and 

overseeing the treatment of inmates diagnosed with gender 

dysphoria in the custody of the Massachusetts Department 

of Corrections in his roles as clinical director, chair of the 

Gender Dysphoria Supervision Group, and member of the 

Gender Dysphoria Treatment Committee.

As a member of the Gender Dysphoria Treatment 

Committee, Dr. Andrade recommended GCS for two 

inmates. But the recommendations were contingent on the 

inmates living in a women’s prison for approximately 

12 months before the surgery. The Massachusetts 

Department of Corrections, like IDOC, houses prisoners 

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36 EDMO V. CORIZON

according to their genitals, so the inmates had not been 

moved (nor had their surgery occurred).

Dr. Andrade has never directly treated patients with 

gender dysphoria, nor has he been a treating clinician for a 

patient who has had GCS. His “experience with gender 

dysphoria comes almost exclusively from [his] participation 

on the Massachusetts Department of Corrections[’] Gender 

Dysphoria Treatment Committee and Supervision Group.” 

Dr. Andrade did not qualify, under the IDOC gender 

dysphoria policy in effect at the time of his assessment of 

Edmo, to assess a person for GCS because he is neither a 

psychologist nor a physician.

Based on his evaluation of Edmo and a review of her 

medical records, Dr. Andrade diagnosed Edmo with “major 

depressive disorder, recurrent, in partial remission,” 

“generalized anxiety disorder,” “alcohol use disorder, 

severe,” and gender dysphoria. Dr. Andrade also diagnosed 

Edmo with borderline personality disorder. The district 

court did not credit this diagnosis, however, because no other 

person (including the State’s other expert, Dr. Garvey) has 

ever diagnosed Edmo with borderline personality disorder 

and Dr. Andrade was unable to identify his criteria for this 

diagnosis. Edmo, 358 F. Supp. 3d at 1120. The record 

amply supports the district court’s finding in this respect.

Dr. Andrade opined that Edmo does not meet the 

WPATH criteria for GCS. He explained that, based on his 

review of Edmo’s pre-incarceration records, Edmo did not 

present as female or discuss her gender dysphoria before 

incarceration. Dr. Andrade testified that he would like to see 

Edmo live as female outside of a correctional setting before 

receiving GCS, or, at the least, live in a women’s prison first. 

IDOC, however, houses prisoners according to their 

genitals. Dr. Andrade also explained that Edmo needs to 

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EDMO V. CORIZON 37

work through some of her trauma, particularly sexual abuse 

that she suffered, and other mental health concerns before 

receiving surgery. Dr. Andrade opined that Edmo’s mental 

health issues will not be cured by GCS.

At the close of the hearing, the district court reiterated 

that it was unsure “how we can hear [Edmo’s request for 

GCS] on a preliminary injunction. . . . [I]f I order it, then it’s 

done.” The court further suggested that the request for GCS 

could “only be resolved in a final hearing” and noted that it 

had, in effect, “treated this hearing as [a] final hearing on the 

issue.”

The court, as it had done at the outset of the hearing, 

asked the parties to address whether the hearing was for a 

preliminary or permanent injunction. In response, Edmo 

contended that the court could order GCS in a preliminary 

injunction. The State did not address the court’s question. It 

instead contended that the standard for a mandatory 

injunction—which can be preliminary or permanent—

should apply.

E. The District Court’s Decision

The district court rendered its decision on December 13, 

2018. After recounting the evidence and making extensive 

factual findings, the district court began its analysis by 

noting that it was unsure whether the standard for a 

preliminary injunction or the standard for a permanent 

injunction applied. The court noted that “the nature of the 

relief requested in this case, coupled with the extensive 

evidence presented by the parties over a 3-day evidentiary 

hearing, [may have] effectively converted these proceedings 

into a final trial on the merits of the plaintiff’s request for 

permanent injunctive relief.” Edmo, 358 F. Supp. 3d at 1122 

n.1. It also indicated that “both parties appear to have treated 

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38 EDMO V. CORIZON

the evidentiary hearing” as a final trial on the merits. Id. The 

district court explained that the difference was immaterial, 

however, because Edmo was entitled to relief under either 

standard. Id.

On the merits, the district court concluded that Edmo had 

established her Eighth Amendment claim. The district court 

first held that Edmo suffers from gender dysphoria, which is 

undisputedly “a serious medical condition.” Id. at 1124.

It then concluded that GCS is medically necessary to 

treat Edmo’s gender dysphoria. See id. at 1124–26. In a 

carefully considered, 45-page opinion, the district court 

specifically found “credible the testimony of Plaintiff’s 

experts Drs. Ettner and Gorton, who have extensive personal 

experience treating individuals with gender dysphoria both 

before and after receiving gender confirmation surgery,” and 

who opined that GCS was medically necessary. Id. at 1125. 

The court rejected the contrary opinions of the State’s 

experts because “neither Dr. Garvey nor Dr. Andrade has 

any direct experience with patients receiving gender 

confirmation surgery or assessing patients for the medical 

necessity of gender confirmation surgery,” and neither of the 

State’s experts had meaningful “experience treating patients 

with gender dysphoria other than assessing them for the 

existence of the condition.” Id. The district court also noted 

that the State’s “experts appear to misrepresent the WPATH 

Standards of Care by concluding that Ms. Edmo, despite 

presenting as female since her incarceration in 2012, cannot 

satisfy the WPATH criteria because she has not presented as 

female outside of the prison setting.” Id. As the district 

court noted, “there is no requirement in the WPATH 

Standards of Care that a patient live for twelve months in his 

or her gender role outside of prison before becoming eligible 

for” GCS. Id. (quotation omitted).

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EDMO V. CORIZON 39

Finally, the district court explained that the State was 

deliberately indifferent to Edmo’s gender dysphoria because 

it “fail[ed] to provide her with available treatment that is 

generally accepted in the field as safe and effective, despite 

her actual harm and ongoing risk of future harm including 

self-castration attempts, cutting, and suicidal ideation.” Id. 

at 1126–27. The district court also stated that the evidence 

“suggest[ed] that Ms. Edmo has not been provided gender 

confirmation surgery because Corizon and IDOC have a de 

facto policy or practice of refusing this treatment for gender 

dysphoria to prisoners,” which amounts to deliberate 

indifference. Id. at 1127.

After analyzing the merits, the district court concluded 

that Edmo satisfied the other prerequisites to injunctive 

relief. Id. at 1127–28. The district court found that, given 

Edmo’s continuing emotional distress and self-castration 

attempts, “Edmo is at serious risk of life-threatening selfharm” if she does not receive GCS. Id. at 1128. The State, 

on the other hand, had not shown that it would be harmed if 

ordered to provide GCS, so the equities favored Edmo. Id.

Having concluded that Edmo was entitled to an 

injunction, the court ordered the State “to provide Plaintiff 

with adequate medical care, including gender confirmation 

surgery.” Id. at 1129. It ordered the State to “take all actions 

reasonably necessary to provide Ms. Edmo gender 

confirmation surgery as promptly as possible and no later 

than six months from the date of this order.” Id.

F. Appellate Proceedings

The State filed timely notices of appeal on January 9, 

2019. It also asked the district court to stay its order pending 

appeal. The district court denied the State’s motion on 

March 4.

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The State then filed in this court a motion to stay pending 

appeal. A motions panel granted that motion. Edmo 

subsequently moved to amend the stay to allow her to 

undergo a previously scheduled pre-surgery consultation. 

The motions panel granted that motion and amended the 

stay.

On April 3, the State filed an “urgent motion” to dismiss 

this appeal as moot. We indicated on April 5 that our court 

would consider that motion with the merits, not on an urgent 

basis.

After hearing oral argument on May 16, we ordered a 

limited remand to the district court to clarify three points. 

Relevant here, we asked the district court to clarify whether 

it granted Edmo a permanent injunction in its December 13, 

2018 order. The district court clarified that it “granted 

permanent injunctive relief.” Edmo v. Idaho Dep’t of Corr., 

No. 1:17-CV-00151-BLW, 2019 WL 2319527, at *2 (D. 

Idaho May 31, 2019). We also asked the district court to 

clarify whether it had concluded that Edmo had succeeded 

on the merits of her Eighth Amendment claim. The district 

court responded that it had. Id.

Having received the district court’s response to our 

limited remand order, we proceed to the issues on appeal. 

The State challenges the district court’s grant of injunctive 

relief to Edmo on multiple grounds. It contends that this 

appeal is moot because the injunction did not comply with 

the PLRA and has, for that reason, automatically expired. It 

contends that the decision not to provide GCS to Edmo 

reflects a difference of prudent medical opinion and cannot 

support an Eighth Amendment claim. It contends that Edmo 

will not be irreparably harmed absent an injunction. It 

contends that the injunction is overbroad. Finally, it 

contends that, to the extent the district court converted the 

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EDMO V. CORIZON 41

evidentiary hearing into a final trial on the merits of Edmo’s 

request for GCS, it was provided inadequate notice and the 

court violated its right to a jury trial.

II. Mootness

“We first address, as we must, the question of mootness 

. . . .” Shell Offshore Inc. v. Greenpeace, Inc., 815 F.3d 623, 

628 (9th Cir. 2016). An appeal is moot “[w]hen events 

change such that the appellate court can no longer grant ‘any 

effectual relief whatever to the prevailing party.’” Id.

(quoting City of Erie v. Pap’s A.M., 529 U.S. 277, 287 

(2000)). In those circumstances, we “lack[] jurisdiction and 

must dismiss the appeal.” Id.

The State contends that the injunction does not comply 

with provisions of the PLRA and, for that reason, has 

automatically expired under the terms of the statute. 

Relevant here, the PLRA provides that a

court shall not grant or approve any 

prospective relief unless the court finds that 

such relief is narrowly drawn, extends no 

further than necessary to correct the violation 

of the Federal right, and is the least intrusive 

means necessary to correct the violation of 

the Federal right. The court shall give 

substantial weight to any adverse impact on 

public safety or the operation of a criminal 

justice system caused by the relief.

18 U.S.C. § 3626(a)(1)(A). Courts often refer to this 

provision as the “need-narrowness-intrusiveness” inquiry. 

Graves v. Arpaio, 623 F.3d 1043, 1048 n.1 (9th Cir. 2010) 

(per curiam) (quoting Pierce v. County of Orange, 526 F.3d 

1190, 1205 (9th Cir. 2008)). The PLRA further provides that 

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any “[p]reliminary injunctive relief shall automatically 

expire on the date that is 90 days after its entry, unless the 

court makes the findings required under subsection (a)(1) 

[quoted above] for the entry of prospective relief and makes 

the order final before the expiration of the 90-day period.” 

18 U.S.C. § 3626(a)(2).

The State contends that the district court did not make 

the PLRA’s requisite need-narrowness-intrusiveness 

findings or make its order final within 90 days, causing the 

injunction to expire under 18 U.S.C. § 3626(a)(2). 

Generally, the expiration of an injunction challenged on 

appeal moots the appeal. See Kitlutsisti v. ARCO Alaska, 

Inc., 782 F.2d 800, 801 (9th Cir. 1986); see also United 

States v. Sec’y, Fla. Dep’t of Corr., 778 F.3d 1223, 1228–29 

(11th Cir. 2015). The State asserts separate, albeit 

overlapping, contentions in their motion to dismiss this 

appeal and in their briefing. We reject those arguments.

A. Need-Narrowness-Intrusiveness Findings

The State first contends that the district court did not 

make the PLRA’s need-narrowness-intrusiveness findings, 

causing the injunction to automatically expire and mooting 

this appeal.11 As we have explained in prior decisions, the 

PLRA “has not substantially changed the threshold findings 

and standards required to justify an injunction.” Gomez v. 

Vernon, 255 F.3d 1118, 1129 (9th Cir. 2001). When 

“determining the appropriateness of the relief ordered,” 

appellate “courts must do what they have always done”: 

11 We question whether the State’s need-narrowness-intrusiveness 

challenge, properly understood, implicates mootness. But because the 

result is the same, we accept the State’s framing for purposes of our 

analysis.

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EDMO V. CORIZON 43

“consider the order as a whole.” Armstrong v. 

Schwarzenegger, 622 F.3d 1058, 1070 (9th Cir. 2010). 

District courts must make need-narrowness-intrusiveness 

“findings sufficient to allow a ‘clear understanding’ of the 

ruling,” but they need not “make such findings on a 

paragraph by paragraph, or even sentence by sentence, 

basis.” Id. (quotation omitted). “What is important, and 

what the PLRA requires, is a finding that the set of reforms 

being ordered—the ‘relief’—corrects the violations of 

prisoners’ rights with the minimal impact possible on 

defendants’ discretion over their policies and procedures.” 

Id.

Here, the district court made the necessary neednarrowness-intrusiveness findings. At the start of its 

December 13, 2018 order, the district court explained that 

any injunction must meet the PLRA’s need-narrownessintrusiveness requirement. See Edmo, 358 F. Supp. 3d at 

1122. The district court then explained how the relief being 

ordered, GCS, “corrects the violations of” Edmo’s rights. 

See Armstrong, 622 F.3d at 1071. Specifically, the district 

court explained that GCS is medically necessary to alleviate 

Edmo’s gender dysphoria and that the State’s denial of GCS 

amounts to deliberate indifference in violation of the Eighth 

Amendment. See Edmo, 358 F. Supp. 3d at 1116–21, 1123–

27, 1129. The district court limited the relief ordered to have 

“the minimal impact possible on [the State’s] discretion over 

their policies and procedures.” See Armstrong, 622 F.3d at 

1071. Specifically, the district court limited the relief to 

“actions reasonably necessary” to provide GCS, cautioned 

that its conclusion is based on “the unique facts and 

circumstances presented” by Edmo, and noted that its 

“decision is not intended, and should not be construed, as a 

general finding that all inmates suffering from gender 

dysphoria are entitled to [GCS].” Edmo, 358 F. Supp. 3d at 

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44 EDMO V. CORIZON

1110, 1129. Finally, the district court rejected the notion that 

injunctive relief would have “any adverse impact on public 

safety or the operation of a criminal justice system.” 

18 U.S.C. § 3626(a)(1)(A). It explained that the State had 

“made no showing that an order requiring them to provide” 

GCS to Edmo “causes them injury.” Edmo, 358 F. Supp. 3d 

at 1128. The district court’s order, considered as a whole, 

made all the findings required by 18 U.S.C. § 3626(a)(1)(A) 

and our precedent. See Armstrong, 622 F.3d at 1070.

B. Finality

The State next argues that the injunction has 

automatically expired under the PLRA because the district 

court did not make its order “final” within 90 days of 

entering injunctive relief. See 18 U.S.C. § 3626(a)(2); see 

also Sec’y, Fla. Dep’t of Corr., 778 F.3d at 1228–29 

(holding that an appeal of a preliminary injunction was moot 

because the district court “did not issue an order finalizing 

its [preliminary-injunction] order,” and “[a]s a result, the 

preliminary injunction expired by operation of law” 90 days 

later). The PLRA provision cited by the State applies to 

preliminary injunctive relief, not permanent injunctive 

relief. See 18 U.S.C. § 3626(a)(2). The permanent 

injunction that the district court entered has not expired. See 

Edmo, 358 F. Supp. 3d at 1122 n.1 (concluding that Edmo is 

“entitled to relief” under the permanent injunction standard); 

see also Edmo, 2019 WL 2319527, at *2 (clarifying on 

limited remand that the district court granted Edmo a 

permanent injunction). It remains in place, albeit stayed.

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EDMO V. CORIZON 45

There is a live controversy on appeal.12 We accordingly 

DENY the State’s motion to dismiss and proceed to the 

merits of the appeal.

III. Challenges to the District Court’s Grant of 

Injunctive Relief

An injunction is an “extraordinary remedy never 

awarded as of right.” Winter v. Nat. Res. Def. Council, Inc., 

555 U.S. 7, 24 (2008). “To be entitled to a permanent 

injunction, a plaintiff must demonstrate: (1) actual success 

on the merits; (2) that it has suffered an irreparable injury; 

(3) that remedies available at law are inadequate; (4) that the 

balance of hardships justify a remedy in equity; and (5) that 

the public interest would not be disserved by a permanent 

injunction.”13 Indep. Training & Apprenticeship Program 

12 Even construed as a preliminary injunction, the district court’s 

December 13, 2018 order is not moot. On May 31, 2019, the district 

court, incorporating its previous findings, renewed the injunction. See 

Edmo, 2019 WL 2319527, at *2. Because the district court renewed the 

injunction, we can consider its merits. See Mayweathers v. Newland, 

258 F.3d 930, 935–36 (9th Cir. 2001) (holding that district courts may 

renew preliminary injunctions under the PLRA while an appeal is 

pending, and considering the merits of the renewed injunction). And we 

have jurisdiction under 28 U.S.C. § 1292(a)(1) regardless of whether the 

district court’s order is considered a preliminary or permanent 

injunction. See Hendricks v. Bank of Am., N.A., 408 F.3d 1127, 1131 

(9th Cir. 2005) (preliminary injunction); TransWorld Airlines, Inc. v. 

Am. Coupon Exch., Inc., 913 F.2d 676, 680–81 (9th Cir. 1990) 

(permanent injunction where the “district court retained jurisdiction to 

determine damages” and to adjudicate a separate claim).

13 We agree with the State that the injunction is mandatory, as 

opposed to prohibitory, because it requires the State to act. Based on that 

distinction, the State argues that Edmo must satisfy a higher burden of 

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46 EDMO V. CORIZON

v. Cal. Dep’t of Indus. Relations, 730 F.3d 1024, 1032 (9th 

Cir. 2013) (citing eBay Inc. v. MercExch., L.L.C., 547 U.S. 

388, 391 (2006)).

We review for abuse of discretion the district court’s 

decision to grant a permanent injunction. Ariz. Dream Act 

Coal. v. Brewer, 855 F.3d 957, 965 (9th Cir. 2017). We 

proof to be entitled to injunctive relief, and that the district court failed 

to hold Edmo to that burden. On that point, we disagree.

The State errs by relying on cases that concern mandatory 

preliminary injunctions. Because mandatory preliminary injunctions go 

“well beyond simply maintaining the status quo [p]endente lite,” they are 

“particularly disfavored” and “are not issued in doubtful cases.” Marlyn 

Nutraceuticals, Inc. v. Mucos Pharma GmbH & Co., 571 F.3d 873, 879 

(9th Cir. 2009) (alteration in original) (quoting Anderson v. United 

States, 612 F.2d 1112, 1114–15 (9th Cir. 1980)). The calculus is 

different in the context of permanent injunctions. A plaintiff must show 

actual success on the merits, see Amoco Prod. Co. v. Village of Gambell, 

480 U.S. 531, 546 n.12 (1987), so there is no concern that a mandatory 

permanent injunction will upset the status quo only for a later trial on the 

merits to show that the plaintiff was not entitled to equitable relief. As a 

result, a plaintiff need not show that “extreme or very serious damage 

will result,” as is required for mandatory preliminary injunctions.

As we have explained, the district court granted Edmo injunctive 

relief under both the preliminary and permanent injunction standards. 

See Edmo, 358 F. Supp. 3d at 1122 n.1; see also Edmo, 2019 WL 

2319527, at *2. Because the standard for granting permanent injunctive 

relief is higher (in that it requires actual success on the merits) and the 

State contends in its opening brief that we should review the injunction 

as a permanent injunction, we consider whether the district court erred 

in granting Edmo permanent injunctive relief. But we would also affirm 

under the mandatory preliminary injunction standard, because the district 

court correctly applied the proper standard for mandatory preliminary 

injunctive relief, and not the lower standard for prohibitory preliminary 

injunctions. See Edmo, 358 F. Supp. 3d at 1122, 1128.

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EDMO V. CORIZON 47

review “any determination underlying the grant of an 

injunction by the standard that applies to that 

determination.” Ting v. AT&T, 319 F.3d 1126, 1134–35 (9th 

Cir. 2003). Accordingly, the district court’s factual findings 

on Edmo’s Eighth Amendment claim are reviewed for clear 

error. See Graves, 623 F.3d at 1048. Clear error exists if the 

finding is “illogical, implausible, or without support in 

inferences that may be drawn from the facts in the record.” 

La Quinta Worldwide LLC v. Q.R.T.M., S.A. de C.V., 

762 F.3d 867, 879 (9th Cir. 2014) (quoting Herb Reed 

Enters., LLC v. Florida Entm’t Mgmt., Inc., 736 F.3d 1239, 

1247 (9th Cir. 2013)). We review de novo the district court’s 

“conclusion that the facts . . . demonstrate an Eighth 

Amendment violation.” Hallett v. Morgan, 296 F.3d 732, 

744 (9th Cir. 2002).

The State contends that the district court erred in 

granting an injunction because (1) Edmo’s Eighth 

Amendment claim fails and (2) Edmo has not shown that she 

will suffer irreparable injury in the absence of an 

injunction.14 We disagree. We hold, based on the district 

court’s factual findings, that Edmo established her Eighth 

Amendment claim and that she will suffer irreparable 

harm—in the form of ongoing mental anguish and possible 

physical harm—if GCS is not provided.

A. The Merits of Edmo’s Eighth Amendment Claim

“[D]eliberate indifference to serious medical needs of 

prisoners” violates the Eighth Amendment. Estelle, 

429 U.S. at 104. Because “society takes from prisoners the 

means to provide for their own needs,” Brown, 563 U.S. 

14 Because the State does not contest the other injunction factors, we 

do not address them.

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48 EDMO V. CORIZON

at 510, the government has an “obligation to provide medical 

care for those whom it is punishing by incarceration,” 

Estelle, 429 U.S. at 103.

To establish a claim of inadequate medical care, a 

prisoner must first “show a ‘serious medical need’ by 

demonstrating that ‘failure to treat a prisoner’s condition 

could result in further significant injury or the ‘unnecessary 

and wanton infliction of pain.’” Jett v. Penner, 439 F.3d 

1091, 1096 (9th Cir. 2006) (quoting McGuckin v. Smith, 

974 F.2d 1050, 1059 (9th Cir. 1991), overruled on other 

grounds by WMX Techs., Inc. v. Miller, 104 F.3d 1133 (9th 

Cir. 1997) (en banc)). Serious medical needs can relate to 

“physical, dental and mental health.” Hoptowit v. Ray, 

682 F.2d 1237, 1253 (9th Cir. 1982), abrogated on other 

grounds by Sandin v. Conner, 515 U.S. 472 (1995).

The State does not dispute that Edmo’s gender dysphoria 

is a sufficiently serious medical need to trigger the State’s 

obligations under the Eighth Amendment. Nor could it. 

Gender dysphoria is a “serious . . . medical condition” that 

causes “clinically significant distress”—distress that impairs 

or severely limits an individual’s ability to function in a 

meaningful way. DSM-5 at 453, 458. As Edmo testified, 

her gender dysphoria causes her to feel “depressed,” 

“disgusting,” “tormented,” and “hopeless,” and it has caused 

past efforts and active thoughts of self-castration. As this 

and many other courts have recognized, Edmo’s gender 

dysphoria is a sufficiently serious medical need to implicate 

the Eighth Amendment. See Rosati v. Igbinoso, 791 F.3d 

1037, 1039–40 (9th Cir. 2015); Kosilek, 774 F.3d at 86; 

De’lonta, 708 F.3d at 525; Battista v. Clarke, 645 F.3d 449, 

452 (1st Cir. 2011); Allard v. Gomez, 9 F. App’x 793, 794 

(9th Cir. 2001); White v. Farrier, 849 F.2d 322, 325 (8th Cir. 

1988); Meriwether v. Faulkner, 821 F.2d 408, 412 (7th Cir. 

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EDMO V. CORIZON 49

1987) (and cases cited therein); Norsworthy, 87 F. Supp. 3d 

at 1187; Konitzer v. Frank, 711 F. Supp. 2d 874, 905 (E.D. 

Wis. 2010).

If, as here, a prisoner establishes a sufficiently serious 

medical need, that prisoner must then “show the [official’s] 

response to the need was deliberately indifferent.” Jett, 

439 F.3d at 1096. An inadvertent or negligent failure to 

provide adequate medical care is insufficient to establish a 

claim under the Eighth Amendment. Estelle, 429 U.S. 

at 105–06; see also Farmer v. Brennan, 511 U.S. 825, 835 

(1994) (“ordinary lack of due care” is insufficient to 

establish an Eighth Amendment claim). In other words, 

“[m]edical malpractice does not become a constitutional 

violation merely because the victim is a prisoner.” Estelle, 

429 U.S. at 106. To “show deliberate indifference, the 

plaintiff must show that the course of treatment the [official] 

chose was medically unacceptable under the circumstances 

and that the [official] chose this course in conscious 

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

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

(quoting Snow v. McDaniel, 681 F.3d 978, 988 (9th Cir. 

2012), overruled in part on other grounds by Peralta v. 

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

1. The Medical Necessity of GCS for Edmo

The crux of the State’s appeal is that it provided adequate 

and medically acceptable care to Edmo.

Accepted standards of care and practice within the 

medical community are highly relevant in determining what 

care is medically acceptable and unacceptable. See Allard v. 

Baldwin, 779 F.3d 768, 772 (8th Cir. 2015); Henderson v. 

Ghosh, 755 F.3d 559, 566 (7th Cir. 2014) (per curiam). 

Typically, “[a] difference of opinion between a physician 

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50 EDMO V. CORIZON

and the prisoner—or between medical professionals—

concerning what medical care is appropriate does not 

amount to deliberate indifference.” Snow, 681 F.3d at 987; 

see also Gibson, 920 F.3d at 220. But that is true only if the 

dueling opinions are medically acceptable under the 

circumstances. See Toguchi v. Chung, 391 F.3d 1051, 1058 

(9th Cir. 2004) (a mere “difference of medical opinion . . . 

[is] insufficient, as a matter of law, to establish deliberate 

indifference,” but not if the “chosen course of treatment ‘was 

medically unacceptable under the circumstances’” 

(alterations in original) (quoting Jackson v. McIntosh, 

90 F.3d 330, 332 (9th Cir. 1996))).

“In deciding whether there has been deliberate 

indifference to an inmate’s serious medical needs, we need 

not defer to the judgment of prison doctors or 

administrators.” Hunt v. Dental Dep’t, 865 F.2d 198, 200 

(9th Cir. 1989). Nor does it suffice for “correctional 

administrators wishing to avoid treatment . . . simply to find 

a single practitioner willing to attest that some well-accepted 

treatment is not necessary.” Kosilek, 774 F.3d at 90 n.12. In 

the final analysis under the Eighth Amendment, we must 

determine, considering the record, the judgments of prison 

medical officials, and the views of prudent professionals in 

the field, whether the treatment decision of responsible 

prison authorities was medically acceptable.

Reviewing the record and the district court’s extensive 

factual findings, we conclude that Edmo has established that 

the “course of treatment” chosen to alleviate her gender 

dysphoria “was medically unacceptable under the 

circumstances.” Hamby, 821 F.3d at 1092 (quoting Snow, 

681 F.3d at 988). This conclusion derives from the district 

court’s factual findings, which are not “illogical, 

implausible, or without support in inferences that may be 

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EDMO V. CORIZON 51

drawn from the facts in the record.” La Quinta Worldwide 

LLC, 762 F.3d at 879 (quotation omitted).

In particular, and as we will explain, this is not a case of 

dueling experts, as the State paints it. The district court 

permissibly credited the opinions of Edmo’s experts that 

GCS is medically necessary to treat Edmo’s gender 

dysphoria and that the State’s failure to provide that 

treatment is medically unacceptable. Edmo’s experts are 

well-qualified to render such opinions, and they logically 

and persuasively explained the necessity of GCS and applied 

the WPATH Standards of Care—the undisputed starting 

point in determining the appropriate treatment for gender 

dysphoric individuals. On the other side of the coin, the 

district court permissibly discredited the contrary opinions 

of the State’s treating physician and medical experts. Those 

individuals lacked expertise and incredibly applied (or did 

not apply, in the case of the State’s treating physician) the 

WPATH Standards of Care. In other words, the district court 

did not clearly err in making its credibility determinations, 

so it is not our role to reevaluate them. The credited 

testimony establishes that GCS is medically necessary.

a. Expert Testimony

Turning first to the expert testimony offered, the district 

court credited the testimony of Edmo’s experts that GCS is 

medically necessary to treat Edmo’s gender dysphoria and 

that the State’s failure to provide that treatment is medically 

unacceptable. See Edmo, 358 F. Supp. 3d at 1120–21, 1125. 

Dr. Ettner and Dr. Gorton opined that GCS is medically 

necessary because Edmo’s current treatment has been 

inadequate, as evidenced by her self-castration attempts. 

They also opined that if Edmo does not receive GCS, there 

is little chance that her gender dysphoria will improve and 

she is at risk of committing self-surgery again, suicide, and 

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52 EDMO V. CORIZON

further emotional decompensation. On the other hand, 

providing GCS to Edmo would, in the opinions of Dr. Ettner 

and Dr. Gorton, align Edmo’s genitalia with her gender 

identity, thereby eliminating the severe distress Edmo 

experiences from her male genitalia.

In sharp contrast, the district court gave “virtually no 

weight” to the opinions of the State’s experts. Edmo, 358 F. 

Supp. 3d at 1126. Dr. Garvey and Dr. Andrade, who 

purported to rely on the WPATH Standards of Care, opined 

that GCS is not medically necessary for Edmo.

The district court did not err in crediting the testimony of 

Edmo’s experts and discounting the testimony of the State’s 

experts. Dr. Ettner and Dr. Gorton are well-qualified to 

opine on the medical necessity of GCS. Both have 

substantial experience treating individuals with gender 

dysphoria. Dr. Ettner has evaluated, diagnosed, and treated 

between 2,500 and 3,000 individuals with gender dysphoria, 

while Dr. Gorton has been the primary care physician for 

approximately 400 patients with gender dysphoria. Both 

have substantial experience evaluating whether GCS is 

medically necessary for patients. Dr. Ettner has evaluated 

hundreds of people for GCS, referring approximately 300 

while refusing others, and Dr. Gorton routinely determines 

the appropriateness of GCS for patients. They also have 

experience providing follow-up care for patients who have 

undergone GCS. And both have published peer-reviewed 

articles concerning the treatment of gender dysphoria.

The State’s experts, by contrast, have substantial 

experience providing health care in institutional settings, but 

lack meaningful experience directly treating people with 

gender dysphoria. Dr. Garvey directly treated a “couple of 

patients” with gender dysphoria early in her career, while 

Dr. Andrade has never provided direct treatment for patients 

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EDMO V. CORIZON 53

with gender dysphoria. Moreover, prior to evaluating Edmo, 

neither had ever evaluated someone in person to determine 

the medical necessity of GCS. Relatedly, Dr. Garvey and 

Dr. Andrade have never provided follow-up care for a person 

who has received GCS. Indeed, Dr. Andrade did not even 

qualify under IDOC policy to assess a person for GCS. And 

neither Dr. Garvey nor Dr. Andrade has published a peerreviewed article concerning the treatment of gender 

dysphoria.

Neither Dr. Ettner nor Dr. Gorton have treated prisoners 

with gender dysphoria, nor are they Certified Correctional 

Healthcare Professionals. But both serve on WPATH’s 

Institutionalized Persons Committee, which “looks at the 

care and the assessment of individuals who are incarcerated 

and develops standards for treatment” of such individuals. 

They are thus familiar with medical treatment in prison 

settings. Moreover, Dr. Ettner has assessed approximately 

30 incarcerated persons with gender dysphoria for GCS and 

other medical care.

More to the point, the more relevant experience for 

determining the medical necessity of GCS is having treated 

individuals with gender dysphoria, having evaluated 

individuals for GCS, and having treated them postoperatively. Such experience lends itself to fundamental 

knowledge of whether GCS is necessary and the potential 

risks of providing or foregoing the surgery. Edmo’s experts 

have the requisite experience; the State’s experts do not. For 

that reason alone, the district court did not clearly err in 

crediting the opinions of Edmo’s experts over those of the 

State.15 See Caro v. Woodford, 280 F.3d 1247, 1253 (9th 

15 The State contends that neither Dr. Ettner nor Dr. Gorton was 

qualified to offer expert opinions as to the appropriate medical care for 

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54 EDMO V. CORIZON

Cir. 2002) (explaining that we “must afford the District 

Court considerable deference in its determination that the 

witnesses were qualified to draw [their] conclusions”).

Independent of the experts’ qualifications, the district 

court did not err in crediting the opinions of Edmo’s experts 

over those of the State because aspects of Dr. Garvey’s and 

Dr. Andrade’s opinions ran contrary to the established 

standards of care in the area of transgender health care—the 

WPATH Standards of Care—which they purported to 

apply.16 See Edmo, 358 F. Supp. 3d at 1125.

Edmo because neither is a psychiatrist. So far as we can discern, the 

argument is that because a psychiatrist (Dr. Eliason) evaluated Edmo for 

GCS, only other psychiatrists are qualified to opine as to the medical 

necessity of GCS and to contradict his assessment. See Oral Arg. 

at 10:00–10:30. We reject that contention. Edmo’s experts, as 

explained, have significant experience evaluating patients for GCS—

precisely what Dr. Eliason did. On the basis of their medical experience 

treating persons with gender dysphoria, they are well-qualified to render 

an opinion on the medical necessity of GCS and whether failure to 

provide the surgery is medically acceptable. See Fed. R. Evid. 702.

16 The State contends that the district court erred in requiring strict 

adherence to the flexible WPATH Standards of Care and in concluding 

that any deviation from those standards is medically unacceptable. But 

the district court correctly recognized that the WPATH Standards of 

Care are flexible, see Edmo, 358 F. Supp. 3d at 1111, and it appropriately 

used them as a starting point to gauge the credibility of each expert’s 

testimony, see id. at 1125–26. Tellingly, each expert for Edmo and the 

State likewise used the WPATH Standards of Care as a starting point. 

As the district court recognized: “There are no other competing, 

evidence-based standards that are accepted by any nationally or 

internationally recognized medical professional groups.” Id. at 1125. 

And as the State acknowledged at the evidentiary hearing, the “WPATH 

standards of care in the seventh edition do provide the best guidance” 

and “are the best standards out there.” For these reasons, the WPATH 

Standards of Care establish a useful starting point for analyzing the 

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EDMO V. CORIZON 55

For example, both Dr. Garvey and Dr. Andrade 

expressed the view that Edmo does not meet the sixth 

WPATH criterion, “12 continuous months of living in a 

gender role that is congruent with gender identity.” WPATH 

SOC at 60. They pointed out that Edmo has not presented 

as female outside of prison and urged that she needs real-life 

experiences in the community before undergoing GCS.

These opinions run head-on into the WPATH Standards 

of Care. The WPATH standards, which the NCCHC 

endorses as the accepted standards for the treatment of 

transgender inmates, apply

in their entirety . . . to all transsexual, 

transgender, and gender nonconforming 

people, irrespective of their housing 

situation. People should not be discriminated 

against in their access to appropriate health 

care based on where they live, including 

institutional environments such as prisons 

. . . . Health care for transsexual, 

transgender, and gender nonconforming 

people living in an institutional environment 

should mirror that which would be available 

to them if they were living in a noninstitutional setting within the same 

community.

credibility and weight to be given to each expert’s opinion and whether 

that opinion was consistent with established standards of care. The State 

does not contest the district court’s finding that the WPATH Standards 

of Care are the “internationally recognized guidelines for the treatment 

of individuals with gender dysphoria.” Id. at 1111. They are the gold 

standard on this issue.

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56 EDMO V. CORIZON

All elements of assessment and treatment as 

described in the [Standards of Care] can be 

provided to people living in institutions. 

Access to these medically necessary 

treatments should not be denied on the basis 

of institutionalization or housing 

arrangements.

WPATH SOC at 67. Dr. Garvey and Dr. Andrade’s view—

that GCS cannot be medically indicated for transgender 

inmates who did not present in a gender-congruent manner 

before incarceration—contradicts these accepted standards. 

Dr. Garvey and Dr. Andrade would deny GCS to a class of 

people because of their “institutionalization,” which the 

WPATH Standards of Care explicitly disavow. They 

provide no persuasive explanation for their deviation.17 And 

nothing in the WPATH Standards of Care or the law 

supports excluding an entire class of gender dysphoric 

individuals from eligibility for GCS.

Both Dr. Garvey and Dr. Andrade also relied on Edmo’s 

failure to attend psychotherapy sessions as an indication that 

her mental health concerns are not well controlled. But 

psychotherapy is not a precondition for surgery under the 

WPATH Standards of Care. WPATH SOC at 28–29.

We acknowledge that the WPATH Standards of Care are 

flexible, and a simple deviation from those standards does 

not alone establish an Eighth Amendment claim. But the 

17 In concluding that Edmo does not meet the sixth WPATH 

criterion, Dr. Garvey expressed concern that there is a lack of evidence 

regarding GCS in prison settings. That rationale acts as self-fulfilling 

prophecy. If prisons and prison officials deny GCS to prisoners because 

of a lack of data, the data will never be generated, and the cycle will 

continue.

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EDMO V. CORIZON 57

State’s experts purported to be applying those standards and 

yet did so in a way that directly contradicted them. These 

unsupported and unexplained deviations offer a further 

reason why the district court did not clearly err in 

discounting the testimony of the State’s experts. See Caro, 

280 F.3d at 1253.

Finally, the district court did not err in discrediting the 

State’s experts because aspects of their opinions were 

illogical and unpersuasive. For example, Dr. Garvey and 

Dr. Andrade expressed the view that Edmo does not meet the 

first WPATH criterion—“persistent, well documented 

gender dysphoria,” WPATH SOC at 60—because of a lack 

of evidence from pre-incarceration records of Edmo 

presenting as female. But both experts acknowledged that 

Edmo has been diagnosed with and treated for gender 

dysphoria since 2012—i.e., for six years as of the evidentiary 

hearing. Neither Dr. Garvey nor Dr. Andrade questioned 

Edmo’s diagnosis, and both agree that she currently suffers 

gender dysphoria. There can be no doubt that Edmo has 

“persistent, well documented gender dysphoria,” so their 

opinion is inexplicable.

Dr. Garvey’s and Dr. Andrade’s opinions on this point 

also ignore that individuals with gender dysphoria do not 

always experience symptoms early in life or throughout their 

life, or do not identify them as such. As Dr. Ettner testified, 

“gender dysphoria intensifies with age.” And as with 

treatment for any other medical condition, treatment for 

gender dysphoria must be based on a patient’s current 

situation.

The opinions of Edmo’s experts are notably devoid of 

these flaws. Dr. Ettner and Dr. Gorton cogently and 

persuasively explained why GCS is medically necessary for 

Edmo and why Edmo meets the WPATH criteria for GCS.

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58 EDMO V. CORIZON

For example, consistent with the WPATH Standards of 

Care, Dr. Ettner explained that Edmo has lived for 

“12 continuous months . . . in a gender role that is congruent 

with gender identity” (the sixth WPATH criterion) because 

she has lived “as a woman to the best of her ability in a male 

prison.” In support of her opinion, Dr. Ettner cited Edmo’s 

“appearance . . . , her disciplinary records, which indicated 

that she had attempted to wear her hair in a feminine 

hairstyle and to wear makeup even though that was against 

the rules and she was – received some sort of disciplinary 

action for that, and her – the way that she was receiving 

female undergarments and had developed the stigma of 

femininity, the secondary sex characteristics, breast 

development, et cetera.” Dr. Gorton similarly explained that 

Edmo satisfies the sixth WPATH criterion because she has 

lived for years in her “target gender role . . . despite an 

environment that’s very hostile to that and some negative 

consequences that she has experienced because of that.”

Moreover, both Dr. Ettner and Dr. Gorton offered 

reasoned explanations tying Edmo’s self-castration attempts 

to her severe gender dysphoria. Dr. Ettner explained that 

doctors regard “surgical self-treatment . . . as an intentional 

attempt to remove the target organ that produces 

testosterone, which, in fact, is the cure for gender 

dysphoria.” As Dr. Gorton elaborated, Edmo’s selfcastration attempts demonstrate deficient treatment for 

“severe genital-focused gender dysphoria.” He rejected the 

notion that Edmo’s depression and anxiety drove her selfcastration attempts: “there [are] a lot of people with 

depression and anxiety who don’t remove their testicles.”

In light of the experts’ backgrounds and experience, and 

the reasonableness, consistency, and persuasiveness of their 

opinions, the district court did not err in crediting the 

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EDMO V. CORIZON 59

opinions of Edmo’s experts and giving little weight to those 

of the State’s experts. The district court carefully examined 

the voluminous record, extensive testimony, and conflicting 

expert opinions in this case and set forth clear reasons, 

supported by the record, for relying on the testimony of 

Edmo’s experts. See La Quinta Worldwide, 762 F.3d at 879 

(a factual finding is clear error if it is “illogical, implausible, 

or without support in inferences that may be drawn from the 

facts in the record”); Caro, 280 F.3d at 1253; Beech Aircraft 

Corp. v. United States, 51 F.3d 834, 838 (9th Cir. 1995) (per 

curiam). The credited expert testimony established that GCS 

is medically necessary to alleviate Edmo’s gender dysphoria.

b. Dr. Eliason’s Assessment

Turning from the expert testimony offered, the State

contends that Edmo’s experts, at most, created a dispute of 

professional judgment with Edmo’s treating psychiatrist, Dr. 

Eliason, who it urges reasonably concluded that GCS is 

inappropriate for Edmo. If that is the case, the argument 

goes, then Edmo’s Eighth Amendment claim fails because 

the dispute is merely a “difference of opinion . . . between 

medical professionals” about “what medical care is 

appropriate.” Snow, 681 F.3d at 987. The problem for the 

State is that Dr. Eliason’s decision “was medically 

unacceptable under the circumstances.” Toguchi, 391 F.3d 

at 1058 (quoting Jackson, 90 F.3d at 332).

In particular, as the district court found, Dr. Eliason did 

not follow accepted standards of care in the area of 

transgender health care. See Edmo, 358 F. Supp. 3d at 1126. 

Dr. Eliason explained in his notes that, in his view, GCS is 

medically necessary in three situations: “congenital 

malformation or ambiguous genitalia,” “severe and 

devastating dysphoria that is primarily due to genitals,” or 

“some type of medical problem in which endogenous sexual 

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60 EDMO V. CORIZON

hormones were causing severe physiological damage.” The 

conclusion of his notes—“[t]his inmate does not meet any of 

those [three] criteria”—suggests that he views those as the 

only three scenarios in which GCS would be medically 

necessary, an impression he did not dispel during his 

testimony. Those “criteria” (Dr. Eliason’s term), however, 

bear little resemblance to the widely accepted, evidencebased criteria set out in the WPATH’s Standards of Care. As 

Dr. Eliason acknowledged, the NCCHC endorses the 

WPATH Standards of Care as the accepted standards for the 

treatment of transgender prisoners. And as the district court 

found and the State does not contest, “[t]here are no other 

competing, evidence-based standards that are accepted by 

any nationally or internationally recognized medical 

professional groups.” Id. at 1125. Dr. Eliason did not follow 

these standards in rendering his decision.

The State challenges the district court’s finding that 

Dr. Eliason “did not apply the WPATH Criteria,” id. at 1126, 

on two grounds. First, citing Dr. Eliason’s testimony at the 

evidentiary hearing, it urges that Dr. Eliason concluded that 

GCS was not medically necessary for Edmo because Edmo’s 

mental health issues were not well controlled (the fourth 

WPATH criterion) and she had not consistently presented as 

female outside of prison (the sixth).

The district court’s rejection of this post hoc explanation 

was not clear error. Neither of the explanations offered by 

Dr. Eliason during the evidentiary hearing appears in 

Dr. Eliason’s notes. Nor did he give these reasons during his 

deposition. Their absence is conspicuous, given that 

Dr. Eliason took the time to indicate instances where, in his 

opinion, GCS is appropriate and to explain that Edmo did 

not satisfy his “criteria.”

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Second, the State highlights that Dr. Eliason’s notes 

recommend further “supportive counseling” for Edmo and 

indicate that Edmo was up for parole. The State construes 

these notes as shorthand for the fourth and sixth WPATH 

criteria, respectively. The State’s proposed reading of 

Dr. Eliason’s notes is unreasonable. His notes are clear that 

GCS is not needed because Edmo did not meet his three 

“criteria,” and the district court was well within its 

factfinding discretion in rejecting the State’s strained 

reading. We therefore conclude that the district court 

reasonably found that Dr. Eliason “did not rely upon any 

finding that Ms. Edmo did not meet the WPATH criteria in 

concluding in his April 2016 assessment that she did not 

meet the criteria for gender confirmation surgery.” Id. 

at 1120.

Notably, neither Dr. Eliason nor the State has offered any 

explanation or support for Dr. Eliason’s “criteria.” 

Dr. Eliason testified that he could not recall where he came 

up with them.

Nor has Dr. Eliason or the State contended that 

Dr. Eliason’s criteria were a reasonable deviation or 

modification of the WPATH Standards of Care. In any 

event, we could not accept that argument. Dr. Eliason’s 

criteria—apparently invented out of whole cloth—are so far 

afield from the WPATH standards that we cannot 

characterize his decision as a flexible application of or 

deviation from those standards. Indeed, as Dr. Gorton 

explained, two of Dr. Eliason’s criteria are inapplicable to 

the care of transgender individuals. Dr. Eliason’s criterion 

of “congenital malformation or ambiguous genitalia” “isn’t 

. . . germane to transgender people.” His statement that GCS 

could be needed when “endogenous sexual hormones were 

causing severe physiological damage,” is, in Dr. Gorton’s 

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62 EDMO V. CORIZON

words, “bizarre. I can’t think of a clinical circumstance 

where . . . your hormones that your body produces are 

attacking you . . . . I just don’t understand what [Dr. Eliason] 

is talking about there.”

Dr. Eliason, in short, did not follow the accepted 

standards of care in the area of transgender health care, nor 

did he reasonably deviate from or flexibly apply them. 

Dr. Eliason did not apply the established standards, even as 

a starting point, in his evaluation.

Putting to the side Dr. Eliason’s failure to follow or 

reasonably deviate from the accepted standards of care, his 

decision was internally contradictory in an important way. 

His notes reflect that GCS would be medically necessary if 

a person is suffering “severe and devastating gender 

dysphoria that is primarily due to genitals.” At his 

deposition, Dr. Eliason conceded that self-castration could 

show gender dysphoria sufficiently severe to satisfy that 

criterion. And at the evidentiary hearing, he acknowledged 

that Edmo “does primarily meet that criteri[on].” Thus, even 

under Dr. Eliason’s own criteria, Edmo should have been 

provided GCS. Neither Dr. Eliason nor the State has 

reconciled this important contradiction between 

Dr. Eliason’s criteria and his determination.

In sum, Dr. Eliason’s evaluation was not an exercise of 

medically acceptable professional judgment. Dr. Eliason’s 

decision was based on inexplicable criteria far afield from 

the recognized standards of care and, even applying 

Dr. Eliason’s criteria, Edmo qualifies for GCS. Given the 

credited expert testimony that GCS is necessary to treat 

Edmo’s gender dysphoria, Dr. Eliason’s contrary 

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determination was “medically unacceptable under the 

circumstances.”18 Snow, 681 F.3d at 988.

2. Deliberate Indifference

The State next contends that even if the treatment 

provided Edmo was medically unacceptable, no defendant 

acted “in conscious disregard of an excessive risk to 

[Edmo’s] health.” Hamby, 821 F.3d at 1092 (quoting Snow, 

681 F.3d at 988). We disagree.

The record demonstrates that Dr. Eliason acted with 

deliberate indifference to Edmo’s serious medical needs. 

Dr. Eliason knew, as of the time of his evaluation, that Edmo 

had attempted to castrate herself. He also knew that Edmo 

suffers from gender dysphoria; he knew she experiences 

“clinically significant” distress that impairs her ability to 

function. He acknowledged that Edmo’s self-castration 

attempt was evidence that Edmo’s gender dysphoria, in his 

words, “had risen to another level.” Dr. Eliason nonetheless 

continued with Edmo’s ineffective treatment plan.

Edmo then tried to castrate herself a second time, in 

December 2016. Dr. Eliason knew of that nearly 

18 Dr. Eliason was not alone in his decision. Dr. Stoddart, 

Dr. Young, and Jeremy Clark agreed with his assessment, as did the 

MTC. The State contends that such general agreement demonstrates that 

Dr. Eliason’s decision was reasonable. But general agreement in a 

medically unacceptable form of treatment does not somehow make it 

reasonable. This is especially so in light of the limited review those 

individuals performed: Dr. Stoddard, Dr. Young, and Jeremy Clark 

agreed with Dr. Eliason’s recommended treatment as he presented it to 

them and without personally evaluating Edmo, and the MTC “does not 

make any individual treatment decisions regarding [gender dysphoric] 

inmates. Those determinations are made by the individual clinicians or 

the medical staff employed by Corizon,” like Dr. Eliason.

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64 EDMO V. CORIZON

catastrophic event, but he did not reevaluate or recommend 

a change to Edmo’s treatment plan, despite indicating in his 

April 2016 evaluation that he would continue to monitor and 

assess Edmo’s condition. Dr. Eliason continued to see Edmo 

after that time, and he considered Edmo’s treatment as a 

member of the MTC. At no point did Dr. Eliason change his 

mind or the treatment plan regarding surgery. Under these 

circumstances, we conclude that Dr. Eliason knew of and 

disregarded the substantial risk of severe harm to Edmo. 

Farmer, 511 U.S. at 837.

The State urges that neither Dr. Eliason nor any other 

defendant acted with deliberate indifference because none 

acted with “malice, intent to inflict pain, or knowledge that 

[the] recommended course of treatment was medically 

inappropriate.” The State misstates the standard. A prisoner 

“must show that prison officials ‘kn[e]w [ ] of and 

disregard[ed]’ the substantial risk of harm,’ but the officials 

need not have intended any harm to befall the inmate; ‘it is 

enough that the official acted or failed to act despite his 

knowledge of a substantial risk of serious harm.’” Lemire v. 

Cal. Dep’t of Corr. & Rehab., 726 F.3d 1062, 1074 (9th Cir. 

2013) (alterations in original) (quoting Farmer, 511 U.S. 

at 837, 842). Neither the Supreme Court nor this court has 

ever required a plaintiff to show a “sinister [prison official] 

with improper motives,” as the State would require. It is 

enough that Dr. Eliason knew of and disregarded an 

excessive risk to Edmo’s health by rejecting her request for 

GCS and then never re-evaluating his decision despite 

ongoing harm to Edmo.

The State also contends that because the defendants 

provided some care to Edmo, no defendant could have been 

deliberately indifferent. The provision of some medical 

treatment, even extensive treatment over a period of years, 

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EDMO V. CORIZON 65

does not immunize officials from the Eighth Amendment’s 

requirements. See Lopez v. Smith, 203 F.3d 1122, 1132 (9th 

Cir. 2000) (en banc) (explaining that “[a] prisoner need not 

prove that he was completely denied medical care” to make 

out an Eighth Amendment claim); see also De’lonta, 

708 F.3d at 526 (“[J]ust because [officials] have provided 

De’lonta with some treatment consistent with the GID 

Standards of Care, it does not follow that they have 

necessarily provided her with constitutionally adequate 

treatment.”). As the Fourth Circuit has aptly analogized,

imagine that prison officials prescribe a 

painkiller to an inmate who has suffered a 

serious injury from a fall, but that the 

inmate’s symptoms, despite the medication, 

persist to the point that he now, by all 

objective measure, requires evaluation for 

surgery. Would prison officials then be free 

to deny him consideration for surgery, 

immunized from constitutional suit by the 

fact they were giving him a painkiller? We 

think not.

De’lonta, 708 F.3d at 526. Here, although the treatment 

provided Edmo was important, it stopped short of what was 

medically necessary.

3. Out-of-Circuit Precedent

Our decision cleaves to settled Eighth Amendment 

jurisprudence, which requires a fact-specific analysis of the 

record (as construed by the district court) in each case. See

Patel v. Kent Sch. Dist., 648 F.3d 965, 975 (9th Cir. 2011) 

(“Deliberate-indifference cases are by their nature highly 

fact-specific . . . .”); see also Rachel v. Troutt, 820 F.3d 390, 

394 (10th Cir. 2016) (“Each step of this [deliberate 

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66 EDMO V. CORIZON

indifference] inquiry is fact-intensive.” (quoting Hartsfield 

v. Colburn, 491 F.3d 394, 397 (8th Cir. 2007))); Roe v. 

Elyea, 631 F.3d 843, 859 (7th Cir. 2011) (“[I]nmate medical 

care decisions must be fact-based with respect to the 

particular inmate, the severity and stage of his condition, the 

likelihood and imminence of further harm and the efficacy 

of available treatments.”); Youmans v. Gagnon, 626 F.3d 

557, 564 (11th Cir. 2010) (“Judicial decisions addressing 

deliberate indifference to a serious medical need, like 

decisions in the Fourth Amendment search-and-seizure 

realm, are very fact specific.”); Chance v. Armstrong, 

143 F.3d 698, 703 (2d Cir. 1998) (“Whether a course of 

treatment was the product of sound medical judgment, 

negligence, or deliberate indifference depends on the facts 

of the case.”).

Several years ago, the First Circuit, sitting en banc, 

employed that fact-based approach to evaluate a gender 

dysphoric prisoner’s Eighth Amendment claim seeking 

GCS. The First Circuit confronted the following record: 

credited expert testimony disagreed as to whether GCS was 

medically necessary; the prisoner’s active treatment plan, 

which did not include GCS, had “led to a significant 

stabilization in her mental state”; and a report and testimony 

from correctional officials detailed significant security 

concerns that would arise if the prisoner underwent GCS. 

Kosilek, 774 F.3d at 86–96. “After carefully considering the 

community standard of medical care, the adequacy of the 

provided treatment, and the valid security concerns 

articulated by the DOC,” a 3–2 majority of the en banc court 

concluded that the plaintiff had not demonstrated GCS was 

medically necessary treatment for her gender dysphoria. Id. 

at 68.

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Our approach mirrors the First Circuit’s, but the 

important factual differences between cases yield different 

outcomes. Notably, the security concerns in Kosilek, which 

the First Circuit afforded “wide-ranging deference,” are 

completely absent here. Id. at 92. The State does not so 

much as allude to them. The medical evidence also differs. 

In Kosilek, qualified and credited experts disagreed about 

whether GCS was necessary. Id. at 90. As explained above, 

the district court’s careful factual findings admit of no such 

disagreement here. Rather, they unequivocally establish that 

GCS is the safe, effective, and medically necessary treatment 

for Edmo’s severe gender dysphoria.

We recognize, however, that our decision is in tension 

with Gibson v. Collier. In that case, the Fifth Circuit held, 

in a split decision, that “[a] state does not inflict cruel and 

unusual punishment by declining to provide [GCS] to a 

transgender inmate.” 920 F.3d at 215. It did so on a “sparse 

record”—which included only the WPATH Standards of 

Care and was notably devoid of “witness testimony or 

evidence from professionals in the field”—compiled by a 

pro se plaintiff. Id. at 220. Despite the sparse record, a 2–1

majority of the Gibson panel concluded that “there is no 

consensus in the medical community about the necessity and 

efficacy of [GCS] as a treatment for gender dysphoria. . . .

This on-going medical debate dooms Gibson’s claim.” Id. 

at 221.

We respectfully disagree with the categorical nature of 

our sister circuit’s holding. Most fundamentally, Gibson

relies on an incorrect, or at best outdated, premise: that 

“[t]here is no medical consensus that [GCS] is a necessary 

or even effective treatment for gender dysphoria.” Id. at 223.

As the record here demonstrates and the State does not 

seriously dispute, the medical consensus is that GCS is 

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effective and medically necessary in appropriate 

circumstances. The WPATH Standards of Care—which are 

endorsed by the American Medical Association, the 

American Medical Student Association, the American 

Psychiatric Association, the American Psychological 

Association, the American Family Practice Association, the 

Endocrine Society, the National Association of Social 

Workers, the American Academy of Plastic Surgeons, the 

American College of Surgeons, Health Professionals 

Advancing LGBTQ Equality, the HIV Medicine 

Association, the Lesbian, Bisexual, Gay and Transgender 

Physician Assistant Caucus, and Mental Health America—

recognize this fact. WPATH SOC at 54–55. Each expert in 

this case agrees. As do others in the medical community. 

See, e.g., U.S. Dep’t of Health & Human Servs., No. A-13-

87, Decision No. 2576; Bao Ngoc N. Tran, et al., Gender 

Affirmation Surgery: A Synopsis Using American College of 

Surgeons National Surgery Quality Improvement Program 

and National Inpatient Sample Databases, 80 Annals Plastic 

Surgery S229, S234 (2018); Frey, A Historical Review of 

Gender-Affirming Medicine, 14 J. Sexual Med. at 991; see 

also What We Know Project, Ctr. for the Study of 

Inequality, Cornell Univ., What Does the Scholarly 

Research Say About the Effect of Gender Transition on 

Transgender Well-Being?, https://whatweknow.inequality.c

ornell.edu/topics/lgbt-equality/what-does-the-scholarly-rese

arch-say-about-the-well-being-of-transgender-people/ (last 

visited July 10, 2019) (reviewing the available literature and 

finding “a robust international consensus in the peerreviewed literature that gender transition, including medical 

treatments such as hormone therapy and surgeries, improves 

the overall well-being of transgender individuals”). The 

Fifth Circuit is the outlier.

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Gibson’s broad holding stemmed from a dismaying 

disregard for procedure. As noted, the “sparse” summary 

judgment record that the pro se plaintiff developed included 

“only the WPATH Standards of Care.” Gibson, 920 F.3d at 

221. Perhaps that factual deficiency doomed Gibson’s 

Eighth Amendment claim. See id. at 223–24. But to reach 

its broader holding that denying GCS cannot, as a matter of 

law, violate the Eighth Amendment—in other words, to 

reject every conceivable Eighth Amendment claim based on 

the denial of GCS—the Fifth Circuit coopted the record from 

Kosilek, a First Circuit decision that predates Gibson by four 

years. Id. at 221–23. We doubt the analytical value of such 

an anomalous procedural approach.

Worse yet, the medical opinions from Kosilek do not 

support the Fifth Circuit’s categorical holding. Dr. Chester 

Schmidt’s and Dr. Stephen Levine’s testimony in Kosilek, 

which the Fifth Circuit relied on, do not support the 

proposition that GCS is never medically necessary. Dr. 

Schmidt and Dr. Levine testified that GCS was not necessary 

in the factual circumstances of that case, that is, based on the 

unique medical needs of the prisoner at issue. See Kosilek, 

774 F.3d at 76–79.

The only suggestion in Kosilek that GCS is never 

medically necessary is in the First Circuit’s recitation of the 

testimony of Dr. Cynthia Osborne. See Gibson, 920 F.3d 

at 221. The First Circuit recounted that Dr. Osborne testified 

that she “did not view [GCS] as medically necessary in light 

of the ‘whole continuum from noninvasive to invasive’ 

treatment options available to individuals with” gender 

dysphoria. Kosilek, 774 F.3d at 77. To the extent this vague 

portrait of Dr. Osborne’s testimony conveys her belief that 

GCS is never medically necessary, she has apparently 

changed her view in the more than ten years since she 

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testified in Kosilek. Like both sides and all four medical 

experts who testified here, Dr. Osborne now agrees that GCS 

“can be medically necessary for some, though not all, 

persons with [gender dysphoria], including some prison 

inmates.” Osborne & Lawrence, Male Prison Inmates With 

Gender Dysphoria, 45 Archives of Sexual Behav. at 1651. 

In her and her co-author’s words, “[GCS] is a safe, effective, 

and widely accepted treatment for [gender dysphoria]; 

disputing the medical necessity of [GCS] based on assertions 

to the contrary is unsupportable.” Id. The predicate medical 

opinions that Gibson is premised upon, then, do not support 

the Fifth Circuit’s view that GCS is never medically 

necessary. The consensus is that GCS is effective and 

medically necessary in appropriate circumstances.19

Gibson is unpersuasive for several additional reasons. It

directly conflicts with decisions of this circuit, the Fourth 

19 We do not suggest that every member of the medical and mental 

health communities agrees that GCS may be medically necessary. There 

are outliers. But when the medical consensus is that a treatment is 

effective and medically necessary under the circumstances, prison 

officials render unacceptable care by following the views of outliers 

without offering a credible medical basis for deviating from the accepted 

view. See Kosilek, 774 F.3d at 90 n.12 (explaining that it is not enough 

for “correctional administrators wishing to avoid treatment . . . simply to 

find a single practitioner willing to attest that some well-accepted 

treatment is not necessary”); Hamilton v. Endell, 981 F.2d 1062, 1067 

(9th Cir. 1992) (“By choosing to rely upon a medical opinion which a 

reasonable person would likely determine to be inferior, the prison 

officials took actions which may have amounted to the denial of medical 

treatment, and the unnecessary and wanton infliction of pain.” (quotation 

omitted)), overruled in part on other grounds as recognized in Snow, 

681 F.3d at 986; cf. also Bragdon v. Abbott, 524 U.S. 624, 650 (1998) 

(“A health care professional who disagrees with the prevailing medical 

consensus may refute it by citing a credible scientific basis for deviating 

from the accepted norm.”).

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Circuit, and the Seventh Circuit, all of which have held that 

denying surgical treatment for gender dysphoria can pose a 

cognizable Eighth Amendment claim. Rosati, 791 F.3d at 

1040 (alleged blanket ban on GCS and denial of GCS to 

plaintiff with severe symptoms, including repeated selfcastration attempts, states an Eighth Amendment claim); 

Fields v. Smith, 653 F.3d 550, 552–53, 558–59 (7th Cir. 

2011) (law banning hormone treatment and GCS, even if 

medically necessary, violates the Eighth Amendment); 

De’lonta, 708 F.3d at 525 (alleged denial of an evaluation 

for GCS states an Eighth Amendment claim).20 Relatedly, 

Gibson eschews Eighth Amendment precedent requiring a 

case-by-case determination of the medical necessity of a 

particular treatment. See, e.g., Colwell v. Bannister, 

763 F.3d 1060, 1068 (9th Cir. 2014) (holding that the 

“blanket, categorical denial of medically indicated surgery 

solely on the basis of an administrative policy . . . is the 

paradigm of deliberate indifference” (quotation omitted)); 

Roe, 631 F.3d at 859.

In this latter respect, Gibson also contradicts and 

misconstrues the precedent it purports to follow: Kosilek. 

According to the Gibson majority, “the majority in Kosilek

effectively allowed a blanket ban on sex reassignment 

surgery.” 920 F.3d at 216. Not so. The First Circuit did 

precisely what we do here: assess whether the record before 

it demonstrated deliberate indifference to the plaintiff’s 

20 The Fifth Circuit unpersuasively attempted to reconcile its 

decision with Rosati and De’lonta, pointing out that those decisions 

“allowed Eighth Amendment claims for [GCS] to survive motions to 

dismiss, without addressing the merits.” Gibson, 920 F.3d at 223 n.8. 

But if Gibson is correct that failing to provide GCS cannot amount to 

deliberate indifference, then a plaintiff cannot state an Eighth 

Amendment claim based on the denial of GCS. Rosati and De’lonta 

would necessarily have been decided differently under Gibson’s holding.

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gender dysphoria. On the record before it, the First Circuit 

determined that either of two courses of treatment (one 

included GCS and one did not) were medically acceptable. 

Kosilek, 774 F.3d at 90. In light of those medically 

acceptable alternatives, the First Circuit explained that it was 

not its place to “second guess medical judgments or to 

require that the DOC adopt the more compassionate of two 

adequate options.” Id. (quotation omitted). It expressly 

cautioned that the opinion should not be read to “create a de 

facto ban against [GCS] as a medical treatment for any 

incarcerated individual,” as “any such policy would conflict 

with the requirement that medical care be individualized 

based on a particular prisoner’s serious medical needs.” Id. 

at 91 (citing Roe, 631 F.3d at 862–63). The Fifth Circuit 

disregarded these words of warning.

21

* * *

In summary, Edmo has established that she suffers from 

a “serious medical need,” Jett, 439 F.3d at 1096, and that the 

treatment provided was “medically unacceptable under the 

circumstances” and chosen “in conscious disregard of an 

excessive risk” to her health, Hamby, 821 F.3d at 1092. She 

established her Eighth Amendment claim of deliberate 

indifference as to Defendant-Appellant Dr. Eliason.

21 Gibson’s final, originalist rationale—that it cannot be cruel and 

unusual to deny a surgery that has only once been provided to an inmate, 

920 F.3d at 226–28—warrants little discussion. Gibson’s originalist 

understanding of the Eighth Amendment does not control; Estelle does, 

and under Estelle a plaintiff establishes an Eighth Amendment claim by 

demonstrating that prison officials were deliberately indifferent to a 

serious medical need. 429 U.S. at 106. This standard protects the 

evolving standards of decency enshrined in the Eighth Amendment.

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B. Irreparable Harm

The State next contends that the district court erred in 

finding that Edmo would be irreparably harmed absent an 

injunction.

In reaching its conclusion, the district court found that 

Edmo experiences ongoing “clinically significant distress,” 

meaning “the distress impairs or severely limits [her] ability 

to function in a meaningful way.” Edmo, 358 F. Supp. 3d 

at 1110–11. This finding is supported by Edmo’s testimony 

that her gender dysphoria causes her to feel “depressed,” 

“disgusting,” “tormented,” and “hopeless”; that she actively 

experiences thoughts of self-castration; and that she “selfmedicat[es]” by cutting her arms with a razor to avoid acting 

on those thoughts and impulses. The district court also 

found that in the absence of surgery, Edmo “will suffer 

serious psychological harm and will be at high risk of selfcastration and suicide.” Id. at 1128. This finding is 

supported by the credited expert testimony of Dr. Ettner and 

Dr. Gorton, who detailed the escalating risks of self-surgery, 

suicide, and emotional decompensation should Edmo be 

denied surgery.

It is no leap to conclude that Edmo’s severe, ongoing 

psychological distress and the high risk of self-castration and 

suicide she faces absent surgery constitute irreparable harm. 

See Stanley v. Univ. of S. Cal., 13 F.3d 1313, 1324 n.5 (9th 

Cir. 1994); Thomas v. County of Los Angeles, 978 F.2d 504, 

511 (9th Cir. 1992); Chalk v. U.S. Dist. Ct. Cent. Dist. of 

Cal., 840 F.2d 701, 709 (9th Cir. 1988). Moreover, the 

deprivation of Edmo’s constitutional right to adequate 

medical care is sufficient to establish irreparable harm. See

Nelson v. NASA, 530 F.3d 865, 882 (9th Cir. 2008) (“Unlike 

monetary injuries, constitutional violations cannot be 

adequately remedied through damages and therefore 

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74 EDMO V. CORIZON

generally constitute irreparable harm.”), rev’d and 

remanded on other grounds, 562 U.S. 134 (2011).

The State offers three contentions as to why the district 

court erred in finding that Edmo would be irreparably 

injured in the absence of an injunction. None is persuasive.

First, the State argues that the “long delay” of “nearly a 

year” between Edmo filing her Amended Complaint and her 

preliminary injunction motion “implies a lack of urgency 

and irreparable harm.” We disagree. The procedural history 

demonstrates that Edmo did not sit on her rights. Proceeding 

pro se, Edmo moved for preliminary injunctive relief when 

she filed her original complaint. The court then appointed 

counsel for Edmo, and shortly after appearing, appointed 

counsel withdrew Edmo’s motion and filed an amended 

complaint. To assess the urgency of surgery, Edmo’s 

counsel promptly sought access to Edmo’s medical records, 

which the State did not produce until more than six months 

later. Edmo moved for injunctive relief shortly thereafter. 

During that time, Edmo and her counsel diligently 

investigated and compiled the necessary record to move for 

injunctive relief. That it took them months to do their 

diligence does not suggest that Edmo will not be harmed 

absent an injunction.

Second, the State contends that Edmo has not established 

irreparable injury because both she and her expert, 

Dr. Gorton, agree that GCS is not an emergency surgery and 

that the State should have six months to provide such 

surgery. The State’s argument would preclude courts from 

ordering non-emergent medical care, even if the Eighth 

Amendment demands it. That is untenable. The State also 

ignores the rationale for the six-month time period. As Dr. 

Gorton explained, all patients who receive GCS “are seen, 

they are evaluated, there is a process you have to go 

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EDMO V. CORIZON 75

through.” In his experience, that process typically concludes 

within six months. That Edmo requested relief on a 

reasonable timeline, based on the medical evidence, does not 

undermine the strong evidence of irreparable injury.

Third, the State contends that Edmo has not established 

irreparable harm because she “has not attempted suicide or 

self-castration for years.” That argument overlooks the 

profound, persistent distress Edmo’s gender dysphoria 

causes, as well as the credited expert testimony that absent 

GCS, Edmo is at risk of further attempts at self-castration, 

and possibly suicide. The district court did not err in finding 

that Edmo would be irreparably harmed in the absence of an 

injunction.

IV. Challenges to the Scope of the Injunction

We turn to the State’s contentions that the district court’s 

injunction was overbroad.

A. Individual Defendants

The State contends that the injunction should not apply 

to Atencio, Zmuda, Yordy, Siegert, Dr. Young, Dr. Craig, 

Dr. Eliason, or Dr. Whinnery because the district court did 

not find that they, individually, were deliberately indifferent 

to Edmo’s medical needs.

As explained in Section III.A, Edmo has established that 

Dr. Eliason was deliberately indifferent to her serious 

medical needs. The injunction was properly entered against 

him because he personally participated in the deprivation of 

Edmo’s constitutional rights. See Colwell, 763 F.3d at 1070.

Edmo sued Attencio, Zmuda, and Yordy in their official 

capacities. An official-capacity suit for injunctive relief is 

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76 EDMO V. CORIZON

properly brought against any persons who “would be 

responsible for implementing any injunctive relief.” Pouncil 

v. Tilton, 704 F.3d 568, 576 (9th Cir. 2012). The State does 

not contest that Attencio, as Director of IDOC, and Zmuda, 

as Deputy Director of IDOC, would be responsible for 

implementing any injunctive relief ordered. Edmo properly 

named them as defendants to her Eighth Amendment claim 

for injunctive relief, regardless of their personal 

involvement. See Colwell, 763 F.3d at 1070–71 (director of 

a state correctional system is a proper defendant in an 

official-capacity suit seeking injunctive relief for Eighth 

Amendment violations). Yordy is no longer the Warden of 

ISCI, but, by operation of the Federal Rules, his successor, 

Al Ramirez, is “automatically substituted as party” in his 

official capacity. Fed. R. Civ. P. 25(d). Ramirez is properly 

a defendant to Edmo’s Eighth Amendment claim for 

injunctive relief, regardless of his personal involvement. See 

Colwell, 763 F.3d at 1070–71 (warden is a proper defendant 

in an official-capacity suit seeking injunctive relief for 

Eighth Amendment violations). Because Edmo may 

properly pursue her Eighth Amendment claim for injunctive 

relief against Attencio, Zmuda, and Ramirez in their official 

capacities, they are properly included within the scope of the 

district court’s injunction. On remand, the district court shall 

amend the injunction to substitute Al Ramirez (or the thencurrent Warden of ISCI) as a party for Yordy.

Edmo also named Yordy as a defendant in his individual 

capacity. She likewise named Siegert, Dr. Young, Dr. Craig, 

and Dr. Whinnery as defendants in their individual 

capacities (though she does not argue on appeal that the 

injunction properly included them). We hold that the 

evidence in the current record is insufficient to conclude that 

they were deliberately indifferent to Edmo’s serious medical 

needs. In particular, the record does not show what they 

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EDMO V. CORIZON 77

knew about Edmo’s condition and what role they played in 

her treatment or lack thereof. Edmo has not established their 

liability, and the district court improperly included them 

within the scope of the injunction. We vacate the district 

court’s injunction to the extent it applies to Yordy, Siegert, 

Dr. Young, Dr. Craig, and Dr. Whinnery in their individual 

capacities. See California v. Azar, 911 F.3d 558, 585 (9th 

Cir. 2018) (vacating in part an overbroad injunction and 

remanding to the district court). On remand, the district 

court shall modify the injunction to exclude those defendants 

from its scope.

B. Corizon

The State also contends that the injunction should not 

apply to Corizon. It urges that Corizon does not have a 

policy barring GCS and argues that such a policy is a 

prerequisite to liability under Monell v. Department of Social 

Services, 436 U.S. 658 (1978). We have not yet determined 

whether Monell applies “to private entities acting on behalf 

of state governments,” such as Corizon. Oyenik v. Corizon 

Health Inc., 696 F. App’x 792, 794 n.1 (9th Cir. 2017). We 

leave that issue for another day. Instead, we vacate the 

injunction as to Corizon and remand with instructions to the 

district court to modify the injunction to exclude Corizon. 

See Azar, 911 F.3d at 585. Doing so still provides Edmo the 

relief she seeks at this stage.22

22 For similar reasons, we need not reach Edmo’s contention and the 

district court’s finding that “Corizon and IDOC have a de facto policy or 

practice of refusing” GCS to prisoners. Edmo, 358 F. Supp. 3d at 1127.

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C. Relief Ordered

The State next contends that the injunctive relief ordered 

is overbroad because it requires the State to provide Edmo 

all “adequate medical care.” The State misconstrues the 

district court’s order. The order, read in context, requires 

defendants to provide GCS, as well as “adequate medical 

care” that is “reasonably necessary” to accomplish that 

end—not every conceivable form of adequate medical care. 

Edmo, 358 F. Supp. 3d at 1129; see also id. at 1109 

(“Plaintiff Adree Edmo alleges that prison authorities 

violated her Eighth Amendment rights by refusing to provide 

her with gender confirmation surgery. For the reasons 

explained below, the Court agrees and will order defendants 

to provide her with this procedure, a surgery which is 

considered medically necessary under generally accepted 

standards of care.”); id. at 1110 (“[F]or the reasons explained 

in detail below, IDOC and Corizon will be ordered to 

provide Ms. Edmo with gender confirmation surgery.”).

The State similarly contends that the injunctive relief 

ordered is overbroad because it requires the State to provide 

Edmo surgery even though the defendants are not surgeons 

and no surgeon has evaluated Edmo. We reject this obtuse 

reading of the district court’s order. The district court 

ordered the State to “take all actions reasonably necessary to 

provide Ms. Edmo gender confirmation surgery.” Edmo, 

358 F. Supp. 3d at 1129. That means that the State must take 

steps within its power to provide GCS to Edmo, such as 

finding a surgeon and scheduling a surgical evaluation. 

Indeed, we modified our stay of the district court’s order to 

permit a surgical consultation, which went forward in April 

2019. Oral Arg. at 12:00–12:10. The State cannot 

reasonably understand the district court’s December 13, 

2018 order to require that the defendants themselves provide 

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EDMO V. CORIZON 79

surgery. To the extent there are issues arising from a surgical 

evaluation, the State can raise those issues with the district 

court.23

V. Challenges to the Procedure Used by the District 

Court

Finally, the State contends that the district court 

improperly converted an evidentiary hearing on a 

preliminary injunction into a final trial on the merits of 

Edmo’s Eighth Amendment claim for GCS without giving 

them adequate notice and in violation of their Seventh 

Amendment right to a jury trial. We address and reject each 

contention.

A. Notice

We first address the State’s contention that the district 

court erroneously converted the evidentiary hearing into a 

final trial on the merits without giving the State “clear and 

unambiguous notice.” Under Federal Rule of Civil 

Procedure 65(a)(2), “[a] district court may consolidate a 

preliminary injunction hearing with a trial on the merits, but 

only when it provides the parties with clear and 

unambiguous notice [of the intended consolidation] either 

before the hearing commences or at a time which will afford 

23 The State contends for the first time in its reply brief that the 

injunctive relief ordered was inappropriate because the WPATH 

Standards of Care require two referrals from qualified mental health 

professionals who have independently assessed the patient before GCS 

may be provided. It similarly contends for the first time in its reply in 

support of its motion to dismiss that the order is overbroad because it 

does not specify the type of GCS ordered. Because the State did not 

present these arguments in its opening brief, we do not consider them. 

See Smith v. Marsh, 194 F.3d 1045, 1052 (9th Cir. 1999).

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the parties a full opportunity to present their respective 

cases.” Isaacson v. Horne, 716 F.3d 1213, 1220 (9th Cir. 

2013) (second alteration in original) (quotation omitted). 

“What constitutes adequate notice depends upon the facts of 

the case.” Michenfelder v. Sumner, 860 F.2d 328, 337 (9th 

Cir. 1988).

A party challenging consolidation must show not only 

inadequate notice, but also “substantial prejudice in the 

sense that [it] was not allowed to present material evidence.” 

Michenfelder, 860 F.2d at 337; see also 11A Charles Alan 

Wright et al., Federal Practice and Procedure § 2950 (3d 

ed. Apr. 2019 update). “We have on occasion upheld a 

district court’s failure to give any notice whatsoever before 

finally determining the merits after only a preliminary 

injunction hearing, where the complaining party has failed 

to show how additional evidence could have altered the 

outcome.” Michenfelder, 860 F.2d at 337.

At the outset, we note that the State was provided notice, 

twice, that the district court considered the evidentiary 

hearing a final trial on the merits of Edmo’s request for GCS. 

At the beginning of the hearing, the district court explained 

“it’s hard for me to envision this hearing being anything but 

a hearing on a final injunction at least as to that part of the 

relief requested [GCS],” and it asked the parties to address 

by the end of the hearing whether it was for a permanent 

injunction. At the close of the hearing, the district court 

again questioned whether it could order GCS in a 

preliminary injunction. It explained that it had, in effect, 

“kind of treated this hearing as the final hearing” on Edmo’s 

request for GCS, and it again asked the parties to address in 

their oral closings or written briefs whether the hearing was 

one for a permanent injunction. The State never answered 

the court’s question or objected to consolidation, despite the 

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EDMO V. CORIZON 81

district court specifically noting it had treated the hearing as 

final. Cf. Reilly v. United States, 863 F.2d 149, 160 (1st Cir. 

1988) (“[W]hen a trial judge announces a proposed course 

of action which litigants believe to be erroneous, the parties 

detrimentally affected must act expeditiously to call the error 

to the judge’s attention or to cure the defect, not lurk in the 

bushes waiting to ask for another trial when their litigatory 

milk curdles.”). This is not a case where the district court 

gave no notice whatsoever.

Regardless, the State has not shown any prejudice. With 

full awareness of the stakes, the district court permitted the 

parties four months of discovery and held a three-day 

evidentiary hearing. The parties called seven witnesses, 

submitted declarations in lieu of live testimony for other 

witnesses, and submitted thousands of pages of exhibits and 

extensive pre- and post-trial briefing. Most importantly, 

both parties put on extensive evidence concerning the 

treatment provided to and withheld from Edmo and why it 

was or was not appropriate—the key issue at the hearing.

When it comes to identifying prejudice, the State is 

tellingly short on specifics. It indicates that it “would have 

objected” to consolidation, but it failed to do so despite 

repeated invitations—indeed, directives—to address the 

issue. The State also urges that it would have requested that 

the named defendants be able to testify live, but it 

stipulated—knowing full well the stakes of the hearing—to 

submit certain testimony via declaration “[i]n lieu of and/or 

in addition to live testimony.” Moreover, the State fails to 

identify what testimony those witnesses would have offered 

or explain how presenting that testimony live, instead of via 

declaration, “could have altered the outcome.” 

Michenfelder, 860 F.2d at 337. The district court did not 

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commit reversible error in consolidating the evidentiary 

hearing with a trial on the merits of Edmo’s request for GCS.

B. Seventh Amendment

We turn to the State’s related contention that the district 

court violated the defendants’ Seventh Amendment right to 

a jury trial by converting the evidentiary hearing into a trial 

on the merits. We review that contention de novo. Palmer 

v. Valdez, 560 F.3d 965, 968 (9th Cir. 2009).

The Seventh Amendment guarantees the right to a trial 

by jury “[i]n Suits at common law, where the value in 

controversy shall exceed twenty dollars.” U.S. Const. 

amend. VII. In a case such as this, where legal claims are 

joined with equitable claims, a party “has a right to jury 

consideration of all legal claims, as well as all issues 

common to both claims.” Plummer v. W. Int’l Hotels Co., 

656 F.2d 502, 504 n.6 (9th Cir. 1981) (citing Curtis v. 

Loether, 415 U.S. 189, 196 n.11 (1974)). “Otherwise, the 

court might limit the parties’ opportunity to try to a jury 

every issue underlying the legal claims by affording 

preclusive effect to its own findings of fact on questions that 

are common to both the legal and equitable claims.” Lacy v. 

Cook County, 897 F.3d 847, 858 (7th Cir. 2018).

Like other constitutional rights, the right to a jury trial in 

civil suits can be waived. See United States v. Moore, 

340 U.S. 616, 621 (1951). It is well established that “[a] 

failure to object to a proceeding in which the court sits as the 

finder of fact waives a valid jury demand as to any claims 

decided in that proceeding, at least where it was clear that 

the court intended to make fact determinations.” Fillmore v. 

Page, 358 F.3d 496, 503 (7th Cir. 2004) (quotation omitted); 

see also 9 Wright & Miller, Federal Practice and Procedure

§ 2321 (“The right to jury trial also may be waived as it has 

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EDMO V. CORIZON 83

in many, many cases, by conduct, such as failing to object to 

or actually participating in a bench trial . . . .”).

For example, in White v. McGinnis, we held that “[a] 

party’s vigorous participation in a bench trial, without so 

much as a mention of a jury, . . . can only be ascribed to 

knowledgeable relinquishment of the prior jury demand.” 

903 F.2d 699, 703 (9th Cir. 1990) (en banc). We explained 

that where a party chooses “to argue his case fully before the 

district judge[,] it is not unjust to hold him to that 

commitment.” Id. By contrast, we have held that “[w]hen a 

party participates in [a] bench trial ordered by the trial court 

while continuing to demand a jury trial, his ‘continuing 

objection’ is ‘sufficient to preserve his right to appeal the 

denial of his request for a jury.’” Solis v. County of Los 

Angeles, 514 F.3d 946, 957 (9th Cir. 2008) (quoting United 

States v. Nordbrock, 941 F.2d 947, 950 (9th Cir. 1991)). 

“This is because the party in such a case is not seeking ‘two 

bites at the procedural apple’ . . . . Rather, when a trial court 

denies a party a jury trial despite the party’s continuing 

demand, the party has little choice but to accede to the trial 

court’s ruling and participate in the bench trial.” Id. (citation 

omitted); see also Lovelace v. Dall, 820 F.2d 223, 228 (7th 

Cir. 1987) (“Another policy justifying the jury demand 

waiver rule is the view that it is unfair to permit a party to 

have a trial, discover that it has lost, and then raise the jury 

issue because it is unsatisfied with the result of the trial.”).

The State seeks a second bite at the apple. It vigorously 

participated in the evidentiary hearing without ever raising 

the right to a jury trial. The State remained silent in the face 

of statements from the district court that it was considering 

treating, and then that it had treated, the hearing as a final 

trial on the merits, which made it clear that the court 

“intended to make fact determinations.” Fillmore, 358 F.3d 

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84 EDMO V. CORIZON

at 503. It also remained silent despite the district court 

asking twice whether the hearing was one for a permanent 

injunction—as clear a time as any to raise any concerns 

about a jury trial.

The State raised the issue of a jury trial for the first time 

on appeal, after the district court ruled against it. Even after 

the district court’s ruling, the State made no objection or 

claim to a jury trial. This conduct waived the State’s right to 

a jury trial with respect to issues common to Edmo’s request 

for an injunction ordering GCS and her legal claims.

VI. Conclusion 

We apply the dictates of the Eighth Amendment today in 

an area of increased social awareness: transgender health 

care. We are not the first to speak on the subject, nor will 

we be the last. Our court and others have been considering 

Eighth Amendment claims brought by transgender prisoners 

for decades. During that time, the medical community’s 

understanding of what treatments are safe and medically 

necessary to treat gender dysphoria has changed as more 

information becomes available, research is undertaken, and 

experience is gained. The Eighth-Amendment inquiry takes 

account of that developing understanding. See Estelle, 

429 U.S. at 102–03.

We hold that where, as here, the record shows that the 

medically necessary treatment for a prisoner’s gender 

dysphoria is gender confirmation surgery, and responsible 

prison officials deny such treatment with full awareness of 

the prisoner’s suffering, those officials violate the Eighth 

Amendment’s prohibition on cruel and unusual punishment.

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EDMO V. CORIZON 85

* * *

We affirm the district court’s entry of an injunction for 

Edmo. However, we vacate the injunction to the extent it 

applies to Corizon, Yordy, Siegert, Dr. Young, Dr. Craig, 

and Dr. Whinnery, in their individual capacities, and remand 

to the district court to modify the injunction accordingly. 

The district court shall also modify the injunction to 

substitute Al Ramirez in his official capacity as Warden of 

ISCI for Yordy.

Although we addressed this appeal on an expedited 

basis, it has been more than a year since doctors concluded 

that GCS is medically necessary for Edmo. We urge the 

State to move forward. We emphatically do not speak to 

other cases, but the facts of this case call for expeditious 

effectuation of the injunction.

In light of the nature and urgency of the relief at issue, 

we will disfavor any motion, absent extraordinary 

circumstances or consent from all parties, to extend the 

period to petition for rehearing or rehearing en banc. Our 

stay of the district court’s December 13, 2018 order shall 

automatically terminate upon issuance of the mandate.

Costs on appeal are awarded to Edmo.

AFFIRMED IN PART, VACATED IN PART, AND 

REMANDED.

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