The H onorab le J oan B . G ott schall, Un it ed Stat es D is tr ic t  J udge f or the Northe rnD i s t ri c tofIl l i noi s , si t t i ng by des i gna t i on.



## In the 

# U n ited S ta tes Co urt o f Ap p ea ls

F o rth eS e v e n th C ir cu it
N os. 10

- 2339 & 10

- 2466 A NDR EA F I EL DS, et al., P la intif fs-A pp ellees , C ross -App el lants , v. J UD Y P. S MITH, et al., D ef endants-A ppell ants , C ross-A pp ellees

. Appeals from the United States District Court fo r the E astern Di stricto f Wisc onsin
. No . 2:0 6-cv-00 11 2-CNC

— Charle s N . Cleve rt, Jr. , Chief Ju dge .
A RG UE D F EB RU AR Y 7, 2011

— D ECI DE D A UGUS T 5, 2011

Befo re R O V NE R a nd W OO D , C ircu it Judges , an d G OTTS CHALL , D i s t r i ctJudg e .  G OT T S CH A LL , D istrict Judge. I n th is app eal, w e are as ke d to rev iew th e d ec is i o n o ft h e d ist ric t c ou rtinv ali dat i ng a W i sc o ns i n s ta te s ta tu te whi chpr o hibi ts the2 N os. 10

- 2339 & 10

- 2466

A gro up o f m edi c al an d m en t al he al th pr ofes s i ona l s s ought 1 leav e from th e cou rt to su b m it a b rief as ami cicur i ae . The m ot i oni s g r a nt e d. W i sco nsi n Departm ent o fCor re cti ons ( “DO C”) f ro m provi ding tr ansge nd eri nm ate s with cer tai n m edi cal tr eat men t s . T he I nma t e S e x Ch a ng e P r e v e nt i o n Act

1 ( “A ct 1 05”) pro vi des i n re l evantpart : ( a) I n thi s su bs ec ti o n: 1. “Ho r m o na l the r apy ” m ea ns the us e o fhorm ones to st i m ula te the deve l opm ent o r al ter ati on ofa perso n’s se xual chara cter i sti cs i n or der t o al t e r th e p e r s o n ’ s p h y s i c a l a p p e a r a n c e s o th a tt he p erson ap p ears m ore l ike the op p osite gend er. 2. “S exual r eas si gnm ent s urge ry ” m eans surg i cal p roced ure s to alter a p erson ’s p h y sical app earan ce s o th a tth e p e r s o n a p p e a r s mo r e l i k e t he op p osite gend er. ( b) The [ W i sco n sin Departm ent o fCor re cti ons] m a y n o ta utho r i z e the p a y men to fa nyfun ds o r th e use o fa ny r es o ur ce s o fthi s st at e o r the paym ent of a ny federa l fund s pass i ng thr ough th e st at e tr ea su r y t o pr o vi de o r t o f aci l i ta te the pr o vi si o n o fhor m o na lthe r apyorse xua l r ea ss i g nm en t s u rg er y . . . . 2 0 0 5 Wi s . A c t1 0 5 , co di fi e d a tWi s . S t a t
. § 3 0 2
. 3 8 6 ( 5 m) ( 2010 )
. The dist ri ct cour t concl ud ed that th is provi si on v i o l a t e s th e E i g h th Ame n d me n t ’ s b a n o n c r u e l a nd un us ua l p un ishm en t and the Fou rteen th A m en d m en t’sN os. 10

- 2339 & 10

- 2466 3 E q u al P ro te c tio n C lau se . D e fen d an ts , var iou s D O C offic ials , no w ap p ea l.

I A num bero fDO C i nm ate s fi l ed thi s l aw sui t a s a p u ta tiv e c las s a c tio n in t h e E as te rn D ist ric t o f W isc on sin on be hal fof al l curr ent a nd future DO C i nm ate s with “s tr o ng, pe r si stent cr o ss - g en deri den ti fi ca ti o n. ” The dis t r i c tc o ur tde ni e d p l a i nt i ff s ’ mo t i o n f o r c l a s s c e r t i f i cati o n, b utpe r m i tt ed the c as e to pr o ce ed to t r i alo n the i nd i vi du alcl ai m s o fthr ee pla i nti ff s. T he three p la in tiffs

— A nd re a F i el ds, M atthew Davi son ( al so known as J ess i ca Davi son) , and Vankem ah M oat on

— ar e m al e- to- fem al e t ra n sse xuals

. A ccor ding to sti pu l ate d fa cts , each has bee n dia gnos ed w i th Gender I denti ty Diso rd er ( “GI D”). GI D is cl ass i fi ed as a psy ch i at r i c di so r der i n th e DS M

- I V- TR, th e cur r en t ed iti on o fthe A m er i can Psy chi atr i c Associ ati on’ s Di agn os tic an d Sta tis tic al M an u al of M en t al D iso rd er s. In d ivi du al s with GID i denti fy str ongl y with a g ender that do es no t m at ch th ei r phy si ca l se x ch ar ac te r i st i cs . The condi ti on i s a sso c i ate d w i th se ver e psy chol ogi caldi str es s. Pr i o r t o the pa ss ag e o fAct1 05 , e ac h o fthe pl aintiffs h ad be en d iag n os ed by D O C p h ys icia n s w ith G ID and had been pre scr ibed hor m ones . A fte r a t ria l in w h ich bo th sid es p re se n te d ex p er t t es tim ony ab o utGI D, i t s t r e a t men t, a nd i t s p o t e nt i a l e ffe c ts on pri son secur ity , the dist ri ct c ourtr ule d i n f avo r of pl aint i ff s. The c o ur t r ul ed th atA ct 10 5 was unc o ns ti tu
-4 N os. 10

- 2339 & 10

- 2466 ti o na l, b o tha s appl i ed an d on i ts f ac e, unde r the Ei g hth a nd F o ur te en thAm en dm en ts
. The di st r i ctcou rt ult i m ate l y i ssued an inj uncti on ba rr i ng defendants fro m enf or ci ng Act 105. W e nee d not reco unt al l the evi dence prese nted at tr i al

— the di str i ct c ourt ’ s 4 0- page o p in ion th or ou gh ly d es c rib es th e t ria l te st im on y, s e eFi e l ds v. Sm ith , 712 F. Supp. 2d 830 ( E.D. W i s. 2010 )

—but a bri ef re vi ew o fthe dist ri ct c ourt ’ s cr i ti calf actual fi nd i ngs i s wa r r a nt e d. The di st r i ctc o ur t cr edi ted m ucho fthe t es ti m o ny f r o m p lai nti ff s’ wi tn es se s, i nc l udi ngthr ee e xpe r ts i n the tr eat m ent o fGI D. Pl ai nti ff s’ exper ts tes tifi ed that, co l l ectiv ely , th ey h ad tre at ed th ou sa n d s o fp at ien ts w ith G ID and p ubl i sh ed numer o us pe er - r ev i ewe d a r ti cl es a nd b oo ks on th e s u bj ec t. O n e e x p er t h a d sp ec ifica lly studie d tra nssexual s in the cor re cti ona l se tting. These expert s e xplai ned that GID can cause an acute se nse that a perso n’s body does not m atch hi s or h er ge nd er i den ti ty. Even be f or e s eek i ng tr eat m ent a nd fro m an ea r l y a g e, pa ti en ts wi l l e xpe r i en ce thi s dys pho r i a an d m ay at te m pt to co nfo rm thei r appearance and behavi or to the g ender w i th wh i ch theyi denti fy. T h e fe e l i n g s o fd y s p h o r i a c a n v a r y i n i n t e n s i t y . S o me p atient s are able to m an ag e the discom fort, w hile others b ec om e un abl e t o functi on without t aking st eps to co r r ec t th e di so r der

. A per so n w ith GI D o fte n e xper i en ce s se ve r e an xi ety, de p r es si o n, a nd o th erps y ch

ol ogi caldi sor ders. Those w i th GI D m ay att em p t to com m i t s uic i de orto m uti l ate thei r own ge ni tal s.N os. 10

- 2339 & 10

- 2466 5

Def en dant s be ganr educ i ng pl ai nt i ff s ’ ho rm one l eve l s on 2 J anuary 12, 2006; on J anuary 27, 2006, the dist ri ctcourt gr a n t e d a p r e l i mi n a r y i nj u n c t i o n b a r r i n g d e f e n da n t s fr om c ont i nui ng t o wi thdra w pla i nt i ff s ’ ho rm one the ra py an d or der i ng d efen dant s t o r etur n pl ai nt i ff s t o the i r pre vi ous ho rm on e lev els. Th e a c c e pt e d s t a nd a r ds o fc a r e di c t a t e a g r a du a l a ppr o ac h t o t r ea tmentb eg i nni ngwi thps y ch o th er apya nd re all i fe e x p er i ence l i vi ng as the opposi te gender. Fo r som e num bero fpati ents, thi s tre atm ent wil l be effecti ve i n contr ol l i ng feel i ngs of dysphori a. W hen the c ondit i on i s m or e s eve re , a docto r can pre scr ibe ho rm ones , wh i ch have the e ffect ofr el i evi ng the psycho l ogi caldi str ess . H or m ones al so have physi caleffects o n the body. Fo r exam ple , m al es m ay experi ence bre astd evel opm ent, r el o ca tion of bo dy f at, a nd s o fte ni ngo fthe s k i n. I n the m ostse ver e ca ses , s exual r eas si gnm ent s urge rym ay be a pp ro priat e. But often the use ofhor m ones wil l be su ffici en t to cont rol th e d isorder. W he n h o r mo n e s a r e wi th d r a wnfr o m a p a t i e n twho has be en r ecei vi ng hor m one tr eat m ent, se ver e co m pli cati o ns may ar i se . The dy sph o r i a an d a ss o ci at ed psy ch

o l o g i c a ls y m p t o m s m a y r e s u r f a c e i n m o r e a c u t e f o r m. I n additi on, ther e m ay be s eve re physi caleffects such as m uscl e wasti ng, hi gh bl oo d press ure, and neuro

l ogi calco m pli cat ion s. A l l thr ee pla i nti ff s in thi s ca se ex p erience d som e of th ese effects w he n D O C doc tors disc onti nued thei r tr eat m en t fol l owing the pass age o f A ct 1 05. 26 N os. 10

- 2339 & 10

- 2466 Plaintiff s also call ed Dr . D avid Bu rnet t, th e D O C ’s M e di c a l Di r e c t o r, a nd Dr
. Ke v i n Ka l l a s , th e DO C M en ta l H ea lth D ire c to r, to t es tify attria l. T h es e o ffici al s e xplai ned that, pri orto t he enac tm ent o fA ct 1 05, ho r mone the r a pyh a d b e e n pr e s c r ib e d t o s o me DOC i nm ate s, incl ud i ng pl ai nti ff s. DO C poli ci es did not perm i t inm ate s t o re cei ve sex r eassi gnm ent s urge ry . Dr s . Ka l l a s a nd Bu r ne t ts e r v e d o n a c o mm i tte e ofDO C offi ci al s that e va l uated wh etherhor m one ther apy was m ed icall y nec essary for any p articu lar inm ate. Inm ates are no t per m i tt ed to s ee ka ny medi ca l t r ea tmento ut si de th e p rison, regard less o f t h eir abili ty to pa y. T he doc tors tes ti fi ed that th ey co uld thi nk o fno othe r sta te l aw o r p oli cy, besides A ct 105 , tha t proh ibi ts p rison d octors f ro m pro vi ding i nm ate s with m edi cal l y nec ess ar y tre atm ent.

II W e e val uate both the dist ri ct c ourt ’ s g ra nt o fi nj uncti ve r el i efa nd the s co pe o ftha t r el i eff o r a bus e o fdi sc r et i o n. K na pp v. Nw. U ni v. , 10 1 F
. 3d 473, 47 8 ( 7th Ci r. 19 96); s ee B rown v. Plata , 13 1 S
. Ct. 19 10, 1 95 7 (2 011) ( Sca l i a, J
. , di ssen t in g ) (noting th at u nd er the P rison L iti gation R eform A ct ( “PLR A ”) , “when a dis tr i ct c ourtente rs a new decr ee w i th new benchm ar ks, the sel ecti on o f tho se benchm ar ks i s . . . rev iew ed under a defe re nti al, abuse

- of

- disc re ti on st an d ar d of re vie w ” ); R uss ian M edia Group, LLC v. Ca ble A m . , Inc. , 598 F.3d 30 2, 30 7 (7t h C ir. 2 01 0) (“[T ]h e a p p ro p ria t e sc op e of th e inj un ction is l eft to the d istri ct cou rt’s so u n d d isc r e t ion .”); Thom as v. Bryant, 614 F. 3d 1288 , 13 21N os. 10

- 2339 & 10

- 2466 7 (11th Cir. 2010) (app lyi ng ab us e of d iscretion stan d ard to eval u at e scope ofi nj uncti on i n conf or m i ty w i th P L R A ); Cra wf

o r d v . C l a r ke, 57 8 F
. 3d 39, 43 ( 1stCi r. 20 09) ( hol ding that dist ri ct c ourtdi d n ot a b use i ts disc re ti on i n a war di ngs y st em- wi de r el i efund er the PLRA)
. The co urt’s f ac tu alfi ndi ng s ar e r ev i ewe d f o r c l ea r e r r o r, a nd an y le g a l d et er m in at ion s a re rev iew ed d e n ov o. Knapp , 101 F. 3d at 478. “Pri son offi ci al s vi ol ate the Eighth A m endm ent’ s p ro scr i pti on a gains t c rueland unusual pu ni shm ent when they displ ay ‘ del iber ate i nd i ffer ence to ser i ous m edi cal needs o fpri sone rs . ’ ” G reeno v. D a ley, 414 F. 3d 645, 65 2- 53 ( 7th C ir. 20 05) ( quoti ng E st el lev. Ga m ble, 42 9 U.S
. 97, 10 4 ( 19 76 ) )
. I n thi s ca se , the di st r i ctc o ur t he l d tha t pl aintiffs su ffer ed fro m a ser iou s m ed ica l n ee d , n am ely G ID , and that de fend an ts acte d w ith d eliberat e ind if

fer ence i n that defe nd ants knew ofthe serio us m edi cal need but r efused to pro vi de hor m on e thera py beca use ofA ct 1 05. D efe nd ants do not chal l enge the di str i ct co ur t’ s ho l di ngtha t GI D i s a se r i o us medi ca l c o ndi ti o n. The y c o nt en d tha t Act 10 5 is c o ns ti tu ti o na l b ec au se the st at e le gis lat u re h as th e p ow er to p ro h ibit ce rt ain m ed ical treatm en ts w he n oth er treatm en t op tions are avai l abl e. A nd defendants ar gue that Act 105 i s j usti fi ed by a l egi ti m ate need t o ensure se curi ty i n sta te pri sons. D efe n d an ts rely p rim ar ily on tw o Se ve n th C irc u it deci si ons w hi ch address ed constitutio nal chal l enges to re fusal s to p rovi de tr eat m ent forge nd erdysphori a o r tr an ss ex ua l i sm. Ov ert wenty - f o ur y ea r s ag o , i n M eriw ether v. Fa ulk ner, 82 1 F
. 2d 4 08 ( 7th Ci r. 19 87) , thi s co urt re ver sed the d ism i ssa l o fa com pla i nt wh i ch al l ege d that8 N os. 10

- 2339 & 10

- 2466 the pl ai nti ff, wh o had previ ou sly been tak i ng hor m ones , w as denie d al l tr eat m ent forherge nd erdyspho ria upon enter i ng pri son. The co urt hel d that the pl ai nti ffst ate d a cl ai m thattr ansse xuali sm was a ser i ous m edi calneed a n d that prison offici als acted w ith d eliberat e ind if

fer en ce in re fusi ng al l tr eat m ent. The co urt note d i n dict a th at“ [ i ] t i s i m po r ta ntt o e m pha size, ho wev er, tha t sh e does not have a r i ght t o any p ar tic u l arty pe oftr eat m ent, su cha s es tr o g enthe rap y whi cha ppea r s to b e th e f ocus ofherco m pla i nt. ” Id. at41 3. Te n y ea r s l at er, i n M agge r tv. Hanks , 1 31 F.3d 670 ( 7th Cir. 1 9 9 7 ) , thi s c o ur t, i n t wo b r i e fp a r a g r a phs, u ph e l d a deci si on g ranti ng sum m ar y j ud gm ent o n a s i m i l ardel iber ate i nd i ffer ence cl ai m wh er e the pl ain ti ffdi d not com e fo r wa r d wi th a nye v i de nc e t o r e b utde fe nd a nt s’ expertwitnes s, wh o tes ti fi ed that p l ai nti ffdi d not sufferfro m ge nd erdysphori a. The co u rt ’s opini on pro ceeded to address “a br oaderi ssue, havi ng to d o w i th th e s i g n ifica n c e o f ge n d er d ys p h or ia in p ris on er s’ c ivil ri ghts litigati on. ” Id. at67 1. T h e c ou rtco m m en te d , aga in in d ict a , that the E ighth A m en d m en t d oes not requ ire th e pr o vi si o n o f“ es o te r i c” t r ea tment s l i k e ho r m o ne th erap y and sexu al r eassign m en t surge ry w hich are “p ro tr ac te d an d ex p en siv e ” a n d n otge n er ally av aila b le to th os e w h o a re n otafflu en t. Id

. a t 6 7 1

- 7 2
. A pri son wo ul d b e r e qu i r e d t o p r o v i de s o me t r e a t men tf or gender dysphori a, but not necess ar i l y “ curat i ve” tr eat
m en t b ec au se th e E igh t h A m en d m en t re q u ire s o n ly m in im u m h ea lth ca re for p ris on inm at es . Id. at67 2.N os. 10

- 2339 & 10

- 2466 9

Pl ai nt i ffM oat on, f or e xa m pl e, e xpe ri en c ed s ui c i dal i dea t i on 3 after D O C officials b eg an w ithd raw ing ho rm on e trea tm en ts. Fi el ds , 712 F. Supp
. 2d at 835. The cour t’ s di scussi on o fhor m one ther apy and se x re as s i g nme nt s ur g e r y i n the s e t wo c a s e s wa s b a s ed on ce r ta i n e m pi r i ca l a ssum p ti o ns

— that the c osto fthes e tr ea tment s i s hi g h a nd tha t ade qua te a l te r na ti ve s ex ist . M or e t h an a d ec ad e a fte r th is c ou rt ’s d ec isio n in M agg ert, t h e d i s t ric t c ou rtin t h is c as e h eld a tr ial in w hi ch thes e e m pir i calas sum pti ons w er e put t o the t est
. At t r i al, de fen dan ts s ti pul at ed th atthe c o sto fpr o vi di ng ho r mon e the r a py i s b e t we e n $ 3 0 0 a nd $ 1 , 0 00 per i nm ate perye ar . The di str i ct c ourtco m pared thi s co st to the c osto fa com m on a nti psychoti c drug used t o tre at m any DOC i nm at es. I n 200 4, DO C paid a tot alo f$2 , 300 f o r h o r mon e s f o r tw o i nma t e s . T ha ts a me y e a r, DO C pai d $ 2.5 m i l l i on t o provi de i nm ate s with queti api ne, an anti psychoti c drug w hi ch co sts m ore than $2, 500 p er inm at e p er ye ar . Sex rea ss ign m en t s u rg er y is s ign ificantl y m or e e xpensiv e, costi ng appro xi m ate l y $ 20, 000. H o wev er, o th ers i g ni fi ca nts ur g er ies may b e m o r e ex p en s ive. I n 20 05, DO C pa id $37, 244 for one coron ary by pas s su r g ery a nd $ 32 , 89 7 f o r one k i dne y t r an spl an t su r g ery. The di st r i ctc o ur t co nc l ude d tha t DOC m i g ht ac t ua ll y i nc ur great er costs by refus ing to prov ide h orm ones , since i nm ate s with GID m i gh t requir e o ther expensi v e t r e a t men t s o r e nh a nc e d mon i t o r i ngby pri son secur i ty. F i e l ds , 7 12 F. S up p. 2d at86 3. I n f act, at 3 or alar gum ent bef or e thi s co urt, co unself ordefendants disc l ai m ed any ar gum ent that Act 105 is ju st i fi ed by cos t10 N os. 10

- 2339 & 10

- 2466

sa vin gs . See O ra l A rg u m en t a t 1 5:1 8, Fie ld v. Sm ith , N os. 10

- 23 39 an d 10 -24 66 , a v ailabl e at http: //w w w . ca7. uscour ts. gov/ f docs/ docs. fw x?dn am e=ar g. M or e i m port antl y her e, defendants d i d not pro du ce any e vi dence thatano thertr eat m ent c oul d be a n adequate r epl acem ent forhor m one th erapy. Pl ai nti ff s’ w it n e s se s re p ea te d ly m ad e t h e p oin t t h at, for ce rt ain pati ents w i th GI D, hor m one th er ap y i s the o nl y t re atm en t th atredu ces dy sph o r i a an d c anpr ev en t th e seve re em oti onaland physi calhar m s a sso ci ate d w i th i t. A l though D OC can provi de psychothera py as w el l as anti psychoti cs a nd anti depressa nts, defendants f ai l ed to prese nt evi dence re butti ng the tes ti m ony that th ese treatm en ts d o noth ing to treat th e un d erlyi ng disord er. Defen dan ts c al l ed th ei r o wn ex per t t o s pea kabo ut GI D: Dr
. Da ni elCl aibo r n, a Ph

. D. i n ps y ch o l o g y who es tim at ed h e h as t re at ed o n ly ab ou t fifty c lien ts w ith G ID ove r a per i od oftwenty y ear s in hi s pri vate prac ti ce. Dr. C laiborn pr ovi ded no tes ti m ony about the a pp ro pri at e tr eat m ent forpl ai nti ff s. H e o ffer ed hi s o pini on th a tGI D i s n o tp r o pe r l y c ha r a c t e r i z e d a s a p s y c ho l o g i cal d iso rd er be c au se a p er so n w ith G ID d oe s n otty p ica lly su fferfro m an i m pai rm ent in psychol ogi calfuncti ons. H owever, defendants have now conceded that GI D is a ser i ous m edi calco nd i ti on. Dr. Cl aibor n’s te sti m on y d oes n ot sup portthe ass er ti on that pl ai nti ff s ca n be effecti vely tr eat ed w i thout hor m ones . I t i s w ell est abl i shed that the Const i tuti on’ s ba n on cruel a nd unusual pu ni shm ent doe s no t per m i t a st ate to deny effecti ve t reatm ent forthe ser i ous m edi calneeds ofN os. 10

- 2339 & 10

- 2466 11 p ris on er s. T h e Su p re m e C ou rta rt icu lat ed th is p rin c ip le i n E st el lev. Ga m ble : A n inm at e m u s t r ely on p ris on au th or itie s t o t re at h is m edi calneeds; i fthe author i ti es f ai l t o do so, tho se ne eds wi l l no t be met. I n the wor stc ases, s ucha fai lure m ay actu all y pr o d u ce p hy sical “torture or a l i nger i ng death, ” the ev i l s o fm osti m m ed i ate concern to the drafter s o fthe A m en d m ent. I n l ess se r i o u s c as es , d en ial of m ed ica l ca re m ay res u lt in p ain an d su ffer in g w h ich n o on e s u gg es ts w ou ld serve an y pe nological pu rp o s e . . . . W e the refore co nc l ude tha t del ibe r at e i ndi ffer en ce t o s er i o us m edi calneeds ofpri sone rs co nsti tutes the “unnecessa r y a nd wan to n infl i ct i o n o f pain, ” pr o sc r ibe d b y the Eighth A m endm ent. 42 9 U. S
. a t 10 3- 04 ( ci ta ti o ns om itt ed)

. S ur ely, ha d the W i s c o ns i n l e g i s l a t ur e p a s s e d a l a w tha tDO C inma tes w ith c ancerm ust be tr eat ed onl y with ther apy and pa in k i l l er s, thi s co ur t woul d ha ve no t r o ubl e co nc l udi ng tha tthe l a w wa s u nc o ns t i t ut i o na l

. R e fus i ngt o p r o v i de effec tive tr eat m ent fora ser i ous m edi calco nd i ti on ser ves no va l i d penol og i calpurpose and am ounts to to rt u re . Id. ; see a ls o R o e v . E lyea , 63 1 F
. 3d 843, 86 1- 63 ( 7th Ci r. 20 11) ( up h old ing ve rdi ct forpl ai nti ffthat p ris on p olic y on tre at m en t o f H ep at itis C w as d elib er at ely i ndi fferent); Kell ey v. M cGinnis , 89 9 F
. 2d 612, 61 6 ( 7th Cir
. 19 90) ( re ver si ng di sm i ssa l o fco m pla i nt al l eging tha t p rison p rovide d i na d eq ua te treatm en t for inm ate’s c hr o ni c f o o t pr o b l e ms)
. Al tho ugh Act 1 0 5 pe r mi t s DOC to pr o vi de pl ainti ff s wi th s o metr eat m ent, the evi dence at12 N os. 10

- 2339 & 10

- 2466 tr ial in d ica te d th at p lain tiffs co u l d n otbe effe c tiv ely tr eat ed w i thout hor m ones . D efe n d an ts p oin t t o t h e Su p r e m e C ou rt ’s d ec isio n in G o nz a les v. C a rha rt, 550 U .S
. 1 2 4 (20 07 ), for th e p ro p os iti o n th a ta l e g i s l a t u r e ma y c o n s t i t u t i o n a l l y l i mi tthe disc re ti on o fphysi ci ans by o u tl aw i ng a parti cul ar m edi ca l pr o ce dur e. I n C a rha rt, the Court u phe l d the const i tuti onal i ty ofthe Part i al

- Bir th A bor ti on Ban A ct o f 2 0 0 3 whi c h o ut l a we d a pa r t i c ul a r pr o c e du r e us ed to per f o r m l at e- te r m abo r ti o ns . The Co ur t no ted the e xi st en ce o f“ m edi ca l unc er ta i nty ” r eg ar di ngwhethe r the banned proce du re was m or e danger ous than al ternativ e p ro c ed u re s. Id. at16 3- 64. Becau se s afe abor ti on al ternati ves to the pr ohibi ted pro cedure appeared t o ex i st, the c o ur t tu r ne d a way the f ac i alc ha l l en g e t o the law

. Id. at16 4. Carha rt is not hel pfulto defendants i n thi s ca se because t h ey did notpre sent any m edi calev i dence that al ternati ve tr eat m ents f orGI D are effecti ve. A s defenda nts point o ut, so m e m edi caluncer tai nty r em ai ns as to th e ca us es o fGI D, b utthe r e was no e vi den ce o funcertai nty about the e ffi cacyo fhor m one ther apy as a tr eat
m ent. J ust a s the l egi sl atur e cannot outl aw al l effecti ve cancertr eat m ents f orpris on inm ate s, i t ca nnot o utl aw the on ly effecti ve tr eat m ent fora ser i ous c ondit i on l i k e GI D. Defe nd ants ar gue that even i fappli cati on o fA ct 1 05 to pla i nti ff s v i ol ate s the Ei ghth Am endm ent, the distri ct c o u r te r r e d i n s u s t a i n i n ga f a c i a l c h a l l e n g e t o th e l a w. A ct 1 05 bans t re atm ent t o all pri sone rs , ev en tho se f orN os. 10

- 2339 & 10

- 2466 13

w hom hor m ones and surg er y a re n ot m edi cal l y nec essar y. A fa c ial chal l enge to the c onst i tuti onal i ty ofa l aw can succe ed on l y where pla i nti ff s ca n “ ‘ est abl i sh that n o s et of cir c u m st an c es ex ist s u n d er w h ich t h e A c t w ou ld b e v a l i d. ’ ” D o e v. Heck, 327 F.3d 492 , 528 (7th C ir. 2003 ) ( quoti ng U ni t e d S t at e s v. Sa l e r no , 48 1 U.S
. 73 9, 74 5 ( 1987 ) )
. N onetheless , “[ t] he pro per f ocus ofco nsti tuti onal inq uir y i s th e g r o up f o r who m the l aw i s a r es tr i ct i o n, not the g ro up f orwh om the l aw i s i rrele va n t. ” P la nn ed P a renth o o d o

f Se. P a . v. Ca sey, 5 05 U. S
. 8 33, 8 94 ( 19 92 )
. The dist ri ct c ourt, i n thi s ca se, f ound that DOC docto rs pre sc rib e h or m on es on ly w h en th e t re at m en t is m ed i c a l ly n ec es sa ry . Fi e l ds , 712 F. Sup p . 2d at 866. Thu s, th e cou rt cor re ctly c oncluded that Act 105 i s i rr el evantto i nm at es who a r e no t di agno se d wi ths ev er e GI D a nd i n m edi calneed o fhor m ones , and any appli cati on o f A ct 1 05 w oul d necess ar i l y v i ol ate the Eighth A m endm ent. Def e nd a nt s h a v e a l s o a r g ue d tha tAc t1 0 5 i s j us t i f i ed by th e st at e’ s i nt er es t i n pr es er ving pr i so n se cur i ty
. De fen dants’ se c u rity expert, Eugene Atherto n, te sti fi ed that m or e fem i nine m al e inm ate s be com e t ar get s forse xual ass aul t in pri sons. Because hor m one th er apy al ter s a perso n ’ s s eco nd ar y s ex char acte ri sti cs s uch as bre ast si ze an d b ody hai r, defendants ar gue that ho rm ones fem i ni ze i nm ate s a nd m ake them m or e su sceptibl e t o i nci ti ng pri son vi ol en c e. Bu t the di str i ct c ourtr ej ecte d thi s a rgum ent, not i ng tha t th e evidence showed tr ansge nd eri nm ate s m ay be t ar get s forvi ol ence eve n wi th o utho r m o ne s. Athe r ton hi m se l f, i n h i s depo si ti o n, te st i fi ed th ati t woul d b e “ an i nc r edibl e st r et ch ” to c o nclud e tha t ba nni ngthe us e o fho r m o ne s co ul d pr ev en t14 N os. 10

- 2339 & 10

- 2466

T he PL R A p ro v id es, in p art: 4 Pr os pec t i ve re l i efi n a ny c ivi l ac t i on with r es pec tt o pr i s on conditi ons s hall ex tend no further than nec es sar y to c orrec t (c on tin u ed

... ) se x u al a ss au lts

. Id. at 868. I n the Col or ado Dep ar tm ent of C o r r e c t i o n s , wh e r e Ath e r t o n wo r k e d f o r ma n y y e a r s, t he sta te had a pol i cy of pr ovi ding necess ar y ho rm ones to i nm ate s with GID. A ther ton tes ti fi ed that th is pol i cy w as rea so n ab le a n d h ad be en im p le m en te d effe c tiv ely i n Col or ado. Defe nd an ts cit e Whit ley v . Alb ers for t h e p ro p os iti on that “ ‘ [ p]r i son adm i ni str ato rs . . . sh ou l d be a cco r ded wi de- r an g i ng defer en ce i n th e ado pti on and executi on o fpol i ci es and practi ces t h at i n thei r j ud gm en t ar e ne ede d to pr es er ve i nt erna l o r dera nd di sc i pl i ne and to m ai ntain i nsti tuti onalse curi ty. ’ ” 4 75 U
. S. 31 2, 32 1- 22 ( 1986 ) ( quoti ng B ell v. Wo lfish , 441 U
. S. 520, 547 (1979 ))
. Bu t defer ence does not extend to “a cti ons tak en i n bad f ai th and forno l egi ti m ate purpose. ” Id. at32 2. The di str i ct cou rt di d not abuse i ts disc re ti on i n concl ud i ng tha t defe nd ants’ ev i dence f ai led to es tabl i sh any secur i ty be ne fi ts asso ci at ed wi tha b ano n h o r m o ne the r apy . The leg isla to r s w h o a p p ro ve d A c t 1 05 m ay h av e h on es tly be l i ev ed th ey wer e i m pr o ving pr i so n se cur i ty, but cour ts “r eta i n[ ] an ind epe n d en t co nsti tuti onalduty t o review f actu al find ings w he re cons titution al rig h t s are at sta ke. ” C a rha rt, 55 0 U.S
. at16 5. Finally, de fend an ts con ten d t ha t the district cou rt’s i nj uncti on vi ol ate s the PLRA , 18 U
. S. C. § 3 626( a) , because i t e nj oi ns A ct 1 05 in i ts enti re ty. They a rgue that 4N os. 10

- 2339 & 10

- 2466 15

(
. . . c o ntinu e d) th e v io la tio n o f th e F ed er a l ri g h t of a p a rt ic u la r p la in tiff or pl ai nt i ff s . The c our ts hal l no tgr an t o r approve an y prospecti ve reli efunles s the court finds that s uch rel ie f is n ar ro wly dr awn, e xt en ds no fur the r thanne c es s ar y to cor rect th e v iola tion of the F ed era l righ t , a n d is the least i nt ru s i ve m eans ne c es s ar y t o c or re c tthe vi ol at i on ofthe F ed era l righ t. T h e c o u rt sha ll giv e sub stan tial w eig ht to any adve rs e i m pac tonpubl i c s afety o r the ope ra t i on of a cr im in a l ju sti ce sy ste m ca u se d b y th e r el ie f. 1 8 U .S.C . § 3 6 2 6 (a )(1)(A ). pl aint i ff s ha ve ne ve r demons tr at ed a ne ed f o r s ex r ea ss i g nm en t su rg er y, w h ich th e law als o p ro h ibit s. Fo r t h e ir par t, pl aint if fs a r g ue tha t defen dan ts wai ve d thi s ar g um en t b y fa ilin g t o ra ise it be f o r e t h e d ist ric t c ou rt . In fact, th e record estab li sh es an ad m issi on, not a w a iv er. On June 9 , 20 10 pla i nt i ff s r equeste d that the di str i ct cour t s up ple m ent i ts fi nd in gs re l ati ng to the PLR A ’ s s ocal l ed “need- narr own ess - in trusi venes s” sta nd ar d. A t a su bs eque nts ta tu s co nfer en ce , the c o ur t as k ed defen dan ts ’ c o uns elno t o nc e, b utt wi ce , “ w he the r o r no t th e Defe nse bel i eve s the orderas tend er ed

. . . i s a s nar ro w as is req u ire d ”; c ou n se l re p lied th at it w as . ( See P ls.’ A p p . 19.) A s a prac ti calm att er, then, defenda n ts ar e pr ecl ud ed f r o m ma k i n gth i s a r g u me n tn o w. Regar dle ss, the dist ri ct cour t’ s or ders est abl ish that the c ou rt e va l uated the re cor d as a wh ol e a nd i denti fi ed evi dence thatfully s up p or ts the sco pe ofthe i nj uncti ve re lief gr a n te d

. See A rm stron g v . Sch w a rzen egg er, 62 2 F
. 3d16 N os. 10

- 2339 & 10

- 2466 10 58 , 1 07 0 ( 9th Ci r . 2 01 0) ( “[T]h e langua g e o fthe PLRA does not sugge st that Congre ss i ntended a pro vi sio n -b yp ro vis ion ex p lan at ion of a d ist ric t c o u r t’s find in gs . . . . [ T] he s t a t ut o r y l a ngua g e [ mea ns] thatthe c o ur t s mus tdo whatth ey ha ve a l way s do ne whende te r m i ni ngthe appr op ria tenes s o fthe re l i efo rder ed: co nsi der the o rder as a w h ole .”); Gom ez v. Ve r non , 25 5 F
. 3d 1118 , 11 29 ( 9th Cir
. 20 01) (the PLR A “has notsubst anti al l y c hanged th e t h r e s hold find ings an d stan d ard s requ ired to j us tify an inju n c tio n ”); Sm i t h v
. Ark. D ep’ tof Cor r. , 1 03 F. 3d 637, 64 7 (8 th C ir. 19 96 ) (sa m e); Wi l l i a ms v . Ed ward s , 87 F
. 3d 126, 133 n. 21 (5th Cir. 1996 ) (sam e). I n the d istr ic t c o u r t’s M ay 13 , 201 0 m em or an d u m ord er , th e c ou rtex p re ss ly addr e s s e d b o th h o r mo n e th e r a p y a n d s e x r e a s s i g nm ent s urge ry . There , the cour t s tat ed that: The defe nd ants ackno w l ed ge that A ct 1 05 re m ove s eve n the consi derat i on o fhor m ones o r surg er y for i nma t e s wi th g e nd e r i s s ue s a nd tha tthe DO C h alt ed ev alu at ion s o finm at es w ith G ID for p os sib le admi ni st r at i o n o fho r m o ne the rapy be ca us e o fthe A c t. H ow ev er , in d et er m i n i n g w h et h er a fac ial c h all enge to A ct 1 05 m ay succee d h er e, the defe nd ants su bmi t th atthe cou rt m us t ta k e i nt o a cc o unta l l i nmat e s i n DOC c us t o dy f o r wh o m ho r mon e the r a py ors e xu a l r e a s s i g nme nts ur g e r y wo ul d b e c o ns i de r ed as tr eat m ent forge nd eri ssu es . I fthati s done, they m ai ntai n that ther e a re ci rcum stan c es w here A ct 1 05 m ayb e appl i ed wi th o utv i o l at i ngthe Co ns ti tu ti o n, and that, as a re sul t, the pla i nti ff s’ f aci alchal l engeN os. 10

- 2339 & 10

- 2466 17 to the l aw m ust f ai l

. U nfo rtunatel y, the def endants do not supp or t thi s point.

. . . . I n cer tai n case s, as with t h e p lainti ff s in thi s ca se, th e effec t o f Act 10 5 i s to wi th dr aw an ongoing cour se of tr eat m ent, the re sul t of w hi ch h as n ega ti ve m edi calco nsequences. I n other case s, the effect o fAc t1 0 5 i s t o p r e v e ntDO C me di c a l p e rs onnel f ro m ev al uati ng i nm ate s fortre atm ent b ecause such eval uati on would be futi l e in l i ght o fA ct 1 05’ s ba n on t h e t re at m en t t h ey m ay d et er m in e t o b e m ed ica lly necess ar y forthe heal th o fthe i nm ate
.

. . . . I n this case , A ct 1 05 bar s the use ofhor m ones “t o stim ulate th e d evelop m en t or alteration of a person ’s sex ua l ch aract eristi cs in ord er to al ter the pe r s o n ’s p hy sical app earan ce so th at th e pe rson ap p ears m ore l i k e th e o ppo si te g en der, ” as wel l a s se xua l r eass i g nm ent s urge ry“t o al tera perso n’s physi calappeara nce so that the p erson appears m or e l i ke the o pp osi te gender. ” W i s. S tat
. § 302. 386( 5m ) ( a)
. The statute appli es i rr espect i ve of an i nm ate ’ s ser i ou s m edi cal need orthe DO C’s cl i ni calj ud gm ent if at the o utse t o f tre at m en t, it is p os sib le t h at th e in m at e w ill devel op the sexualchar acte ri sti cs o fthe op p osi te g en der

. The r ea cho fthi s statut e i s swe eping i nasm uch as i t i s appli cabl e to any i nm ate wh o i s no w i n the c us to dy o fthe DOC o r may ata ny t i m e be i n the custo dy of th e DOC , as wellas any m edi calpro fes-18 N os. 10

- 2339 & 10

- 2466 si onalw h o m ay consi der ho rm one ther apy o r gender re ass i gnm ent a s nec ess ar y t re atm ent foran inm ate
. Fi e l ds , 7 1 2 F . Sup p . 2d at 865-67. Th e d istri ct cou rt’s J une 22, 20 10 “additi onalfin d ings” furthersupport i ts co nc l us i o n tha t th e st atut e i s f ac i al l y i nvali d. The r e, the cour t found that the i nj uncti on was “nar ro w l y t ai l or ed i n that enj oi ni ng the enf or cem ent o f[ A ct 1 05] pro hibi ts on ly u n c on st itu tio n al a p p lica tio n s o f th e s ta tu te [,] wh i c h th i s c o u r t h a s f o u n d t o b e u n c o n s t i t u t i o na l a ny ti m e i t i s appli ed, ” an d the i nj unc ti o n e xt en ded no fur th ertha n n ec ess ar y t o c o r r ec t th e Ei g hth Am en dm en t vi ol ati on be cause “ enj oi ni ng al l appli cati ons of[ A ct 1 05] i s ne ce ss ar y t o pr ev en t co ns ti tu ti ona l v i o l at i o ns . ” The dist ric t co urt al so speci fi cal l y r efer enced i ts pri or fi nd i ng that the const i tuti onal vi ol ati on ste m m ed fr om “remov i ng ‘ ev en th e co ns i der at i o n o f ho r m o ne s o r surger y. ’ ” ( See App. 1 74

- 75
. ) W e ag r ee . Ev al ua tingthe re cor d as a wh ol e, the dis tr i ct c ourtdi d not abuse i ts disc re ti on i n enj oi ni ng the enti re ty ofA ct 1 05. H av in g d et er m in ed th at th e d ist ric t c ou rtp ro p er ly hel d that Act 10 5 vi ol ate s the Ei ghth Am endm ent, bo th on i ts f ace and as a pp l i ed to p l ai nti ff s, we need not ad d re ss the di st r i ctc o ur t’ s al te r na te ho l di ngtha t th e l aw vi ol ate s the Equal Pro tect i on Clau se . Pl ai nti ff s hav e ass er ted a c ond i ti onalcr oss - appeal o fthe dist ri ct c o u r t ’ s d e n i a l o fc l a s s c e r t i fi c a t i o n . B u tb e c a u s e we ha v e u ph e l d the di s t r i c tc o ur t ’ s i nj un c t i o n, we al so d o n otad d re ss th e c ro ss -ap p ea l.N os. 10

- 2339 & 10

- 2466 19 III Th e j ud g men to fthe di s t r i c tc o ur ti s a ffi r med

.

8- 5- 11