### In the 

# United States Court of Appeals

For the Seventh Circuit

____________________ No. 18

- 2075

M ARK A. C AMPBELL

, Plaintiff

- Appellee

,

v.

K EVIN K ALLAS

, et al.

, Defendant s

- Appellants

.

____________________

Appeal from the United States District Court

for the Western District of Wisconsin

. No. 16

- cv

- 261

- jdp

— James D. Peterson

, Chief Judge

.

____________________

A RGUED O CTOBER 26, 2018

— D ECIDED A UGUST 19, 2019

____________________

Before W OOD

, Chief Judge , and S YKES and S CUDDER

, Circuit Judges

.

S YKES

, Circuit Judge

. Mark Campbell, also known as

Nicole Rose Campbell, is an inmate in the Wis consin prison

system. In 2007 Campbell pleaded guilty to first

- degree

sexual assault of a child and is now serving a 34

- year sentence. Campbell has been diagnos ed with gender dysphoria;

she is biologically male but identifies as female

. Department2 No. 18

- 2075

of Corrections (“DOC”) medical staff are treating Campbell’s

condition with cross

- gender hormone therapy.

B eginning in September 2013, Campbell repeatedly requested a more radical intervention: sex

- reassignment

surgery. National standards of care recommend that patients

undertake one year of “real life” experience as a person of

their self

- identified gender before resorting to irreversible

surgical options. That preparatory period presents challenges for officials charged with the administration of sex

segregated prison s

. DOC officials consulted an outside

expert, who determined that Campbell was a potential

surgical candidate. But t he expert’s cautious conclusion was conditioned on DOC officials developing a safe, workable

solution to the real

- life

- experience dilemma. Citing these

concerns and DOC policy, officials denied Campbell’s request.

After filing gri evances and exhausting administrative

appeals, Campbell sued Dr. Kevin Kallas, the DOC Mental

Health Director, and a host of other prison officials under

4 2 U.S.C. § 1983. She alleged that the defendants were

deliberately indifferent t o her serious medical needs in

violation of the Eighth Amendment and sought damages

and injunctive relief. Both sides moved for summary judgment, and the defen dants also claimed qualified immunity.

The district court denied the motions. As relevant here

, the

judge rejected the claim of qualified immunity, concluding

that caselaw clearly establishe d a constitutional right to

effective medical treatment.

We reverse

. Qualified immunity shields a public official

from suit for damages unless cas e law clea rly puts him on

notice that his action is unconstitutional . The judge’s ap-No. 18

- 2075 3

proach to the qualified

- immunity question was far too

general. The Eighth Amendment requires prison healthcare

professionals to exercise medical judgment when making

decisions about an inmate’s treatment. And they cannot

completely deny the care of a serious medical condition. But

cases recognizing those broad principle s could not have

warned these defendants that treating an inmate’s gender

dysphoria with hormone therapy and deferrin g consideration of sex

- reassignment surgery violate s the Constitution.

Moreover, it’s doubtful t hat a prisoner can prove a case of

deliberate indifference when, as here, prison officials follow ed accepted medical standards. The defendants are

immune from damages liability.

I. Background

A. Standards of Care

Campbell suffers from gender dysphoria, an acute form

of mental distress stemming from strong feelings of incongruity b etween one’s anatomy and one’s gender identity. See

A M

. P SYCHIATRIC A SS ’ N

, D IAGNOSTIC & S TATISTICAL M ANUAL

OF M ENTAL D ISORDERS 451 (5th ed. 2013). To “provide clinical

guidance for health professionals

, ” the World Professional

Association for Transgender Health established national

standards of care for transsexual, transgender, and ge nder

nonconforming individuals. W ORLD P ROFESSIONAL A SS ’ N FOR

T RANSGENDER H EALTH

, S TANDARDS OF C ARE FOR THE H EALTH

OF T RANSSEXUAL

, T RANSGENDER

, & G ENDER N ONCONFORMING

P EOPLE 1 (7th version 2011 ) (“the Standards ”)

, https://www.wpath.org/ media/cms/ Documents/SOC %20v7 /

Standards%20of%20Care

_ V7%20 Full%20Book_English .pdf

. The parties cite the Standards extensively and treat them as4 No. 18

- 2075

authoritative

. “While flexible,” these clinical guidelines

“offer standards for promoting o ptimal health care.” Id. at 2.

The S tandards outline a range of treatment options for individuals with gender dysphoria. Patients may be encouraged to alter their “gender expression” by living

continuously or part

- time in another gender role. Id. at 9.

Hormone therapy, which can “feminize or masculinize the

body,” is appropriate for some patients. Id. The Standards

provide four criteria for hormone

- therapy eligibility:

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 ... ; [and]

4. If significant medical or mental health concerns are present, they must be reasonably

well

- controlled.

Id. at 34. Psychotherapy is not an “absolute” prerequisite for

hormone therapy or surgery but is “highly recommended.”

Id. at 28.

Surgery is “the last and the most considered step in the

treatment process, ” and not all gender

- dysphoric patients

are surgical candidates. Id. at 54. The Standards outlin e several surgic al approaches. Id. at 57

– 61. Some modify

secondary sex characteristics via breast reduction or augmentation, and facial

- and voice

- feminization surgery. Id. at

57. The Standards don’t require hormonal interventions or

extensive preparatory periods for thes e surgeries , though

12 months of feminizing hormone therapy is recommendedNo. 18

- 2075 5

for male

- to

- female patients

. Id. at 58

– 59

. S urgeries altering a

patient’s reproductive organs carry stricter eligibility criteria.

Id. at 59

– 61. A patient meets the criteria for a hysterectomy

and ovariectomy (removal of the uterus and ovaries ) or an

orchiectomy (removal of the testicles) if he or she satisfies

the hormone

- therapy criteria and has completed a year of

continuous hormone therapy

. Id. at 60.

For operations commonly referred to as sex

- reassignment

surgeries

— surgeries that replace an individual’s existing

genitals with approximations of those of the opposite sex

—
the Standards add yet another requirement. In addition to a

year of hormone therapy, the S tandards require patients to

have “12 continuous months of living in a gender role that is

congruent with their gender identity.” Id. The World Professional Association for Transgender Health justifies this

requirement by citing an “expert clinical consensus that this

experience provides ample opportunity for patients to

experience and socially adjust in their desired gender role []

before undergoing irreversible surgery.” Id. at 6 0

. The one

ye ar preparatory period helps patients adjust to the “profound personal and social consequences” of adjusting one’s

gender expression. Id. at 61. The Standards don’t include an

exception to the real

- life

- experience requirement for patients

living in institut ional settings. Id. at 67

– 68. T he World Professional Association for Transgender Health explicitly states

that the S tandards can be utilized effectively under those

conditions

. Id.

B. DOC Policies and Procedures

The DOC established policies to address th e unique chal

lenges posed by the incarceration of transgender inmate s

. The Gender Dysphoria Committee (the “Committee”) is6 No. 18

- 2075

charged with handling medi cal treatment and accommodation re quests by an inmate with gender dysphoria. Several of

the defend ants are current and former c ommittee members;

Dr. Kallas serves as DOC Mental Health Director and chairs

the Committee

.

DOC Policy 500.70.27 lays out the protocol for trans

gender inmates

. Wisconsin Department of Corrections,

Div ision of Adult Inst ituti ons , Policy and Procedures, Policy

No. 500.70.27 (Nov. 11, 2017) at Separate Appendix of

Defendants

– Appellants at 64

– 73, Campbell v. Kallas

, No. 18

- 2075 (7th Cir. July 18, 2018)

, ECF No. 17. An i nmate

may self

- identify as transgender at any point during hi s incarceration, making him eligible for several accommodations. Id. at 66. The inmate may order “clothing, shoes,

undergarments [,] and prescription eyeglass frames

... that

correspond to the desired gender.” Id. at 73. Undergarments

matching the inmate’s gender identity are also allowed,

provided “they are not visible to others when leaving the

cell” or worn in a “disruptive or provoca tive ” manner. Id.

Make up is unavailable for an inmate in male facilities, but an

inmate may purchase feminine shower products and request

a hair

- removal product. Id.

In addition to these lifestyle accommodations, the DOC

offers several forms of medical tre atment. Once an inmate

self

- identifies as transgender, prison medical staff or an

outside consultant may assign a clinical diagnosis of gender

dysphoria. Id. at 66

. A c linically diagnosed inmate is entitled

to appropriate psychological treatment, psychiatr ic care,

hormone therapy (under certain circumstances), and “[o]ther

treatment determined to be medically necessary by the

Transgender Committee.” Id. at 68.No. 18

- 2075 7

Requests for new hormonal or surgical interventions are

processed by a hierarchy of prison medical officials who

review the inmate’s condition. Id. at 69

– 70

. When an inmate

first requests hormone therapy or surgery, the Supervisor of

the Psychological Services Unit is notified. Id. at 69. The

Supervisor assigns a staff member to determine whether t o diagnose the patient with gende r dysphoria and whether a

“more specialized evaluation” by a gender

- dysphoria consultant is needed. Id. The Psychological Services Unit report

is forwarded to the Mental Health Director , who may call in

a gender

- dysphoria con sultant for further evaluation. Id. If

the consultant recommends hormone therapy or surgery, the

Director reviews the report. The consultant’s recommendations are not binding and can either be approved or denied

by the Director in consultation with the Com mittee

. Id. at 69

–

70. Finally, the policy notes : “ D ue to the limitations inherent

in being incarcerated, a real

- life experience for the purpose

of gender

- reassignment therapy is not possible for inmate s who reside within a correctional facility. However, t reatment
and accommodations may be provided to lessen gender

dysphoria.” Id. at 70.

C

. Campbell’s Course of Treatment

Campbell is currently incarcerated at the Racine Correctional Institution. Prior to her incarceration, she self

administered hormone trea tments

. Although she considered

sex

- reassignment surgery, she never discussed it with a

physician.

Campbell raised gender

- identity concerns with a prison

psychologist in January 2012. The Committee hire d Cynthia

Osborne to evaluate Campbell. Osborne is a gender

dysphoria expert and has consulted on numerous cases for8 No. 18

- 2075

prison systems around the country. In August 2012 Osborne

diagnosed Campbell with gender dysphoria but stopped

well short of recommending sex

- reassignment s urgery.

Osborne explained that the 12

- month real

- life experience

required by t he World Professional Association for

Transgender Health could not be fully imp lemented in the

prison setting

. She noted that Campbell had “never had the

opportunity to meaningfu lly consolidate [her] preferred

female identity into a successful life” and would “not be able

to do such consolidation in the restrictive environment of

incarceration.” Given that challenge

, as well as Campbell’s

“comorbid psychiatric conditions and vulne rabilities

, ”

Osborn e determined that “only reversible interventions

should be considered” and that “[s]ex [

- ] reassignment surgery [was] wholly contraindicated.” Osborne recommended

hormone therapy, counseling, and “that the DOC consider

what feminizing allo wances might be made,” even though

“[s]uch accommodations are rarely if ever medically necessary.”

The Committee adopted Osborne’s recommendations,

initiating hormone therapy and permitting Campbell to don

feminine clothing and glasses and use feminine sho wer products. O n September 5, 2013, Campbell submitted a

request for sex

- reassignment surgery. Dr. Kallas, following

the Committee’s recommendation, denied Ca mpbell’s request

, citing Osborne’s finding that “surgical interventions

were contraindicated.” Dr. Kallas explained that DOC

“policy does not prohibit surgical intervention

, ” but he and

the Committee recognized “the inherent difficulty for any

inmate to meet eligibility requirements for gen der reassign-No. 18

- 2075 9

ment surgery while in prison

— specifically, the need for a

valid real

- life experience in the desired gender role.”

Campbell con tinued to file surgery requests, and DOC

officials again consult ed with Osborne. She reviewed

Camp bell’s file, talked with the treating psychologist, and

met with Campbell face to face. On August 4, 2014, Osborne

submitted her second report . Echoing themes from her first

report, Osborne described the S tandards as imperfect guides

for treating gender dysphoria in prison. O n the possibility of

surgery, Osborne explained that given “the persistent presence of severe anatomic dysphoria [

, ] inmate Campbell may

be a candidate for” sex reassignment. The length of

Campbell’s sentence and her track record of cooperating

with medical personnel bolstered the case for surgery.

Turning to the “real life experience ” requirement,

Osborn e explained that “[m]any gender dysphoria experts

believe that the challenges of completing a valid real

- life

experience

... in the context of incarceration present a formidable obstacle to” sex

- reassignment surgery. She noted that

“there is no empirical evid ence on which the DOC can rely

in its efforts to predict outcomes, prevent harm [,] and maintain safety” in developing a real

- life experience for

Campbell. Thus, the DOC’s “[r]eluctance to embark on a

social experiment” was “understandable and prudent. ” For

inmates with lengthy sentences, however, Osborne questioned “whether the [real

- life experience] as traditionally

understood” should be required. Modifying or eliminating

the requirement would carry risks for Campbell, but the

DOC should undertake “ an exam ination of the [real

- life

experience] concept in order to determine whether there is a

workable approach for inmates.” Still, g iven these challeng-10 No. 18

- 2075

es, she concluded that “conservative approaches

... for

incarcerated individuals are wholly warranted.”

Summariz ing her conclusions, Osborne explained that

Campbell had not undergone a valid real

- life experience

while incarcerated , de spite Campbell’s claim to the contrary

. D eparting from the requirement “may be justifiable in rare

circums tances in correctional setti ngs ”

— including Campbell’s case. Osborne stated that Campbell could be a surgical

candidate but conditioned her assessment on the DOC’s

development of “a safe and reasonable approach to resolving the [real

- life experience] conundrum.”

On September 29, 2014, Campbell filed a nother request
seeking approval for a real

- life experience and sex

reassignment surgery. D r. K allas responded on October 23,

assuring Campbell that “ the DOC is continuing to look at

how we can provide at least some elements of a real

- life

experience.” Nevertheless, “providing a true or full real

- life

experience that will help to determine future suitability for

surgical interventions remain[ed] problematic in an incarcerated setting.” Refer ring to Osborne’s second report,

Dr. Kallas , with the Committee’s recommendation, denied

Campbell’s request. Campbell sent additional letters on

March 15 and April 4, 2015, but Dr. Kallas again denied t he

requests for sur gery citing the “considerable limitations in

what [officials could] provide for a real

- life experience.”

Dr. Kallas also rejected Campbell’s request for electrolysis for

hair removal and “light makeup,” neither of which was

“currently permitted ” in the pri son.

In the wake of these denials, Campbell filed four administrative grievances reiterat ing her arguments for sex

reassignment surgery, electrolysis, and makeup. All wereNo. 18

- 2075 11

denied. In response to the electrolysis and makeup requests,

DOC officials determine d that “makeup is not a medically

necessary accommodation” and “[a]lternatives to electrolysis” were readily available.

D

. District

- Court Proceedings

I n April 2016 Campbell filed su it under 42 U.S.C. § 1983

alleging that DOC officials were deliberate ly in differen t to

her serious medical needs in violation of the Eighth

Amendment

. 1 The suit seeks damages and injunctive relief

ordering “necessary medical care, including [sex

reassignment surgery] , and other appropriate treatment,

including light makeup, electrolysis, breast augmentation

, and voice therapy.”

Both sides moved for summary judgment, introducing

du eling expert opinions on Campbell’s suitability for surgery. Dr. Kathy Oriel, o ne of Campbell’s experts

, determined

that “no physician with adequate expertise and experience

in gender medicine would” dispute Campbell’s need for sex

reassignment surgery

. Dr. Chester W. Schmidt, the defen se

expert

, opined that sex

- reassignment surgery was not medically necessary.

Campbell argued that because DOC officials “implemented and enforce[d] a blanket ban on medically necessary

treatment

... and applied it to Campbell, ” they “ acted with

deliberate indifference as a matter of law .” The defendants

sought qualified immunity

, argu ing that their treatment

1 Campbell later amended her complaint to bring an equal

- protection

claim under the Fourteenth Amendment. That claim is not at issue in this

appeal.12 No. 18

- 2075

decisi ons were not a substantial departure from accepted

professional judgment.

The district judge denied the motions for the most part.

Because DOC officials knew about Campbell’s gender

dysphoria and admitted its status as a serious medical

condition, the judge saw one key remaining question:

whether sex

- reassignment surgery was medically necessary.

On that issue Dr. Oriel’s expert testimony generated a factual dispute

, so the judge held that “Campbell ha[d]

adduced evidence sufficient to show deliberate in difference

, ” preclud ing summary judgment. The medical necessity of sex

- reassignment surgery in Campbell’s case would be

determined at a bench trial.

The judge also addressed Campbell’s requests for electrolysis and makeu p, articulating a preliminary deter mination that providing those accommodations “would offer

more effective treatment” for Campbell’s gender dysphoria

and finding “no apparent medical reason to deny” them. But

Campbell hadn’t moved for summary judgment on those

claims, so the judge gave the defendants notice and an

opportunity to respond under Rule 56(f) of the Federal Rule s

of Civil Procedure . They replied with two arguments: First, a ruling on electrolysis and makeup prior to a ruling on

surgery would be premature. Second, they cited the l ack of

record evidence that Campbell, “ on an individualized basis,

has a medical need for electrolysis and makeup.” The judge

postponed further consideration of the issue until trial.

The judge ’s discussion of qualified immunity was brief

and framed the inquiry at a high level o f generality. He

ruled that b ecause the Eighth Amendment does not permit

state officials to deny effective treatment for the ser iousNo. 18

- 2075 13

medical needs of prisoners, the “[d]efendants had fair notice

that denying effective treatment” fo r Campbell’s gender

dysphoria would violate the Constitution. The judge rebuffed the defendants’ request for a more fact

- specific

analysis focusing on sex

- reassignment surgery.

II. Discussion

A

. Appellate Jurisdiction

Th e defendants appeal the denial of qualified immunity.

“ [P] retrial orders denying qualified immunity generally fall

within the collateral order doctrine.” Plumhoff v. Rickard

, 572 U.S. 765

, 772 (2014) (citation omitted). Campbell ’s suit

seeks damages and injunctive relief , and the case will proceed to trial on the claim for injunctive relief even if t h e

defendants are entitled to qualified immun ity on the damages claim

. Campbell argues that we should therefore decline

to exercise jurisdiction over this interlocutory appeal.

That p osition cannot be squared with Supreme Court and

circuit precedent. It has long been clear t hat a n order den ying qualified immunity, “to the extent that it turns on an

issue of law, is an appealable ‘final decision’ within the

meaning of 28 U.S.C. § 1291 n otwithstanding the absence of

a final judgment.” Mitchell v. Forsyth , 472 U.S. 511, 530

(1985). Qualified immunity is a form of immunity from

suit

— that is, the trial process and attendant burdens

— not
merely immunity from damages. Id. at 526

– 27.

T he Suprem e Court ha s not had occasion to decide

whether an order denying qualified immuni ty may be

immediately appeal ed when the suit also seeks injunctive

relief

. Id. at 520 n.5. We have done so, however. I n Scott v.

Lacy , 811 F.2d 1153 (7th Cir. 1987)

, the plaintiff sought14 No. 18

- 2075

money damages and injunctive relief in a suit against public

university officials. Id. at 1154. He argued that the collateral

order doctrine i s inapplicable to suits seeking injunctive

relief as well as damages because the case could still proceed

to trial regardless of the outcome of an interlocutory appeal

of a qualified

- immunity ruling

. Id. at 1153.

Acknowledging a circuit split on th is question, we followed the majority rule and held “that a pending request for

an injunction does not defeat jurisdiction of interlocutory

appeals based on claims of immunity.” Id. We restated the

reasoning in Forsyth and added that “if a request for an

injunction prevented appeal on the question of immunity,

plaintiffs who wished to harass officials to travail would

need only demand equitable relief.” Id. at 1154.

Every circuit to address this question agrees

. See Aci erno

v. Cloutier , 40 F.3d 597 (3d Cir. 1994) (en banc); Schopler v.

Bliss , 903 F.2d 1373 (11th Cir. 1990) ; DiMartini v. Ferrin

, 889 F.2d 922 (9th Cir. 1989); Giacalone v. Abrams , 850 F.2d 79

(2d Cir. 1988); DeVargas v. Mason & Hanger

- Silas Mason Co.

, 844 F .2d 714 (10th Cir. 1988); Drake v. Scott , 812 F.2d 395 (8th

Cir. 1987); Kennedy v. City of Cleveland , 797 F.2d 297 (6th Cir.

1986); de Abadia v. Izquierdo Mora , 792 F.2d 1187 (1st Cir.

1986). The Fourth Circuit

— the outlier when we decided

Scott

— has since r eversed course. See Young v. Lynch

, 846 F.2d 960 (4th Cir. 1988).

As we’ve noted, t he Supreme Court hasn’ t squarely revisited the question left open in Forsyth . But in Behrens v.

Pelletier , 516 U.S. 299 (1996) , the Court came quite close to

embracing the rule we adopted in Scott

. The plaintiff there

raised multiple claims, including Bivens claims against

which the defendant unsuccessfully sought qualified im-No. 18

- 2075 15

munity

. Id. at 302

– 03. The plaintiff argued that the d efendant’s interlocutory appeal was inappropriate because he

would still “ be required to endure discovery and trial on

matters separate from the claims against which immunity

was asserted .” Id. at 31 1 . The Court clarified that a qualified

immunity appeal “cannot be foreclosed by the mere addition

of other claims to the suit.” Id. at 312 (emphasis added). Then,

v enturing beyond the specific facts of the case , the Court

expressed the same concern we identified in Scott : under the

p laintiff ’s reasoning, “the qualified

- immunity right not to be

su bjected to pretrial proceedings” or “ to trial itself [would]

be eliminated, so long as the complaint seeks injunctive

relief .” Id. (emphasis added). Behrens represents a variation

on Scott

— the case concerned multiple substantive claims

rather than multiple forms of relief

— but the variation was so slight that the Court saw fit to cite Scott in support of its

conclusion. Id. at 312 n.5.

Campbell urges us to reconsider Scott

, a step that would

reviv e a long

- d ormant circuit split and come close to contradicting Behrens

. W e need “compelling reasons” to overrule

circuit precedent

. Russ v. Watts , 414 F.3d 783, 78 8 (7th Cir.

2005). W e may do so when “our position remains a minority

one among other ci rcuits, when the Supreme Court issues a

decision on an analogous issue that compels us to reconsider

our position, or when an intracircuit conflict exists.” Glaser v.

Wound Care Consultants, Inc. , 570 F.3d 907, 915 (7th Cir. 2009)

(citations omitted) . None of those conditions are satisfied

here

. And w hile Campbell claims that she “is not asking this

[c] ourt to reconsider qualified

- immunity jurisprudence writ

large,” each of her arguments does just that. She argues that

Scott rests on misperceptions about the efficacy of qualified

immunity as a shield against the burdens of litigat ion. She16 No. 18

- 2075

cites recent scholarship criticizing qualified immunity and

marsha l s policy arguments focu sed on judicial resources

. And she draws our atte ntion to separate opinions by some Supreme Court justices rais ing questions about the doctrine.

W e have no authority to depart from the Supreme

Court’s qualified

- immunity jurisprudence. And w hile some

justices have questioned qualified immunity

, those mis givings haven’t stopped the Court from vigorously applying

the doctrine

. See, e.g.

, District of Columbia v. Wesby , 138 S. Ct.

577 (2018). Campbell’s fallback argument asks us to carve

out an exception to Scott for cases involving a substantial

risk of harm . But in true emergenc ies

, a plaintiff can seek

preliminary injunctive relief. See Wheeler v. Wexford Health

Sources, Inc. , 689 F.3d 680, 681

– 83 (7th Cir. 2012). We proceed

to the merits.

B

. Qualified Immunity

We review qualified

- immunity questions independently

. Green v. Newport , 868 F.3d 629, 632 (7th Cir. 2017).

The Eighth Amendment ’s protection against cruel and

unusual punishment includes the right of prisoners to be

free from “pain and suffering [that] no one suggests would

serve any penological purpose. ” Estelle v. Gamble , 429 U.S.

97, 10 3 (1976). As applied in the context of prison medical

care, “deliberate indifference to a prisoner’s serious illness or

injury states a cause of action under § 1983” for violation of

the Eighth Amend ment. Id

. We evaluate d eliberate

indifference claims by “first examining whether a plaintiff

suffered from an objectively serious medical condition [] and

then determining whether the individual defendant was

deliberately indifferent to that condition.” Pet ties v. Carter

,No. 18

- 2075 17

836 F.3d 722, 728 (7th Cir. 2016) (en banc). The parties agree

that gender dysphoria is a serious medical condition. See

Maggert v. Hanks , 131 F.3d 670, 671 (7th Cir. 1997) (describing

gender dysphoria as a “serious psychiatric disorder”).

To prove deliberate indifference, “mere negligence is not

enough.

... [A] plaintiff must provide evidence that an

official actually knew of and disregarded a substantial risk of

harm.” Petties , 836 F.3d at 728

. The linchpin is a lack of

professional judgment

. “A medical professional is entitled to

deference in treatment decisions unless ‘no minimally

competent professional would have so responded under

those circumstances.’” Sain v. Wood , 512 F.3d 886, 894

– 95 (7th

Cir. 2008) (quoting Coll ignon v. Milwaukee County , 163 F.3d

982, 988 (7th Cir. 1998)). A prison medical professional faces

liability only if his course of treatment is “such a substantial

departure from accepted professional judgment, practice, or

standards [] as to demonstrate th at the person responsible

actually did not base the decision on such a judgment.” Id. at

895 (quoting Collignon , 163 F.3d at 988).

Qualified immunity protects government officials from

damages liability “insofar as their conduct does not violate

clearly es tablished statutory or constitutional rights of which

a reasonable person would have known.” Estate of Clark v.

Walker , 865 F.3d 544, 549

– 50 (7th Cir. 2017) (quoting Pearson

v. Callahan , 555 U.S. 223, 231 (2009)). We evaluate “(1) whether the facts, taken in the light most favorable to the plaintiff [] , show that the defendant s violated a constitutional

right; and (2) whether th at constitutional right was clearly

established at the time of the alleged violation .” Gonzalez v.

City of Elgin , 578 F.3d 526, 540 (7th Cir. 2009). The latter18 No. 18

- 2075

inquiry is often dispositive and may be addressed first

. Pearson , 555 U.S. at 236. We do so here.

To be “clearly established,” a constitutional right “must

have a sufficiently clear foundation in then

- existing precedent.” Wesby

, 138 S. Ct. at 589. The principle of fair notice

pervades the doctrine. Qualified immunity applies unless

the specific contours of the right “ were sufficiently definite

that any reasonable official in the defendant’s shoes would

have understood that he was violating it.” Plumhoff , 572 U.S.

at 77 8

– 79

.
Given this emphasis on notice, clearly established law

cannot be framed at a “ high level of gen erality. ” Ashcroft v.

al

- Kidd , 563 U.S. 731, 742 (2011). As t he Supreme Court

recently reminded us, “[a] rule is too general if the unlawfulness of the officer’s conduct ‘does not follow immediately

from the conclusion that [the rule] was firmly establishe d.’”

Wesby , 138 S. Ct. at 590 (quoting Anderson v. Creighton

, 483 U.S. 635, 641 (1987) (second alteration in original) ).

Existing caselaw must “dictate the resolution of the parties’

dispute,” Comsys, Inc. v. Pacetti , 893 F.3d 468, 472 (7th Cir.

2018), so while “a case directly on point” isn’t required,

“precedent must have placed the

... constitutional question

beyond debate

, ” White v. Pauly , 137 S. Ct. 548, 551 (2017)

(quotation marks omitted) ; see also Kisela v. Hughes , 138 S. Ct.

1148, 1152

– 53 (2018). Put slightly differently, a right is

clearly established only if “every reasonable official would

have understood that what he is doing violates that right.”

Taylor v. Barkes , 135 S. Ct. 2042, 2044 (2015) (quoting Reichle

v. Howards , 566 U.S. 658, 664 (2012)) (emphasis added).

The Supreme Court’s message is unmistakable: Frame

the constitutional right in terms granular enough to provideNo. 18

- 2075 19

fair notice because qualified immunity “protects all but the

plainly incompetent or those who knowingly violate the

law.” Kisela , 138 S. Ct. at 1152 (quotation marks omitted)

.
Here the ju dge framed the qualified

- immunity question

in very broad terms, asking whether it was clearly established that “ denying effective treatment” for Campbell’s

medical condition violates the Eig hth Amend ment. That

for mulation

— which is basically a highly conceptualized

version of the deliberate

- indifference standard

— is far too

general. On appeal Campbell likewise frames the issue at too
high a level of generality , arguing that the defendants viola ted clearly established law by failing to exercise individualized medical judgment and persisting in an ineffective

course of treatment. These broad principles have support in

our caselaw , bu t neither has been applied in a factual context

specific enough t o provide fair notice to the defendants that

their conduct was unconstitutional

.
Campbell relies on Roe v. Elyea , 631 F.3d 843 (7th Cir.

2011)

, and Fields v. Smith , 653 F.3d 550 (7th Cir. 2011) , but

neither case clearly establishes that the conduct at issue here

was unconstitutional

. In Elyea

, Illinois inmate s with hepatitis

requested antiviral drugs but were denied medication

because a prison policy barred that treatment for inmates

with fewer than 18 months of i ncarceration remaining.

631 F.3d at 850. We explained that “ inmate medical care

decisions must be fact

- based with respect to the particular

inmate ” rather than the product of categorical rules and that

administrative considerations cannot trump “reasonable

medical judgment.” Id. at 8 5 9 , 863 (emphasis omitted)

. Treatment protocols are permissible, but in “ an individual

case

, ... prison officials still must make a determination that20 No. 18

- 2075

application of the protocols result [s] in adequate medical

care .” Id. at 860.

In Fields we considered a facial Eighth Amendment

challenge to a Wisconsin statute that flatly prohibited DOC

officials from providing sex

- reassignment surgery or hormone

therapy to inmates. 653 F.3d at 552

– 53. The district court held

that the “defendants acted with deliberate indifference in

that [they] knew of [plaintiffs’] serious medical need but

refused to provide hormone therapy because of” the statute.

Id. at 555. We affirmed , but we did not specifically addre ss

the issue of sex

- reassignment surgery because the plaintiffs’

request was limited to hormone therapy. Id. at 556.

Campbell argues that Elyea and Fields clearly establish a

right to individualized medical judgment

. But t o accept that

framing would contradict the Supreme Court’s instruction to

eschew broad generalities. When considering deliberate

indifference claims challenging the medical judgment of

prison healthcare personnel, qualified

- immunity analysis

requires us to frame the leg al question with reasonable

specificity.

T he proper inquiry is whether then

- existing caselaw

clearly established a constitutional right to gender

- dysphoria

treatment beyond hormone therapy. This framing is specific

enough to ensure that “ the unlawf ulness of the officer’s

conduct

... follow [s] immediately from the conclusion that

[th e rule] was firmly established. ” Wesby , 138 S. Ct. at 590

( quotation marks omitted ) (second alteration in original)

. And in th is fact

- intensive area of constitutional law, a broader formulation would violate the Supreme Court’s instruction that the specific contours of the right must be

“ sufficiently defini te that any reasonable official

... wouldNo. 18

- 2075 21

have understood that he was violat ing it.” Plumhoff , 572 U.S.

at 779

.

N either Elyea nor Fields provides the required level of

specificity. Elyea amounts to a general admonition that

officials must exercise medical judgment rather than mechanically apply categorical rules. And Fields doesn’t place

“beyond debate” the proposition that medical professionals

violate the Eighth Amendment when they pro vide hormone

therapy but decide

— after extensive deliberation and consultation with an outside expert

— to deny sex

- reassignment

surgery. White

, 137 S. Ct. at 551. In both cases prison official s refused to provide any treatment for serious diseases based

solely on categorical rules. That simply didn’t occur here.

The se DOC officials consulted an expert in the field and,

facing a gray area of profe ssional opinion , decided to deny

the “last and

... most considered step” of gender

- dysphoria

treatment.

No case in the Federal Reporter could have warned these

DOC officials that their treatment choice was unconstitutional

. When the defendants were making these decisions,

only one federal appellate decision had addressed the merits

of a deliberate

- indifference claim involving sex

reassignment surgery: Kosilek v. Spencer , 774 F.3d 63 (1st Cir.

2014) (en banc). 2 There the First Circuit concluded that

2 In De’lonta v. Johnson , 708 F .3d 520 (4th Cir. 2013), the Fourth Circuit

reversed a district

- court order dismissing a gender

- dysphoric inmate’s

Eighth Amendment challenge at screening under 28 U.S.C. § 1915A.

Even setting aside that difference in procedural posture, De’lonta bears

no resemblance to this case. Unlike the defendants here, in De’lonta the

Virginia Department of Corrections officials “never allowed [the plaintiff] to be evaluated by a [gender

- dysphoria] specialist in the first place.”

Id. at 526 n.4; see also id. at 523 (explaining that the plaintiff had “never22 No. 18

- 2075

prison officials who provided hormone therapy and lifestyle

accommodations but denied a request for surgery did not

violate the Eighth Amendment. 3 See id. at 90, 96.

Campbell next argues that then

- existing caselaw clearly

establishe d that prison officials cannot abandon medical

judgment by “persist [ ing ] in a course of treatment known to

be ineffective .” Greeno v. Daley , 414 F.3d 645, 655 (7th Cir.

2005). It’s true that we’ve identified this species of

deliberate

- indifferen ce claim

. See Petties , 836 F.3d at 729

– 30.

But we’ve never applied that general principle to facts

resembling these

. Campbell’s lightly developed argument

does n o t convince us that this right was “ established not as a

broad general proposition but in a particularized sense so

that the contours of the right are clear to a reasonable official.” Dibble v. Quinn , 793 F.3d 803, 808 (7th Cir. 2015) (quotation marks omitted)

.

We’ve previously noted that “[f]or purposes of qualified

immunity, [the Eighth

- Amendme nt] duty” to treat prison-

been evaluated by a [gender

- dysphoria] specialist concerning her need

for sex reassignment surgery”). Rosati v. Igbinoso , 791 F.3d 1037 (9th Cir.

2015), is similar. There the Ninth Circuit rever sed an order dismissing a

gender

- dysphoric inmate’s Eighth Amendment challenge at screening.

Unlike the defendants here, in Rosati the defendants applied a blanket

policy against sex

- reassignment surgery and never allowed the plaintiff

to be evaluated by a gender

- dysphoria specialist. Id. at 1039

– 40.

3 A divided panel of the Fifth Circuit recently announced agreement with

Kosilek

. Gibson v. Collier , 920 F.3d 212 (5th Cir. 2019). The panel majority

focused on the ongoing debate over the efficacy of sex

- reas signment

surgery in general and wasn’t prepared to accept the World Professional

Association of Transgender Health’s Standards as authoritative. Id. at 221

– 24. We don’t need to venture beyond the record and address that wider

debate to decide this appeal.No. 18

- 2075 23

ers’ serious medical conditions “need not be litigated and

then established disease by disease or injury by injury.”

Estate of Clark , 865 F.3d at 553. Campbell seizes on this

aphorism and argues that by the same token

, “rights need

not be established treatment by treatment.”

That argument overlooks the n ature of this deliberate

indifference claim . I n Estate of Clark

, the prison official

“chose to do nothing” in response to a known risk of substantial harm to the prisoner. Id

. When p rison officials

utterly fail to provide care for a serious medical condition

, the constitutional violation is ob vious and qualified immunity offers little protection. See Orlowski v. Milwau kee County

, 872 F.3d 417, 422 (7th Cir. 2017) (denying qualified immunity where, in the face of clear symptoms, officers “chose to do

nothing”).

To be sure, t he constitutional concern in cases involving

no treatment at all is not disease

- or injury

- specific. But

prison s aren’t obligated to provide every reques ted treatment once medical care begins

. In a deliberate

- indifference

c ase challenging the medical judgment of prison healthcare

pro fessionals who actually diagnose and treat an inmate’s

medical condition (as opposed to ignoring it) , we necessarily

evaluate those discrete treatment decisions . A nd we defer to

those decisions “unless no minimally competent professional would have” made them. Sain , 512 F.3d at 895 (quotation

marks omitted)

. D ecid ing whether a particular treatment
plan was a “substantial depar ture from accepted professional judgment, practice, or standards ”

— a necessary predicate

to establish an Eighth Amendment violation

— requires a

close examin ation of professional standards and the specific

choices made by care providers

. Id. (quotation marks omit-24 No. 18

- 2075

ted). Given th e fact

- specific nature of these claims, the notice

aspect of qualified

- immunity doctrine is crucial

.
Campbell also relies on our recent decision in Mitchell v.

Kallas , 895 F.3d 492 (7th Cir. 2018) , another gender

- dyspho ria

case involving a Wisconsin inmate

, Osborne

, and Dr. Kallas

. In that case Dr. Kallas denied a prisoner ’s request for hormone therapy d espite Osborne’s unequivocal endorsement

of the treatment . He cited a DOC policy requiring at least six

remaining months of incarceration to initiate a hormone

regimen

. Id. at 497. The inmate raised deliberate

- indifference

claim s based on a “fail[ure] to provide [recommended] care

for a non

- medical reason” and “inexplicable delays.” Id. at

498.

Because prisons around the country applied varied evaluation periods for hormone

- therapy eligibility

, we held that

“Dr. Kallas was not on notice that a 13

- month evaluation

would violate” the Eighth Amendment. Id. at 500. T o the

extent that the claim was b ased on the length of time it took

to complete the assessment, we concluded that qualified

immunity protected Dr. Kallas from damages liability

.

But we rejected the immunity defense to the failure

- to

treat claim . We framed the question as “whether a prison

doctor would have known that it was unconstitutional never to provide ” h ormone therapy. Id. at 499. Interpreting the

refusal to begin hormone therapy as a complete denial of

care, we observed that “[ p]rison off icials have been on notice

for years that leaving serious medical conditions, including

gender dysphoria, untreated can amount to unconstitutional

deliberate indifference .” Id. Given our decision in Fields

, “circuit precedent clearly established that a tot al absence ofNo. 18

- 2075 25

treatment for the serious medical needs created by gender

dysphoria is unconstitutional.” Id. (emphasis added).

W e hadn’t decided Mitchell when DOC officials were

making decisions about Campbell ’s care , so it has little

relevance to the qual ified

- immunity analysis here . Moreover, Mitchell illustrates the difference between a complete

denial of care and context

- specific judgment calls. A plausible interpretation of the record in Mitchell was that the DOC

offered the inmate no treatment whatsoe ver . As we’ve

explained

, our caselaw clearly establishes that regardless of

the disease or injury at issue

, utterly failing to treat a serious

medical condition constitutes deliberate indifference.

Campbell, by contrast , received extensive treatment in the

form of hormone therapy , counseling, and various lifestyle

accommodations

.
Deciding w hether to provide additional medical interventions

— especially when the inmate’s preferred course of

treatment poses considerable challenges to prison administration

— is not the same as deciding to provide no treatment at all. Denying a specific therapy in a particular case might amount to a constitutional violation , but qualified

immunity applies absent reasonably specific notice to prison

officials.

In short, w hen the defendants denied Campbell’s request

for sex

- reassignment surgery, no case clearly established a

right to gender

- dysphoria treatment beyond hormone

therapy. As for Campbell’s requests for electrolysi s and

makeup, our cases offer no indication that denying arguably

non medical cosmetic accommodations violates the Eighth

Amendment.26 No. 18

- 2075

Q ualified

- immunity analysis also asks whether “ the facts,

taken in the light most favorable to the plaintiff [] , show that

t he defendant s violated a constitutional right. ” Gonzalez

, 578 F.3d at 540. Because no case clearly establishe s that

denying treatment beyond hormone therapy is unconstitutional

, qualified immunity applies regardless. So it’s enough

to note that a factfinder may infer deliberate indifference

only where a prison medical professional makes “ a medical

decision that has no support in the medical community” and

provides “ a suspect rationale

... for making it.” Petties

, 836 F.3 d at 729 n.2. And “ e ven admitted medical malpractice

does not automatically give ris e to a constitutional violation” ; only “ sub

- minimal competence

... crosses the threshold into deliberate indifference .” Id. at 729. P rison healthcare

providers necessarily ex ercise medical judgment

— and thus

by definition do not act with deliberate indifference

— when

they base treatment decisions on accepted national standards and the advice of an expert.

I I I. Conclusion

Because clearly established law did not require

Wisconsin prison officials to provide Campbell with gender

dysphoria treatment beyond hormone therapy, the defendants are immune from damages liability

. The district c o urt’s

decision to the contrary is

R EVERSEDNo. 18 -2075 27

W OOD

, Chief Judge

, dissenting. The Supreme Court has

pounded home the point that when deciding whether quali

‐

fi ed immunity applies, lower courts cannot view the law at a “high level of generality.” Ashcroft v. al

‐ Kidd

, 563 U.S. 731, 742

(2011). Nonetheless, while “a case directly on point” may be

su ffi cient, it is not necessary. White v. Pauly

, 137 S. Ct. 548, 551

(2017). The majority opinion in the case before us recognizes

this distinction, admi tt ing that “‘[f]or purposes of quali fi ed

immunity, [the Eighth

‐ Amendment] duty’ to treat prisoners’

serious medical conditions ‘need not be litigated and then es

‐
tablished disease by disease or injury by injury.’” Ante at 22

(quoting Estate of Clark v. Walker

, 865 F.3d 544, 553 (7th Cir.

2017)). The Eighth Amendment applies whether the serious

condition is Type I diabetes, paraplegia, congestive heart fail

‐

ure, or a broken leg, even though the treatments for those con

‐
ditions are quite di ff erent. Yet the majority fails to follow this

rule. Instead, it states that Campbell must show a clearly es

‐
tablished right speci fi c to her condition—gender dysphoria—

and to the particular way the medical profession addresses it.

Ante at 20. With respect, that is the wrong question, and so it

leads to the wrong answer. I therefore dissent.

Before outlining my disagreement with the majority, I

should emphasize my agreement with much of what it says. I

join in full Part II.A of the majority’s opinion, which addresses

our jurisdiction over this interlocutory appeal. Like my col

‐ leagues, I see no reason to break with our sister circuits, over

‐
rule Sco tt v. Lacy

, 811 F.2d 1153 (7th Cir. 1987), and decline

jurisdiction because of Campbell’s outstanding request for in

‐ junctive relief. My disagreement is limited to the majority’s

application of the quali fi ed immunity inquiry to this case.

Even there, I have no quarrel with much of the reasoning. As

the majority notes, the relevant Eighth Amendment inquiry is28 No. 18

‐ 2075

whether Kallas and the other defendants were deliberately in

‐
di ff erent to Campbell’s serious medical condition. Ante at 16.

As the majority recognizes, gender dysphoria is a serious

medical condition for which prison o ffi cials must provide

treatment. Ante at 17 (citing Maggert v. Hanks

, 131 F.3d 670,

671 (7th Cir. 1997)). We diverge only on the description of the

clearly established right and whether Campbell has presented

enough evidence to show (if believed by a trier of fact) that

Kallas violated that right.

I

This case comes to us from the denial of quali fi ed immun

‐ ity by the district court. That means our review is limited. We

must answer only two questions: whether defendants vio

‐
lated a constitutional right, and whether that constitutional

right was clearly established at the time defendants acted.

Ashcroft v. Iqbal

, 556 U.S. 662, 673 (2009). This means not only

that we must take the facts in the light most favorable to the

plainti ff

, Tolan v. Co tt on

, 572 U.S. 650, 656–57 (2014), but also—

as is the case any time there are disputed issues of material

fact—that we have no jurisdiction to resolve any factual dis

‐ putes. Johnson v. Jones

, 515 U.S. 304, 313 (1995). We thus ap

‐ proach the facts in much the same way as we would if we

were reviewing a motion to dismiss or a grant of summary judgment. See, e.g.

, Tolan

, 572 U.S. at 657 (vacating the grant

of quali fi ed immunity because “[i]n holding that Co tt on’s ac

‐

tions did not violate clearly established law, the Fifth Circuit

failed to view the evidence at summary judgment in the light

most favorable to Tolan”).

Some 22 years ago, this court stated that because prisoners

were “entitled only to minimum care,” they were not entitledNo. 18

‐ 2075 29

to sexual

‐ reassignment surgery (“SRS”) 1 or hormone therapy,

because the minimal record before the court indicated that

those treatments were expensive and “esoteric medical treat

‐

ment that only the wealthy can a ff ord ....” Maggert

, 131 F.3d

at 671–72. But that was not our last word on this issue. In Fields

v. Smith

, 653 F.3d 550 (7th Cir. 2011), we evaluated a claim that

the total denial of either medically necessary hormones or medically necessary SRS violated the Eighth Amendment.

Unlike in Maggert

, in Fields we had the bene fi t of a full trial

record. Id. at 555. We determined that time and the crucible of

trial had disproven the “empirical assumptions” on which

Maggert relied. Id. Both hormones and SRS were, for example,

signi fi cantly cheaper than other treatments and surgeries that

the Wisconsin Department of Corrections had provided in re

‐

cent years. Id.

Despite the majority’s contention, ante at 20, while the

bulk of our discussion in Fields focused on hormone therapy,

we also speci fi cally addressed the Fields plainti ff s’ a tt empt to

strike down Wisconsin’s surgery ban. On this point, we up

‐
held the district court’s enjoining of Wisconsin’s surgery ban,

because that statute forbade “even the consideration of

... sur

‐ gery” regardless of whether SRS was medically necessary for

1 I recognize that the term “sexual

‐ reassignment surgery” is now con

‐
sidered an outdated and inaccurate descriptor of this procedure. This sur

‐ gical treatment is now more commonly referred to as gender confirmation

surgery. See, e.g.

, Gender Confirmation Surgery

, U NIVERSITY OF M ICHIGAN

S CHOOL OF M EDICINE

, https://www.uofmhealth.org/conditions

‐ treat

‐ ments/gender

‐ confirmation

‐ surgery (last visited July 26, 2019) (explaining

the available options for gender confirmation surgery in the University of

Michigan Health System). For the sake of consistency, however, I use the

term “SRS” here, as it is the label given to this surgery by the majority, the

parties, and the WPATH Standards.30 No. 18

‐ 2075

an individual prisoner. Id. at 558–59. We concluded that “[i]t

is well established that the Constitution’s ban on cruel and

unusual punishment does not permit a state to deny e ff ective

treatment for the serious medical needs of prisoners.

... Re

‐ fusing to provide e ff ective treatment for a serious medical

condition serves no valid penological purpose and amounts

to torture.” Id. at 556. Our bo tt om line was simple: “Just as the

legislature cannot outlaw all e ff ective cancer treatments for

prison inmates, it cannot outlaw the only e ff ective treatment

for a serious condition like [gender dysphoria].” Id. at 557.

Recently, in Estate of Clark

, we recognized that “[t]he Su

‐

preme Court has long held that prisoners have an Eighth

Amendment right to treatment for their ‘serious medical

needs,’” 865 F.3d at 553, and thus that this right is clearly es

‐
tablished. “For purposes of quali fi ed immunity, that legal

duty need not be litigated and then established disease by dis

‐

ease or injury by injury.” Id. The majority opinion now seems

to walk back the la tt er statement. But in doing so it confuses

the legal de fi nition of the clearly established right with the

factual question of the medical necessity of a particular treat

‐

ment for a particular patient.

Our inquiry should be simple: fi rst, we must determine

whether Campbell su ff ers from a medical need that is clearly

established as objectively serious; second, we must determine

whether, as a subjective ma tt er, it was clear to the defendants

that they were being deliberately indi ff erent to Campbell’s

objectively serious medical need.

The fi rst half of this inquiry is easy. We recognized in 1997

that “[g]ender dysphoria

... is a serious psychiatric disorder.”

Maggert

, 131 F.3d at 671. It has thus been established for more

than 20 years that gender dysphoria is a serious medical need;No. 18

‐ 2075 31

commendably, the defendants in this litigation do not con

‐
tend that it is not. See also Fields

, 653 F.3d at 554–55; Meri

‐ whether v. Faulkner

, 821 F.2d 408, 413 (7th Cir. 1987) (holding

that “plainti ff ’s complaint [asserting that she received no

treatment for her gender dysphoria] does state a ‘serious

medical need’”).

That takes us to the second inquiry: whether the defend

‐

ants were deliberately indi ff erent in refusing Campbell’s re

‐ quests for surgery. Because the deliberate indi ff erence inquiry

is a subjective one, it necessarily “turns on [a defendant’s]

mental state, and it is well established what the law requires

in that regard.” Zaya v. Sood

, 836 F.3d 800, 807 (7th Cir. 2016).

If a defendant “consciously disregard[s] the risks of [denying

an inmate’s medical care], then his conduct violates clearly es

‐
tablished law under the Eighth Amendment.” Id. at 807–08.

Proving someone’s state of mind is always di ffi cult. See

Pe tt ies v. Carter

, 836 F.3d 722, 728 (7th Cir. 2016) ( en banc )

(“Rarely if ever will an o ffi cial declare, ‘I knew this would

probably harm you, and I did it anyway!’”). But it is not im

‐ possible: circumstantial evidence pointing to deliberate indif

‐
ference can be gathered in medical cases just as in others. See

id. The obvious case is a defendant who sees a su ff ering in

‐

mate and ostentatiously does nothing to help her. See, e.g.

, Mitchell v. Kallas

, 895 F.3d 492, 499 (7th Cir. 2018) (“Prison of

‐

fi cials have been on notice for years that leaving serious med

‐
ical conditions, including gender dysphoria, untreated can

amount to unconstitutional deliberate indi ff erence.”). None

‐ theless, that is the beginning, not the end, of the deliberate

‐
indi ff erence inquiry. See Zaya

, 836 F.3d at 805 (“[W]e have

also made clear that an inmate need not show that he was ‘lit

‐ erally ignored’ to prevail on a deliberate

‐ indi ff erence claim.”).32 No. 18

‐ 2075

A plainti ff may prove deliberate indi ff erence through evi

‐
dence that the defendant’s treatment was far outside of med

‐
ical norms. “[I]f the defendant’s chosen ‘course of treatment’

departs radically from ‘accepted professional practice,’ a jury

may infer from the treatment decision itself that no exercise

of professional judgment actually occurred.” Id. (quoting

Pyles v. Fahim

, 771 F.3d 403, 409 (7th Cir. 2014)). Similarly, it

has long “been established that the choice of an ‘easier and

less e ffi cacious treatment’ can demonstrate that the actor dis

‐ played ‘deliberate indi ff erence

... rather than an exercise of

professional judgment.’” Roe v. Elyea

, 631 F.3d 843, 861 (7th

Cir. 2011) (internal citation omi tt ed) (quoting Estelle v. Gamble

, 429 U.S. 97, 104 n.10 (1976)). Finally, “[a]nother situation that

might establish a departure from minimally competent med

‐
ical judgment is where a prison o ffi cial persists in a course of

treatment known to be ine ff ective.” Pe tt ies

, 836 F.3d at 729–30.

Importantly, whether a defendant had a deliberately indif

‐
ferent state of mind is not a legal question; it is a factual one.

See Zaya

, 836 F.3d at 808 (“As we’ve explained, that’s [ i.e.

whether the defendant was deliberately indi ff erent] a ques

‐

tion of fact that needs to be resolved by a jury.”); Pe tt ies

, 836

F.3d at 728 (“We must determine what kind of evidence is ad

‐ equate for a jury to draw a reasonable inference that a prison

o ffi cial acted with deliberate indi ff erence.” (emphasis

added)). We can thus resolve this case now only if there is no disputed issue of material fact on this point.

The question whether a particular course of treatment for

an objectively serious medical condition amounts to deliber

‐

ate indi ff erence can be answered only with evidence from the

medical community. For that reason, courts cannot look to

outdated factual evidence from past cases to determineNo. 18

‐ 2075 33

whether some course of treatment is within acceptable

boundaries. If the medical community uniformly decides that

a recent advance is the only proper course of treatment, a de

‐
fendant cannot rely on a case from before that advance oc

‐
curred to say that her outdated treatment choice was reason

‐
able. A court’s role is only to determine whether a plainti ff has

put forward su ffi cient evidence to allow a fact fi nder to con

‐
clude that the treatment she received was so far outside the

bounds of medical professional judgment that it amounted to

deliberate indi ff erence.

II

What, then, is the evidence about treatments for gender

dysphoria? Is it undisputed that responsible doctors might

choose the course that Wisconsin followed, or is there evi

‐
dence that, if believed by a jury, would show that Wisconsin’s

choice was so far out of line with accepted practice that it

amounted to deliberate indi ff erence? We do not write here on

a clean slate. In Fields

, the district court “addressed both hor

‐

mone therapy and sex reassignment surgery,” and we upheld

its fi nding that banning either treatment despite its medical

necessity violated the Eighth Amendment. Fields

, 653 F.3d at

558–59. While no other court of appeals has dealt with a pris

‐

oner’s claim for SRS in the context of quali fi ed immunity, our

sister circuits are largely in accord about whether the denial

of SRS can violate the Eighth Amendment: It can. See Rosati v. Igbinoso

, 791 F.3d 1037, 1040 (9th Cir. 2015) (holding that the

denial of SRS stated a claim under the Eighth Amendment);

De’lonta v. Johnson

, 708 F.3d 520, 525–26 (4th Cir. 2013) (same).

The cases denying a plainti ff ’s claim for SRS do so not because

the denial of SRS can never be deliberate indi ff erence, but be

‐

cause the factual record before them did not contain evidence34 No. 18

‐ 2075

that, if believed, would show that only SRS would be appro

‐ priate for that plainti ff

. See Lamb v. Norwood

, 899 F.3d 1159,

1162–63 (10th Cir. 2018). In Lamb

, the court noted that the

“sparseness of the summary judgment record precludes a rea

‐
sonable fact

‐ fi nder from inferring deliberate indi ff erence.” Id.

It also relied on the fact that “Paul Corbier, M.D. stated under

oath that Michelle’s existing treatment has proven bene fi cial

and that surgery is impractical and unnecessary in light of the

availability and e ff ectiveness of more conservative therapies.”

Id. Kosilek v. Spencer

, 774 F.3d 63 (1st Cir. 2014) ( en banc ), is

similar. There the First Circuit rejected Kosilek’s plea for SRS,

but it went out of its way to say that “this case presents unique

circumstances; we are simply unconvinced that our decision

on the record before us today will foreclose all litigants from

successfully seeking SRS in the future. Certain facts in this

particular record—including the medical providers’ non

‐ uni

‐
form opinions regarding the necessity of SRS, Kosilek’s crim

‐
inal history, and the feasibility of postoperative housing—

were important factors impacting the decision.” Id. at 91. It is

also noteworthy that the First Circuit decided Kosilek only af

‐

ter a lengthy trial. Id. at 74–81 (describing the trial record);

Kosilek v. Spencer

, 889 F. Supp. 2d 190, 212 (D. Mass. 2012)

(making fi ndings of fact after “a 28

‐ day trial”).

The one court of appeals to foreclose SRS entirely said that

it was doing so based on a lack of record evidence. See Gibson

v. Collier

, 920 F.3d 212, 220–21 (5th Cir. 2019). In Gibson

, the

Fifth Circuit held that Gibson could not survive summary judgment because she had provided no evidence that SRS was

the only medically acceptable treatment option for her. Id. She

“did not dispute that the medical controversy” over SRS—

which the Fifth Circuit found existed based on Kosilek— “con

‐

tinues to this day.” Id. at 221. Campbell, by contrast, hasNo. 18

‐ 2075 35

produced precisely the evidence that the Fifth Circuit wanted.

As the majority opinion notes, Campbell’s experts have testi

‐

fi ed that SRS is both medically necessary for her and uncon

‐
troversial within the medical community. Indeed, Dr. Kathy

Oriel opined that “‘no physician with adequate expertise and

experience in gender medicine would’ dispute Campbell’s

need for sex

‐ reassignment surgery.” Ante at 11. If the trier of

fact credited that testimony, Campbell could prevail.

The majority a tt empts to distinguish De’lonta because it

was an appeal of a motion to dismiss under 28 U.S.C. § 1915A,

and because the plainti ff there had not yet been evaluated by

a gender

‐ identity medical specialist. Ante at 21 n.2. But just as

in a motion

‐ to

‐ dismiss posture, in a quali fi ed immunity inter

‐ locutory appeal we must draw inferences and resolve factual

disputes in the plainti ff ’s favor. And the fact that the defend

‐

ants in De’lonta had not yet allowed De’lonta to see a specialist

has no bearing on the legal question whether refusing to pro

‐
vide universally accepted surgery would violate the Eighth

Amendment. As the Fourth Circuit recognized, a surgical

consultation was merely one step toward curing the potential

constitutional violation. See De’lonta

, 708 F.3d at 526 & n.4.

The Ninth Circuit’s decision in Rosati

, which rests on a procedural and factual posture similar to that in De’lonta

, is

also instructive. There the court held that Rosati stated an Eighth Amendment claim despite prison o ffi cials having en

‐ gaged a medical consultant, because the consultant was “a

physician’s assistant with no experience in transgender med

‐

icine.” Rosati

, 791 F.3d at 1040. While Cynthia Osborne, the

defendants’ outside consultant in our case, does specialize in

gender identity issues, she is not a doctor. And Campbell has

adduced signi fi cant evidence that Osborne’s opinion about36 No. 18

‐ 2075

the need for surgery is not only incorrect, it is also well out

‐
side the bounds accepted by the medical community. This

presents a question of fact for a trial, where the trier of fact

will decide whether to accept or reject Campbell’s views.

As the district court recognized, when viewed in the light

most favorable to Campbell, the evidence shows that despite

being treated with hormones, Campbell’s gender dysphoria

has not improved. She has continued to threaten self

‐ castra

‐

tion and to experience suicidal ideation. The defendants are

aware of Campbell’s continued su ff ering and have neverthe

‐
less refused her further treatment. Campbell’s experts have

opined that no reasonable medical professional would recom

‐
mend any course of treatment in her case except surgery. The

majority opinion swipes this evidence away. Instead it

chooses to reach its own conclusion that, despite members of

the medical community swearing to the contrary, SRS is not

so well

‐ established that Kallas could be deliberately indi ff er

‐

ent by refusing to provide it. But that is a conclusion of fact

that lies outside our competence. It also rests on the fl awed

legal basis of an “injury by injury” determination of clearly

established law.

I respectfully dissent.