The Hon. David H. Souter, Associate Justice (Ret.) of the *

Supreme Court of the United States, sitting by designation.

United States Court of Appeals

For the First Circuit

No. 10-1965

SANDY J. BATTISTA,

Plaintiff, Appellee,

v.

HAROLD W. CLARKE, Commissioner of the Massachusetts

Department of Correction, and MICHAEL CORSINI,

Superintendent of Massachusetts Treatment Center,

Defendants, Appellants.

__________

KATHLEEN M. DENNEHY; ROBERT MURPHY; STEVE FAIRLY; SUSAN J.

MARTIN; GREGORY J. HUGHES; UMASS CORRECTIONAL HEALTH PROGRAM;

TERRE MARSHALL,

Defendants.

APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF MASSACHUSETTS

[Hon. Douglas P. Woodlock, U.S. District Judge]

Before

Boudin, Circuit Judge,

Souter, Associate Justice, *

and Stahl, Circuit Judge.

Richard C. McFarland, Legal Division, Department of

Correction, with whom Nancy Ankers White, Special Assistant

Attorney General, was on brief for appellants.

Neal E. Minahan, with whom Christopher D. Man and McDermott

Will & Emery LLP were on brief for appellee.
May 20, 2011
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BOUDIN, Circuit Judge. In 1983, in state court in

Massachusetts, Sandy Battista (born "David Megarry") was convicted

of the rape of a child, robbery, and kidnapping. After serving

that sentence, Battista was involuntarily committed in 2003 in a

civil proceeding, Mass. Gen. Laws ch. 123A, § 14 (2008), to the

Massachusetts Treatment Center for Sexually Dangerous Persons

("Treatment Center"). Such persons are held civilly without limit

in time until adjudged safe for release. Id. §§ 9, 14.

The Treatment Center, for which the Massachusetts

Department of Correction ("the Department") is responsible, Mass.

Gen. Laws ch. 123A, § 2, is an all-male facility housing three

groups: criminals participating in treatment programs, civilly

committed residents, and those awaiting adjudication as "sexually

dangerous persons." Massachusetts law requires that civil

detainees like Battista be separated from criminal ones. Durfee v.

Maloney, Nos. CIV. A. 98-2523B, CIV. A. 98-3082B, 2001 WL 810385,

at *15 (Mass. Super. Ct. July 16, 2001).

Battista is anatomically male but suffers from "gender

identity disorder" ("GID"), a psychological condition involving a

strong identification with the other gender. GID is a disorder

recognized in the American Psychiatric Association's Diagnostic and

Statistical Manual of Mental Disorders (4th ed. 1994). The

diagnostic criteria include not only "cross-gender identification"

but also "clinically significant distress or impairment in social,
In response to Battista's initial requests, a Department 1

psychiatric consultant stated in 1997 that the name change and

desired treatments were "bizarre at best, and psychotic at worst"

and recommended various medical and psychological testing, as well

as therapy. The consultant also considered Battista's requests to

be "elective procedures" equivalent to "tummy tucks and

liposuctions."

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occupational, or other important areas of functioning." Id. at

537-38.

In 1996, Battista changed her name to Sandy and began to

seek treatment from the Department, including administration of

female hormones and access to female garb. Her early demands were

met with skepticism and resistance. In 1997, a Department 1

consultant diagnosed her GID, but the Department offered no further

evaluation or treatment until 2004. Prior to this case, Battista

filed two suits seeking GID treatment and accumulated expert

opinions confirming the seriousness of her condition and

recommending accommodations including hormone therapy.

Battista filed her complaint in the present suit in July

2005 and in October 2005 sought to castrate herself with a razor

blade. The suit, against various officials of the Department,

charged deliberate indifference to her medical needs in violation

of the Eighth and Fourteenth Amendments and 42 U.S.C. § 1983

(2006), as well as state law, including Mass. Gen. Laws ch. 12,

§§ 11H-11I. In particular, Battista sought an injunction requiring

that hormone therapy and female garb and accessories be provided to

her.
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In and around 2005 and 2006, the Department fenced with

its own healthcare provider, the University of Massachusetts

Correctional Health Program, which offered strong support for the

GID diagnosis, asserted that harm could easily occur without

adequate treatment, and recommended hormone therapy as medically

necessary. The Department instead hired another gender specialist,

who then agreed that hormone treatment might be appropriate along

with other therapy.

Battista's first request to the district court for a

preliminary injunction was denied in March 2006, with a finding

that the defendants had not at this stage been shown to be

deliberately indifferent to her medical needs. Battista v.

Dennehy, No. 05-11456-DPW, 2006 WL 1581528, at *9-10, *12 (D. Mass.

Mar. 22, 2006). After the further medical assessments continued to

recommend hormone therapy, the Department stated that it would not

implement treatments until security concerns were further

evaluated. This proved to be a drawn-out process.

In August 2008, the first security review by the

Department concluded that a feminine appearance would endanger

Battista. The core security concern throughout has been that

sexual contacts or assaults by other detainees would be made more

likely by female clothing and accessories and the enhancement of

breasts due to hormone therapy. The report, however, was fairly

cursory, comprising only a few paragraphs, and in December 2008 the
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district court entered a preliminary injunction requiring

psychotherapy, access to women's attire and accessories, monthly

reports on Battista’s condition, and a recommendation on hormone

therapy after a six-month review.

In the six-month report, the doctors again prescribed the

hormones. A first dose was administered, but then the Department

put another indefinite hold on treatment pending a second security

review. The September 2009 review again found the safety risk too

high. This new report was more substantial although it more or

less duplicated an earlier report prepared for an inmate who also

had requested and been denied hormone therapy. Its security

evaluation is at the core of the Department's substantive objection

to hormone therapy for Battista.

Although hormone therapy had been provided for GID to

inmates of some male prisons, the September 2009 report included

data gathered under the Prison Rape Elimination Act of 2003

("PREA") § 4, 42 U.S.C. § 15603, to argue that the risk of sexual

assault was higher at the Treatment Center as compared to other

facilities of the Department, including prisons. The report noted

that Treatment Center residents were sex offenders and that the

Treatment Center had an open floor plan. It stressed Battista's

past infractions and the inability to move her to another facility

because of her civil commitment status.
The modified preliminary injunction now on appeal was issued 2

on August 23, 2010, and requires "[w]ithin seven (7) business days

of the entry of this Order, the DOC shall provide hormone therapy

to Battista in accordance with the recommendation of Dr. Levine,

Dr. Zakai, and Ruth Khowais, Psy.D. on June 19, 2009, and the

prescription by endocrinologist Dr. Mohammed Saad dated August 4,

2009 and August 14, 2009."

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A bench trial took place in June and August 2010. In the

course of the trial, Battista offered an evaluation from

psychiatrist George Brown. He testified that Battista was eligible

and ready for hormonal treatment, that the past treatment for her

GID "falls below any reasonable standard of care," and that with a

high degree of medical certainty . . . when

this patient loses hope again regarding access

to appropriate care, she will engage in

surgical self-treatment by autocastration or

will hire someone to do this for her. This

could lead to an inadvertent death due to

exsanguination.

On August 3, 2010, the court stated that it would enter

a modified preliminary injunction order requiring hormone therapy

to begin shortly. On August 23, 2010, the district court delivered

a detailed oral decision, which recounted the history and made

numerous findings in support of its injunction, applying the usual

four-part test for preliminary relief, Iantosca v. Step Plan Svcs.,

Inc., 604 F.3d 24, 29 n.5 (1st Cir. 2010) (likelihood of success,

irreparable harm, balance of hardships on the opposing sides,

public interest).

In its decision, the district court unqualifiedly

required hormone therapy. The injunction is styled as preliminary 2
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because both sides sought a ruling on implementation issues--

specifically, how restricted Battista may be in her confinement--

which the district court now has under consideration; but hormone

therapy has now been definitively decreed. That directive was

stayed by the district court pending appeal, as defendants

requested, solely because the district court feared harm to

Battista if hormone therapy were begun and later stopped again.

The district court's ultimate finding of "deliberate

indifference" rests on several different subordinate findings,

which can be recast and summarized under two headings: first, that

Battista has an established medical need for hormone therapy, may

suffer severe harm without it, and (implicitly) that such therapy

is feasible despite safety concerns; and second, that the

defendants' reliance on their administrative discretion in invoking

and dealing with security concerns has been undercut by a

collection of pretexts, delays, and misrepresentations. 

The focus of this appeal is narrow. The Department

concedes that Battista suffers from GID and needs treatment and

that hormone therapy has been recommended as medically necessary;

but it says that security concerns reasonably underpin its refusal

and contests the finding of deliberate indifference. Because the

individual defendants are sued only in their official capacity for

injunctive relief and no damages are sought, qualified immunity is
In the district court, Battista asserted but then abandoned 3

earlier damage claims and focused her suit on forward-looking

injunctive relief. Had this appeal involved individual liability

for damages and qualified immunity, a different outcome could

easily have been possible as to such claims.

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not an issue nor need the separate roles of individual defendants

be sorted out.3

Defendants suggest that review is de novo; the plaintiff,

that it is essentially for abuse of discretion in the grant of

preliminary relief. In truth, the standard of review varies

depending on the precise underlying issue in the mosaic of

arguments and counter-arguments. Legal issues are open to de novo

review, factual findings are reviewed for clear error, and judgment

calls by the district judge may get deference depending on the

circumstances. Venegas-Hernández v. Asociación de Compositores y

Editores de Música Latinoamericana (ACEMLA), 424 F.3d 50, 53 (1st

Cir. 2005).

The substantive standard for liability is a more

complicated story. In the district court, the parties and the

judge focused on the Eighth Amendment test used to assess medical

care, or the lack of it, for criminal prisoners, namely, whether

the defendants were "deliberately indifferent" to the needs of

their charge. Farmer v. Brennan, 511 U.S. 825, 837 (1994); Estelle

v. Gamble, 429 U.S. 97, 104-05 (1976). This choice of tests was

hardly surprising: although protection of civilly committed persons
The decisions are not uniform. Compare Ketchum v. Marshall, 4

No. 90-F-1627, 963 F.2d 382, 1992 WL 111209, at *2 (10th Cir. 1992)

(unpublished table decision) (using deliberate indifference test

for medical care for the civilly committed without mentioning

Youngberg), with Patten v. Nichols, 274 F.3d 829, 833-42 (4th Cir.

2001) (applying professional judgment test, not deliberate

indifference), with Sain v. Wood, 512 F.3d 886, 894-95 (7th Cir.

2008) (treating both standards as equivalent to deliberate

indifference), and Ambrose v. Puckett, 198 F. App'x 537, 539-40

(7th Cir. 2006) (treating both standards as equivalent to

professional judgment).

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rests on due process concepts rather than the Eighth Amendment,

deliberate indifference is the familiar test for medical care.

The Eighth Amendment standard is in part one of

subjective intent. Farmer, 511 U.S. at 839-40. The phrasing

itself implies at least a callous attitude, but subjective intent

is often inferred from behavior and even in the Eighth Amendment

context--contrary to the defendants' assertion--a deliberate intent

to harm is not required. Id. at 835. Rather, it is enough for the

prisoner to show a wanton disregard sufficiently evidenced "by

denial, delay, or interference with prescribed health care."

DesRosiers v. Moran, 949 F.2d 15, 19 (1st Cir. 1991).

Because Battista is civilly committed, a different, more

plaintiff-friendly standard arguably applies here: whether the

defendant failed to exercise a reasonable professional judgment.

Youngberg v. Romeo, 457 U.S. 307, 321 (1982). Battista has 4

repeatedly invoked a due process standard and claimed it to be more

favorable but does not pinpoint the Youngberg formulation.

However, fine-tuning is unnecessary. The two standards are not all
-11-

that far apart and, to the extent that the Youngberg phrasing

governs and is more helpful to Battista, that only reinforces the

outcome reached by the district judge.

Both the Farmer and Youngberg tests leave ample room for

professional judgment, constraints presented by the institutional

setting, and the need to give latitude to administrators who have

to make difficult trade-offs as to risks and resources. This is a

regular theme in the Eighth Amendment cases, Farmer, 511 U.S. at

844, and it is equally important under Youngberg. There, while

stressing that civilly committed persons are entitled to an extra

margin of protection, the Court also stated that there can be more

than one reasonable judgment, and that the choice in such cases is

for the professional. 457 U.S. at 321, 324-25.

Finally, while an "intent to punish" is not required even

under Farmer, it could certainly be highly significant under Farmer

and, a fortiori, under Youngberg. So it is useful to dispose at

the outset of plaintiff's claim that Robert Murphy--the

superintendent of the Treatment Center--admitted that whether

Battista should "be punished for her lack of good judgment by

withholding medical care" was "a consideration" when Murphy wrote

the security report rejecting hormone therapy.

This overreads Murphy's testimony. That Battista had

regularly evaded Treatment Center restrictions and engaged in

sexual contacts with other detainees was fully established, and it
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enhanced the danger to her in the future if her attractiveness to

other detainees was increased. So that fact was legitimately a

"consideration" that could affect whether hormone treatment could

be safely allowed. The term "punish" was not Murphy's own but was

inserted into the question itself by Battista's counsel during the

deposition:

Q: Should Battista be punished for

her lack of good judgment by withholding

medical care?

A: That's a consideration, yes.

However, even without an evil motive, the district court

could reasonably find that there had been "denial," "delay" and

"interference" under Eighth Amendment precedent and that a

reasonable professional judgment had not been exercised under

Youngberg. It has been fifteen years since Battista first asked

for treatment, and for ten years, health professionals have been

recommending hormone therapy as a necessary part of the treatment.

When during the delay Battista sought to mutilate herself, the

Department could be said to have known that Battista was in

"substantial risk of serious harm." Farmer, 511 U.S. at 847.

But the question remains whether the withholding of

hormone therapy was "wanton" or outside the bounds of "reasonable

professional judgement." Medical "need" in real life is an elastic

term: security considerations also matter at prisons or civil

counterparts, and administrators have to balance conflicting
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demands. The known risk of harm is not conclusive: so long as the

balancing judgments are within the realm of reason and made in good

faith, the officials' actions are not "deliberate indifference,"

Farmer, 511 U.S. at 844-45, or beyond "reasonable professional"

limits, Youngberg, 457 U.S. at 321, 324-25.

Here, despite much early resistance, Brugliera v. Comm'r

of Mass. Dep't of Corr., No. 07-40323-JLT (D. Mass. Dec. 18, 2009);

Kosilek v. Maloney, 221 F. Supp. 2d 156, 159-60 (D. Mass. 2002),

hormone therapy for GID is now provided in some cases in

Massachusetts prisons. The defendants point to this to establish

their good faith; Battista, to show that providing her the therapy

would be consistent with security needs. Both positions are

overstated. Hormone therapy has not been welcomed by the

Department, but both the Treatment Center's internal environment

and Battista herself arguably presented added risks.

The Treatment Center is the one facility where Battista

can be housed as a civil inmate and, while the Department could

establish a branch elsewhere, Mass. Gen. Laws ch. 123A, § 2, this

would pose administrative difficulties and be isolating for

Battista. The civil-side residents of the Treatment Center contain

a disproportionate number of male sex offenders who might threaten

one who presents herself as female. And Battista has a record of

infractions and sexual contacts and risk-taking that colorably

place her at greater risk from invited or uninvited sexual contact.
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Nor is Battista's willingness to take risks for herself

decisive. The defendants have an obligation to take reasonable

measures to protect inmates, Farmer, 511 U.S. at 833 (quoting

Cortes-Quinones v. Jimenez-Nettleship, 842 F.2d 556, 558 (1st

Cir.), cert. denied, 488 U.S. 823 (1988)), and Battista is quite

likely to sue if preventable harm occurs. Battista will bear some

of the risk of the hormone therapy, but not all of it. And, while

she could be kept in protective custody available at the Treatment

Center, this custody--as currently structured--involves confinement

for most of the day and other disadvantages that Battista is

unwilling to tolerate.

The legal labels applied to facts are reviewed on appeal

more closely than a district court fact-finding, but often with

some deference to the district judge. United States v. QuiñonesMedina, 553 F.3d 19, 22 (1st Cir. 2009). Yet this would be a much

harder case if defendants had proffered a persuasive and untainted

professional judgment that--while hormone therapy would help

Battista--the dangers, security costs and other impediments made it

infeasible. For the problem is not one of callous guards or inept

medical care but of conflicting considerations. As we said in an

earlier case involving the Treatment Center:

Any professional judgment that decides an

issue involving conditions of confinement must

embrace security and administration, and not

merely medical judgments. . . . The

administrators are responsible to the state

and to the public for making professional
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judgments of their own, encompassing

institutional concerns as well as individual

welfare. Nothing in the Constitution

mechanically gives controlling weight to one

set of professional judgments.

Cameron v. Tomes, 990 F.2d 14, 20 (1st Cir. 1993).

Yet in this instance, as the record now stands, the

defendants have forfeited the advantage of deference. Initially,

the district judge was far from anxious to grant the relief sought.

It was only after what the judge perceived to be a pattern of

delays, new objections substituted for old ones, misinformation and

other negatives that he finally concluded that he could not trust

the defendants in this instance. The details are laid out in his

oral opinion and the record contains support for his conclusion.

Several examples stand out.

First, for some time, the Department refused to take the

GID diagnosis and request for hormone therapy seriously. Its

representatives resisted it in other cases, and when their own

medical advisers supported the request for Battista, the defendants

went back and forth apparently looking for an out. It may take

some education to comprehend that GID is a disorder that can be

extremely dangerous. But the education seems to have taken an

unduly long time in this instance, especially in light of the selfmutilation attempt. 

Second, once the medical prescription was clear, several

years passed before the defendants produced a substantial security
Finally faced with a decision by the district court to 5

require therapy, defendants now say they have offered to create a

modified protective custody arrangement that would provide Battista

and others with both protection from other residents and "access to

treatment, work, educational programs, and recreation." This may

on investigation be less than the quotation suggests but that is

another matter.

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justification; and this, it turns out, depended in part on

inaccurate data in paragraphs largely written by Department counsel

and inserted at counsel's request after Murphy had made his

decision and submitted his initial draft. Murphy admitted in his

trial affidavit that he had miscounted the PREA incidents in 2007

and 2008; there were really 41, not 68, reported incidents at the

Treatment Center.

Third, for some time, the defendants portrayed the choice

facing the court as one between keeping Battista in a severely

constraining protective custody unit and denying her hormone

therapy. Defendants now show some signs of retreating from this

all or nothing choice, but not far: this is consistent with a 5

pattern of slow retreats to the next redoubt. The district court

may well be right that a detailed solution will be developed only

when the choice is forced on defendants.

In the end, there is enough in this record to support the

district court's conclusion that "deliberate indifference" has been

established--or an unreasonable professional judgment exercised--

even though it does not rest on any established sinister motive or

"purpose" to do harm. Rather, the Department's action is undercut
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by a composite of delays, poor explanations, missteps, changes in

position and rigidities--common enough in bureaucratic regimes but

here taken to an extreme. This, at least, is how the district

court saw it, and it had a reasonable basis for that judgment.

There are a few loose ends to address. One is that the

defendants say that the harm faced by Battista is neither immediate

nor irreparable--common requisites for preliminary relief--but, as

already noted, the injunction is not preliminary as to her

entitlement to hormone therapy. And while the risk of selfmutilation is unpredictable, it grows as the litigation drags on.

They also say that the risk of physical assault will be increased

by therapy, which may be so but is not decisive: medical treatment

often poses risks and invites trade-offs.

Another set of defendant arguments is contained only in

the reply brief. These include a claim that the decision is

inconsistent with the court's earlier denial of relief. This

claim, perhaps imprudently, draws attention to the experience with

the Department gained by the district court after that denial.

Anyway, claims first raised only in reply briefs are forfeit,

Rivera-Muriente v. Agosto-Alicea, 959 F.2d 349, 354 (1st Cir.

1992), and we note only that none of them appear promising even if

they had been preserved.

Affirmed.