Opinion ID: 2761209
Heading Depth: 4
Heading Rank: 1

Heading: Initial testimony

Text: First to testify in 2006 was an expert witness for Kosilek, Dr. George Brown, who had previously evaluated Kosilek in 2001 and was an author of the Standards of Care. Prior to testifying, Dr. Brown issued a written report assessing Kosilek’s readiness for surgery and evaluating her current mental and physical presentation, as compared with 2001. Dr. Brown noted that Kosilek consistently presented as female and that [a]ccess to makeup and female undergarments, laser hair removal, along with hormonal treatments . . . have all seemed to significantly reinforce and consolidate the outward expression of [Kosilek's] gender identity as female. Other positive effects of treatment were also described: Hormonal treatments have resulted in obvious breast growth since my last assessment, decrease in upper body strength, increase in hip size, changes in amount and texture of body hair, skin texture changes, testicular volume decrease, and a large reduction in spontaneous erections . . . . Psychologically, the effects of these combined treatments have [included] . . . resolution of depression, resolution of suicidality and suicide gestures and attempts, improved mood with reduction in irritability, anxiety, and depression . . . . Based on his observations, Dr. Brown concluded that Kosilek was eligible for SRS, having met all of the readiness criteria. -19- Before the court, Dr. Brown's testimony emphasized that the provision of female clothing and effects, hair removal, and hormones had resulted in a lessening of the severity of [Kosilek's] dysphoria. According to Dr. Brown [s]he was clearly less depressed, less anxious, less irritable . . . . She was not suicidal . . . . Despite these significant improvements, Dr. Brown testified that he believed SRS to be an appropriate and medical[ly] necessary component of Kosilek's treatment. He related instances in which incarcerated persons who could not complete the triadic sequence6 exhibited an increase in negative symptoms, including a resurgence of self-harming behavior. Dr. Brown further testified that, if not granted surgery, he believed Kosilek’s feelings of hopelessness will intensify, and that she would likely attempt suicide. In reaching this conclusion, Dr. Brown emphasized that other parts of the treatment plan [e.g., hormones, hair removal, and the provision of female clothing] . . . all contribute in their own way to a level of improvement. Nonetheless, he felt that, if Kosilek lost hope of receiving SRS, her current treatment plan would not stop a deterioration of her mental state and the possible reemergence of suicidal ideation. 6 The steps of this sequence, if fully completed, progress from GID diagnosis and therapeutic treatment, through endocrine treatment, and culminate -- after at least a one-year-long reallife experience -- with the consideration of SRS. -20- Dr. Kaufman from the Fenway Center also testified, reiterating that the Fenway Center believed SRS to be an appropriate and medically necessary step in Kosilek's treatment. She further stated her belief that, if not given surgery, Kosilek would present a significant risk of suicide: if she's not able to have surgery, I think that she'll be hopeless and feel helpless and at that point really will have nothing else to live for. Next to testify was Mark Burrows (Burrows), who had been Kosilek’s treating psychiatrist for approximately five years. Burrows testified to Kosilek's strong desire for SRS, and to her feelings of hope associated with completing the formalization of her gender presentation. Burrows also stated that denying surgery would likely have a negative impact on Kosilek's mental health. He believed that it was slightly more probable than not that a denial of the surgery would result in Kosilek attempting to commit suicide. Burrows also spoke about his belief that, if given SRS, Kosilek should not continue to reside at MCI-Norfolk, as the risks involved in her possibly being assaulted are obvious. Dr. Appelbaum of UMass was also called as a witness for Kosilek. He testified as to UMass's trust in the Fenway Center's recommendations, and to his belief that the DOC need not have sought out a peer review of the Fenway Report, given the Fenway Center's expertise in the treatment of GID. -21- Kosilek testified next. She expressed the depth of her desire for SRS, and she stated that she would continue to experience mental anguish regarding her gender identity so long as she had male genitalia. If not provided with SRS, Kosilek said that she would not want to continue existing [as an anatomical male] and might instead attempt to commit suicide. She disagreed with the suggestion that treatment short of SRS could adequately relieve her mental distress, stating that [t]he problem is my genitals. That's what needs to be fixed. Kosilek also testified as to feeling discomfort in the all-male environment of MCI-Norfolk and having a strong desire to be transferred to MCI-Framingham. She felt that the inmates at MCI-Framingham would be more accepting and welcoming of her than those at MCI-Norfolk. The DOC offered testimony from Dr. Chester Schmidt, a licensed psychiatrist and Associate Director of the Johns Hopkins School of Medicine. Dr. Schmidt expressed his belief that Kosilek had undergone an excellent adaptation through treatment with hormones, hair removal, psychotherapy, and the provision of female garb. These treatments had alleviated the severity of her mental distress and allowed Kosilek to significantly consolidate her gender identity. Dr. Schmidt acknowledged that, if not provided SRS, Kosilek's level of mental distress would likely increase, with depression or attempts at self-harm possible. On the whole, however, he believed that her positive adaptation and the -22- consolidation of her gender identity indicated that the current course of treatment provided by the DOC was medically adequate. Dr. Schmidt explained that the severity of dysphoria associated with GID may wax and wane, with patients feeling depressed or hopeless at times, but generally being able to alleviate these depressive symptoms with appropriate psychotherapy and medical interventions. He felt that these measures, in combination with Kosilek's current course of treatment, would allow her to live safely and maintain a level of contentment. On cross-examination, Dr. Schmidt was questioned regarding his alleged rejection of the Standards of Care. Dr. Schmidt responded that he found the Standards of Care very useful for patients and that he commonly requested that patients familiarize themselves with these Standards when they began to seek care for SRS. Asked if he had stricter requirements for SRS eligibility than those in the Standards of Care, Dr. Schmidt emphasized that he neither advocate[s] for nor . . . speak[s] against the decisions for the cross-gender hormones or eventually for surgery. Rather, he believes such decisions are best made by the patient, based on their personal needs and desires. In line with this belief, Dr. Schmidt stated that he does not specifically recommend SRS, but at a patient's request he will release medical files and send a letter indicating that a patient is ready for surgery to their chosen SRS provider. -23- Dr. Schmidt further testified that he viewed the Standards of Care as guidelines. He explained, however, that [t]here are many people in the country who disagree with those standards who are involved in the [GID] field. Because of this disagreement, Dr. Schmidt expressed hesitation to refer to the Standards of Care, or the recommendation for SRS, as medically necessary. He emphasized the existence of alternative methods and treatment plans accepted within the medical community. He also questioned whether the Standards of Care's requirement of a reallife experience could occur in prison, opining that the real-life experience required a range of social and vocational experiences unavailable within a penological setting. Osborne testified next, reiterating her agreement with Kosilek's GID diagnosis, but disagreeing that SRS was a medically necessary treatment. In reference to the Standards of Care, Osborne testified that she fully agreed that SRS was an effective and appropriate treatment for GID. She emphasized, however, that she did not view SRS as medically necessary in light of the whole continuum from noninvasive to invasive treatment options available to individuals with GID. Regarding Kosilek personally, Osborne indicated that she believed Kosilek's current treatment plan had been highly effective in allowing Kosilek to feel hopeful, euphoric, and not depressed about her gender identity. Osborne, like Dr. Schmidt before her, again expressed skepticism as to -24- whether a real-life experience could occur in jail, given that a single-sex environment necessarily limited the sorts of social and human interactions available. Osborne agreed that not providing Kosilek with SRS might give rise to possible suicidal ideation, but noted that the DOC had significant expertise in treating prisoners exhibiting self-harming behavior. She felt that Kosilek's current treatment plan, in conjunction with protective measures aimed at ensuring her personal safety, was an appropriate and medically acceptable response to Kosilek's GID.