Opinion ID: 2761209
Heading Depth: 2
Heading Rank: 4

Heading: Consideration of SRS

Text: In line with the Harry Benjamin Standards of Care (the Standards of Care or the Standards),3 Dr. Seil recommended that Kosilek be considered for SRS after one year of hormonal 2 Facial hair removal was delayed because of difficulty finding a provider that was willing to perform these services on Kosilek. The minutes of the DOC's Executive Staff Meetings show that they proactively sought out service providers throughout this period of delay, and electrolysis was completed in November 2004. 3 The Standards of Care are a set of treatment recommendations issued by the Harry Benjamin International Gender Dysphoria Association that provide guidance on the treatment of individuals with GID. Relevant to Kosilek II is the sixth version of the Standards of Care. See Harry Benjamin Int'l Gender Dysphoria Ass'n, Standards of Care for Gender Identity Disorders, Sixth Version (2001) (Standards of Care). A seventh version of the Standards of Care was published in 2011, and adopts the Harry Benjamin Association's new name. See World Professional Ass'n for Transgender Health (WPATH), Standards of Care for the Health of Transsexual, Transgender, and Gender–Nonconforming People, Version 7 (2011). The Standards of Care are intended to provide flexible directions for the treatment of GID, and state that [i]ndividual professionals and organized programs may modify the Standards' requirements in response to a patient's unique . . . situation or an experienced professional's evolving [treatment methodology]. Standards of Care at 1-2 (emphasis added). -7- treatment.4 Accordingly, in 2004 the DOC began the process of finding an appropriate professional to evaluate Kosilek's eligibility for, and the necessity of, SRS. At the DOC's Executive Staff Meetings there was some debate regarding who should be hired to conduct this evaluation. The UMass Mental Health Program Director, Dr. Kenneth Appelbaum, suggested that the DOC consult with the Fenway Community Health Center (the Fenway Center). The Fenway Center is a Boston-based facility focused on serving the lesbian, gay, bisexual, and transgender community. In contrast, the DOC's Director of Mental Health and Substance Abuse Services, Gregory Hughes (Hughes), suggested consulting with Cynthia Osborne (Osborne), a gender identity specialist employed at the Johns Hopkins School of Medicine who had experience working with other departments of correction regarding GID treatment. Hughes expressed concern with using the Fenway Center because of the perception that their approach was to come out with recommendations that globally endorsed a full panoply of treatments. It was thought that Osborne, in contrast, may do more objective evaluations. Dr. Appelbaum noted, however, that the Fenway Center's approach was, to his knowledge, probably more 4 This treatment plan aligns with the Standards of Care's triadic sequence for GID treatment. This sequence begins with diagnosis and the provision of therapy, progresses to endocrine treatments, and culminates with consideration of SRS after at least one full year living a real life experience in the preferred gender role. Many individuals with GID choose not to complete the full sequence. -8- the norm than the exception. The DOC also recognized that having a Boston-based treatment provider might more easily facilitate the process of Kosilek's evaluation. The Fenway Center was retained by the DOC, and Kosilek was evaluated by Kevin Kapila, M.D., and Randi Kaufman, Psy.D., in a ninety-minute interview. Drs. Kapila and Kaufman also reviewed Kosilek's medical records. On February 24, 2005, they issued a report recommending that Kosilek receive SRS (the Fenway Report). The Fenway Report acknowledged Kosilek's positive response to the treatment provided by the DOC. Her joy around being feminized through hormone therapy, facial and body hair removal, and her ability to have access, and to dress in, feminine attire and make-up is palpable. These responses further suggest that being able to express herself as female has been helpful in alleviating her gender dysphoria. . . . [I]t is clear that her increasingly feminine presentation has been beneficial to her psychologically. Nonetheless, it also emphasized that Kosilek remained significantly distressed by having male genitalia, as well as not having female genitalia. In light of this continuing distress, the Fenway Center doctors stated that it is quite likely that Michelle will attempt suicide again if she is not able to change her anatomy. The report also concluded that Kosilek had fully progressed through the Standards of Care's triadic sequence, and that she appear[ed] to be ready for SRS. SRS, the doctors believed, would most likely allow Michelle to have full relief from the symptoms of gender -9- dysphoria and would quite possibly increase her chance for survival by greatly decreasing the potential for future suicidal ideation. The Fenway Report was received by the DOC and reviewed by Dr. Appelbaum and his UMass colleague, Dr. Arthur Brewer. The UMass doctors informed the DOC that they found no clear contraindications to SRS, but noted that they were unaware of any other case in which an inmate has undergone sex reassignment surgery while incarcerated. After considering the information from UMass, the DOC decided to have Osborne conduct a peer review of the Fenway Report. In a letter to Osborne, the DOC stated that it was requesting her services because [t]he treatment of Gender Identity Disorder within a correctional environment is a complicated issue and one that the Department takes very seriously. We are aware of the substantial expertise you possess in this area and hope that you can provide us with assistance in determining appropriate -10- treatment.5 On April 12, 2005, the DOC sent Osborne copies of all previous medical evaluations of Kosilek. On April 28, 2005, the DOC Director of Health Services, Susan Martin (Martin), wrote UMass, stating her concern that UMass had not address[ed] the lack of detail, clarity and specific recommendations in the evaluation done by the Fenway Clinic, and had failed to provide an independent recommendation as to the appropriateness of surgery. She also asked for specific logistical information, including a list of doctors who might provide the surgery, what procedures would be performed, and what recovery time could be expected. On May 10, 2005, Drs. Appelbaum and Brewer replied, indicating that they deferred to the Fenway Center's recommendation of surgery, as they were not experts in the area of SRS -- a medical procedure specifically excluded from their contract to provide services to the DOC. They provided a preliminary list of surgeons to consider, none of whom were licensed to practice medicine in Massachusetts. 5 Osborne previously worked with the Virginia and Wisconsin Departments of Correction regarding their treatment of prisoners with GID. It is unclear from the record whether the Fenway Center had previously developed treatment plans for GID within a penological setting. When the DOC asked what consideration the Fenway Center gave to issues such as criminal history [and] violence against women, the center responded that independent of other psychological disorders [Fenway experts] don't consider criminal history, homicide, [or] brutality. On January 5, 2005 -- before the Fenway Center released its report -- the DOC's Director of Health Services expressed concern about these omissions. -11- On May 20, 2005, Osborne finished her peer review of the Fenway Report. She began by making clear that her review was limited to reading and evaluating the reports of others. As a result, she could not independently diagnose Kosilek, but she agreed with the conclusion that Kosilek suffered from GID. Still, she disagreed with what she believed to be a lack of comprehensiveness in the report and an inclination to minimize the possibility of comorbid conditions. Namely, Osborne highlighted that Kosilek had previously been diagnosed with Antisocial Personality Disorder, a diagnosis neither confirmed nor denied by the Fenway Report, and that the report included no indication that Kosilek had been assessed for other pathologies likely to lead to self-harming behavior. Osborne expressed belief that threats of self-harm or suicide should serve as a contraindication to surgery, and that such threats were not a valid or clinically acceptable justification for surgery. In consequence, she disagreed with the Fenway Center's statements that surgery was medically necessary as a means to diminish the likelihood that Kosilek would attempt suicide in the future. Osborne's report also highlighted that the Standards of Care admit of flexible application, and noted that the Standards state that the diagnosis of GID invites the consideration of a variety of therapeutic options, only one of which is the complete therapeutic triad. She emphasized that [t]here is currently no -12- universal professional consensus regarding what constitutes medical necessity in GID. In reference to the Standards of Care's application in a penological setting, Osborne noted that the Standards of Care include a criterion that candidates for SRS exhibit satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality. She believed that this requirement was inherently in conflict with the Standard's application to incarcerated persons, as she felt incarceration indicated a lack of mastery over such antisocial leanings. Moreover, Osborne noted that non-incarcerated individuals often face external constraints in their choice of treatments or determine, as a result of their real life experience, that other, non-invasive treatments are personally preferable to SRS. In consequence, she felt that it was unrealistic for inmates to expect that prison life [would] provide no constraints or obstacles to cross gender preferences and that it was outside[] the bounds of good clinical practice for care providers to try to meet this expectation. Given the isolation attendant to incarceration, Osborne also emphasized that prisoners might often lack awareness of the frequency with which individuals choose alternative treatments over SRS. After considering Osborne's peer review, Martin again reached out to the doctors at UMass. On May 25, 2005, she expressed continuing concern with the Fenway Report, highlighting -13- that Osborne's peer review had raised at least three questions regarding the report's thoroughness: (1) why the report omitted consideration of potential comorbidities; (2) why the report did not rely on formal psychological testing, but only an in-person interview; and (3) why Kosilek's claims that she would likely seek to end her life if not provided with SRS were seen to justify, rather than serve as a contraindication to, surgery. Martin also expressed dissatisfaction that the February 24, 2005 evaluation by the Fenway Clinic does not indicate whether sex reassignment surgery is a medical necessity for Michele [sic] Kosilek and fails to adequately address the issue of whether the current treatment provided to Kosilek provides sufficient relief of the symptoms of gender dysphoria. A response from Drs. Appelbaum and Brewer came on June 14, 2005. The doctors made clear that they were not experts in the treatment of GID, and that they deferred to the Fenway Center's treatment recommendation. Referring to the differences between the preferred treatment plans of the Fenway Center and Osborne, the doctors reminded Martin that Osborne's report had emphasized the dearth of empirical research upon which to base treatment decisions for GID and had highlighted the lack of professional consensus regarding the medical necessity of SRS. The Fenway Center issued a follow-up report aimed at answering Osborne's critique of its initial recommendation. In -14- this report, Drs. Kapila and Kaufmann noted that suicidal ideation was common among individuals suffering from GID, and that it often decreased with the provision of care. Therefore, the likelihood that Kosilek would become suicidal if denied surgery was, to the doctors, not a contraindication to her eligibility, but instead was a symptom that could be alleviated by provision of SRS. The doctors also disagreed with Osborne's belief that incarceration was a significant contraindication to surgery, noting that the Standards of Care specifically state that [p]ersons who are receiving treatment for [GID] should continue to receive appropriate treatment . . . after incarceration. For example, those who are receiving psychotherapy and/or cross-sex hormonal treatments should be allowed to continue this medically necessary treatment . . . . The Fenway Center doctors further discussed their belief that a key step of the triadic sequence, the real-life experience, could occur in prison. This treatment prerequisite requires that an individual live full-time in their preferred cross-gender role for at least one year prior to being deemed eligible for SRS. The purpose of this requirement is ensure that GID patients have an opportunity to experience a full measure of life in a cross-gender role, including the social scrutiny that may arise among professional counterparts and peers. Prison, the Fenway Center's doctors surmised, might be considered a more -15- stringent real-life experience, because a prisoner's gender presentation would be subject to full-time monitoring by prison personnel and other inmates. The report concluded by reiterating the Fenway Center's recommendation that Kosilek receive SRS. The doctors recognized that performing such a procedure would . . . bring up issues of housing and safety, but emphasized that hormone therapy and [SRS] are the only clinical treatments found to be effective for GID.