Opinion ID: 2761209
Heading Depth: 4
Heading Rank: 3

Heading: The court-appointed expert

Text: At the conclusion of the first round of testimony, the district court decided to appoint an independent expert to assist in determining what constituted the medical standard of treatment for GID. On October 31, 2006, with the parties' input, the district court selected Dr. Stephen Levine, a practitioner at the Center for Marital and Sexual Health in Ohio and a clinical professor of psychiatry at Case Western Reserve University School of Medicine. Dr. Levine had helped to author the fifth version of the Standards of Care, and served as Chairman of the Harry Benjamin International Gender Dysphoria Association's Standards of Care Committee. A month after his appointment, Dr. Levine issued a written report. The report began by explaining the dual roles that WPATH -- formerly the Harry Benjamin Association and the organization that wrote the Standards of Care -- plays in its provision of care to individuals with GID: WPATH is supportive to those who want sex reassignment surgery (SRS). . . . Skepticism and strong alternate views are not well tolerated. Such views have been known to be greeted with antipathy from the large numbers of nonprofessional adults who attend each [of] the organization's biennial meetings. . . . The [Standards of Care are] the product of an enormous effort to be balanced, but it -26- is not a politically neutral document. WPATH aspires to be both a scientific organization and an advocacy group for the transgendered. These aspirations sometimes conflict. The limitations of the [Standards of Care], however, are not primarily political. They are caused by the lack of rigorous research in the field. Dr. Levine further emphasized that large gaps exist in the medical community's knowledge regarding the long-term effects of SRS and other GID treatments in relation to its positive or negative correlation to suicidal ideation. Dr. Levine next discussed the possibility of Kosilek having a real-life experience in prison. He explained that the Fenway Center, in stating that a real-life experience could be had in prison, failed to offer a mild caveat that the real life test was designed to test the patients' capacity to function as a female in the community by mastering the demands of . . . family, social relationships, educational accomplishment, [and] vocational performance. Such experiences and relationships, Dr. Levine noted, are not a part of Kosilek's daily life in prison. Dr. Levine's final conclusion was that: Dr. Schmidt's view, however unpopular and uncompassionate in the eyes of some experts in GID, is within prudent professional community standards. Treatment stopping short of SRS would be considered adequate by many psychiatrists, gender team members, and gender patients themselves, if Kosilek were a citizen in the community. . . . [T]here are a number of acceptable community standards which derive from differing assumptions about disorders, -27- their causes, and the possible effective interventions. He recognized that the different treatment plans advocated by Dr. Schmidt and the Fenway Center each . . . [had] merit, as well as limitations. Dr. Levine further wrote that doctors generally do not recommend treatment to GID patients. . . . The decision is [the patient's], when and if they still want it. Dr. Levine testified on December 16, 2006. He first reiterated his belief that Dr. Schmidt's view, although not preferred by some GID specialists, was within prudent professional standards. He noted that Kosilek had received significant relief on her current treatment plan, and that many patients with GID live comfortably without completing the triadic sequence. He believed that Kosilek had already successfully consolidated her gender identity, such that the removal of her male genitalia might relieve dysphoria, but it was not necessary to complete that consolidation. He also indicated variability and difficulty in forecasting depressive symptoms and self-harming behavior in GID patients. He explained that he believed Kosilek would certainly express deep disappointment if denied SRS -- described as the sole current focus of her life -- but that coping mechanisms might well change her outlook in months and years to come, allowing her to live happily without the provision of SRS. The district court then asked Dr. Levine to narrow the lens of his inquiry by presuming that there were absolutely no -28- external contraindications to surgery and that Kosilek had indeed had a real-life experience in prison. Given these presumptions, the court asked Dr. Levine to testify as to whether it would still be prudent to not provide Kosilek with SRS. Dr. Levine acknowledged his belief that prudent professionals would generally not deny surgery to a fully eligible individual. Still, he hesitated to declare Dr. Schmidt's approach medically unacceptable. He answered that the provision of SRS would surely be a prudent course of treatment, but then stated that I also believe it's prudent not to give her Sex Reassignment Surgery for lots of reasons. He again emphasized for the court that the treatment of GID was an evolving field, in which practitioners could reasonably differ in their preferred treatment methods. Dr. Levine explained that in many instances patients cannot or do not want to receive SRS, and prudent physicians commonly employ a range of treatments to ameliorate these patients' dysphoria.