Opinion ID: 184722
Heading Depth: 2
Heading Rank: 1

Heading: Farmer's Efforts to Obtain Treatment

Text: 2 Transsexualism is a gender identity disorder, the sufferers of which believe that they are cruelly imprisoned within a body incompatible with their real gender identity. THE MERCK MANUAL OF MEDICAL INFORMATION 418 (1997). The disorder is commonly accompanied by a desire to change one's anatomic sexual features to conform physically with one's perception of self. To relieve this gender discomfort, transsexuals may pursue some combination of hormone therapy, surgery, and psychological counseling. They may also choose to live in their preferred gender role by dressing, naming, and conducting themselves in conformity with that gender. See id. at 418-19. 3 Farmer is a pre-operative male-to-female transsexual, i.e., she identifies herself as a woman although she is biologically male. For several years prior to her incarceration, Farmer lived as a woman in her dress and conduct. She also received hormone therapy and silicone breast injections. Farmer has never undergone sex re-assignment surgery. However, before her imprisonment, she had an unsuccessful black market operation to remove her testicles, and, while in prison, she attempted to perform self-castration. 4 Since at least 1991, Farmer has actively sought treatment for her transsexualism. She has lodged administrative complaints within the institutions in which she has been incarcerated. She has also initiated multiple lawsuits claiming violations of her constitutional rights arising from her conditions of imprisonment and lack of medical treatment. And, most relevant to the instant case, she has written numerous letters to BOP officials, including Moritsugu, to inform them that she desired, but was not receiving, treatment for her transsexualism. See Letters from Farmer to Prison Officials, reprinted in Joint Appendix (J.A.) 66-80. In these letters, Farmer has claimed that, because her condition has worsened during the course of her confinement, she is entitled to some form of treatment. Farmer claims that her pleas for assistance largely have gone unanswered; on this score, she points out that she has received only intermittent counseling from the BOP during her incarceration. 5 The BOP's general health care mission is to provide essential medical care, defined as care that is either medically mandatory or presently medically necessary in the clinical judgment of health care professionals. See FEDERAL BUREAU OF PRISONS, U.S. DEP'T OF JUSTICE, PROGRAM STATEMENT, No. 6000.04 (Dec. 15, 1994) (HEALTH SERVICES MANUAL), , Ch. 1, § 1, reprinted in J.A. 61. The term medically mandatory applies to cases in which urgent intervention is required. Id. The term presently medically necessary describes treatment without which an inmate could not be maintained without significant risk of either further serious deterioration of his/her condition or significant reduction of the chance of possible repair after release, or without significant pain or discomfort. Id. In addition to this broad mission statement, the BOP's medical policy includes a provision specifically applicable to the treatment of transsexualism, which declares: 6 It is the policy of the [BOP] to maintain a transsexual inmate at the level of change existing upon admission. Should the Clinical Director determine that either progressive or regressive treatment changes are indicated, the Medical Director must approve these prior to implementation. The use of hormones to maintain secondary sexual characteristics may be continued at approximately the same levels as prior to incarceration (with appropriate documentation from community physicians/hospitals) and with the Medical Director's approval. 7 HEALTH SERVICES MANUAL, Ch. 5, § 14, reprinted in J.A. 64. 8 The present case centers on the course of predominantly unanswered correspondence by which Farmer sought Moritsugu's intervention in her treatment program. Moritsugu, for his part, acknowledges receiving one letter from Farmer. In that letter, dated July 30, 1992, Farmer apparently requested some combination of treatment--hormones, castration, and/or psychotherapy--for her transsexualism. That letter, in turn, prompted Moritsugu's response of August 11, 1992. See Letter from Moritsugu to Farmer (Aug. 11, 1992), reprinted in J.A. 52-53. 9 In his letter to Farmer, Moritsugu recited the BOP's general medical policy, as described above. He then proceeded to address briefly each potential form of treatment for transsexualism. As to hormones, Moritsugu stated that Farmer was not on hormones when she arrived in the federal prison system, and that he had not received a request for such treatment from the medical personnel of the facility in which she was incarcerated. As to castration, Moritsugu again emphasized that he had not received a recommendation for such treatment from the relevant medical personnel, and added that he would only consider authorizing castration if it was clinically necessary, rather than simply a cosmetic procedure or a procedure to further transsexual change. J.A. 52. Finally, as to psychotherapy, Moritsugu observed that Farmer had received counseling, but that her transsexualism was a general emotional state, which did not present a specific mental health problem that mental health personnel [could] isolate for treatment. Id. at 52-53. He concluded by stating that mental health personnel were available to assist Farmer if she had specific needs. Id. at 53. 10 Farmer claims to have written Moritsugu on four subsequent occasions, requesting that he reconsider his decision. Moritsugu, however, does not acknowledge receiving, and did not respond to, any of these alleged letters.