Opinion ID: 2761209
Heading Depth: 3
Heading Rank: 1

Heading: Testimony related to medical necessity

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.
Following the close of initial testimony, the district court ordered UMass to review the testimony of all medical experts and to issue a report regarding whether the treatment proposed by Dr. Schmidt was an adequate method of treating Kosilek's GID. In this report -- submitted to the court on September 18, 2006 -- Drs. Appelbaum and Brewer made clear that they worked with and relied upon Dr. Kapila and Dr. Kaufman who assist[ed] to prepare this response. The report stated that the UMass doctors have been informed by Dr. Kaufman and Dr. Kapila that . . . trial testimony . . . confirms their opinion that Michelle Kosilek has a 'serious medical need' because there is a 'substantial risk of serious harm if it is not adequately treated.' In conclusion, the report reiterated that the Fenway Center believed Dr. Schmidt's proposed -25- treatment plan would not provide adequate care, and UMass endorsed that conclusion.
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.
Several witnesses were recalled for additional testimony. Drs. Kapila and Kaufman appeared again on behalf of Kosilek. Both reiterated their belief that Kosilek had a serious medical need and that, given Kosilek's high risk of suicide if denied the surgery, SRS was the only adequate treatment plan. Dr. Appelbaum also testified again, as did the UMass Medical Director. Both UMass -29- doctors reaffirmed their endorsement of the Fenway Center's treatment recommendations. Kosilek also presented additional witness testimony from Dr. Marshall Forstein, Associate Professor of Psychiatry at Harvard Medical School, who had previously evaluated Kosilek during Kosilek I. Dr. Forstein issued a written report, in which he noted that the question of the most prudent form of treatment is complicated by the diagnosis of GID being on the margins of typical medical practice. Despite this recognition, he testified that he believed SRS was necessary for Kosilek. He felt that, if she was not given SRS, there was a significant risk that Kosilek would attempt suicide or self-mutilation. Although Dr. Forstein believed that psychotherapy might help with frustration, with harassment, and with depression, he was uncertain whether Kosilek could ever fully reconcile with being incompletely transitioned. 2. Testimony regarding safety and security concerns a. Initial testimony In line with the June 10, 2005, security report prepared by Commissioner Dennehy, multiple DOC officials testified regarding the safety and security concerns that were likely to arise if Kosilek was provided SRS. First to testify was Spencer, who at that time served as Superintendent of MCI-Norfolk. Spencer began by explaining the general layout and security measures at MCI-Norfolk. He also -30- explained that the prison had, so far, successfully been able to accommodate Kosilek's receipt of care without incident. Spencer was unaware of any issues or incidents of harassment related to Kosilek's breast growth and increasingly feminine appearance. He stated, however, that he would have significant concerns housing an anatomically female prisoner in MCI-Norfolk, an all-male prison. Despite the lack of historical incidents specific to Kosilek, he emphasized that inmates do get assaulted, inmates have been raped . . . [a]nd putting a female in a correctional environment like MCI-Norfolk would be of high concern to me. If Kosilek remained at MCI-Norfolk, Spencer testified that he believed she would only be safe if housed in the Special Management Unit, a highly restricted secure building separated from the general population. Bissonnette, Superintendent of MCI-Framingham, also testified about the security concerns she believed would arise if Kosilek was transferred to the all-female prison after receiving SRS. She explained that MCI-Framingham does not have private cells, save for the segregation and medical units. All women in the general population are required to cohabitate, and that prison would be unable to provide a single-occupancy cell for Kosilek. She also explained that Kosilek's presence could create significant disruption in MCI-Framingham's population, given that Kosilek had been convicted for violently murdering her wife, and that a -31- significant portion of women at MCI-Framingham were victims of domestic abuse. Bissonnette acknowledged that there were procedures in place designed to help women cope with exposure to upsetting or traumatic experiences with other prisoners, but maintained that these security concerns would require that Kosilek, if transferred to MCI-Framingham, be housed in the segregated Close Custody unit. Bissonnette explained that she had significant hesitation about incarcerating anyone long-term in the Close Custody unit, given the potential negative effects of such long-term segregation. Commissioner Dennehy also testified. She described the security concerns arising from cross-gender housing as obvious to any experienced corrections officer. In line with her belief that the safety and security concerns about post-operative housing were clear, Dennehy stated that she would not feel comfortable allowing SRS -- even if mandated by the court -- if she could not identify an adequate method of safely housing Kosilek after her operation. Dennehy reiterated Spencer's and Bissonnette's concerns, stating that she deeply trusted both Superintendents' professional judgments regarding the security of housing Kosilek at their respective facilities. Dennehy also explained why reliance on an interstate compact to transfer Kosilek would be problematic. She emphasized that other states take prisoners on a fully voluntary -32- basis, and that no state may be willing or able to accommodate a transfer request for Kosilek. Commissioner Dennehy was also questioned about negative press surrounding the DOC's possible provision of SRS to Kosilek. Specifically, she was asked about her professional relationship with a state senator who had vocally opposed surgery and sponsored legislation to deny its provision. She was also asked about any contact with the then-lieutenant governor, who was another strong opponent of providing SRS to prisoners. Dennehy stated that she was aware of negative press reports and political opposition surrounding Kosilek's request, but that her decision not to provide SRS was based only on security concerns and had not been influenced by this public pressure. The district court recalled Dennehy on October 18, 2006, to ask additional questions regarding a growing amount of press coverage surrounding the case. Dennehy acknowledged that she was aware of significant news coverage of Kosilek's case, but denied personally following the story in the media. She explained that there were staff members within the DOC trained to deal with press inquiries and that she generally received only summaries of news coverage from her staff. Again, Dennehy strongly denied forming any opinion about correctional safety procedures based on media reports or public opinion. -33- b. Commissioner Clarke Dennehy ended her tenure as DOC Commissioner on April 30, 2007, and in November 2007 the position was filled by Harold Clarke. After Clarke took over, the district court requested that he familiarize himself with a selected number of trial transcripts. Clarke was ordered to file a report, on the basis of those transcripts, indicating whether he believed that the DOC had legitimate reasons to refuse Kosilek's request for SRS. Clarke's report, filed approximately a month after the district court's order, stated that his conclusions were based on more than three decades of correctional experience and were not influenced by political or media pressure. He expressed concern regarding threats of suicide being used as a means for prisoners to receive wanted benefits or concessions from staff. Finding it to be bad practice for prison administrators to give in to demands accompanied by the threat of suicide, Clarke stated that he believed the Massachusetts prison system had taken significant measures to ensure it was prepared to deal with suicidal ideation among its prison population. In addition to considering the issue of suicide, Clarke's report reemphasized the significant postoperative security concerns expressed by his predecessor. He stated that housing Kosilek at MCI-Norfolk created clear security concerns related to mixed-gender prison populations, while housing Kosilek at MCI-Framingham would pose a significant risk of -34- destabilizing that environment, given the number of women prisoners who were victims of domestic violence. Clarke also stated his belief that a separate unit to house GID prisoners was not feasible, given that prisoners with GID might have a wide range of security classifications and security needs, making cohabitation unsafe. In reference to the possibility of an interstate transfer, Clarke reiterated the concern that any interstate transfer would be completely voluntary and that a receiving state might later decide to return Kosilek, at which time the housing concerns would reemerge. Testifying before the court, Clarke acknowledged that he had received several letters from outraged state politicians claiming that provision of the surgery would be an affront to the taxpayers and citing state budget concerns as a reason to deny Kosilek surgery. The letters argued that a strained state budget should not be used to accommodate what the legislators believed to be an elective procedure and that the DOC would be unwise to provide it. Clarke, however, explained that he had not answered these letters, as he believed providing an answer would be inappropriate given his role as DOC Commissioner. He also denied being in any way influenced by cost concerns in reaching his conclusion regarding safety and security concerns. Clarke similarly testified that he was aware of media coverage regarding Kosilek's -35- request, but he had not personally viewed the news or heard the radio stories.