Opinion ID: 2761209
Heading Depth: 2
Heading Rank: 3

Heading: The Objective Prong: Serious Medical Need

Text: To sustain a claim under the objective prong of the Eighth Amendment, Kosilek must show that she has a serious medical need for which she has received inadequate treatment. See Estelle, 429 U.S. at 106; Sires, 834 F.2d at 13 (finding no Eighth Amendment violation where the prisoner failed to present[] any evidence of a serious medical need that has gone unmet); see also Derbes, 369 F.3d at 583 (a prison's constitutional obligation to provide medical services does not require a perfect plan for every inmate); DeCologero, 821 F.2d at 42 ([T]hough it is plain that an inmate deserves adequate medical care, he cannot insist that his institutional host provide him with the most sophisticated care that money can buy.). A significant risk of future harm that prison administrators fail to mitigate may suffice under the objective prong. Helling v. McKinney, 509 U.S. 25, 35 (1993); see also Baze v. Rees, 553 U.S. 35, 50 (2008) ([S]ubjecting individuals to a risk of future harm . . . can qualify as cruel and unusual punishment.); Roe v. Elyea, 631 F.3d 843, 858 (7th Cir. -45- 2011) ([T]he Eighth Amendment 'protects [an inmate] not only from deliberate indifference to his or her current serious health problems, but also from deliberate indifference to conditions posing an unreasonable risk of serious damage to future health.' (quoting Board v. Farnham, 394 F.3d 469, 479 (7th Cir. 2005))). That GID is a serious medical need, and one which mandates treatment, is not in dispute in this case. The parties do not spar over the fact that Kosilek requires medical care aimed at alleviating the harms associated with GID -- to the contrary, the DOC has provided such care since 2003. Rather, the parties disagree over whether SRS is a medically necessary component of Kosilek's care, such that any course of treatment not including surgery is constitutionally inadequate. The parties' disparate positions on this issue are fit for succinct summary. Kosilek argues that the only constitutionally sufficient treatment regimen is to adhere to the Standards of Care's triadic sequence in full, including the provision of SRS. Kosilek emphasizes that doctors at both UMass and Fenway Clinic -- doctors hired by the DOC -- confirmed at trial that SRS was medically necessary. The failure to provide treatment, these doctors testified, would almost certainly lead to a deterioration in Kosilek's mental state and a high likelihood of self-harming behaviors. In light of this risk, and given that they believed Kosilek had successfully met all eligibility criteria for SRS, -46- these doctors believed that any course of treatment excluding SRS is insufficient to treat Kosilek's GID. In contrast, the DOC argues that full progression through the Standards of Care's triadic sequence is not the only adequate treatment option, as Kosilek's GID may be appropriately managed with treatment short of SRS. The DOC maintains that the evidence does not meet the standards for negligent treatment of a medical condition, much less the higher Eighth Amendment standard. See Estelle, 429 U.S. at 106 (Thus, a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim of medical mistreatment under the Eighth Amendment.); Watson, 984 F.2d at 540 (stating that simple medical malpractice does not rise[] to the level of cruel and unusual punishment). Relying on the advice of accredited medical professionals, the DOC argues that its alternative course of treatment -- which provides Kosilek such alleviative measures as psychotherapy, hormones, electrolysis, and the provision of female garb and accessories -- is sufficient to treat Kosilek's GID and far exceeds a level of care that would be so inadequate as to shock the conscience. See Torraco, 923 F.2d at 235 (quoting Sires, 834 F.2d at 13). Moreover, this course of treatment has, in practice, greatly diminished Kosilek's mental distress and allowed her a fair measure of contentment. Should suicidal ideation arise -47- in the future, the DOC contends that -- based on the advice of its medical experts and its own penological experience -- it would be able to address that future risk appropriately through psychotherapy and antidepressants. We begin by discussing the district court's conclusions regarding the objective prong. We then examine de novo the question whether the treatment offered was constitutionally adequate. 1. The district court's medical prudence determination The district court ruled that SRS was a medically necessary treatment, and that Dr. Schmidt's alternative belief was outside the bounds of medical prudence.9 However, the court's finding that Dr. Schmidt's views were medically imprudent was based on several erroneous determinations. First, the court ruled that, unlike prudent medical professionals, Dr. Schmidt did not follow the Standards of Care in his treatment of GID. This finding ignored critical nuance in Dr. Schmidt's testimony and based its conclusion on a severely strained reading of Dr. Levine's expert testimony. 9 For the sake of clarity, we reiterate that medical imprudence -- without more -- is insufficient to establish an Eighth Amendment violation. See Estelle, 429 U.S. at 105-06; Watson, 984 F.2d at 540. Instead, a prisoner must satisfy both prongs of the Eighth Amendment inquiry, proving that the level of care provided is sufficiently harmful to evidence deliberate indifference to serious medical needs. Estelle, 429 U.S. at 106. -48- As an initial matter, the Standards of Care themselves admit of significant flexibility in their interpretation and application. They state, for example, that [t]he Standards of Care [a]re Clinical Guidelines and are intended to provide flexible directions to medical professionals in crafting treatment plans. Standards of Care at 1 (emphases added). The Standards of Care also specifically warn that [a]ll readers should be aware of the limitations of knowledge in this area. Standards of Care at 1. Individual professionals and organized programs, the Standards of Care continue on, may modify [the standards] as appropriate. Id. at 2. Dr. Levine's testimony acknowledged this flexibility: [DR. LEVINE]: [T]he Standards of Care was a consensus document from people from seven different countries or something, you know, who come from different systems, and it was a political process that forged together a set of standards . . . . So prudent is a wonderful word, but it's not like it has one simple definition. . . . THE COURT: But is this an area in which you think prudent professionals can reasonably differ as to what is at least minimally adequate treatment for this condition? [DR. LEVINE]: Yes, and do. Moreover, the district court put great weight on the fact that the Standards of Care require that patients receive two letters of recommendation prior to SRS. The court concluded, -49- therefore, that prudent professionals who treat individuals suffering from severe gender identity disorders write such letters of recommendation, and it faulted Dr. Schmidt as imprudent for his failure to engage in this practice. In so doing, the court relied on Dr. Levine's testimony, which it believed stated that a prudent professional would not [refuse] to write letters of recommendation. Dr. Schmidt's testimony, however, makes clear that although he does not advocate or recommend surgery to his patients, if a patient chooses to seek SRS, he releases all of their medical files to a surgeon and writes that surgeon a letter confirming that the patient is eligible for surgery. Insofar as Dr. Schmidt had not advocated for the surgery, this neutrality aligns with what Dr. Levine describes as the accepted practice for doctors in the treatment of GID: [i]f the patient meets eligibility requirements . . . we then write a letter of support . . . I understand how others may perceive this as a recommendation . . . [but] we tell ourselves we are opening a gate to their decision. Therefore, whatever the semantic force of the district court's distinction, we see no material difference between the letters written by Dr. Schmidt confirming a patient's readiness for surgery and what the Standards of Care refers to as a letter of recommendation. The district court next concluded that Dr. Schmidt was imprudent because antidepressants and psychotherapy alone are -50- inadequate to treat GID. Again, the court claimed that it relied on the testimony of Dr. Levine, but misconstrued his testimony in support of its conclusion. Dr. Levine did in fact state that gender dysphoria is not significantly ameliorated . . . by treating [patients] with a prozac-like drug alone. He continued on, however, to explain that he did not believe this was the treatment plan advocated by Dr. Schmidt or the DOC. To the contrary, he understood that Kosilek would continue to receive ameliorative treatment for her GID and, if she entered a depressive or suicidal state based on her inability to receive SRS, antidepressants and psychotherapy would be used to help stabilize her mental state so as to alleviate the risk of suicide while working with her to craft new perspectives and life goals beyond surgery. He felt that the treatment might well be successful in this capacity, when combined with the direct alleviative treatments currently provided. Finally, the district court found Dr. Schmidt imprudent because he did not believe that a real-life experience could occur in prison, given that it was an isolated, single-sex environment. The district court disagreed, stating that it had concluded a reallife experience could occur in prison, as Kosilek would remain incarcerated for her entire life. In reaching this determination, the court made a significantly flawed inferential leap: it relied on its own -- non-medical -- judgment about what constitutes a -51- real-life experience to conclude that Dr. Schmidt's differing viewpoint was illegitimate or imprudent. Prudent medical professionals, however, do reasonably differ in their opinions regarding the requirements of a real-life experience -- and this reasonable difference in medical opinions is sufficient to defeat Kosilek's argument. Cf. Bismark v. Fisher, 213 F. App'x 892, 897 (11th Cir. 2007) (Nothing in our case law would derive a constitutional deprivation from a prison physician's failure to subordinate his own professional judgment to that of another doctor . . . .); Estate of Cole by Pardue v. Fromm, 94 F.3d 254, 261 (7th Cir. 1996); Bowring v. Godwin, 551 F.2d 44, 48 (4th Cir. 1977). In fact, Dr. Levine noted that an incarcerative environment might well be insufficient to expose Kosilek to the variety of societal, familial, and vocational pressures foreseen by a real-life experience. This viewpoint aligned with that of Dr. Schmidt and Osborne. And, although Dr. Forstein's written report appears to presume Kosilek had completed a real-life experience, it echoed this same point: being in prison has helped [Kosilek] consolidate her desire . . . simplifying the issues, without the stressors and choices that she would have had to make out in the outside real world. We find no support for the district court's conclusion that no reasonable medical expert could opine that Kosilek lacked real-life experience, particularly in light of the contrary testimony from medical experts concerning the range of -52- social, environmental, and professional considerations that are necessary to constitute a real-life experience under the Standards of Care. The district court thus erred by substituting its own beliefs for those of multiple medical experts.10 The district court's finding of medical imprudence relied heavily on inferences we do not believe can rightly be drawn from Dr. Levine's testimony; this finding also ignored significant contrary evidence regarding the breadth and variety of acceptable treatments for GID within the medical community.11 Its conclusion that the Fenway Center's recommendation constituted the sole acceptable treatment plan is, thus, contradicted by the record. 10 There are obvious reasons for the range of judgments in this area. Although the medical experts disagreed over whether experience in a prison setting could qualify as real-life experience, none of the experts who opined that it could do so appear to have considered the fact that after SRS, Kosilek would most likely be housed in the drastically different setting of a female facility. This distinction was reflected in Dr. Forstein's report, which stated that [Kosilek's] 'real life experience' leads her to the conclusion that so long as she is in a male prison . . . she cannot perceive herself as a true woman. This statement acknowledges that any real-life experience available to Kosilek was shaped by her current, all-male prison environment. Kosilek introduced no evidence to show that her experience there would satisfy the requirement that she have real-life experience in her post-operative housing environment. 11 The district court ignored or minimized significant portions of Dr. Levine's testimony on the theory that the doctor had based his evaluation of medical prudence on the erroneous assumption[] that Kosilek may not have had a real-life experience in prison and faced no other extrinsic obstacles to surgery. As explained above, in doing so the court improperly supplanted a question of medical opinion -- on which experts may differ -- with its own decision based on a layman's view, and terming all contrary views imprudent. -53- 2. Adequacy of the DOC's treatment plan Regarding the medical adequacy of Kosilek's treatment, the district court held that psychotherapy and antidepressants alone would not adequately treat Kosilek's GID. This finding mischaracterizes the issues on appeal and unduly minimizes the nature of the DOC's preferred treatment plan. The DOC does not claim that treating Kosilek's GID merely with therapy and antidepressants alone would constitute adequate care. Cf. Fields v. Smith, 653 F.3d 550, 556 (7th Cir. 2011) (accepting, in the absence of contrary evidence, expert testimony that psychotherapy as well as antipsychotics and antidepressants . . . do nothing to treat the underlying disorder [of GID]). In fact, since Kosilek I the DOC has acknowledged the need to directly treat Kosilek's GID. Beginning in 2003, it has provided hormones, electrolysis, feminine clothing and accessories, and mental health services aimed at alleviating her distress. The parties agree that this care has led to a real and marked improvement in Kosilek's mental state. There is also no dispute that this care would continue, whether or not SRS is provided. The question before our court, therefore, is not whether antidepressants and psychotherapy alone are sufficient to treat GID, or whether GID constitutes a serious medical need. Rather, the question is whether the decision not to provide SRS -- in light of the continued provision of all ameliorative measures currently -54- afforded Kosilek and in addition to antidepressants and psychotherapy -- is sufficiently harmful to Kosilek so as to violate the Eighth Amendment. It is not. See Smith v. Carpenter, 316 F.3d 178, 186 (2d Cir. 2003) ([I]t's the particular risk of harm faced by a prisoner due to the challenged deprivation of care, rather than the severity of the prisoner's underlying medical condition, considered in the abstract, that is relevant for Eighth Amendment purposes.); see also Estelle, 429 U.S. at 106 (requiring proof of acts or omissions sufficiently harmful as to illustrate deliberate indifference to a serious medical need); Estate of Bearden ex rel. Bearden v. Anglin, 543 F. App'x 918, 921 (11th Cir. 2013); Leavitt, 645 F.3d at 497. Kosilek admits that the DOC's current treatment regimen has led to a significant stabilization in her mental state. Kosilek's doctors testified to the same, highlighting her joy around being feminized. This claim is also borne out by the passage of significant time since she exhibited symptoms of suicidal ideation or attempted to self-castrate. In addition to alleviating her depressive state, this treatment has also resulted in significant physical changes and an increasingly feminine appearance. The significance of a future risk of suicidality is not one that this court takes lightly, and Kosilek is right to note that a clear risk of future harm may suffice to sustain an Eighth -55- Amendment claim. See Helling, 509 U.S. at 35 (determining that an unreasonable risk of future harm may amount to an Eighth Amendment violation); Baze, 553 U.S. at 49; Roe, 631 F.3d at 858. Nonetheless, the risk of suicidal ideation is born from Kosilek's GID-related mental distress. Therefore an assessment of the gravity of that risk, and its appropriate treatment, must encompass the entirety of the DOC's treatment plan, not merely the potential addition of psychotherapy and antidepressants. Kosilek is provided hormones, facial hair removal, feminine clothing and accessories, and access to regular mental health treatment. The DOC also stands ready to protect Kosilek from the potential for self-harm by employing its standard and accepted methods of treating any prisoner exhibiting suicidal ideation. Trial testimony established that this plan offers real and direct treatment for Kosilek's GID. It employs methods proven to alleviate Kosilek's mental distress while crafting a plan to minimize the risk of future harm. See Carpenter, 316 F.3d at 186. It does not wantonly disregard Kosilek's needs, but accounts for them. See Torraco, 923 F.2d at 235. The law is clear that where two alternative courses of medical treatment exist, and both alleviate negative effects within the boundaries of modern medicine, it is not the place of our court to second guess medical judgments or to require that the DOC adopt the more compassionate of two adequate options. Layne v. -56- Vinzant, 657 F.2d 468, 474 (1st Cir. 1981) (quoting Westlake v. Lucas, 537 F.2d 857, 860 n.5 (6th Cir. 1976)); Bismark, 213 F. App'x at 897; Medrano v. Smith, 161 F. App'x 596, 599 (7th Cir. 2006); Sanchez v. Vild, 891 F.2d 240, 242 (9th Cir. 1989); Bowring, 551 F.2d at 48. That the DOC has chosen one of two alternatives -- both of which are reasonably commensurate with the medical standards of prudent professionals, and both of which provide Kosilek with a significant measure of relief -- is a decision that does not violate the Eighth Amendment.12 Kosilek warns, however, that upholding the adequacy of the DOC's course of treatment in this case -- despite her medical 12 This holding in no way suggests that correctional administrators wishing to avoid treatment need simply to find a single practitioner willing to attest that some well-accepted treatment is not necessary. We do not establish here a per se rule allowing a dissenting medical opinion to carry the day. Rather, our determination is limited to the particular record on appeal, which involves a medical condition that admits of a number of valid treatment options. This fact was testified to by Dr. Levine, recognized by the UMass doctors in their correspondence with the DOC, and corroborated by Dr. Forstein in his written report. The DOC did not engage in a frenzy of serial consultations aimed at finding the one doctor out of a hundred willing to testify that SRS was not medically necessary. Rather, it made a considered decision to seek out a second opinion from an expert previously considered in its initial selection process. Our opinion rests on the facts presented in this record, and we find merely that the regimen of care provided by the DOC -- which includes hormonal treatments as well as feminine products, clothing, and hair removal, and which has successfully alleviated the severity of a prisoner's distress -- is not sufficiently harmful to Kosilek to constitute an Eighth Amendment violation. -57- history and record of good behavior -- will create a de facto ban against SRS as a medical treatment for any incarcerated individual. We do not agree. For one, the DOC has specifically disclaimed any attempt to create a blanket policy regarding SRS. We are confident that the DOC will abide by this assurance, as any such policy would conflict with the requirement that medical care be individualized based on a particular prisoner's serious medical needs. See, e.g., Roe, 631 F.3d at 862-63 (holding that the failure to conduct an individualized assessment of a prisoner's needs may violate the Eighth Amendment). For another, this case presents unique circumstances; we are simply unconvinced that our decision on the record before us today will foreclose all litigants from successfully seeking SRS in the future. Certain facts in this particular record -- including the medical providers' non-uniform opinions regarding the necessity of SRS, Kosilek's criminal history, and the feasibility of postoperative housing -- were important factors impacting the decision. D. The Subjective Prong: Deliberate Indifference
The subjective element of an Eighth Amendment claim for injunctive relief requires not only that Kosilek show that the treatment she received was constitutionally inadequate, but also that the DOC was -- and continues to be -- deliberately indifferent -58- to her serious risk of harm. See Farmer, 511 U.S. at 844-45.13 On the record presented, this is a burden Kosilek cannot meet. Even if the district court had been correct in its erroneous determination that SRS was the only medically adequate treatment for Kosilek's GID, the next relevant inquiry would be whether the DOC also knew or should have known this fact, but nonetheless failed to respond in an appropriate manner. See Wilson v. Seiter, 501 U.S. 294, 298 (1991). In answering this question, it is not the district court's own belief about medical necessity that controls, but what was known and understood by prison officials in crafting their policy. Id. at 300 (requiring a showing of purposefulness or intent on the part of prison administrators). In this case, the DOC solicited the opinion of multiple medical professionals and was ultimately presented with two alternative treatment plans, which were each developed by different medical experts to mitigate the severity of Kosilek's mental distress. The choice of a medical option that, although disfavored by some in the field, is presented by competent professionals does 13 Although the DOC has not specifically argued that the conflicting medical opinions preclude a finding of subjective deliberate indifference, we do not find this argument waived. As we have explained above, the subjective and objective analyses overlap. See supra note 7; see also Leavitt, 645 F.3d at 498. The DOC's contention that the district court erred in deeming SRS medically necessary and in rejecting Dr. Schmidt's approach as imprudent necessarily entails the DOC's subjective belief that SRS was unnecessary. The contrary position -- i.e., that SRS is not objectively necessary but that the DOC did not disagree as to the need for SRS -- would be wholly illogical. -59- not exhibit a level of inattention or callousness to a prisoner's needs rising to a constitutional violation.14 Cf. Torraco, 923 F.2d at 234 ([T]his court has hesitated to find deliberate indifference to a serious need '[w]here the dispute concerns not the absence of help, but the choice of a certain course of treatment,' [but] deliberate indifference may be found where the attention received is 'so clearly inadequate as to amount to a refusal to provide essential care.' (internal citations omitted)). Moreover, a later court decision -- ruling that the prison administrators were wrong in their estimation of the treatment's reasonableness -- does not 14 If the prison itself should have been aware that some of the medical advice it was receiving was imprudent -- that is, if any layperson could have realized that the advice was imprudent -- then the decision to still follow that advice may qualify as deliberate indifference. See Farmer, 511 U.S. at 846 n.9 (If, for example, the evidence before a district court establishes that an inmate faces an objectively intolerable risk of serious injury, the defendants could not plausibly persist in claiming lack of awareness . . . .); Hadix v. Johnson, 367 F.3d 513, 526 (6th Cir. 2004) (If [the challenged prison conditions] are found to be objectively unconstitutional, then that finding would also satisfy the subjective prong because the same information that would lead to the court's conclusion was available to the prison officials.). The facts of this case, however, are highly distinct from such a scenario. Nor did the district court's conclusion render the DOC's continued refusal to provide SRS deliberately indifferent. On the contrary, the evidence was conflicting as to the medical need for SRS. The choice between reasonable medical views was not for the district court to make, and the DOC remained entitled to reasonably rely on Schmidt's and Osborne's expert opinions. Moreover, even assuming arguendo that the DOC was on notice that its treatment was insufficient, the DOC's continued refusal also rested on valid security concerns, discussed below, such that its actions did not amount to deliberate indifference in any event. -60- somehow convert that choice into one exhibiting the sort of obstinacy and disregard required to find deliberate indifference. Cf. Nadeau v. Helgemoe, 561 F.2d 411, 417 (1st Cir. 1977) (refusing to substitute the values and judgment of a court for the values and judgment of the . . . prison administration).
The subjective prong also recognizes that, in issues of security, [p]rison administrators . . . should be accorded wideranging deference in the adoption and execution of policies and practices that in their judgment are needed to preserve internal order and discipline and to maintain institutional security. Bell, 441 U.S. at 547. Although we cannot abdicate our responsibility to ensure that the limits imposed by the Constitution are not ignored, Blackburn v. Snow, 771 F.2d 556, 562 (1st Cir. 1985), we do not sit to substitute our own judgment for that of prison administrators, see Nadeau, 561 F.2d at 417. As long as prison administrators make judgments balancing security and health concerns that are within the realm of reason and made in good faith, their decisions do not amount to a violation of the Eighth Amendment. Battista, 645 F.3d at 454. The DOC officials explained that they believed SRS would create new security issues, the most significant being the provision of safe housing options for Kosilek after her surgery. They further explained the importance of keeping other inmates from -61- believing that they could use threats of suicide to extract concessions from the prison administration. Nonetheless, rather than deferring to the expertise of prison administrators, the district court ignored the DOC's stated security concerns, reasoning both that Kosilek could be housed safely and that the DOC had not acted out of a legitimate concern for Kosilek's safety and the security of the DOC's facilities. As explained below, this was in error.
were reasonable Recognizing that reasonable concerns would arise regarding a post-operative, male-to-female transsexual being housed with male prisoners takes no great stretch of the imagination. See Farmer, 511 U.S. at 848-49 (summarizing evidence that a prison's refusal to provide segregated housing to a pre-operative male-to-female transsexual could pose significant security concerns). At the same time, as particularly relevant in Kosilek's case, the DOC's security report reflected that significant concerns would also arise from housing a formerly male inmate -- with a criminal history of extreme violence against a female domestic partner -- within a female prison population containing high numbers of domestic violence survivors. Nonetheless, in dismissing the DOC's concerns, the district court relied heavily on the fact that security issues have not yet arisen within MCI-Norfolk's general population. Rejecting the testimony of multiple -62- individuals with decades of penological experience -- all of whom acknowledged the risk of housing a female prisoner at MCI-Norfolk -- the district court reasoned that Kosilek's past safety was indicative of a likelihood that she could reside safely at the prison after her operation. This reasoning wrongly circumvents the deference owed to prison administrators: the appropriate inquiry was not whether the court believed that Kosilek could be housed safely, but whether the DOC has a reasoned basis for its stated concerns. Indeed, that Kosilek had so far been safe within MCI-Norfolk's prison population does not negate the DOC's well-reasoned belief that safety concerns would arise in the future after SRS. Cf. Jones v. N.C. Prisoners' Labor Union, 433 U.S. 119, 132-33 & n.9 (1977) (holding, in the First Amendment context, that the rights of prisoners may be abridged based on a reasonable belief that future harm or disruption may occur); cf. Hudson v. Palmer, 468 U.S. 517, 526-27 (1984) (requiring prison administrators to implement prophylactic solutions to foreseeable security issues reasonably within the scope of their expertise). Moreover, the fact that, preoperatively, Kosilek has not been subject to assault or threats does not vitiate the concern that she would be victimized after receiving SRS.15 15 These concerns were obvious to more than just those individuals within the DOC with significant penological experience. The likelihood that issues surrounding secure housing would arise after -63- The district court also reasoned that the DOC [could] reasonably assure the safety of Kosilek and others after sex reassignment surgery by housing Kosilek in a segregated protective custody unit. It then noted, however, that there existed a strong argument that such isolation would amount to a form of extrajudicial punishment that is prohibited by the Eighth Amendment. This warning echoes the very concerns highlighted by the DOC, which expressed disagreement with the use of long-term isolation as a housing solution for Kosilek, based on its potential negative effects on her mental health. See also Battista, 645 F.3d at 454 (explaining that creating a segregated treatment center to house a GID prisoner would pose administrative difficulties and be isolating). The deference awarded to prison administrators cannot be defeated by such circular reasoning, which dismisses the DOC's concern in one breath only to recognize its validity in the next. The prison administrators in this case have decades of combined experience in the management of penological institutions, and it is they, not the court, who are best situated to determine what security concerns will arise. See Bell, 441 U.S. at 548 ([J]udicial deference is accorded [in part] because the administrator ordinarily will . . . have a better grasp of his domain than the reviewing judge . . . .). The DOC's judgment SRS was also acknowledged by Kosilek's treating psychologist, Mark Burrows, and by the Fenway Center doctors in their initial report. -64- regarding post-operative housing is without doubt within the realm of reason, Battista, 645 F.3d at 454, and the district court's alternative belief as to the possibility of safely housing Kosilek does not suffice to undermine this reasonableness. The DOC officials also expressed concern that providing Kosilek SRS would incentivize the use of suicide threats by prisoners as a means of receiving desired benefits. Although the district court determined that, in this case, Kosilek's risk for suicidal ideation was very real, this finding does not invalidate the DOC's reasonable belief that providing SRS might lead to proliferation of false threats among other prisoners. The DOC's concern -- regarding the unacceptable precedent that would be established in dealing with future threats of suicide by inmates to force the prison authorities to comply with the prisoners' particular demands -- cannot be discounted as a minor or invalid claim. Such threats are not uncommon in prison settings and require firm rejection by the authorities, who must be given ample discretion in dealing with such situations. Given the circumstances presented here, we cannot say that the DOC lacks reasonable security concerns.
about safety and security The district court ultimately dismissed the DOC's concerns as pretextual, reasoning that DOC was in fact acting in response to public and political criticism. The primary evidence -65- on record tending to support this theory includes a press interview by Commissioner Dennehy, Dennehy's relationships with a state senator and the lieutenant governor, and the acknowledgment that the DOC was aware of negative news coverage regarding Kosilek's request for surgery. In her testimony, Dennehy denied being influenced by such media and political pressures, and stated that the decision not to provide SRS was founded in bona fide security concerns alone. The district court, however, found this testimony non-credible, and this credibility finding is the sort of determination to which our court gives deference. See Fed. R. Civ. P. 52(a)(6). Even accepting that Dennehy's motivations were colored by political and media pressure, however, does not take Kosilek's claim as far as it needs to go. As an initial matter, the fact that Dennehy was motivated in part by concerns unrelated to prison security does not mean that the security concerns articulated by the DOC were irrelevant, wholly pretextual, or -- most importantly -- invalid on the merits. In Battista, our court held that deference to the decisions of prison administrators could be overcome where those administrators admittedly relied on inflated data, identified a security concern only several years after refusing to provide treatment for an acknowledged medical need, and engaged in a pattern of changing positions and arguments before the court. Battista, 645 F.3d at -66- 455. Such gross delays and misstatements were not present here.16 Rather, the DOC testified consistently that it believed the postoperative security concerns surrounding Kosilek's treatment were significant and problematic.17 Even if not entitled to deference, see id., those concerns still matter insofar as they are reasonable and valid, and Kosilek did not put on any evidence showing that they wholly lacked merit.18 16 Great weight was placed on the fact that Dennehy told a reporter that there were significant security concerns about post-operative housing three days before she met with Superintendents Spencer and Bissonnette. The record reveals, however, that discussions about housing had previously occurred at Executive Staff Meetings, and Dennehy testified that she had conducted phone calls with both Superintendents prior to meeting to formalize their security report. This timeline, therefore, is far from sufficient to establish that the DOC's security assessments were unprincipled or invalid. 17 That the DOC may have, in the district court's assessment, engaged in a pattern of prevarication regarding whether they understood that SRS was being recommended by UMass as medically necessary, does not undercut the consistency with which they identified safety and security concerns -- concerns which are within their expert province -- that would arise from the surgery. 18 Kosilek did cross-examine Commissioner Clarke to show that a transgendered prisoner had safely been housed in a Washington State prison under his supervision. Left unexplored, however, were the numerous ways in which MCI-Norfolk's environment, facilities, or population might be distinct from this prison in Washington. Neither was there a comparison between that prisoner's criminal history and the criminal history of Kosilek. That an individual was housed safely by Commissioner Clarke while employed in another state does not rebut Superintendent Bissonnette's testimony that moving her to MCI-Framingham would cause climate problems in that particular prison. See Feeley v. Sampson, 570 F.2d 364, 371 (1st Cir. 1978) (rejecting uniform housing conditions for detainees, without regard to their disparate criminal history, because Constitutional rights cannot be defined in terms of literal comparisons of this nature). -67- Second, when determining the appropriateness of injunctive relief, our focus must include current attitudes and conduct. Farmer, 511 U.S. at 845 ('[D]eliberate indifference[] should be determined in light of the prison authorities' current attitudes and conduct': their attitudes and conduct at the time suit is brought and persisting thereafter. (quoting Helling, 509 U.S. at 36)). Dennehy has not served as DOC Commissioner since 2007. Given the age of this litigation and the changes in DOC leadership that have occurred since the suit was filed, the district court's assumption that Dennehy's attitudes necessarily carried over to her successors and governed their actions is unsupported by the record. Although consideration of Dennehy's motivation is surely relevant, it is insufficient to show that the DOC continued to be motivated by public pressure even after her departure, or that this is what motivates the DOC presently. Indeed, it was Commissioner Clarke -- and not Dennehy -- who made the decision here. And the only evidence tending to show that Commissioner Clarke may have considered public and political criticism were two letters received by Clarke -- who did not respond -- from Massachusetts legislators. These letters, however, relate almost in their entirety to concerns about the cost of SRS, and the district court soundly rejected any argument that the DOC, or Clarke specifically, had adopted its safety and security measures as a pretextual means of addressing the cost concerns -68- raised by state legislators. Moreover, Clarke was never found by the court to be noncredible.19 The district court improperly imputed its belief that Commissioner Dennehy had acted out of concern for public and political pressure to its assessment of the motivations of future DOC Commissioners. This error ignores the requirement, in cases of injunctive relief, that a court consider the attitudes and beliefs of prison administrators at the time of its decision. Id. at 84546. The effect of this error is particularly clear given that Clarke has now been replaced by Commissioner Spencer, so that Dennehy is now several administrations and more than seven years removed from the decisionmaking process. Without proof that the DOC remains motivated by pretextual or improper concerns with public pressure, even if it was assumed that Dennehy was improperly motivated, the district court's finding that injunctive relief was required is unsupportable.