Court Opinion

ID: 4293045
Source: CourtListenerOpinion
Date Created: 2018-07-10 22:00:24.282314+00
Date Added: 2024-06-11T14:39:14.713931
License: Public Domain

In the

    United States Court of Appeals
                    For the Seventh Circuit
                         ____________________
No. 16-3350
LISA MITCHELL,
                                                       Plaintiff-Appellant,
                                      v.

KEVIN KALLAS, et al.,
                                                    Defendants-Appellees.
                         ____________________

           Appeal from the United States District Court for the
                     Western District of Wisconsin.
              No. 15-cv-108 — William M. Conley, Judge.
                         ____________________

     ARGUED JANUARY 10, 2018 — DECIDED JULY 10, 2018
                ____________________

   Before WOOD, Chief Judge, HAMILTON, Circuit Judge, and
BUCKLO, District Judge. *
    WOOD, Chief Judge. Lisa Mitchell is a transgender person
who has identiﬁed as a woman her entire life. After an arrest
in Wisconsin, oﬃcials from the state’s Department of Correc-
tions (“DOC”) repeatedly prevented Mitchell from obtaining

   *Of   the Northern District of Illinois, sitting by designation.
2                                                   No. 16-3350

access to the treatments she needed to express her gender
identity. It took DOC over a year to evaluate Mitchell’s candi-
dacy for hormone therapy, and even then, nothing happened.
Instead, DOC refused to provide Mitchell with the treatment
its own expert recommended, on the ground that Mitchell
was within a month of release from the prison. Although
DOC’s Mental Health Director, Dr. Kevin Kallas, encouraged
Mitchell to ﬁnd a community provider to prescribe her hor-
mones, DOC parole oﬃcers prevented Mitchell from follow-
ing this advice. Still under state custody, the terms of Mitch-
ell’s parole actually prohibited her from taking hormones or
dressing as a woman.
    Mitchell sued, contending that the prison doctors and the
parole oﬃcers violated her constitutional rights. It is well es-
tablished that persons in criminal custody are entirely de-
pendent on the state for their medical care. Estelle v. Gamble,
429 U.S. 97, 103 (1976). Prison oﬃcials thus have a constitu-
tional duty to provide inmates with the care they require for
their serious medical needs. Prison staﬀ cannot bide their time
and wait for an inmate’s sentence to expire before providing
necessary treatments. This aﬃrmative obligation ends when
imprisonment does, but state oﬃcials may not block a parolee
from independently obtaining health care. The only limitation
is that the condition be serious enough to trigger constitu-
tional protection; otherwise the nature of the disorder is irrel-
evant. Because the district court prematurely rejected some of
Mitchell’s claims, we reverse in part.
                                I
    In 2008, Mitchell received a diagnosis of gender dyspho-
ria. A few years later, she was convicted of a crime and sent
to Wisconsin’s Columbia Correctional Institution on October
No. 16-3350                                                    3

11, 2011, to serve her sentence. On November 25, 2011, Mitch-
ell asked for hormone treatment. Her request initiated a mul-
tistep process that DOC outlined in its then-new policy on
Health Care Treatment of Gender Identity Disorder. That pol-
icy was ﬁrst implemented on December 19, 2011. Step one un-
der the policy required Mitchell’s clinician to conduct a pre-
liminary assessment. She did so, producing a written report
about Mitchell on February 10, 2012. Next, the Gender Dys-
phoria Committee reviewed the report and decided to refer
Mitchell’s request for hormone therapy to its outside consult-
ant, Cynthia Osborne. Osborne is a social worker and assis-
tant professor at Johns Hopkins University, in Maryland; she
specializes in providing gender-dysphoria evaluations. Since
Osborne visited the Wisconsin facilities roughly every two
months, Dr. Kallas informed Mitchell that she would meet
with Osborne in April. That interview did not occur until May
22, 2012, however, nearly six months after Mitchell’s initial re-
quest for care.
    During the months leading up to and following the inter-
view, Mitchell repeatedly inquired about her health care re-
quest. She asked Dr. Dawn Laurent, the prison’s Psychologi-
cal Services Unit Supervisor, for an update on April 8, 2012.
Dr. Laurent did not respond. Instead, Mitchell’s assigned cli-
nician wrote back, promising to follow up. Mitchell also wrote
letters to Dr. Kallas. In his October 8 reply, Dr. Kallas in-
formed Mitchell that Osborne’s report was “nearly complete”
and should be ﬁnished “in a matter of days.” He explained
that Osborne was just trying to get in touch with two people
whom Mitchell named as references. Dr. Kallas recognized
that “considerable time ha[d] passed” and thanked Mitchell
for her patience.
4                                                  No. 16-3350

    The long delay was not cost-free for Mitchell. While she
waited, her psychological health was deteriorating. In
May 2012, she reported feeling unsafe with silverware. A cli-
nician’s notes from July reﬂect that she was “not doing well
regarding gender identity disorder issues.” Though she was
receiving periodic counseling services, the notes from these
sessions suggest that they focused on her other mental health
conditions, such as her post-traumatic stress (the result of a
violent hate crime committed against her when she was 18).
To the extent Mitchell’s gender dysphoria was discussed, the
notes primarily refer to the harassment Mitchell experienced
and her desire to know the status of her treatment request.
    Osborne did not submit a draft of her report until Novem-
ber 15, 2012. Curiously, the report was dated September 27.
Mitchell received a copy of the draft on November 28, and the
report was ﬁnalized on December 2. Though Osborne’s con-
clusions came a full year after Mitchell asked for hormone
treatment, her recommendations strongly supported Mitch-
ell’s request. Osborne concluded that Mitchell “is an excellent
candidate for hormone therapy” and predicted that this treat-
ment would very likely improve Mitchell’s “functional stabil-
ity and sense of psychological well-being.” Osborne expected
that hormones would help not only with Mitchell’s gender
dysphoria, but also with her post-traumatic stress as well.
     Based on Osborne’s unequivocal recommendation, Mitch-
ell resubmitted her request for hormone therapy the same day
that she reviewed the draft report. Dr. Kallas turned her down
on January 2, 2013. His letter explained that she was not eligi-
ble for treatment because she was scheduled to be released
that month. As a “point of information,” Dr. Kallas said, DOC
starts inmates on hormone therapy only when they have at
No. 16-3350                                                  5

least six months left on their sentences, in order to allow for
the several-month process of getting the person stabilized on
the medication. Dr. Kallas encouraged Mitchell to seek hor-
mone treatment upon her release; he even oﬀered a copy of
Osborne’s report and information about community provid-
ers.
   But Mitchell was thwarted again after her release on Janu-
ary 8, 2013. When she tried to follow up on Dr. Kallas’s sug-
gestion, her parole oﬃcers ﬂatly forbade her from seeking
hormone therapy. Indeed, as a condition of her parole, she
was required to dress and present as a man. Though Mitchell
provided the agents with a copy of Osborne’s report and rec-
ommendations, the oﬃcers did not relent.
    On February 18, 2015, Mitchell ﬁled a pro se complaint in
federal court against Dr. Kallas, Dr. Laurent, and DOC parole
oﬃcers Joseph Ruhnke, Brittany Wolfe, and Nicole Raisbeck.
(Mitchell also initially sued two DOC Secretaries, but she has
not appealed the dismissal of these defendants.) The district
court understood the suit as one under 42 U.S.C. § 1983 alleg-
ing deliberate indiﬀerence to a serious medical need. As re-
quired by the Prison Litigation Reform Act (PLRA), the court
began by screening Mitchell’s complaint. 28 U.S.C.
§ 1915A(a). It concluded that Mitchell failed to state a claim
against the parole oﬃcers under the Eighth Amendment (as
applied to the states through the Fourteenth Amendment),
and so it dismissed them without prejudice. Though the court
allowed the claims against Drs. Kallas and Laurent to pro-
ceed, it later granted summary judgment for them. It deter-
mined that neither one was deliberately indiﬀerent to Mitch-
ell’s gender dysphoria, and regardless, both were entitled to
qualiﬁed immunity. Mitchell ﬁled an earlier appeal in which
6                                                  No. 16-3350

she challenged some aspects of her parole, but we dismissed
on the ground that it was moot. Mitchell v. Wall, 808 F.3d 1174
(7th Cir. 2015). The merits are now before us, and as there is
no mootness problem this time, we consider whether the dis-
trict court properly dismissed Mitchell’s claims.
                               II
    As we noted earlier, because a person is deprived of her
liberty while incarcerated, she “must rely on prison authori-
ties to treat [her] medical needs.” Gamble, 429 U.S. at 103. Un-
able to call her own doctor or walk into a hospital, an inmate
with medical problems will go without treatment unless the
prison provides care. If prison medical staﬀ exhibit deliberate
indiﬀerence to an inmate’s serious medical condition, they
subject her to unnecessary and wanton pain and suﬀering and
thereby run afoul of the Eighth Amendment. Id. at 104–05; Pet-
ties v. Carter, 836 F.3d 722, 727–28 (7th Cir. 2016) (en banc).
    The state defendants do not dispute that Mitchell’s gender
dysphoria is a serious medical condition or that she never re-
ceived hormones while in DOC custody. They maintain, how-
ever, that no jury could ﬁnd that they were deliberately indif-
ferent to her condition. To establish deliberate indiﬀerence, a
plaintiﬀ must show that the defendant “actually knew of and
disregarded a substantial risk of harm.” Petties, 836 F.3d at
728. Failing to provide care for a non-medical reason, when
that care was recommended by a medical specialist, can con-
stitute deliberate indiﬀerence. Perez v. Fenoglio, 792 F.3d 768,
778 (7th Cir. 2015). So too can inexplicable delays in treatment
where the delays serve no penological purpose. Petties,
836 F.3d at 730. The district court held that neither the 13-
month delay in evaluating Mitchell’s request nor its ultimate
denial constituted deliberate indiﬀerence. Moreover, the
No. 16-3350                                                    7

court determined, the defendants were entitled to qualiﬁed
immunity because there was no clearly established right to
hormone treatment when requested. We take a fresh look at
the district court’s conclusions, viewing the record in the light
most favorable to Mitchell. See Orlowski v. Milwaukee Cnty.,
872 F.3d 417, 421 (7th Cir. 2017); Zimmerman v. Doran, 807 F.3d
178, 182 (7th Cir. 2015).
                               A
    We start with Dr. Laurent. For a defendant to be liable un-
der section 1983, she must be personally responsible for the
alleged deprivation of the plaintiﬀ’s constitutional rights. Wil-
son v. Warren Cnty., 830 F.3d 464, 469 (7th Cir. 2016). The per-
sonal-involvement requirement is satisﬁed if the constitu-
tional violation occurs at a defendant’s direction or with her
knowledge or consent. Id. Here, the alleged deprivation of ad-
equate medical care occurred because of the time it took to
resolve Mitchell’s treatment request and the ultimate out-
come—rejection. Dr. Laurent was not a member of the Gender
Dysphoria Committee, nor did she take part in the decisions
to get a consultation from Osborne or to deny Mitchell’s re-
quest for hormones.
    Nonetheless, Dr. Laurent may be liable under section 1983
if she acquiesced in the failure to provide necessary medical
treatment. Minix v. Canarecci, 597 F.3d 824, 833–34 (7th Cir.
2010). Dr. Laurent was the psychological services supervisor
at the prison where Mitchell was housed. In that role, she
signed treatment notes from sessions where Mitchell com-
plained about her distress and the harassment she experi-
enced as a result of her gender dysphoria. Though Dr. Lau-
rent was not Mitchell’s assigned clinician, she did meet with
Mitchell for one session. Additionally, in April 2012, Mitchell
8                                                    No. 16-3350

directly asked Dr. Laurent for an update on when she would
meet with Osborne.
    Yet, even assuming that she knew about Mitchell’s dis-
tress, there is no evidence that Dr. Laurent could have sped
up Osborne’s evaluation or the Committee’s deliberations, or
could have inﬂuenced the Committee’s ﬁnal decision. In fact,
there is evidence that as a psychologist, Dr. Laurent had no
authority to order hormone therapy. Because Dr. Laurent was
not suﬃciently involved in the failure to provide hormone
therapy, the district court properly granted summary judg-
ment in her favor.
                                B
    Next we turn to Dr. Kallas. As DOC’s Mental Health Di-
rector and a member of the Gender Dysphoria Committee,
Dr. Kallas was directly involved in Mitchell’s treatment. He
contacted Osborne for a consultation and sat on the Commit-
tee that ultimately denied Mitchell’s request.
    We begin with the question whether Dr. Kallas is entitled
to qualiﬁed immunity. A prison oﬃcial is immune from suit
if the constitutional right at issue was not clearly established
at the time of the violation, and thus a reasonable oﬃcer
would not have known that his conduct was unlawful. Or-
lowski, 872 F.3d at 421. In deciding whether a right was clearly
established, it is essential to assess the case at the right level
of speciﬁcity. White v. Pauly, 137 S. Ct. 548, 551–52 (2017). But
this particularity requirement does not go so far as to mandate
a mirror-image precedent from the Supreme Court or this
court. Ziglar v. Abbasi, 137 S. Ct. 1843, 1866–67 (2017) (stating
that the “very action in question” need not have been found
to be unlawful (citation omitted)). As we put it recently, the
No. 16-3350                                                    9

Eighth Amendment duty “need not be litigated and then es-
tablished disease by disease or injury by injury.” Estate of
Clark v. Walker, 865 F.3d 544, 553 (7th Cir. 2017) (rejecting a
highly speciﬁc framing of the right at stake); see also Estate of
Perry v. Wenzel, 872 F.3d 439, 460 (7th Cir. 2017) (same).
    Dr. Kallas urges that he is entitled to qualiﬁed immunity
because no binding decision guarantees inmates the right to a
speedier gender dysphoria evaluation or short-term hormone
therapy prior to release. That formulation, however, frames
the right too narrowly. Dr. Kallas has conceded (consistently
with other cases) that Mitchell’s gender dysphoria was a seri-
ous medical need. See Fields v. Smith, 653 F.3d 550, 556
(7th Cir. 2011); Maggert v. Hanks, 131 F.3d 670, 671 (7th Cir.
1997); Meriwether v. Faulkner, 821 F.2d 408, 413 (7th Cir. 1987).
The ﬁrst question is thus whether a prison doctor would have
known that it was unconstitutional never to provide a person
with the appropriate treatment for her particular case (and for
many others)—hormone therapy. Fields, 653 F.3d at 556.
    Prison oﬃcials have been on notice for years that leaving
serious medical conditions, including gender dysphoria, un-
treated can amount to unconstitutional deliberate indiﬀer-
ence. E.g., Arnett v. Webster, 658 F.3d 742, 753 (7th Cir. 2011)
(refusing to provide a prescribed treatment or to follow a spe-
cialist’s advice can violate the Eighth Amendment); Fields,
653 F.3d at 556 (“Refusing to provide eﬀective treatment for a
serious medical condition serves no valid penological pur-
pose and amounts to torture.”). An absence of treatment is
equally actionable whether the inmate’s suﬀering is physical
or psychological. See Meriwether, 821 F.2d at 413. Because cir-
cuit precedent clearly established that a total absence of treat-
10                                                  No. 16-3350

ment for the serious medical needs created by gender dyspho-
ria is unconstitutional, Dr. Kallas may not claim qualiﬁed im-
munity for the denial of Mitchell’s request for care.
    The question remains, however, whether on this record
such a total denial of care could be found by a jury. The facts
in this respect are disputed. On the one hand, Mitchell never
received the hormone therapy that Osborne, on DOC’s behalf,
concluded that she needed. Instead, while Mitchell waited for
a response to her plea, she got nothing but occasional visits
with psychologists. Although Dr. Kallas argues that these vis-
its were themselves “treatment,” the notes from those ses-
sions indicate that they were not focused on her gender dys-
phoria, but instead were primarily designed to deal with her
post-traumatic stress and the harassment she faced. And more
broadly, psychological visits are not automatically a substi-
tute for other medical treatments. See De’lonta v. Johnson, 708
F.3d 520, 525–26 (4th Cir. 2013) (providing “some treatment”
does not necessarily mean providing “constitutionally adequate
treatment”); Fields, 653 F.3d at 556. No one would say that a
psychologist could treat someone’s epilepsy, nor would we
say that a counseling session is a substitute for high blood
pressure medication, even though stress can have an adverse
eﬀect on blood pressure. In some cases, a psychological con-
dition, such as bipolar disorder, should not be treated by
counseling alone: medication can be essential. So it is with her
gender dysphoria, Mitchell says. And even if the therapy ses-
sions addressed Mitchell’s gender dysphoria to a degree, she
may still recover if they did nothing actually to treat her con-
dition. See Arnett, 658 F.3d at 751; see also Fields, 653 F.3d at
556 (“Although DOC can provide psychotherapy as well as
antipsychotics and antidepressants, defendants failed to pre-
sent evidence rebutting the testimony that these treatments
No. 16-3350                                                   11

do nothing to treat the underlying disorder [gender dyspho-
ria].”). Given the opinions of the prison doctors and Osborne,
Mitchell has presented enough evidence to move forward.
    To the extent that Mitchell may be complaining about the
length of time it took for the assessment to be completed, as
opposed to the lack of treatment, our answer is diﬀerent. It is
true that delays in care for “non-life-threatening but painful
conditions may constitute deliberate indiﬀerence if the delay
exacerbated the injury or unnecessarily prolonged an in-
mate’s pain.” Arnett, 658 F.3d at 753; see also McGowan v. Hu-
lick, 612 F.3d 636, 640 (7th Cir. 2010). Yet prisons have limited
resources, and that fact makes some delay inevitable. Petties,
836 F.3d at 730. For a delay in treatment to qualify as deliber-
ate indiﬀerence, we must weigh “the seriousness of the con-
dition and the ease of providing treatment.” Id. As we have
said, the serious nature of gender dysphoria is not disputed
here. But the ease of evaluating the appropriateness of hor-
mone therapy remains to be considered. There is little evi-
dence about the typical length of these evaluations, either in
prisons or in the community. The few courts that have con-
sidered this question (some after the events in question) have
determined that even longer delays in evaluating an inmate’s
candidacy for hormone treatment did not amount to deliber-
ate indiﬀerence. See Arnold v. Wilson, No. 1:13cv900, 2014
WL 7345755, at *6 (E.D. Va. Dec. 23, 2014) (24-month delay in
prescribing hormones); Rowe v. Corr. Med. Servs., Inc.,
No. 1:08-cv-827, 2010 WL 3779561, at *6–7 (W.D. Mich. Aug.
18, 2010) (15-month delay). Because Dr. Kallas was not on no-
tice that a 13-month evaluation would violate Mitchell’s
Eighth Amendment right, he is entitled to qualiﬁed immunity
on any possible claim of unreasonable delay.
12                                                   No. 16-3350

    That is not to say that this delay cannot be criticized. Far
from it. The lack of any sense of urgency, or even of the need
for prompt follow-through, is quite disturbing. But on these
facts, no clearly established law would have signaled to
Dr. Kallas that this delay amounted to deliberate indiﬀerence.
                                C
    With respect to Dr. Kallas, that leaves the question
whether he was deliberately indiﬀerent in failing to treat
Mitchell’s condition during the entirety of her stay at DOC,
even after Osborne recommended that Mitchell receive hor-
mone therapy. Mitchell accuses Dr. Kallas of doing nothing
while the evaluation process was ongoing, and then (through
the Committee) denying her request because she was going to
be released within a month. Dr. Kallas claimed that DOC had
an unwritten rule that an inmate may start hormone therapy
only if she has six months left on her sentence, and he denied
her request on that basis. He later explained in an aﬃdavit
that this period was intended to allow time to ﬁgure out the
proper hormone dosage while monitoring both physical and
psychological side eﬀects.
    The ﬁrst problem is that this requirement appears no-
where in DOC’s written policy on gender dysphoria. This
conspicuous absence from DOC’s freshly-minted policy
raises the factual question whether DOC actually had such a
practice. Moreover, the question remains whether Dr. Kallas
and the Committee exercised medical judgment in applying
the policy to Mitchell’s request. Neither professional disa-
greement nor medical malpractice constitutes deliberate in-
diﬀerence. Cesal v. Moats, 851 F.3d 714, 721, 724 (7th Cir. 2017).
Thus, if the trier of fact ﬁnds that there was such a policy and
No. 16-3350                                                    13

that Dr. Kallas and the Committee had a medical basis for de-
ciding not to start Mitchell’s hormone treatments, then Dr.
Kallas will not be liable. If the factﬁnder alternatively con-
cludes that there was no such policy, or that Dr. Kallas failed
to assess whether application of the policy was appropriate in
Mitchell’s case, then it would follow that he did not exercise
his medical judgment and was deliberately indiﬀerent. “The
denial of hormone therapy based on a blanket rule, rather
than an individualized medical determination, constitutes de-
liberate indiﬀerence in violation of the Eighth Amendment.”
Hicklin v. Precynthe, No. 4:16-cv-01357, 2018 WL 806764, at *11
(E.D. Mo. Feb. 9, 2018); accord Kosilek v. Spencer, 774 F.3d 63,
91 (1st Cir. 2014); De’lonta v. Angelone, 330 F.3d 630, 635
(4th Cir. 2003); Allard v. Gomez, 9 F. App’x 793, 794–95 (9th Cir.
2001).
   We have no reason to doubt that hormone therapy poses a
health risk if not properly controlled. But the same could be
said about medications for countless other conditions. It
seems exceedingly unlikely that DOC would refuse to com-
mence a course of treatment for an inmate who was about to
leave, just because continuity of care protocols would require
a hand-oﬀ to a diﬀerent provider. Would it really refuse to
address breathing problems, or cardiac problems, or even a
broken leg, just because one doctor begins the treatment and
another completes it? At this stage, the parties disagree about
the critical question whether DOC could have provided
Mitchell with something more than counseling services—per-
haps a limited prescription for hormones—to bridge the gap
between her release from custody and the time when she
found a new provider in the community.
14                                                  No. 16-3350

    In sum, there remain material disputes about whether
Dr. Kallas and the Committee balanced the pros and cons of
starting Mitchell on hormones, or if they just looked at the cal-
endar and reﬂexively dismissed her request. The district court
should not have granted summary judgment on Mitchell’s
claim for the refusal to provide care.
                               III
    Finally, we consider Mitchell’s argument that the parole
oﬃcers were improperly dismissed from this case. The dis-
trict court concluded that Mitchell failed to allege suﬃcient
facts to support a ﬁnding that the parole oﬃcers were person-
ally involved in making decisions about her gender dysphoria
treatment or that they were obligated to provide her such
treatment.
   Reading Mitchell’s pro se complaint in the light most fa-
vorable to her, as we must, Perez, 792 F.3d at 776, we conclude
that she did state a claim against the parole oﬃcers. Mitchell’s
complaint did not suggest that her parole oﬃcers had a legal
duty to arrange hormone therapy for her. Rather, her argu-
ment was that the oﬃcers impermissibly forbade her from
dressing as a woman and seeking hormone treatment on her
own. She alleged that the agents had ample notice that a bar
on taking hormones would harm her. They had a copy of her
medical records and Osborne’s report, which even mentioned
that hormone treatment would help ward oﬀ recidivism.
    We have not yet addressed whether parole oﬃcers can be
liable for deliberate indiﬀerence to a parolee’s serious medical
need, though we have found that their actions implicate the
Eighth Amendment in some situations. See Hankins v. Lowe,
786 F.3d 603, 606 (7th Cir. 2015) (holding that parolee stated
No. 16-3350                                                    15

an Eighth Amendment claim that her parole oﬃcer subjected
her to restrictive conditions past the expiration of her term of
parole). One district court has contemplated that parole oﬃc-
ers can be liable for deliberate indiﬀerence by placing condi-
tions on a plaintiﬀ that prevent her from taking the medically
indicated course of care. Stewart v. Raemisch, No. 09-C-123,
2009 WL 3754173, at *3 (E.D. Wis. Nov. 4, 2009) (entertaining
a suit against a parole agent where parolee was required to
seek employment but could not for medical reasons). And we
have held that custodial prison staﬀ violate the Eighth
Amendment by interfering with or preventing necessary
medical care. McDonald v. Hardy, 821 F.3d 882, 888 (7th Cir.
2016); see also Gamble, 429 U.S. at 104–05. Though parole of-
ﬁcers may have no duty under Gamble to provide a parolee
with medical care or ensure that she receives it, they at least
may be constitutionally obligated not to block a parolee who
is trying to arrange such care for herself without any basis in
the conditions of parole. See 429 U.S. at 105 (deliberate indif-
ference to a serious medical issue “[r]egardless of how evi-
denced” states a cause of action under section 1983). From
that perspective, Mitchell pleaded enough to proceed on the
theory that the parole oﬃcers acted with deliberate indiﬀer-
ence to her gender dysphoria by blocking her from getting
care.
    In its ruling on Mitchell’s motion to reconsider, the district
court oﬀered an additional reason for dismissing the parole
oﬃcers: it was concerned that the claims against the parole
oﬃcers and those against the doctors were not suﬃciently re-
lated to continue in the same lawsuit. When screening prison-
ers’ complaints under the PLRA, courts can and should sever
an action into separate lawsuits or dismiss defendants who
are improperly joined under Federal Rule of Civil Procedure
16                                                  No. 16-3350

20(a)(2). Owens v. Hinsley, 635 F.3d 950, 952 (7th Cir. 2011). A
prisoner may join defendants in the same action only if the
claims against each one “aris[e] out of the same transaction,
occurrence, or series of transactions or occurrences … .”
FED. R. CIV. P. 20(a)(2)(A); George v. Smith, 507 F.3d 605, 607
(7th Cir. 2007).
    The question then is whether Mitchell’s claim against the
parole oﬃcers should have been brought in a separate law-
suit. Out of concern about unwieldy litigation and attempts to
circumvent the PLRA’s fee requirements, we have urged dis-
trict courts and defendants to beware of “scattershot” plead-
ing strategies. E.g., Owens v. Evans, 878 F.3d 559, 561 (7th Cir.
2017); Owens v. Godinez, 860 F.3d 434, 436 (7th Cir. 2017). We
target for dismissal “omnibus” complaints—often brought by
repeat players—that raise claims about unrelated conduct
against unrelated defendants. E.g., Evans, 878 F.3d at 561;
Hinsley, 635 F.3d at 952.
    Mitchell’s complaint stands in stark contrast to these scat-
tershot suits. Mitchell has focused on a series of events stem-
ming from one issue: her inability to get hormone therapy
while she remained in state custody. One of the defendants’
arguments underscores that Mitchell’s claims belong to-
gether. In an attempt to disclaim deliberate indiﬀerence, Dr.
Kallas stresses that he gave Osborne’s report to Mitchell,
along with information about Wisconsin providers, so that
she could seek hormone therapy in the community once she
was released on parole. The parole oﬃcers, however, told her
she was not allowed to follow through on Dr. Kallas’s advice.
She thus suﬀered an ongoing denial of treatment arising out
of one fundamental occurrence, well within the bounds of
Rule 20(a)(2). The fact that Mitchell has diﬀerent theories of
No. 16-3350                                                  17

liability against the diﬀerent defendants does not diminish
the fact that her claims are suﬃciently related. “The two sets
of claims are against diﬀerent defendants, but they belong in
the same suit because they arise out of the same set of con-
nected transactions.” Terry v. Spencer, 888 F.3d 890, 894 (7th
Cir. 2018). Given Mitchell’s allegations of a fairly continuous
period in which two sets of defendants denied or interfered
with her access to needed medical treatment, it is easy to im-
agine that if the claims were tried separately, each set of de-
fendants could try to shift blame to the other. Handling the
claims against both sets of defendants in one case minimizes
the risk of unfairness from such inconsistent defenses suc-
ceeding in separate trials.
    The fact that the district court dismissed Mitchell’s claim
against the parole agents without prejudice does not change
our conclusion, nor does the fact that her claim probably
would not be time-barred under Wisconsin’s generous six-
year statute of limitations. See Kennedy v. Huibregtse, 831 F.3d
441, 442 (7th Cir. 2016). Mitchell was entitled not to split her
claims against these two sets of defendants. On remand, she
will be entitled to proceed against both Dr. Kallas and the pa-
role oﬃcers.
                              IV
    Punishment for Mitchell’s crimes cannot extend to the
deprivation of the medical treatment she requires for her se-
rious gender dysphoria. The Wisconsin DOC staﬀ must ap-
proach Mitchell’s request for treating gender dysphoria with
the same urgency and care as it would any other serious med-
ical condition. We AFFIRM the judgment in favor of Dr. Lau-
rent, but we REVERSE with respect to Dr. Kallas and Parole
18                                          No. 16-3350

Agents Ruhnke, Wolfe, and Raisbeck, and REMAND for pro-
ceedings consistent with this opinion.