United States District Court, S.D. Illinois
JANIAH MONROE, MARILYN MELENDEZ, EBONY STAMPS, LYDIA HELENA VISION, SORA KUYKENDALL, and SASHA REED, Plaintiffs,
JOHN BALDWIN, STEVE MEEKS, and MELVIN HINTON, Defendants.
MEMORANDUM AND ORDER
J. ROSENSTENGEL CHIEF U.S. DISTRICT JUDGE.
Monroe, Marilyn Melendez, Ebony Stamps, Lydia Helena Vision,
Sora Kuykendall, and Sasha Reed are transgender women in the
custody of the Illinois Department of Corrections
(“IDOC”) (Doc. 1). They filed this putative class
action under 42 U.S.C. § 1983, alleging IDOC provides
transgender inmates inadequate treatment for gender
dysphoria, in violation of the Eighth Amendment
(Id.). Plaintiffs bring this suit against the IDOC
Director, Chief of Health Services, and Mental Health
Supervisor in their official capacities (Id.).
to the Complaint, IDOC utilizes a committee of unqualified
officials to oversee the security, placement, and treatment
of transgender inmates (“the Transgender
Committee”) (Doc. 1). Through the Transgender Committee
and other flawed policies, IDOC often delays or denies
hormone therapy for reasons not recognized by the medical
community; fails to provide adequate hormone therapy and
hormone monitoring; fails to consider and provide surgery as
part of medically necessary treatment for gender dysphoria;
prevents and fails to permit, accommodate, and facilitate
social transition necessary to treat gender dysphoria; and
fails to provide access to clinicians competent to treat
gender dysphoria, resulting in misdiagnosis and inappropriate
seek a preliminary injunction directing Defendants to: (1)
cease the policy and practice of allowing the Transgender
Committee to make the medical decisions regarding gender
dysphoria resulting in denials and delays of treatment; (2)
cease the policy and practice of denying and delaying hormone
therapy for reasons that are not recognized as
contraindications to treatment; (3) cease IDOC's policy
and practice of refusing to evaluate and provide surgery to
treat gender dysphoria; and (4) cease the policy and practice
of depriving gender dysphoric prisoners of medically
necessary social transition, including by mechanically
assigning housing based on genitalia.
also seek medically necessary treatment for Plaintiffs and
the putative class members, including: (1) access to
clinicians who meet the competency requirements stated in the
Standards of Care to treat gender dysphoria; (2) evaluation
for gender dysphoria upon request or clinical indications of
the condition; (3) timely medically prescribed treatment for
gender dysphoria, including, but not limited to, hormone
therapy and monitoring and gender-affirming surgery; (4)
medically necessary social transition, including
individualized placement determinations, avoidance of cross-
gender strip searches, and access to gender-affirming
clothing and grooming items; and (5) training for IDOC staff
on the importance of social transition, including using
proper names and pronouns for transgender inmates. Finally,
Plaintiffs request the Court appoint a medical expert in
gender dysphoria to oversee IDOC's implementation of the
Court held a two-day hearing on the motion for preliminary
injunction and now makes the following findings of facts and
conclusions of law (Docs. 155 & 156).
of Gender Dysphoria
dysphoria refers to a condition in which a person experiences
clinically significant distress stemming from incongruence
between one's experienced or expressed gender and
one's assigned gender (Doc. 157, p. 95; Doc. 158, p. 14).
Gender dysphoria is considered a medical condition and has
been removed from the mental and behavioral disorders in the
World Health Organization Classification of Diseases and the
Diagnostic Statistical Manual of Mental Disorders (Doc. 158,
p. 95). The World Professional Association for Transgender
Health (“WPATH”) is a professional association
dedicated to understanding and treating gender dysphoria
(Doc. 157, p. 98). WPATH dictates medically-accepted
Standards of Care for treating gender dysphoria (Id.
at p. 7). According to WPATH, its Standards of Care are
“the highest standards of health care” for
transgender people (Doc. 123, Ex. 13, p. 8). IDOC purports to
follow the Standards of Care and has updated its mental
health standards operating procedure manual to incorporate
them (Doc. 143, Ex. 4, pp. 4, 10). According to WPATH,
treatment options for gender dysphoria include social role
transition, cross-sex hormone therapy, psychotherapy, and
surgery (Doc. 158, p. 14).
lists the minimum qualifications a mental health professional
must attain in order to assess and treat gender dysphoria
(Id. at p. 25). Specifically, a person must: hold a
master's degree in behavioral science; be familiar with
the Diagnostic Statistical Manual of Mental Disorders or the
International Classification of Diseases; have documented
supervision in psychotherapy; understand the variations of
gender identities and gender expressions; have continuing
education in the assessment and treatment of gender
dysphoria; have cultural competence; and be aware of the
growing body of literature in the area (Id. at pp.
25-26). Individuals who are new to the field should work
under the supervision of someone with competence who is
regarded as an expert in gender dysphoria (Id. at p.
role transition is living in the role congruent to one's
affirmed identity. For instance, in the case of a transgender
woman, social transition would include wearing a female
hairstyle, female clothing, and makeup, and using a feminine
name, female toiletries, and a female bathroom (Doc. 158, p.
16). In a prison setting, social transition would require a
transgender woman be afforded the same canteen items that
female prisoners can access, have means to safe and effective
hair removal, be referred to by a female name, and be
permitted to wear makeup or clothing that affirms her gender
(Id. at p. 17).
helps individuals become more resilient, deal with stigma,
manage family situations, and cope with the social problems
that are attendant to gender dysphoria (Id. at p.
are different surgical options for transgender individuals,
including reconstruction of the genitalia, also known as
gender-affirming surgery (Id. at pp. 20, 90).
Reconstruction eliminates the major source of hormones that
contribute to and cause gender dysphoria (Id. at pp.
20-21). After reconstruction, the urogenital organs function
and appear the same as one's peers (Id.). In
2014, Medicare declared gender-affirming surgery to be
medically necessary and safe (Id. at p. 88). Studies
indicate that less than one percent of patients who undergo
gender-affirming surgery around the world experience regret
(Id. at p. 90). Other studies show suicide and
self-harm dramatically decrease following reconstruction
surgery (Id.). Other surgical options include
removal of the breasts and chest reconstruction (Id.
at p. 21).
hormone therapy involves taking hormones to masculinize or
feminize the body (Id. at p. 14). An individual
should not begin hormone therapy unless he or she has
well-documented gender dysphoria above the age of majority
and has no significant mental health concerns that prevent
him or her from giving informed consent (Id. at p.
19). Hormone therapy is often a necessary component of
treating gender dysphoria (Id. at p. 156).
Endocrine Society Guidelines are internationally recognized
baseline guidelines for the adequate treatment of gender
dysphoria (Doc. 157, p. 91). Hormone therapy that falls below
the Guidelines is considered less-than-adequate treatment
(Id. at pp. 98-99). The Guidelines state that once a
person begins hormone therapy, they should undergo baseline
lab testing to monitor hormone levels (Id. at p.
102). Hormone levels need to be checked every two to three
months for the first year of treatment, and dosages should be
adjusted accordingly until a target hormone level is achieved
(Id.). After this period, hormone levels should be
checked once or twice each year (Id.). An individual
who suddenly stops taking hormones is at risk for serious
medical or mental health complications (Id. at p.
and Estradiol are the two main agents involved in hormone
therapy for transgender women (Id. at pp. 103-04).
Spironolactone is a testosterone-blocker, and Estradiol is
estrogen (Id. at pp. 104, 109). Estradiol is
administered at a starting dose of two milligrams and
titrated to four or six milligrams (Id. at p. 104).
Four milligrams typically results in target concentrations
(Id. at p. 105). For transgender men, hormone
treatment involves testosterone injections (Id. at
is a diuretic that can elevate potassium levels and cause
heart arrhythmias, kidney failure, and death (Id. at
p. 107). Estradiol enlarges the pituitary gland, which can
cause blindness if the gland gets too big (Id. at
pp. 107-08). Thus, monitoring hormone levels is important for
efficacy and safety (Id. at p. 108).
are other forms of estrogen besides Estradiol, but the
Endocrine Society Guidelines do not recommend them because
they are very difficult to monitor (Id. at pp.
109-110). For example, Premarin and Menest, which are
conjugated estrogens, are not naturally produced by the body;
they come from pregnant horse urine (Id. at p. 110).
people may receive hormone therapy but still experience
symptoms of gender dysphoria because their body does not
match their gender identity (Id. at p. 109). Hormone
therapy does not shrink genitals or make them disappear
Policies on Transgender Inmates
Administrative Directive 04.03.104, “Evaluation of
Offenders with Gender Identity Disorders, ” sets forth
the policies and procedures for evaluating and treating
inmates with gender dysphoria (“the GID
Directive”) (Doc. 1, p. 17; Doc. 123, Ex. 10). The GID
Directive creates the Transgender Committee, which is a group
of IDOC officials who are responsible for reviewing
placements, security concerns, and overall health-related
treatment plans for transgender prisoners with gender
dysphoria, as well as overseeing gender-related
accommodations (Doc. 61, p. 29). The Transgender Committee
has five voting members: IDOC's Chief of Psychiatry,
Chief of Health Services, Chief of Mental Health Services,
Chief of Operations, and Transfer Coordinator (Doc. 158, pp.
102, 146-52; Doc. 61, pp. 20-21). None of these individuals
meets WPATH's minimum qualifications for treating
transgender people and two have no medical training (Doc.
158, pp. 146-51).
Committee meets once each month to review inmates'
treatment and care (Id. at p. 105). The Committee
reviews approximately twenty cases at each meeting and goes
over treatment plans and inmate requests (Id.).
IDOC's therapists present issues to the Transgender
Committee on behalf of the inmate (Id. at pp.
111-13). The Committee reviews information about each inmate,
including the inmate's treatment plan, but does not
review an inmate's complete medical records (Id.
at pp. 113, 163). The Committee generally allots six minutes
to hear an inmate's case (Id. at p. 162). The
Committee decides issues based on a majority vote of its five
members, but nonmedical members do not vote on medical issues
(Id. at pp. 157, 187). After the Committee renders a
decision, the inmate's therapist or physician is
responsible for carrying out the plan (Id. at p.
113). There is no formal appeals process for challenging the
Committee's decisions (Id. at pp. 160-61).
William Puga is a physician who specializes in psychiatry
(Doc. 158, p. 102). He has served as IDOC's Chief of
Psychiatry since March 2018 (Doc. 158, pp. 102, 135). He
oversees the psychiatric treatment at all thirty-one
facilities and is the chairman of the Transgender Committee
(Id. at p. 104). Since he began working with the
Committee, Dr. Puga has become familiar with the Standards of
Care, has read about endocrinology and surgical issues, and
has studied how other states work with transgender offenders
(Id. at p. 109). Dr. Puga also authors a newsletter
for the psychiatric staff that discusses psychiatrists'
role in treating and evaluating transgender inmates
Committee considers whether or not an inmate should begin
hormone therapy (Id. at p. 114). Dr. Puga estimates
that about seventy IDOC inmates are on hormones
(Id.). According to Dr. Puga, if an inmate was
taking hormones prior to incarceration, the Committee
generally approves the continuation of hormone therapy
without much scrutiny (Id.). But if an inmate wants
to begin hormone therapy for the first time, the Committee
conducts a review to determine whether therapy is appropriate
and safe (Id.). Periodically, the Committee denies
requests to begin hormone therapy if the inmate is
psychiatrically unstable or if hormone therapy is
contraindicated due to an inmate's medical history of
conditions like embolisms, liver disease, or cardiac issues
(Id. at pp. 114-15). If the Committee approves
hormone therapy, the inmate's physician administers the
hormones (Id. at p. 121).
therapy can cause complications (Id. at p. 117). For
instance, in April 2019, a transgender inmate had a stroke
that left her partially paralyzed and affected her speech
(Id.). IDOC concluded that the hormones caused the
stroke (Id. at pp. 117-18).
has raised the issue of misgendering (calling transgender
people by the wrong pronouns) with its employees and has
provided education and training for correctional officers on
dealing with transgender inmates (Id. at p. 125).
IDOC also encourages facilities to call inmates by their
preferred name and has terminated employees who are verbally
abusive to transgender inmates (Id. at pp. 126-27).
Puga testified the Committee will entertain requests for
gender-affirming surgery but it has not actually evaluated a
specific inmate as a surgical candidate (Id. at p.
120). Also, the Committee addresses social transition issues,
but the therapists and the facilities make many decisions
such as showering accommodations and access to commissary
items (Id. at pp. 123-24).
Committee reviews transfer requests from transgender female
inmates who want to reside at female facilities (Id.
at p. 128). Dr. Puga contacts the inmate's current
facility, reviews disciplinary and medical records, speaks
with the inmate's therapist, and gathers as much relevant
information as he can to present to the Committee
(Id. at pp. 128-29, 132). Dr. Puga believes a total
of two transgender females have transferred to a female
facility (Id.). Dr. Puga testified that one of the
inmates was “fairly successful” at the female
facility (Id.). The other inmate, Janiah Monroe,
stopped taking her hormones and was sexually active
(Id.). Dr. Puga talked to the warden and mental
health staff at the female facility, who reported the
transgender women were not well received (Id. at p.
129). Dr. Puga stated that many women in IDOC's care have
been exposed to domestic, physical, or emotional violence,
and transgender women sometimes scare the other women
(Id. at p. 130). Dr. Puga received information that
Monroe threatened staff and other inmates (Id. at
pp. 134-35). Women at the facility filed complaints against
Monroe under the Prison Rape Elimination Act; some were false
but many were legitimate (Id. at p. 130). The female
facility eventually placed Monroe in segregation for her own
safety (Id. at pp. 135-36). According to Dr. Puga,
these difficulties have not deterred the Committee from
considering transfer requests on an individual basis
Puga does not recall learning about gender dysphoria in
medical school (Id. at p. 139). He treated two
transgender patients while in private practice, three
transgender patients while working at a hospital, and three
transgender patients while working as a consultant to a
school district (Id.). Dr. Puga did not serve as
these individuals' primary provider for gender dysphoria
(Id. at p. 141). Dr. Puga has never treated a
transgender individual under the supervision of a
WPATH-certified physician, prescribed hormones to a
transgender patient, been involved in monitoring hormone
levels of a transgender patient, approved surgery for a
transgender patient, or presided over the social transition
of a transgender patient (Id. at pp. 144-45). He is
unaware of any standards for prescribing hormones and
testified, “For psychiatry I have guidelines for
medications that we prescribe but I don't know how
medicine works, frankly” (Id. at p. 175). He
stated, “Dr. Reister has probably the most experience
out of everybody [on the Committee] as far as working with
[transgender patients]” (Doc. 158, p. 103).
Shane Reister is the southern regional psychologist for IDOC
who consults the Transgender Committee (Doc. 143, Ex. 3, pp.
6-7). He has a doctorate in psychology and his experience
includes a practicum at an LGBT specialty site (Id.
at p. 5). Dr. Reister worked at a correctional facility in
Rushville, Illinois, where he organized an LGBT group therapy
program (Id.). He also attended a WPATH conference a
couple of years ago and is scheduled to attend a second
conference this year (Id. at pp. 5-6). He has been a
member of WPATH for five years (Id.). Dr. Reister
developed sensitivity training for IDOC staff, which is
designed to help employees interact appropriately with
transgender inmates (Id. at p. 7). Dr. Reister does
not prescribe hormones; he defers to Dr. Puga for medical
treatment of patients with gender dysphoria because these
decisions are outside Dr. Reister's competency
(Id. at p. 16).
Tangpricha testified on behalf of Plaintiffs (Id. at
p. 88). He is board-certified in endocrinology and
specializes in treating transgender individuals
(Id.). Dr. Tangpricha holds a medical degree from
Tufts University and a Ph.D. from Boston University
(Id.). He estimates he has treated more than 360
transgender patients and has published thirty peer-reviewed
articles related to gender dysphoria, including the WPATH
Standards of Care (Id. at pp. 90-91). Dr. Tangpricha
was also involved in creating the Endocrine Society
Guidelines (Id. at p. 91). The first version of the
Guidelines was published in 2008, and an updated version was
published in 2017 (Id. at p. 145). Dr. Tangpricha is
the president of WPATH, on the board of directors for the
American Association for Clinical Endocrinologists
(“AACE”), and chairs AACE's national
education committee (Id. at p. 92).
Tangpricha testified that gender dysphoria is a serious
medical condition and that failure to properly treat the
condition can result in anxiety, depression, self-harm, and
suicide (Id. at p. 95). Dr. Tangpricha reviewed the
record in this case and is familiar with the Transgender
Committee (Id. at p. 11). He does not believe any of
the voting members on the Committee are qualified to make
decisions about hormone therapy (Id.). Dr.
Tangpricha reviewed an IDOC medical record where the
Committee denied an inmate's request for an increased
dosage of estrogen and a bra without providing a medical
reason or completing a blood test to determine hormone levels
(Id. at pp. 115-16). In another record, the
Committee denied a request for an increased dosage of
estrogen because the inmate was not “stable”
(Id. at pp. 117-18). But the remarks under the
mental health section of the document state “Currently
stable. Attending all programming. Working full-time in
inmate commissary” (Id.). Dr. Tangpricha could
not find any medical rationale for the denial of the request
(Id.). He reviewed other similar ...