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Monroe v. Baldwin

United States District Court, S.D. Illinois

December 19, 2019




         Janiah 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.).

         The Complaint

         According 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 treatment.

         Plaintiffs 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.

         Plaintiffs 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 above-referenced relief.

         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).


         Treatment of Gender Dysphoria

         Gender 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).

         WPATH 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. 26).

         Social Role Transition

         Social 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).


         Psychotherapy 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. 14).


         There 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).

         Cross-Sex Hormone Therapy

         Cross-sex 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).

         The 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. 103).

         Spironolactone 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 p. 106).

         Spironolactone 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).

         There 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).

         Transgender 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 (Id.).

         IDOC's Policies on Transgender Inmates

         IDOC's 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).

         The 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).

         Dr. William Puga

         Dr. 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 (Id.).

         The 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).

         Hormone 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).

         IDOC 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).

         Dr. 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).

         The 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 (Id.).

         Dr. 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).

         Dr. Shane Reister

         Dr. 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).

         Expert Testimony

         Dr. Vin Tangpricha

         Dr. Vin 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).

         Dr. 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 ...

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