by Virginia Su*

An inmate’s right to effec­tive med­ical treat­ment remains one of the core pro­tec­tions safe­guard­ed by the Eighth Amend­ment. The applic­a­bil­i­ty of this Con­sti­tu­tion­al pro­tec­tion nat­u­ral­ly expands over time, as the devel­op­ment and under­stand­ing of nov­el med­ical sci­ence pro­gress­es. As stat­ed by Chief Jus­tice War­ren in an often-quot­ed phrase, “[t]he Amend­ment must draw its mean­ing from the evolv­ing stan­dards of decen­cy that mark the progress of a matur­ing soci­ety.”1 This pro­gres­sive prin­ci­ple direct­ly con­flicts with the blan­ket denials issued by Depart­ments of Cor­rec­tions2 across the coun­try pro­hibit­ing trans­gen­der inmates from receiv­ing Gen­der Con­fir­ma­tion Surgery (“GCS”), a med­ical pro­ce­dure now well-under­stood and accept­ed with­in the med­ical com­mu­ni­ty as an effec­tive, even nec­es­sary, course of treat­ment to alle­vi­ate gen­der dys­pho­ria.3 Ulti­mate­ly, this Con­tri­bu­tion argues that the Eighth Amend­ment guar­an­tees the unen­cum­bered right to gen­der con­fir­ma­tion surgery for incar­cer­at­ed individuals.


The Eighth Amend­ment pro­tects against “cru­el and unusu­al pun­ish­ments.”4 In apply­ing this pro­tec­tion to an inmate’s med­ical care, the Supreme Court looks to whether there was an “unnec­es­sary and wan­ton inflic­tion of pain” which is “repug­nant to the con­science of mankind.”5 Inmates exist in a par­tic­u­lar­ly vul­ner­a­ble pock­et of soci­ety, hav­ing to rely exclu­sive­ly on the gov­ern­ment for the sat­is­fac­tion of their basic needs.6 If the gov­ern­ment fails to treat an inmate’s seri­ous med­ical con­di­tion, that con­di­tion will sim­ply be left untreat­ed, as inmates do not have oth­er options to pur­sue med­ical care.7 This vul­ner­a­bil­i­ty is par­tic­u­lar­ly salient with trans­gen­der inmates, as they rely on the gov­ern­ment for not only the sat­is­fac­tion of their basic needs, but also their con­tin­ued safe­ty.8 Thus, the poten­tial cru­el­ty asso­ci­at­ed with the government’s fail­ure to pro­vide ade­quate med­ical care has far-reach­ing impli­ca­tions, affect­ing the over­all safe­ty of the country’s pris­ons.9

The frame­work estab­lished by the Supreme Court to find a Con­sti­tu­tion­al vio­la­tion requires the inmate to bear the bur­den of show­ing both “(1) an objec­tive prong that requires proof of a seri­ous med­ical need, and (2) a sub­jec­tive prong that man­dates a show­ing of prison admin­is­tra­tors’ delib­er­ate indif­fer­ence to that need.”10 The wealth of dis­cus­sion sur­round­ing this top­ic, how­ev­er, exists pri­mar­i­ly with­in the sec­ond prong.11 Once an inmate has made the thresh­old show­ing of a seri­ous med­ical need—in the case of most trans­gen­der inmates, a seri­ous case of gen­der dysphoria—courts have then ana­lyzed whether the prison administrator’s delib­er­ate indif­fer­ence regard­ing the inmate’s seri­ous med­ical need con­sti­tutes an “unnec­es­sary and wan­ton inflic­tion of pain.”12 This requires a show­ing of pur­pose­ful con­duct, a notably stricter require­ment than neg­li­gence or med­ical mal­prac­tice.13

Cir­cuit courts have split on whether a denial of GCS to trans­gen­der inmates who present a seri­ous case of gen­der dys­pho­ria con­sti­tutes delib­er­ate­ly indif­fer­ent con­duct. In Edmo v. Cori­zon, Inc., the Ninth Cir­cuit found that delib­er­ate indif­fer­ence only requires con­scious dis­re­gard of an exces­sive risk.14 Thus, when prison offi­cials knew that Edmo’s gen­der dys­pho­ria had risen to a poten­tial­ly dan­ger­ous lev­el, the affir­ma­tive deci­sion to con­tin­ue to with­hold med­ical­ly nec­es­sary surgery ran afoul of the Eighth Amend­ment.15

The Fifth Cir­cuit, in Gib­son v. Col­lier, reached a con­trary result on sim­i­lar facts.16 In doing so, the Fifth Cir­cuit reached beyond the ‘con­scious dis­re­gard’ stan­dard applied by the Ninth Cir­cuit and placed addi­tion­al empha­sis on the sub­jec­tive men­tal state of the prison offi­cials tend­ing to the inmate, requir­ing the inmate to show that offi­cials act­ed “with mali­cious intent—that is, with knowl­edge that they were with­hold­ing med­ical­ly nec­es­sary care.”17 Exam­ples pro­vid­ed by the Fifth Cir­cuit of mali­cious intent includ­ed how plain­tiff must show offi­cials “refused to treat him, ignored his com­plaints, inten­tion­al­ly treat­ed him incor­rect­ly, or engaged in any sim­i­lar con­duct that would clear­ly evince a wan­ton dis­re­gard for any seri­ous med­ical needs.”18 These exam­ples illus­trate the demand­ing nature of the Fifth Circuit’s new, unprece­dent­ed stan­dard.19


Per­haps most cen­tral to the delib­er­ate indif­fer­ence analy­sis is the con­cept of med­ical neces­si­ty, which has also drawn dis­agree­ments between cir­cuits on its prop­er appli­ca­tion.20 Many cir­cuits agree that the request­ed med­ical treat­ment must be con­sid­ered med­ical­ly nec­es­sary for the inmate to sus­tain an Eighth Amend­ment claim.21 The cir­cuits do not, how­ev­er, agree on who should be able to make that deter­mi­na­tion of med­ical neces­si­ty. The First and Fifth Cir­cuits have adopt­ed a test which looks to whether “a gen­uine debate exists with­in the med­ical com­mu­ni­ty about the neces­si­ty and effi­ca­cy of that care.”22 This approach reach­es beyond the expert tes­ti­mo­ny con­cern­ing the spe­cif­ic inmate in the case, look­ing instead for “uni­ver­sal accep­tance” by the med­ical com­mu­ni­ty at large that GCS is med­ical­ly nec­es­sary to treat gen­der dys­pho­ria.23 While “uni­ver­sal accep­tance” does not require una­nim­i­ty among all experts in the field, it will not be found if there is “robust and sub­stan­tial good faith dis­agree­ment divid­ing respect­ed mem­bers of the expert com­mu­ni­ty[.]”24 Under this method of analy­sis, a nov­el treat­ment with­out near-uni­ver­sal endorse­ment by all experts in the med­ical field will not be con­sti­tu­tion­al­ly guar­an­teed to an inmate, even if all med­ical experts tes­ti­fy­ing to the inmate’s con­di­tion agree that this is the nec­es­sary course of treat­ment under the fac­tu­al circumstances.

In con­trast, the Ninth Cir­cuit has looked at med­ical neces­si­ty through the nar­row­er lens of what would be con­sid­ered nec­es­sary for the spe­cif­ic inmate at issue.25 Under this approach, broad sweep­ing state­ments about GCS are less rel­e­vant to the court’s deci­sion. Instead, the focus is on the patient and what would con­sti­tute a med­ical­ly nec­es­sary course of treat­ment for that spe­cif­ic patient. In under­tak­ing this analy­sis in Edmo, the Ninth Cir­cuit exam­ined the opin­ion tes­ti­mo­ny of med­ical experts in the dis­trict court regard­ing the neces­si­ty of GCS for the inmate at issue, and also relied on the med­ical dis­course in the wide­ly-accept­ed pro­fes­sion­al guide­lines on care for patients with gen­der dys­pho­ria, the WPATH Stan­dards of Care (“WPATH”).26 The Ninth Cir­cuit then drew an accord­ing­ly nar­row hold­ing, explic­it­ly stat­ing that their find­ings on what con­sti­tutes med­ical neces­si­ty were lim­it­ed to the indi­vid­u­al­ized expe­ri­ences of Adree Edmo her­self, and can­not be extrap­o­lat­ed to oth­er indi­vid­u­als seek­ing GCS.27 

There are two rea­sons why the Ninth Circuit’s approach to find­ing med­ical neces­si­ty of GCS should be adopt­ed. First, requir­ing a demand­ing stan­dard of near-uni­ver­sal endorse­ment does not com­port with the foun­da­tion­al prin­ci­ples in Eighth Amend­ment jurispru­dence set forth by the Supreme Court in Estelle. In Estelle, the Supreme Court laid out sim­ply that, to state a cog­niz­able claim, a pris­on­er must “allege acts or omis­sions suf­fi­cient­ly harm­ful to evi­dence delib­er­ate indif­fer­ence to seri­ous med­ical needs.”28 Requir­ing that an act be “suf­fi­cient­ly harm­ful” implies that the analy­sis con­cerns only the inmate at issue, and not a larg­er body of peo­ple who are eli­gi­ble to receive a par­tic­u­lar treat­ment. It would be counter-intu­itive for the Supreme Court to require an indi­vid­u­al­ized injury but leave open the pos­si­bil­i­ty that this injury could be com­plete­ly inval­i­dat­ed due to facts beyond the imme­di­ate injury and inmate. What is required, sim­ply, is the indi­vid­ual inmate’s inabil­i­ty to receive med­ical­ly nec­es­sary treat­ment, and this is prov­able with­out con­sult­ing a com­mu­ni­ty-wide sur­vey regard­ing the effi­ca­cy of a course of treat­ment at large.

The sec­ond rea­son the Ninth Circuit’s approach should be adopt­ed is because it com­ports with our com­mon­ly under­stood approach­es to med­ical treat­ment. Ail­ments are indi­vid­u­al­ized, and treat­ments must reflect that. The trans­gen­der com­mu­ni­ty is no excep­tion to this prin­ci­ple. Among trans­gen­der indi­vid­u­als, expe­ri­ences sur­round­ing gen­der dys­pho­ria vary wide­ly.29 This dis­par­i­ty nec­es­sar­i­ly requires physi­cians to tai­lor a course of med­ical treat­ment that is most effec­tive for that spe­cif­ic patient. The WPATH Stan­dards, the pre­em­i­nent guide­lines for physi­cians treat­ing a patient’s unique tran­si­tion process, rec­og­nize this need for flex­i­bil­i­ty in treat­ment.30 A legal analy­sis that dis­re­gards the indi­vid­u­al­ized nature of med­ical treat­ment, rely­ing instead on an impos­si­ble deter­mi­na­tion that GCS must be uni­ver­sal­ly required in all cir­cum­stances, miss­es the mark. The Eighth Amend­ment guar­an­tees ade­quate med­ical care to indi­vid­u­als, which is a ques­tion that must be addressed on the lev­el of the indi­vid­ual. The Fifth Circuit’s broad-reach­ing require­ment for uni­ver­sal accep­tance ignores the nec­es­sary nuances of med­ical care and is ulti­mate­ly incom­pat­i­ble with exist­ing Eighth Amend­ment jurisprudence.

It is worth not­ing that, even if courts elect to adopt the stan­dard for med­ical neces­si­ty set forth by the First and Fifth Cir­cuits, GCS should still be con­sid­ered a med­ical­ly nec­es­sary course of treat­ment. Due in large part to the WPATH Stan­dards, there is now wide­spread accep­tance regard­ing GCS, even if it may have been a nov­el treat­ment at one point. The WPATH Stan­dards remain the gold-stan­dard for physi­cians treat­ing gen­der dys­pho­ria, and its stance on the neces­si­ty of GCS for patients is unam­bigu­ous.31 To date, GCS remains a cru­cial com­po­nent of treat­ment for gen­der dys­pho­ria.32 Fur­ther stud­ies have also found that GCS has “an unde­ni­able ben­e­fi­cial effect” by con­tribut­ing pos­i­tive­ly to the patient’s sub­jec­tive well-being, cosme­sis, and sex­u­al func­tion.[33] This is fur­ther under­scored by how mul­ti­ple major med­ical and men­tal health groups in the Unit­ed States—including the Amer­i­can Med­ical Asso­ci­a­tion, the Amer­i­can Psy­chi­atric Asso­ci­a­tion, the Amer­i­can Col­lege of Sur­geons, as well as many others—have rec­og­nized the WPATH Stan­dards of Care as rep­re­sent­ing the con­sen­sus of the med­ical com­mu­ni­ty regard­ing the appro­pri­ate treat­ment for trans­gen­der and gen­der dys­phor­ic indi­vid­u­als.34 Even if the Fifth Circuit’s test for deter­min­ing med­ical neces­si­ty were adopt­ed, the Fifth Circuit’s ulti­mate con­clu­sion that GCS is not med­ical­ly nec­es­sary direct­ly con­tra­dicts con­ven­tion­al and wide­ly-endorsed med­ical prac­tices. This, there­fore, pro­vides not only no com­pelling basis for future courts to fol­low, but also an open oppor­tu­ni­ty for the Supreme Court to clar­i­fy the law in line with its prece­dent in Estelle.

When a trans­gen­der inmate is denied a well-accept­ed course of treat­ment deter­mined by trust­wor­thy experts to be med­ical­ly nec­es­sary for their care, this con­sti­tutes a vio­la­tion of the Cru­el and Unusu­al Pun­ish­ment Clause of the Eighth Amend­ment and con­tra­venes the Supreme Court’s empha­sis on “evolv­ing stan­dards of decen­cy that mark the progress of a matur­ing soci­ety.”35

* Vir­ginia Su is a J.D. Can­di­date (2022) at New York Uni­ver­si­ty School of Law. This piece is a com­men­tary on a prob­lem pro­duced by the Evan A. Evans Moot Court Com­pe­ti­tion in Madi­son, Wis­con­sin, host­ed by the Uni­ver­si­ty of Wis­con­sin School of Law. The issue in the prob­lem dealt with the ques­tion of whether a depart­ment of cor­rec­tions’ blan­ket pol­i­cy deny­ing gen­der con­fir­ma­tion surgery con­sti­tutes delib­er­ate indif­fer­ence to a trans­gen­der inmate’s seri­ous med­ical needs in vio­la­tion of the Eighth Amendment.

1. Trop v. Dulles, 356 U.S. 86, 101 (1958).

2. See Elliot Ober­holtzer, The Dis­mal State of Trans­gen­der Incar­cer­a­tion Poli­cies, Prison Pol’y Initiative
(Nov. 8, 2017), (“Only one state, Delaware, explic­it­ly out­lined care such as surgery, elec­trol­y­sis and gyne­co­log­i­cal exams for trans peo­ple in their policy.”).

3. See World Pro­fes­sion­al Ass’n for Trans­gen­der Health (“WPATH”), Stan­dards of Care for the Health of Trans­sex­u­al, Trans­gen­der, and Gen­der Non­con­form­ing Peo­ple, Ver­sion 7 (2011) [here­inafter “WPATH”] (find­ing that GCS is essen­tial and med­ical­ly nec­es­sary for those patients for whom seri­ous symp­toms of gen­der dys­pho­ria per­sist despite alter­na­tive cours­es of treatment).

4. U.S. Con­st. amend. VIII.

5. Estelle v. Gam­ble, 429 U.S. 97, 105–06 (1976).

6. See id. at 103 (find­ing the ele­men­tary prin­ci­ples of the Eighth Amend­ment “estab­lish the government’s oblig­a­tion to pro­vide med­ical care for those whom it is pun­ish­ing by incarceration”).

7. See id.

8. See Allen J. Beck, Sex­u­al Vic­tim­iza­tion in Pris­ons and Jails Report­ed by Inmates, Bureau of Just. Stats. 9 (2014), (tables doc­u­ment­ing a recent Depart­ment of Jus­tice study of Amer­i­can pris­ons and jails show­ing that over one-third of impris­oned trans­gen­der peo­ple were sex­u­al­ly abused at least once dur­ing their term of confinement).

9. Cf. Kosilek v. Spencer, 774 F.3d 63, 73–74 (1st Cir. 2014) (find­ing “infea­si­bil­i­ty” in hous­ing a trans­gen­der inmate in either a male or female peno­log­i­cal institution).

10. Kosilek, 774 F.3d at 82.

11. See gen­er­al­ly Kosilek, 774 F.3d 63 (1st Cir. 2014); Gib­son v. Col­lier, 920 F.3d 212 (5th Cir. 2019); Edmo v. Cori­zon, Inc., 935 F.3d 757 (9th Cir. 2019).

12. Estelle, 429 U.S. at 104–05 (quot­ing Gregg v. Geor­gia, 428 U.S. 153, 173 (1976)).

13. See Kosilek, 774 F.3d at 82 (find­ing the delib­er­ate indif­fer­ence stan­dard nec­es­sar­i­ly means that “not all short­ages or fail­ures in care exhib­it the intent and harm­ful­ness required to fall with­in its ambit.”).

14. 935 F.3d 757, 786 (cit­ing Ham­by v. Ham­mond, 821 F.3d 1085, 1092 (9th Cir. 2016).

15. See Edmo, 935 F.3d at 773 (find­ing delib­er­ate indif­fer­ence where the Depart­ment of Correction’s experts tes­ti­fied that Edmo’s self-cas­tra­tion attempt was a notable esca­la­tion of her gen­der dys­pho­ria yet had con­tin­ued to sug­gest no mod­i­fi­ca­tion or esca­la­tion of treat­ment to match).

16. See Gib­son, 920 F.3d at 219 (the Court find­ing, and the state not con­test­ing, that Gibson’s record of psy­cho­log­i­cal dis­tress, sui­ci­dal ideation, and threats of self-harm all pre­sent­ed a seri­ous med­ical need).

17. Id. (empha­sis added).

18. Id. at 220 (quot­ing John­son v. Treen, 759 F.2d 1236, 1238 (5th Cir. 1985)).

19. See gen­er­al­ly Estelle, 429 U.S. 97. As the sem­i­nal case dis­cussing the Eighth Amendment’s appli­ca­tion to the med­ical needs of inmates, Estelle does not men­tion any dis­tinct require­ment for addi­tion­al mal­ice on the parts of prison offi­cials in order for a con­sti­tu­tion­al vio­la­tion to occur. Rather, the Supreme Court has tak­en the oppo­site stance. Instead of plac­ing the bur­den on the inmate to show affir­ma­tive mal­ice before being grant­ed relief, Estelle speaks broad­ly to denial of med­ical care as “unnec­es­sary suf­fer­ing [that] is incon­sis­tent with con­tem­po­rary stan­dards of decen­cy.”  Id. at 103. Fur­ther­more, in express­ly iden­ti­fy­ing acci­dents as an excep­tion to any vio­la­tion of the Eighth Amend­ment, Estelle allows the neg­a­tive infer­ence that inten­tion­al con­duct, regard­less of sub­jec­tive men­tal state, would suf­fice for a violation.

20. See Edmo, 935 F.3d at 786 (find­ing “[a]ccepted stan­dards of care and prac­tice with­in the med­ical com­mu­ni­ty” to be rel­e­vant in deter­min­ing what is med­ical­ly unac­cept­able care); see also Toguchi v. Chung, 391 F.3d 1051, 1058 (9th Cir. 2004) (find­ing a mere “dif­fer­ence of med­ical opin­ion . . . [is] insuf­fi­cient, as a mat­ter of law, to estab­lish delib­er­ate indif­fer­ence,” but not if the “cho­sen course of treat­ment ‘was med­ical­ly unac­cept­able under the cir­cum­stances’” (quot­ing Jack­son v. McIn­tosh, 90 F.3d 330, 332 (9th Cir. 1996))).

21. See e.g., Gau­dreault v. Munic­i­pal­i­ty of Salem, Mass., 923 F.2d 203, 208 (1st Cir. 1990) (stat­ing that the objec­tive prong of the Eighth Amend­ment test requires that one be “diag­nosed by a physi­cian as man­dat­ing treat­ment, or one that is so obvi­ous that even a lay per­son would eas­i­ly rec­og­nize the neces­si­ty for a doctor’s atten­tion.”); Edmo, 935 F.3d at 786 (“[U]nder the Eighth Amend­ment, we must deter­mine . . . whether the treat­ment deci­sion of respon­si­ble prison author­i­ties was med­ical­ly accept­able.”); Gib­son, 935 F.3d at 236 (dis­cussing the require­ment of med­ical neces­si­ty to sat­is­fy the sub­jec­tive prong of delib­er­ate indifference).

22. Gib­son, 920 F.3d at 220; see also Kosilek, 774 F.3d at 91–92 (“The choice of a med­ical option that, although dis­fa­vored by some in the field, is pre­sent­ed by com­pe­tent pro­fes­sion­als does not exhib­it a lev­el of inat­ten­tion or cal­lous­ness to a prisoner’s needs ris­ing to a con­sti­tu­tion­al violation.”).

23. Gib­son, 920 F.3d at 220.

24.  Id. 

25. See Edmo, 935 F.3d at 787 (look­ing pri­mar­i­ly at the record and the dis­trict court’s exten­sive fac­tu­al find­ings to con­clude that Edmo’s course of treat­ment to alle­vi­ate her gen­der dys­pho­ria “was med­ical­ly unac­cept­able under the cir­cum­stances.” (quot­ing Ham­by v. Ham­mond, 821 F.3d 1085, 1092 (9th Cir. 2016))).

26. See id. (declar­ing the WPATH Stan­dards of Care as “the undis­put­ed start­ing point in deter­min­ing the appro­pri­ate treat­ment for gen­der dys­phor­ic individuals”).

27. See id. at 767 (“We also empha­size that the analy­sis here is indi­vid­ual to Edmo and rests on the record in this case. We do not endeav­or to project whether indi­vid­u­als in oth­er cas­es will meet the thresh­old to estab­lish an Eighth Amend­ment violation.”).

28. Estelle, 429 U.S. at 106 (empha­sis added).

29. See Dan Schnei­der, Com­ment: Decen­cy, Evolved: The Eighth Amend­ment Right to Tran­si­tion in Prison, 2016 Wis. L. Rev. 835, 839 (2016) (“Not all trans­gen­der indi­vid­u­als nec­es­sar­i­ly expe­ri­ence gen­der dys­pho­ria, and those who do may expe­ri­ence it to wild­ly dif­fer­ent degrees. Some expe­ri­ence only minor but per­sis­tent dis­com­fort; oth­ers will expe­ri­ence such severe psy­chic pain that it tru­ly qual­i­fies as a men­tal dis­or­der, one that in its worst instances can lead to self-muti­la­tion and suicide.”).

30. See WPATH at 2 (Due to the wide-rang­ing expe­ri­ences of patients with gen­der dys­pho­ria, it is nec­es­sary to adopt “flex­i­ble clin­i­cal guide­lines” for each patient.)

31. See id. at 5 (describ­ing GCS as not only effec­tive treat­ment for many patients, but also “med­ical­ly nec­es­sary” for some).

32. See id. at 3 (not­ing that for many patients, relief from gen­der dys­pho­ria can­not be attained unless the patient under­goes mod­i­fi­ca­tion of their pri­ma­ry and/or sec­ondary sex char­ac­ter­is­tics to estab­lish gen­der con­gru­ence with their gen­der identity.).

33. See id. at 55.

34. See Edmo, 935 F.3d at 769.

35. Estelle, 429 U.S. at 103.