949 F.3d 489
9th Cir.2020Background
- Plaintiff Adree Edmo, a transgender woman incarcerated in Idaho, was diagnosed with gender dysphoria, received four years of hormone therapy, and requested sex‑reassignment surgery (SRS); prison clinicians (Dr. Scott Eliason and a multidisciplinary committee) declined pending stabilization of comorbid mental‑health conditions and additional evaluation of risks.
- Edmo sued under 42 U.S.C. § 1983 alleging an Eighth Amendment violation for denial of medically necessary treatment; the district court held an evidentiary hearing, credited experts aligned with WPATH Standards, and issued a preliminary (later treated as final) injunction ordering SRS.
- A Ninth Circuit three‑judge panel affirmed the injunction, finding SRS "medically necessary" and concluding defendants acted with deliberate indifference.
- This opinion is Judge O’Scannlain’s dissent from the denial of rehearing en banc (joined by several judges), arguing the panel erred by treating WPATH as the constitutional standard, collapsing the deliberate‑indifference test into negligence, and creating a circuit split.
- Dissenters emphasize (1) the absence of medical consensus on WPATH criteria, (2) that reasonable medical disagreement (dueling experts) cannot satisfy the subjective deliberate‑indifference standard, and (3) conflicts with First, Fifth, and Tenth Circuit precedents that refused to require SRS.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether denial of SRS violated the Eighth Amendment (deliberate indifference) | Edmo: SRS is medically necessary under WPATH; denial was conscious disregard of serious medical need | Idaho/Eliason: Continued hormones + counseling is a medically acceptable, prudent alternative given comorbidities and suicide risk | Panel: Affirmed injunction, finding deliberate indifference; dissent: panel erred—treatment was within acceptable medical judgment and not deliberate indifference |
| Role of WPATH Standards in defining constitutionally adequate care | Edmo: WPATH is the applicable "gold standard" and supports SRS eligibility | Idaho: WPATH is guidance only, not definitive; physicians may reasonably deviate | Panel: Relied heavily on WPATH to find doctor’s care unacceptable; dissent: unconstitutional to constitutionalize a private, contested standard |
| Proper legal test for "medically unacceptable" care and subjective state of mind | Edmo: Deviation from WPATH shows medical unacceptability and awareness of excessive risk | Idaho: Deliberate indifference requires subjective knowledge/recklessness, not mere disagreement or negligence | Panel: Infers deliberate indifference from medical unacceptability; dissent: this collapses subjective culpability into negligence and violates Farmer precedent |
| Weight to give competing expert testimony and procedural handling | Edmo: District court correctly credited experts who applied WPATH | Idaho: District court improperly discounted State experts and possibly consolidated preliminary injunction into final trial without clear notice | Panel/District Court: Credited plaintiff’s experts and entered/affirmed injunction; dissent: record shows dueling experts—reasonable disagreement precludes Eighth Amendment liability |
| Whether Ninth Circuit’s decision conflicts with other circuits | N/A (plaintiff relied on WPATH authority) | Idaho: Other circuits have refused to require SRS and treat WPATH as non‑binding | Held: Ninth panel created a split; dissenters stressed conflict with First (Kosilek), Fifth (Gibson), and Tenth (Lamb) Circuits |
Key Cases Cited
- Estelle v. Gamble, 429 U.S. 97 (1976) (Eighth Amendment deliberate‑indifference standard for prisoner medical care)
- Farmer v. Brennan, 511 U.S. 825 (1994) (subjective knowledge/recklessness requirement for deliberate indifference)
- Jackson v. McIntosh, 90 F.3d 330 (9th Cir. 1996) (two‑part test: medically unacceptable course + conscious disregard of excessive risk)
- Snow v. McDaniel, 681 F.3d 978 (9th Cir. 2012) (difference of medical opinion insufficient for deliberate indifference)
- Kosilek v. Spencer, 774 F.3d 63 (1st Cir. en banc 2014) (reversing injunction for SRS; WPATH not dispositive and reasonable disagreement precludes Eighth Amendment liability)
- Gibson v. Collier, 920 F.3d 212 (5th Cir. 2019) (declining to recognize Eighth Amendment claim for SRS amid substantial medical disagreement)
- Lamb v. Norwood, 899 F.3d 1159 (10th Cir. 2018) (summary judgment for defendants where licensed physicians recommended conservative therapy over SRS)
- Wilson v. Seiter, 501 U.S. 294 (1991) (Eighth Amendment proscribes deliberate acts intended to chastise/deter; deliberate indifference requires more than inadvertence)
- Whitley v. Albers, 475 U.S. 312 (1986) (Eighth Amendment requires obduracy and wantonness, not mere lack of due care)
- Toguchi v. Chung, 391 F.3d 1051 (9th Cir. 2004) (deliberate indifference is a high legal standard; evaluation of medical judgments)