Kosilek v. Spencer
2014 U.S. App. LEXIS 23673
| 1st Cir. | 2014Background
- Michelle Kosilek, an anatomically male prisoner diagnosed with gender identity disorder (GID), received hormones, electrolysis, female clothing/accessories, and psychotherapy from Massachusetts DOC but sought sex reassignment surgery (SRS).
- After initial litigation (Kosilek I) the DOC revised its GID policy to permit additional treatment when medically required; UMass and Fenway clinicians evaluated Kosilek and Fenway recommended SRS as medically necessary.
- The DOC obtained a peer review (Cynthia Osborne) and raised post-operative housing and safety/security concerns (risk of assault in male facility; disruption and lack of single cells in female facility; isolation harms if segregated housing used).
- The district court found SRS medically necessary, concluded the DOC’s security reasons were pretextual and motivated by political pressure, and enjoined the DOC to provide SRS.
- The First Circuit (en banc) reviewed whether the DOC’s chosen non-surgical treatment violated the Eighth Amendment (objective: serious medical need / adequacy of care; subjective: deliberate indifference), reversed the injunction, and remanded with instructions to dismiss.
Issues
| Issue | Plaintiff's Argument (Kosilek) | Defendant's Argument (DOC) | Held |
|---|---|---|---|
| Whether DOC’s treatment without SRS is constitutionally inadequate (objective prong) | SRS is medically necessary under the Standards of Care; alternatives will not prevent deterioration or suicide | DOC’s regimen (hormones, electrolysis, clothing, psychotherapy, suicide-response plans) is within prudent professional standards and adequate | Court: DOC’s chosen treatment is within acceptable medical standards; denial of SRS alone did not violate the Eighth Amendment objective prong |
| Whether DOC acted with deliberate indifference (subjective prong) | DOC knew SRS was necessary (UMass/Fenway) but denied it, exhibiting obstinacy and pretextual motives | DOC reasonably relied on alternative expert opinions and legitimate security concerns; acted in good faith | Court: No deliberate indifference — DOC reasonably relied on competent medical opinions and legitimate penological security judgments |
| Weight to give prison security concerns when assessing Eighth Amendment claims | Security concerns cannot justify deliberate indifference to a medically necessary, life‑saving treatment | Security and housing feasibility are central; courts must defer to prison administrators unless concerns are plainly unreasonable or pretextual | Court: Deference to DOC’s security assessments appropriate here; security concerns were reasonable and not shown wholly pretextual |
| Standard of review on appeal (mixed legal/factual questions) | (Implicit) defer to district court’s factual findings and credibility | (DOC) appellate review of legal application; court may review de novo mixed questions | Court: ultimate constitutional conclusions reviewed de novo but factual findings and credibility get deference; on this record de novo review supports reversal of injunction |
Key Cases Cited
- Estelle v. Gamble, 429 U.S. 97 (1976) (Eighth Amendment forbids deliberate indifference to serious medical needs)
- Farmer v. Brennan, 511 U.S. 825 (1994) (deliberate indifference requires actual knowledge and disregard of substantial risk)
- Helling v. McKinney, 509 U.S. 25 (1993) (Eighth Amendment protects against unreasonable risk of future harm)
- Baze v. Rees, 553 U.S. 35 (2008) (risk-of-harm principle relevant to Eighth Amendment analysis)
- Whitley v. Albers, 475 U.S. 312 (1986) (wide deference to prison administrators on security measures)
- Ornelas v. United States, 517 U.S. 690 (1996) (discussing de novo review of mixed questions in a different doctrinal context)
- Torraco v. Maloney, 923 F.2d 231 (1st Cir. 1991) (Eighth Amendment: adequacy of care must not shock the conscience)
- DesRosiers v. Moran, 949 F.2d 15 (1st Cir. 1991) (bench-trial factual findings reviewed for clear error)
- Leavitt v. Corr. Med. Servs., Inc., 645 F.3d 484 (1st Cir. 2011) (overlap of objective/subjective prongs; medical-need elasticity)
- Battista v. Clarke, 645 F.3d 449 (1st Cir. 2011) (security considerations and deliberate-indifference analysis)