first circuit upholds order requiring prison to offer sex change operation

8/13/2019 First Circuit upholds order requiring prison to offer sex change operation

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United States Court of AppealsFor the First Circuit

No. 12- 2194

MI CHELLE KOSI LEK,

Pl ai nt i f f , Appel l ee,

v.

LUI S S. SPENCER, Commi ss i oner of t heMassachuset t s Depart ment of Corr ect i on,

Def endant , Appel l ant .

APPEAL FROM THE UNI TED STATES DI STRI CT COURTFOR THE DI STRI CT OF MASSACHUSETTS

[ Hon. Mar k L. Wol f , U. S. Di st r i ct J udge]

Bef or e

Tor r uel l a, Thompson, and Kayat t a,Ci r cui t J udges.

Ri char d C. McFar l and, Legal Di vi si on, Depar t ment of Cor r ect i on, wi t h whom Nancy Anker s Whi t e, Speci al Assi st antAt t or ney Gener al , was on br i ef , f or appel l ant .

Fr ances S. Cohen, wi t h whom J ef f Gol dman, Chr i st i na Chan,Bi ngham McCut chen LLP, J oseph L. Sul man, Davi d Br ody, and LawOf f i ce of J oseph L. Sul man, wer e on br i ef , f or appel l ee.

Andr ew D. Beckwi t h on br i ef f or t he Massachuset t s Fami l yI nst i t ut e, ami cus cur i ae i n suppor t of appel l ant .Cor i A. Labl e, Dani el V. McCaughey, Kr i st i n G. Al i , and Ropes

& Gr ay LLP on br i ef f or Wor l d Pr of essi onal Associ at i on f or Tr ansgender Heal t h, Ment al Heal t h Amer i ca, Cal l en- Lor de Communi t yHeal t h Cent er , Whi t man- Wal ker Heal t h, GLMA: Heal t h Pr of essi onal sAdvanci ng LGBT Equal i t y, and Mazzoni Cent er , ami ci cur i ae i nsuppor t of appel l ee.

J oshua Bl ock, Mat t hew R. Segal , and Davi d C. Fat hi on br i ef


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f or Amer i can Ci vi l Li ber t i es Uni on, Amer i can Ci vi l Li ber t i es Uni onof Massachuset t s, Legal Ai d Soci et y, Har var d Pr i son LegalAssi st ance Pr oj ect , Pr i soner s' Legal Ser vi ces of New Yor k, andPr i soner s' Legal Ser vi ces of Massachuset t s, ami ci cur i ae i n suppor tof appel l ee.

J enni f er Levi and Bennet t H. Kl ei n on br i ef f or Gay & Lesbi an

Advocat es & Def ender s, Equal i t yMai ne, Human Ri ght s Campai gn,MassEqual i t y, Massachuset t s Tr ansgender Pol i t i cal Coal i t i on,Nat i onal Cent er f or Tr ansgender Equal i t y, Nat i onal Gay & Lesbi an Task For ce, and Tr ansgender New Hampshi r e, ami ci cur i ae i n suppor tof appel l ee.

J anuar y 17, 2014

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THOMPSON, Circuit Judge. Twent y year s af t er pr i son

i nmat e Mi chel l e Kosi l ek f i r st r equest ed t r eat ment f or her sever e

gender i dent i t y di sor der , t he di st r i ct cour t i ssued an or der

r equi r i ng t he def endant , Lui s S. Spencer , Commi ssi oner of t he

Massachuset t s Depart ment of Corr ect i on ( t he "DOC") , 1 t o pr ovi de

Kosi l ek wi t h sex r eassi gnment surger y. The cour t f ound t hat t he

DOC' s f ai l ur e t o pr ovi de the sur ger y —whi ch was sai d by a gr oup of

qual i f i ed doct or s t o be medi cal l y necessar y to t r eat Kosi l ek' s

condi t i on — vi ol at ed Kosi l ek' s Ei ght h Amendment r i ght s. The DOC

appeal s t he di st r i ct cour t ' s or der . Havi ng car ef ul l y consi der ed

t he r el evant l aw and t he ext ensi ve f act ual r ecor d, we af f i r m t he

j udgment of t he di st r i ct cour t .

I. BACKGROUND

A. Gender Identity Disorder and Sex Reassignment Surgery

The concept s of gender i dent i t y di sor der and sex

r eassi gnment sur ger y si t cent er st age i n t hi s case and f eat ur e

pr omi nent l y i n t hi s opi ni on. Ther ef or e, bef or e we go any f ur t her ,

we pr ovi de a l i t t l e cont ext . As t hi s cour t has expl ai ned, gender

i dent i t y di sor der i s " a psychol ogi cal condi t i on i nvol vi ng a st r ong

i dent i f i cat i on wi t h t he ot her gender . " Bat t i st a v. Cl ar ke, 645

F. 3d 449, 450 ( 1st Ci r . 2011) . I t i s a di sor der r ecogni zed by t he

Amer i can Psychi at r i c Associ at i on, whi ch descr i bes gender i dent i t y

1 For ease of r ef er ence we wi l l speak of t he def endant as t heDOC, si nce t he DOC' s commi ss i oner has changed mul t i pl e t i mes dur i ngt he l i f e span of Kosi l ek' s l awsui t s.

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di sorder as havi ng t wo component s. Amer i can Psychi at r i c Ass' n,

Di agnost i c and St at i st i cal Manual of Ment al Di sor der s, Four t h

Edi t i on - Text Revi si on 576 ( 2000) ( "DSM- I V- TR") . 2 The f i r s t i s

"evi dence of a st r ong and per si st ent cr oss- gender i dent i f i cat i on,

whi ch i s t he desi r e t o be, or t he i nsi st ence t hat one i s, of t he

ot her sex. " I d. The second i s "evi dence of per si st ent di scomf or t

about one' s assi gned sex or a sense of i nappr opr i at eness i n t he

gender r ol e of t hat sex. " I d.

Thi s cur r ent di agnosi s of gender i dent i t y di sor der grew

out of an ear l i er di agnosi s of t r anssexual i sm, whi ch f i r st appear ed

as an of f i ci al di sor der i n t he t hi r d edi t i on of t he DSM, publ i shed

i n 1980. J udi t h S. St er n & Cl ai r e V. Mer ki ne, Br i an L. v. Admi n.

f or Chi l dr en' s Ser vi ces: Ambi val ence Towar d Gender I dent i t y

Di sor der as a Medi cal Condi t i on, 30 Women' s Rt s. L. Rep. 566, 567-

68 ( 2009) . I n t he 1950s and 1960s, r esear ch began t o show t hat a

"combi nat i on of psychot herapy, hormone t r eat ment , and surgi cal

r econf i gur at i on of t he geni t al i a" coul d be used t o t r eat gender

i dent i t y di sor der . I d. at 571. Thi s i dea gai ned t r act i on i n t he

1960s and 1970s, i d. , and as we wi l l di scuss mor e f ul l y bel ow, t hi s

2 DSM- I V- TR, t he ver si on appl i cabl e i n Kosi l ek' s cases, usest he t er m gender i dent i t y di sor der . A newer edi t i on, DSM- 5, was

r el eased i n May 2013. DSM- 5 r epl aces t he t er m gender i dent i t ydi sorder wi t h gender dysphor i a t o avoi d any negat i ve st i gma. SeeAmer i can P s ychi at r i c As s ' n, Gender Dy s phor i a,ht t p: / / www. dsm5. org/ Document s/ Gender %20Dysphor i a%20Fact %20Sheet . pdf ( l ast vi si t ed J an. 16, 2014) . Because t he t er m gender i dent i t ydi sor der was used t hr oughout Kosi l ek' s cases and was t he then-appr opr i ate nomencl at ur e, we wi l l use t hat t er m.

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t r i adi c appr oach i s st i l l ut i l i zed by many pr act i t i oner s t oday.

Sex r eassi gnment surger y i n par t i cul ar has been per f ormed i n Nor t h

Amer i ca si nce at l east t he 1950s, and i t has been est i mat ed t hat as

of J anuary 2006, 30, 000 sex r eass i gnment surger i es have been

per f or med i n t he Uni t ed St at es. I d. at 571- 72.

Wi t h t hi s bi gger pi ct ur e i n pl ace, we move on t o t he

f act s of t hi s case. We agai n not e t hat t hi s case has an over

t went y- year hi st or y. Thi s has i ncl uded t wo t r i al s and t wo l engt hy,

f act- i nt ensi ve deci si ons i ssued by t he di st r i ct cour t , t he l at t er

of whi ch i s t he subj ect mat t er of t hi s appeal . Because of t hi s,

and because t he di st r i ct cour t ' s opi ni on was so f act - i nt ensi ve, i t

i s necessar y f or us t o l ay out a good deal of backgr ound.

B. Kosilek's Conviction

Mi chel l e Kosi l ek, née Rober t , who i s si xt y- f our year s

ol d, was bor n and st i l l i s anat omi cal l y mal e. Kosi l ek suf f er s f r om

gender i dent i t y di sor der . Thi s has r esul t ed i n Kosi l ek' s l ong- hel d

bel i ef t hat she3 i s a woman cr uel l y t r apped i n a man' s body.

Kosi l ek, who spent some of her chi l dhood i n an or phanage,

suf f er ed r egul ar abuse as a chi l d, i n par t because of her expr essed

desi r e t o l i ve as a gi r l . As she gr ew ol der , she al t er nat ed

between l i vi ng as a man and a woman. Kosi l ek' s t eenage and ear l y

3 We wi l l r ef er t o Kosi l ek as her pr ef er r ed gender of f emal e,usi ng f emi ni ne pr onouns.

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adul t year s wer e mar r ed by ar r est s, i ncar cer at i ons, beat i ngs, heavy

dr i nki ng, dr ug use, and a st i nt as a pr ost i t ut e.

Somet i me i n t he 1980s, Kosi l ek marr i ed Cheryl McCaul , a

vol unt eer counsel or at a dr ug r ehabi l i t at i on f aci l i t y, who Kosi l ek

met whi l e bei ng t r eat ed t here. McCaul t hought she coul d cur e

Kosi l ek' s gender i dent i t y di sor der , but Kosi l ek' s desi r e t o be

f emal e di d not go away. I n 1990, Kosi l ek mur dered McCaul . Kosi l ek

f l ed t he ar ea but was ul t i matel y appr ehended i n New Yor k.

Kosi l ek awai t ed t r i al at t he Br i st ol Count y J ai l . Whi l e

t here, Kosi l ek, who had t aken f emal e hormones many years ear l i er ,

st ar t ed t aki ng f emal e hor mones ( i n t he f or mof bi r t h cont r ol pi l l s)

t hat she i l l i ci t l y obt ai ned f r om a guar d. She al so, at her own

expense, consul t ed wi t h a gender i dent i t y di sor der speci al i st ,

t hough she was not al l owed t o undergo any t r eat ment . Whi l e

awai t i ng t r i al , Kosi l ek t wi ce t r i ed t o ki l l her sel f ; one at t empt

was made whi l e she was t aki ng t he ant i depr essant Prozac. Kosi l ek

al so at t empt ed sel f - cast r at i on.

Kosi l ek was event ual l y t r i ed and, i n 1992, was convi ct ed

of McCaul ' s mur der and sent enced t o l i f e i n pr i son wi t hout t he

possi bi l i t y of par ol e. She was t ur ned over t o t he DOC and si nce

1994 has been r esi di ng i n t he gener al popul at i on at MCI - Nor f ol k, a

medi umsecur i t y mal e pr i son. Ther e Kosi l ek st ar t ed l i vi ng, t o t he

ext ent possi bl e, as a woman, l egal l y changi ng her name f r omRobert

t o Mi chel l e.

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C. Kosilek's Lawsuits

I n 1992, Kosi l ek f i l ed a pr o se compl ai nt agai nst t he DOC

i n t he Uni t ed St at es Di st r i ct Cour t f or t he Di st r i ct of

Massachuset t s. 4 See Kosi l ek v. Mal oney, 221 F. Supp. 2d 156 ( D.

Mass. 2002) ( "Kosi l ek I " ) . Kosi l ek al l eged t he DOC was denyi ng her

adequate medi cal care i n vi ol at i on of t he Ei ght h Amendment .

Kosi l ek sought damages and an i nj unct i on order i ng t hat she be

pr ovi ded wi t h sex r eass i gnment surgery. The case was assi gned t o

J udge Mar k L. Wol f , and proceeded f or some years wi t h t he par t i es

engagi ng i n di scover y and mot i on pr act i ce.

Meanwhi l e, i n December 2000, havi ng not yet r ecei ved t he

r el i ef she was seeki ng, Kosi l ek f i l ed t hi s case — a second pr o se

l awsui t agai nst t he DOC and some of i t s medi cal pr ovi der s. See

Kosi l ek v. Spencer , 889 F. Supp. 2d 190 ( D. Mass. 2012) ( "Kosi l ek

I I " ) . Agai n t he gr avamen of Kosi l ek' s compl ai nt was that t he DOC

was denyi ng her adequat e medi cal car e i n vi ol at i on of t he Ei ght h

Amendment by not pr ovi di ng her wi t h sex r eass i gnment sur gery. Thi s

case al so went t o J udge Wol f .

I n Febr uar y 2002, Kosi l ek' s f i r st l awsui t , Kosi l ek I ,

f i nal l y pr oceeded t o a non- j ur y t r i al . Due t o some pr et r i al

ski r mi shi ng, onl y Kosi l ek' s cl ai m f or i nj uncti ve r el i ef r emai ned

( her damages cl ai m was gone) . The t r i al l ast ed a coupl e of weeks.

4 Kosi l ek i ni t i al l y sued t he Br i st ol Count y Sher i f f , but l at eramended t he compl ai nt t o i ncl ude t he DOC af t er she was t r ansf err edt o i t s cust ody.

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D. The Kosilek I Decision

On August 28, 2002, J udge Wol f i ssued hi s deci si on. See

Kosi l ek I , 221 F. Supp. 2d at 156. The cour t expl ai ned t hat t o

make out an Ei ght h Amendment vi ol at i on, both an obj ect i ve and a

subj ect i ve component must be sat i sf i ed. I n shor t , t he obj ect i ve

component r equi r es t hat t he i nmate has a ser i ous medi cal need that

has not been adequat el y t r eat ed. The subj ect i ve pi ece, on t he

ot her hand, f ocuses on t he st at e of mi nd of t he pr i son of f i ci al s

and r equi r es t hat t hey were aware t he i nmate was at r i sk f or

ser i ous har m. 5

The cour t f ound t hat Kosi l ek suf f er ed f r oma severe f or m

of gender i dent i t y di sorder t hat caused her gr eat ment al angui sh.

I t went on t o hol d t hat t hi s di sorder was a ser i ous medi cal need

wi t hi n t he meani ng of t he Ei ght h Amendment . To addr ess t he i ssue

of what t ypes of t r eat ment mi ght be war r ant ed, t he cour t l ooked t o

t he Har r y Benj ami n St andar ds of Car e ( t he "Standar ds of Car e") , 6

whi ch i t f ound t o be t he accept ed pr ot ocol s used by pr of essi onal s

5 We wi l l go i nt o much gr eat er dept h regar di ng the Ei ght hAmendment st andar d i n our own anal ysi s, but f or now i t suf f i ces t oi nt r oduce t he concept of t he t wo- pr onged t est .

6 The oper at i ve ver si on of t he St andar ds of Car e f or bot hKosi l ek I and Kosi l ek I I i s t he Si xt h Ver si on, i ssued i n Febr uar y

2001. See Har r y Benj ami n I nt ' l Gender Dysphor i a Ass' n, St andar dsof Car e f or Gender I dent i t y Di sor der s, Si xt h Ver si on ( 2001) . TheSeventh Ver si on came out i n 2011 under a new name. Wor l dPr of essi onal Associ at i on f or Tr ansgender Heal t h, St andar ds of Car ef or t he Heal t h of Transsexual , Transgender , and Gender -Nonconf ormi ng Peopl e, Versi on 7 ( 2011) ( t he "St andards of Care,Ver si on 7" ) .

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i n t he Uni t ed St at es t o t r eat gender i dent i t y di sor der . The

St andar ds of Car e i ndi cat ed t hat , dependi ng on t he sever i t y of an

i ndi vi dual ' s gender i dent i t y di sor der , psychot her apy al one or

psychot herapy al ong wi t h t he admi ni st r at i on of f emal e hormones

coul d const i t ut e suf f i ci ent t r eat ment . I n ot her i nst ances,

however , sex r eass i gnment surgery was medi cal l y necessary. The

cour t f ound t hat , despi t e DOC doctors r ecommendi ng t hat Kosi l ek

r ecei ve f emal e hormones and possi bl y surgery, t he DOC, whi ch at t he

t i me was headed up by Commi ssi oner Mi chael Mal oney, had not

pr ovi ded Kosi l ek wi t h any of t he t r eat ment pr escr i bed by t he

St andards of Care.

The cour t chr oni cl ed t he st eps t aken by Mal oney t o avoi d

pr ovi di ng Kosi l ek wi t h t r eat ment . Fi r st , when an exper t hi r ed by

t he DOC, Marshal l For st ei n, M. D. , r ecommended psychotherapy and

hor mones f or Kosi l ek, and al so, t hat she be al l owed t o consul t wi t h

a sur geon who speci al i zed i n sex reass i gnment surgery, t he DOC

t er mi nat ed i t s r el at i onshi p wi t h Dr . For st ei n. Mal oney t hen made

i t cl ear t o DOC doct or s t hat he di d not want t o pr ovi de Kosi l ek or

any t r ansgender pr i soner wi t h hormones or sur ger y, and t he DOC

pr oceeded t o f i nd a Canadi an doct or , Rober t Di ckey, M. D. , who

bel i eved i nmates shoul d never be consi dered f or sex reass i gnment

surger y. Dr . Di ckey advocat ed a " f r eeze- f r ame" pol i cy wher eby

t r ansgender i ndi vi dual s woul d be f r ozen i n t he f r ame i n whi ch t hey

ent er ed pr i son. For i nst ance, onl y per sons recei vi ng hor mones

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bef or e t hey wer e i n pr i son woul d get hor mones i n pr i son. Despi t e

Mal oney havi ng l i t t l e f ami l i ar i t y wi t h t he r at i onal e behi nd Dr .

Di ckey' s phi l osophy on t he t r eat ment of gender i dent i t y di sorder ,

and not havi ng read the St andards of Care, Mal oney adopt ed Dr .

Di ckey' s f r eeze- f r ame pol i cy f or t he DOC.

Dr . Di ckey t est i f i ed at t r i al , but t he cour t di d not f i nd

hi m per suasi ve because he di d not subscr i be t o t he St andar ds of

Car e, whi ch t he cour t f ound t hat pr udent pr of essi onal s f ol l ow, and

hi s appr oach di d not al l ow f or i ndi vi dual assessment . The cour t

f ound Kosi l ek' s exper t s credi bl e and r el i ed on t hei r t est i mony t o

f i nd that t he obj ect i ve component of t he Ei ght h Amendment had been

sat i sf i ed, namel y that Kosi l ek had a ser i ous medi cal need t hat had

not been adequatel y t r eat ed.

But t he cour t f ound Kosi l ek had f al l en shor t of

est abl i shi ng an Ei ght h Amendment vi ol at i on because t he subj ect i ve

component of del i ber at e i ndi f f er ence had not been sat i sf i ed.

Mal oney, t he cour t concl uded, knew many f act s f r om whi ch he coul d

have i nf er r ed Kosi l ek woul d suf f er ser i ous har m i f her gender

i dent i t y di sor der was not t r eat ed, but he di d not act ual l y dr aw

t hat r equi r ed i nf er ence. I nst ead J udge Wol f f ound Mal oney' s

r ef usal t o al l ow Kosi l ek t r eat ment was " r oot ed i n si ncer e secur i t y

concer ns, and i n a f ear of publ i c and pol i t i cal cri t i ci smas wel l . "

The end r esul t : because t her e was no Ei ght h Amendment vi ol at i on,

t he cour t di d not or der t he DOC t o do anythi ng.

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Nonethel ess, J udge Wol f expected i t woul d do somethi ng.

He wr ot e: "Thi s cour t ' s deci si on put s Mal oney on not i ce that

Kosi l ek has a ser i ous medi cal need whi ch i s not bei ng pr oper l y

t r eat ed. Ther ef or e, he has a dut y t o r espond r easonabl y t o i t .

The cour t expect s t hat he wi l l . "

E. The After-Effects of Kosilek I

Fol l owi ng t he cour t ' s di ct at e, l ot s of act i vi t y ensued at

t he DOC. Fi r st , t he DOC l i f t ed i t s f r eeze- f r ame pol i cy ar ound

December 2002. I n i t s pl ace went a pol i cy al l owi ng i nmat es

suf f er i ng f r om gender i dent i t y di sor der t o r ecei ve a l evel of

t r eat ment commensur ate wi t h that whi ch t hey were recei vi ng upon

ent er i ng pr i son ( i ncl udi ng r ecei pt of hor mones) , but al so pr ovi di ng

f or i ncr eased or decr eased t r eat ment i f i t was det ermi ned t o be

medi cal l y i ndi cat ed by t he Uni ver si t y of Massachuset t s Cor r ect i onal

Heal t h Pr ogr am( "UMass" ) , t he ent i t y under cont r act wi t h t he DOC t o

pr ovi de medi cal ( i ncl udi ng ment al heal t h) ser vi ces t o al l i nmat es.

Pr i or t o t he i mpl ement at i on of any pr ogr essi ve or r egr essi ve

t r eat ment changes, t he DOC' s Di r ect or of Heal t h Ser vi ces and t he

Commi ss i oner were requi r ed t o consi der whether t he changes woul d

r esul t i n any saf et y or secur i t y concer ns.

A coupl e of mont hs l ater , i n Febr uary 2003, t he DOC

br ought i n a gender i dent i t y speci al i st , Davi d Sei l , M. D. , t o

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eval uat e Kosi l ek. 7 Dr . Sei l i nt er vi ewed Kosi l ek and r evi ewed her

medi cal r ecor ds, and t hen conveyed hi s f i ndi ngs and r ecommendat i on

i n wr i t i ng. Per DOC pol i cy, whi ch r equi r ed any r ecommendat i ons

i nvol vi ng gender i dent i t y di sorder t o go to bot h UMass' s Medi cal

Di r ect or and i t s Ment al Heal t h Pr ogr amDi r ect or , t he r epor t went t o

Kennet h Appel baum, M. D. , who hel d t he l at t er posi t i on.

Dr . Sei l wr ot e t he f ol l owi ng. Li ke Dr s. For st ei n and

Di ckey bef or e hi m, he di agnosed Kosi l ek wi t h gender i dent i t y

di sorder . He f ound Kosi l ek' s "gender dysphor i a8 i nt ense, " and

t hough Kosi l ek had done what she coul d t o obt ai n r el i ef by l i vi ng

as a woman, her basi c di sor der had been l ef t unt r eat ed dur i ng her

i ncar cer at i on. Dr . Sei l , who not ed t hat Kosi l ek had been l i vi ng as

a woman i n a mal e pr i son wi t hout secur i t y i ssues t hus f ar ,

i ndi cat ed t hat t he St andar ds of Car e "need[ ed] t o be observed. " He

f ur t her f ound t hat Kosi l ek was not cur r ent l y sui ci dal because she

t hen f el t some power over her pur sui t of becomi ng a woman.

7 UMass' s pol i cy was t o ut i l i ze consul t ant s i n mat t er s t hatwent beyond t he exper t i se of i t s di r ect st af f .

8 Dr . Sei l , and var i ous ot her medi cal pr ovi der s i nvol ved i nt hi s case, somet i mes use t he t er m gender dysphor i a. As i ndi cat edpr evi ousl y, t he Amer i can Psychi at r i c Associ at i on now uses t hi s t er mi n pl ace of gender i dent i t y di sor der . The cur r ent ver si on of t he

St andar ds of Car e says gender dysphor i a i s " br oadl y def i ned asdi scomf or t or di st r ess t hat i s caused by a di scr epancy bet ween aper son' s gender i dent i t y and t hat per son' s sex assi gned at bi r t h. "St andar ds of Car e, Ver si on 7, at 2. I t i s not cer t ai n whet her t hemedi cal pr ovi der s i n t hi s case wer e al l usi ng t he t er m genderdysphor i a t o mean pr eci sel y t he same thi ng but , at a mi ni mum, i tappear s t hey wer e al l usi ng i t si mi l ar l y.

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Dr . Sei l made sever al r ecommendat i ons. Fi r st , Kosi l ek

shoul d be pr ovi ded wi t h est r ogen t her apy, el ect r ol ysi s

( speci f i cal l y, per manent f aci al hai r r emoval ) , and access t o

gender - appr opr i at e per sonal i t ems, such as f emal e cl ot hi ng and

make- up. Addi t i onal l y, Kosi l ek shoul d be al l owed t o see t he

t her api st she had been t r eat i ng wi t h, mast er ' s- l evel psychol ogi st

Mark Bur r owes, more of t en t han once a mont h. Fur t her , f emi ni zi ng

pr ocedur es, such as r hi nopl ast y (pl ast i c sur ger y per f or med on t he

nose) or br east augment at i on, shoul d be consi der ed i n t he f ut ur e.

Fi nal l y, Dr . Sei l not ed t hat sex reassi gnment sur ger y was t he l ast

st ep i n t r eat i ng gender i dent i t y di sor der . He expl ai ned t hat , as

pr ovi ded i n t he St andar ds of Car e, an eval uat i on of t he necessi t y

of t he surger y must wai t unt i l af t er a pat i ent has l i ved as a woman

f or at l east a year . 9 Whi l e Kosi l ek had been l i vi ng as a woman f or

many years, she had not had t he benef i t of hor mone ther apy and

el ect r ol ysi s. Ther ef or e Dr . Sei l r ecommended t hat af t er Kosi l ek

had a year of hor mone t r eat ment under her bel t , an exper i enced

gender i dent i t y speci al i st shoul d eval uat e her t o det er mi ne whet her

surger y was needed.

9 Dr . Sei l was r ef er r i ng t o t he f act t hat t he St andar ds of Car e requi r e t hat pr i or t o recei vi ng sex reassi gnment sur ger y, aper son must l i ve f ul l - t i me f or one year i n t he pr ef er r ed genderr ol e. Thi s r equi r ement i s commonl y cal l ed t he r eal - l i f eexper i ence, and i t i s somet hi ng we wi l l di scuss i n mor e det ai ll at er .

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The DOC began i mpl ement i ng Dr . Sei l ' s r ecommendat i ons.

I n Apr i l 2003, Kosi l ek st ar t ed t r eat i ng wi t h an endocr i nol ogi st t o

devel op a hormone t herapy t r eat ment pl an. Concomi t ant l y, per DOC

pol i cy, t he secur i t y i mpl i cat i ons of Kosi l ek r ecei vi ng hor mones

were assessed. On J ul y 29, 2003, Lui s Spencer , now t he DOC

Commi ssi oner but t hen t he Super i nt endent of MCI - Nor f ol k, r epor t ed

t o t hen DOC Commi ss i oner Mal oney that he di d not bel i eve t here were

any cur r ent secur i t y concer ns wi t h Kosi l ek bei ng pr ovi ded est r ogen

t her apy, but once Kosi l ek began t o exhi bi t physi cal changes

secur i t y concer ns mi ght have t o be reeval uat ed.

And so on August 26, 2003, Kosi l ek began f emal e hormone

t r eat ment . Then, st ar t i ng i n Oct ober 2003, Kosi l ek was pr ovi ded

wi t h cer t ai n gender - appr opr i at e i t ems, such as f emal e under gar ment s

and make- up. As nei t her Dr . Sei l nor t he endocr i nol ogi st Kosi l ek

was t r eat i ng wi t h had made speci f i c r ecommendat i ons as t o whether

f emi ni zi ng pr ocedur es were needed, none were pr ovi ded. The DOC di d

f i nd a f aci l i t y wi l l i ng t o pr ovi de Kosi l ek wi t h el ectr ol ysi s and,

af t er a secur i t y revi ew of t he f aci l i t y was conducted, el ect r ol ysi s

t r eat ment s were schedul ed f or November t he f ol l owi ng year .

I n December 2003, Kat hl een Dennehy, who had been t he

DOC' s Deputy Commi ssi oner under Mal oney, was el evat ed t o

Commi ss i oner . Ri ght away she i nf ormed t he st af f she want ed t o

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"r egr oup on t hi s GI D st uf f . "10 And she want ed Kosi l ek r eeval uated

bef or e appr ovi ng " l aser hai r r emoval or anythi ng el se. "11

As of September 2004, Kosi l ek had been on hor mones f or a

year and, pur suant t o the St andar ds of Car e and Dr . Sei l ' s

r ecommendat i on, was el i gi bl e to be eval uated f or sex reass i gnment

sur ger y. The i ssue of conduct i ng eval uat i ons f or pr i soner s wi t h

gender i dent i t y di sorder was t aken up at execut i ve st af f meet i ngs,

at t ended by UMass and DOC personnel , around t hi s t i me. Those

t ypi cal l y i n at t endance f r om t he DOC i ncl uded Susan Mar t i n, t he

DOC' s Di r ect or of Heal t h Servi ces, and Gr egory Hughes, t he DOC' s

Di r ect or of Ment al Heal t h and Subst ance Abuse Ser vi ces, as wel l as

a coupl e ot her DOC of f i ci al s. Repr esent i ng UMass was i t s Ment al

Heal t h Progr am Di r ect or Dr . Appel baum, al ong wi t h some addi t i onal

UMass per sonnel .

At one meet i ng, Dr . Appel baum spoke about r et ai ni ng the

Fenway Communi t y Heal t h Cent er ( t he "Fenway Cent er " ) , a Bost on

heal t hcar e f aci l i t y f ocused on ser vi ng t he l esbi an, gay, bi sexual ,

and t r ansgender communi t y. Hughes, however , had some r eser vat i ons;

he f el t t he Fenway Cent er mi ght be t oo sympathet i c t o t he pr i soners

and t oo qui ck t o r ecommend t r eat ment . Dr . Appel baum count ered,

st at i ng t he Fenway Cent er ' s appr oach r epr esent ed t he nor m r at her

10 "GI D" i s an acronym f or gender i dent i t y di sor der .

11 I t i s uncl ear f r om t he r ecor d what happened, i f anyt hi ng,based on Dennehy' s desi r es t o r egr oup and reeval uate.

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t han t he except i on and t here real l y were not many ot her pr ovi ders

i n t he area wi t h whomt o consul t . Hughes sai d he had spoken wi t h

a J ohns Hopki ns gender i dent i t y speci al i st , Cynt hi a Osbor ne, a

l i censed soci al wor ker , who was wor ki ng wi t h t he Vi r gi ni a and

Wi sconsi n depart ment s of cor r ect i ons, whi ch had al so been sued by

t r ansgender pr i soner s. I t was not ed on t he meet i ng mi nut es t hat

Osborne "may do more obj ect i ve eval uat i ons, " and was "[ m] ore

sympat het i c t o DOC posi t i on. "

Despi t e Hughes' s qual ms about t he Fenway Cent er and the

possi bl e opt i on of usi ng Osbor ne, t he DOC went ahead wi t h ret ai ni ng

t he Fenway Cent er . Kosi l ek was eval uat ed by Kevi n Kapi l a, M. D. ,

and Randi Kauf man, Psy. D. , who conduct ed a ni nety- mi nut e i nt ervi ew

wi t h her and r evi ewed her medi cal r ecor ds. The doct or s i ssued

t hei r r epor t wi t h sever al f i ndi ngs on Febr uar y 24, 2005 ( t he

"Fenway Report " ) . As had been document ed i n t he past , Kosi l ek

"cl ear l y f i t [ ] " t he di agnosi s f or gender i dent i t y di sor der .

Kosi l ek had been on hormone t herapy and l i vi ng f ul l - t i me as a woman

f or sevent een mont hs by t hat t i me. Kosi l ek' s abi l i t y t o l i ve as a

woman, her good behavi or , and her absence of conf l i ct wi t h others,

suggest ed, accor di ng t o t he doct or s, an " i nt ense mot i vat i on, as

wel l as a r eal adapt abi l i t y t o her envi r onment . " They not ed her

f avor abl e response t o t he use of hor mones, el ect r ol ysi s, and use of

f emi ni ne pr oduct s. But , t hey not ed, Kosi l ek was st i l l "qui t e

di st r essed, " and gi ven Kosi l ek' s "previ ous sui ci de at t empt s, her

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ongoi ng di st r ess, and l ack of ot her goal s i n her l i f e, " t he doct or s

f ound i t was qui t e l i kel y Kosi l ek woul d at t empt sui ci de agai n i f

she was not provi ded wi t h sex r eass i gnment surgery. Kosi l ek had a

ser i ous medi cal need, t hey f el t , and t her e was a subst ant i al r i sk

of har m i f her di sor der was l ef t unt r eat ed.

The r epor t went on t o not e t hat Kosi l ek had moved

successf ul l y t hr ough t he st eps out l i ned i n t he St andar ds of Car e,

t her e had not been any adver se react i ons t o Kosi l ek' s f emi ni zed

appear ance, and Kosi l ek had benef i t t ed psychol ogi cal l y f r om her

changes. Dr s. Kapi l a and Kauf man concl uded Kosi l ek was l i kel y

r eady f or sex r eassi gnment sur ger y. The surger y, t he doct or s

opi ned, woul d pr ovi de Kosi l ek wi t h f ul l r el i ef f r omt he sympt oms of

gender i dent i t y di sorder and l i kel y i ncr ease her chance of

sur vi val . The ul t i mat e r ecommendat i on of t he speci al i st s r et ai ned

by the DOC as advi sed by i t s own doctors: Kosi l ek shoul d be gi ven

t he surgery.

Unhappy wi t h t he Fenway Repor t , t he DOC t urned t o t he

J ohns Hopki ns gender i dent i t y speci al i st , Cynthi a Osbor ne, whose

name had been bat t ed ar ound at t he ear l i er DOC meet i ng. The DOC

asked Osborne t o conduct a peer r evi ew12 of t he Fenway Repor t and

12 Peer r evi ew i s t he t ermused by t he DOC —we pr esume becausesoci al wor ker Osbor ne was t asked pr i mar i l y wi t h r evi ewi ng t her ecommendat i on of her so- cal l ed peer s, t he Fenway Cent er doctors,as opposed t o i nt ervi ewi ng Kosi l ek and conduct i ng an i ndependentassessment .

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she agr eed. The r epor t , al ong wi t h ot her eval uat i ons conduct ed of

Kosi l ek, wer e sent t o Osbor ne on Apr i l 12, 2005.

I n t he meant i me, on Apr i l 15, 2005, Dr . Appel baum, who at

t he t i me was a def endant i n t hi s l awsui t al ong wi t h UMass and some

ot her doctor s, f i l ed ( at t he di st r i ct cour t ' s r equest ) a st at us

r epor t . I t advi sed t he cour t of Dr s. Kapi l a and Kauf man' s sex

r eass i gnment sur gery r ecommendat i on f or Kosi l ek. Dr . Appel baum

al so sai d he had advi sed the DOC of t he doct ors' r ecommendat i on and

had i nf ormed t hem he was unawar e of any medi cal r eason why Kosi l ek

shoul d not r ecei ve t he sur ger y.

The cour t r esponded wi t h an Apr i l 25, 2005 or der

di r ect i ng t he DOC t o pr ovi de a r epor t addr essi ng pot ent i al secur i t y

concer ns shoul d Kosi l ek under go t he sur ger y. I t al so di r ect ed t he

DOC t o i ndi cat e whet her i t was goi ng t o pr ovi de Kosi l ek wi t h t he

surger y r ecommended by t he Fenway Cent er doct or s.

A f ew days l ater , on Apr i l 28, 2005, t he DOC r esponded t o

t he UMass st atus r eport . The l et t er was penned by Susan Mart i n

( r ecal l she was t he DOC Di r ect or of Heal t h Ser vi ces) and sent t o

Dr . Appel baum and UMass' s Medi cal Di r ect or , Ar t hur Br ewer , M. D.

( al so a def endant ) . Dennehy and ot her DOC of f i ci al s wer e copi ed.

Mar t i n mal i gned Dr . Appel baum' s st at us r epor t , asser t i ng t hat t he

DOC di d not consi der i t an adequate revi ew of t he Fenway Repor t or

a cl ear expl anat i on of UMass' s r ecommendat i on. Mart i n r equest ed

t hat t he UMass doct ors make cl ear whether t hey t hought Kosi l ek

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shoul d be operated on. She al so want ed answers t o var i ous

quest i ons r el at i ng t o, among ot her t hi ngs, t he sur ger y' s l ogi st i cs,

such as who woul d per f or mi t , t he r ecover y pr ocess, and t he success

rat e.

Dr s. Appel baum and Br ewer , i n a May 10, 2005 r esponse

l et t er t o t he DOC, cl ar i f i ed t hei r st ance on t he Fenway Repor t . As

t hey expl ai ned, UMass def er r ed t o t he Fenway Cent er and st ood

behi nd t he doctors' sex r eass i gnment surgery r ecommendat i on f or

Kosi l ek. They wer e awar e of no ment al heal t h bar r i er s t o Kosi l ek

bei ng operated on and t he next st ep was f i ndi ng a surgeon. I t

appear ed t here were no physi ci ans i n Massachuset t s who coul d

per f or m t he sur ger y, so some out - of - st at e pr act i t i oner s wer e

suggest ed. The doct or s al so of f er ed t o l ook i nt o t he l ogi st i cs of

pr ovi di ng t he sur ger y.

I n t he i nt er i m, Osbor ne compl et ed her r evi ew of t he

Fenway Report . 13 She chr oni cl ed her f i ndi ngs i n a r epor t dat ed May

20, 2005, whi ch she sent t o t he DOC. I t began wi t h t he caveat t hat

Osbor ne had not conduct ed a cl i ni cal eval uat i on of Kosi l ek and her

r epor t was based sol el y on her r evi ew of t he Fenway Repor t and some

of t he ot her eval uat i ons of Kosi l ek. Though she di d not doubt

13 We pause t o say a l i t t l e more about Osbor ne' squal i f i cat i ons. Accor di ng t o her C. V. , at l east as of 2006, shehel d a mast er ' s degr ee i n educat i on and soci al work. Osbor ne wasal so an assi st ant pr of essor of psychi at r y at J ohns Hopki nsUni ver si t y School of Medi ci ne and on t he consul t i ng f acul t y of t heUni ver si t y' s Cent er f or Sexual Heal t h and Medi ci ne.

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Kosi l ek met t he cr i t er i a f or gender i dent i t y di sor der , Osbor ne went

on t o l odge numer ous cr i t i ci sms agai nst Dr s. Kapi l a and Kauf man' s

approach.

Fi r st , Osbor ne di spar aged the Fenway Repor t f or not

addr essi ng t he i ssue of whet her Kosi l ek was suf f er i ng f r om any

per sonal i t y di sor der s. She opi ned t hat " [ c] l ar i t y r egar di ng t he

pr esence, absence, nat ur e and sever i t y" of any per sonal i t y

di sor der , especi al l y gi ven t hat cl i ni ci ans had at one poi nt

di agnosed Kosi l ek wi t h ant i soci al per sonal i t y di sor der , was

cr i t i cal because i t s pr esence coul d compl i cat e a gender i dent i t y

di sor der di agnosi s. Osbor ne al so ar gued t hat t hr eat s of sui ci de

and sel f - har m si gnal ser i ous ment al i l l ness apar t f r om gender

i dent i t y di sorder , whi ch demands t r eat ment and, i n f act , counsel s

agai nst pr ovi di ng sex r eass i gnment surgery. She t hought t he Fenway

Repor t had gi ven shor t shr i f t t o t hi s i ssue.

Osbor ne then t ur ned her f ocus t o t he St andards of Care,

expr essi ng her concer ns t hat t hey di d not t r ansl at e wel l i nt o a

pr i son envi r onment . She wr ot e: " I n my vi ew, pr ovi di ng surger y, or

even hor mones, t o i ncar cer at ed i ndi vi dual s, i s an undeni abl e

l ower i ng of t he St andar ds, and an expl i ci t vi ol at i on of t he

cr i t er i a r egar di ng soci opat hy and sui ci dal i t y. " Whi l e Osbor ne

r ecogni zed t he St andar ds of Car e as hel pf ul , she not ed t hey had no

r egul at or y aut hor i t y. Al so, t her e was no uni ver sal consensus i n

t he psychi at r i c communi t y about what const i t ut ed medi cal necessi t y

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i n t he t r eat ment of gender i dent i t y di sor der . She cr i t i ci zed t he

Fenway Repor t f or f ai l i ng t o addr ess ot her possi bl e t r eat ment

opt i ons f or Kosi l ek or t o pr ovi de an adequat e expl anat i on f or i t s

surger y r ecommendat i on. Kosi l ek, i n Osbor ne' s eyes, had an

unr eal i st i c expectat i on t hat she was owed cer t ai n t r eat ment s and

Kosi l ek woul d i nst ead benef i t f r om a t hor ough assessment f or

psychi at r i c di sor der s and t r eat ment desi gned t o addr ess any such

di sor der s al ong wi t h her gender i dent i t y di sor der .

On May 25, 2005, t he back and f or t h bet ween t he DOC and

UMass cont i nued. Mart i n sent Dr s. Appel baum and Br ewer another

cr i t i ci sm- l aced l et t er . Whi l e t he doct or s had answer ed some of t he

DOC' s quest i ons, t hey had not pr ovi ded a compr ehensi ve r evi ew of

t he appr opr i at eness or necessi t y of sur ger y f or Kosi l ek. Ci t i ng

t he DOC' s Ei ght h Amendment obl i gat i ons, Mar t i n l ament ed t hat

nei t her UMass nor t he Fenway Repor t had of f ered gui dance on whet her

sur ger y was "a medi cal necessi t y f or Kosi l ek. " Fi nal l y, Mar t i n

i nf ormed t hem of t he DOC' s engagement of Osborne to revi ew t he

Fenway Report and encl osed a copy of Osbor ne' s report . Mart i n

asked UMass t o r evi ew t he report and gi ve t he DOC i t s ul t i mate

r ecommendat i on as t o the appr opr i at eness of surgery f or Kosi l ek.

The same day Mar t i n f i r ed of f her l et t er , a news pi ece,

whi ch was hi ghl y negat i ve t owar d Kosi l ek and her quest f or surger y,

appear ed on a l ocal t el evi si on st at i on. Commi ssi oner Dennehy had

been i nter vi ewed f or t he pi ece on May 16, and one of her comment s

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made i t on ai r . 14 A Massachuset t s st ate senat or , who had f i l ed

l egi sl at i on seeki ng t o pr ohi bi t t he st at e f r om payi ng f or sex

r eassi gnment sur ger y f or i nmat es, al so spoke t o t he r epor t er .

"When you go t o pr i son you l ose some r i ght s. You al so l ose your

r i ght s t o get a sex change oper at i on, " he st at ed. The senat or , who

was an acquai ntance of Dennehy, had cal l ed Dennehy on her cel l

phone to advi se her t hat he woul d be par t i ci pat i ng i n t he news

pi ece. The pi ece concl uded wi t h t he r epor t er i ndi cat i ng: "Lat er

t hi s week, t he st at e wi l l t el l t he f eder al cour t t hat sex sur ger y

f or Mi chel l e Kosi l ek woul d r esul t i n a secur i t y ni ght mar e. "15

Despi t e the secur i t y concerns t he DOC expr essed t o t he

medi a, Dennehy and her st af f had yet ( as of t he t i me she was

i nt er vi ewed) t o of f i ci al l y convene t o conduct t hei r i nt er nal

secur i t y r evi ew. Not unt i l May 19, t hr ee days af t er her i nt er vi ew,

di d t hey act ual l y meet . I n at t endance were Dennehy, DOC counsel ,

Super i nt endent Spencer of MCI - Norf ol k, and Super i nt endent Lynne

Bi ssonnet t e of MCI - Fr ami ngham, t he women' s pr i son where Kosi l ek

mi ght be sent were she t o under go surger y. Dennehy di d not have

t he benef i t of wr i t t en r epor t s f r omSpencer or Bi ssonnet t e, despi t e

14 She was quot ed: "The cour t s ar e tel l i ng us t hat medi cal

pr of essi onal s make medi cal r ecommendat i ons and cor r ect i onaladmi ni st r at or s assess t he saf et y and secur i t y concer ns. "

15 I t seems l i kel y t hat t he r epor t er l ear ned t hi s i nf or mat i onf r om Dennehy her sel f , t hough i t i s uncl ear whet her i t coul d havecome f r om someone on her st af f . Ei t her way t he DOC does notdi sput e t hat t hi s t i dbi t came f r om wi t hi n t he DOC.

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DOC pol i cy cal l i ng f or t he super i nt endent s t o make such

r ecommendat i ons, because ( as Dennehy l at er t est i f i ed) t he secur i t y

concer ns seemed sel f - evi dent .

On J une 10, 2005, t he DOC br ought t he cour t back i nt o the

l oop, f i nal l y f i l i ng t he st at us r epor t whi ch t he cour t had or der ed

back on Apr i l 25. The DOC i nf ormed J udge Wol f i t had deci ded not

t o pr ovi de Kosi l ek wi t h sex r eassi gnment sur ger y. I n suppor t of

i t s deci si on, t he DOC at t ached Osbor ne' s repor t . I t al so at t ached

t he cour t - or der ed secur i t y r epor t , whi ch was pr i nci pal l y aut hor ed

by DOC at t orneys wi t h i nput f r om Dennehy.

The secur i t y r epor t , whi ch sai d i t was based on Dennehy' s

t hi r t y year s of cor r ect i onal knowl edge and exper i ence, as wel l as

t he exper i ence of col l eagues she had spoken wi t h, st ated t he

f ol l owi ng. Al l owi ng t he sur ger y t o go f or war d "woul d cr eat e

subst ant i al saf et y and secur i t y pr obl ems f or DOC. " She cl ai med

t hat out - of - st at e sur ger y, whi ch appear ed t o be t he onl y opt i on

based on a dear t h of doctors i n Massachuset t s, woul d cause " compl ex

secur i t y and l ogi st i cal i ssues" and mi ght gi ve Kosi l ek a chance t o

escape cust ody. Kosi l ek' s post - sur ger y conf i nement was al so a

cause f or concer n. Dennehy argued Kosi l ek woul d be at r i sk f or

sexual assaul t i f she wer e t o r emai n i n a mal e pr i son, and housi ng

her i n a f emal e pr i son woul d come wi t h i t s own host of pr obl ems.

Speci f i cal l y, Dennehy ant i ci pat ed "ser i ous cl i mat e i ssues" si nce

t he maj or i t y of t he women at MCI - Fr ami nghamhad hi st or i es of t r auma

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and i t was wel l known t hat Kosi l ek had ki l l ed her wi f e. The women

mi ght pose a t hr eat t o Kosi l ek and vi ce ver sa. Kosi l ek woul d need

t o be i sol at ed and r est r i ct i vel y conf i ned i n ei t her pr i son and

t hi s, Dennehy concl uded, mi ght be del et er i ous t o Kosi l ek' s ment al

heal t h. Ci t i ng t hese concer ns, al ong wi t h what she per cei ved as an

uncl ear st ance f r om UMass on whether sur gery was necessar y, 16 and

gi ven Osbor ne' s cr i t i ques of t he Fenway Repor t , Dennehy i ndi cat ed

t hat t he DOC was denyi ng Kosi l ek' s r equest f or surger y.

Af t er t he st at us r epor t was f i l ed wi t h t he cour t , t he DOC

and UMass cont i nued t o cl ash over what t he DOC per cei ved t o be

UMass' s equi vocat i ons. Dr s. Appel baum and Br ewer di r ect ed a J une

14, 2005 l et t er at t he DOC. Cal l i ng t he DOC' s st at ement s i n i t s

pr evi ous l et t er s and st at us r epor t "di si ngenuous, " t he doct or s

emphasi zed t hat i t was not wi t hi n t hei r pur vi ew t o deci de whet her

sur ger y i s medi cal l y necessar y f or Kosi l ek as t hat t er m i s

contempl at ed by t he Ei ght h Amendment . UMass, t hey expl ai ned, had

consi st ent l y rel i ed on t he exper t i se of out si de consul t ant s, al l of

whom had sai d t he same t hi ng. The doctors agai n under l i ned t hat

sol el y f r oma cl i ni cal per spect i ve i t appear ed t hat Kosi l ek shoul d

be of f er ed sur ger y.

16 The repor t quoted t he supposedl y ambi guous l anguage f r omUMass' s l et t er : " t he t r eat ment r ecommended i n t he Fenwayr epor t . . . appear s t o be r easonabl e and appr opr i at e, si nce t hepat i ent has met cr i t er i a f or t he di agnosi s of gender i dent i t ydi sorder and has r eached a poi nt i n cl i ni cal t r eat ment wher e sexualr eassi gnment sur ger y, i f desi r ed, woul d be t he next st ep. "

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On Oct ober 7, 2005, Dr s. Kapi l a and Kauf man prepared and

i ssued anot her r epor t , t hi s one a r esponse t o Osbor ne' s cr i t i ques

of t hei r Fenway Repor t , whi ch t hey sent t o UMass and whi ch UMass

passed on t o t he DOC. Ci t i ng medi cal l i t er at ur e and st udi es, t he

doct or s t ook ai m at Osbor ne' s cr i t i ci sms, expl ai ni ng why her

chal l enges t o t hei r r ecommendat i on f or sur ger y wer e cl i ni cal l y

unf ounded or i r r el evant . The r epor t al so ar gued t hat Kosi l ek was

st abl e, not cur r ent l y sui ci dal , and a good candi dat e f or sur ger y.

The doct or s st r enuousl y i nsi st ed t hat t hei r r ecommendat i on of

sur ger y was an i nf or med cl i ni cal j udgment r oot ed i n Kosi l ek' s

gender i dent i t y di sorder di agnosi s, her mar ked ment al heal t h

i mpr ovement si nce bei ng pr ovi ded hormones and bei ng al l owed t o l i ve

as a woman, and t he wel l - document ed ef f ect i veness of surgery. The

doct or s r ei t er at ed t hei r r ecommendat i on t hat Kosi l ek be pr ovi ded

wi t h t he sur ger y. Dr . Appel baum submi t t ed t hi s r epor t t o t he DOC

on Oct ober 17, 2005, r est at i ng UMass' s endor sement of t he or i gi nal

Fenway Repor t ' s r ecommendat i ons and request i ng t hat t he DOC i ssue

a deci si on appr ovi ng t hose r ecommendat i ons.

As t o t he st at us of Kosi l ek' s l awsui t , as of J ul y 2005,

Kosi l ek had l et al l t he medi cal pr ovi der def endant s ( Dr s. Appel baum

and Br ewer , and UMass, among ot her s) out of t he case. That same

mont h she f i l ed an amended compl ai nt , t hi s t i me wi t h t he benef i t of

an at t orney, wi t h Dennehy as t he sol e named def endant . Kosi l ek no

l onger sought damages, she onl y r equest ed i nj unct i ve r el i ef

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r equi r i ng t he DOC t o pr ovi de her wi t h adequate medi cal care,

i ncl udi ng sex r eassi gnment sur ger y. The case went t o t r i al a

l i t t l e l ess than a year l at er .

F. The Kosilek II Trial

1. Round One of Testimony

The non- j ury t r i al , whi ch l i ke Kosi l ek I was presi ded

over by J udge Wol f ( by t hen Chi ef J udge) , began on May 30, 2006.

Test i mony i ni t i al l y went unt i l t he end of J une, wi t h mul t i pl e

wi t nesses t est i f yi ng. 17

Fi r st t he cour t hear d f r om Geor ge Br own, M. D. , a

pr act i ci ng psychi at r i st who hel ped aut hor t he St andar ds of Car e,

and who t est i f i ed as an exper t on Kosi l ek' s behal f ( he al so

t est i f i ed i n Kosi l ek I ) . As he had done back i n 2001, Dr . Br own

eval uated Kosi l ek and r evi ewed her medi cal r ecor ds. He pr epared a

wr i t t en r epor t , and i n i t di agnosed Kosi l ek wi t h chr oni c and sever e

gender i dent i t y di sor der . He di d not t hi nk she met t he cr i t er i a

f or ant i soci al per sonal i t y di sor der . Dr . Br own al so di d not t hi nk

Kosi l ek was t r yi ng t o game the syst em, wr i t i ng t hat he was " har d

pr essed t o devel op a rat i onal expl anat i on f or why someone woul d

wor k so f er vent l y to obt ai n t hi s ser i ous, pai nf ul sur ger y" ot her

t han as a means t o t r eat gender i dent i t y di sorder . Dr . Br own al so

opi ned t hat Kosi l ek had met or exceeded t he readi ness cr i t er i a f or

17 We summari ze t he t est i mony i n the or der i t was gi ven, savef or Dr . Schmi dt . He actual l y t est i f i ed bef or e Kosi l ek f i ni shedput t i ng on her wi t nesses ( we assume f or schedul i ng conveni ence) .

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sex r eass i gnment sur ger y. Among other t hi ngs, she had compl eted a

mor e t han t wo- year moni t or ed, r eal - l i f e exper i ence l i vi ng as a

woman whi l e i ncar cer at ed. Fur t her , he wr ot e, Kosi l ek had " r ecei ved

an unambi guous di agnosi s of severe gender i dent i t y di sorder f r omno

f ewer t han ni ne ment al heal t h pr of essi onal s who have i nt er vi ewed

her , many of whomare r ecogni zed i nt er nat i onal exper t s i n t he f i el d

of gender i dent i t y di sor der . " Dr . Br own st r essed, "[ n] o f ur t her

t r eat ment or r eal - l i f e exper i ence i s necessar y, " and Kosi l ek shoul d

r ecei ve t he sur gery, whi ch Dr . Br own deemed "medi cal l y necessary. "

Hammer i ng the poi nt home, Dr . Br own test i f i ed, consi st ent

wi t h hi s wr i t t en r epor t , t hat t he hor mones and psychot her apy

Kosi l ek was r ecei vi ng, t hough t hey had hel ped r el i eve her

dysphor i a, wer e "[ a] bsol ut el y not " suf f i ci ent t o el i mi nat e t he

ser i ous r i sk of har m Kosi l ek f aced, up t o and i ncl udi ng sui ci de.

When asked whet her sex reassi gnment surger y was medi cal l y

necessar y, Dr . Br own st at ed: "Absol ut el y. I f I can wal k away f r om

t hese pr oceedi ngs wi t h one poi nt bei ng cl ear i n peopl e' s mi nds,

i t ' s that . " Wi t hout sur ger y, he added, "t he degr ee of l i kel i hood

of [ Kosi l ek] suf f er i ng ser i ous medi cal consequences up t o and

i ncl udi ng sui ci de ar e exceedi ngl y hi gh. " As f or ant i depr essant s,

t hey ar e f or t he t r eat ment of pat i ent s wi t h maj or depr essi ve

di sorder , whi ch Dr . Br own st r essed Kosi l ek di d not have. Wi t h

r egar ds t o gender i dent i t y di sorder , such ant i depr essant

medi cat i ons had been shown t o be "very i nef f ect i ve" as t hey mi ght

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onl y sl i ght l y r el i eve some depr essi ve sympt oms but woul d not t r eat

t he under l yi ng gender i dent i t y di sorder . Onl y sur ger y, Dr . Br own

t est i f i ed, had t he "si gni f i cant pot ent i al " t o cur e Kosi l ek' s

medi cal condi t i on.

Next came Dr . Kennet h Appel baum' s t est i mony. The Fenway

Cent er doct or s, he sai d, had si gni f i cant exper i ence i n t he ar ea of

gender i dent i t y di sor der and wer e wel l - t r ai ned, cr edent i al ed, and

knowl edgeabl e. He t hought t hei r assessment s wer e t ypi cal l y

r easonabl e and consi st ent wi t h t he appr oaches f ol l owed by most

ot her medi cal pr ovi der s. I n gener al , Dr . Appel baumdi d not see why

t he DOC woul d need t o consul t wi t h Osbor ne ( an out - of - st ate,

mast er ' s- l evel soci al wor ker ) gi ven t hat i t had al r eady recei ved

t he r ecommendat i ons of t he Fenway Cent er doct ors ( a l ocal physi ci an

and doct or al psychol ogi st ) , who wer e, i n Dr . Appel baum' s mi nd,

hi ghl y exper i enced i n deal i ng wi t h gender i dent i t y di sor der . As

f or Osbor ne, Dr . Appel baum r ecal l ed t hat t he DOC' s Hughes had

comment ed t hat she woul d be more sensi t i ve t o t he DOC' s concerns

because she di d not bel i eve sex reass i gnment sur gery was

appr opr i at e i n t he cor r ect i ons set t i ng. Fi nal l y, Dr . Appel baum

t est i f i ed t hat f r omhi s conver sat i ons wi t h Kosi l ek' s t r eat ment t eam

at t he pr i son, i t was hi s under st andi ng Kosi l ek had shown good

adj ust ment bei ng on hormones and r ecei vi ng t herapy.

Dr . Randi Kauf man f r om t he Fenway Cent er t hen t ook t he

st and. She r ei t er at ed t he concl usi on she made i n her r epor t , i n

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par t i cul ar t hat Kosi l ek had successf ul l y compl et ed t he r eal - l i f e

exper i ence cont empl ated by t he St andards of Care. She al so

t est i f i ed t hat , t o a r easonabl e degr ee of medi cal cer t ai nt y, t her e

was a "ver y hi gh l i kel i hood" Kosi l ek woul d at t empt sui ci de i f

deni ed t r eat ment f or her gender i dent i t y di sorder . Though Kosi l ek

benef i t t ed f r om bei ng on hor mones, Dr . Kauf man f el t Kosi l ek had a

l evel of gender i dent i t y di sor der t hat coul d not be t r eat ed wi t h

anyt hi ng l ess t han sur ger y. "She' s done al l t he t hi ngs t hat peopl e

do t o change t hei r gender pr esent at i on, " she sai d, and " [ t ] her e

r eal l y i sn' t anyt hi ng l ef t except f or sur ger y. " Kosi l ek had a

medi cal need f or t he surger y.

Mar k Bur r owes, a l i censed ment al heal t h counsel or wi t h a

mast er ' s degr ee i n counsel i ng psychol ogy, who had been t r eat i ng

Kosi l ek f or f our or f i ve year s, al so t est i f i ed. Kosi l ek, he

agr eed, was r eady f or sex r eass i gnment surgery. Not havi ng t he

surger y woul d be det r i ment al and coul d r esul t i n Kosi l ek maki ng an

at t empt on her l i f e. Sui ci de moni t or i ng woul d not be an adequat e

al t er nat i ve t o sur ger y si nce Kosi l ek' s mal e geni t al i a st i l l caused

her di st r ess.

Fi nal l y, Mi chel l e Kosi l ek was cal l ed by her at t or neys.

She spoke about her l i f e at MCI - Nor f ol k. Gener al l y she got al ong

qui t e wel l wi t h most of t he peopl e t here, t hough a smal l per cent age

of t he cor r ect i on of f i cer s gave her a har d t i me. Kosi l ek had,

si nce she got t o pr i son, wor ked on a dai l y basi s. She t est i f i ed

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t hat t he hormone t r eat ment s had made her a l i t t l e l ess depr essed

but she cont i nued t o f eel di st r ess over her body. Kosi l ek, who

sai d she was not cur r ent l y sui ci dal , f el t t he hor mones wer e not

enough and she needed surgery. She di d not want t o cont i nue l i vi ng

wi t h her mal e geni t al i a and, i f deni ed sur ger y, ant i depr essant s and

psychotherapy woul d not hel p mat t ers.

The DOC t hen put on i t s case. Fi r st , Chest er Schmi dt ,

M. D. , a psychi at r i st at t he J ohns Hopki ns School of Medi ci ne, and

associ at e di r ect or of t he J ohns Hopki ns Cent er f or Sexual Heal t h

and Medi ci ne, t est i f i ed as an expert f or t he DOC. He became

i nvol ved i n t hi s case t hr ough hi s connect i on wi t h Cynt hi a Osbor ne.

As t o hi s gener al appr oach f or t r eat i ng pat i ent s wi t h gender

i dent i t y di sor der , Dr . Schmi dt st at ed he does ut i l i ze t he St andar ds

of Car e but t hi nks of t hem mor e as pr ot ocol s or gui del i nes, as

opposed t o actual st andar ds of car e. He does not agr ee wi t h t he

i dea, set f or t h i n t he St andar ds of Car e, t hat sex r eassi gnment

sur ger y i s medi cal l y necessary i n pat i ent s wi t h sever e gender

i dent i t y di sor der . I n f act , Dr . Schmi dt di d not r ecal l ever seei ng

a case where he t hought sur gery was medi cal l y necessary. I t was

hi s and hi s J ohns Hopki ns col l eagues' pr act i ce t o nei t her advocat e

nor speak agai nst a pat i ent ' s desi r e f or sur ger y, but t o l eave i t

i n t he hands of t he pat i ent . He woul d not send a l et t er of

r ecommendat i on t o a sur geon on behal f of a pat i ent , but he woul d

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r el ease hi s f i l e t o t he sur geon and si mpl y i ndi cat e he saw no

cont r ai ndi cat i ons t o sur ger y.

Af t er gi vi ng hi s gener al over vi ew, Dr . Schmi dt t ur ned hi s

f ocus t o Kosi l ek, whom he had personal l y eval uated i n November

2005. Kosi l ek di d meet t he cr i t er i a f or gender i dent i t y di sor der ,

he concl uded. However , Dr . Schmi dt di d not bel i eve surgery was

medi cal l y necessar y as Kosi l ek, he theor i zed, had made an

"excel l ent adapt at i on" wi t hout sur ger y t hus f ar . He al so f el t t he

r eal - l i f e exper i ence cont empl at ed i n t he St andar ds of Car e was

vi r t ual l y i mpossi bl e t o r epl i cat e i n pr i son. But besi des t hi s

bar r i er , Dr . Schmi dt admi t t ed he di d not see any cont r ai ndi cat i ons

t o surger y. Shoul d Kosi l ek become depr essed i f she di d not r ecei ve

t he surger y, Dr . Schmi dt t hought she coul d be t r eat ed wi t h

ant i depressant s and psychother apy, and managed i n a medi cal

f aci l i t y shoul d her sui ci dal desi r es become sever e. Thi s l at t er

scenar i o was a possi bi l i t y, as Dr . Schmi dt r ecogni zed Kosi l ek' s

r i sk of sui ci de based on what she had sai d and done i n t he past .

But , Dr . Schmi dt opi ned, psychot herapy and medi cat i ons coul d

ef f ect i vel y r educe Kosi l ek' s dysphor i a t o a l evel wher e she was no

l onger at r i sk f or ser i ous har m.

Next Cynt hi a Osbor ne, t he J ohns Hopki ns soci al worker and

DOC consul t ant , gave t est i mony echoi ng Dr . Schmi dt . By t he t i me of

t r i al , she had met wi t h and i nt ervi ewed Kosi l ek. Osbor ne agr eed

wi t h Kosi l ek' s sever e gender i dent i t y di sor der di agnosi s. Yet ,

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l i ke Dr . Schmi dt , i n gener al , she di d not bel i eve t he r eal - l i f e

exper i ence cal l ed f or by t he St andar ds of Car e coul d happen i n a

pr i son envi r onment . Al so, Kosi l ek was not , i n her opi ni on, a good

candi dat e f or sex r eassi gnment sur ger y, nor was i t medi cal l y

necessary, because Kosi l ek had r esponded ver y wel l t o hormone

t r eat ment . Rather , Osbor ne t hought support gr oups or gr oup t herapy

coul d be used t o t r eat Kosi l ek ef f ect i vel y. Kosi l ek' s t hr eat s of

sui ci de i f deni ed surgery di d not change Osbor ne' s mi nd on what

t r eat ment was warr ant ed. I ndeed, she mi ni mi zed concer ns about

sui ci de by not i ng that any good ment al heal t h syst emwoul d know how

t o deal wi t h a pat i ent ' s sui ci dal i t y. Osbor ne, agai n l i ke Dr .

Schmi dt , di d not f ul l y agr ee wi t h t he St andar ds of Car e' s s t at ement

t hat sex r eass i gnment surger y i s medi cal l y necessar y i n cases of

sever e gender i dent i t y di sor der .

Lui s Spencer , t hen st i l l Super i nt endent of MCI - Nor f ol k,

al so t est i f i ed f or t he DOC. He expl ai ned t he set - up at MCI -

Nor f ol k, descr i bi ng i t as havi ng one of t he mor e secur e per i met er s

i n Massachuset t s. I t i s sur r ounded by wal l s on al l si des, an

el ect r i f i ed f ence, and guar d tower s whi ch ar e manned twent y- f our

hour s a day, seven days a week. Appr oxi matel y one- t hi r d of t he

i nmat es at MCI - Nor f ol k, Spencer expl ai ned, ar e ser vi ng a l i f e

sent ence and one- t hi r d have commi t t ed sexual f el oni es.

Spencer al so t est i f i ed about Kosi l ek. She had adj ust ed

f ai r l y wel l t o l i f e at MCI - Nor f ol k and had not r epor t ed any thr eat s

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or har assment f r om ot her i nmat es. As of t he t i me of t r i al , no

secur i t y concer ns i nvol vi ng Kosi l ek had ar i sen; however , Spencer

had some appr ehensi on goi ng f orward shoul d Kosi l ek r ecei ve t he

surger y. He woul d have "gr ave concer ns" put t i ng Kosi l ek back i n

t he gener al popul at i on wi t h t he f ul l anat omy of a f emal e. Spencer

worr i ed t hat she coul d be r aped or assaul t ed and he saw no

al t er nat i ve but t o house her i n t he hi gh- secur i t y Speci al

Management Uni t . Thi s uni t was a st andal one secur e bui l di ng where

Kosi l ek woul d r emai n i n her cel l t went y- t hr ee hour s a day and coul d

onl y l eave when shackl ed and escor t ed by t wo guards. The

quest i oni ng al so br i ef l y t ouched on Kosi l ek' s t hr eat s of sui ci de

wer e she not t o r ecei ve t he sur ger y. Spencer sai d hi s pol i cy i s

not t o negot i at e wi t h i nmat es who thr eat en sui ci de, as t o do so

woul d under mi ne hi s and t he st af f ' s aut hor i t y. Rat her , he woul d

i mpl ement t he DOC' s ment al heal t h pol i cy and t ake the appr opr i ate

st eps t o guar d a sui ci dal i nmat e' s saf et y.

Gr egory Hughes, who was t he DOC' s Di r ect or of Ment al

Heal t h and Subst ance Abuse Servi ces unt i l 2005, and who hol ds a

mast er ' s degr ee i n soci al wor k, was quest i oned next . Hughes

t est i f i ed about t he af t er mat h of Kosi l ek I and t he DOC' s ef f or t s t o

compl y wi t h t he cour t ' s deci si on. Hi s r ol e i ncl uded over seei ng and

f aci l i t at i ng t he ser vi ces suppl i ed t o Kosi l ek, and i n par t i cul ar

maki ng happen t he i ndependent eval uat i on J udge Wol f ordered i n

Kosi l ek I . He t est i f i ed about hi s di ssat i sf act i on wi t h t he Fenway

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Repor t , quest i oni ng i t s t hor oughness and i t s heavy r el i ance on

Kosi l ek' s sel f - r epor t i ng. He was concer ned t hat t he doct or s had

not r evi ewed any of Kosi l ek' s medi cal r ecor ds or ment al heal t h

hi st or y or i nt er vi ewed ot her peopl e t o ver i f y Kosi l ek' s sel f -

r eport s. And whi l e Hughes knew t he doctors suggest ed surgery, he

sai d he was uncer t ai n about whether t here were ot her

r ecommendat i ons and what next st ep t he DOC shoul d t ake. Because he

was concer ned wi t h t he Fenway Repor t ' s qual i t y, Hughes had deci ded

t o cont act Osbor ne. Hughes al so t est i f i ed t hat he r epor t ed hi s

concerns about t he report t o Dr s. Appel baumand Br ewer and t hat t he

DOC sought t hei r t hought s dur i ng st af f meet i ngs. Hughes recal l ed

t he doct or s sayi ng t her e wer e no cont r ai ndi cat i ons t o sur ger y but

di d not bel i eve t hey used t he t er m "medi cal l y necessary. "

Rober t Dumond, who was t he Di r ect or of t he DOC' s Research

and Pl anni ng Di vi si on, and who had pr evi ousl y pr ovi ded ment al

heal t h scr eeni ngs at MCI - Frami ngham, t est i f i ed on t he DOC' s behal f .

Dumond, who had a mast er ' s degree i n psychol ogy and exper i ence i n

t he ar eas of vi ct i mi zat i on and sexual assaul t i n t he pr i son system,

was asked by the DOC t o consi der t he r i sk f actor s f or post -

oper at i ve i ndi vi dual s i n pr i son. Pl aci ng Kosi l ek at MCI - Frami ngham

post - sur ger y, he r esponded, coul d "dest abi l i ze[ ] t he saf et y and

secur i t y of t he i nst i t ut i on" and creat e a r i sk f or Kosi l ek t o

become a vi ct i m or vi ct i mi zer .

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Ar t hur Beel er was al so cal l ed by the DOC t o t est i f y about

secur i t y i ssues. Beel er , a t hi r t y- year empl oyee wi t h t he Feder al

Bur eau of Pr i sons, was warden at t he Federal Cor r ect i on Compl ex,

Feder al Medi cal Cent er i n Buckner , Nor t h Car ol i na. Beel er t our ed

MCI - Nor f ol k and MCI - Fr ami ngham, spoke wi t h Super i nt endent Spencer ,

and r evi ewed t he DOC' s ment al heal t h pol i ci es i n pr epar at i on f or

hi s test i mony. I n hi s opi ni on, Kosi l ek was cur r ent l y saf e and

secur e at MCI - Nor f ol k, based i n par t on t he set - up of t he

f aci l i t i es and her cel l and t he f act t hat Kosi l ek had never been

assaul t ed t her e. Beel er i ndi cat ed t hat he "woul d be ver y

concer ned" about pl aci ng Kosi l ek i n t he women' s gener al popul at i on

at MCI - Frami ngham and was sat i sf i ed t hat t he ment al heal t h

pr ocedur e at MCI - Nor f ol k was suf f i ci ent t o addr ess i nmat e sui ci de

i deat i on and behavi or . Beel er caut i oned agai nst gi vi ng i n t o an

i nmat e' s t hr eat s of sui ci de, l i keni ng i t t o openi ng Pandor a' s box.

Beel er was not per mi t t ed t o t est i f y speci f i cal l y about whet her

secur i t y concer ns shoul d pr ecl ude Kosi l ek f r om get t i ng sur ger y

because, t he cour t f ound, he was not suf f i ci ent l y i nf or med about

" t he f act s concer ni ng Kosi l ek" because Beel er had not l ooked at her

di sci pl i nar y or medi cal r ecor ds.

Susan Mar t i n, t he DOC' s Di r ect or of Heal t h Ser vi ces

dur i ng t he r el evant t i me per i od, was next up. Af t er speaki ng some

about t he cont r act ual r el at i onshi p between t he DOC and UMass,

Mar t i n t ur ned t o t he Fenway Cent er ' s eval uat i on of Kosi l ek. Li ke

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Hughes, she was not sat i sf i ed wi t h t he eval uat i on. Mar t i n di d not

t hi nk t he Fenway Report was ver y t horough and she r ai sed t hi s

concern t o UMass at t he t i me. Though Mar t i n knew t he Fenway Cent er

doct ors were recommendi ng sur gery, she di d not t hi nk t hey were

cl ear enough about what exact l y needed t o happen and when. Because

of t hese per cei ved omi ssi ons, Mart i n deci ded t o have Osbor ne revi ew

t he r epor t .

When asked about UMass' s r ol e, Mart i n i ndi cated she

t hought i t was UMass' s j ob t o determi ne whether t he Fenway Cent er ' s

r ecommendat i ons "wer e medi cal l y necessar y and cl i ni cal l y sound, "

and UMass, she sai d, woul d not do t hi s. She consi der ed i t UMass' s

r esponsi bi l i t y t o f i nd a sur geon, and si mpl y pr ovi di ng t he DOC wi t h

a l i st of possi bl e sur geons was not suf f i ci ent .

Next came DOC Commi ssi oner Kat hl een Dennehy' s t est i mony.

I f f aced wi t h a cour t or der compel l i ng t he DOC t o pr ovi de Kosi l ek

wi t h sex reassi gnment sur gery, Dennehy sai d she woul d pr obabl y

r et i r e bef ore i mpl ement i ng somethi ng she consi dered unsaf e. And

based "st r i ct l y [ on] saf et y and secur i t y concer ns" she sai d she

woul d st i l l vet o t he sur ger y even i f UMass t ol d her i t was

medi cal l y necessary and even i f Kosi l ek woul d l i kel y at t empt

sui ci de i f deni ed t he sur ger y. ( Dennehy cl ai med she was st i l l

awai t i ng cl ear di r ect i on f r om UMass. )

When asked, Dennehy acknowl edged her awar eness of t he

negat i ve publ i c at t ent i on t hat Kosi l ek' s bi d had been r ecei vi ng.

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She admi t t ed she knew t hat a Massachuset t s senat or , who she was

f r i endl y wi t h and who had spoken i n t he news pi ece, vocal l y opposed

sex r eass i gnment surgery f or i nmates and was pushi ng f or

l egi sl at i on t o put a st op t o i t s pr ovi si on. She al so sai d she knew

of t he Massachuset t s Li eut enant Gover nor ' s opposi t i on t o sur ger y

f or t r ansgender i nmat es.

Fi nal l y, Lynne Bi ssonnet t e, Super i nt endent of MCI -

Frami ngham, was cal l ed upon t o di scuss t he f easi bi l i t y of Kosi l ek' s

post - oper at i ve pl acement t her e. She expl ai ned t he set - up at MCI -

Fr ami ngham. The women l i ved i n mul t i - person r ooms or dor mi t ory-

st yl e housi ng uni t s, wi t h t he except i on of t he women i n t he

segr egat i on or medi cal uni t s who had si ngl e cel l s. For t he most

par t t he bui l di ngs at MCI - Fr ami ngham wer e sur r ounded by a si ngl e,

non- el ect r i f i ed t wel ve- f oot - hi gh f ence. Ther e had been,

Bi ssonnet t e i ndi cat ed, no pr i soner escapes dur i ng her t hr ee- year

t enure at Fr ami ngham.

As f or t he popul at i on at t he f aci l i t y, accor di ng t o

Bi ssonnet t e, a l arge maj or i t y of t he women t here had been vi ct i ms

of domest i c vi ol ence or sexual assaul t . Al so, a maj or i t y had

ment al heal t h i ssues wi t h about a hal f r ecei vi ng medi cat i on f or

t hose i ssues. Bi ssonnet t e st at ed t hat i f a woman coul d not

ef f ect i vel y be mai nt ai ned by t he ment al heal t h pr of essi onal s at t he

pr i son, she was sent f or i npat i ent t r eat ment at a Massachuset t s

Depar t ment of Ment al Heal t h f aci l i t y, wher e secur i t y was not t he

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equi val ent of what was pr ovi ded at t he pr i son. And whereas

Massachuset t s pr ovi des a speci al secur e hospi t al f or mal e

pr i soner s, Br i dgewat er St at e Hospi t al , she expl ai ned t hat no

compar at i ve f aci l i t y exi st s f or women.

Bi ssonnet t e' s t est i mony t hen t ur ned t o Kosi l ek

speci f i cal l y, whose cr i mi nal r ecor d she had r evi ewed. Bi ssonnet t e

di d not t hi nk Kosi l ek was an appr opr i at e candi dat e t o be housed at

MCI - Frami nghampost - oper at i vel y and not ed sever al concer ns. Fi r st ,

Bi ssonnet t e consi der ed Kosi l ek a f l i ght r i sk based on t he weak

per i met er at MCI - Fr ami ngham, t he l engt h of Kosi l ek' s sent ence, and

t he f act t hat Kosi l ek had f l ed Massachuset t s af t er ki l l i ng her

wi f e. 18 Second, Bi ssonnet t e wor r i ed about t he l ack of avai l abl e

i npat i ent ment al heal t h car e. Kosi l ek woul d have t o be sent t o a

l ess secur e hospi t al f or t he gener al publ i c shoul d she r equi r e

car e. Thi r d, Bi ssonnet t e consi der ed Kosi l ek bot h a pot ent i al

pr edat or and vi ct i m wi t hi n t he i nmat e popul at i on — a pr edat or

because Kosi l ek had st r angl ed her wi f e and a vi ct i mbecause a l ar ge

pr oport i on of MCI - Fr ami ngham' s popul at i on had been t he vi ct i ms of

domest i c vi ol ence and sexual abuse and mi ght seek t o harm her .

Fur t her , and f or essent i al l y those same r easons, Bi ssonnet t e f el t

Kosi l ek woul d have a negat i ve ef f ect on t he pr i son popul at i on.

18 Bi ssonnet t e consi der ed Kosi l ek' s ear l i er f l i ght , even t hought he DOC cl assi f i cat i on manual says pr e- cust odi al f l i ght shoul d notbe consi der ed when cl assi f yi ng i nmat es.

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I n l i ght of al l of t hese concer ns, wer e Bi ssonnet t e

r equi r ed t o house Kosi l ek, she woul d put her i n t he Cl ose Cust ody

Uni t , t he si ngl e cel l segr egat i on uni t , wher e i nmat es cannot hol d

any empl oyment and are pl aced i n r est r ai nt s whenever t hey l eave t he

cel l . Si nce Kosi l ek i s ser vi ng a l i f e sent ence, Bi ssonnet t e

expr essed concern t hat housi ng her i n an envi r onment t hi s

r est r i ct i ve f or such an ext ended per i od of t i me woul d have a

negat i ve i mpact on Kosi l ek' s ment al heal t h.

On cross- exami nat i on Bi ssonnet t e made a f ew concessi ons.

She agr eed t hat MCI - Fr ami nghamcur r ent l y houses appr oxi mat el y f or t y

of f ender s who ar e ser vi ng l i f e sent ences f or mur der . Fur t her , t he

i nst i t ut i on houses i n t he gener al popul at i on i nmat es who ar e

convi ct ed of hei nous cr i mes agai nst chi l dr en al ongsi de pr i soner s

who ar e mot her s. Bi ssonnet t e expl ai ned t hat i f i nmat es ar e

percei ved t o exper i ence t r auma based on t he pr esence of other

i nmat es, t her e ar e pol i ci es and pr ocedur es i n pl ace t o f ol l ow ( such

as si mpl y or der i ng a cel l t r ansf er ) and t he ment al heal t h and

secur i t y st af f woul d r espond appr opr i at el y. Though Bi ssonnet t e

agai n acknowl edged Kosi l ek coul d be housed i n t he Cl ose Cust ody

Uni t saf el y, she per si st ed t hat t hi s was not t he "best set t i ng f or

any i nmat e over a l ong per i od of t i me. " 19

19 Dur i ng t he f i r st r ound of t est i mony some more negat i ve pr esscame out . The Bost on Gl obe r an an edi t or i al on J une 15, 2006,whi ch t ook t he posi t i on t hat Kosi l ek shoul d not r ecei ve t hesur ger y. The edi t or i al r ef er r ed t o t he "di st ast ef ul ness of a wi f eki l l er angl i ng t o ser ve out hi s sent ence of l i f e wi t hout par ol e i n

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2. Responses to the First Round of Testimony

Af t er t he f i r st bout of t est i mony, whi ch concl uded at t he

end of J une 2006, J udge Wol f t hen di r ected t he UMass doct ors t o

r evi ew Dr . Schmi dt ' s t est i mony and t o i nf or mt he cour t whet her t he

l at t er ' s pr oposed appr oach was wi t hi n pr udent pr of essi onal

st andar ds. Dr s. Appel baum and Br ewer r esponded i n a r epor t f i l ed

wi t h t he cour t on Sept ember 18, 2006. They cont i nued t o endorse

t he Fenway Cent er doct or s' concl usi on t hat Kosi l ek had a ser i ous

medi cal need r equi r i ng sur ger y. I n t hei r opi ni on, Dr . Schmi dt ' s

pr oposed al t er nat i ve cour se of psychot her apy, medi cat i on, and

sui ci de wat ch f el l "out si de t he bounds of accept abl e pr of essi onal

st andar ds" and woul d not const i t ut e "adequat e medi cal car e. " Such

i nt er vent i ons woul d "l i kel y do l i t t l e" t o r educe Kosi l ek' s

dysphor i a or t he r i sk of har m t o her . Onl y sur ger y, t hey

concl uded, coul d do t hi s, and t her e was " no good cl i ni cal r eason t o

wi t hhol d t hat t r eat ment at t hi s t i me. "

The j udge al so or der ed Dennehy t o r evi ew t he evi dence

pr esent ed at t r i al and deci de whet her t he DOC woul d rever se i t s

posi t i on on sur ger y f or Kosi l ek. Af t er doi ng so, Dennehy i ndi cat ed

t o t he cour t t hat Dr s. Appel baum' s and Br ewer ' s t est i mony conf i r med

what she suspect ed ( but appar ent l y di d not pr evi ousl y f i nd cl ear ) :

t hat t he doct or s bel i eved surger y was medi cal l y necessar y. Dennehy

st ood f i r mt hough; she advi sed J udge Wol f t hat her deci si on not t o

a women' s pr i son. "

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al l ow sex r eassi gnment sur ger y f or Kosi l ek r emai ned. Her saf et y

and secur i t y concer ns wi t h pr ovi di ng surger y, whi ch Dennehy cal l ed

"al ar mi ng and subst ant i al , " had not changed.

3. Second Round of Testimony

Test i mony r esumed i n ear l y Oct ober 2006, wi t h var i ous

wi t nesses t aki ng and r e- t aki ng t he st and. Fi r st came Dr .

Appel baum, who emphasi zed sever al poi nt s. Kosi l ek had a ser i ous

medi cal need because t her e was a ser i ous r i sk of har m i f she was

not adequatel y t r eat ed; and he had i nf ormed Dennehy of t hi s.

Ant i depr essant s wer e unl i kel y t o ef f ect i vel y t r eat Kosi l ek because

t he sour ce of her di st r ess was her gender i dent i t y di sorder and

medi cat i on woul d not t ar get t hi s under l yi ng condi t i on. Rat her ,

surger y, he expl ai ned, was t he " r ecogni zed and appr opr i at e

t r eat ment " and t he onl y t r eat ment " l i kel y t o si gni f i cant l y r el i eve,

i f not el i mi nat e Mi ss Kosi l ek' s di st r ess. "

Dr . Kevi n Kapi l a f r om t he Fenway Cent er al so spoke. He

cal l ed Kosi l ek' s gender i dent i t y di sor der "one of t he mor e sever e

cases" he had ever seen and he test i f i ed about t he report he and

Dr . Kauf man had wr i t t en. I n hi s opi ni on, Kosi l ek had a ser i ous

medi cal need and t her e was a subst ant i al r i sk of har m i f she was

not t r eat ed wi t h sur ger y. Dr . Kapi l a al so t est i f i ed t hat he

t hought Dr . Schmi dt ' s r ecommendat i on was unr easonabl e.

Speci f i cal l y, Dr . Kapi l a ( who had r evi ewed Dr . Schmi dt ' s t est i mony)

opi ned t o a r easonabl e degr ee of medi cal cer t ai nt y t hat Dr .

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Schmi dt ' s pl an t o t r eat Kosi l ek wi t h psychot her apy and medi cat i on

was i nadequat e. Poi nt i ng t o hi s own eval uat i on of Kosi l ek af t er

she had been r ecei vi ng psychotherapy and hormones f or sevent een

mont hs, Dr . Kapi l a not ed her sympt oms had st i l l not r esol ved; "she

st i l l was deal i ng wi t h di scomf or t ar ound havi ng mal e geni t al i a. "

Dr . Schmi dt ' s appr oach woul d not deal wi t h t hi s core pr obl em—onl y

sur ger y coul d — and, Dr . Kapi l a cont i nued, one t r i es t o t r eat t he

probl em, not merel y t he symptoms.

Dr . Kauf man t hen got r ecal l ed. Whi l e she agr eed

Kosi l ek' s dysphor i a had i mpr oved as a resul t of r ecei vi ng hor mone

t r eat ment s and gender - appr opr i at e i t ems and cl ot hi ng, Dr . Kauf man

per si st ed i n opi ni ng t hat Kosi l ek st i l l had a ser i ous medi cal need

and i f she di d not r ecei ve sur ger y t her e was a subst ant i al r i sk of

ser i ous har m. Despi t e al l t he t r eat ment Kosi l ek had r ecei ved, she

st i l l cont i nued t o exper i ence sever e dysphor i a. Li ke Dr . Kapi l a,

Dr . Kauf man di d not t hi nk t he t r eat ment advocat ed by Dr . Schmi dt

was adequat e. I t i s i mpor t ant t o di st i ngui sh bet ween depr essi on

and dysphor i a, she sai d, and Dr . Schmi dt ' s t r eat ment woul d not

suf f i ci ent l y addr ess t he l at t er .

UMass' s Medi cal Di r ect or , Dr . Ar t hur Br ewer , was up next .

He had l i t t l e t o add t o t he t est i mony of t he ot her medi cal

pr ovi der s because, as medi cal di r ect or , he was not i nvol ved i n

UMass' s ment al heal t h pr ogr am and had no r ol e i n Kosi l ek' s

t r eat ment . Hi s posi t i on r emai ned t he same as i n hi s and Dr .

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Appel baum' s Sept ember 18, 2006 l et t er , whi ch suppor t ed t he Fenway

Cent er doct or s and cr i t i ci zed Dr . Schmi dt ' s appr oach.

J udge Wol f t hen agai n hear d f r om Commi ssi oner Dennehy.

She accept ed t hat Kosi l ek had a ser i ous medi cal need but sai d she

had pr evi ousl y been conf used about whether sur gery was medi cal l y

necessary. Whi l e she had now "deduced" UMass' s opi ni on on t he

appr opr i at eness of surgery f or Kosi l ek, she had not changed her

t hought s on t he secur i t y and saf et y concer ns r el at ed t o pr ovi di ng

such sur gery. Absent t hese concer ns, Dennehy agr eed she woul d have

no reason t o i nt er f er e wi t h any medi cal or der f or t r eat ment .

The cour t quest i oned Dennehy about her awar eness of any

publ i ci t y sur r oundi ng Kosi l ek' s case. Dennehy was gener al l y awar e

of a coupl e of ar t i cl es appear i ng i n t he Bost on paper s and admi t t ed

ski mmi ng one. She al so knew about an ar t i cl e on a nat i onal news

medi a websi t e. I n gener al she t r i ed not t o r ead newspaper ar t i cl es

t hat i nvol ved her and she never t hought about what t he publ i c and

pol i t i cal r eact i on woul d be i f t he DOC al l owed Kosi l ek t o have

sur ger y.

4. The Court-Appointed Expert

Af t er hear i ng al l t he wi t nesses each si de wi shed t o

pr esent , J udge Wol f deci ded t o appoi nt an exper t i n or der t o hel p

hi mdeci de whet her t he car e pr oposed by Dr . Schmi dt was obj ect i vel y

adequat e. See Fed. R. Evi d. 706 ( pr ovi di ng t hat t he cour t may on

i t s own i ni t i at i ve appoi nt an exper t ) . Af t er sol i ci t i ng t he

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par t i es' t hought s on who t o appoi nt , J udge Wol f sel ect ed St ephen

Levi ne, M. D. , on Oct ober 31, 2006. Dr . Levi ne pr act i ced at t he

Cent er f or Mar i t al and Sexual Heal t h i n Ohi o and was a cl i ni cal

pr of essor of psychi at r y at Case West er n Reserve Uni ver si t y School

of Medi ci ne. The cour t i nf or med Dr . Levi ne t hat Kosi l ek had been

l i vi ng as a woman i n pr i son and i nst r uct ed hi m t o t r eat t hi s case

as i f Kosi l ek wer e j ust anot her pat i ent out i n f r ee soci et y,

wi t hout al l t he i ssues at t endant t o her bei ng i ncar cer at ed.

A mont h l at er , Dr . Levi ne, who di d not i nt er vi ew Kosi l ek,

i ssued a wr i t t en r eport . Comment i ng on t he vi ews hel d by Dr s.

Br own and Schmi dt , he not ed t hey "r ef l ect t he cur r ent pol ar i t i es

wi t hi n psychi at r y" wi t h each of t hei r r espect i ve posi t i ons havi ng

mer i t . He wr ote t hat "Dr . Schmi dt ' s vi ew, however unpopul ar and

uncompass i onat e i n t he eyes of some exper t s i n GI D, i s wi t hi n

pr udent pr of essi onal communi t y st andar ds. "

I n addi t i on t o submi t t i ng hi s r epor t , Dr . Levi ne al so

t est i f i ed on December 19, 2006. At f i r st , he r ei t er at ed t hat t he

t r eat ment r ecommended by Dr . Schmi dt , t hough perhaps not popul ar ,

was wi t hi n pr udent prof essi onal st andar ds. He t hought Kosi l ek had

obt ai ned a good amount of r el i ef f r om bei ng on hormones and

dressi ng as a woman and was pr obabl y as f emi ni ne as she was goi ng

t o be; sur ger y woul d be " i ci ng on t he cake" he sai d. Dr . Levi ne,

l i ke Dr . Schmi dt , st opped shor t of sayi ng t hat Kosi l ek woul d t r y t o

ki l l her sel f i f she was deni ed sur ger y. He t hought i t was j ust a

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possi bi l i t y and Kosi l ek' s i mpul se coul d per haps change over t i me.

And, he added, even i f Kosi l ek recei ved t he sur ger y, i t was

possi bl e t hat , havi ng not hi ng l ef t t o f i ght f or , she coul d st i l l

exper i ence an emot i onal cr i si s and cont empl at e sui ci de. I n

gener al , Dr . Levi ne had cr i t i ci sms of bot h Dr . Schmi dt ' s and Dr .

Br own' s r eport s, but he t hought t hey were both r easonabl e.

Dur i ng quest i oni ng by J udge Wol f , i t seemed Dr . Levi ne

had not f ol l owed some of t he cour t ' s di r ect i ves about not t aki ng

i nt o account t he f act t hat Kosi l ek was i n pr i son. Pr esumi ng

Kosi l ek woul d never be f r ee, Dr . Levi ne di d agr ee Kosi l ek had l i ved

a r eal - l i f e exper i ence as a woman i n pr i son. He al so bel i eved she

essent i al l y met al l t he el i gi bi l i t y and r eadi ness requi r ement s f or

surger y under t he St andar ds of Car e. Dr . Levi ne opi ned t hat

pr ovi di ng Kosi l ek wi t h sur ger y, assumi ng she had met t he r eal - l i f e

exper i ence r equi r ement , woul d be consi st ent wi t h pr udent

pr of essi onal pr act i ce. And al t hough Dr . Levi ne had ear l i er i n hi s

t est i mony f

first circuit upholds order requiring prison to offer sex change operation

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