Transgender Inmates: The Law of Effective Medical Care Commentary
Transgender Inmates: The Law of Effective Medical Care
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John Knight, Senior Staff Attorney at the American Civil Liberties Union of Illinois, says that the Seventh Circuit’s recent decision affirming the need for hormone therapy for transgender inmates offers a new level of protection against political biases that would cause transgender inmates serious harm…

The Seventh Circuit’s decision in Fields v. Smith is remarkable because of its clear recognition that effective medical care for transgender people must include hormone therapy; its rejection as ineffective “treatment alternatives,” such as the anti-depressants Wisconsin proposed to offer; and its dismissal of the state’s claim that the medical treatments had been denied to keep transgender inmates secure. The decision follows a long history of cases recognizing Gender Identity Disorder (GID), the medical condition that impacts many transgender individuals, as a serious medical need, but sets the record straight regarding the importance of hormone therapy to treat GID. It puts to rest a blatantly discriminatory piece of legislation passed due to popular biases being put ahead of medical research, singling out a small group of inmates, and blocking medical treatments necessary only for them.

The Seventh Circuit recognized the importance of medical treatment for transgender inmates in 1987, when it definitively stated in Meriwether v. Faulkner that GID is a serious medical condition that demands treatment. The Meriwether court stopped short of ordering any specific treatment, such as hormone therapy, however. Securing effective medical treatment for GID has been a challenge for transgender inmates ever since, largely because courts’ already ample deference to the decisions made by prison administrators and prison doctors has, if anything, only grown since 1987.

There have been exceptions to the many cases denying transgender inmates treatment when courts have been faced with particularly egregious instances of a transgender inmate being denied effective treatment, such as De’Lonta v. Angelone, where a transgender female inmate engaged in genital self-mutilation after being taken off hormone therapy because of a blanket prison policy, rather than medical judgment. This inspired the Fourth Circuit to reverse the district court’s dismissal of De’Lonta’s case. There have also been some unfavorable decisions made without the benefit of a complete factual record, including qualified expert testimony, often in cases brought by transgender inmates acting pro se. Examples include another Seventh Circuit decision, Maggert v. Hanks, in which the court, after noting that the plaintiff had never been diagnosed with GID, reached several surprising and inaccurate conclusions about transgender medical care. These included the finding that effective treatment for GID always requires sex reassignment surgery (SRS) and that such treatment is extremely expensive, therefore justifying its denial. The Fields court reviewed the trial evidence—which tested and disproved the empirical assumptions behind the Maggert ruling—and put aside the Maggert court assumptions in favor of the facts supporting the district court’s decision.

A major barrier to accessing transgender medical care is just how politically unpopular it is to provide such care, especially to prisoners. The Inmate Sex Change Prevention Act, struck down by the Fields court, passed by overwhelming majorities in both houses of the Wisconsin legislature and was signed into law by a Democratic governor. Fortunately, doctors are less likely to bow to the popular will behind such laws than are legislators. The top medical administrators at the Wisconsin Department of Corrections criticized the proposed act during their legislative testimony, describing the necessity of medical treatment for transgender persons, the harms inflicted on inmates by denying them treatment, and the burdens on the prison staff forced to address the life-threatening symptoms of untreated GID, such as depression and suicide attempts.

Powerful testimony from the prison medical administrators and some highly qualified transgender medical care experts led the district court to conclude that the act violated the Eighth Amendment, with which the Seventh Circuit agreed: “Surely, had the Wisconsin legislature passed a law that … inmates with cancer must be treated only with therapy and pain killers, this court would have no trouble concluding that the law was unconstitutional. Refusing to provide effective treatment for a serious medical condition serves no valid penological purpose and amounts to torture.” One hopes that a day will arrive soon when public sentiment about transgender people has improved, but until then it is gratifying to know that the courts are willing to offer some level of protection against the serious harm transgender persons have experienced for far too long.

John Knight is a Senior Staff Attorney at the American Civil Liberties Union of Illinois and the director of the LGBT and AIDS Project. He directs litigation in the Midwest to confront bias and discrimination against LGBT individuals and speaks frequently in public about these issues. As part of these duties he was co-counsel for the Fields v. Smith legal team.

Suggested citation: John Knight, Transgender Inmates: The Law of Effective Medical Care, JURIST – Hotline, Sept. 7, 2011,

This article was prepared for publication by Edward SanFilippo, an associate editor for JURIST’s professional commentary service. Please direct any questions or comments to him at

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