In a strident decision, a federal judge ruled this week that the Florida Department of Corrections (DOC) was violating the constitutional rights of a transgender inmate by denying her access to hormone therapy and female clothing and grooming standards. Praising the plaintiff for her perseverance in the face of years of adversity, he held that “ignorance and bigotry” were the top reasons she was denied medically necessary care.
Plaintiff Reiyn Keohane, 24, had been living for several years as a woman and had even begun hormone treatment before she became incarcerated, but she was provided no treatment under the care of the DOC. Over several years, she filed countless grievances for access to the medical treatment she had already been undergoing and for access to female clothing and grooming standards. These grievances were dismissed or ignored, despite the fact that Keohane attempted self-harm of her genitals and suicide on several occasions.
Chief U.S. District Judge Mark Walker, an Obama appointee, was unimpressed by the DOC’s excuses. The DOC claimed that because it was now providing Keohane with hormone therapy, the case was moot. In his opinion, however, Walker noted the DOC only changed course after “staring down the barrel of a federal lawsuit,” having previously ignored her “deafening call for help.”
“[I]f Ms. Keohane’s treatment in Defendant’s custody isn’t deliberate indifference, then surely there is no such beast,” he wrote, referring to the standard for Eighth Amendment violations. “Ultimately, this case is about whether the law, and this Court by extension, recognizes Ms. Keohane’s humanity as a transgender woman. The answer is simple. It does, and I do.”
As has been the situation in several different cases related to medical care for transgender people in prison, the Florida DOC had instituted a “freeze-frame” policy for treating gender dysphoria. According to that policy, transgender inmates can only receive treatment they were already receiving before they entered the prison system. Even though Keohane was undergoing hormone therapy before she was arrested, the jail refused to continue her treatment. After she was sentenced, the DOC then used the fact that she was denied treatment in jail to continue to deny her treatment in prison.
When Keohane filed her first grievance requesting to resume hormone therapy in 2014, it was denied because she had canceled an appointment with her pediatric endocrinologist. The reason she couldn’t turn up for that appointment, however, was “because she was in jail at the time,” as Walker emphasized in the opinion. Keohane was then told in a subsequent grievance denial, “You have not received hormone treatment since 2013. You will not be placed on hormonal therapy while incarcerated in the Florida State Dept. of Corrections.”
The system was rigged against her.
The DOC may have decided to acquiesce in dropping the “freeze-frame” policy and providing Keohane with hormone therapy after she filed her suit, but Walker pointed out that there was no evidence about the change “to show Defendant engaged in substantial deliberation in amending this policy. Zero. None.” He likewise found no compelling basis for any such “freeze-frame” policy in the first place:
Moreover, the law has never been that Defendant can have a blanket ban on medically necessary treatment if an inmate didn’t receive that treatment before entering the state’s custody. If that were the case, the law would essentially permit a de facto death sentence to any inmate diagnosed with cancer after incarceration.
Indeed, the primary explanation Walker could discern for ever instituting such a policy was “ignorance and bigotry.” As an immediate example, he noted that one of DOC’s experts on prison security “was downright baffled” over the differences between transgender people and gay people. Moreover, he detailed how almost every medical expert connected to Keohane’s case had little, if any, experience working with transgender patients. Those who had at least some knowledge of the standards of care for gender dysphoria were skeptical of their veracity.
Anti-trans bigotry was particularly apparent when it came to the DOC’s chief medical officer, Dr. Timothy Whalen, who described transitioning as “the only process that I’m aware of where we go against nature to help somebody.” Further parroting the talking points of anti-LGBTQ groups, he dismissed the American Medical Association and American Psychiatric Association as “political” organizations and compared hormone therapy to “offering diets to anorexics.” Whalen admitted that his religion “enters into” his views on the matter, including his belief that it’s possible gender dysphoria just doesn’t exist at all.
Though Whalen was not part of Keohane’s treatment team, he was the final decision maker for exceptions to the DOC’s policies. Likewise, many of the other medical professionals who did treat Keohane followed Whalen’s lead of trying to treat Keohane’s depressive symptoms without making any effort to treat the underlying gender dysphoria. None believed seeking exemptions to the policies were a possible approach.
Dr. Jose Santeiro, for instance, evaluated Keohane to determine if she had a medical need to socially transition, but determined she had no need for access to female clothing and grooming standards. He had not read her counseling notes, which included her history of self-harm, yet tried to delineate between a “physical” need to socially transition and a “mental-health” need. Walker dismissed this distinction as a “flawed conception of ‘medically necessary’ treatment.”
Another member of Keohane’s treatment team, Andre Rivero-Guevara, likewise testified that his preferred response to a suicidal inmate suffering from gender dysphoria would be to place her in special housing with psychiatric medication rather than allow her to socially transition. “Mr. Rivero would simply medicate and isolate the inmate until they’re momentarily talked down from the metaphorical ledge,” Walker wrote. “As [Keohane’s expert, Dr. George R. Brown] testified at trial, this is like ‘putting a Band-Aid over a wound that requires significant intervention and the Band-Aid isn’t sufficient.’”
At different times, DOC claimed that there were safety concerns in allowing Keohane to transition, but could not convince Walker of their legitimacy. Walker characterized the DOC’s unwillingness to make exceptions to their policies on Keohane’s behalf as serving only “to prolong her mental suffering without any legitimate penological purpose.”
In his ruling, Walker said Keohane was simply asking for the bare minimum offered to all inmates, and praised her for “see[ing] herself as a warrior queen in this fight.” This was a reference to testimony Keohane gave earlier in the case, which Walker included in a footnote:
At trial, Ms. Keohane aptly compared herself to Daenerys Targeryen — “a queen and a warrior who has been through hardship and has learned how to survive it, who not only stands up for herself, but for other people and who values . . . human dignity and believes that all people should be able to have it.”
Walker enjoined the DOC from ever reenacting or enforcing a “freeze-frame” policy and ordered them to provide Keohane with hormone therapy and access to female clothing and grooming standards.
The American Civil Liberties Union (ACLU) has since praised the ruling, noting that Keohane “fought the DOC tooth and nail for years.”
“Today is a great day for our client, and we celebrate with her,” ACLU of Florida staff attorney Daniel Tilley said in a statement.
Keohane’s is the latest in a series of recent court victories involving transgender inmates also denied proper medical care in the prison system. Nevertheless, discrimination is likely to continue, particularly since the Trump administration recently rescinded guidance designed to protect against such mistreatment.