## Facts

- Transgender women incarcerated in the Illinois Department of Corrections (IDOC) brought a putative class action under 42 U.S.C. § 1983 seeking injunctive relief for alleged unconstitutional treatment of gender dysphoria.
- IDOC used a “Transgender Committee” to influence decisions on security placement and medical treatment for transgender prisoners.
- Plaintiffs presented evidence that IDOC delayed diagnosis and treatment; provided inadequate hormone dosing and monitoring; and delayed or denied hormone therapy for reasons inconsistent with accepted medical standards.
- Plaintiffs presented evidence that IDOC categorically refused to provide, and would not evaluate prisoners for, gender-affirming surgery even when requested.
- Plaintiffs presented evidence that IDOC restricted social-transition measures (e.g., gender-affirming clothing, grooming items, and presentation) and tolerated persistent misgendering and slurs.
- Plaintiffs presented evidence that IDOC generally housed transgender women based on birth sex and allowed strip searches by male guards, increasing psychological distress and safety risks.
- Individual accounts included multi-year delays in diagnosis and severe distress, including suicide attempts and self-harm or attempted self-castration.
- The court held a two-day evidentiary hearing with testimony from plaintiffs and expert witnesses in transgender health; IDOC did not present live testimony from officials.

## Issues

1. Whether plaintiffs showed a likelihood of success on the merits that IDOC’s policies and practices constituted deliberate indifference to a serious medical need (gender dysphoria) in violation of the Eighth Amendment.
2. Whether plaintiffs showed irreparable harm and an inadequate remedy at law absent preliminary injunctive relief.
3. Whether the balance of harms and the public interest favored an injunction requiring changes to IDOC’s treatment and management of transgender prisoners.

## Decision

- The court granted the motion for a preliminary injunction in substantial part.
- The court found plaintiffs were likely to succeed in proving that IDOC’s system for treating gender dysphoria reflected deliberate indifference to serious medical needs.
- The court found a substantial risk of irreparable harm (including self-harm and suicide risk) and that money damages would not adequately remedy ongoing injury.
- The court found the balance of harms and public interest favored requiring constitutionally adequate care and practices.
- The court ordered IDOC to implement reforms, including limiting the Transgender Committee’s control over treatment decisions, improving access to and monitoring of hormone therapy, requiring evaluation for surgery when medically indicated, permitting social-transition accommodations, and modifying certain housing/search practices to reduce risk.

## Legal Principles

- Gender dysphoria can constitute a serious medical need under the Eighth Amendment.
- Deliberate indifference may be shown where prison policies or decision structures cause unjustified delays, denials, or departures from accepted medical standards, even if some care is provided.
- A categorical refusal to consider a medically recognized treatment option, without individualized clinical evaluation, may support an inference of deliberate indifference.
- Preliminary injunctive relief requires a showing of likely success on the merits, irreparable harm with no adequate legal remedy, and that equities and the public interest favor relief.

## Conclusion

The court concluded that plaintiffs made the required preliminary showing that IDOC’s committee-driven system, treatment delays and denials, categorical non-evaluation for surgery, and restrictions on social transition likely violated the Eighth Amendment, warranting injunctive orders compelling systemic changes to medical decision-making and related prison practices.


Monroe v. Baldwin, No. 18-CV-00156-NJR-MAB, 2019 WL 6918474 (S.D. Ill. Dec. 19, 2019)