The U.S. Court of Appeals for the 1st Circuit upheld the district court's order to Massachusetts officials at the state's Treatment Center for Sexually Dangerous Persons ("Treatment Center") to provide hormone therapy for a civil detainee. The court held that refusal to provide such treatment was a constitutional violation based on the 8th and 14th Amendments.
Sandy Battista, currently under civil commitment at the Treatment Center after imprisonment for a sexual offense, is anatomically male but has been diagnosed with "gender identity disorder" ("GID"), a psychological condition involving strong identification with the other gender. In 1996 Battista began seeking treatment for GID, including administration of hormone therapy and access to female clothing. The Department of Corrections ("Department") has acknowledged her condition since 1997, but has consistently denied treatment even in the face of Battista trying to castrate herself.
In 2005, Battista filed the present complaint against Department officials for deliberate indifference to medical needs in violation of the 8th and 14th Amendments. The Department accepted the GID diagnosis, but asserted that Battista faced security concerns by living in the Treatment Center as a woman, mainly due to the risk of sexual assault from other inmates. In August 2010, the trial court issued a preliminary injunction ordering hormone therapy to begin. The district court's finding of "deliberate indifference" rested on two main grounds: 1) that Battista established a medical need and such therapy was feasible, and 2) that the administrative discretion defendants had in dealing with security concerns was undercut by years of unnecessary delays and misrepresentations to Battista.
Here, the court of appeals affirmed the trial court's decision. The court first enumerated the tests for whether confinement under the 8th and 14th Amendments is constitutionally acceptable. Under the 8th Amendment, defendants cannot be "deliberately indifferent" to the medical needs of the prisoner. Under the 14th Amendment, which the court notes is arguably more applicable for civil commitment cases, the defendant must exercise "reasonable professional judgment." Both tests give deference to the judgment of prison administrators. The court noted that under either formulation, it was reasonable for the trial court to conclude that continued refusal to provide hormone therapy was constitutionally impermissible. The court noted that the pattern of "delays, poor explanations, missteps, changes in position and rigidities – common enough in bureaucratic regimes but here taken to an extreme," showed that the defendants "forfeited the advantage of deference." The court of appeals provide three examples to illustrate the indifference/unreasonableness demonstrated by the Department: 1) the Department was initially dismissive of the diagnosis; 2) the Department came up with the security justification several years after it heard expert opinions stating hormone therapy was medically necessary, casting doubt on the credibility of security concern argument; and 3) the Department claimed that the only way to keep Battista safe was solitary confinement, but has retreated from this extreme position recently.