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Florida Prisoner’s Gender Dysphoria Requires Hormone Therapy, 
Social Transitioning Treatment

Following a bench trial, on August 22, 2018 a Florida federal district court held that state prison officials were deliberately indifferent to transgender prisoner Reiyn Keohane’s serious medical condition of gender dysphoria. The court said the denial of hormone therapy, as well as bras, panties and access to female grooming standards, “ends now.” [See: PLN, Nov. 2018, p.40].

Keohane was born anatomically male but began to identify as female at age eight. Since she was 14, Keohane has worn women’s clothing, makeup and hair styles, adopted a feminine name, and used female pronouns at school and with family and friends. “In short, she’s lived as a woman in all aspects of her life since her early teens,” the district court wrote.

That changed on September 22, 2013, when Keohane was charged with attempted second-degree murder in connection with an incident involving her roommate. Just six weeks earlier, Keohane had begun hormone therapy to treat her gender dysphoria. That treatment was denied at the Lee County Jail, and under the Florida Department of Corrections’ (FDOC) “freeze policy,” it was also denied when she began serving a 15-year sentence.

Keohane filed a flurry of grievances at several prisons seeking hormone therapy and social transitioning, which the court defined for purposes of its order as access to female clothing and grooming standards. The FDOC’s denial was “based on security concerns instead of articulating any medical opinion as to whether social transitioning should be part of Ms. Keohane’s treatment plan in addition to hormone therapy and counseling,” the court wrote.

The denial of the hormone therapy and social transitioning resulted in Keohane trying to commit suicide several times and attempting self-castration. 

The district court noted that if Keohane’s treatment “isn’t deliberate indifference, then surely there is no such beast.” One FDOC counselor said rather than treat the underlying medical need, he “would simply medicate and isolate the inmate until they’re momentarily talked down from the metaphorical ledge,” the court found.

Hormone therapy resulted in “feminizing” changes to Keohane’s body, but the FDOC was forcing her “to live outwardly as a man” and continued to deny care because its freeze policy prohibited hormone therapy if the prisoner was not receiving it when they entered the state prison system, and prison officials argued there was “no medical need for access to female clothing and grooming standards.” That position, however, began to change when the FDOC “was staring down the barrel of a federal lawsuit.”

Suddenly, the FDOC abandoned its freeze policy and provided Keohane with hormone therapy. Despite that policy change, the district court found Keohane’s challenge to the freeze policy was not moot because the change came “late in the game” and was not an “unambiguous termination.” The court held the freeze policy was unconstitutional, entered a permanent injunction against its enforcement and ordered that Keohane continue to receive hormone therapy unless it is determined to be “medically contraindicated.”

The district court found that denial of access to female clothing and grooming standards based on “security concerns” constituted deliberate indifference to Keohane’s gender dysphoria. She also was denied “access to medical personnel capable of evaluating her treatment needs,” the court stated. “A lot can explain the denial of care in this case, starting at the top with ignorance and bigotry.” 

In a footnote, the court cited testimony by the FDOC’s security expert, James Upchurch, who said he was “downright baffled over the differences between transgender people, gay people, and people diagnosed with gender dysphoria.” The prison system’s chief medical officer, Dr. Timothy Whalen, testified that the only proper care for gender dysphoria is psychotherapy and psychiatric medication. In providing insight as to why the FDOC’s rate of prisoner deaths had increased in recent years, Dr. Whalen testified that “non-urgent” care was not considered medically necessary.

The court disagreed. It found the Constitution requires not just emergent care, but also care for psychological conditions that can result in self-harm or psychological suffering. The evidence showed that Keohane was undisputedly diagnosed with gender dysphoria and that the standard of care established by the World Professional Association for Transgender Health prescribes, in part, social transitioning. 

A permanent injunction was entered to ensure Keohane received that standard of care, including the ability to “socially transition by allowing her access to female clothing and grooming standards consistent with Defendant’s security policies governing female inmates’ hair length, possession and purchase of makeup, and possession of female undergarments including bras, sports bras, and panties.”

The FDOC appealed that order on September 21, 2018, and the case remains pending before the Eleventh Circuit. See: Keohane v. Jones, 328 F.Supp.3d 1288 (N.D. Fla. 2018). 

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Related legal case

Keohane v. Jones