Accusing them of ignorance and bigotry, a federal judge this week excoriated Florida corrections officials for refusing to accommodate a transgender inmate, despite the prisoner's repeated suicide attempts and persistent requests to wear bras and panties and to have access to women's grooming items.
U.S. District Judge Mark Walker on Wednesday ordered the Florida Department of Corrections to continue providing hormone treatments to Reiyn Keohane, who was born a male but began identifying as female at age 8 and started wearing women's clothing, makeup and hairstyles at 14, according to court records.
The judge also ordered the state to allow Keohane, who had begun hormone therapy before she started serving a 15-year sentence for attempted murder in 2014, to wear women's undergarments and have access to grooming items available to female inmates.
After Keohane sued the Department of Corrections and several prison officials, including Secretary Julie Jones, in 2016, she was allowed to resume the hormone treatments. But prison officials continued to refuse to allow Keohane, who is incarcerated at the all-male Walton Correctional Institution, to wear women's undergarments, let her hair grow or groom as a woman.
The hormone therapy is causing "feminizing" changes to Keohane's body, but she is forced "to live outwardly as a man in ways that, though seemingly banal to some, strike at the heart of what it means to be perceived as a man or woman," Walker wrote in a blistering, 61-page order.
Walker in a footnote explained that he used female pronouns when referring to Keohane "out of respect" for the inmate.
The judge chastised Jones and the department for being "indifferent" to the prisoner's needs, scolding that "if Ms. Keohane's treatment in defendant's custody isn't deliberate indifference, then surely there is no such beast."
"Defendant's deliberate denial of care — that is, the denial of access to female clothing and grooming standards despite its knowledge of her diagnosis and her history of self-harm — has caused Ms. Keohane to continue to suffer unnecessarily and poses a substantial risk of harm to her health," he wrote.
Walker accused state officials of providing "shifting explanations" for the denial of hormone treatment and access to such things as female clothing.
The case is "about whether the law, and this court by extension, recognizes Ms. Keohane's humanity as a transgender woman," Walker wrote.
"The answer is simple. It does, and I do," he went on.
Department of Corrections spokeswoman Michelle Glady said the agency is reviewing Walker's order but would not specifically say whether Keohane is currently allowed to wear bras and panties and groom as a woman.
"The department provides constitutionally mandated health care to all inmates in our custody, to include any treatment deemed medically necessary by a doctor," Glady said in an email.
Keohane, who is now 24, was formally diagnosed at age 16 with "gender dysphoria," a psychiatric diagnosis that generally "refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth," according to court records.
Keohane repeatedly requested to be allowed to "socially transition" and to resume hormone therapy, after entering the prison system in 2014.
Instead, prison officials several times "forcibly shaved" Keohane's head after she protested the agency's hair-length policy, which requires men to wear their hair above the ears, according to court records. Prison workers also confiscated her self-made bras and panties.
"These disciplinary actions have almost always contributed to the feelings of anxiety, disgust, and hopelessness accompanying Ms. Keohane's gender dysphoria, leading her to consider or attempt to harm herself," Walker wrote, including Keohane's account of an attempted self-castration. "Ultimately, defendant has chosen an easier course of treatment to maximize 'uniformity,' and ease 'security concerns,' by ignoring the substantial risk of harm to Ms. Keohane's mental health that results from denying such 'minor accommodations' as panties and access to defendant's female grooming standards. This ends now."
Last year, Keohane and corrections officials reached an agreement in which her hair would not be forcibly cut "pending entry of judgment on the trial of this case," Daniel Tilley, an American Civil Liberties Union of Florida attorney who represents Keohane, told The News Service of Florida. The law firm DLA Piper also has represented Keohane.
"The ruling powerfully explains to prison and jail officials across the country why they need to provide this basic health care to transgender inmates in their care," Tilley said.
Keohane's hormone therapy stopped in 2013 after she was arrested and locked up in a Lee County jail. Because Keohane wasn't on the treatment when she entered the prison system, corrections officials denied her request to resume hormone therapy, a policy Walker referred to as "freeze-frame" language.
Prison officials argued that the legal challenge is moot because they have since dropped the "freeze-frame" policy.
But Walker said the state couldn't be trusted to stick to its revised protocol.
The fact that the "freeze-frame" policy was only applied to inmates with gender dysphoria "doesn't mitigate the absurdity of such an approach," which Walker found was unconstitutional.
"Indeed, this targeting only reinforces this court's suspicion that bigotry and ignorance swayed defendant's decision making for treating (or, rather, not treating) Ms. Keohane's gender dysphoria," the judge wrote.
After denying Keohane hormone therapy for two years, the corrections department began providing the treatment after she sued the state, a move that particularly riled Walker.
The "prolonged denial" of hormone treatment constitutes "deliberate indifference" to Keohane's medical condition, Walker found.
In another footnote, Walker wrote that Department of Corrections' chief of security operations, James Upchurch, "was downright baffled over the differences between transgender people, gay people, and people diagnosed with gender dysphoria" when testifying during the trial.
Upchurch — who admitted he had "never heard of gender dysphoria" before the case — said, "I don't think there are a lot of people out there who know or would know who is what, and I don't think there are a lot of inmates out there who really know if they are one or the other."
Department of Corrections chief medical officer Timothy Whalen also earned Walker's wrath. Whalen testified that the corrections department isn't implementing treatment standards, such as social transitioning, recommended by the World Professional Association for Transgender Health, or WPATH.
And Whalen, the department's chief doctor, "wasn't shy about his qualms with WPATH Standards," or other mainstream medical organizations that rely on the standards, Walker wrote, quoting Whalen's trial testimony.
"It's the only process that I'm aware of where we go against nature to help somebody. And while I'm trying to grasp that, I still have trouble making that leap," Walker quoted Whalen as saying. The judge also wrote that Whalen "thinks there's a possibility gender dysphoria just doesn't exist at all."
Walker scolded corrections officials for "delays, rigidities, and shifting explanations" in response to Keohane's request for social transitioning.
For example, the three members of her treatment team concluded there was nothing they could do about Keohane's request to wear female undergarments because they believed corrections officials' security policies prohibited such treatment.
Given the "severe constraints" placed on self-expression inside prisons, the only way for Keohane "to express her gender identity is through pronouns, undergarments and grooming," Walker wrote.
"She's simply asking defendant to see her and treat her as she is; namely, a woman stuck in a male body that's stuck in a cage for the foreseeable future. Even defendant's own expert agrees that allowing for social transitioning is a compassionate part of Ms. Keohane's treatment plan," he wrote. "Ms. Keohane is not an animal. She is a transgender woman. Forthwith, defendant shall treat her with the dignity the Eighth Amendment commands."