BOISE — The 9th Circuit Court of Appeals on Thursday partially lifted a pause in a court case so an Idaho transgender inmate could receive “all presurgical treatments … necessary for gender confirmation surgery.”
That ruling is in response to a motion filed by attorneys for Adree Edmo, 31, a transgender woman who sued the Idaho Department of Correction and its health care partner, Corizon Health, after officials did not provide her with gender confirmation surgery.
Edmo has been diagnosed with gender dysphoria, a condition in which the rift between a person’s preferred gender and their birth gender is severe, distressing and hurtful. In extreme cases, the disorder is treated through surgery. Edmo was born male and identifies as a female; everyone involved in the case has agreed she has gender dysphoria, a term she did not know until prison staff told her about it in 2012.
Edmo, sentenced for sexual abuse of a 15-year-old boy at a house party, has sued the state for not providing her with the surgery, though she has received other treatments.
In December, a federal district judge ruled authorities had to provide the surgery for Edmo. The state then appealed the case to the 9th Circuit Court of Appeals, which, in August, made the same finding as the district court. The 9th Circuit Court placed a stay on the district court’s order for the surgery.
Edmo’s lawyers last month asked the 9th Circuit Court to partially lift the stay so Edmo could prepare for the surgery. Deborah Ferguson, one of Edmo’s attorneys, told the Idaho Press on Friday that process can take up to six months.
On Thursday, the circuit court judges granted that motion and lifted the stay. On Friday, Edmo’s attorneys filed a motion in the Idaho district court “so that the Court can ensure immediate implementation of its order in accordance with the partial lifting of the stay.”
“We are very glad these pre-surgical matters can move forward,” Ferguson wrote to the Idaho Press in a message Friday.
Gov. Brad Little has said he’ll take the case to the U.S. Supreme Court.
“I continue to evaluate this case with my legal counsel and remain committed to appealing it to the U.S. Supreme Court in order to prevent the hardworking taxpayers of Idaho from being forced to pay for a surgery that is not medically necessary,” Little wrote in a statement to the Idaho Press on Friday.
If Edmo receives the surgery, she would be only the second person in the country to undergo the process while in prison, and the first in Idaho. Authorities have estimated 30 inmates live with the condition in Idaho’s prison system. Between October 2016 and August 2017, three inmates — two who had gender dysphoria and one who was living with sexual identification issues — killed themselves at the same facility where Edmo lived.
After the 9th Circuit Court’s August ruling, attorneys representing the Idaho Department of Correction and the case’s other defendants filed a petition for a rehearing, arguing the treatment Edmo received was “medically acceptable.” The 9th Circuit Court has yet to rule on that motion, though they granted the motion to partially lift the stay so Edmo could undergo presurgery procedures.
Edmo’s attorneys have argued she needs the surgery soon, because her gender dysphoria is severe, and hurting her. She has twice tried to castrate herself while in prison — once in 2015, and once in 2016.
Despite Edmo’s castration attempts, Dr. Scott Eliason, Corizon’s regional psychiatric director who treated Edmo for a time, did not recommend her for gender confirmation surgery.
Eliason testified at a 2018 hearing that he did not recommend the surgery because he felt Edmo had other, uncontrolled mental health challenges, including depression and alcohol abuse disorder. He also said he did not feel Edmo had adequately lived as a woman for 12 straight months, which is a commonly accepted prerequisite for the surgery.
In October 2018, Edmo testified about her experience living with gender dysphoria, and about her castration attempts — and how she broke the blade out of a disposable razor to use in the second attempt.
“But I wasn’t able to actually sever the testicle because there was too much blood,” Edmo said, according to a transcript of the hearing. “I didn’t know there would be that much blood in the area, and I couldn’t see anymore what I was cutting. So I abandoned it and got medical help.”
Leading up to the cutting, Edmo, who has felt a sense of gender dysphoria since she was 5 or 6 years old, said she felt a sense of urgency and said she felt like she “had to” castrate herself.
But she knew there were risks involved too, she said. The first time she tried to castrate herself, she said, she left a note for prison guards.
“I did leave a note before I did it, letting officers know that I in no way — I was only trying to help myself,” she said.
Randi Ettner, an expert on gender dysphoria who testified for Edmo during the hearing, and who has evaluated, diagnosed and treated between 2,500 and 3,000 people with the condition, said self-castration isn’t uncommon among those in prison who are not receiving adequate treatment for gender dysphoria.
“We typically see this in prisons when people are not receiving adequate care for gender dysphoria,” Ettner said, according to the transcript. “They will attempt to perform their own surgery. Unfortunately, some people die from blood loss.”
Ettner, who had met with Edmo and reviewed her medical records, was asked during the hearing what she believes the risks would be to Edmo if she did not receive gender confirmation surgery.
“The risks would be, as typical in inadequately treated, or untreated gender dysphoria, either surgical self-treatment, emotional decompensation, or suicide. I think that in Ms. Edmo’s case,” Ettner said, “she is at particular risk for suicide, given that she has a high degree of suicide ideation.”
Edmo, in the hearing, said she was unsure if she would attempt to castrate herself again. Sometimes, she said, the dysphoria is more intense than others.
“The typical feelings that I feel with gender dysphoria are: I feel depressed. I feel sometimes, when it’s extreme, I feel disgusting. I feel tormented. I feel hopeless. I feel like, with no hope, I have no … reason to keep going,” Edmo said. “It’s extreme.”
Those emotions act as something of a baseline to her life, but there are times when they take over completely. That’s why she said she couldn’t promise she would avoid another castration attempt.
“Given the extreme episodes that I go through in gender dysphoria I — I don’t doubt that I would actually try it again,” she said. “I don’t — I can’t tell you when I will have another episode of gender dysphoria. I don’t know when it’s going to happen. I just know it’s always there, and sometimes it’s worse than others.”
She said she’s been cutting her arm instead, as a way to offset the mental agony of the dysphoria.
“Because while I’m in a gender dysphoria episode, the mental anguish and torment I go through about who I feel I am, versus my physical body, I need to feel actual pain to actually bring me out of that episode,” she said.
Additionally, she said, she knows gender confirmation surgery won’t fix everything in her life. She lives with depression, and prior to going to prison she drank heavily — both conditions Corizon officials said could be contributing to her negative emotions.
But the surgery, Edmo said, would make a difference.
“I feel like I won’t have as much depression about myself and my physical body,” she said. “I don’t think I will be so anxious that people are always knowing that I’m different and … you know, not only that, I feel like I can actually express who I truly am more visibly and more adequately.”
The 9th Circuit Court of Appeals ruled in August that officials had not provided Edmo with proper medical treatment. In their petition for a re-hearing, the attorneys representing the state, however, argue the treatment Edmo received was “medically acceptable.”
During the October 2018 hearing, Edmo said prison staff — including the people treating her for gender dysphoria — referred to her using male pronouns.
“They are mostly — they use ‘him’, ‘his,’” Edmo said. “(On) multiple occasions, they use Mr. Edmo. Very few medical providers ever call me ‘Edmo.’ Very rarely do I ever hear any of them call me ‘Ms. Edmo.’”
A policy change the week before the hearing, on Oct. 5, 2018, required, among other things, department employees to refer to inmates who have gender dysphoria by their chosen pronouns.
“Are you happy with that?” Brady Hall, the attorney representing the department, asked Edmo in court. “Does that please you in any way?”
“It’s a very slight relief,” Edmo answered.
Yet it was Corizon doctors in prison who diagnosed her with gender dysphoria in the first place, she said. Prior to that, she’d never heard the term and identified as gay, because that’s what people around her told her she was. Receiving that diagnosis, she said, was “exciting.”
“Because I felt like this was the start of getting my life back together,” she said in court.
She began to undergo hormone therapy, something she said helped clear her mind. She felt better when she was on those hormones, she said. She noticed a difference when medical staff members, because of complications, took her off one of the testosterone suppressants she’d been prescribed.
“So I felt that testosterone building up, and I sent in concern forms to the providers asking: please, is there any other testosterone suppressant that you can find for me, or anything, because I can feel it building, and it’s not good for me,” Edmo testified. “It feels disgusting. It’s gross.”
Eventually, at her repeated requests, her providers did put her back on the testosterone suppressant in June 2018.
In prison, Edmo had worn makeup and put her hair in a ponytail, she remembered, although officers in the prison told her not to, citing the need to protect her from sexual assault by other inmates, said Hall, the department’s attorney.
“Do you see there is kind of this conflict?” Hall asked Edmo while cross-examining her. “You want to feminize in prison, and IDOC has allowed you to do this in a number of ways. But there are limits to that placed by security, and it’s due to the goal of protecting you from sexual assault. Do you understand that?”
Yet, the department, in the same change to its policy issued days before that hearing, had changed what inmates with gender dysphoria could wear. They could purchase makeup and female underwear through the prison commissary — and in some, less severe cases of gender dysphoria, access to those items could possibly be enough to ease the dysphoria. Edmo’s case was more severe, and she has since received all the benefit she can from hormone treatment, according to the 9th Circuit Court.
“Today, Edmo is hormonally confirmed, which means that she has the hormones and secondary sex characteristics (characteristics, such as women’s breasts, that appear during puberty but are not part of the reproductive system) of an adult female,” the judges at the 9th Circuit Court of Appeals wrote in their August decision. “Edmo has gained the maximum physical changes associated with hormone treatment.”
Eliason testified Corizon Health does not have a company policy prohibiting gender confirmation surgery, it had just never been found necessary.
Yet, during the October hearing in the district court in Idaho, Eliason testified gender confirmation surgery was not mentioned in a “Corizon guideline document,” filed under seal in the court.
The 9th Circuit Court of Appeals also mentioned its absence, noting, “Corizon’s policy does not mention (gender confirmation surgery).”