{"id":3044,"date":"2025-11-03T14:16:08","date_gmt":"2025-11-03T19:16:08","guid":{"rendered":"https:\/\/journals.law.harvard.edu\/jlg\/?p=3044"},"modified":"2025-11-04T08:15:55","modified_gmt":"2025-11-04T13:15:55","slug":"inordinate-delay-as-denial-lessons-from-seeking-gender-affirmation-surgery-in-prisons","status":"publish","type":"post","link":"https:\/\/journals.law.harvard.edu\/jlg\/2025\/11\/inordinate-delay-as-denial-lessons-from-seeking-gender-affirmation-surgery-in-prisons\/","title":{"rendered":"Inordinate Delay as Denial: Lessons from Seeking Gender-Affirmation Surgery in Prisons"},"content":{"rendered":"\n

D Dangaran[1]<\/sup><\/p>\n\n\n\n

Justice too long delayed is justice denied.<\/em> \u2013 Dr. Martin Luther King, Jr.[2]<\/sup><\/p>\n\n\n\n

This essay underscores and explores a simple legal argument that is currently underutilized, but offers a lot of promise, particularly in light of the Trump administration\u2019s Executive Orders[3]<\/sup>: when a person needs a specific type of medical care, delaying access to that care violates their constitutional and civil rights. That person\u2019s specific context\u2014whether incarcerated or in the free world\u2014dictates exactly which rights are implicated, but the claim exists both behind bars and outside of prison walls. <\/p>\n\n\n\n

While working at Rights Behind Bars, I served as lead counsel on the legal team for three transgender[4]<\/sup> people who filed civil lawsuits based on their long, painful wait for gender-affirmation surgery[5]<\/sup> while behind bars.[6]<\/sup> One of my former clients, Reverend Ronnie Fuller, a Black transgender man, requested top surgery[7]<\/sup> for nearly eight years. Even after his facility referred him for top surgery over two years ago, he was never seen by a surgeon for a consultation.[8]<\/sup> He was released on parole a few months after filing his complaint, which he voluntarily dismissed.[9]<\/sup> I sent many more demand letters[10]<\/sup> to various state prison systems regarding the same issue for different clients. At least one of my demand letter clients, a transgender man in Connecticut, received top surgery after his prison received the letter\u2014whether the surgery can be attributed to the intervention or not. Demand letters alone, however, are not always this effective. For example, in one client\u2019s case, it was only after we filed a complaint in federal court that the head of the medical department in her facility quickly referred her to a surgical consultation[11]<\/sup>\u2014the precise action my client had requested for years, including through a demand letter that my cocounsel and I filed months before the complaint.<\/p>\n\n\n\n

Each case poses unique challenges, but a frustrating commonality is the simplicity of the remedy requested: getting prison medical providers to fulfill their constitutional responsibility to provide medically necessary care.[12]<\/sup> In many cases, there is no outright<\/em> denial; rather, the endless delay with no medical reasoning or justification creates what amounts to an effective<\/em> denial. The prison medical staff often keeps the trans person waiting for surgery in limbo, never providing the ultimate denial that would clearly expose the prison medical staff to liability and invite legal action.[13]<\/sup>After a few years working in this area, the repeated tactic of delay has started to look like a pattern across the country. This is worrisome because the \u201c[d]elay of treatment for trans[] patients not only exposes them to a longer duration of pain, suffering, and decreased social functionality, but also unnecessarily places their lives at risk.\u201d[14]<\/sup> Studies have shown the serious psychosocial and physical harm of delaying necessary gender-affirming care.[15]<\/sup><\/p>\n\n\n\n

This Essay argues that inordinate delay is constructive denial of medically necessary care,[16]<\/sup> focusing on transgender people seeking surgical care as a case study.[17]<\/sup> By examining this marginalized sub-population, we can learn about and start to create change for entire prison populations by ripple effect.[18]<\/sup><\/p>\n\n\n\n

I make two moves in this Essay. In Part I, I provide the legal basis for claims against delayed medical care in the prison context, including claims for gender-affirming care. In Part II, I describe some of the implications for a potential delay claim outside the prison context, hypothesizing a delay claim for gender-affirming surgery in the free world under the Americans with Disabilities Act. This essay is the first to explore a delay claim for accessing gender-affirmation surgery in prisons. Future work will be necessary to examine such a claim in the free world context more fully.<\/p>\n\n\n\n

I. Delay as Denial in Prison<\/h3>\n\n\n\n

When people in prison and their advocates consider pursuing a medical care claim, the natural starting point is the Eighth Amendment. Nearly fifty years ago, the Supreme Court held that \u201cdelaying access to medical care\u201d is a kind of \u201cdeliberate indifference to serious medical needs of prisoners [that] constitutes the \u2018unnecessary and wanton infliction of pain\u2019 proscribed by the Eighth Amendment.\u201d[19]<\/sup> A few years later, in Carlson v. Green<\/em>,[20]<\/sup> the Court allowed a damages remedy where an incarcerated man died after an eight-hour delay in treating his asthmatic attack.[21]<\/sup><\/p>\n\n\n\n

Federal courts have since upheld the right of incarcerated plaintiffs to pursue relief\u2014either damages or injunctive relief\u2014in many different medical delay contexts.[22]<\/sup> Prison officials may raise a defense on the merits regarding the length of a delay or the severity of the harm experienced as a result of that delay.[23]<\/sup> While the Eighth Amendment deliberate-indifference inquiry requires plaintiffs to prove they had an objectively serious medical need that went unmet by an official actor who was aware of the substantial risk of harm,[24]<\/sup> plaintiffs have a claim even when there is no risk of death.[25]<\/sup> Courts can even reject prison medical officials\u2019 explanations for delaying medical care as \u201cmerely a pretext\u201d for denying that care, including when those officials refer plaintiffs to further evaluations before they can receive a particular treatment.[26]<\/sup><\/p>\n\n\n\n

Trans people have successfully brought claims regarding prison officials\u2019 failure to provide necessary gender-affirming care. First, failing to provide an evaluation for gender-affirming care can itself be an Eighth Amendment violation.[27]<\/sup> Recently, courts have explicitly found that delaying necessary gender-affirming medical care can also be grounds for an Eighth Amendment claim.[28]<\/sup> Courts have also directly ordered prison officials to provide gender-affirming surgery to a trans plaintiff.[29]<\/sup> Scholars have discussed the right to gender-affirming surgery behind bars and the contentious debate that has ensued as courts have begun to recognize that right.[30]<\/sup> But these scholars have not specifically explored a delay claim. I think administrative delay is the more likely source of \u201can invisible ban\u201d on surgery than \u201cthe practice of denying\u201d such surgeries.[31]<\/sup><\/p>\n\n\n\n

II. Delay as Denial in the Free World<\/h3>\n\n\n\n

The outrageous delay in providing necessary medical care is not unique to the prison context,[32]<\/sup> nor to the gender-affirming surgery context.[33]<\/sup> But the applicable Eighth Amendment analysis is <\/em>unique to the prison context.[34]<\/sup>And the Fourteenth Amendment\u2019s Equal Protection Clause provides \u201cno constitutional right to health care.\u201d[35]<\/sup> What legal protections may apply in the free world under a delay theory of liability?<\/p>\n\n\n\n

Section 1557 of the Affordable Care Act (ACA) outlaws discrimination in the healthcare system.[36]<\/sup> The Department of Health and Human Services published a final rule that explicitly \u201cclarifies that \u2018sex\u2019 under section 1557 includes gender identity and gender stereotyping.\u201d[37]<\/sup> Might discrimination prohibited under the ACA include delay in gender-affirming care? One transgender man thought so, suing and prevailing under section 1557 under a disparate treatment theory of discrimination when his gender-affirming care was delayed and he experienced hostile treatment while receiving care.[38]<\/sup> But a claim for disparate treatment is not the same as a head-on claim for delay; the latter really is a claim against constructive denial.[39]<\/sup> More research is necessary to find examples of any Affordable Care Act litigation that successfully raised a claim for delayed treatment the way the Eighth Amendment claims so clearly do. <\/p>\n\n\n\n

I posit that there is a viable Americans with Disabilities Act[40]<\/sup> (\u201cADA\u201d) claim against both public and private medical providers for the effective denial caused by inordinate delay in providing gender-affirming medical care in the free world, as well as in prison. At least one federal court has held that the failure to provide psychiatric treatment, or even a psychiatric evaluation, evidences a denial of a reasonable accommodation of a psychiatric disability.[41]<\/sup> As I describe in a recent article,[42]<\/sup> because there is a viable ADA claim for the outright denial of access to medical services,[43]<\/sup> the outright ban on a particular type of treatment also amounts to an ADA violation.[44]<\/sup> And because the ADA applies within prisons and in the free world against private as well as government actors, there is a clear path towards utilizing it for all delay claims if plaintiffs believe the delay evidences a denial of access to medical services. <\/p>\n\n\n\n

Title II of the ADA provides that \u201cno qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by such entity.\u201d[45]<\/sup> And Title III of the ADA, which prohibits discrimination by private entities in places of public accommodation,[46]<\/sup> requires covered parties to provide \u201creasonable modifications in policies, practices, or procedures\u201d for individuals with disabilities so they may fully participate in the benefits administered by the covered parties.[47]<\/sup><\/p>\n\n\n\n

In both cases, a plaintiff must prove (1) that they have a disability or have been regarded as having a disability, (2) that they are otherwise qualified to receive the benefits provided by the entity, and (3) that they were denied those benefits or otherwise discriminated against on the basis of their disability.[48]<\/sup><\/p>\n\n\n\n

The ADA defines a disability as either having physical or mental impairments that substantially limit major life activities, having a record of such an impairment, or being regarded as having such an impairment.[49]<\/sup> Notably, the text of the ADA excludes gender identity disorder, a related but outdated diagnosis,[50]<\/sup> from coverage as a disability.[51]<\/sup> Courts have thus focused on the first element in addressing ADA claims regarding gender dysmorphia. But the Fourth Circuit has held that because gender dysphoria has come to mean something different than gender identity disorder, it is not barred by this exclusion.[52]<\/sup> The Fourth Circuit is the only circuit court to have reached the issue, and, as I have detailed elsewhere, the majority of district courts are in agreement.[53]<\/sup><\/p>\n\n\n\n

To meet the first element, a plaintiff must further show that their gender dysphoria impairs major life activities, which under the ADA \u201cinclude, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.\u201d[54]<\/sup><\/p>\n\n\n\n

The third element is met if a plaintiff seeks a reasonable accommodation and the public entity fails to grant it.[55]<\/sup>The burden shifts to Defendants to \u201cdemonstrate that implementing the modification would fundamentally alter the nature of the program.\u201d[56]<\/sup> Providing access to medical services cannot possibly pose a substantial burden on the administration of medical facilities, whether in prison or not. The Supreme Court has held that the \u201calleged deliberate refusal of prison officials to accommodate\u201d a person\u2019s \u201cdisability-related\u201d hygiene and medical care needs could have \u201cconstituted \u2018exclu[sion] from participation in or . . . deni[al of] the benefits of\u2019 the prison\u2019s \u2018services, programs, or activities.\u2019\u201d[57]<\/sup>After all, the Court has held that \u201cservices, programs, or activities\u201d as stated in the ADA includes medical prison programs.[58]<\/sup><\/p>\n\n\n\n

Thus, a transgender person who is experiencing impairments to sleeping, thinking, concentrating, or communicating because of their gender dysphoria being too overwhelming is a qualified person with a disability. If that person requests a reasonable accommodation (access to medical services, including but not limited to hormone therapy, gender-affirmation surgery, electrolysis, etc.) from a public medical facility and the facility constructively denies their request by making them wait for years to receive it, then the person has a colorable ADA claim.<\/p>\n\n\n\n

This legal theory should continue to be tested in courts.[59]<\/sup> Only then will we fully realize the ADA\u2019s full potential to go beyond what the Eighth Amendment, Fourteenth Amendment, or ACA could. We need to embrace the disability justice future that the ADA inspires.<\/p>\n\n\n\n

III. Conclusion<\/h3>\n\n\n\n

Disability law has brought us landmark progress before.[60]<\/sup> And it can do so again. The inordinate delay in providing trans people necessary medical care will only worsen under the Trump administration given the screeching halt to the provision of gender-affirming care to adults in the Bureau of Prisons,[61]<\/sup> or to anyone under 19 in the free world from medical providers and institutions that receive federal funding.[62]<\/sup> In the federal climate, it is unclear how long the delays in receiving care will last. But if my clients behind bars are any example, state agencies can stall over seven years before providing necessary gender-affirming care.[63]<\/sup> No one should need to wait that long for a surgery that would abate significant psychological harm. The present moment is a bitter reminder that we cannot delay in our pursuit of justice. That means we should not shy away from bringing novel legal claims that have the potential to help trans people targeted by the federal government and state governments to receive their necessary accommodations: timely access to medical services. Precious lives depend on receiving this care. Research shows that we should not wait to provide gender-affirming care to youth or adults.[64]<\/sup> Nor should we wait to bring claims alleging prolonged delay violates important civil rights Congress provided to all with disabilities, which includes people with gender dysphoria.<\/p>\n\n\n\n

\n\n\n\n

[1]<\/sup>\u00a0Assistant Professor of Law, University of Hawai\u2018i at M\u0101noa William S. Richardson School of Law. Previously the Director of Gender Justice at Rights Behind Bars. I\u2019d like to express my gratitude to Allie Zenwirth for her helpful emails spurring me to keep thinking about ways to develop this piece, and to the editors of JLG for inviting me to their wonderful symposium and editing this piece so thoughtfully.<\/p>\n\n\n\n

[2]<\/sup> Martin Luther King, Jr., Letter From Birmingham Jail<\/em>, Atl. Monthly<\/span> (1963).<\/p>\n\n\n\n

[3]<\/sup> See <\/em>Exec. Order No. 14,168, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government<\/em>, 90 Fed. Reg. 8,615 \u00a7\u00a7 4(a), (c) (Jan. 20, 2025) (ordering that \u201c[t]he Attorney General and Secretary of Homeland Security shall ensure that [transgender women] are not detained in women\u2019s prisons,\u201d id.<\/em> \u00a7 4(a), and that \u201c[t]he Attorney General shall ensure that . . . no Federal funds are expended for any medical procedure, treatment, or drug for the purpose of conforming an [incarcerated transgender person\u2019s] appearance to that of the opposite sex,\u201d id.<\/em> \u00a7 4(c)).<\/p>\n\n\n\n

[4]<\/sup> This Essay will use \u201ctrans\u201d and \u201ctransgender\u201d interchangeably. According to the American Psychiatric Association (\u201cAPA\u201d), the term \u201c[t]ransgender refers to the broad spectrum of individuals whose gender identity is different from their birth-assigned gender.\u201d Am. Psych. Ass\u2019n, Diagnostic & Statistical Manual of Mental Disorders<\/span> 511 (5th ed. text revision 2022) [hereinafter DSM-5-TR].<\/p>\n\n\n\n

[5]<\/sup> \u201cMedically necessary gender-affirmation surgery . . . [is] designed to align a person\u2019s body with their gender identity.\u201d E. Coleman et al., Standards of Care for the Health of Transgender & Gender Diverse People, Version 8<\/em>, Int’l J. Transgender Health<\/span> S1, S128 (2022) [hereinafter WPATH SOC-8].<\/p>\n\n\n\n

[6]<\/sup> See <\/em>Doe v. Ga. Dep\u2019t of Corr., 730 F. Supp. 3d 1327 (N.D. Ga. 2024); Complaint, Fuller v. Ga. Dep\u2019t of Corr., No. 1:25-cv-246-TRJ-CCB (N.D. Ga. Jan. 17, 2025); Opening Brief, Haverkamp v. Linthicum, No. 24-40709 (5th Cir. Feb. 5, 2025).<\/p>\n\n\n\n

[7]<\/sup> For transgender men and other individuals assigned female at birth, the efficacy of \u201cgender-affirming chest surgery or \u2018top surgery\u2019 (i.e. \u2018subcutaneous mastectomy\u2019) . . . has been demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance.\u201d WPATH SOC-8, supra <\/em>note 5,at S128.<\/p>\n\n\n\n

[8]<\/sup> See <\/em>Complaint \u00b6 37, Fuller<\/em>, No. 1:25-cv-246-TRJ-CCB (N.D. Ga. Jan. 17, 2025).<\/p>\n\n\n\n

[9]<\/sup> See <\/em>Notice of Voluntary Dismissal Without Prejudice, Fuller<\/em>, No. 1:25-cv-246-TRJ-CCB (N.D. Ga. May 22, 2025).<\/p>\n\n\n\n

[10]<\/sup> Demand letters are used by plaintiffs\u2019 lawyers to notify the recipients of their legal obligations and their liability if they do not correct their alleged behavior. See generally <\/em>Bret Rappaport, A Shot Across the Bow: How to Write an Effective Demand Letter<\/em>, 5 J. Ass’n Legal Writing Dirs.<\/span> 32, 34\u201335 (2008).<\/p>\n\n\n\n

[11]<\/sup> See Doe<\/em>, 730 F. Supp. 3d at 1338.<\/p>\n\n\n\n

[12]<\/sup> See <\/em>Estelle v. Gamble, 429 U.S. 97, 104 (1976) (establishing the Eighth Amendment right to the treatment of serious medical needs).<\/p>\n\n\n\n

[13]<\/sup> See, e.g.<\/em>, Doe<\/em>, 730 F. Supp. 3d at 1338 (finding preliminary injunctive relief for gender-affirming surgery not ripe because \u201cDefendants have not completed the decision-making process and denied [Plaintiff] that surgery\u201d).<\/p>\n\n\n\n

[14]<\/sup> Sylvia Rivera Law Project, \u201cIt\u2019s War In Here\u201d: A Report on the Treatment of Transgender and Intersex People in New York State Men\u2019s Prisons<\/span> 1, 28 (2007), https:\/\/srlp.org\/wp-content\/uploads\/2007\/04\/Its-War-In-Here-full-version.pdf<\/a> [https:\/\/perma.cc\/PCX8-EF6F<\/a>]. <\/p>\n\n\n\n

[15]<\/sup> Tim C. van de Grift et al., Waiting for Transgender Care and Its Effects on Health and Equality: A Mixed-Methods Population Study in the Netherlands<\/em>, 73 eClinicalMedicine<\/span> 1, 4\u20135 (2024) (finding in a study of 975 participants that \u201c[w]hen excluding participants without (medical treatment planned and those with finished transitions, 53.1% of participants [were] waiting for care\u201d); see id.<\/em> at 5 (noting \u201c[t]reatments with the largest number and\/or percentage of individuals waiting[] included psycho-diagnostic consults (i.e., initial intake), mastectomy, cross-sex hormone treatment, psychological care and counseling, feminizing genital surgery and puberty suppression treatment\u201d); id.<\/em> at 6\u20139 (discussing the effects of extensive waiting lists, including inequality, barriers to care, and more extensive treatments); Ariella R. Tabaac et al., Barriers to Gender-affirming Surgery Consultations in a Sample of Transmasculine Patients in Boston, Mass.<\/em>, 2020 Plastic & Reconstructive Surgery\u2013Global Open<\/span> 1, 7 (2020) (\u201cWhen barriers to surgery cause unnecessary delays in accessing care, they have the potential to affect psychosocial risk in the form of increased depression, anxiety, and other symptoms associated with unresolved gender dysphoria. Avoidable delays may also affect the difficulty of surgery and impair surgical outcomes, for chest patients who bind frequently and for whom the risk of skin breakdown and loss of elasticity only grows with time.\u201d (citations omitted)).<\/p>\n\n\n\n

[16]<\/sup> I have found only one other scholar who has framed \u201cdelay as denial\u201d in the prison health care context. See <\/em>Joel H. Thompson, Today\u2019s Deliberate Indifference: Providing Attention Without Providing Treatment to Prisoners With Serious Medical Needs<\/em>, 45 Harv. C.R.-C.L. L. Rev.<\/span> 635, 645 (2010). Joel H. Thompson described some examples of how prison medical providers \u201cevade\u201d providing care \u201c[w]ithout expressly denying care,\u201d but did not fully explore the specific legal ramifications of such delay. See id.<\/em><\/p>\n\n\n\n

[17]<\/sup> Much has been said in other medical contexts, such as HIV\/AIDS medication, Hepatitis-C treatment, and various reproductive health necessities. See, e.g.<\/em>, Tessa Bialek & Dr. Matthew J. Akiyama, Policies for Expanding Hepatitis C Testing and Treatment in United States Prisons and Jails<\/em>, 57 U. Mich. J.L. Reform<\/span> 1, 24\u201329 (2023) (discussing delay litigation for Hepatitis-C treatment in carceral settings); Kate Bock, Abortion Access for Incarcerated People Post-<\/em>Dobbs, 30 Mich. J. Gender & L.<\/span> 277, 284 (noting \u201cwardens with anti-abortion views may even be able to deny women abortion access through procedural delays\u201d); Mitchell O\u2019Shea Carney, Cycles of Punishment: The Constitutionality of Restricting Access to Menstrual Health Products in Prisons<\/em>, 61 B.C. L. Rev<\/span>. 2541, 2588\u201391 (2020) (discussing cases of delay in providing menstrual health products); Amber M. Charles, Indifference, Interruption, and Immunodeficiency: The Impact and Implications of Inadequate HIV\/AIDS Care in U.S. Prisons<\/em>, 92 B.U. L. Rev.<\/span> 1979, 2006\u201312 (discussing cases of delayed AIDS treatment); Taleed El-Sabawi, Death by Withdrawal<\/em>, 71 UCLA L. Rev.<\/span> 378, 410 (2024) (discussing the delayed treatment of alcohol withdrawal as unlawful); Samantha Laufer, Reproductive Healthcare for Incarcerated Women: From Rights to Dignity<\/em>, 56 Am. Crim. L. Rev.<\/span> 1785, 1793 (2019) (discussing delayed abortion); Estalyn Marquis, Nothing Less Than the Dignity of Man: Women Prisoners, Reproductive Health and Unequal Access to Justice Under the Eighth Amendment<\/em>, 106 Calif. L. Rev.<\/span> 203, 218\u201325 (2018) (discussing delay in emergency contraception or pregnancy care). This Essay is limited to transgender surgeries, which have not been explored under purely a delay theory in legal scholarship before.<\/p>\n\n\n\n

[18]<\/sup> See <\/em>D Dangaran, Abolition as Lodestar<\/em>, 44 Harv. J.L. & Gender<\/span> 161, 215 (2021) (\u201cBy centering the most vulnerable among us\u2014poor trans people of color in prison\u2014we will . . . knock down structural barriers in ways that will benefit all people in prison . . . .\u201d).<\/p>\n\n\n\n

[19]<\/sup> Estelle<\/em>, 429 U.S. at 104\u201305 (quoting Gregg v. Georgia, 428 U.S. 153, 173 (1976)).<\/p>\n\n\n\n

[20]<\/sup> 446 U.S. 14 (1980).<\/p>\n\n\n\n

[21]<\/sup> See id.<\/em> at 16 n.1.<\/p>\n\n\n\n

[22]<\/sup> See, e.g.<\/em>, Thomas v. Martija, 991 F.3d 763, 769\u201372 (7th Cir. 2021) (holding plaintiff\u2019s claims regarding a prison medical director\u2019s delay in renewing a plaintiff\u2019s low-bunk permit and referring plaintiff to a specialist survived summary judgment); Petties v. Carter, 836 F.3d 722, 730\u201333 (7th Cir. 2016) (en banc) (holding an Eighth Amendment claim regarding a six-week delay in providing a necessary treatment survived summary judgment and listing \u201cinexplicable delays or departures from common medical standards\u201d as \u201cevidence that can support an inference of deliberative indifference\u201d); Williams v. Liefer, 491 F.3d 710, 716 (7th Cir. 2007) (upholding jury verdict on Eighth Amendment claim where prison medical officials\u2019 delay in treating high blood pressure \u201cunnecessarily prolonged and exacerbated [the plaintiff\u2019s] pain\u201d); Jett v. Penner, 439 F.3d 1091, 1093\u201395, 1098\u201399 (9th Cir. 2006) (denying defendants\u2019 summary judgment where plaintiff waited six months to meet with an orthopedic specialist and nineteen months to see a hand specialist consultation to treat a fractured thumb); Wilhelm v. Rotman, 680 F.3d 1113, 1122\u201323 (9th Cir. 2012) (reversing dismissal where a doctor referred plaintiff to a surgery for a hernia, id.<\/em> at 1117, but failed to \u201crequest the referral properly\u201d and caused a one-year delay); Ancata v. Prison Health Servs., Inc., 769 F.2d 700, 704 (11th Cir. 1985) (\u201c[I]f necessary medical treatment has been delayed for non-medical reasons, a case of deliberate indifference has been made out.\u201d); McElligot v. Foley, 182 F.3d 1248, 1255 (11th Cir. 1999) (holding a prison medical official may \u201cact with deliberate indifference by delaying the treatment of serious medical needs, even for a period of hours\u201d).<\/p>\n\n\n\n

[23]<\/sup> See <\/em>Gutierrez v. Peters, 111 F.3d 1364, 1374 (7th Cir. 1997) (finding a pilonidal cyst was a serious medical condition, id.<\/em> at 1373, but dismissing for failure to state a claim because a six-day delay for seeing a doctor was not unreasonably long for an infected cyst deemed not that severe). But see<\/em> Williams<\/em>, 491 F.3d at 716 (upholding jury verdict on Eighth Amendment claim where plaintiff experienced \u201csix extra hours of pain\u201d due to a delay in treating high blood pressure).<\/p>\n\n\n\n

[24]<\/sup> See <\/em>Farmer v. Brennan, 511 U.S. 825, 833\u201334 (1994).<\/p>\n\n\n\n

[25]<\/sup> See, e.g.<\/em>, Harrison v. Barkley, 219 F.3d 132, 138 (2d Cir. 2000) (holding that a one year delay in treating a tooth cavity constituted an Eighth Amendment violation); Hoeft v. Menos, 347 F. App\u2019x 225, 227 (7th Cir. 2009) (finding that \u201csix months of extensive pain from untreated cavities and tooth loss that prevented [an inmate] from properly chewing his food\u201d qualified as a serious medical condition under the Eighth Amendment); Hunt v. Dental Dep\u2019t, 865 F.2d 198, 200\u201301 (9th Cir. 1989) (reversing summary judgment against plaintiff who suffered a three-month delay to provide dentures and remedy severe pain from eating without dentures).<\/p>\n\n\n\n

[26]<\/sup> Durmer v. O\u2019Carroll, 991 F.2d 64, 66\u201368 (3d Cir. 1993) (holding a prison unconstitutionally delayed providing prescribed physical therapy to treat a plaintiff\u2019s stroke\u2014specifically by referring the plaintiff to further evaluations). <\/p>\n\n\n\n

[27]<\/sup> See, e.g.<\/em>, Zayre-Brown v. N.C. Dep\u2019t of Pub. Safety, No. 3:22-CV-191, 2024 WL 1641795, at *4 (W.D.N.C. Apr. 16, 2024), appeal dismissed sub nom. <\/em>Zayre-Brown v. N.C. Dep\u2019t of Adult Corr., No. 24-6477, 2024 WL 4925046 (4th Cir. Nov. 25, 2024) (requiring prison to either provide the plaintiff with surgery or set up a committee that would properly assess whether a surgery referral would be in her best interest); Campbell v. Kallas, No. 16-CV-261, 2020 WL 7230235, at *1, *8 (W.D. Wis. Dec. 8, 2020) (requiring prison officials to schedule a consultation with a qualified surgeon who could assess a transgender plaintiff\u2019s need for gender-affirmation surgery); Soneeya v. Spencer, 851 F. Supp. 2d 228, 252 (D. Mass. 2012) (requiring a Massachusetts prison to consider whether the plaintiff was a candidate for surgery).<\/p>\n\n\n\n

[28]<\/sup> See <\/em>Clark v. Quiros, No. 3:19-CV-575, 2024 WL 3552472 at *1, *8, *12\u201313, *21 (D. Conn. July 26, 2024); Iglesias v. Fed. Bureau of Prisons, 598 F. Supp. 3d 689, 701\u201309 (S.D. Ill. 2022) (holding that the federal Bureau of Prisons\u2019 bureaucratic deflections, impeding the plaintiff\u2019s referral for surgery and proper housing placement, violated the Eighth Amendment and Fifth Amendment equal protection).<\/p>\n\n\n\n

[29]<\/sup> See, e.g.<\/em>, Edmo v. Corizon, Inc., 935 F.3d 757, 767 (9th Cir. 2019) (affirming the district court\u2019s injunction requiring an Idaho prison to provide surgery); Cordellion\u00e9 v. Comm\u2019r, Ind. Dep\u2019t of Corr., No. 3:23-CV-135, 2024 WL 4333152, at *1, *21 (S.D. Ind. Sep. 17, 2024); Norsworthy v. Beard, 87 F. Supp. 3d 1164, 1195 (N.D. Cal. 2015), appeal dismissed<\/em>, 802 F.3d 1090 (9th Cir. 2015) (granting a preliminary injunction requiring the California prison to provide the plaintiff with surgery). But see<\/em> Gibson v. Collier, 920 F.3d 212, 220 (5th Cir. 2019) (deciding that because there is disagreement amongst the expert medical community over whether gender-affirmation surgery is ever medically necessary or beneficial in treating gender dysphoria, prison officials could not be deliberately indifferent for banning that type of care). Gibson <\/em>is an outlier that has been explicitly critiqued by other circuits. See Edmo<\/em>, 935 F.3d at 794\u201397 (providing an extended critique of Gibson <\/em>and finding it \u201ccontradicts and misconstrues the precedent it purports to follow,\u201d id.<\/em> at 797). <\/p>\n\n\n\n

[30]<\/sup> See, e.g.<\/em>, Jameson Rammell, Polarizing Procedures: Transsexual Inmates, Sex Reassignment Surgery, and the Eighth Amendment<\/em>, 50 J. Marshall L. Rev.<\/span> 747, 775\u201385 (2017) (exploring the deliberate indifference test as applied to early gender-affirming care cases); Tammi S. Etheridge, Safety v. Surgery: Sex Reassignment Surgery and the Housing of Transgender Inmates<\/em>, 15 Geo. J. Gender & L.<\/span> 585, 589\u2013606 (2014) (applying the Eighth Amendment to medical needs and safe housing needs, and assessing the prison\u2019s safety and security defense<\/em> to such claims); Yvette K. W. Bourcicot & Daniel Hirotsu Woofter, Prudent Policy: Accommodating Prisoners with Gender Dysphoria<\/em>, 12 Stan. J. C.R. & C.L.<\/span> 283, 289\u2013317 (2016) (exploring Eighth Amendment and Equal Protection Clause claims for medical treatment for transgender people behind bars).<\/p>\n\n\n\n

[31]<\/sup> Kane Levings, Cruel and Unusual Punishment: The Invisible Ban on Sex-Reassignment Surgery for Transgender Inmates<\/em>, 17 J. Health & Biomedical L.<\/span> 67, 87 (2020) (note).<\/p>\n\n\n\n

[32]<\/sup> See, e.g.<\/em>, Theresa Gaffney, Gender-affirming Surgery Disappeared from the U.S. for Decades. Now the Field is Fighting to Keep its Gains<\/em>, STAT<\/span> (Dec. 23, 2024), https:\/\/www.statnews.com\/2024\/12\/23\/gender-affirming-surgery-increased-demand-but-future-access-faces-challenges\/ <\/a>[https:\/\/perma.cc\/DVY9-PWAR<\/a>] (\u201cSurgeons typically require at least one consultation before scheduling bottom surgery. There can be a months or years-long waitlist for those meetings, then a similar delay before an operation date. Patients often need to provide referral letters from mental health providers and show that they\u2019ve been taking hormones for at least a year. It\u2019s a long process filled with administrative hurdles.\u201d); van de Grift et al., supra<\/em> note 15, at 4\u20135; Tabaac et al., supra<\/em> note 15, at 7.<\/p>\n\n\n\n

[33]<\/sup> See, e.g.<\/em>, Daniel Lublin Pollock & Natalie E. Rainer, Healthcare Access: A Review of Major Barriers to Health Care Services for Women<\/em>, 6 Geo. J. Gender & L.<\/span> 825, 828 (2005) (reporting survey results of \u201cnearly 4,000 non-elderly women\u201d that showed \u201c24 percent reported delaying or going without care because they could not afford it, compared to 16 percent of men\u201d).<\/p>\n\n\n\n

[34]<\/sup> Criminal bans on gender-affirming care have proliferated since 2021. See, e.g.<\/em>, Lewis A. Grossman, Criminalizing Transgender Care<\/em>, 110 Iowa L. Rev.<\/span> 281, 298\u2013300 (2024) (charting the recent trend and providing that as of 2024, \u201cthirty-six percent of American transgender youth live in states that prohibit both medication and surgery for treatment of gender dysphoria in minors,\u201d id.<\/em> at 300). It might be tempting to consider an Eighth Amendment claim against this punishment, but the Supreme Court\u2019s decision in City of Grants Pass v. Johnson<\/em>, 603 U.S. 520 (2024), dashes any hope there. See id.<\/em> at 542 (\u201cThe Cruel and Unusual Punishments Clause focuses on the question what \u2018method or kind of punishment\u2019 a government may impose after a criminal conviction, not on the question whether a government may criminalize a particular behavior in the first place . . . .\u201d).<\/p>\n\n\n\n

[35]<\/sup> Pollock & Rainer, supra<\/em> note 33, at 834 (noting incarcerated people are \u201c[t]he only exception\u201d to this rule because of the Eighth Amendment right).<\/p>\n\n\n\n

[36]<\/sup> Patient Protection and Affordable Care Act, Pub. L. No. 111-148, \u00a7 1557(a), 124 Stat. 119, 260 (codified as amended in scattered sections of U.S.C.).<\/p>\n\n\n\n

[37]<\/sup> Wyatt Fore, Trans\/Forming Healthcare Law: Litigating Antidiscrimination Under the Affordable Care Act<\/em>, 28 Yale J.L. & Feminism<\/span> 243, 248 (2017) (quoting 45 C.F.R. \u00a7 92.4 (2016)).<\/p>\n\n\n\n

[38]<\/sup> See <\/em>Rumble v. Fairview Health Servs., No. 14-cv-02037, 2015 WL 1197415, at *16 (D. Minn. Mar. 16, 2015); see also <\/em>Fore, supra <\/em>note 37,at 261, 266 (discussing Rumble<\/em> as a disparate treatment claim).<\/p>\n\n\n\n

[39]<\/sup> See <\/em>Fore, supra <\/em>note 37, at 262 (discussing how doctors \u201cmay constructively deny care to a patient by applying inappropriate standards of care,\u201d but not discussing constructive denial for delay in care, specifically).<\/p>\n\n\n\n

[40]<\/sup> Pub. L. No. 101-336, 104 Stat. 327 (codified as amended at 42 U.S.C. \u00a7\u00a7 12101\u201312213 and at 47 U.S.C. \u00a7 225).<\/p>\n\n\n\n

[41]<\/sup> Paine ex rel. Eilman v. Johnson, No. 06-cv-3173, 2010 WL 785397, at *8 (N.D. Ill. Feb. 26, 2010).<\/p>\n\n\n\n

[42]<\/sup> See <\/em>D Dangaran, Interwoven Remedies: The Healthcare-Disability Overlap in Gender-Affirming Care Behind Bars<\/em>, 62 Am. Crim. L. Rev.<\/span> 1271, 1294\u201396 (2025).<\/p>\n\n\n\n

[43]<\/sup> See, e.g.<\/em>, Kiman v. N.H. Dep\u2019t of Corr., 451 F.3d 274, 277\u201380, 287 (1st Cir. 2006) (holding the denial of necessary medical care, including medications, could allege an ADA claim).<\/p>\n\n\n\n

[44]<\/sup> See, e.g.<\/em>, Wagner ex rel. Wagner v. Fair Acres Geriatric Ctr., 49 F.3d 1002, 1011\u201312 (3d Cir. 1995) (upholding a Rehabilitation Act claim brought against a senior facility that could not treat the plaintiff\u2019s Alzheimer conditions, and thus denied his application as a prospective resident). Section 504 of the Rehabilitation Act, 29 U.S.C. \u00a7 794, is construed using the same standards as the ADA. See <\/em>42 U.S.C. \u00a7 12132; 28 C.F.R. \u00a7 35.130(b); Ingram v. Kubik, 30 F.4th 1241, 1256 (11th Cir. 2022).<\/p>\n\n\n\n

[45]<\/sup> 42 U.S.C. \u00a7 12132.<\/p>\n\n\n\n

[46]<\/sup> 42 U.S.C. \u00a7 12182(a).<\/p>\n\n\n\n

[47]<\/sup> Id.<\/em> \u00a7 12182(b)(2)(A)(ii).<\/p>\n\n\n\n

[48]<\/sup> See, e.g.<\/em>, Fauconier v. Clarke, 966 F.3d 265, 276 (4th Cir. 2020).<\/p>\n\n\n\n

[49]<\/sup> 42 U.S.C. \u00a7 12102(1).<\/p>\n\n\n\n

[50]<\/sup> Compare<\/em> Am. Psych. Ass\u2019n, Diagnostic & Statistical Manual of Mental Disorders<\/span> 577 (4th Ed., text revision) (2000), with<\/em> Am. Psych. Ass\u2019n, Diagnostic & Statistical Manual of Mental Disorders<\/span> 513 (5th ed. 2013).<\/p>\n\n\n\n

[51]<\/sup> See <\/em>42 U.S.C. \u00a7 12211(b)(1).<\/p>\n\n\n\n

[52]<\/sup> Williams v. Kincaid, 45 F.4th 759, 766\u201369 (4th Cir. 2022), cert denied,<\/em> 143 S. Ct. 2414 (2023).<\/p>\n\n\n\n

[53]<\/sup> See <\/em>D Dangaran, Bending Gender: Disability Justice, Abolitionist Queer Theory, and ADA Claims for Gender Dysphoria<\/em>, 137 Harv. L. Rev. F.<\/span> 237, 257 (2024) (collecting cases).<\/p>\n\n\n\n

[54]<\/sup> 42 U.S.C. \u00a7 12102(2)(A).<\/p>\n\n\n\n

[55]<\/sup> See, e.g.<\/em>, Finley v. Huss, 102 F.4th 789, 820 (6th Cir. 2024).<\/p>\n\n\n\n

[56]<\/sup> See, e.g.<\/em>, Montalvo v. Radcliffe, 167 F.3d 873, 877 (4th Cir. 1999); see <\/em>42 U.S.C. \u00a7 12182(b)(2)(A)(ii).<\/p>\n\n\n\n

[57]<\/sup> United States v. Georgia, 546 U.S. 151, 157 (2006) (quoting 42 U.S.C. \u00a7 12132) (alterations in original)<\/p>\n\n\n\n

[58]<\/sup> Pa. Dep\u2019t of Corr. v. Yeskey, 524 U.S. 206, 219 (1998).<\/p>\n\n\n\n

[59]<\/sup> See, e.g.<\/em>, Complaint, Fuller v. Ga. Dep\u2019t of Corr., No. 1:25-cv-246-TRJ-CCB (N.D. Ga. Jan. 17, 2025); Second Amended Complaint, Doe v. Ga. Dep\u2019t of Corr., No. 1:23-cv-5578-MLB (N.D. Ga. Dec. 17, 2024).<\/p>\n\n\n\n

[60]<\/sup> See, e.g.<\/em>, <\/em>Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 607 (1999) (\u201c[U]nder Title II of the ADA, States are required to provide community-based treatments for persons with mental disabilities when the State\u2019s treatment professionals determine that such placement is appropriate, the affected persons do not oppose such treatment, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.\u201d). For a discussion of the Olmstead<\/em> case and the slow implementation, which had intersectional implications, see Liat Ben-Moshe, Decarcerating Disability: Deinstitutionalization and Prison Abolition<\/span> 253\u201357 (2020). See also<\/em> id.<\/em> at 261\u201362 (stating that \u201cwhat led the judges [in Olmstead<\/em>] is entrenched ableism and not a belief in the full competency of people with psychiatric and cognitive disabilities that should grant them the right to live with their peers and chosen families in the community\u201d).<\/p>\n\n\n\n

[61]<\/sup> See <\/em>Exec. Order No. 14,168, supra <\/em>note 3, \u00a7 4(c).<\/p>\n\n\n\n

[62]<\/sup> Exec. Order No. 14,187, Protecting Children from Chemical and Surgical Mutilation, 90 Fed. Reg. 8,771 (Jan. 28, 2025).<\/p>\n\n\n\n

[63]<\/sup> See <\/em>Complaint, Fuller<\/em>, No. 1:25-cv-246-TRJ-CCB, \u00b6 2 (alleging Rev. Fuller requested top surgery over seven years ago).<\/p>\n\n\n\n

[64]<\/sup> See <\/em>Tabaac et al., supra<\/em> note 15, at 2, 7; Maeghan B. Ross et al., Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care\u2014A Qualitative Exploration<\/em>, <\/em>2023 Int’l J. Env’l Rich. & Pub. Health<\/span> 1, 12\u201313 (discussing how much wait time served as a barrier to transgender study participants).<\/p>\n","protected":false},"excerpt":{"rendered":"

D Dangaran[1] Justice too long delayed is justice denied. \u2013 Dr. Martin Luther King, Jr.[2] This essay underscores and explores a simple legal argument that is currently underutilized, but offers a lot of promise, particularly in light of the Trump administration\u2019s Executive Orders[3]: when a person needs a specific type of medical care, delaying access to that care violates […]<\/p>\n","protected":false},"author":221,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[6,26,5],"tags":[],"class_list":["post-3044","post","type-post","status-publish","format-standard","hentry","category-articles","category-online-journal","category-symposia-articles"],"jetpack_featured_media_url":"","jetpack_shortlink":"https:\/\/wp.me\/peZQij-N6","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/posts\/3044","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/users\/221"}],"replies":[{"embeddable":true,"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/comments?post=3044"}],"version-history":[{"count":0,"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/posts\/3044\/revisions"}],"wp:attachment":[{"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/media?parent=3044"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/categories?post=3044"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/journals.law.harvard.edu\/jlg\/wp-json\/wp\/v2\/tags?post=3044"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}