Clark v. Valletta

23-7377-cv
Clark v. Valletta
United States Court of Appeals
For the Second Circuit
August Term 2024
Argued: October 28, 2024
Decided: October 6, 2025
No. 23-7377-cv
V ERONICA-MAY CLARK ,
Plaintiff-Appellee,
v.
GERALD V ALLETTA, RICHARD B USH,
AND B ARBARA KIMBLE -GOODMAN,
Defendants-Appellants.*
Appeal from the United States District Court
for the District of Connecticut
No. 19-cv-575
Vanessa Lynne Bryant, Judge.
* The Clerk of Court is respectfully directed to amend the caption as set
forth above.

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Before: S ULLIVAN, PARK , and ROBINSON, Circuit Judges.
Plaintiff Veronica-May Clark is a transgender inmate in the
Connecticut prison system claiming that corrections officials violated
the Eighth Amendment by failing to provide certain treatments for
gender dysphoria, including stronger hormone therapy and a
vaginoplasty. Defendants moved for summary judgment on
qualified-immunity grounds. The district court (Bryant, J.) denied the
motion, finding that Defendants violated a clearly established right
“to be free from deliberate indifference to serious medical needs.” We
conclude that Defendants are entitled to qualified immunity. Inmates
have no clearly established right to be treated by gender-dysphoria
specialists or to receive specific treatments for gender dysphoria. And
reasonable officers could disagree on the legality of Defendants’
efforts to treat Clark, including with talk therapy and antidepressants.
The order of the district court is REVERSED, and the case is
REMANDED with instructions to grant Defendants’ motion for
summary judgment on qualified-immunity grounds.
Judge Robinson concurs in part and dissents in part in a
separate opinion.
J AMES M. B ELFORTI , Janelle R. Medeiros, Terrence M.
O’Neill, Assistant Attorneys General, for William Tong,
Attorney General of Connecticut, Hartford, CT, for
Defendants-Appellants.
E LANA B ILDNER , Dan Barrett, Sapana Anand, American
Civil Liberties Union Foundation of Connecticut,
Hartford, CT; Daniel S. Noble, Krieger Lewin LLP, New
York, NY; Evan I. Cohen, Matthew B. Danzer, Kelsey A.

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Powderly, Finn Dixon & Herling LLP, Stamford, CT, for
Plaintiff-Appellee.
PARK, Circuit Judge:
Plaintiff Veronica-May Clark is a transgender inmate in the
Connecticut prison system claiming that corrections officials violated
the Eighth Amendment by failing to provide certain treatments for
gender dysphoria, including stronger hormone therapy and a
vaginoplasty. Defendants moved for summary judgment on
qualified-immunity grounds. The district court denied the motion,
finding that Defendants violated a clearly established right “to be free
from deliberate indifference to serious medical needs.” We conclude
that Defendants are entitled to qualified immunity. Inmates have no
clearly established right to be treated by gender-dysphoria specialists
or to receive specific treatments for gender dysphoria. And
reasonable officers could disagree on the legality of Defendants’
efforts to treat Clark, including with talk therapy and antidepressants.
The order of the district court is reversed, and the case is remanded
with instructions to grant Defendants’ motion for summary judgment
on qualified-immunity grounds.
I. BACKGROUND
A. Factual Background
Clark, then known as Nicholas Clark,1 was convicted of
murder, assault, burglary with a deadly weapon, and violation of a
1 Clark’s name-was changed to “Veronica-May Clark” by order of
Connecticut Probate Court in December 2021. See Dist. Ct. Dkt. 3 at 105.

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protective order in 2009. As part of that offense, Clark broke into his
ex-wife’s house, severely disfigured her with a pipe, and beat her new
partner to death. Clark is serving a 75-year sentence without the
possibility of parole in the Connecticut prison system.
In April 2016—more than seven years into that sentence—
prison clinicians learned that Clark identified as a transgender
woman. A health-care provider at Cheshire Correctional Institution
diagnosed Clark with gender dysphoria the next month.2 In July
2016, Clark attempted self-castration with a nail clipper.
Shortly afterward, prison officials transferred Clark to
Connecticut’s Garner Correctional Institution—a high-security prison
for adult men with significant mental-health issues—as Clark
recovered from the self-inflicted wound. As relevant here, Clark was
placed under the care of three Garner officials: Defendants Dr. Gerald
Valletta, Barbara Kimble-Goodman, and Richard Bush.
1. Defendants’ Care
Dr. Gerald Valletta, Garner’s principal physician, cared for
Clark from August 2016 until March 2020. Valletta is a medical
doctor, not a mental-health provider, who lacked expertise in treating
gender dysphoria. Valletta treated Clark’s injury with wound care,
antibiotics, and pain medication until September 2016, when Clark
2 The American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders defines “gender dysphoria” as “a marked
incongruence between one’s experienced/expressed gender and primary
and/or secondary sex characteristics.” Am. Psychiatric Ass’n, Diagnostic &
Statistical Manual of Mental Disorders 512 (5th rev. ed. 2022).

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began refusing medications. Valletta’s general care also included
medical treatment for a hernia, abdominal pain, jaw pain, an alleged
sexual assault, a wrist injury, a chronic cough, and hunger strikes,
along with routine exams and vaccinations.
At their first meeting on August 1, 2016, Clark asked Valletta
for various gender-dysphoria treatments. Valletta soon referred
Clark to an unnamed mental-health Advanced Practice Registered
Nurse. But unsatisfied with that treatment, Clark filed a grievance on
August 24, 2016, complaining of continual denial of access, “going on
five months now, to transition-related healthcare.” Joint App’x at 33.
In September and October of that year, Clark submitted requests to
Valletta for hormone therapy, laser hair removal, and a vaginoplasty.
Valletta denied Clark’s requests based on his understanding
that Connecticut prison policy allowed for the continuation, but not
the initiation, of hormone therapy for inmates. Valletta thus believed
that he lacked the authority to refer Clark to an outside
endocrinologist for such treatment. Clark further alleges that Valletta
never looked into surgical intervention.
But Clark did receive mental-health treatment and lifestyle
accommodations at Garner. The male prison, for example, stocked
female commissary items like bras to purchase. Clark also met with
Barbara Kimble-Goodman, a psychiatric Advanced Practice
Registered Nurse, seven times between November 2016 and June
2018. Kimble-Goodman treated Clark’s dysphoric mood with
psychotherapy and psychiatric medications when Clark accepted
them. Like Valletta, Kimble-Goodman lacked specialized training for
treating transgender inmates. Her authority was limited to providing

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mental-health care, and she could not herself procure hormone
therapy or surgical interventions for inmates.
During meetings on November 7, 2016, February 2, 2017, and
June 6, 2017, Clark complained to Kimble-Goodman of a dysphoric
mood. Clark also reported the denial of hormone therapy because of
the prison’s continuation-only policy. Kimble-Goodman noted that
Clark was “stressed” and felt “poison[ed]” by having male genitalia.
Joint App’x at 95. She offered Clark antidepressant medication to
help stabilize these moods, but Clark refused to accept a prescription
until July 2017.
In July 2017, Valletta learned of a change in prison policy and
referred Clark to receive further evaluation for gender dysphoria and
to see an endocrinologist for potential hormone therapy. On
September 20, 2017, Clark met with an endocrinologist from the
University of Connecticut (“UConn”). That specialist prescribed
hormones, requested bloodwork, and proposed that specialists
reevaluate Clark in three months. Valletta’s role in that care was to
follow the endocrinologist’s dosing recommendations, order lab
work when requested by the specialists, and resubmit approvals for
follow-up visits.
Hormone therapy and antidepressants helped Clark’s mood.
On November 28, 2017, Clark reported “improved sleep, appetite,
and motivation,” as well as higher self-esteem, slowed male-pattern
baldness, and a reduced sex drive. Special App’x at 15. Clark’s mood
was “really good, best ever.” Id. By April 2018, Clark reported feeling
“better than ever, best in my life.” Id.

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But Clark began refusing antidepressants in April 2018 because
they caused stomach upset during a hunger strike. Later that month,
Clark submitted a grievance due to not receiving estradiol—a female
hormone—for four days because the medication had expired. Clark
complained that this was the fourth or fifth such incident. That fall,
Clark alleged another four-day lapse in hormone treatment because
of the prison’s failure to fill the prescription.
In May 2018, Clark complained to Valletta about the transition
treatment, again requesting a vaginoplasty and threatening self-
castration. Valletta requested additional lab work and said that he
would “look into bottom surgery as an option.” Special App’x at 16.
On June 28, 2018, Clark met with Kimble-Goodman, who described
Clark as being “[s]tressed out about the hormones and meds,”
shaving often, and feeling “depressed [when] in the cell, [and] happy
out of the cell.” Id. Clark also told Kimble-Goodman about writing
to Planned Parenthood for help with the hormone treatment.
In response to Clark’s concerns that the hormone therapy was
not being administered properly, Valletta ordered lab work to
monitor the therapy eleven times from September 29, 2017, to
February 4, 2020. The tests from October 2017 to September 2019
showed Clark’s testosterone levels remaining normal for an adult
man—and even increasing—despite the hormone treatment. In July
2018, Clark reported feeling “traumatized” by persisting erections
and advancing male pattern baldness—issues Clark attributed to
persistently high testosterone levels. Special App’x at 17.
Valletta arranged sporadic check-ins for Clark’s hormone
therapy. After an initial September 20, 2017 appointment, Clark was

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next seen by UConn Endocrinology on August 13, 2019, although the
endocrinologist had recommended a follow-up in three months.
After that, Clark saw the endocrinologist again on October 8, 2019,
and February 11, 2020, and the endocrinologist increased Clark’s
dosage after both visits.
Throughout this time, Clark repeatedly demanded surgical
intervention. On July 18, 2018, Clark filed a fourth inmate request
form demanding such care—this time seeking a vaginoplasty, facial
reconstruction, excision of Clark’s Adam’s apple, and hair restoration.
Clark wrote: “I do not know how to communicate how much pain I’m
in.” Special App’x at 18. Valletta met with Clark about this request
on July 24, 2018, and submitted a new order for onsite mental-health
care to replace Kimble-Goodman, who had left Garner.
During this period, Clark also met twice with Richard Bush, a
licensed clinical social worker to whom the prison directed some of
Clark’s grievance requests. Like Valletta and Kimble-Goodman, Bush
had no special training on treating transgender inmates. His role as a
social worker was limited to providing talk therapy and assessing and
referring Clark for additional care as needed. He knew that Clark was
being seen by an advanced psychiatric nurse and the UConn
endocrinology department for gender-dysphoria treatment. He had
no authority to order surgical care for patients. At their first meeting
on March 8, 2019, Clark complained to Bush about inaction on Clark’s
inmate grievances. Bush responded that Clark had no pending
grievances and provided talk therapy.
Bush saw Clark for the second—and last—time on September
12, 2019. Clark was upset that nothing seemed to be happening with

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respect to the transition and requested a referral to a new mental-
health provider. Bush listened and provided support, but did not
arrange for new treatment. A different prison official responded to
Clark’s subsequent requests for sex-reassignment surgery and
improved hormone therapy in October 2019, assuring Clark that “per
our discussion you were notified you are on MDSC list for further
eval.” Special App’x at 21.
The Department of Corrections returned Clark to Cheshire
Correctional Institution in March 2020, after which Defendants were
no longer responsible for Clark’s care.
2. Standards of Care
According to the American Psychiatric Association’s
Diagnostics and Statistics Manual, gender dysphoria entails “increased
rates of depression, suicidality, and other mental disorder co-
occurrence.” Am. Psychiatric Ass’n, Diagnostic & Statistical Manual of
Mental Disorders 519 (5th rev. ed. 2022). It is undisputed that Clark
suffered from severe gender dysphoria. But how to treat that disorder
is not settled in the scientific and medical community.
Clark’s expert, Dr. George R. Brown, is a professor of
psychiatry at East Tennessee State University’s College of Medicine.
He has served since 1990 on the World Professional Association for
Transgender Health’s (WPATH) Committee to Revise the Standards of
Care and co-authored recent versions of the Standards. He considers
the Standards “authoritative for the evaluation and treatment” of
gender dysphoria. Dist. Ct. Dkt. 133, Ex. 1, at 31. Those guidelines
“can be modified based on individualized patient circumstances and
their health care professional’s clinical judgment.” Id. at 31-32. He

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also believes that “[w]ith appropriate treatment, individuals with a
[gender-dysphoria] diagnosis can be fully cured of all symptoms.” Id.
at 32.
Brown opined that gender-dysphoria treatment “involves both
psychological and medical aspects.” Id. In his view, common
treatment methods include “hormone therapy, social role transition,
and surgical intervention.” Id. “What is required in any individual
case, however, may vary.” Id. Other treatments involve “electrolysis,
voice therapy, breast augmentation, [and] facial reconstruction.” Id.
In Brown’s opinion, the Department of Corrections had
“provided inadequate, substandard medical, psychiatric, and
surgical care” for Clark’s severe dysphoria. Id. at 51. First, Brown
found Clark’s mental-health care lacking because it was not
“specialized psychological treatment” for gender dysphoria. Id.
Second, Brown remarked that Clark “received overly conservative,
inadequate hormonal care” for gender dysphoria. Id. at 50. Clark’s
“assessments were far too infrequent, resulting in an inordinate
amount of time in an undertreated condition at very small doses of
estrogen that were largely ineffective for the first two years or more.”
Id. Third, Brown believed that Clark “can’t be treated adequately
without access to gender confirmation surgery.” Dist. Ct. Dkt. 133,
Ex. 3, at 247. Although Brown’s clinical practice is to reserve surgery
as “a last resort,” he opined that Clark was in the “subset” of
transgender people requiring surgical intervention. Id.
Defendants’ expert, Dr. Stephen Levine, pointed to
“considerable growing disagreement within the medical and
scientific communities on how to best treat people with gender

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dysphoria.” Dist. Ct. Dkt. 128, Ex. E, at 3. Levine is a professor of
psychiatry at Case Western University’s School of Medicine and was
once chair of the group responsible for the fifth edition of the
WPATH’s Standards of Care. But he opined that WPATH’s
recommendations are now dubious because WPATH “has
transformed into an advocacy organization” that “fail[s] to perform
appropriate scientific study methods.” Id. at 2.
According to Levine, gender-dysphoria treatment “can come in
various forms,” including lifestyle accommodations and
psychotherapy. Id. at 3. More “advanced form[s] of affirmative
treatment” involve hormone therapy and surgical intervention. But
“[t]here remains a very high risk that people with gender dysphoria
who have had genital surgery will still have severe psychiatric
problems, including but not limited to, continuing gender dysphoria,
depression, substance abuse, anxiety, suicide attempts, and
completed suicides.” Id. at 4.
Levine described Clark’s treatment as “far less than ideal.”
Dist. Ct. Dkt. 133, Ex. 4, at 4. But based on interviews and medical
records, he found that Clark suffered from “poor judgment,
unrealistic expectations, and exaggerated psychological pain.” Dist.
Ct. Dkt. 128, Ex. E, at 9. Levine further diagnosed Clark with “Alcohol
and Substance Abuse Disorder,” “Mixed Character Disorder with
paranoid, grandiose, histrionic manipulation, narcissistic entitlement
and dependent features,” and “[p]ossible traumatic stress disorder
due to being forced into sexual availability in prison.” Id. at 9-10.
As Levine explained, Clark had a “serious form of character
pathology” and was “highly unrealistic.” Id. at 11-12. For example,

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Clark hoped to be extradited to the United Kingdom, where doctors
could provide a functioning uterus. See id. at 12-13. “Clark’s
unrealistic outlook and misconceptions about genital surgery”
concerned Levine, “because in order for a person with gender
dysphoria to be a good candidate for genital surgery, they must
understand the actual implications of the surgery.” Id. at 13. Levine
thus found Clark unfit for sex-reassignment surgery. See id. at 14.
B. Procedural History
In April 2019, Clark sued Defendants Valletta, Kimble-
Goodman, and Bush. The amended complaint alleged deliberate
indifference in violation of the Eighth Amendment and intentional
infliction of emotional distress for failure to “provide adequate and
necessary medical treatment” for gender dysphoria. Joint App’x at
39. Clark also sought injunctive relief against the Commissioner of
Connecticut’s Department of Corrections, which is not at issue in this
interlocutory appeal.
Defendants moved for summary judgment on qualified-
immunity grounds and the merits of Clark’s claims. As to qualified
immunity, they argued that there was no violation of Clark’s Eighth
Amendment rights. Defendants also argued that there is no clearly
established right to particular gender-dysphoria treatments and that
other reasonable officials also would have denied Clark’s requests.
Clark cross-moved for summary judgment on all claims.
The district court partially granted Clark’s motion on the
deliberate-indifference claim. It first found that prison officials had
deprived Clark of “adequate care” through mental-health treatment
from unqualified providers, delayed and insufficient hormone

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treatment, and denial of a vaginoplasty. Special App’x at 46. The
court then inferred that Defendants acted with the requisite subjective
indifference to Clark’s needs because it was “obvious” that the failure
to refer Clark to a qualified provider would perpetuate “acute
anguish.” Id. at 56-58.
The district court concluded that Defendants were not entitled
to qualified immunity. Although it noted the Supreme Court’s
instruction that clearly established rights “cannot be overly general so
as to make a rule of virtually unqualified liability simply by alleging
violation of extreme abstract rights,” it nonetheless found that
Defendants had violated the clearly established “right to be free from
deliberate indifference to serious medical needs.” Id. at 60-61
(quotation marks omitted). The district court reasoned that
Defendants “failed to facilitate any informed care from a provider
qualified to treat” Clark’s condition. Id. at 64. In its view, “no
reasonable official would have believed it was lawful to fail to
provide informed care” to Clark. Id. at 64-65.
Defendants timely appealed the denial of qualified immunity.
II. DISCUSSION
Defendants argue that they are entitled to qualified immunity
because (1) Clark had no clearly established right to specific gender-
dysphoria treatments and (2) their actions were objectively
reasonable. We agree.
A. Legal Standards
“We review a district court’s denial of a motion for summary
judgment sounding in qualified immunity de novo” and “draw all

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factual inferences in favor of, and take all factual assertions in the light
most favorable to, the party opposing summary judgment.” Coollick
v. Hughes, 699 F.3d 211, 219 (2d Cir. 2012) (quotation marks omitted).3
“Qualified immunity shields federal and state officials from
money damages unless a plaintiff pleads facts showing (1) that the
official violated a statutory or constitutional right, and (2) that the
right was ‘clearly established’ at the time of the challenged conduct.”
Ashcroft v. al-Kidd, 563 U.S. 731, 735 (2011).4 Even if an officer violated
a plaintiff’s clearly established rights, he “will still be entitled to
qualified immunity if it was objectively reasonable for him to believe
that his acts did not violate those rights.” Outlaw v. City of Hartford,
884 F.3d 351, 367 (2d Cir. 2018). These protections “balance[] two
important interests—the need to hold public officials accountable
when they exercise power irresponsibly and the need to shield
officials from harassment, distraction, and liability when they
perform their duties reasonably.” Pearson v. Callahan, 555 U.S. 223,
231 (2009).
The Eighth Amendment prohibits the infliction of “cruel and
unusual punishment.” U.S. Const., amend. VIII. In Estelle v. Gamble,
3 “This Court has jurisdiction to review an interlocutory order
denying qualified immunity so long as defendants pursue the appeal on
stipulated facts, or on the facts that the plaintiff alleges are true, or on the
facts favorable to the plaintiff that the trial judge concluded the jury might
find.” Francis v. Fiacco, 942 F.3d 126, 139 (2d Cir. 2019) (cleaned up).
4 “[C]ourts have discretion to decide which of the two prongs of
qualified-immunity analysis to tackle first.” al-Kidd, 563 U.S. at 735. We
proceed under the clearly-established-law prong before “expending scarce
judicial resources to resolve difficult and novel questions.” Id. (cleaned up).

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the Supreme Court held that “deliberate indifference to serious
medical needs of prisoners constitutes the unnecessary and wanton
infliction of pain proscribed by the Eighth Amendment[,] . . . whether
the indifference is manifested by prison doctors in their response to
the prisoner’s needs or by prison guards in intentionally denying or
delaying access to medical care.” 429 U.S. 97, 104-05 (1976) (cleaned
up). But objective indifference is not enough to violate the Eighth
Amendment. A “prison official cannot be found liable under the
Eighth Amendment . . . unless the official knows of and disregards an
excessive risk to inmate health or safety; the official must both be
aware of facts from which the inference could be drawn that a
substantial risk of serious harm exists, and he must also draw the
inference.” Farmer v. Brennan, 511 U.S. 825, 837 (1994).
B. Clearly Established Law
“A Government official’s conduct violates clearly established
law when, at the time of the challenged conduct, the contours of a
right are sufficiently clear that every reasonable official would have
understood that what he is doing violates that right.” al-Kidd, 563 U.S.
at 741 (cleaned up).
“The Supreme Court has repeatedly told courts not to define
clearly established law at a high level of generality, instead
emphasizing that clearly established law must be particularized to the
facts of the case.” Francis, 942 F.3d at 146 (cleaned up). “We do not
require a case directly on point, but existing precedent must have
placed the statutory or constitutional question beyond debate.”
Taylor v. Barkes, 575 U.S. 822, 825 (2015) (quotation marks omitted).
“The rule must be settled law, which means it is dictated by

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controlling authority or a robust consensus of cases of persuasive
authority. It is not enough that the rule is suggested by then-existing
precedent.” District of Columbia v. Wesby, 583 U.S. 48, 63 (2018)
(cleaned up).
1. Clearly Established Rights in Deliberate-Indifference Cases
In addition to being firmly settled, the clearly established rights
at issue must be sufficiently particularized to an inmate’s individual
circumstances. Specificity is necessary because qualified immunity
focuses “on whether the officer had fair notice that her conduct was
unlawful.” Kisela v. Hughes, 584 U.S. 100, 104 (2018) (cleaned up). In
Taylor, the Supreme Court held that prison officials were immune
from deliberate-indifference claims for “failing to prevent” a
detainee’s suicide based on an allegedly inadequate screening
protocol. 575 U.S. at 823. The Court found “no violation of clearly
established law” because no Supreme Court decision “establishes a
right to the proper implementation of adequate suicide prevention
protocols,” or “even discusses” such protocols. Id. at 826. And circuit
precedent concluding that prison officials can be “recklessly
indifferent” to suicidality was not specific enough to put the officials
in Taylor on notice “that they were overseeing a system that violated
the Constitution.” Id. at 827. So even in deliberate-indifference cases,
“[t]o be clearly established, a right must be sufficiently clear that
every reasonable official would have understood that what he is
doing violates that right.” Id. at 825 (cleaned up).
The district court here erred by conducting its qualified-
immunity analysis at too high a level of generality. It defined the
relevant right as “the right to be free from deliberate indifference to

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serious medical needs.” Special App’x at 61.5 But such a right “is far
too general a proposition to control this case.” City & County of San
Francisco v. Sheehan, 575 U.S. 600, 613 (2015). “Qualified immunity is
no immunity at all if ‘clearly established’ law can simply be defined
as the right to be free from” a given constitutional injury. Id.
Clark argues that our precedents clearly establish a broad right
to be free from deliberate indifference. That is incorrect. In LaBounty
v. Coughlin, 137 F.3d 68 (2d Cir. 1998), on which the district court
relied, we denied prison officials qualified immunity from claims
brought by prisoners exposed to crumbling asbestos. But that case
involved total inaction in the face of an obvious hazard—it did not
address any question of discretion in medical care. And our
statement in LaBounty recognizing “the right to be free from
deliberate indifference to serious medical needs, established in Estelle
v. Gamble,” id. at 74 (citations omitted), must be read consistent with
the Supreme Court’s warnings against framing rights too broadly.
The other circuit precedents on which Clark relies are similarly
inapt. The district court described Hathaway v. Coughlin, 37 F.3d 63
(2d Cir. 1994), as establishing that “a practitioner who merely
provides the same course of treatment when it clearly does not
alleviate an inmate’s suffering—as evidenced by the inmate’s
numerous complaints—acts with deliberate indifference.” Special
App’x at 64. But Hathaway, like LaBounty, cannot be read to create a
broad right against deliberate indifference divorced from its factual
5 Clark asks us to recognize an even broader constitutional right “to
be free of chronic and substantial pain that is important and worthy of
comment or treatment.” Appellee’s Br. at 33 (quotation marks omitted).

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context. The inmate in that case “complained of hip pain on nearly
fifty occasions,” but the doctor, who knew that the inmate’s hip pins
were broken, did not tell the inmate about them for two years and
instead offered “largely ineffective” painkillers. Hathaway, 37 F.3d at
68. We held only that a “jury could infer deliberate indifference” from
the doctor’s failure to arrange any further treatment despite knowing
about the broken pins. Id. at 68-69.
Here, Defendants provided Clark with psychotherapy,
antidepressants, lifestyle accommodations, and hormone therapy—
all of which are reasonable treatments for gender dysphoria. Indeed,
these treatments helped Clark feel “really good, [the] best ever,” at
least for a while. Joint App’x at 122. Clark’s course of treatment is
unlike the total inaction in LaBounty or the deception in Hathaway, and
those cases could not have put reasonable officers on notice that
Defendants’ efforts to provide care to Clark violated the Constitution.
Finally, Clark seizes on language from our decision in Collymore
v. Myers, 74 F.4th 22, 30 (2d Cir. 2023), to argue there is “a right to be
free of chronic and substantial pain that is important and worthy of
comment or treatment.” Appellee’s Br. at 44 (cleaned up). But
Collymore did not—and could not—clearly establish such a sweeping
right. We held only that a painful scalp infection was “a serious
medical condition” under the objective prong of the Eighth
Amendment deliberate-indifference standard. 74 F.4th at 30.6 We
6 Collymore explicitly limited its holding to the objective component
of the deliberate-indifference standard. See 74 F.4th at 31 (“While it may be
that the defendants did not act with ‘deliberate indifference’ or that some
or all of the conduct can be classified as malpractice at worst, the district

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rejected the assertion that the seriousness of a skin condition had to
be determined “body-part by body-part.” Id. But Defendants do not
contest that Clark’s gender dysphoria is a serious medical condition;
they challenge the conclusion that their treatment of that condition
clearly violated the Eighth Amendment. Nothing in Collymore
suggests that Defendants were on notice that their years of treatment
violated Clark’s Eighth Amendment rights.
Other courts have rejected broad framings of rights to gender-
dysphoria treatment. For example, the Seventh Circuit held in a
similar case—i.e., addressing qualified immunity from an inmate’s
Eighth Amendment claims based on the denial of sex-reassignment
surgery after hormone treatment—that the “proper inquiry is
whether then-existing caselaw clearly established a constitutional
right to gender-dysphoria treatment beyond hormone therapy.”
Campbell v. Kallas, 936 F.3d 536, 546 (7th Cir. 2019). “When
considering deliberate-indifference claims challenging the medical
judgment of prison healthcare personnel, qualified-immunity
analysis requires us to frame the legal question with reasonable
specificity.” Id.
The dissent contends that the majority takes an overly narrow,
treatment-by-treatment approach in defining the constitutional
question. Post at 23. But that argument rests on a mischaracterization
of the record—namely, that Defendants completely failed to treat
Clark’s condition. It is true that when officials fail to do anything to
address an inmate’s serious medical needs, the constitutional concern
court did not pass on those issues and this Court will not consider them
now.”).

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is not about the failure to provide a specific treatment.7 See infra
Section II.B.3. In contrast, “once medical care begins” and an inmate
“challeng[es] the medical judgment of prison healthcare professionals
who actually diagnose and treat an inmate’s medical condition (as
opposed to ignoring it), we necessarily evaluate those discrete
treatment decisions.” Campbell, 936 F.3d at 548. Here, as recounted
above, there was a progression of care that included talk therapy,
medication for depression, and later, hormone therapy. Qualified
immunity thus applies unless Defendants were on notice that failing
to include Clark’s requested treatments in that course of care would
amount to a constitutional violation.8
7 Indeed, the out-of-circuit cases that the dissent cites to support its
broad framing all involve obvious lapses in responding to a serious medical
condition. See Pfaller v. Amonette, 55 F.4th 436, 453 (4th Cir. 2022) (denying
qualified immunity where a doctor ignored his supervisor’s directives to
monitor an inmate’s hepatitis for two and a half years); Estate of Clark v.
Walker, 865 F.3d 544, 553 (7th Cir. 2017) (denying qualified immunity where
a prison official “chose to do nothing” despite knowing an inmate was
suicidal); Russell v. Lumitap, 31 F.4th 729, 742-43 (9th Cir. 2022) (denying
qualified immunity where a doctor did not order hospitalization of an
inmate exhibiting clear signs of a heart attack); Murray v. DOC, 29 F.4th 779,
783-84, 790-91 (6th Cir. 2022) (denying qualified immunity where a doctor
failed to assess an inmate with deep-vein thrombosis after he presented
with signs of a cerebral edema that resulted in permanent blindness). Here,
in contrast, the record shows that Defendants’ treatment regimen largely
addressed the serious risks of harm attending Clark’s gender dysphoria.
8 Even adopting the dissent’s overly general framing of the right at
issue as the right to “an individualized assessment and . . . adequate care”
for a serious medical condition, post at 24, our conclusion remains the same
because Clark received both, see infra at 26-28.

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21
In sum, Supreme Court precedent requires us “not to define
clearly established law at a high level of generality” lest we subject
defendants to liability without fair notice that their conduct is
unlawful. al-Kidd, 563 U.S. at 742. The district court’s overbroad
framing excludes any reference to gender dysphoria or the specific
treatments Clark demands for that condition. It also avoids the near-
unanimous weight of authority holding that there is no right to an
inmate’s preferred gender-dysphoria treatments. Following the
context-specific approach in Taylor, the proper inquiry here is
whether there is a clearly established right to a specific course of
gender-dysphoria treatment, including hormone therapy and sex-
reassignment surgery.9 The answer is no.
2. No Right to Specific Gender-Dysphoria Treatments
Neither the Supreme Court nor this Court has recognized,
much less clearly established, any constitutional right to specific
gender-dysphoria treatments.
First, the Supreme Court has never addressed the medical care
owed to transgender inmates under the Eighth Amendment. In
Farmer v. Brennan, the Court recognized that prison officials’ duty to
protect prisoners from violence could support a failure-to-protect
claim from a transgender inmate placed in the general population.
9 Defendants argue that the inquiry should be confined to whether
Clark had “a right to hormone therapy within a certain time frame and
vaginoplasty surgery.” Appellants’ Br. at 2. But this framing is too narrow
because it focuses on just two aspects of Clark’s complaint, which also
alleges a deprivation of other requested treatments, including facial-
reconstruction surgery and hair removal.

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22
511 U.S. at 833. It then clarified the subjective prong of deliberate
indifference and remanded without fashioning any rights specific to
transgender prisoners, let alone specific treatment for gender
dysphoria.
Second, this Court has not recognized any right to gender-
dysphoria treatment or denied qualified immunity in similar cases.
The only Second Circuit case to address similar issues is Cuoco v.
Moritsugu, 222 F.3d 99 (2d Cir. 2000), in which a transgender detainee
who had been taking hormones before imprisonment alleged that
prison medical officials withheld estrogen in violation of prison
policy and the Constitution. We found no constitutional violation in
withholding such treatment, even though Cuoco suffered visible
symptoms of withdrawal and threatened suicide. And we held that
the defendants were entitled to qualified immunity. Id. at 109-11. As
to two mental-health providers, we concluded that it was “objectively
reasonable” to “refus[e] to intervene in the medical treatment of
another doctor’s patient simply because the patient demanded it.” Id.
at 111. Cuoco does not come close to establishing an inmate’s right to
specific treatments for gender dysphoria.
Third, most other circuits have rejected deliberate-indifference
claims for denial of specific gender-dysphoria treatments. The First
Circuit has held that denial of sex-reassignment surgery did not
violate the Eighth Amendment when other ameliorative measures
were provided to an inmate. See Kosilek v. Spencer, 774 F.3d 63, 96 (1st
Cir. 2014) (en banc). The Fifth Circuit similarly rejected a claim for
denial of sex-reassignment surgery because there “is no intentional or
wanton deprivation of care if a genuine debate exists within the

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23
medical community about the necessity or efficacy of that care.”
Gibson v. Collier, 920 F.3d 212, 220 (5th Cir. 2019) (en banc). The Tenth
Circuit also rejected deliberate-indifference claims from an inmate
who—like Clark—received hormones and psychotherapy but wanted
sex-reassignment surgery and stronger hormones. See Lamb v.
Norwood, 899 F.3d 1159, 1162-63 (10th Cir. 2018) (holding that “prison
officials do not act with deliberate indifference when they provide
medical treatment even if it is subpar or different from what the
inmate wants”); see also Keohane v. Fla. Dep’t of Corr. Sec’y, 952 F.3d
1257, 1277 (11th Cir. 2020) (“[Defendants] chose a meaningful course
of treatment to address [plaintiff’s] gender-dysphoria symptoms—
treatment that, while perhaps different from (and less than) what
[plaintiff] preferred, is sufficient to clear the low deliberate-
indifference bar.”); Reid v. Griffin, 808 F.3d 1191, 1193 (8th Cir. 2015)
(“[Plaintiff] does not suggest any actions that the defendants could
have taken to prevent her from inflicting self harm other than
providing estrogen-replacement therapy—treatment to which she is
not entitled under the law.”).
The Seventh Circuit has similarly afforded qualified immunity
from deliberate-indifference claims for specific gender-dysphoria
treatments. Although the court had earlier established that “a total
absence of treatment for the serious medical needs created by gender
dysphoria is unconstitutional,” it has since granted qualified
immunity when the plaintiff “received extensive treatment in the
form of hormone therapy, counseling, and various lifestyle

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24
accommodations”—regardless of “the inmate’s preferred course of
treatment.” Campbell, 936 F.3d at 549 (quotation marks omitted).10
Clark argues that we “should not rely on” Gibson and
Campbell—both from 2019—because they “employed arcane notions
of how to treat gender dysphoria.” Appellee’s Br. at 70 n.14. Clark
instead points to the Ninth Circuit’s “contemporary” decision—also
from 2019—on treatment for transgender inmates. See id. (citing Edmo
v. Corizon, Inc., 935 F.3d 757, 767 (9th Cir. 2019) (holding that a prison
psychologist was deliberately indifferent for denying an inmate’s
requests for sex-reassignment surgery despite providing hormone
therapy)). We agree with the other courts of appeals to address the
issue and decline to follow the Ninth Circuit’s stray decision. See
Edmo v. Corizon, Inc., 949 F.3d 489, 505-11 (9th Cir. 2020) (noting the
dissent of nine judges from the denial of rehearing en banc).
All of this underscores the absence of clearly established law
supporting Clark’s gender-dysphoria claims. See Burns v. Martuscello,
890 F.3d 77, 94 (2d Cir. 2018) (noting that out-of-circuit decisions must
“clearly foreshadow[] a particular ruling on the issue” (quotation
marks omitted)).
10 Neither of the other two out-of-circuit cases cited by the dissent
clearly establishes a right to the gender-dysphoria treatments requested by
Clark. Those cases simply held that the district court erred in dismissing a
pro se complaint when completing its screening function under the Prison
Litigation Reform Act, 28 U.S.C. § 1915A. See Rosati v. Igbinoso, 791 F.3d
1037, 1039-40 (9th Cir. 2015); De’lonta v. Johnson, 708 F.3d 520, 526 (4th Cir.
2013).

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25
3. Not a Total Deprivation of Care
To be sure, some Eighth Amendment violations are “so
obvious” that “officials can still be on notice that their conduct
violates established law even in novel factual circumstances.” Hope v.
Pelzer, 536 U.S. 730, 741 (2002) (involving guards shackling an inmate
to a post and leaving him in the sun for seven hours); see also Taylor v.
Riojas, 592 U.S. 7, 8-9 (2020) (holding that “any reasonable officer
should have realized that” leaving an inmate naked in cells teeming
with “raw sewage” for six days constituted cruel and unusual
punishment, regardless of specific precedents).
We have applied this exception to deny qualified immunity
when officials “failed to take any steps to mitigate” an egregious and
obvious health risk. Vega v. Semple, 963 F.3d 259, 280 (2d Cir. 2020)
(denying qualified immunity to officials who “took no action
whatsoever” to mitigate prisoners’ radon exposure). So total inaction
in the face of a “known carcinogen” was “obviously unconstitutional”
in light of cases establishing that exposure to environmental tobacco
smoke could violate the Eighth Amendment. Id. at 276-77 (quotation
marks omitted). But the more particularized inquiry required by
Taylor applies when defendants take some action that “allegedly
should have been better.” Id. at 280; cf. post at 26 n.8 (asserting that
talk therapy and psychiatric medication did not constitute
“meaningful treatment” for Clark’s gender dysphoria).
It is not the case here that Defendants “failed to take any steps
to mitigate” Clark’s gender dysphoria. Vega, 963 F.3d at 280. Clark
admits that Defendants provided (1) lifestyle accommodations, (2) at
least nine sessions of talk therapy, (3) antidepressant medication, (4)

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26
two and a half years of hormone therapy, (5) eleven rounds of lab
work to monitor that treatment, and (6) five appointments with
UConn’s endocrinology practice. Although such treatment may not
have been Clark’s preferred course, that “is not the same as deciding
to provide no treatment at all.”11 Campbell, 936 F.3d at 549.
Defendants’ actions also fall outside the obviousness exception from
Hope, 536 U.S. at 741. Nothing about the medical care Clark received
amounts to the “obvious cruelty,” id. at 731, involved in chaining an
inmate to a post in the heat or leaving an inmate in raw sewage.
Nonetheless, the district court concluded that Clark suffered a
total deprivation of “informed care from a provider qualified to treat
11 The dissent resists this conclusion because Dr. Valletta initially
denied Clark hormone therapy under “a blanket policy divorced from
applicable medical standards.” Post at 32; see also id. at 28. Putting aside
the dissent’s characterization of prevailing medical standards at the time of
Clark’s treatment, we have found deliberate indifference only when an
official invokes prison policy with willful blindness to a serious risk of
harm. See Salahuddin v. Goord, 467 F.3d 263, 282 (2d Cir. 2006) (finding that
a doctor who postponed an inmate’s liver biopsy under prison policy was
not deliberately indifferent because “he was not aware of a substantial risk
that postponing the liver biopsy would cause serious harm”). Here, there
is no evidence that Valletta knew that following DOC policy with respect
to hormone therapy would result in serious harm to Clark. Cf. Johnson v.
Wright, 412 F.3d 398, 404 (2d Cir. 2005) (concluding that a jury could find
deliberate indifference where defendants “ignore[d] the unanimous advice
of Johnson’s treating physicians, including prison physicians, and appl[ied]
the Guideline’s substance abuse policy”). To the contrary, the record shows
that Valletta referred Clark for an intake appointment with an
endocrinologist as soon as he learned he could do so while also providing
Clark with general mental-health treatment.

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27
[gender dysphoria].” Special App’x at 64. Neither the district court
nor Clark defines “informed care”—a standard that appears nowhere
in our deliberate-indifference caselaw. The district court reasoned
that it “was obvious to these Defendants that the failure to refer”
Clark to “someone competent” would perpetuate Clark’s anguish. Id.
at 58. Clark argues the same on appeal. See Appellee’s Br. at 46-48.
This framing fails for several reasons.
First, Defendants provided various forms of treatment over
several years, which Clark disregards simply by limiting the analysis
to “informed care from a qualified provider.” Defendants’ efforts,
however unsatisfactory to Clark, were not “complete inaction in the
face of a risk to a prisoner’s health.” Vega, 963 F.3d at 279 (emphasis
added). Adding qualifiers like “informed” or “qualified” to denote a
particular standard of care reprises the adequate-treatment analysis
for which “existing precedent must have placed the statutory or
constitutional question beyond debate.” Taylor, 575 U.S. at 825
(cleaned up). It is also incorrect to say that all of Defendants’ care—
which helped Clark at one point feel “really good, best ever”—
amounted to complete inaction in violation of the Eighth Amendment
simply because Defendants were “uninformed.”
Second, as a factual matter, the record does not support the
allegation that Clark was deprived of informed care. Accepting the
allegation that a lack of “expertise in gender dysphoria” rendered
Defendants uninformed disregards the expert care Clark received.
Valletta procured such care by referring Clark for endocrinology
treatment at UConn. Clark admitted to meeting with specialists in
hormone treatment five times between September 2017 and February

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28
2020. Joint App’x at 117-18. Although Clark claims “never [to have]
received the monitoring that would be critical for someone on
hormone therapy,” Clark also admits that Valletta ordered eleven
rounds of lab work. See id. at 117-19. Clark thus received some care
from qualified specialists.12
Third, as a legal matter, even if Clark were deprived of
“informed care” for gender dysphoria, that would not violate the
Constitution. The Eighth Amendment requires that “inmates receive
adequate food, clothing, shelter, and medical care” and that prison
officials take “reasonable measures to abate” a “substantial risk of
serious harm.” Farmer, 511 U.S. at 832, 847. “It is well-established”
within this legal framework “that mere disagreement over the proper
treatment does not create a constitutional claim.” Chance v.
Armstrong, 143 F.3d 698, 703 (2d Cir. 1998). “[O]nly those
deprivations denying the minimal civilized measure of life’s
necessities are sufficiently grave to form the basis of an Eighth
Amendment violation.” Wilson v. Seiter, 501 U.S. 294, 298 (1991)
(cleaned up). Treatment by gender-dysphoria specialists is not such
a necessity. And a deprivation of such “informed care” alone cannot
support a deliberate-indifference claim. This case falls outside the
narrow exceptions in our Eighth Amendment cases reserved for
12 Clark’s amended complaint is telling. It alleged what Clark now
claims it did not: a lack of “adequate care,” not a total deprivation of
“informed care from a qualified provider.” The amended complaint
referred to “adequate” care over twenty times, and not once alleged a total
deprivation of “informed” care. See Joint App’x at 28-42.

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29
obvious and egregious violations or total inaction in the face of known
hazards.
C. Objective Reasonableness
Even if the right at issue were clearly established, we have
made clear that the official “will still be entitled to qualified immunity
if it was objectively reasonable for him to believe that his acts did not
violate those rights.” Outlaw, 884 F.3d at 367. An action is objectively
reasonable unless “every reasonable official would have understood
that what he is doing violates” a clearly established right. al-Kidd, 563
U.S. at 741 (cleaned up); see also Green v. City of New York, 465 F.3d 65,
83 (2d Cir. 2006) (holding that qualified immunity is warranted unless
“no officer of reasonable competence could have made the same
choice in similar circumstances” (quotation marks omitted)). This
objective standard does not ask “whether the defendant officer acted
in good faith or what he himself knew or believed, but rather what
would have been known to or believed by a reasonable officer in the
defendant’s position.” Outlaw, 884 F.3d at 367.
1. Disagreements About Treatment of Gender Dysphoria
The district court concluded that “no reasonable official would
have believed it was lawful to fail to provide informed care,” given
Clark’s “numerous and consistent complaints describing severe
anguish.” Special App’x at 64-65. This was wrong for several reasons.
First, as the record reflects, medical experts disagree about how
to treat gender dysphoria. Defendants’ expert stated that there is
“considerable growing disagreement within the medical and
scientific communities on how to best treat people with gender

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30
dysphoria.” Dist. Ct. Dkt. 128, Ex. E, at 3. Clark’s expert, by contrast,
claimed that the WPATH Standards of Care are “authoritative for the
evaluation and treatment of [gender dysphoria] and related gender
conditions.” Dist. Ct. Dkt. 133, Ex. 1, at 31. But he also acknowledged
that “[t]reatments are individualized for patients” with a gender-
dysphoria diagnosis. Id. at 29.
Clark claims that WPATH’s Standards “articulate a professional
consensus about the psychiatric, psychological, medical, and surgical
treatment and management of gender dysphoria.” Appellee’s Br. at
9. But Levine, who once chaired the Committee responsible for the
Standards, criticized recent revisions because they “often minimize or
do not seriously consider the considerable gaps in knowledge about
outcomes of their recommendations.” Dist. Ct. Dkt. 128, Ex. E, at 2;
see also Gibson, 920 F.3d at 221 (noting that “the WPATH Standards of
Care reflect not consensus, but merely one side in a sharply contested
medical debate”). The fact that Defendants’ care did not follow
WPATH’s Standards thus does not mean that no competent officers
would have thought their course of treatment was lawful.13
Second, the relevant caselaw establishes that Defendants’
treatment of Clark was objectively reasonable. Most circuits to
13 In his deposition, Levine testified that Clark’s treatment was “far
less than ideal.” Dist. Ct. Dkt. 133, Ex. 4, at 4. But Levine tempered that
assessment with an acknowledgment of “prison life and prison culture”
and his assessment that Clark’s expectations about treatment were
“unrealistic.” Id. at 4, 8. “[L]ess than ideal” medical treatment can be
objectively reasonable treatment in the Eighth Amendment context, so it
does not follow that every reasonable official would have thought Clark’s
treatment was unlawful.

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31
consider the issue agree that the Eighth Amendment does not entitle
transgender inmates to the full array of gender-dysphoria treatments.
See, e.g., Kosilek, 774 F.3d at 96; Gibson, 920 F.3d at 216. For example,
the Tenth Circuit held that prison officials were not deliberately
indifferent when they provided a transgender inmate with
“psychological counseling and hormone treatments” but denied
“surgery or the hormone dosages that [the inmate] wants.” Lamb, 899
F.3d at 1163. Nothing in our caselaw would cause Connecticut prison
officials to think otherwise.
Given the disagreement surrounding gender-dysphoria care, it
simply cannot be said that every reasonable official would believe that
providing lifestyle accommodation, psychotherapy, antidepressants,
and a delayed course of low-dose hormones violated Clark’s Eighth
Amendment rights. “There is no intentional or wanton deprivation
of care if a genuine debate exists within the medical community about
the necessity or efficacy of that care.” Gibson, 920 F.3d at 220.
2. Subjective Indifference and Objective Reasonableness
Finally, Clark argues that deliberate-indifference claims should
not be subject to an objective-reasonableness analysis because such
claims necessarily require a subjective disregard of a substantial risk
of harm to the inmate. Appellee’s Br. at 65. This argument defies
well-established principles of qualified immunity.
The Supreme Court has made clear that qualified immunity
turns on an objective assessment of the defendant’s actions. See
Anderson v. Creighton, 483 U.S. 635, 641 (1987); Harlow v. Fitzgerald, 457
U.S. 800, 818 (1982). “Subjective inquiry into a government
employee’s motivations in acting or refusing to act has been rejected

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32
because it generally implicates questions of fact and is therefore
incompatible with the expressed policy that summary judgment be
readily available to protect government employees from suit.” P.C. v.
McLaughlin, 913 F.2d 1033, 1040 (2d Cir. 1990).
Neither the Supreme Court nor this Court has excepted
deliberate indifference from this rule. Nor can we simply collapse
Farmer’s subjective inquiry into the objective-reasonableness
standard. The Supreme Court’s decision in Saucier v. Katz instructs
that qualified immunity’s reasonableness inquiry “has a further
dimension” and “remain[s] distinct” from constitutional standards.
533 U.S. 194, 204-05 (2001).14
The Ninth Circuit, which once employed Plaintiff’s collapsed
inquiry, abandoned it after Saucier. See Est. of Ford v. Ramirez-Palmer,
301 F.3d 1043, 1049 (9th Cir. 2002). “[I]t is no less true for purposes of
the Eighth Amendment than it was in Saucier that the qualified
immunity inquiry has a further dimension.” Id. (quotation marks
omitted). “Thus, a reasonable prison official understanding that he
cannot recklessly disregard a substantial risk of serious harm, could
know all of the facts yet mistakenly, but reasonably, perceive that the
exposure in any given situation was not that high. In these
circumstances, he would be entitled to qualified immunity.” Id. at
14 Saucier made clear that the “inquiries for qualified immunity and
excessive force remain distinct.” 533 U.S. at 204. The Court rejected the
view that the inquiries merge because a “reasonable officer” would not
think it lawful to use “unreasonable” force. Id. at 206. Even if an officer’s
actions were “unreasonable” in the constitutional sense, “Anderson still
operates to grant officers immunity for reasonable mistakes as to the
legality of their actions.” Id.

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33
1050. The Supreme Court similarly applied Saucier to treat qualified
immunity as analytically distinct from the Eighth Amendment
inquiry in Hope. 563 U.S. at 739-42.15
Defendants are thus entitled to qualified immunity on
objective-reasonableness grounds even if they had violated Clark’s
clearly established rights, which they did not, as explained above. To
hold otherwise would improperly excise Eighth Amendment claims
from the objective-reasonableness protections of qualified immunity
based on irrelevant and impermissible consideration of a defendant’s
subjective state of mind.
III. CONCLUSION
In sum, the district court improperly denied qualified
immunity to Defendants because there is no clearly established right
to specific gender-dysphoria treatments. Defendants also are entitled
to qualified immunity because their actions were objectively
reasonable. Accordingly, the order of the district court is reversed,
and the case is remanded with instructions to grant Defendants’
motion for summary judgment on qualified-immunity grounds.
15 Some circuits have collapsed the objective-reasonableness prong of
qualified immunity into the subjective element of deliberate indifference.
See Thorpe v. Clarke, 37 F.4th 926, 939 (4th Cir. 2022); Walker v. Benjamin, 293
F.3d 1030, 1037 (7th Cir. 2002); Beers-Capitol v. Whetzel, 256 F.3d 120, 142 n.15
(3d Cir. 2001). But we decline to follow this approach because it conflicts
with the Supreme Court’s instructions in Saucier and Anderson, as well as
our objective-reasonableness precedents.

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No. 23-7377
Clark v. Valletta
B ETH ROBINSON, Circuit Judge, concurring in part, dissenting in part:
This case is not about the right to vaginoplasty, “stronger hormone
therapy,” or any specific treatment for that matter. Maj. Op. at 3. Nor does it
present a constitutional challenge to a considered medical judgment as to Clark’s
reasonable medical needs. Id. The majority describes a different case from the one
presented in this appeal. Clark’s claims here arise from: (1) Defendants Valletta’s
and Kimble-Goodman’s failures to facilitate any treatment directed at Clark’s
undisputedly serious medical condition—such as gender informed
psychotherapy, hormone treatments, or evaluation for possible surgical
interventions—for a period of thirteen months notwithstanding her evident
anguish, and (2) Defendant Valletta’s subsequent failure to comply with the
endocrinologist’s hormone treatment plan for Clark’s serious medical condition
for a period of 20 months despite clear evidence of Clark’s distress.
Considering the facts through the proper frame, the district court got it right.
Defendants Valletta and Kimble-Goodman are not entitled to qualified immunity
under our clearly established law.1 In concluding otherwise, the majority
1 For the reasons stated in footnote 6 of this opinion, I agree with the majority that Defendant
Bush is entitled to qualified immunity. As to Valletta and Kimble-Goodman, I would affirm the
district court’s denial of qualified immunity.

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2
improperly relies on disputed evidence proffered by Defendants; defines the right
at issue too narrowly—both in light of Clark’s complaint and arguments, and the
generally applicable law; and ignores the distinction in the caselaw between
challenges to prison medical providers’ considered medical judgments and
challenges, like Clark’s, to blanket policies that are inconsistent with medical
standards of care and wholesale failures to comply with otherwise adequate
treatment plans. For these reasons, I respectfully dissent.
I. The Record
We have jurisdiction to immediately review a district court’s denial of
qualified immunity based only on “stipulated facts, or on the facts that the plaintiff
alleges are true, or on the facts favorable to the plaintiff that the trial judge
concluded the jury might find.” Francis v. Fiacco, 942 F.3d 126, 139 (2d Cir. 2019).2
There are no stipulated facts on appeal, and therefore, we can only credit the facts
that Clark alleged are true at summary judgment.3 The critical events underlying
Clark’s claims fell into two phases: (1) from April 2016 through July 2017, during
2 In quotations from caselaw, the appendices, and the parties’ briefing, this dissent omits all
internal quotation marks, footnotes, and citations, and accepts all alterations, unless otherwise
noted.
3 To the extent that the majority incorporates other evidence, such as Defendants’ expert’s views
about standards of care, or Valletta’s characterization of Clark’s expectations and other
psychiatric diagnoses, it strays from this requirement. See Dissent at 11–12.

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3
which Clark was denied care directed at her gender dysphoria despite tremendous
anguish; and (2) from September 2017 to August 2019, during which time Clark
was denied care consistent with her care plan despite her repeated urgent
requests.
A. April 2016 to September 2017
Clark has been incarcerated in the custody of the Connecticut Department
of Corrections (“CDOC”) since 2007. Around May 2016, following Clark’s self-
report, a CDOC medical provider diagnosed Clark with gender dysphoria.4
Gender dysphoria is clinically significant distress associated with an incongruence
between a person’s gender identity and assigned sex at birth. In July 2016, Clark
attempted to castrate herself by tying a shoelace around her penis and scrotum
and cutting her scrotum with a pair of nail clippers. She was taken to the
emergency room at an area hospital and treated for her wounds. A CDOC
psychologist noted that Clark’s “high level of psychological distress relative to
[her] gender dysphoria” led to her self-castration attempt. Jt. App’x 75 ¶ 23.
4 Many of the cases discussed later in this dissent use the term “gender identity disorder” rather
than “gender dysphoria.” As the First Circuit noted “the term ‘gender identity disorder’ has . . .
been replaced with the term ‘gender dysphoria’ in the medical community.” Kosilek v. Spencer,
774 F.3d 63, 69 n.1 (1st Cir. 2014). Consistent with the record in this case, I will use the term
“gender dysphoria.”

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4
CDOC mental providers categorized her risk level as a level five, which is the most
severe level of risk in CDOC’s classification system.
In July 2016, Clark was transferred to Garner Correctional Institution
(“Garner”) where she submitted a request to see a doctor about her gender
dysphoria. Over the next year, she received care from two CDOC clinicians: Dr.
Gerald Valletta, a medical doctor and a principal physician at Garner at the time,
and Advanced Practice Registered Nurse (“APRN”) Barbara Kimble-Goodman, a
mental health provider.
Clark first met with Valletta in August 2016. During this first meeting,
Valletta treated Clark’s wounds from her attempted self-castration and made the
following note: “[Clark] referred to M[ental] H[ealth] [and] case manager.” Dist.
Ct. Dkt. No. 137 at 55 (sealed). He couldn’t recall whether he took any affirmative
steps to refer Clark to a mental health provider. However, ten days after their
initial appointment, Clark met with a mental health provider who noted that she
had clinically significant distress and a strong desire to be rid of her primary and
secondary male characteristics.
In September and October 2016, Clark submitted written requests asking for
treatment for her gender dysphoria—namely, “transition-related health care.”
Dist. Ct. Dkt. 133-19 at 27, 29. She wrote, “It would be impossible to overstate the

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5
internal psychological trauma I experience every moment of every day I go
without treatment.” Id. at 29. And she pled, “[P]lease, with my entire being, allow
me access to transition-related health care.” Id.
Gender dysphoria that goes untreated or is insufficiently treated poses a risk
to the individual’s physical and mental health. The World Professional
Association for Transgender Health (“WPATH”) Standards of Care are
authoritative for the evaluation and treatment of gender dysphoria. Treatment of
gender dysphoria under the WPATH Standards of Care is individualized for
patients and may include gender-informed psychotherapy, gender confirming
hormonal treatment, and gender affirming surgeries.5
Ordinarily, when an incarcerated person requires treatment beyond the
capabilities of a CDOC provider, the provider may refer a patient to an outside
specialist. To do so, the provider submits a request for referral to the CDOC’s
Utilization Review Committee (“URC”). When a patient is approved to see a
specialist and that specialist recommends the incarcerated patient return for a
follow-up appointment, the principal physician is responsible for submitting
further requests to the URC for each follow up appointment.
5 Though we are to consider only Clark’s allegations and evidence in this context, I note that
Defendants’ own expert’s list of treatments that may be appropriate for gender dysphoria
includes these same treatments. See Dist. Ct. Dkt. No. 128-7 at 3–4 ¶¶ 9-12.

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6
Valletta had no training in treating gender dysphoria, and no prior
experience treating people for gender dysphoria. But he knew what gender
dysphoria was, knew Clark’s diagnosis, and knew it was a chronic condition. He
was responsible for referring Clark to a specialist if necessary. Nevertheless, in
response to Clark’s pleas, Valletta did not request a referral from the CDOC URC
to facilitate even an assessment as to appropriate course of care in her case. Instead,
he responded to Clark’s early September request:
As per CMHC/DOC policy, transitional treatment would
be CONTINUED if inmate already has been on
medication in the community, but transitional treatment
will not be initiated while . . . incarcerated.
Dist. Ct. Dkt. No. 133-19 at 27 (September request).
He likewise responded to her late September request:
I’m informed that current practices @ CMHC/DOC are
that hormonal/transitional therapy will be continued but
not initiated upon incarceration.
Id. at 29. In other words, Valletta denied Clark any evaluation or treatment
focused on her gender dysphoria not based on his own medical assessment—he
knew he was not in a position to offer one—but rather, based on a purported
unwritten policy barring an individual who was not already receiving gender
affirming care from receiving treatment for gender dysphoria while incarcerated
without regard to medical need or standards of care.

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7
Clark first saw Kimble-Goodman in November 2016. Kimble-Goodman
conducted a mental health evaluation and could prescribe mental health
medications. Kimble-Goodman had no training regarding gender dysphoria. In
the initial appointment, Clark told Kimble-Goodman about her distress and that
her male genitalia were “poisoning” her. Jt. App’x 78 ¶ 37. Kimble-Goodman
recommended a follow-up appointment in three months. When they met again in
February 2017, they discussed medication for depression, which Clark was
apprehensive about taking.
Between November 2016 and July 2017, Kimble-Goodman saw Clark
several times. She did not treat Clark specifically for her gender dysphoria, but
offered Clark talk therapy and a prescription for antidepressants. She knew what
gender dysphoria was, and that Clark was diagnosed with the condition, but she
made no effort to facilitate a referral for gender informed psychotherapy or any
other treatment.
In the meantime, it was not until July 2017, a year after Clark attempted to
physically castrate herself with nail clippers, that Valletta submitted the necessary
paperwork to refer Clark to an outside endocrinologist for evaluation for hormone
treatment. The record isn’t clear as to whether he did so because the purported
CDOC policy had changed or because CDOC management prodded him to do so

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8
after students at the Columbia University School of Law threatened litigation.
Valletta referred Clark to an endocrinologist two months later.
During this time, Clark suffered considerable psychological distress. She
reported to Kimble-Goodman that she felt “poisoned” every day, and said, she felt
like she was “dying.” Dist. Ct. Dkt. No. 137 at 61 (sealed). Valletta’s and Kimble-
Goodman’s failure to make any appropriate referrals despite their own lack of
qualifications to treat gender dysphoria during this thirteen-month period
underlies one aspect of Clark’s deliberate indifference claim.
B. September 2017 to October 2019
Once Valletta facilitated an assessment for one gender dysphoria treatment
modality—hormone treatment—he failed to facilitate compliance with the
recommended treatment plan.
Clark met with an endocrinologist in September 2017. That specialist
recommended that Clark: (1) start hormone therapy, (2) undergo lab work in four
weeks and again at twelve weeks to monitor her hormone levels, and (3) follow
up with the endocrinologist in three months, on or around December 14, 2017.
Ordering lab work and facilitating necessary follow-up appointments were among
Valletta’s responsibilities. Clark didn’t have the recommended follow-up
appointment in three months despite receiving approval for it. Rather, as set forth

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9
more fully below, she didn’t see the endocrinologist again until a year and eight
months after her follow-up appointment should have occurred.
Clark began hormone therapy under Valletta’s supervision in September
2017. Her October 2017 bloodwork reflected that her overall testosterone level was
within the range of a normal adult male. In November, she reported to Kimble-
Goodman benefits from hormone therapy including improved sleep, appetite,
motivation, and mood.
That soon changed. Her January bloodwork revealed that her testosterone
level had increased, indicating that her hormone therapy was ineffective.
In April 2018, Clark requested a health services review of her treatment, and
emphasized that she did not believe she was receiving a high enough dose of
hormones. She described her distress at having to shave three times daily, and the
absence of the expected feminizing effects of the hormones. (She also noted that
for the fourth or fifth time, her prescription had not been refilled.) When she met
with Valletta after that she reported that she was frustrated at the low level of her
hormone dosage relative to other transgender inmates. In response, he told her he
would run additional lab work, and he reassured her about the plan that was in
place. He made no note of the fact that Clark was many months overdue for her
recommended follow-up appointment with the endocrinologist. Clark’s

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10
subsequent May 2018 blood work showed that her testosterone levels had
increased rather than decreased.
In June 2018, Clark reported to Kimble-Goodman that she was stressed
because she had to shave multiple times each day; she didn’t think she was getting
the correct dosage of her hormones.
And then in July 2018, Clark again requested a health service review. She
reported that she felt traumatized by her facial hair, chest hair, and other signs that
the hormones weren’t having the expected effect, and wrote “I do not know how
to communicate how much pain I am in.” Dist. Ct. Dkt. No. 133-19 at 15. She
emphasized that she believed she needed a higher dosage of hormones to reduce
her muscle mass, and wrote, “Please, help me.” Id. Again, Valletta, whose
responsibilities included scheduling recommended follow-up appointments with
the endocrinologists, did nothing to schedule the three-month follow-up
appointment that was by then more than six months overdue.
Again in February 2019, Clark submitted an inmate request asking whether
her hormone medication was properly dosed. The response section of the form
indicates only that Clark was seen. By this point, Clark was well over a year
overdue for her three-month follow-up with the endocrinologist.

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11
And in June 2019, Clark submitted a grievance noting that she had asked
“medical” in writing to let her know if she would be seeing the endocrinologist
soon, and the request was answered by a mental health worker. She asked why
her medical requests were continually being ignored by the medical department.
CDOC responded that because the endocrinology department was backed up it
was difficult to get appointments, but that she had one scheduled within the next
month.
Clark finally had her second appointment with an endocrinologist in
August 2019—approximately twenty months later than recommended. The
endocrinologist recommended a follow-up appointment in two months after Clark
underwent lab testing. The endocrinologist noted that she would benefit from a
higher dose of hormones, but that updated lab work was necessary. Her
September 2019 lab test revealed that her testosterone had increased. And in
October 2019, the endocrinologist doubled her hormone therapy medication and
recommended repeated lab work in three months and a follow-up appointment in

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12
four months. At the next follow-up visit, the endocrinologist increased her dosage
again. Clark was then transferred to another facility in March 2020.6
To summarize, though Clark was eventually referred to an endocrinologist,
Valletta, her primary care physician, failed to follow the protocol the
endocrinologist prescribed, including failing to schedule the recommended
follow-up appointment for twenty months beyond the recommended time. He did
so despite multiple test results indicating that the hormone therapy was
ineffective. During this period, Clark continued to experience and communicate
considerable distress around her hormone levels while Valletta took no steps to
schedule a follow-up assessment as required by her treatment plan. This wasn’t
because Valletta made a considered judgment that she did not need higher levels
of hormones. It was because he simply ignored his responsibility to facilitate
Clark’s follow-up evaluations.
6 During this period, Clark also briefly consulted with Defendant Richard Bush, a licensed clinical
social worker. My dissent does not extend to the qualified immunity determination as it relates
to Bush. By the time he saw Clark, Bush knew she was being seen by APRN Reischerl, a
psychiatric APRN, for evaluation in connection with her gender related needs. For that reason, I
do not contend that clearly established law put Bush on notice that his failure to independently
seek additional mental health treatment for Clark’s gender dysphoria would violate her
constitutional rights. Therefore, I concur with the majority that the district court erred in denying
Bush qualified immunity.

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13
II. Qualified Immunity Analysis
We generally lack jurisdiction to consider a denial of summary judgment,
but we may review a district court’s order denying a motion for summary
judgment based on qualified immunity “to the extent the denial turns on an issue
of law.” Terebesi v. Torreso, 764 F.3d 217, 229 (2d Cir. 2014). We may exercise
appellate jurisdiction “only for the limited purpose of deciding whether, on the
basis of stipulated facts, or on the facts that the plaintiff alleges are true, or on the
facts favorable to the plaintiff that the trial judge concluded the jury might find,
the immunity defense is established as a matter of law.” Id. “Within these
constraints,” we review the district court’s assessment without deference. Id.
“Qualified immunity shields government officials from civil damages
liability unless the official violated a statutory or constitutional right that was
clearly established at the time of the challenged conduct.” Taylor v. Barkes, 575 U.S.
822, 825 (2015). For a right to be clearly established, it must be “sufficiently clear
that every reasonable officer would have understood that [the officer’s conduct]
violates that right.” Id.
The majority’s analysis is infected by two critical flaws: First, the majority
misdefines the right at issue here. And second, the majority fails to recognize the
distinction between a constitutional challenge to a considered medical judgment

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14
by a prison medical official, and a challenge to conduct that is not driven by any
informed medical judgment. I consider each in more detail.
A. Defining the Clearly Established Right
The majority defines the right at issue in this case as an incarcerated person’s
“right to a specific course of gender-dysphoria treatment, including hormone
therapy and sex-reassignment surgery.” Maj. Op. at 21. There are two problems
with this characterization, one factual and one legal. The factual problem is that
the majority’s framing ignores Clark’s actual claims in this case and instead
substitutes a narrative that focuses on the arguably more provocative argument—
not advanced in this case—that on this record Clark had a clearly established right
to gender affirming surgery upon request. Second, it runs headlong into the
Supreme Court’s oft-repeated admonition that a “case directly on point” is not
required. See e.g., Taylor, 575 U.S. at 825; Ashcroft v. al-Kidd, 563 U.S. 731, 741 (2011);
see also LaBounty v. Coughlin, 137 F.3d 68, 73 (2d Cir. 1998) (“An overly narrow
definition of the right can effectively insulate the government’s actions by making
it easy to assert that the narrowly defined right was not clearly established.”). I
elaborate on each concern below.

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15
i. Clark’s Claims
The case the majority has decided bears little resemblance to the case
presented on appeal. Clark’s complaint is not premised on the claim that the
defendants violated her clearly established constitutional rights by failing to
arrange for “stronger hormone therapy and a vaginoplasty.” Maj. Op. at 3. Her
complaint is that she didn’t get any care directed at her gender dysphoria for
thirteen months, and that even once she began getting some care, Defendants
prevented her from complying with the treatment plan.
Clark’s fifteen-page complaint lays out a narrative consistent with the facts
recounted above. It identifies a host of potential treatments Defendants denied
Clark, and emphasizes that Clark has never been evaluated by a medical provider
specializing in caring for transgender people. Jt. App’x 37 ¶ 39. Clark’s deliberate
indifference claim is predicated on Defendants’ failure to provide her “adequate
and necessary medical treatment . . . consistent with prevailing medical
standards,” which may include a number of identified treatments. It does not
identify the denial of surgery (for which she was never even evaluated) as the crux
of her claim. Jt. App’x 39 ¶ 47.

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16
Likewise, nothing in the district court’s extensive and thoughtful decision
turns on any defendant’s failure to schedule gender affirming surgery for Clark.
Instead, the district court summarized its assessment as follows:
Here, the experts agree that Ms. Clark was denied
adequate care. It took years, and this litigation, for DOC
officials to refer Ms. Clark to see someone with
experience and expertise in treating gender dysphoria. It
took over ten months after her self-castration attempt to
receive any care aside from a referral to a mental health
provider that had no experience or expertise in treating
patients with gender dysphoria. Then, when she
received some treatment in the form of hormone therapy,
the DOC failed to follow the medical protocol prescribed
by that specialist and ignored multiple test results which
reflected the increasing need to follow the prescribed
protocol. The record is devoid of any evidence of the
DOC’s attempt to follow the protocol or of any
documentary scheduling or other impediments to
following the protocol. During this time, she received
some treatment for her dysphoria in the form of talk
therapy but said “therapy” was conducted by someone
without any experience or expertise in treating someone
with gender dysphoria. When eventually Ms. Clark was
referred to someone with experience and expertise in
treating someone with gender dysphoria, the DOC
continued to fail to provide Ms. Clark with the treatment
recommended by that expert. This is not adequate care.

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17
Clark v. Quiros, 693 F. Supp. 3d 254, 287–88 (D. Conn. 2023). That’s what Ms. Clark’s
claims are about. This simply isn’t a denial-of-gender-affirming-surgery case.7
ii. Framing the Right
In any event, the law doesn’t support the majority’s narrow framing of the
right in question, focusing on the “right to specific gender-dysphoria treatments.”
Maj. Op. at 13.
Crucial to the “clearly established” inquiry is the level of generality at which
the right is defined. See LaBounty, 137 F.3d at 73 (“The chronic difficulty with this
analysis for courts is in accurately defining the right at issue.”); see also John C.
Jeffries, What’s Wrong with Qualified Immunity?, 62 Fla. L. Rev. 851, 852 (2010)
(“[D]etermining whether an officer violated ‘clearly established’ law has proved
to be a mare’s nest of complexity and confusion.”). A right is not clearly defined
by a broad imperative like the prohibition against unreasonable searches, but “a
case directly on point” is not required. Taylor, 575 U.S. at 825; see also Williams v.
Greifinger, 97 F.3d 699, 703 (2d Cir. 1996) (“A court need not have passed on the
identical course of conduct in order for its illegality to be ‘clearly established.’”).
7 Counsel for Clark confirmed this at oral argument. She was asked both “do we have to address
whether there is a clearly established constitutional right to a vaginoplasty in order to resolve the
case,” Oral Arg. at 27:35–41, and “do we have to address whether there is a clearly established
constitutional right to hormone treatment,” id. at 27:43–45. She answered “no,” id. at 27:41–43,
and “absolutely not,” id. at 27:46–47.

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18
As a general matter, the Eighth Amendment protects against prison
officials’ deliberate indifference to serious medical needs. The term “deliberate
indifference” first appeared in Estelle v. Gamble, 429 U.S. 97, 104 (1976), where the
Supreme Court held that the government must provide medical care to address
the serious medical needs of incarcerated persons. It distinguished between
“deliberate indifference to serious medical needs” of prisoners and “negligen[ce]
in diagnosing or treating a medical condition.” Id. at 106. Only the former violates
the Eighth Amendment. Id. Since Estelle, a two-prong framework has developed:
plaintiffs must allege (1) a serious medical need, and (2) that prison officials who
were both aware of that need and capable of addressing it did not do so. See
Hathaway v. Coughlin, 37 F.3d 63, 66 (2d Cir. 1994).
It is true that the Supreme Court has regularly required a high level of
specificity in Fourth Amendment claims, but it has not required the same level of
granularity in Eighth Amendment claims. Compare City of Tahlequah, Oklahoma v.
Bond, 595 U.S. 9, 12–13 (2021) (“Such specificity is especially important in the
Fourth Amendment context, where it is sometimes difficult for an officer to
determine how the relevant legal doctrine . . . will apply to the factual situation the
officer confronts.”) with Ortiz v. Jordan, 562 U.S. 180, 190 (2011) (stating that “the
pre-existing law was not in controversy” because it had long been established that

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19
a “prison official may be held liable for deliberate indifference to a prisoner’s
Eighth Amendment right to protection against violence while in custody if the
official knows that the inmate faces a substantial risk of serious harm and
disregards that risk by failing to take reasonable measures to abate it”); Hope v.
Pelzer, 536 U.S. 730, 739 (2002) (the test for qualified immunity is not whether “the
very action in question has previously been held unlawful” but is whether “in the
light of pre-existing law the unlawfulness [is] apparent”). See also Thorpe v. Clarke,
37 F.4th 926, 940 (4th Cir. 2022) (“[W]hile the Court has regularly insisted on highly
particularized law in the Fourth Amendment context, it has not done the same
with Eighth Amendment claims.”).
Our review of qualified immunity in the Eighth Amendment deliberate-
indifference context bears this out. In Hathway v. Coughlin, we addressed a
plaintiff’s claim that the prison doctor and other defendants showed deliberate
indifference to his chronic hip pain. There, a specialist informed prison officials
that the plaintiff suffered from a degenerative disease in the left hip joint. 37 F.3d
at 65. The plaintiff complained of pain at least forty-nine times over the course of
three years. Id. In response, the prison doctor prescribed new orthopedic shoes,
recommended that he be housed on a first-floor cell and be exempted from heavy
lifting and prescribed him pain killers on most occasions. Id. Significantly, the

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20
prison doctor did not disclose to Hathaway that he had broken pins in his hip, did
not discuss the possibility of surgery with him despite Hathaway’s sudden
resurgence of hip pain, and did not refer him for a surgical reevaluation until more
than two years after the x-ray showing the broken pins, despite requests for
treatment from Hathaway and advocates on his behalf. Id.
We concluded that, based on the facts as alleged in the complaint, that the
plaintiff had plausibly alleged the defendants acted with deliberate indifference to
his serious medical need and that the plaintiff’s “federal rights [were] well-
established.” Id. at 67. If a jury were to find deliberate indifference, the doctor
would not be “entitled to qualified immunity because it would not be objectively
reasonable for him to believe his conduct did not violate [the plaintiff’s] rights.”
Id. at 69. In so concluding, we did not assess whether existing caselaw established
a specific right to treatment for pain caused by broken pins in the hip, or even
orthopedic pain more generally. Instead, we focused on the mere presence of
deliberate indifference to Hathaway’s serious medical needs, over a dissent
arguing otherwise. Id. at 71.
Likewise, in LaBounty v. Coughlin, we addressed the plaintiff’s claim that he
was exposed to asbestos while incarcerated and the defendants knowingly failed
to protect him from such exposure. 137 F.3d at 72. We concluded that the district

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21
court’s formulation of the right at issue—“to be free from crumbling asbestos”—
was too narrow. Id. at 74. In doing so, we said, “Such a restricted view of the right
conflates the specific conduct at issue with the defined right running afoul of this
Court’s recognition that a court need not have passed on the identical course of
conduct for its illegality to be ‘clearly established.’” Id. We then concluded that
“the right to be free from deliberate indifference, established in Estelle . . . best
encompasses the alleged conduct.” Id. That right was clearly established. Id. We
reaffirmed LaBounty’s holding a few years later in Warren v. Keane, 196 F.3d 330,
333 (2d Cir. 1999), which involved exposure to environmental tobacco smoke.
And in Collymore v. Krystal Myers, RN, we considered a claim that prison
officials failed for years to provide an incarcerated individual with adequate
medical care for painful infections and lesions on his scalp. 74 F.4th 22 (2d Cir.
2023). Noting that no Supreme Court or Second Circuit cases had held that “a
scalp condition causing painful open sores is a serious medical need,” the district
court dismissed Collymore’s claims as barred by officials’ qualified immunity. Id.
at 29–30. We reversed, emphasizing that “Eighth Amendment claims for the
deprivation of medical care are not analyzed body-part by body-part.” Id. at 30.
What was relevant was that Collymore had plausibly alleged “severe and
unmanaged pain.” Id. The “absence of precedents involving scalp infection” was

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22
irrelevant. Id. In so holding, we didn’t break new legal ground; rather, we applied
well-established Eighth Amendment law. Though the issue in Collymore was
whether the plaintiff suffered from a serious medical condition—a question that is
decidedly not at issue here—our observation that we don’t analyze qualified
immunity defenses to claims of deprivation of medical care “body-part by body-
part” applies with equal force in this context. Id.
And that’s where the majority gets it wrong. It analyzes the qualified
immunity question at the level of a specific diagnosis and course of treatment. As
reflected above, our Eighth Amendment caselaw doesn’t support that approach.
See also Vega v. Semple, 963 F.3d 259, 276–77 (2d Cir. 2020) (concluding that officers
weren’t entitled to qualified immunity in case involving radon exposure because a
prior precedent had concluded that exposure to environmental tobacco was
unconstitutional).
Nor do our sister circuits require such specificity. See, e.g., Pfaller v.
Amonette, 55 F.4th 436, 453 (4th Cir. 2022) (rejecting the notion that the precedent
on the precise illness is required because “requiring such specificity in the case of
a treatment provider’s decisions would allow a doctor limitless opportunity to
deny medical care unless the precise required treatment for a specific underlying
illness had been addressed by our Court”); Estate of Clark v. Walker, 865 F.3d 544,

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23
553 (7th Cir. 2017) (“For purposes of qualified immunity, [the Eighth Amendment
right to treatment for serious medical needs] need not be litigated and then
established disease by disease or injury by injury.”); Russell v. Lumitap, 31 F.4th
729, 737–38 (9th Cir. 2022) (“It is not necessary to have a case involving a heart
attack, a case involving appendicitis, or a case involving a bowel obstruction for a
§ 1983 claim based on one of those conditions to survive qualified immunity.”);
Murray v. Department of Corrections, 29 F.4th 779, 790 (6th Cir. 2022) (“Courts have
frequently rejected officials’ contentions that a legal duty need be litigated and
then established disease by disease or injury by injury.”).
The majority’s reliance on Taylor v. Barkes to support its treatment-specific
framing of the issue here is misplaced. Maj. Op. at 16, 21, 25. In Taylor, the
defendants had not personally interacted with the incarcerated individual who
took his life; at issue was the adequacy of their generic suicide-screening measures
for all incarcerated individuals. 575 U.S. at 824. The Court concluded that
qualified immunity applied because there was no caselaw identifying what
minimum procedures a prison had to use to screen individuals for suicidality. Id.
at 826–27.
Had the prison officials in Taylor failed to act after knowingly engaging with
an actively suicidal inmate, the analysis would have been completely different.

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See, e.g., Troutman v. Louisville Metro Department of Corrections, 979 F.3d 472, 482
(6th Cir. 2020) (“Inmates do not have a guaranteed Eighth Amendment right to be
screened correctly for suicidal tendencies, however, prison officials who have been
alerted to a prisoner’s serious medical needs [including suicidality] are under an
obligation to offer medical care to such a prisoner.”) (emphasis added)); Smith-
Dandridge v. Geanolous, 97 F.4th 569, 575–76 (8th Cir. 2024) (concluding that
“deliberate indifference to serious medical needs” includes “the risk of suicide,”
and assessing whether defendants in that case knew individual was at substantial
risk for suicide); Short v. Hartman, 87 F.4th 593, 613 (4th Cir. 2023) (“An officer’s
failure to act if they demonstrably knew or had reason to know that a suicide was
imminent constitutes deliberate indifference.”). The majority’s suggestion that
Taylor abrogates the principle that prison officials act with deliberate indifference
when they are aware of a prisoner’s serious medical needs and fail to take action,
and its suggestion that Taylor calls for a diagnosis-by-diagnosis or treatment-by-
treatment analysis, stretches that decision far beyond its context and analysis.
When prison medical providers know that an incarcerated individual
suffers from a serious medical condition, they are obliged to conduct an
individualized assessment and provide adequate care—not necessarily the best
care, or the care the individual would prefer—but reasonable care. See Farmer v.

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25
Brennan, 511 U.S. 825, 832 (1994) (stating that the Eighth Amendment “imposes
duties” on prison officials including “ensur[ing] that inmates receive adequate . . .
medical care”); Kosilek v. Spencer, 774 F.3d 63, 91 (1st Cir. 2014) (en banc) (stating
that a ban on certain treatments for gender dysphoria would “conflict with the
requirement that medical care be individualized based on a particular prisoner’s
serious medical needs”). That’s true whether the condition is ongoing hip pain
caused by broken hardware from a prior surgery, Hathaway, 37 F.3d at 65, a painful
scalp condition, Collymore, 74 F.4th at 30, a heart attack, appendicitis or a bowel
obstruction, Russell, 31 F.4th at 737–38, or any other serious health condition.
There is no exception to this well-established constitutional obligation if the
serious medical condition happens to be gender dysphoria.
B. Blanket Policies or Total Inaction versus Considered Medical Decisions
The majority’s analysis misses another key feature of the applicable caselaw:
the distinction between a challenge to a prison official’s considered medical
judgment on the one hand, and one to an official’s wholesale failure to act, or
action in reliance on blanket policies rather than individual assessment, on the
other. This distinction flows from Estelle itself, which clearly distinguished
between “deliberate indifference to serious medical needs” of prisoners and
“negligen[ce] in diagnosing or treating a medical condition.” 429 U.S. at 106.

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The caselaw involving medical care for incarcerated transgender
individuals bears out this distinction. First are cases, like this one, involving
wholesale failure to provide relevant medical care, often based on blanket policies
that are not anchored in accepted medical standards.8
The most prominent example is the Seventh Circuit’s decision in Fields v.
Smith, 653 F.3d 550 (7th Cir. 2011). In Fields, the Seventh Circuit concluded that
enforcement of a statutory blanket prohibition of hormone therapy and gender
affirming surgery for transgender inmates would constitute deliberate
indifference to inmates’ serious medical needs. Id. at 559. That court explained,
“Just as the legislature cannot outlaw all effective cancer treatments for prison
inmates, it cannot outlaw the only effective treatment for a serious condition like
[gender identity disorder].” Id. at 557; see also Roe v. Elyea, 631 F.3d 843, 859 (7th
8 The majority tries to situate this case outside of the wholesale failure to act category, asserting
that Clark received a progression of care from “talk therapy, medication for depression, and later,
hormone therapy.” Maj. Op. at 20. The majority thus argues that there was never a failure to
treat Clark for gender dysphoria. Id. The record belies that claim. Valletta himself explained that
he would not provide treatment for the Clark’s gender dysphoria because a policy barred
initiation of “transitional treatment” for inmates who first present with gender dysphoria while
incarcerated. Dist. Ct. Dkt. No. 133-19 at 27 (September request). And generic talk therapy and
depression medications are no more meaningful treatment for the severe gender dysphoria Clark
exhibited than they would be for a palpable breast lump or a broken leg.

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27
Cir. 2011) (explaining that “inmate medical care decisions must be fact-based with
respect to the particular inmate” rather than the product of categorical rules).
The Ninth Circuit addressed a similar circumstance in which defendants
responded to a transgender inmate’s medical needs by applying a blanket policy
not grounded in accepted medical standards. Rosati v. Igbinoso, 791 F.3d 1037 (9th
Cir. 2015). The court concluded that the plaintiff, who had been denied any
evaluation by a gender dysphoria specialist, plausibly alleged a deliberate
indifference claim. Id. at 1039–40. See also Colwell v. Bannister, 763 F.3d 1060, 1063
(9th Cir. 2014) (holding that the “blanket, categorical denial of medically indicated
surgery solely on the basis of an administrative policy . . . is the paradigm of
deliberate indifference”); Hoptowit v. Ray, 682 F.2d 1237, 1252–53 (9th Cir.
1982) (“Access to the medical staff has no meaning if the medical staff is not
competent to deal with the prisoners’ problems.”), abrogated on other grounds
by Sandin v. Conner, 515 U.S. 472 (1995).
The Fourth Circuit addressed a similar situation in De’lonta v. Johnson, 708
F.3d 520 (4th Cir. 2013). There, the plaintiff, like Clark here, had engaged in self-
mutilation in an effort to self-treat her gender dysphoria. Id. at 522. The
defendants did provide her some treatment directed specifically at her gender
dysphoria. Id. But they declined to refer her for evaluation for surgery despite

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28
evidence that the treatments they were providing were not mitigating her distress.
Id. at 522–23. There is no indication that the failure to refer was driven by a
considered medical judgment; to the contrary, the only medical evidence
supported her request for further evaluation. The Fourth Circuit concluded that
the plaintiff had plausibly alleged deliberate indifference, and it reversed the
district court’s dismissal of the plaintiff’s Eighth Amendment claims. Id. at 526. In
reaching this conclusion, the court emphasized, “[J]ust because [the defendants]
have provided [the plaintiff] with some treatment consistent with the [gender
identity disorder] Standards of Care, it does not follow that they have necessarily
provided [the plaintiff] with constitutionally adequate treatment.” Id.
The majority contends some of these cases are irrelevant because they arise
from a different procedural posture. But the majority does not even attempt to
explain how the policy Valletta enforced is in any way materially different from
the blanket prohibition of hormone therapy and gender affirming surgery for
transgender inmates that constituted deliberate indifference to inmates’ serious
medical needs in Fields, 653 F.3d at 559.
In marked contrast to these cases are those in which an incarcerated
individual challenges a considered medical decision by prison medical providers.
For example, in Campbell v. Kallas, the Seventh Circuit extended qualified

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immunity to prison officials who made a considered medical decision to deny the
plaintiff’s request for gender affirming surgery. 936 F.3d 536 (2019). In that case,
after the plaintiff raised her gender identity concerns with a prison psychologist,
the prison’s Gender Dysphoria Committee, which was responsible for handling
medical treatment of transgender inmates, hired a gender dysphoria expert to
evaluate the plaintiff. Id. at 540. The expert diagnosed the plaintiff with gender
dysphoria and recommended that the plaintiff start hormone therapy and be given
lifestyle accommodations but didn’t recommend gender affirming surgery. Id. at
540–41. The Committee adopted the specialist’s recommendations and the
plaintiff received the recommended care. Id. at 541. The plaintiff subsequently
filed several requests for gender affirming surgery. Id. The Committee continued
to consult with the retained expert, who concluded that the plaintiff could be a
candidate for surgery, but that the conditions of incarceration supported more
conservative approaches. Id.
Framing the inquiry as “whether then-existing caselaw clearly established a
constitutional right to gender-dysphoria treatment beyond hormone therapy,” the
Seventh Circuit concluded that the defendants were entitled to qualified
immunity. Id. at 546–47. Specifically, the court said it wasn’t clearly established
“that medical professionals violate the Eighth Amendment when they provide

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hormone therapy but decide—after extensive deliberation and consultations with an
outside expert—to deny sex-reassignment surgery.” Id. at 547 (emphasis added).
The court distinguished its decision in Fields by emphasizing that in that case
“prison officials refused to provide any treatment for [a] serious disease[] based
solely on categorical rules.” Id. In contrast, in Campbell, the prison officials
“consulted an expert in the field and, facing a gray area of professional opinion,
decided to deny the ‘last and most considered step’ of gender-dysphoria
treatment.” Id.
The First Circuit similarly concluded that prison officials didn’t violate the
Eighth Amendment when they declined to authorize gender affirming surgery in
addition to the hormone therapy and mental health treatment the transgender
inmate was receiving. Kosilek, 774 F.3d at 67. The Kosilek court recounted the
extensive medical assessments that led to the officials’ decision. Id. at 69–82. And
it emphasized that the officials were presented with two treatment plans
developed by medical experts and “reasonably commensurate with the medical
standards of prudent professionals,” and they chose the plan that conflicted with
the plaintiff’s requests. Id. at 90. In so concluding, it stressed that any blanket
policy regarding gender affirming surgery “would conflict with the requirement

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that medical care be individualized based on a particular prisoner’s serious
medical needs.” Id. at 91.
Similarly, in Lamb v. Norwood, the challenged treatment decision resulted
from informed medical judgment, not a blanket policy or mere failure to act. 899
F.3d 1159, 1162–63 (10th Cir. 2018) (“Lamb II”). In that case, a transgender inmate
was receiving weekly counseling and hormone therapy. Id. She wanted different
hormone dosages and surgery. Id. The prison’s medical director and a panel of
practitioners that included specialists in psychiatry and behavioral psychology
concluded the treatment plan was appropriate. Lamb v. Norwood, 262 F. Supp. 3d
1151, 1157 (D. Kan. 2017) (“Lamb I”). The Tenth Circuit held that the defendants
were entitled to qualified immunity for their informed judgment. Lamb II, 899 F.3d
at 1162–63.9
9 In Gibson v. Collier, the Fifth Circuit held that “a state does not inflict cruel and unusual
punishment by declining to provide [gender confirming surgery] to a transgender inmate.” 920
920 F.3d 212, 215 (5th Cir. 2019). It did so on the pro se incarcerated plaintiff’s “sparse record,”
which only included the WPATH Standard of Care and was devoid of “witness testimony or
evidence from professionals in the field.” Id. at 220–21. Its categorical holding is based on the
premise that “[t]here is no medical consensus that [gender conforming surgery] is necessary or
even effective treatment for gender dysphoria.” Id. at 223. In other words, it concludes that
because medical professionals may disagree generally about the most effective course of
treatment for gender dysphoria, a prison official’s decision to deny that treatment can never
violate the Eighth Amendment. That decision is out of step with every other court to address the
issue—none of which conclude that Eighth Amendment mandates a specific treatment, but all
conclude that incarcerated persons are entitled to an informed, adequate care based on an
individualized assessment of their serious medical needs.

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The critical question driving the analysis in all of these cases is not whether
the plaintiff sought a particular treatment—be it counseling, hormone therapy, or
surgery. The critical question is whether the challenged medical decision was the
product of a blanket policy divorced from applicable medical standards, or an
individualized assessment consistent with prevailing medical standards. That’s
why the Seventh Circuit’s respective decisions in Fields and Campbell are entirely
consistent.
In this case, there was no reasoned medical decision to deny Clark any
informed assessment of her gender dysphoria—including evaluation by an
endocrinologist for possible hormone treatment—for over a year. There was no
Gender Dysphoria Committee consulting with a qualified expert, Campbell, 936
F.3d at 540; there were no extensive medical assessments leading to two competing
treatment plans “reasonably commensurate with the medical standards of
prudent professionals,” Kosilek, 774 F.3d at 90; and there was no medical
evaluation by a medical director and a panel of practitioners that included
specialists in psychiatry and behavioral psychology, Lamb I, 262 F. Supp. 3d at
1157. There was simply Valletta’s and Kimble-Goodman’s blanket refusal to
pursue any treatment directed at Clark’s gender dysphoria for over a year despite
her evident anguish, purportedly pursuant to an across-the-board policy, and then

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Valletta’s utter refusal to follow up with the recommended treatment for more
than a year and a half after that, despite multiple blood tests revealing that the
hormone dosages were ineffective.
The cases relied upon by the majority do not support its position. This case
falls squarely in the camp of the likes of Fields, Rosati and De’lonta. And the
outcome is governed by our decision in Hathway in which we explained, “A jury
could infer deliberate indifference from the fact that [the defendant] knew the
extent of [the plaintiff]’s pain, knew that the course of treatment was largely
ineffective, and declined to do anything more to attempt to improve [the
plaintiff]’s situation.” 37 F.3d at 68. If Valletta and Kimble-Goodman are found
deliberately indifferent, they would not be “entitled to qualified immunity
because it would not be objectively reasonable for [them] to believe [their] conduct
did not violate [Clark’s] rights.” Id. at 69.
Moreover, even if the proper focus in the cases was the specific treatments
provided rather than whether the treatment decisions were informed by medical
judgment consistent with prevailing professional standards, the plaintiffs in all
three of the above cases relied upon by the majority—Kosilek, Campbell, and Lamb
II—received the hormone therapy that Clark was completely denied for over a
year following her anguished act of self-mutilation, and was effectively denied for

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twenty months after that. Again, that’s not the right way to look at these cases;
but even following the majority’s own flawed framework, there is scant caselaw
supporting the suggestion that denying medically indicated hormone therapy
cannot amount to deliberate indifference.10
* * *
Today, the majority creates a rule that shields prison officials from denying
inmates medical care unless and until courts have specifically concluded that an
inmate has the right to that specific treatment for that specific serious medical
condition. That requirement is at odds with the Supreme Court’s guidance, this
Court’s caselaw, and that of our sister circuits. And it transforms qualified
immunity into absolute immunity.
Of course, it’s possible that the majority’s decision is not intended to have
such an expansive impact. Perhaps it simply carves out a “gender dysphoria”
exception to the otherwise generally applicable rules governing deliberate
10 While the procedural posture of this appeal precludes consideration of Defendants’ expert’s
opinion, I note that even he concludes that Clark’s treatment was unreasonable. Dist. Ct. Dkt. No.
133-6 at 4 (describing Clark’s treatment as “far less than ideal” and “insufficient”); id. at 5
(explaining that Clark should have a gender therapist in addition to her general mental health
counseling); id. at 8 (“I agree with you that she did not have an adequate early response to her
endocrine treatment and she should have had much more careful medical attention than she was
getting.”); id. at 9 (agreeing that Clark’s requests for hormone treatment “were reasonable
requests made repeatedly”). The most Defendant’s expert does is create a dispute as to whether
gender affirming surgery was medically indicated—a question not raised in this appeal. There is
no basis in the record for suggesting that reasonable medical providers can disagree as to whether
the course of treatment Clark actually received—or the lack thereof—was adequate.

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indifference to serious medical needs and qualified immunity. After all, it’s hard
to imagine that I would be penning this dissent in a case where prison officials
declined to refer an inmate with a palpable lump in her breast for further tests or
an evaluation by someone with experience treating breast cancer. But that can’t
be. Everyone—including the defendants’ expert and defendants—concedes that
Clark suffers from a serious medical condition. And there is no principled basis
in the law for carving out an exception to the protections of the Eighth Amendment
for individuals suffering from one specific serious medical condition.
The majority’s approach here is damaging—it turns qualified immunity into
absolute immunity; makes it even more difficult for incarcerated individuals to
access the medical care they are constitutionally entitled to; and paves the way for
correctional facilities to deny care to an already marginalized community. For
these reasons, I respectfully dissent.

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