Michelle KOSILEK, Plaintiff, Appellee, v. Luis S. SPENCER, Commissioner of the Massachusetts Department of Correction, Defendant, Appellant, 774 F.3d 63

Opinion En Banc TORRUELLA, Circuit Judge. This case involves important issues that arise under the Eighth Amendment to the U.S. Constitution. We are asked to determine whether the district court erred in concluding that the Massachusetts Department of Correction (“DOC”) has violated the Cruel and Unusual Punishment Clause of the Eighth Amendment by providing allegedly inadequate medical care to prisoner Michelle Kosilek (“Kosilek”).

More precisely, we are faced with the question whether the DOC’s choice of a particular medical treatment is constitutionally inadequate, such that the district court acts within its power to issue an injunction requiring provision of an alternative treatment — a treatment which would give rise to new concerns related to safety and prison security.

After carefully considering the community standard of medical care, the adequacy of the provided treatment, and the valid security concerns articulated by the DOC, we conclude that the district court erred and that the care provided to Kosilek by the DOC does not violate the Eighth Amendment. We therefore reverse the district court’s grant of injunctive relief, and we remand with instructions to dismiss the case. I. Background This litigation has now spanned more than twenty years and produced several opinions of significant length. See Kosilek v.

Spencer, 889 F.Supp.2d 190 (D.Mass.2012) (“Kosilek II ”); Kosilek v. Maloney, 221 F.Supp.2d 156 (D.Mass.2002) (“Kosilek I ”). In light of the expansive record, we recite here only the facts necessary to clarify the issues on appeal. A. Michelle Kosilek Michelle Kosilek — born in 1949 as Robert Kosilek — is an anatomically male prisoner in her mid-sixties who suffers from gender identity disorder (“GID”) and self-identifies as a female.

In 1992 Kosilek was convicted of first-degree murder and sentenced to a term of life imprisonment without parole for the 1990 strangulation of her then-wife, Cheryl McCaul, whose body was found abandoned in the backseat of a vehicle at a local shopping mall. See Commonwealth v. Kosilek, 428 Mass. 449, 668 N.E.2d 808 (1996). While awaiting trial for McCaul’s murder, Kosilek twice attempted to commit suicide. She also once tied a string around her testicles in an attempt at self-castration, but removed the string when it became painful.

Since 1994, Kosilek has been housed at MCI-Norfolk, a medium security male prison in Massachusetts. Throughout the twenty-year duration of her incarceration at MCI-Norfolk, Kosilek has not attempted to harm herself. B. Kosilek I Kosilek first sued the DOC in 1992, alleging that its failure to provide direct treatment for her GID was a violation of the Eighth Amendment. At that time, Kosilek was receiving only “supportive therapy” to cope with the distress caused by her GID.

Kosilek initially sought both damages and injunctive relief requiring the DOC to provide her with sex reassignment surgery (“SRS”), although only her claim for injunctive relief survived to trial. The district court issued a decision in 2002, in which it concluded that Kosilek had proven the existence of a serious medical need and had shown that her then-current Treatment plan was inadequate. The court concluded, however, that the DOC was unaware that a failure to provide additional treatment to Kosilek might result in serious harm.

Moreover, it held that the DOC’s failure to provide treatment was rooted, at least in part, in “sincere security concerns.” As a result, the court ruled that the DOC was not in violation of the Eighth Amendment. Despite finding for the DOC, the district court’s opinion made clear that Kosilek required additional treatment for her GID, and that the DOC would need to develop and implement an improved treatment plan.

The court warned that a failure to provide treatment in the future, now that the DOC was on notice of the potential for harm if only “supportive therapy” was provided, could amount to an Eighth Amendment violation. C. The DOC offers treatment The DOC responded to Kosilek I by revamping its policy for GID treatment. In the past, the DOC had adopted a policy of “freezing” a prisoner’s treatment at whatever level that prisoner had attained prior to incarceration. Hormonal treatment, for example, would be available only to prisoners who had been prescribed hormones prior to incarceration.

In place of this “freeze-frame” policy, after Kosilek I the DOC adopted a plan that allowed prisoners to receive additional treatment beyond the level of that received before entering prison, when such care was medically required. Under this new plan, medical recommendations would be made by the University of Massachusetts Correctional Health Program (“UMass”), a health-services provider contracted by the DOC. The DOC Commissioner and the DOC Director of Health Services were responsible for assessing whether any change in treatment would create increased security concerns. Kosilek was evaluated by Dr.

David Seil, a gender-identity specialist, who pre-scribfed a course of treatment to alleviate the mental distress- — often referred to as “dysphoria” — associated with her GID. In line with Dr. Seil’s recommendations, in 2003 the DOC began providing Kosilek with significant ameliorative treatment aimed at directly addressing the mental distress caused by GID. In addition to continued mental health treatment, she was provided female, gender-appropriate clothing and personal effects, and electrolysis was performed to permanently remove her facial hair.

Kosilek also began a course of hormonal treatments recommended by an endocrinologist. These treatments resulted in “breast development and shrinkage of her testicles.” All of the treatments described continue to be offered to Kosilek to the present day. D. Consideration of SRS In line with the Harry Benjamin Standards of Care (the “Standards of Care” or “the Standards”), Dr. Seil recommended that Kosilek be considered for SRS after one year of hormonal treatment. Accordingly, in 2004 the DOC began the process of finding an appropriate professional to evaluate Kosilek’s eligibility for, and the necessity of, SRS.

At the DOC’s Executive Staff Meetings there was some debate regarding who should be hired to conduct this evaluation. The UMass Mental Health Program Director, Dr. Kenneth Appelbaum, suggested that the DOC consult with the Fenway Community Health Center (the “Fenway Center”). The Fen-way Center is a Boston-based facility focused on serving the lesbian, gay, bisexual, and transgender community.

In contrast, the DOC’s Director of Mental Health and Substance Abuse Services, Gregory Hughes (“Hughes”), suggested consulting with Cynthia Osborne (“Osborne”), a gender identity specialist employed at the Johns Hopkins School of Medicine who had experience working with other departments of correction regarding GID treatment. Hughes expressed concern with using the Fenway Center because of “the perception that their approach was to come out with recommendations that globally endorsed a full panoply of treatments.” It was thought that Osborne, in contrast, “may do more objective evaluations.” Dr.

Appelbaum noted, however, that the Fen-way Center’s approach was, to his knowledge, probably “more the norm than the exception.” The DOC also recognized that having a Boston-based treatment provider might more easily facilitate the process of Kosilek’s evaluation. The Fenway Center was retained by the DOC, and Kosilek was evaluated by Kevin Kapila, M.D., and Randi Kaufman, Psy.D., in a ninety-minute interview. Drs. Kapila and Kaufman also reviewed Kosilek’s medical records. On February 24, 2005, they issued a report recommending that Kosilek receive SRS (the “Fenway Report”).

The Fenway Report acknowledged Kosilek’s positive response to the treatment provided by the DOC. Her joy around being feminized through hormone therapy, facial and body hair removal, and her ability to have access, and to dress in, feminine attire and make-up is palpable. These responses further suggest that being able to express herself as female has been helpful in alleviating her gender,dysphoria.... [I]t is clear that her increasingly feminine presentation hás been beneficial to her psychologically.

Nonetheless, it also emphasized that Kosi-lek remained significantly distressed by “having male genitalia, as well as not having female genitalia.” In light of this continuing distress, the Fenway Center doctors stated that “it is quite likely that Michelle will attempt suicide again if she is not able to change her anatomy.” The report also concluded that Kosilek had fully progressed through the Standards of Care’s triadic sequence, and that she “appear[ed] to be ready” for SRS.

SRS, the doctors believed, would most likely “allow Michelle to have full relief from the symptoms of gender dysphoria” and would quite possibly “increase her chance for survival” by greatly decreasing the potential for future suicidal ideation. The Fenway Report was received by the DOC and reviewed by Dr. Appelbaum and his UMass colleague, Dr. Arthur Brewer.

The UMass doctors informed the DOC that they found no clear contraindications to SRS, but noted that they were “unaware of any other case in which an inmate has undergone sex reassignment surgery while incarcerated.” After considering the information from UMass, the DOC decided to have Osborne conduct a peer review of the Fenway Report. In a letter to Osborne, the DOC stated that it was requesting her services because “[t]he treatment of Gender Identity Disorder within a correctional environment is a complicated issue and one that the Department takes very seriously.

We are aware of the substantial expertise you possess in this area and hope that you can provide us with assistance in determining appropriate treatment.” On April 12, 2005, the DOC sent Osborne copies of all previous medical evaluations of Kosilek. On April 28, 2005, the DOC Director of Health Services, Susan Martin (“Martin”), wrote UMass, stating her concern' that UMass had not “address[ed] the lack of detail, clarity and specific recommendations in the evaluation done by the Fenway Clinic,” and had failed to provide an independent recommendation as to the appropriateness of surgery.

She also asked for specific logistical information, including a list of doctors who might provide the surgery, what procedures would be performed, and what recovery time could be expected. On May 10, 2005, Drs. Appelbaum and Brewer replied, indicating that they deferred to the Fenway Center’s recommendation of surgery, as they were not experts in the area of SRS — a medical procedure specifically excluded from their contract to provide services to the DOC. They provided a preliminary list of surgeons to consider, none of whom were licensed to practice medicine in Massachusetts.

On May 20, 2005, Osborne finished her peer review of the Fenway Report. She began by making clear that her review was limited to reading and evaluating the reports of others. As a result, she could not independently diagnose Kosilek, but she agreed with the conclusion that Kosilek suffered from GID. Still, she disagreed with what she believed to be a lack of comprehensiveness in the report and an inclination to minimize the possibility of comorbid conditions.

Namely, Osborne highlighted that Kosilek had previously been diagnosed with Antisocial Personality Disorder, a diagnosis neither confirmed nor denied by the Fenway Report, and that the report included no indication that Kosilek had been assessed for other pathologies likely to lead to self-harming behavior. Osborne expressed belief that threats of self-harm or suicide should serve as a contraindication to surgery, and that such threats were not a valid or clinically acceptable justification for surgery.

In consequence, she disagreed with the Fenway Center’s statements that surgery was medically necessary as a means to diminish the likelihood that Kosilek would attempt suicide in the future.

Osborne’s report also highlighted that the Standards of Care admit of flexible application, and noted that the Standards state that “the diagnosis of GID invites the consideration of a variety of therapeutic options, only one of which is the complete therapeutic triad.” She emphasized that “[tjhere is currently no universal professional consensus regarding what constitutes medical necessity in GID.” In reference to the Standards of Care’s application in a penological setting, Osborne noted that the Standards of Care include a criterion that candidates for SRS exhibit “satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality.” She believed that this requirement was inherently in conflict with the Standard’s application to incarcerated persons, as she felt incarceration indicated a lack of mastery over such antisocial leanings.

Moreover, Osborne noted that non-incarcerated individuals often face external constraints in their choice of treatments or determine, as a result of their “real life experience,” that other, non-invasive treatments are personally preferable to SRS. In consequence, she felt that it was unrealistic for inmates to expect “that prison life [would] provide no constraints or obstacles to cross gender preferences” and that it was “outside[] the bounds of good clinical practice” for care providers to try to meet this expectation.

Given the isolation attendant to incarceration, Osborne also emphasized that prisoners might often lack awareness of the frequency with which individuals choose alternative treatments over SRS. After considering Osborne’s peer review, Martin again reached out to the doctors at UMass.

On May 25, 2005, she expressed continuing concern with the Fenway Report, highlighting that Osborne’s peer review had raised at least three questions regarding the report’s thoroughness: (1) why the report omitted consideration of potential comorbidities; (2) why the report did not rely on formal psychological testing, but only an in-person interview; and (3) why Kosilek’s claims that she would likely seek to end her life if not provided with SRS were seen to justify, rather than serve as a contraindication to, surgery.

Martin also expressed dissatisfaction that “the February 24, 2005 evaluation by the Fenway Clinic does not indicate whether sex reassignment surgery is a medical necessity for Michele [sic] Kosilek” and “fails to adequately address the issue of whether the current treatment provided to Kosilek provides sufficient relief of the symptoms of gender dysphoria.” A response from Drs. Appelbaum and Brewer came on June 14, 2005. The doctors made clear that they were not experts in the treatment of GID, and that they deferred to the Fenway Center’s treatment recommendation.

Referring to the differences between the preferred treatment plans of the Fenway Center and Osborne, the doctors reminded Martin that Osborne’s report had emphasized the “dearth of empirical research upon which to base treatment decisions” for GID and had highlighted the lack of “professional consensus” regarding the “medical necessity” of SRS. The Fenway Center issued a follow-up report aimed at answering Osborne’s critique of its initial recommendation. In this report, Drs.

Kapila and Kaufmann noted that suicidal ideation was common among individuals suffering from GID, and that it often decreased with the provision of care. Therefore, the likelihood that Kosilek would become suicidal if denied surgery was, to the doctors, not a contraindication to her eligibility, but instead was a symptom that could be alleviated by provision of SRS.

The doctors also disagreed with Osborne’s belief that incarceration was a significant contraindication to surgery, noting that the Standards of Care specifically state that “[pjersons who are receiving treatment for [GID] should continue to receive appropriate treatment ... after incarceration. For example, those who are receiving psychotherapy and/or cross-sex hormonal treatments should be allowed to continue this medically necessary treatment. ...” The Fenway Center doctors further discussed their belief that a key step of the triadic sequence, the “real-life experience,” could occur in prison.

This treatment prerequisite requires that an individual live full-time in their preferred cross-gender role for at least one year prior to being deemed eligible for SRS. The purpose of this requirement is ensure that GID patients have an opportunity to experience a full measure of life in a cross-gender role, including the social scrutiny that may arise among professional counterparts and peers.

Prison, the Fenway Center’s doctors surmised, might be considered a “more stringent” real-life experience, because a prisoner’s gender presentation would be subject to full-time monitoring by prison personnel and other inmates. The report concluded by reiterating the Fen-way Center’s recommendation that Kosilek receive SRS. The doctors recognized that performing “such a procedure would ... bring up issues of housing and safety,” but emphasized that “hormone therapy and [SRS] are the only clinical treatments found to be effective for GID.” E.

The DOC’s Security Report On April 25, 2005, the district court issued an order requiring that the DOC conduct a review of any potential safety and security concerns arising from the provision of SRS. In the next month, the DOC worked to formalize its security concerns into a report, which it eventually submitted to the court on June 10, 2005. As made clear by the minutes of the DOC’s staff meetings, however, these security issues were a topic of discussion prior to the court’s order.

Previously, on January 5, 2005, the meeting attendees had discussed how and if Kosilek’s prior violent acts against her wife should impact their evaluation and treatment plan. On April 20, 2005, the parties discussed potential security concerns that would arise should Kosilek be housed, post-surgery, in MCI-Framingham, Massachusetts’ only female prison. During that meeting, DOC personnel noted that they were prepared to provide an evaluation of general climate and security concerns implicated by the provision of surgery.

On May 19, 2005, DOC Commissioner Kathleen Dennehy (“Dennehy”) convened a meeting with the Superintendent of MCI-Norfolk, Luis Spencer (“Spencer”), and the Superintendent of MCI-Framing-ham, Lynne Bissonnette (“Bissonnette”), as well as the DOC’s legal counsel. The purpose of this meeting was to formally discuss the security concerns previously expressed by both superintendents in phone conversations with Dennehy. It was also an opportunity to begin preparation of the report requested by the district court. The report focused mainly on issues of safety and security surrounding Kosilek’s post-operative housing.

Dennehy conveyed concern regarding housing Kosilek at MCI-Norfolk, noting that approximately twenty-five percent of male offenders in the Massachusetts prison system are classified as sex offenders and concluding that “Kosilek would clearly be a target for assault and victimization in a male prison.” The report also expressed concerns with housing Kosilek at MCI-Framingham, including the absence of single-bed cells, such that all inmates had to share cells, and the possibility that Kosilek’s presence might exacerbate mental distress among the significant portion of MCI-Framing-ham’s population that had previously experienced domestic abuse and trauma at the hands of male partners.

Given the stated infeasibility of housing Kosilek in the general population of either MCI-Framingham or MCI-Norfolk, the report considered segregated housing in a protected ward. It expressed concern, however, about the possible deleterious impact on Kosilek’s mental health caused by any housing solution that required long-term isolation. The report also noted that it was not within the DOC’s ability to create a special ward for prisoners with GID, given that these prisoners present a significant range of criminal histories, security ratings, and treatment needs that are antithetical to co-housing.

On June 10, 2005, citing both its internal review of safety and security and Osborne’s reported concerns regarding the appropriateness of SRS, the DOC informed the district court that it had chosen to continue Kosilek’s current ameliorative treatment, but not to provide her with SRS. F. Kosilek II Trial commenced on May 30, 2006, with what would be the first of three rounds of testimony. For the sake of clarity and concision, we summarize this testimony topically, rather than temporally. We begin with evidence regarding the standard of care for treatment of GID. 1. Testimony related to medical necessity a.

Initial testimony First to testify in 2006 was an expert witness for Kosilek, Dr. George Brown, who had previously evaluated Kosilek in 2001 and was an author of the Standards of Care. Prior to testifying, Dr. Brown issued a written report assessing Kosilek’s readiness for surgery and evaluating her current mental and physical presentation, as compared with 2001. Dr.

Brown noted that Kosilek consistently presented as female and that “[ajccess to makeup and female undergarments, laser hair removal, along with hormonal treatments ... have all seemed' to significantly reinforce and consolidate the outward expression of [Ko-silek’s] gender identity as female.” Other positive effects of treatment were also described: Hormonal treatments have resulted in obvious breast growth since my last assessment, decrease in upper body strength, increase in hip size, changes in amount and texture of body hair, skin texture changes, testicular volume decrease, and a large reduction in spontaneous erections....

Psychologically, the effects of these combined treatments have [included] ... resolution of depression, resolution of suicidality and suicide gestures and attempts, improved mood with reduction in irritability, anxiety, and depression.... Based on his observations, Dr. Brown concluded that Kosilek was eligible for SRS, having met all of the readiness criteria. Before the court, Dr. Brown’s testimony emphasized that the provision of female clothing and effects, hair removal, and hormones had resulted in a lessening of “the severity of [Kosilek’s] dysphoria.” According to Dr.

Brown “[s]he was clearly less depressed, less anxious, less irritable.... She was not suicidal....” Despite these significant improvements, Dr. Brown testified that he believed SRS to be an appropriate and “medical[ly] necessary component” of Kosilek’s treatment. He related instances in which incarcerated persons who could not complete the triadic sequence exhibited an increase in negative symptoms, including a resurgence of self-harming behavior. Dr. Brown further testified that, if not granted surgery, he believed Kosilek’s feelings of “hopelessness will intensify,” and that she would likely attempt suicide.

In reaching this conclusion, Dr. Brown emphasized that “other parts of the treatment plan [e.g., hormones, hair removal, and the provision of female clothing] ... all contribute in their own way to a level of improvement.” Nonetheless, he felt that, if Kosilek lost hope of receiving SRS, her current treatment plan would not stop a deterioration of her mental state and the possible reemergence of suicidal ideation. Dr. Kaufman from the Fenway Center also testified, reiterating that the Fenway Center believed SRS to be an appropriate and medically necessary step in Kosilek’s treatment.

She further stated her belief that, if not given surgery, Kosilek would present a significant risk of suicide: “if she’s not able to have surgery, I think that she’ll be hopeless and feel helpless and at that point really will have nothing else to live for.” Next to testify was Mark Burrows (“Burrows”), who had been Kosilek’s treating psychiatrist for approximately five years. Burrows testified to Kosilek’s strong desire for SRS, and to her feelings of hope associated with completing the formalization of her gender presentation.

Burrows also stated that denying surgery would likely have a negative impact on Kosilek’s mental health. He believed that it was “slightly” “more probable than not” that a denial of the surgery would result in Kosilek attempting to commit suicide. Burrows also spoke about his belief that, if given SRS, Kosilek should not continue to reside at MCI-Norfolk, as “the risks involved in her possibly being assaulted are obvious.” Dr. Appelbaum of UMass was also called as a witness for Kosilek.

He testified as to UMass’s trust in the Fenway Center’s recommendations, and to his belief that the DOC need not have sought out a peer review of the Fenway Report, given the Fenway Center’s expertise in the treatment of GID. Kosilek testified next. She expressed the depth of her desire for SRS, and she stated that she would continue to experience mental anguish regarding her gender identity so long as she had male genitalia. If not provided with SRS, Kosilek said that she “would not want to continue existing [as an anatomical male]” and might instead attempt to commit suicide.

She disagreed with the suggestion that treatment short of SRS could adequately relieve her mental distress, stating that “[t]he problem is my genitals. That’s what needs to be fixed.” Kosilek also testified as to feeling discomfort in the all-male environment of MCI-Norfolk and having a strong desire to be transferred to MCI-Framingham. She felt that the inmates at MCI-Fram-ingham would be more accepting and welcoming of her than those at MCI-Norfolk. The DOC offered testimony from Dr. Chester Schmidt, a licensed psychiatrist and Associate Director of the Johns Hopkins School of Medicine. Dr.

Schmidt expressed his belief, that Kosilek had undergone an “excellent adaptation” through treatment with hormones, hair removal, psychotherapy, and the provision of female garb. These treatments had alleviated the severity of her mental distress and allowed Kosilek to significantly consolidate her gender identity. Dr. Schmidt acknowledged that, if not provided SRS, Kosilek’s level of mental distress would likely increase, with depression or attempts at self-harm possible.

On the whole, however, he believed that her positive adaptation and the consolidation of her gender identity indicated that the current course of treatment provided by the DOC was medically adequate. Dr. Schmidt explained that the severity of dysphoria associated with GID may “wax and wane,” with patients feeling depressed or hopeless at times, but generally being able to alleviate these depressive symptoms with appropriate psychotherapy and medical interventions.

He felt that these measures, in combination with Kosilek’s current course of treatment, would allow her to live safely and maintain a level of contentment. On cross-examination, Dr. Schmidt was questioned regarding his alleged rejection of the Standards of Care. Dr. Schmidt responded that he found the Standards of Care “very useful for patients” and that he commonly requested that patients familiarize themselves with these Standards when they began to seek care for SRS. Asked if he had stricter requirements for SRS eligibility than those in the Standards of Care, Dr.

Schmidt emphasized that he neither “advocate[s] for nor ... speak[s] against the decisions for the cross-gender hormones or eventually for surgery.” Rather, he believes such decisions are best made by the patient, based on their personal needs and desires. In line with this belief, Dr. Schmidt stated that he does not specifically recommend SRS, but at a patient’s request he will release medical files and send a letter indicating that a patient is ready for surgery to their chosen SRS provider. Dr.

Schmidt further testified that he viewed the Standards of Care as “guidelines.” He explained, however, that “[t]here are many people in the country who disagree with those standards who are involved in the [GID] field.” Because of this disagreement, Dr. Schmidt expressed hesitation to refer to the Standards of Care, or the recommendation for SRS, as medically necessary. He emphasized the existence of alternative methods and treatment plans accepted within the medical community.

He also questioned whether the Standards of Care’s requirement of a real-life experience could occur in prison, opining that the real-life experience required a range of social and vocational experiences unavailable within a penological setting. Osborne testified next, reiterating her agreement with Kosilek’s GID diagnosis, but disagreeing that SRS was a medically necessary treatment. In reference to the Standards of Care, Osborne testified that she fully agreed that SRS was an effective and appropriate treatment for GID.

She emphasized, however, that she did not' view SRS as medically necessary in light of “the whole continuum from noninvasive to invasive” treatment options available to individuals with GID. Regarding Kosilek personally, Osborne indicated that she believed Kosilek’s current treatment plan had been highly effective in allowing Kosi-lek to feel “hopeful, euphoric, and not depressed” about her gender identity. Osborne, like Dr.

Schmidt before her, again expressed skepticism as to whether a real-life experience could occur in jail, given that a single-sex environment necessarily limited the sorts of social and human interactions available. Osborne agreed that not providing Kosilek with SRS might give rise to possible suicidal ideation, but noted that the DOC had significant expertise in treating prisoners exhibiting self-harming behavior. She felt that Kosilek’s current treatment plan, in conjunction with protective measures aimed at ensuring her personal safety, was an appropriate and medically acceptable response to Kosilek’s GID. b.

The UMass report Following the close of initial testimony, the district court ordered UMass to review the testimony of all medical experts and to issue a report regarding whether the treatment proposed by Dr. Schmidt was an adequate method of treating Kosilek’s GID. In this report — submitted to the court on September 18, 2006 — Drs. Ap-pelbaum and Brewer made clear that they “worked with and relied upon Dr. Kapila and Dr. Kaufman” who “assisted] to prepare this response.” The report stated that the UMass doctors “have been informed by Dr. Kaufman and Dr.

Kapila that ... trial testimony ... confirms’ their opinion that Michelle Kosilek has a ‘serious medical need’ because there is a ‘substantial risk of serious harm if it is not adequately treated.’ ” In conclusion, the report reiterated that the Fenway Center believed Dr. Schmidt’s proposed treatment plan would not provide adequate care, and UMass endorsed that conclusion. c. The court-appointed expert At the conclusion of the first round of testimony, the district court decided to appoint an independent expert to assist in determining what constituted the medical standard of treatment for GID.

On October 31, 2006, with the parties’ input, the district court selected Dr. Stephen Levine, a practitioner at the Center for Marital and Sexual Health in Ohio and a clinical professor of psychiatry at Case Western Reserve University School of Medicine. Dr. Levine had helped to author the fifth version of the Standards of Care, and served as Chairman of the Harry Benjamin International Gender Dysphoria Association’s Standards of Care Committee. A month after his appointment, Dr. Levine issued a written report.

The report began by explaining the dual roles that WPATH — formerly the Harry Benjamin Association and the organization that wrote the Standards of Care-plays in its provision of care to individuals with GID: WPATH is supportive to those who want sex reassignment surgery (SRS)_Skepticism and strong alternate views are not well tolerated. Such views have been known to be greeted with antipathy from the large numbers of nonprofessional adults who attend each [of] the organization’s biennial meetings....

The [Standards of Care are] the product of an enormous effort to b'e balanced, but it is not a politically neutral document. WPATH aspires to be both a scientific organization and an advocacy group for the transgendered. These aspirations sometimes conflict. The limitations of the [Standards of Care], however, are not primarily political. They are caused by the lack of rigorous research in the field. Dr.

Levine further emphasized that “large gaps” exist in the medical community’s knowledge regarding the long-term effects of SRS and other GID treatments in relation to its positive or negative correlation to suicidal ideation. Dr. Levine next discussed the possibility of Kosilek having a real-life experience in prison.

He explained that the Fenway Center, in stating that a real-life experience could be had in prison, “failed to offer a mild caveat that the real life test was designed to test the patients’ capacity to function as a female in the community by mastering the demands of ... family, social relationships, educational accomplishment, [and] vocational performance.” Such experiences and relationships, Dr. Levine noted, are not a part of Kosilek’s daily life in prison. Dr. Levine’s final conclusion was that: Dr.

Schmidt’s view, however unpopular and uncompassionate in the eyes of some experts in GID, is within prudent professional community standards. Treatment stopping short of SRS would be considered adequate by many psychiatrists, gender team members, and gender patients themselves, if Kosilek were a citizen in the community.... [T]here are a number of acceptable community standards which derive from differing assumptions about disorders, their causes, and the possible effective interventions. He recognized that the different treatment plans advocated by Dr.

Schmidt and the Fenway Center “each ... [had] merit,” as well as limitations. . Dr. Levine further wrote that doctors generally “do not recommend treatment to GID patients.... The decision is [the patient’s], when and if they still want it.” Dr. Levine testified on December 16, 2006. He first reiterated his belief that Dr. Schmidt’s view, although not preferred by some GID specialists, was within “prudent professional standards.” He noted that Kosilek had received significant relief on her current treatment plan, and that many patients with GID live comfortably without completing the triadic sequence.

He believed that Kosilek had already successfully consolidated her gender identity, such that the removal of her male genitalia might relieve dysphoria, but it was not necessary to complete that consolidation. He also indicated variability and difficulty in forecasting depressive symptoms and self-harming behavior in GID patients.

He explained that he believed Kosilek would certainly express deep disappointment if denied SRS — described as the sole current focus of her life — but that coping mechanisms might well change her outlook in months and years to come, allowing her to live happily without the provision of SRS. The district court then asked Dr. Levine to narrow the lens of his inquiry by presuming that there were absolutely no external contraindications to surgery and that Kosilek had indeed had a real-life experience in prison. Given these presumptions, the court asked Dr.

Levine to testify as to whether it would still be prudent to not provide Kosilek with SRS. Dr. Levine acknowledged his belief that prudent professionals would generally not deny surgery to a fully eligible individual. Still, he hesitated to declare Dr. Schmidt’s approach medically unacceptable.

He answered that the provision of SRS would surely be a prudent course of treatment, but then stated that “I also believe it’s prudent not to give her Sex Reassignment Surgery for lots of reasons.” He again emphasized for the court that the treatment of GID was an evolving field, in which practitioners could reasonably differ in their preferred treatment methods. Dr. Levine explained that in many instances patients cannot or do not want to receive SRS, and prudent physicians commonly employ a range of treatments to ameliorate these patients’ dysphoria. d.

Additional rounds of testimony Several witnesses were recalled for additional testimony. Drs. Kapila and Kaufman appeared again on behalf of Kosilek. Both reiterated their belief that Kosilek had a serious medical need and that, given Kosilek’s high risk of suicide if denied the surgery, SRS was the only adequaté treatment plan. Dr. Appelbaum also testified again, as did the UMass Medical Director. Both UMass doctors reaffirmed their endorsement of the Fenway Center’s treatment recommendations. Kosilek also presented additional witness testimony from Dr.

Marshall For-stein, Associate Professor of Psychiatry at Harvard Medical School, who had previously evaluated Kosilek during Kosilek I. Dr. Forstein issued a written report, in which he noted that “the question of the most prudent form of treatment is complicated by the diagnosis of GID being on the margins of typical medical practice.” Despite this recognition, he testified that he believed SRS was necessary for Kosilek. He felt that, if she was not given SRS, there was a significant risk that Kosilek would attempt suicide or- self-mutilation. Although Dr.

Forstein believed that psychotherapy might “help with frustration, with harassment, and with depression,” he was uncertain whether Kosilek could ever fully “reconcile with being incompletely transitioned.” • 2. Testimony regarding safety and security concerns a. Initial testimony In line with the June 10, 2005, security report prepared by Commissioner Den-nehy, multiple DOC officials testified regarding the safety and security concerns that were likely to arise if Kosilek was provided SRS. First to testify was Spencer, who at that time served as Superintendent of MCI-Norfolk.

Spencer began by explaining the general layout and security measures at MCI-Norfolk. He also explained that the prison had, so far, successfully been able to accommodate Kosilek’s receipt of care without incident. Spencer was unaware of any issues or incidents of harassment related to Kosilek’s breast growth and increasingly feminine appearance.' He stated, however, that he would have significant concerns housing an anatomically female prisoner in MCI-Norfolk, an all-male prison.

Despite the lack of historical incidents specific to Kosilek, he emphasized that “inmates do get assaulted, inmates have been raped ... [a]nd putting a female in a correctional environment like MCI-Norfolk would be of high concern to me.” If Kosilek remained at MCI-Norfolk, Spencer testified that he believed she would only be safe if housed in the Special Management Unit, a highly restricted secure building separated from the general population.

Bissonnette, Superintendent of MCI-Framingham, also testified about the security concerns she believed would arise if Kosilek was transferred to the all-female prison after receiving SRS. She explained that MCI-Framingham does not have private cells, save for the segregation and medical units. All women in the general population are required to cohabitate, and that prison would be unable to provide a single-occupancy cell for Kosilek.

She also explained that Kosilek’s presence could create significant disruption in MCI-Framingham’s population, given that Kosi-lek had been convicted for violently murdering her wife, and that a significant portion of women at MCI-Framingham were victims of domestic abuse. Bissonnette acknowledged that there were procedures in place designed to help women cope with exposure to upsetting or traumatic experiences with other prisoners, but maintained that these security concerns would require that Kosilek, if transferred to MCI-Framingham, be housed in the segregated Close Custody unit.

Bissonnette explained that she had significant hesitation about incarcerating anyone long-term in the Close Custody unit, given the potential negative effects of such long-term segregation. Commissioner Dennehy also ■ testified. She described the security concerns arising from cross-gender housing as “obvious” to any experienced corrections officer.

In line with her belief that the safety and security concerns about post-operative housing were clear, Dennehy stated that she would not feel comfortable allowing SRS — even if mandated by the court — if she could not identify an adequate method of safely housing Kosilek after her operation. Dennehy reiterated Spencer’s and Bissonnette’s concerns, stating that she deeply trusted both Superintendents’ professional judgments regarding the security of housing Kosilek at their respective facilities. Dennehy also explained why reliance on an interstate compact to transfer Kosilek would be problematic.

She emphasized that other states take prisoners on a fully voluntary basis, and that no state may be willing or able to accommodate a transfer request for Kosilek. Commissioner Dennehy was also questioned about negative press surrounding the DOC’s possible provision of SRS to Kosilek. Specifically, she wa,s asked about her professional relationship with a state senator who had vocally opposed surgery and sponsored legislation to deny its provision. She was also asked about any contact with the then-lieutenant governor, who was another strong opponent of providing SRS to prisoners.

Dennehy stated that she was aware of negative press reports and political opposition surrounding Kosilek’s request, but that her decision not to provide SRS was based only on security concerns and had not been influenced by this public pressure. The district court recalled Dennehy on October 18, 2006, to ask additional questions regarding a growing amount of press coverage surrounding the case. Dennehy acknowledged that she was aware of significant news coverage of Kosilek’s case, but denied personally following the story in the media.

She explained that there were staff members within the DOC trained to deal with press inquiries and that she generally received only summaries of news coverage from her staff. Again, Dennehy strongly denied forming any opinion about correctional safety procedures based on media reports or public opinion. b. Commissioner Clarke Dennehy ended her tenure as DOC Commissioner on April 30, 2007, and in November 2007 the position was filled by Harold Clarke. After Clarke took over, the district court requested that he familiarize himself with a selected number of trial transcripts.

Clarke was ordered to file a report, on the basis of those transcripts, indicating whether he believed that the DOC had legitimate reasons to refuse Kosilek’s request for SRS. Clarke’s report, filed approximately a month after the district court’s order, stated that his conclusions were based on more than three decades of correctional experience and were not influenced by political or media pressure. He expressed concern regarding threats of suicide being used as a means for prisoners to receive wanted benefits or concessions from staff.

Finding it to be bad practice for prison administrators to give in to demands accompanied by the threat of suicide, Clarke stated that he believed the Massachusetts prison system had taken significant measures to ensure it was prepared to deal with suicidal ideation among its prison population. In addition to considering the issue of suicide, Clarke’s report reemphasized the significant post-operative security concerns expressed by his predecessor.

He stated that housing Kosilek at MCI-Norfolk created clear security concerns related to mixed-gender prison populations, while housing Kosilek at MCI-Framingham would pose a significant risk of destabilizing that environment, given the number of women prisoners who were victims of domestic violence. Clarke also stated his belief that a separate unit to house GID prisoners was not feasible, given that prisoners with GID might have a wide range of security classifications and security needs, making cohabitation unsafe.

In reference to the possibility of an interstate transfer, Clarke reiterated the concern that any interstate transfer would be completely voluntary and that a receiving state might later decide to return Kosilek, at which time the housing concerns would reemerge. Testifying before the court, Clarke acknowledged that he had received several letters from outraged state politicians claiming that provision of the surgery would be an “affront to the taxpayers” and citing state budget concerns as a reason to deny Kosilek surgery.

The letters argued that a strained state budget' should not be used to accommodate what the legislators believed to be an “elective” procedure and that the DOC would be “unwise” to provide it. Clarke, however, explained that he had not answered these letters, as he believed providing an answer would be inappropriate given his role as DOC Commissioner. He also denied being in any way influenced by cost concerns in reaching his conclusion regarding safety and security concerns.

Clarke similarly testified that he was aware of media coverage regarding Kosilek’s request, but he had not personally viewed the news or heard the radio stories. G. Kosilek II The district court issued an extensive opinion on September 4, 2012. This opinion concluded that Kosilek had a serious medical need and that-based on the court’s belief that Dr. Schmidt was not a prudent professional-the only adequate way to treat this need was through SRS.

Moreover, the court determined that the DOC’s stated security concerns were merely pre-textual and concluded that the DOC had in fact made its decision based on public and political pressure. This, the court concluded, amounted to deliberate indifference under the Eighth Amendment. Stating its belief that the DOC would continue to deny Kosilek adequate treatment in the future, the district court granted an injunction requiring that the DOC provide Kosilek with SRS. II. Discussion A.

The Eighth Amendment and Medical Care in Prison “Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.” U.S. Const, amend. VIII. From this brief amendment, courts have derived the principles that govern the permissible conditions under which prisoners are held and that establish the medical treatment those prisoners must be afforded. See Farmer v. Brennan, 511 U.S. 825, 832, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994).

Where “society takes from prisoners the means to provide for their own needs,” the failure to provide such care “may actually produce physical torture or a lingering death.” Brown v. Plata, — U.S.-, 131 S.Ct. 1910, 1928, 179 L.Ed.2d 969 (2011) (internal quotation marks omitted). Undue suffering, unrelated to any legitimate peno-logical purpose, is considered a form of punishment proscribed by the Eighth Amendment. Estelle v. Gamble, 429 U.S. 97, 103, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976).

The Eighth Amendment is meant to prohibit “unnecessary and wanton infliction of pain,” which is “repugnant to the conscience of mankind.” Id. at 105-06, 97 S.Ct. 285 (internal quotation marks omitted). The Amendment’s focus on pun.ishment means that not all shortages or failures in care exhibit the intent and harmfulness required to fall within its ambit. See Farmer, 511 U.S. at 837, 114 S.Ct. 1970 (reasoning that the Eighth Amendment’s prohibition of punishment implies

an act done with intentionality). Therefore, to prove an Eighth Amendment violation, a prisoner must satisfy both of two prongs: (1) an objective prong that requires proof of a serious medical need, and (2) a subjective prong that mandates a showing of prison administrators’ deliberate indifference to that need. See Estelle, 429 U.S. at 106, 97 S.Ct. 285 (holding that inadequate treatment must be “sufficiently harmful to evidence deliberate indifference to serious medical needs”); Sires v.

Berman, 834 F.2d 9, 12 (1st Cir.1987) (“A plaintiff must satisfy two elements to present a viable [Eighth Amendment] claim: he must show a serious medical need, and he must prove the defendant’s purposeful indifference thereto.”). First, a medical need must be “serious.” Id. This objective prong requires that the need be “one that has been diagnosed by a physician as mandating treatment, or one that is so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.” Gaudreault v. Municipality of Salem, Mass., 923 F.2d 203, 208 (1st Cir.1990).

This prong does not impose upon prison administrators a duty to provide care that is ideal, or of the prisoner’s choosing. See United States v. Derbes, 369 F.3d 579, 583 (1st Cir.2004) (stating that prison administrators are “by no means required to tailor a perfect plan for every inmate; while [they are] constitutionally obligated to provide medical ser vices to inmates, these services need only be on a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards” (internal quotation marks and citations omitted)); United States v.

DeCologero, 821 F.2d 39, 43 (1st Cir.1987) (same); Ferranti v. Moran, 618 F.2d 888, 891 (1st Cir.1980) (“[Ajllegations [that] simply reflect a disagreement on the appropriate course of treatment ... fall[ ] short of alleging a constitutional violation.”)- Rather, the Constitution proscribes care that is “ ‘so inadequate as to shock the conscience.’ ” Torraco v. Maloney, 923 F.2d 231, 235 (1st Cir.1991) (quoting Sires, 834 F.2d at 13).

Second, even if medical care is so inadequate as to satisfy the objective prong, the Eighth Amendment is not violated unless prison administrators also exhibit deliberate indifference to the prisoner’s needs. Estelle, 429 U.S. at 105-06, 97 S.Ct. 285. For purposes of this subjective prong, deliberate indifference “defines a narrow band of conduct,” Feeney v. Corr. Med. Servs. Inc., 464 F.3d 158, 162 (1st Cir.2006), and requires evidence that the failure in treatment was purposeful.

See Estelle, 429 U.S. at 105, 97 S.Ct. 285 (hold ing that “an inadvertent failure to provide adequate medical care” is not a constitutional violation); id. at 106, 97 S.Ct. 285 (“Medical malpractice does not become a constitutional violation merely because the victim is a prisoner.”); Watson v.

Caton, 984 F.2d 537, 540 (1st Cir.1993) (“The courts have consistently refused to create constitutional claims out of disagreements between prisoners and doctors about the proper course of a prisoner’s medical treatment, or to conclude that simple medical malpractice rises to the level of cruel and unusual punishment.”). “The obvious case would be a denial of needed medical treatment in order to punish the inmate.” Watson, 984 F.2d at 540. While deliberate indifference may also be exhibited by a “wanton disregard” to a prisoner’s needs, Battista v.

Clarke, 645 F.3d 449, 453 (1st Cir.2011), such disregard must be akin to criminal recklessness, requiring consciousness of “ ‘impending harm, easily preventable.’ ” Watson, 984 F.2d at 540. When evaluating medical care and deliberate indifference, security considerations inherent in the functioning of a penological institution must be given significant weight.

Battista, 645 F.3d at 454 (“[S]ecurity considerations also matter at prisons ... and administrators have to balance conflicting demands.”). “[W]ideranging deference” is accorded to prison administrators “in the adoption and execution of policies and practices that in their judgement are needed to ... maintain institutional security.” Whitley v. Albers, 475 U.S. 312, 321-22, 106 S.Ct. 1078, 89 L.Ed.2d 251 (1986) (quoting Bell v. Wolfish, 441 U.S. 520, 547, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979)) (internal quotation marks omitted).

In consequence, even a denial of care may not amount to an Eighth Amendment violation if that decision is based in legitimate concerns regarding prisoner safety and institutional security. Cameron v. Tomes, 990 F.2d 14, 20 (1st Cir.1993) (requiring courts to “embrace security and administration, ... not merely medical judgments” in assessing claims of deliberate indifference); Sires, 834 F.2d at 13 (“[S]afety factors are properly included in the evaluation of the medical needs of an inmate.”)- Importantly, prison administrators need only have “ ‘responded reasonably to the risk.’ ” Giroux v.

Somerset Cnty., 178 F.3d 28, 33 (1st Cir.1999) (quoting Farmer, 511 U.S. at 844, 114 S.Ct. 1970). B. Standard of Review The test for establishing an Eighth Amendment claim of inadequate medical care encompasses a multitude of questions that present elements both factual and legal. Review of such “mixed questions” is of a variable exactitude; the more law-based a question, the less deferentially we assess the district court’s conclusion.

In Re Extradition of Howard, 996 F.2d 1320, 1328 (1st Cir.1993) (“The standard of review applicable to mixed questions usually depends upon where they fall along the degree-of-deference continuum.... ”). The ultimate legal conclusion of whether prison administrators have violated the Eighth Amendment is reviewed de novo. See, e.g., Thomas v. Bryant, 614 F.3d 1288, 1307 (11th Cir.2010) (“Whether the record demonstrates that [the prisoner] was sprayed with chemical agents ... and that he suffered psychological injuries from such sprayings are questions of fact.

Whether these deprivations are objectively ‘sufficiently serious’ to satisfy the objective prong, is a question of law....” (internal citations omitted)); Hallett v. Morgan, 296 F.3d 732, 744 (9th Cir.2002) (“The district court’s factual findings regarding conditions at the Prison are reviewed for clear error. However, its conclusion that the facts do not demonstrate an Eighth Amendment violation is a question of law that we review de novo.” (citing Campbell v. Wood, 18 F.3d 662, 681 (9th Cir.1994) (en banc))); Hickey v.

Reeder, 12 F.3d 754, 756 (8th Cir.1993) (“Whether conduct, if done with the required culpability, is sufficiently harmful to establish an Eighth Amendment violation is an objective or legal determination which we' decide de novo.”); Alberti v. Klevenhagen, 790 F.2d 1220, 1225 (5th Cir.1986) (“[O]nee the facts are established, the issue of whether these facts constitute a violation of constitutional rights is a question of law that may be assayed anew upon appeal.”).

Subsidiary legal questions, such as whether an actor’s conduct amounted to deliberate indifference for purposes of the Eighth Amendment, are likewise reviewed de novo. Cf. Ornelas v. United States, 517 U.S. 690, 699, 116 S.Ct. 1657, 134 L.Ed.2d 911 (1996) (holding that, for Fourth Amendment purposes, reasonable suspicion and probable cause determinations should receive de novo appellate review); United States v. Camacho, 661 F.3d 718, 724 (1st Cir.2011) (we review de novo a district court’s subsidiary reasonable suspicion and probable cause determinations in evaluating a motion to suppress); United States v.

Bucci, 582 F.3d 108, 115-17 (1st Cir.2009). Our court awards deference to the district court's resolution of questions of pure fact and issues of credibility. See, e.g., DesRosiers v. Moran, 949 F.2d 15, 19 (1st Cir.1991) (reviewing factual findings regarding the adequacy of care deferentially); Torraco, 923 F.2d at 234 (finding that issues of culpability in a deliberate indifference inquiry are usually questions for a jury). We will reverse the district court’s findings on such factual questions only for clear error.

DesRosiers, 949 F.2d at 19 (“[W]e assay findings of fact in a bench trial only for clear error.”). We find clear error when we are left with “ ‘a strong, unyielding belief, based on the whole of the record,’ that the judge made a mistake.” In re O'Donnell, 728 F.3d 41, 45 (1st Cir.2013) (quoting Islamic Inv. Co. of the Gulf (Bah.) Ltd. v. Harper (In re Grand Jury Investigation), 545 F.3d 21, 24 (1st Cir.2008)). We may also find clear error when the district court commits an error of law that affects its fact-finding analysis. See Uno v.

City of Holyoke, 72 F.3d 973, 978 (1st Cir.1995) (“[T]he jurisprudence of clear error ‘does not inhibit an appellate court’s power to correct errors of law, including those that may infect a so-called mixed finding of law and fact, or a finding of fact that is predicated on a misunderstanding of the governing rule of law.’ ” (quoting Thornburg v. Gingles, 478 U.S. 30, 106, 106 S.Ct. 2752, 92 L.Ed.2d 25 (1986))). This standard of review tracks the Supreme Court’s framework for appellate review of claims of excessive punishment or fines under the Eighth Amendment. United States v.

Bajakajian, 524 U.S. 321, 336-37 & n. 10, 118 S.Ct. 2028, 141 L.Ed.2d 314 (1998). In Bajakajian, the Supreme Court concluded that the excessiveness of a fine was a question properly considered de novo by appellate courts, applying “the standard of gross disproportionality articulated in [its] Cruel and Unusual Punishments Clause precedents.” Id. at 336, 118 S.Ct. 2028. “[T]he application of a constitutional standard to the facts of a particular case,” the Supreme Court reasoned, may appropriately require de novo appellate review to ensure consistency in the law’s development.

Id. at 336 n. 10, 118 S.Ct. 2028; see also Cooper Indus. v. Leatherman Tool Grp., Inc., 532 U.S. 424, 435-36, 121 S.Ct. 1678, 149 L.Ed.2d 674 (2001) (extending de novo review of the excessiveness inquiry associated with the Excessive Fines Clause of the Eighth Amendment to punitive damages awards); Ornelas, 517 U.S. at 699, 116 S.Ct. 1657 (holding that “as a general matter determinations of reasonable suspicion and probable cause should be reviewed de novo on appeal”).

The considerations set forth in Ornelas, and applied in Bajakajian and Leatherman Tool, are equally relevant here. “Medical ‘need’ in real life is an elastic term,” Battista, 645 F.3d at 454, “that take[s its] substantive content from the particular context[ ] in which the standards are being assessed.” Ornelas, 517 U.S. at 696, 116 S.Ct. 1657.

Similarly, the “legal rules” for what constitutes care in violation of the Eighth Amendment “acquire content only through application”-a fact which favors de novo appellate review “to maintain control of, and to clarify, the legal principles.” See id. at 697, 116 S.Ct. 1657. C. The Objective Prong: Serious Medical Need To sustain a claim under the objective prong of the Eighth Amendment, Kosilek must show that she has a serious medical need for which she has received inadequate treatment.

See Estelle, 429 U.S. at 106, 97 S.Ct. 285; Sires, 834 F.2d at 13 (finding no Eighth Amendment violation where the prisoner failed to “presentí] any evidence of a serious medical need that has gone unmet”); see also Derbes, 369 F.3d at 583 (a prison’s constitutional obligation to provide medical services does not require “a perfect plan for every inmate”); DeCologero, 821 F.2d at 42 (“[T]hough it is plain that an inmate deserves adequate medical care, he cannot insist that his institutional host provide him with the most sophisticated care that money can buy.”).

A significant risk of future harm that prison administrators fail to mitigate may suffice under the objective prong. Helling v. McKinney, 509 U.S. 25, 35, 113 S.Ct. 2475, 125 L.Ed.2d 22 (1993); see also Baze v. Rees, 553 U.S. 35, 50, 128 S.Ct. 1520, 170 L.Ed.2d 420 (2008) (“[Subjecting individuals to a risk of future harm ... can qualify as cruel and unusual punishment.”); Roe v.

Elyea, 631 F.3d 843, 858 (7th Cir.2011) (“[T]he Eighth Amendment ‘protects [an inmate] not only from deliberate indifference to his or her current serious health problems, but also from deliberate indifference to conditions posing an unreasonable risk of serious damage to jfuture health.’ ” (quoting Board v. Farnham, 394 F.3d 469, 479 (7th Cir.2005))). That GID is a serious medical need, and one which mandates treatment, is not in dispute in this case.

The parties do not spar over the fact that Kosilek requires medical care aimed at alleviating the harms associated with GID — to the contrary, the DOC has provided such care since 2003. Rather, the parties disagree over whether SRS is a medically necessary component of Kosilek’s care, such that any course of treatment not including surgery is constitutionally inadequate. The parties’ disparate positions on this issue are fit for succinct

summary. Kosilek argues that the only constitutionally sufficient treatment regimen is to adhere to the Standards of Care’s triadic sequence in full, including the provision of SRS. Kosilek emphasizes that doctors at both UMass and Fenway Clinic — doctors hired by the DOC — confirmed at trial that SRS was “medically necessary.” The failure to provide treatment, these doctors testified, would almost certainly lead to a deterioration in Kosilek’s mental state and a high likelihood of self-harming behaviors.

In light of this risk, and given that they believed Kosilek had successfully met all eligibility criteria for SRS, these doctors believed that any course of treatment excluding SRS is insufficient to treat Kosi-lek’s GID. In contrast, the DOC argues that full progression through the Standards of Care’s triadic sequence is not the only adequate treatment option, as Kosilek’s GID may be appropriately managed with treatment short of SRS. The DOC maintains that the evidence does not meet the standards for negligent treatment of a medical condition, much less the higher Eighth Amendment standard.

See Estelle, 429 U.S. at 106, 97 S.Ct. 285 (“Thus, a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim of medical mistreatment under the Eighth Amendment.”); Watson, 984 F.2d at 540 (stating that “simple medical malpractice” does not “rise[] to the level of cruel and unusual punishment”).

Relying on the advice of accredited medical professionals, the DOC argues that its alternative course of treatment — which provides Kosilek such alleviative measures as psychotherapy, hormones, electrolysis, and the provision of female garb and accessories — is sufficient to treat Kosilek’s GID and far exceeds a level of care that would be “so inadequate as to shock the conscience.” See Torraco, 923 F.2d at 235 (quoting Sires, 834 F.2d at 13). Moreover, this course of treatment has, in practice, greatly diminished Kosilek’s mental distress and allowed her a fair measure of contentment.

Should suicidal ideation arise in the future, the DOC contends that — based on the advice of its medical experts and its own penological experience' — -it would be able to address that future risk appropriately through psychotherapy and antidepressants. We begin by discussing the district court’s conclusions regarding the objective prong. We then examine de novo the question whether the treatment offered was constitutionally adequate. 1. The district court’s medical prudence determination The district court ruled that SRS was a medically necessary treatment, and that Dr.

Schmidt’s alternative belief was outside the bounds of medical prudence. However, the court’s finding that Dr. Schmidt’s views were medically imprudent was based on several erroneous determinations. First, the court ruled that, unlike prudent medical professionals, Dr. Schmidt did not “follow” the Standards of Care in his treatment of GID. This finding ignored critical nuance in Dr. Schmidt’s testimony and based its conclusion on a severely strained reading of Dr. Levine’s expert testimony. As an initial matter, the Standards of Care themselves admit of significant flexibility in their

interpretation and application. They state, for example, that “[t]he Standards of Care [a]re Clinical Guidelines ” and are “intended to provide flexible directions ” to medical professionals in crafting treatment plans. Standards of Care at 1 (emphases added). The Standards of Care also specifically warn that “[a]ll readers should be aware of the limitations of knowledge in this area.” Standards of Care at 1. “Individual professionals and organized programs,” the Standards of Care continue on, “may modify [the standards]” as appropriate. Id. at 2. Dr. Levine’s testimony acknowledged this flexibility: [DR.

LEVINE]: [T]he “Standards .of Care” was a consensus document from people from seven different countries or something, you know, who come from different systems, and it was a political process that forged together a set of standards.... So “prudent” is a wonderful word, but it’s not like it has one simple definition. THE COURT: But is this an area in which you think prudent professionals can reasonably differ as to what is at least minimally adequate treatment for this condition? [DR. LEVINE]: Yes, and do.

Moreover, the district court put great weight on the fact that the Standards of Care require that patients receive two letters of recommendation prior to SRS. The court concluded, therefore, that “prudent professionals who treat individuals suffering from severe gqnder identity disorders write such letters of recommendation,” and it faulted Dr. Schmidt as imprudent for his failure to engage in this practice. In so doing, the court relied on Dr. Levine’s testimony, which it believed stated that a prudent professional would not “[refuse] to write letters of recommendation.” Dr.

Schmidt’s testimony, however, makes clear that although he does not advocate or recommend surgery to his patients, if a patient chooses to seek SRS, he releases all of their medical files to a surgeon and writes that surgeon a letter confirming that the patient is eligible for surgery. Insofar as Dr. Schmidt had not advocated for the surgery, this neutrality aligns with what Dr. Levine describes as the accepted practice for doctors in the treatment of GID: “[i]f the patient meets eligibility requirements ... we then write a letter of support ...

I understand how others may perceive this as a recommendation ... [but] we tell ourselves we are opening a gate to their decision.” Therefore, whatever the semantic force of the district court’s distinction, we see no material difference between the letters written by Dr. Schmidt confirming a patient’s readiness for surgery and what the Standards of Care refers to as a letter of recommendation. The district court next concluded that Dr. Schmidt was imprudent because antidepressants and psychotherapy alone are inadequate to treat GID. Again, the court claimed that it relied on the testimony of Dr.

Levine, but misconstrued his testimony in support of its conclusion. Dr. Levine did in fact state that “gender dysphoria is not significantly ameliorated ... by treating [patients] with a prozac-like drug alone.” He continued on, however, to explain that he did not believe this was the treatment plan advocated by Dr. Schmidt or the DOC.

To the contrary, he understood that Kosilek would continue to receive ameliorative treatment for her GID and, if she entered a depressive or suicidal state based on her inability to receive SRS, antidepressants and psychotherapy would be used to help stabilize her mental state so as to alleviate the risk of suicide while working with her to craft new perspectives and life goals beyond surgery. He felt that the treatment might well be successful in this capacity, when combined with the direct alleviative treatments currently provided. Finally, the district court found Dr.

Schmidt imprudent because he did not believe that a real-life experience could occur in prison, given that it was an isolated, single-sex environment. The district court disagreed, stating that it had concluded a real-life experience could occur in prison, as Kosilek would remain incarcerated for her entire life. In reaching this determination, the court made a significantly flawed inferential leap: it relied on its own — non-medical—-judgment about what constitutes a real-life experience to conclude that Dr. Schmidt’s differing viewpoint was illegitimate or imprudent.

Prudent medical professionals, however, do reasonably differ in their opinions regarding the requirements of a real-life experience-and this reasonable difference in medical opinions is sufficient to defeat Ko-silek’s argument. Cf. Bismark v. Fisher, 213 Fed.Appx. 892, 897 (11th Cir.2007) (“Nothing in our case law would derive a constitutional deprivation from a prison physician’s failure to subordinate his own professional judgment to that of another doctor.... ”); Estate of Cole by Pardue v. Fromm, 94 F.3d 254, 261 (7th Cir.1996); Bowring v. Godwin, 551 F.2d 44, 48 (4th Cir.1977). In fact, Dr.

Levine noted that an incar-cerative environment might well be insufficient to expose Kosilek to the variety of societal, familial, and vocational pressures foreseen by a real-life experience. This viewpoint aligned with that of Dr. Schmidt and Osborne. And, although Dr.

For-stein’s written report appears to presume Kosilek had completed a real-life experience, it echoed this same point: “being in prison has helped [Kosilek] consolidate her desire ... simplifying the issues, without the stressors and choices that she would have had to make out in the outside real world.” We find no support for the district court’s conclusion that no reasonable medical expert could opine that Kosilek lacked real-life experience, particularly in light of the contrary testimony from medical experts concerning the range of social, environmental, and professional considerations that are necessary to constitute a real-life experience under the Standards of Care.

The district court thus erred by substituting its own beliefs for those of multiple medical experts. The district court’s finding of medical imprudence relied heavily on inferences we do not believe can rightly be drawn from Dr. Levine’s testimony; this finding also ignored significant contrary evidence regarding the breadth and variety of acceptable treatments for GID within the medical community. Its conclusion that the Fenway Center’s recommendation constituted the sole acceptable treatment plan is, thus, contradicted by the record. 2.

Adequacy of the DOC’s treatment plan Regarding the medical adequacy of Ko-silek’s treatment, the district court held that psychotherapy and antidepressants alone would not adequately treat Kosilek’s GID. This finding mischaraoterizes the issues on appeal and unduly minimizes the nature of the DOC’s preferred treatment plan. The DOC does not claim that treating Kosilek’s GID merely with therapy and antidepressants alone would constitute adequate care. Cf. Fields v.

Smith, 653 F.3d 550, 556 (7th Cir.2011) (accepting, in the absence of contrary evidence, expert testimony that “psychotherapy as well as anti-psychotics and antidepressants ... do nothing to treat the underlying disorder [of GID]”). In fact, since Kosilek I the DOC has acknowledged the need to directly treat Kosilek’s GID. Beginning in 2003, it has provided hormones, electrolysis, feminine clothing and accessories, and mental health services aimed at alleviating her distress. The parties agree that this care has led to a real and marked improvement in Kosilek’s mental state.

There is also no dispute that this care would continue, whether or not SRS is provided. The question before our court, therefore, is not whether antidepressants and psychotherapy alone are sufficient to treat GID, or whether GID constitutes a serious medical need. Rather, the question is whether the decision not to provide SRS-in light of the continued provision of all ameliorative measures currently afforded Kosi-lek and in addition to antidepressants and psychotherapy — is sufficiently harmful to Kosilek so as to violate the Eighth Amendment. It is not. See Smith v.

Carpenter, 316 F.3d 178, 186 (2d Cir.2003) (“[I]t’s the particular risk of harm faced by a prisoner due to the challenged deprivation of care, rather than the severity of the prisoner’s underlying medical condition, considered in the abstract, that is relevant for Eighth Amendment purposes.”); see also Estelle, 429 U.S. at 106, 97 S.Ct. 285 (requiring proof of “acts or omissions sufficiently harmful” as to illustrate deliberate indifference to a serious medical need); Estate of Bearden ex rel. Bearden v. Anglin, 543 Fed.Appx. 918, 921 (11th Cir.2013); Leavitt, 645 F.3d at 497.

Kosilek admits that the DOC’s current treatment regimen has led to a significant stabilization in her mental state. Kosilek’s doctors testified to the same, highlighting her “joy around being feminized.” This claim is also borne out by the passage of significant time since she exhibited symptoms of suicidal ideation or attempted to self-castrate. In addition to alleviating her depressive state, this treatment has also resulted in significant physical changes and an increasingly feminine appearance.

The significance of a future risk of sui-cidality is not one that this court takes lightly, and Kosilek is right to note that a clear risk of future harm may suffice to sustain an Eighth Amendment claim. See Helling, 509 U.S. at 35, 113 S.Ct. 2475 (determining that an “unreasonable risk” of future harm may amount to an Eighth Amendment violation); Baze, 553 U.S. at 49, 128 S.Ct. 1520; Roe, 631 F.3d at 858. Nonetheless, the risk of suicidal ideation is born from Kosilek’s GID-related mental distress.

Therefore an assessment of the gravity of that risk, and its appropriate treatment, must encompass the entirety of the DOC’s treatment plan, not merely the potential addition of psychotherapy and antidepressants. Kosilek is provided hormones, facial hair removal, feminine clothing and accessories, and access to regular mental health treatment. The DOC also stands ready to protect Kosilek from the potential for self-harm by employing its standard and accepted methods of treating any prisoner exhibiting suicidal ideation. Trial testimony established that this plan offers real and direct treatment for Kosilek’s GID.

It employs methods proven to alleviate Kosi-lek’s mental distress while crafting a plan to minimize the risk of future harm. See Carpenter, 316 F.3d at 186. It does not wantonly disregard Kosilek’s needs, but accounts for them. See Torraco, 923 F.2d at 235. The law is clear that where two alternative courses of medical treatment exist, and both alleviate negative effects within the boundaries of modern medicine, it is not the place of our court to “second guess medical judgments” or to require that the DOC adopt the more compassionate of two adequate options. Layne v.

Vinzant, 657 F.2d 468, 474 (1st Cir.1981) (quoting Westlake v. Lucas, 537 F.2d 857, 860 n. 5 (6th Cir.1976)); Bismark, 213 Fed.Appx. at 897; Medrano v. Smith, 161 Fed.Appx. 596, 599 (7th Cir.2006); Sanchez v. Vild, 891 F.2d 240, 242 (9th Cir.1989); Bowring, 551 F.2d at 48. That the DOC has chosen one of two alternatives-both of which are reasonably commensurate with the medical standards of prudent professionals, and both of which provide Kosilek with a significant measure of relief — is a decision that does not violate the Eighth Amendment.

Kosilek warns, however, that upholding the adequacy of the DOC’s course of treatment in this case — despite her medical history and record of good behavior — will create a de facto ban against SRS as a medical treatment for any incarcerated individual. We do not agree. For one, the DOC has specifically disclaimed any attempt to create a blanket policy regarding SRS. We are confident that the DOC will abide by this assurance, as any such policy would conflict with the requirement that medical care be individualized based on a particular prisoner’s serious medical needs.

See, e.g., Roe, 631 F.3d at 862-63 (holding that the failure to conduct an individualized assessment of a prisoner’s needs may violate the Eighth Amendment). For another, this case presents unique circumstances; we are simply unconvinced that our decision on the record before us today will foreclose all litigants from successfully seeking SRS in the future. Certain facts in this particular record — including the medical providers’ non-uniform opinions regarding the necessity of SRS, Kosilek’s criminal history, and the feasibility of postoperative housing — were important factors impacting the decision. D.

The Subjective Prong: Deliberate Indifference 1. The DOC’s reliance on medical experts The subjective element of an Eighth Amendment claim for injunctive relief requires not only that Kosilek show that the treatment she received was constitutionally inadequate, but also that the DOC was — and continues to be — deliberately indifferent to her serious risk of harm. See Farmer, 511 U.S. at 844-45, 114 S.Ct. 1970. On the record presented, this is a burden Kosilek cannot meet.

Even if the district court had been correct in its erroneous determination that SRS was the only medically adequate treatment for Kosilek’s GID, the next relevant inquiry would be whether the DOC also knew or should have known this fact, but nonetheless failed to respond in an appropriate manner. See Wilson v. Seiter, 501 U.S. 294, 298, 111 S.Ct. 2321, 115 L.Ed.2d 271 (1991). In answering this question, it is not the district court’s own belief about medical necessity that controls, but what was known and understood by prison officials in crafting their policy.

Id. at 300, 111 S.Ct. 2321 (requiring a showing of purposefulness or intent on the part of prison administrators). In this case., the DOC solicited the opinion of multiple medical professionals and was ultimately presented with two alternative treatment plans, which were each developed by different medical experts to mitigate the severity of Kosilek’s mental distress. The choice of a medical option that, although' disfavored by some in the field, is presented by competent professionals does not exhibit a level of inattention or callousness to a prisoner’s needs rising to a constitutional violation. Cf.

Torraco, 923 F.2d at 234 (“[T]his court has hesitated to find deliberate indifference to a serious need ‘[w]here the dispute concerns not the absence of help, but the choice of a certain course of treatment,’ [but] deliberate indifference may be found where the attention received is ‘so clearly inadequate as to amount to a refusal to provide essential care.’ ” (internal citations omitted)).

Moreover, a later court decision — ruling that the prison administrators were wrong in their estimation of the treatment’s reasonableness — does not somehow convert that choice into one exhibiting the sort of obstinacy and disregard required to find deliberate indifference. Cf. Nadeau v. Helgemoe, 561 F.2d 411, 417 (1st Cir.1977) (refusing to “substitute the values and judgment of a court for the values and judgment of the ... prison administration”). 2.

The DOC’s security concerns The subjective prong also recognizes that, in issues of security, “[p]rison administrators ... should be accorded wide-ranging deference in the adoption and execution of policies and practices that in their judgment are needed to preserve internal order and discipline and to maintain institutional security.” Bell, 441 U.S. at 547, 99 S.Ct. 1861. Although we cannot “abdicate our responsibility to ensure that the limits imposed by the Constitution are not ignored,” Blackburn v.

Snow, 771 F.2d 556, 562 (1st Cir.1985), we do not sit to substitute our own judgment for that of prison administrators, see Nadeau, 561 F.2d at 417. As long as prison administrators make judgments balancing security and health concerns that are “within the realm of reason and made in good faith,” their decisions do not amount to a violation of the Eighth Amendment. Battista, 645 F.3d at 454. The DOC officials explained that they believed SRS would create new security issues, the most significant being the provision of safe housing options for Kosilek after her surgery.

They further explained the importance of keeping other inmates from believing that they could use threats of suicide to extract concessions from the prison administration

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