Clark v. Valletta: No Clearly Established Right to Specific Gender-Dysphoria Treatments; Objective Reasonableness Remains Distinct in Eighth Amendment Qualified Immunity

Introduction

In Clark v. Valletta, No. 23-7377-cv (2d Cir. Oct. 6, 2025), the U.S. Court of Appeals for the Second Circuit reversed the district court’s denial of qualified immunity to three Connecticut correctional health professionals who were sued for allegedly inadequate treatment of a transgender prisoner’s gender dysphoria. The plaintiff, Veronica‑May Clark, sought damages under the Eighth Amendment for alleged deliberate indifference, arguing defendants failed to provide stronger hormone therapy, a vaginoplasty, and care from providers experienced in gender dysphoria.

The panel (Judges Sullivan, Park, and Robinson), in an opinion by Judge Park, held that (1) inmates have no clearly established right to treatment by gender‑dysphoria specialists or to specific gender‑affirming treatments; (2) given professional disagreement about gender-dysphoria care and the course of treatment provided here (talk therapy, antidepressants, and hormone therapy with monitoring), reasonable officials could disagree about the legality of defendants’ conduct; and (3) qualified immunity therefore shields defendants from damages. Judge Robinson concurred in part and dissented in part, arguing that as to two defendants the case concerned a wholesale failure to provide individualized, medically informed care—first by enforcing a blanket “no initiation” policy for 13 months and later by failing to follow an endocrinologist’s plan for roughly 20 months—conduct that, in her view, violated clearly established law.

The court remanded with instructions to grant summary judgment to the defendants on qualified-immunity grounds. An injunctive claim against the Commissioner was not at issue in this interlocutory appeal.

Summary of the Opinion

• The district court had denied qualified immunity after framing the right at issue as the broad “right to be free from deliberate indifference to serious medical needs.”
• The Second Circuit reversed, holding that clearly established rights must be particularized to the facts. In this context, there is no clearly established right to be treated by gender‑dysphoria specialists or to receive specific gender‑affirming treatments (e.g., a particular hormone dosage or vaginoplasty).
• The court rejected the argument that defendants’ course of care amounted to a total deprivation. Clark received lifestyle accommodations, talk therapy, antidepressants, hormone therapy, lab monitoring, and several endocrinology appointments. While not plaintiff’s preferred course, that is not the same as “no treatment.”
• The “obviousness” exception to clearly established law (Hope v. Pelzer; Taylor v. Riojas) did not apply; the care here was not akin to the extreme conditions that make unlawfulness apparent even without precedent.
• Even if a right were clearly established, defendants would still be entitled to qualified immunity because their conduct was objectively reasonable amid medical disagreement about gender-dysphoria care and given out‑of‑circuit authority rejecting a constitutional entitlement to specific gender‑affirming treatments.
• The court emphasized that qualified immunity’s objective reasonableness inquiry remains distinct from Farmer’s subjective deliberate‑indifference inquiry, citing Saucier and Anderson, and declined to follow circuits that collapse the two.

Analysis

Precedents Cited and Their Role

• Estelle v. Gamble, 429 U.S. 97 (1976): Established that deliberate indifference to serious medical needs violates the Eighth Amendment, distinguishing this from negligence. The foundational Eighth Amendment medical-care case.
• Farmer v. Brennan, 511 U.S. 825 (1994): Clarified deliberate indifference’s subjective prong—official must know of and disregard a substantial risk. Farmer involved a transgender inmate but on failure-to-protect; it did not create treatment-specific rights.
• Ashcroft v. al‑Kidd, 563 U.S. 731 (2011); District of Columbia v. Wesby, 583 U.S. 48 (2018); Kisela v. Hughes, 584 U.S. 100 (2018): Qualified immunity requires rights to be clearly established and particularized; “beyond debate.” The Second Circuit leaned on these to reject broad formulations.
• Taylor v. Barkes, 575 U.S. 822 (2015): No clearly established right to specific suicide-screening protocols. Used to reinforce that broad deliberate-indifference formulations are insufficient for clearly established law.
• City & County of San Francisco v. Sheehan, 575 U.S. 600 (2015): Cautioned against defining rights at too high a level of generality.
• Hathaway v. Coughlin, 37 F.3d 63 (2d Cir. 1994); LaBounty v. Coughlin, 137 F.3d 68 (2d Cir. 1998): Plaintiffs pointed to these as recognizing a broad right. The panel distinguished them: Hathaway involved known untreated broken hip hardware and concealment; LaBounty involved total inaction in the face of an obvious hazard. Neither clearly established a right to specific gender‑dysphoria treatments.
• Collymore v. Myers, 74 F.4th 22 (2d Cir. 2023): Held a painful scalp infection states a serious medical condition but did not clearly establish standards for treatment in this case type.
• Vega v. Semple, 963 F.3d 259 (2d Cir. 2020): Denied qualified immunity where officials took no action to mitigate radon exposure—illustrates the “obviousness”/total inaction line not met here.
• Salahuddin v. Goord, 467 F.3d 263 (2d Cir. 2006); Johnson v. Wright, 412 F.3d 398 (2d Cir. 2005): On policies vs medical judgment; the panel found no evidence here that following policy reflected knowing disregard of a serious risk.
• Outlaw v. City of Hartford, 884 F.3d 351 (2d Cir. 2018); Anderson v. Creighton, 483 U.S. 635 (1987); Harlow v. Fitzgerald, 457 U.S. 800 (1982); Saucier v. Katz, 533 U.S. 194 (2001): Qualified immunity’s objective reasonableness is distinct and protects reasonable mistakes; relied on to keep the QI prong separate from Farmer’s subjective test.

Survey of Out-of-Circuit Gender-Dysphoria Cases

• Kosilek v. Spencer, 774 F.3d 63 (1st Cir. 2014) (en banc): Upheld denial of surgery where other measures were provided and treatment decisions were medically individualized.
• Gibson v. Collier, 920 F.3d 212 (5th Cir. 2019) (en banc): No Eighth Amendment violation in denying gender-confirming surgery amid medical debate about necessity/efficacy.
• Lamb v. Norwood, 899 F.3d 1159 (10th Cir. 2018): No deliberate indifference where inmate received counseling and hormones despite wanting higher dosages and surgery.
• Keohane v. Fla. Dep’t of Corr. Sec’y, 952 F.3d 1257 (11th Cir. 2020); Reid v. Griffin, 808 F.3d 1191 (8th Cir. 2015): Similar “some-care” holdings.
• Campbell v. Kallas, 936 F.3d 536 (7th Cir. 2019): Granted qualified immunity where inmate received hormones, counseling, and accommodations; emphasized specificity in QI framing when medical judgment is exercised.
• Edmo v. Corizon, Inc., 935 F.3d 757 (9th Cir. 2019): The Ninth Circuit found deliberate indifference for denying surgery despite hormones. The Second Circuit characterized Edmo as an outlier and noted a split within the Ninth Circuit at rehearing (en banc denied with a large dissent).
• Rosati v. Igbinoso, 791 F.3d 1037 (9th Cir. 2015); De’lonta v. Johnson, 708 F.3d 520 (4th Cir. 2013): Let gender-dysphoria claims proceed at screening where allegations suggested blanket policies or refusal to evaluate for surgery; distinguished as different posture and not controlling.

Legal Reasoning: How the Second Circuit Reached Its Result

1) Clearly Established Law Must Be Particularized

The court held that framing the right as “freedom from deliberate indifference” is too abstract in the qualified-immunity context. Following al‑Kidd, Taylor v. Barkes, and Wesby, courts must define the right with reasonable specificity tied to the facts. Applying Taylor v. Barkes, the question here is not whether there is a general right to adequate medical care, but whether existing precedent clearly established that inmates have a right to be treated by gender-dysphoria specialists or to particular treatments (e.g., stronger hormones, vaginoplasty). The panel answered no—neither the Supreme Court nor the Second Circuit had so held, and most circuits to have spoken rejected such a right.

2) No Clearly Established Right to Specific Gender-Dysphoria Treatments

The opinion canvasses Supreme Court, Second Circuit, and other circuits’ decisions and concludes there is no “settled law” creating a right to specific gender-affirming interventions or to specialist care. Farmer did not establish treatment-specific rights for transgender inmates. The Second Circuit’s own Cuoco v. Moritsugu (2000) found no constitutional violation where estrogen was withheld even amid withdrawal symptoms and suicidal ideation, and granted qualified immunity to mental health providers who declined to intervene in another doctor’s prescribing decisions.

On the broader landscape, First, Fifth, Tenth, Eleventh, Eighth, and Seventh Circuit cases generally support that provision of some care (e.g., counseling, hormones, accommodations) satisfies the Eighth Amendment even when the inmate desires different or additional treatment. The Ninth Circuit’s contrary approach in Edmo is, in the Second Circuit’s view, insufficient to constitute a “robust consensus.” Absent controlling or consensus authority, the right asserted is not clearly established.

3) Not a Total Deprivation; “Obviousness” Exception Does Not Apply

Because Clark received a multi-year course of care—including psychotherapy, antidepressants, hormone therapy, repeated lab monitoring, and multiple endocrinology visits—the court rejected characterization of the record as “complete inaction.” The “obviousness” line of cases (e.g., Hope v. Pelzer, Taylor v. Riojas) applies when the conduct is egregiously cruel or there is total inaction in the face of grave risks. Here, the medical debate and mixed treatment record place the case on the “some care that allegedly should have been better” side of the line, where specificity in clearly established law is required.

The court also declined to adopt “informed care from a qualified provider” as a constitutional baseline, noting that neither “informed care” nor a specialist requirement exists in its deliberate-indifference jurisprudence, and that Clark did, in fact, see an external endocrinologist multiple times with physician-ordered lab monitoring.

4) Objective Reasonableness is a Separate Shield

Even if a right had been clearly established, the panel held that reasonable officials could differ about the lawfulness of defendants’ conduct given professional disagreement about best practices for treating gender dysphoria and the non-consensus status of WPATH Standards. Qualified immunity turns on an objective assessment of what a reasonable official would understand, not on subjective good faith. The court relied on Saucier and Anderson to reaffirm that qualified immunity’s objective reasonableness inquiry “has a further dimension” and cannot be collapsed into Farmer’s subjective deliberate-indifference test. The Second Circuit explicitly declined to follow circuits that conflate the two.

The Dissent’s Perspective

Judge Robinson concurred that defendant Bush was entitled to qualified immunity but dissented as to Dr. Valletta and APRN Kimble‑Goodman. In her view:

• Misframed Issue: The majority recast the case as about a right to vaginoplasty or specific hormone dosages. Clark’s actual claims, she stressed, concerned (a) a 13‑month failure to facilitate any gender‑specific treatment following a self‑castration attempt due to an unwritten “no initiation” policy, and (b) a 20‑month failure to follow the endocrinologist’s plan despite distress and lab results showing ineffective dosing.
• Right Properly Framed: The clearly established right is not treatment-by-treatment but the right to an individualized assessment and adequate medical care for serious medical needs; courts do not slice Eighth Amendment medical claims “body-part by body-part.” She cited Hathaway, LaBounty, Collymore, and sister-circuit decisions recognizing that blanket refusals or wholesale failures to act can constitute deliberate indifference.
• Policy vs. Medical Judgment: The dissent emphasized the difference between considered medical judgments (which often garner deference and qualified immunity) and categorical, non-medical denials of care. She aligned this case with Fields v. Smith (Seventh Circuit) and De’lonta/Rosati (Fourth/Ninth Circuits), where blanket policies or refusals to evaluate further were treated as deliberate indifference.
• Record Posture: On summary judgment/qualified immunity, the appellate court should credit the plaintiff’s facts and avoid defense expert gloss. The dissent criticized the majority’s reliance on disputed materials to recast the care as meaningfully “some care” rather than an extended failure to address the serious condition with individualized, medically informed decision-making.
• Practical Concern: The majority’s approach risks turning qualified immunity into near-absolute immunity in prison medical cases and, in particular, carving a de facto exception for gender dysphoria from otherwise settled deliberate-indifference principles.

Impact and Implications

• Qualified Immunity in Prison Medical Cases: Clark reinforces that, in the Second Circuit, plaintiffs seeking damages must tether the “clearly established” right to specific factual contexts—especially when officials provided some course of treatment. Broad formulations (“freedom from deliberate indifference”) will not defeat qualified immunity.
• Gender-Dysphoria Care in Custody: There is no clearly established right in the Second Circuit to be treated by gender‑dysphoria specialists or to particular gender‑affirming interventions (e.g., surgery, specific hormone regimens) as a matter of damages liability. Plaintiffs will need to show total inaction, egregious disregard of obvious risks, or a directly controlling precedent on comparable facts to overcome qualified immunity.
• Weight of Professional Standards: The court found WPATH Standards do not reflect binding consensus for constitutional purposes, particularly where medical experts disagree. Litigants cannot rely on WPATH alone to show that a right was “clearly established.”
• Objective Reasonableness Lives On: The Second Circuit’s explicit reaffirmation that qualified immunity’s objective reasonableness prong remains distinct—even for Eighth Amendment claims—creates a clear circuit position, diverging from circuits that merge the two analyses. This will shape briefing and outcomes in future deliberate‑indifference damages suits within the Circuit.
• Injunctive vs. Damages Relief: While qualified immunity bars damages here, injunctions are not affected by qualified immunity. Plaintiffs alleging ongoing inadequate gender‑dysphoria care may continue to seek prospective relief against appropriate officials. As a practical matter, Clark channels much of the litigation strategy toward injunctive pathways where the “clearly established” hurdle does not apply.
• Policy and Documentation: Correctional systems within the Second Circuit should ensure documented, individualized assessments and continuity-of-care steps (referrals, specialist follow‑ups, monitoring labs) to demonstrate “some care” and objective reasonableness. Categorical policies that preclude evaluation or treatment initiation present higher risk, particularly if the record shows officials knew of acute distress and did not take reasonable steps to abate it.
• Strategic Litigation Takeaways: Plaintiffs will benefit from developing records that demonstrate either (a) complete inaction in the face of serious medical needs (to trigger the “obviousness” line) or (b) controlling precedent with closely analogous facts. Defendants will emphasize professional disagreement, mixed clinical presentations, and documented steps taken to show reasonableness.

Complex Concepts Simplified

• Deliberate Indifference (Eighth Amendment): To prove a violation, a prisoner must show (1) a serious medical need (objective) and (2) that officials knew of and disregarded an excessive risk to health (subjective). Negligence or disagreement over treatment usually is not enough.
• Qualified Immunity (Damages Shield): Government officials are shielded from money damages unless (1) they violate a constitutional right, and (2) that right was clearly established at the time. Even then, if it was objectively reasonable to think their conduct lawful, qualified immunity still applies.
• Clearly Established Law: Requires specificity—existing authority must put the legal question “beyond debate.” General statements of law rarely suffice; the facts must align closely with precedent.
• Objective Reasonableness: A separate qualified-immunity inquiry that asks whether a reasonable official in the defendant’s position could believe the conduct lawful. It is analytically distinct from the Eighth Amendment’s subjective deliberate-indifference test.
• “Obviousness” Exception: In rare, egregious circumstances (e.g., chaining an inmate to a post in the sun, confining in sewage), unlawfulness is so apparent that specific precedents are unnecessary.
• WPATH Standards: Professional guidelines for transgender health care. Courts may consider them as evidence, but they do not automatically establish constitutional baselines, especially where medical consensus is disputed.

Conclusion

Clark v. Valletta is a significant Second Circuit pronouncement on the contours of qualified immunity in prison medical-care cases involving gender dysphoria. The court holds that there is no clearly established Eighth Amendment right to be treated by gender‑dysphoria specialists or to specific gender‑affirming treatments, and it underscores that qualified immunity’s objective reasonableness analysis remains distinct and robust in Eighth Amendment damages litigation. The decision aligns the Second Circuit with the majority of circuits that have declined to constitutionalize specific gender‑dysphoria interventions in the absence of consensus and in the presence of some course of treatment.

The dissent highlights a competing vision rooted in the prohibition against blanket, non-medical denials of care and the requirement of individualized, medically informed responses to serious needs. That tension will likely continue to animate lower-court litigation, particularly over whether a record reflects “some care” versus a wholesale failure to act.

• Key takeaways:
  • Rights must be particularized: broad “deliberate indifference” formulations are insufficient for clearly established law.
  • No clearly established right to specific gender-dysphoria treatments or to specialist providers in the Second Circuit.
  • Providing some care (even if imperfect or disputed) generally avoids the “obviousness” exception and supports qualified immunity.
  • Qualified immunity’s objective reasonableness inquiry remains a separate, potent defense in Eighth Amendment damages suits.
  • Injunctive relief remains available notwithstanding qualified immunity and may be the preferred vehicle for systemic change.

As a practical matter, Clark raises plaintiffs’ burdens in damages actions alleging inadequate gender‑dysphoria treatment. It simultaneously encourages correctional systems to document individualized assessments and continuity of care and may push future plaintiffs toward prospective relief to secure medically appropriate care without the strictures of qualified immunity.