Haverkamp v. Linthicum: No Standing Without a Likely Medical Referral — Fifth Circuit Clarifies Traceability and Redressability in Prison-Surgery Challenges

Introduction

In Haverkamp v. Linthicum, the United States Court of Appeals for the Fifth Circuit affirmed the dismissal of an equal protection suit brought by a Texas inmate seeking sex-reassignment surgery. The court did not reach sovereign immunity, instead resolving the case on Article III standing. The central holding is pragmatic and potentially far-reaching: when a prisoner seeks injunctive relief compelling a specific medical procedure, the plaintiff must adduce evidence that the treating physicians would in fact recommend or refer the prisoner for that procedure. Absent such evidence, any injury is attributable to the independent judgment of third-party medical professionals not before the court, breaking traceability and undermining redressability.

The plaintiff, David Allen Haverkamp (also known as Bobbie Lee Haverkamp), a 78-year-old inmate diagnosed with gender dysphoria, alleged that state officials discriminated in violation of the Equal Protection Clause by refusing to provide sex-reassignment surgery. The district court dismissed on sovereign immunity grounds. The Fifth Circuit affirmed the dismissal, but solely because Haverkamp lacked standing to seek the relief requested.

This commentary examines the opinion’s background, procedural posture, core holding, cited precedents, legal reasoning, and its likely impact on prison litigation involving gender dysphoria and other medical procedures, particularly where physician gatekeeping interposes third-party decision-making between a plaintiff’s injury and a policy-level defendant.

Summary of the Opinion

The Fifth Circuit, per Judge Cory T. Wilson, held that Haverkamp failed to establish Article III standing because the alleged injury — denial of sex-reassignment surgery — was not fairly traceable to the actions of the defendants (Dr. Lannette Linthicum and Dr. Owen Murray) and was not likely redressable by the requested injunction. Although TDCJ classifies sex-reassignment surgery as elective and not medically necessary, and although Dr. Murray reportedly communicated that the Clinic’s consultants could not refer inmates for the surgery, the record lacked evidence that any treating TDCJ physician would have referred Haverkamp for surgery, especially after Haverkamp’s treating psychiatrist, Dr. Walter Meyer, retired in 2018.

The court emphasized two points:

Traceability: The causal chain from policy-level defendants to the alleged injury was broken by the independent medical judgment of treating physicians not before the court.
Redressability: Even if the court ordered policy-level changes or compelled access to the surgery, such relief would not bypass a treating physician’s contrary medical judgment; therefore, the court could not likely redress Haverkamp’s alleged injury.

Because standing was lacking, the court affirmed the dismissal without reaching sovereign immunity or the merits of the equal protection claim.

Analysis

Precedents Cited and Their Role

Lujan v. Defenders of Wildlife, 504 U.S. 555 (1992) and Spokeo, Inc. v. Robins, 578 U.S. 330 (2016): The court applied the classic three-part standing test: injury in fact, traceability, and redressability. It highlighted Lujan’s requirement that injury be fairly traceable to defendants’ challenged actions, not to independent third parties, and Spokeo’s requirement of likely redressability by judicial relief.
Paterson v. Weinberger, 644 F.2d 521 (5th Cir. 1981): When defendants mount a factual attack on jurisdictional facts, plaintiffs must substantiate standing by a preponderance of the evidence. This raised Haverkamp’s evidentiary burden beyond mere pleading-stage allegations.
Green Valley Special Util. Dist. v. City of Schertz, 969 F.3d 460 (5th Cir. 2020) (en banc) and Daves v. Dallas County, 22 F.4th 522 (5th Cir. 2022) (en banc): These cases confirm that courts may choose the order of addressing jurisdictional questions. The Fifth Circuit elected to resolve standing first, avoiding sovereign immunity analysis.
Gibson v. Collier, 920 F.3d 212 (5th Cir. 2019): Gibson rejected an Eighth Amendment challenge to a TDCJ policy and held that a state does not inflict cruel and unusual punishment by declining to provide sex-reassignment surgery. The Haverkamp panel distinguished Gibson in two ways:
- Gibson involved a claim that policy prevented any consideration of medical necessity; here, Haverkamp had at least some evaluation and discussion with a treating psychiatrist.
- Gibson underscored the “sharply contested medical debate” regarding such surgeries — a point the panel used to emphasize the absence of consensus on medical necessity and the importance of treating-physician judgment for traceability and redressability.
Delaughter v. Woodall, 909 F.3d 130 (5th Cir. 2018): In Delaughter, medical necessity (hip replacement) was undisputed, supporting an Eighth Amendment claim premised on delay. Haverkamp is the foil: necessity is disputed, and there is no evidence that a treating physician would recommend the procedure, undercutting traceability and redressability.
Ex parte Young, 209 U.S. 123 (1908): The district court relied on sovereign immunity and Ex parte Young limits, but the Fifth Circuit did not reach these questions. Nonetheless, the opinion acknowledges that even assuming Ex parte Young relief were available, standing would still fail.
United States v. Varner, 948 F.3d 250 (5th Cir. 2020): Cited for the Diagnostic and Statistical Manual’s description of gender dysphoria; contextual rather than outcome-determinative.
United States v. Skrmetti, 145 S. Ct. 1816 (2025) (Thomas, J., concurring) and Frontiero v. Richardson, 411 U.S. 677 (1973): These citations inform the description of the surgery and broader debates over sex and gender; they are not central to the standing analysis.
Haverkamp v. Linthicum (Haverkamp I), 6 F.4th 662 (5th Cir. 2021): The prior appeal vacated the district court’s denial of sovereign immunity for insufficient enforcement connection but did not dismiss defendants in light of state representations. The present decision effectively ends the case on standing grounds without revisiting Ex parte Young’s application.

Legal Reasoning

The Fifth Circuit’s reasoning focuses on the second and third elements of standing — traceability and redressability — and on the evidentiary burden during a factual attack on jurisdiction.

Traceability: Injury must stem from defendants, not independent third parties.
The alleged injury is denial of sex-reassignment surgery. Yet the record contains no evidence that any TDCJ treating physician (post-2018) determined Haverkamp to be an appropriate surgical candidate or would have referred Haverkamp for the procedure. This absence is decisive: even if policy-level actors disfavor the surgery or communicate constraints, the immediate causal decisionmaker is the treating physician whose medical judgment governs whether a referral would occur. Because those physicians are not defendants, and because there is no evidence that any would have referred Haverkamp absent the defendants’ actions, the injury is not fairly traceable to the defendants.
Redressability: Court-ordered relief would not likely remedy the injury.
The requested injunction either compels provision of surgery or prohibits implementation of Policy G-51.11 to bar surgery. The court reasoned that such relief could not bypass a treating physician’s medical judgment; if no treating physician would refer Haverkamp for surgery — a real possibility given advanced age (78) and comorbidities (obesity-range BMI, diabetes, hypertension, hypercholesterolemia, risk of chronic kidney disease) — then an injunction would not likely lead to surgery. Without a likely medical referral, the court cannot redress the alleged injury.
Evidence at the standing stage: preponderance required upon factual challenge.
The defendants made a factual attack on jurisdictional facts, triggering the plaintiff’s burden to produce competent evidence establishing standing by a preponderance of the evidence. While Haverkamp’s former treating psychiatrist, Dr. Meyer, later opined in a 2023 expert report that surgery was medically necessary, his contemporaneous treatment notes (through 2016) were equivocal, conditioned any consideration on at least one year of high-dose estrogen, and did not include an actual referral. After Dr. Meyer’s 2018 retirement, the record is silent as to any treating physician’s support for referral. Under Paterson, such evidentiary gaps are fatal at this stage.
Distinguishing policy bans from physician-gated decisions.
The court contrasted this case with scenarios where a facial policy categorically forecloses individualized assessment (as alleged in Gibson). Haverkamp’s case included some level of evaluation and discussion, so the injury is not attributable to a blanket refusal to consider medical necessity. Instead, the operative barrier is the absence of a treating-physician recommendation — a third-party decision that breaks the causal chain.

Impact

Haverkamp’s principal contribution is a sharpened articulation of standing in suits seeking to compel prison medical procedures, especially where clinical gatekeeping by non-party physicians intervenes between a policy and the requested care.

Prison medical litigation will face a higher evidentiary bar at the standing stage. Plaintiffs must do more than allege policy-level hostility or general medical necessity. They will need evidence that a treating physician actually would recommend or refer them for the specific procedure, or that the policy categorically prevents individualized assessment. Declarations, medical records, and contemporaneous notes from current treating physicians will be critical.
Litigation strategy will likely shift. Plaintiffs who cannot obtain a supportive referral (or at least a competent declaration that a referral would be made but for the policy) will struggle to establish traceability and redressability. Tailoring relief to require individualized evaluation, rather than a judicial order to perform surgery, may improve redressability — provided plaintiffs can show that evaluation has been denied or is futile due to a categorical policy.
Equal Protection claims will often be resolved at the threshold. Haverkamp does not address whether denying surgery while providing different forms of vaginoplasty to cisgender women is discriminatory. But by requiring proof of a likely medical referral at the standing stage, many equal protection challenges to surgery denials may never reach the merits unless the medical predicate is established.
Reinforces Gibson’s caution about contested medical necessity. The court’s reliance on the medical debate and individualized risk factors (age, comorbidities) underscores the judiciary’s hesitance to override clinical discretion via injunctions. This is particularly salient for surgeries deemed elective by corrections systems or subject to significant medical controversy.
Doctrinal clarity on sequencing jurisdictional issues. By resolving the appeal on standing and leaving sovereign immunity and Ex parte Young unaddressed, the court reiterates that federal courts may dispose of cases at the most straightforward jurisdictional threshold.

Complex Concepts Simplified

Article III Standing: A federal court can decide a case only if the plaintiff shows (1) an actual injury, (2) caused by the defendant (traceability), and (3) likely fixable by the court (redressability). If an independent third party (like a doctor) is the real decisionmaker, the causal link to a policy-level defendant may fail.
Traceability: The injury must be fairly attributable to the defendant’s actions, not to someone else’s independent decision. If a treating physician’s medical judgment is the immediate cause of the denial, traceability to policy officials may be lacking absent proof that the policy made the physician act as they did.
Redressability: A court order must likely remedy the injury. If a court cannot force a doctor to recommend a surgery, an injunction against policy officials may not lead to the requested care, defeating redressability.
Factual vs. Facial Standing Attack: In a facial attack, courts accept the complaint’s allegations. In a factual attack, defendants introduce evidence, and the plaintiff must prove standing with evidence (preponderance of the evidence).
Sovereign Immunity and Ex parte Young: States are generally immune from suit, but Ex parte Young allows suits for prospective relief against state officials enforcing unconstitutional policies. Haverkamp closed on standing, so the court did not decide whether Ex parte Young relief could validly compel or direct medical treatment here.
Equal Protection vs. Eighth Amendment: Equal Protection addresses discriminatory treatment between similarly situated persons; the Eighth Amendment forbids cruel and unusual punishments, including deliberate indifference to serious medical needs. Gibson addressed the Eighth Amendment and found no constitutional requirement to provide sex-reassignment surgery; Haverkamp raised Equal Protection but was dismissed on standing grounds before reaching that question.
Policy G-51.11: The Managed Care Committee policy outlines evaluation and hormone therapy for gender dysphoria but is silent on sex-reassignment surgery. The Fifth Circuit emphasized that Haverkamp received some evaluation, distinguishing cases where policies categorically forbid evaluation or consideration.
“Sex-reassignment surgery” terminology: The court used this term for simplicity, noting debate over nomenclature and surgical efficacy. The terminology itself did not affect the disposition.

Conclusion

Haverkamp v. Linthicum establishes a clear and practical standing principle for prison medical-care litigation in the Fifth Circuit: an inmate seeking an injunction to obtain a specific surgery must produce evidence that a treating physician would recommend or refer the inmate for the procedure, or that a policy categorically prevents individualized medical assessment. Absent such evidence, the injury is attributable to the independent professional judgments of non-party physicians, defeating traceability and redressability.

The court’s approach underscores the importance of medical evidence at the jurisdictional stage, especially when defendants mount factual attacks, and it reinforces the judiciary’s reluctance to intrude upon clinical discretion through mandatory injunctive relief. While the decision sidesteps sovereign immunity and equal protection merits, its standing analysis will shape how future plaintiffs structure and prove medical-treatment claims against policy-level officials. The key takeaway is strategic and evidentiary: to pass the Article III gate, plaintiffs must bridge the gap between policy and practice with concrete medical proof that the requested procedure would occur but for the defendants’ actions.