Kingdom v. Trump

• Court: District Court, District of Columbia
• Decided: June 17, 2026
• Docket: Civil Action No. 2025-0691
• Status: Published

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA

ALISHEA KINGDOM, et al.,

Plaintiffs,

v. Case No. 1:25-cv-691-RCL DONALD J. TRUMP, et al.,

Defendants.

MEMORANDUM OPINION

Plaintiffs in this dispute are inmates in the custody of the Bureau of Prisons (“BOP”) who

have been medically diagnosed with gender dysphoria. During their periods of incarceration, BOP

has provided Plaintiffs with hormone therapy, social accommodations, and surgery (collectively

“gender-affirming care”), to mitigate the negative psychological effects of their condition. On

January 20, 2025, President Trump issued Executive Order (“EO”) 14168, titled “Defending

Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal

Government.” Section 4(c) of the EO provides that federal funds shall not be spent on any medical

treatment for the purpose of conforming an inmate’s appearance to that of the opposite sex. BOP

subsequently promulgated two Implementing Memoranda to guide the agency’s execution of the

EO’s commands. On June 3, 2025, this Court stayed both Implementing Memoranda pursuant to

5 U.S.C. § 705, enjoined Defendants from enforcing the EO as applied to gender-affirming care,

and ordered BOP to provide gender-affirming care in accordance with BOP policy and practice in

effect immediately prior to the issuance of the EO on January 20, 2025. This Court also certified

1 a class consisting of “all persons who are currently or will be incarcerated in BOP facilities with a

current diagnosis of gender dysphoria or who receive such a diagnosis in the future.”

On February 19, 2026, BOP Issued Program Statement 5260.01 (“the Program

Statement”), titled “Management of Inmates with Gender Dysphoria,” that superseded the original

Implementing Memoranda. Like those Memoranda and the EO, the Program Statement is a near

total ban on gender-affirming care. At bottom, the Program Statement seeks to provide only

psychotherapy and psychotropic medication to treat gender dysphoria. Plaintiffs, on behalf of the

class, have moved to preliminarily enjoin enforcement of the Executive Order and the Program

Statement, and to stay the Program Statement while this litigation is pending. For the reasons that

follow, Plaintiffs’ Motion is GRANTED with a modification to the scope of the requested

injunction.

With this Opinion, the Court has no intention of wading into the culture war being waged

against transgender individuals. As detailed below, the Court simply decides whether the Bureau

of Prisons followed mandatory administrative procedure when it issued its new policy concerning

the provision of gender-affirming care to inmates diagnosed with gender dysphoria.

I. BACKGROUND

Before considering the merits of Plaintiffs’ challenge to the Program Statement, the Court

finds it necessary to summarize the evidence both parties present regarding gender-affirming care,

as well as the factual background of the new policy and the procedural history of this case.

A. Gender Dysphoria and Gender-Affirming Care

Gender dysphoria is a serious medical condition codified in the American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Declaration of Dr.

Dan H. Karasic in Support of Plaintiffs’ Motion for a Preliminary Injunction (“First Karasic

Decl.”) ¶ 48, ECF No 7-2. The term “gender dysphoria” describes distress related to the

2 incongruence between one’s gender identity and attributes related to one’s sex assigned at birth.

Id. ¶ 47. “The condition is associated with clinically significant distress or impairment in social,

occupational, or other important areas of functioning.” Id. ¶ 49. “When untreated, gender

dysphoria can cause significant distress including increased risk of depression, anxiety, self-harm

and suicidality.” Id. ¶ 51. Defendants do not contest that gender dysphoria exists and that it can

have serious manifestations. Where the parties split is over the medical necessity and efficacy of

several modes of treatment collectively known as “gender-affirming care.” That care includes

hormone therapy, social accommodations to help patients live in line with their gender identities,

and surgery when clinically indicated. Plaintiffs present evidence that gender-affirming care is

widely accepted and effective to treat gender dysphoria. Defendants, by contrast, point primarily

to caselaw and the declaration of a single medical expert with little experience treating gender

dysphoria to demonstrate an emerging “medical debate” over the efficacy and risks associated with

this care.

Through the declarations of medical expert Dr. Dan H. Karasic, 1 Plaintiffs present evidence

of what they characterize as the dominant medical view on gender-affirming care. That view is

summarized as follows: Gender dysphoria is amenable to treatment and the prevailing treatment

for it—gender-affirming care (including hormone therapy, social transition, and surgery when

clinically indicated)—is highly effective. Id. ¶¶ 50–52, 64, 66. Gender-affirming care can

eliminate the distress of gender dysphoria by helping patients live consistently with their gender

1 Dr. Karasic, is a psychiatrist and Professor Emeritus of Psychiatry at the University of California – San Francisco. He has more than 30 years of experience treating patients with gender dysphoria, has served as the chair of the American Psychiatric Association Workgroup on Gender Dysphoria, and previously sat on the Board of Directors of the World Professional Association for Transgender Health (“WPATH”). First Karasic Decl. ¶¶ 4–8, ECF No. 7-2. Dr. Karasic contributed to the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People and remains active in the work of WPATH. Id. ¶ 8.

3 identity. Id. ¶¶ 63, 72. It is supported by all major American medical and mental health

professional organizations and is reflected in the clinical practice guidelines for the treatment of

gender dysphoria that are regularly relied on by healthcare providers. Id. ¶¶ 53–62.

Gender-affirming care has been studied for over half a century and decades of scientific

research and clinical experience have demonstrated that social transition and hormone therapy are

effective in treating gender dysphoria. Id. ¶¶ 28, 72, 73; Declaration of Dr. Dan Karasic in Support

of Plaintiffs’ Motion for an Updated Preliminary Injunction (“Third Karasic Decl.”) ¶ 24, ECF No.

179-2. This evidence is of the type and quality that supports many other widely accepted medical

treatments. First Karasic Decl. ¶ 73, ECF No. 7-2; Third Karasic Decl. ¶ 25, ECF No. 179-2.

Moreover, there is substantial evidence that hormone therapy for treatment of gender dysphoria is

safe and presents risks comparable to the risks associated with other well-accepted medical

treatments, including the use of hormones to treat other conditions in cisgender individuals. See

generally Declaration of Dr. Ole-Petter Hamnvik (“Hamnvik Decl.”), ECF No. 179-3.

For patients for whom gender-affirming care is clinically indicated, no alternative

treatments have been demonstrated to be effective. First Karasic Decl. ¶ 81, ECF No. 7-2.

Moreover, there is no evidence that psychotherapy or psychotropic medications on their own can

alleviate the distress of gender dysphoria. Third Karasic Decl. ¶¶ 41–45. Gender-affirming care

is, therefore, medically necessary. First Karasic Decl. ¶ 28, ECF No. 7-2. Denying individuals

with gender dysphoria the ability to socially transition or obtain hormone therapy will predictably

lead to mental health risks. Id. ¶¶ 28, 39, 80, 82. These risks include exacerbated depression,

anxiety, suicidal ideation, and self-harm. Id. ¶ 83. In extreme cases, individuals may even resort

to self-treatment by attempting to self-castrate or remove their own breasts. Id. ¶¶ 83–84.

4 The government, for its part, suggests that the dominant view no longer enjoys consensus.

To support the ban on gender-affirming care contained in the Program Statement, Defendants point

to evidence throughout the administrative record that purports to demonstrate a “debate” in the

medical community concerning the efficacy of and risks associated with gender-affirming care.

That evidence primarily includes citations to other judicial opinions 2 and a declaration from

medical expert Dr. Kristopher Kaliebe, a psychiatrist retained for the purposes of this litigation

with limited experience treating patients with gender dysphoria. Declaration of Dr. Kristopher

Kaliebe (“Kaliebe Decl.”) ¶ 1, ECF No. 160-2; see also Deposition of Dr. Kristopher Kaliebe in

Keohane v. Dixon (“Kaliebe Tr.”) at 6 (16:07–16:10), 9–10 (20:9–21:10), ECF No. 179-5

(testifying that he has only ever treated around 6 to 8 adult patients with gender dysphoria out of

approximately 20,000 patients over the course of his career).

The government argues that the “debate” in the medical community results from newly

available information that WPATH is a political organization whose guidelines cannot withstand

scientific scrutiny. Mem. in Opp’n to Mot. for Prelim. Injunction (“Opp’n”) at 1–2, ECF No. 186.

Specifically, the government claims that concerns about the body of research underlying the

WPATH model have resulted in a “newer more rapidly evolving clinical landscape” that has

hampered the identification of a universal standard of care. Administrative Record (“AR”) at 3–

8, ECF No. 186–1. As a result, the government notes that many European countries “have

distanced themselves” from the WPATH standards and that leading organizations in the United

2 The government repeatedly cites caselaw as demonstrating “medical debate.” See, e.g., Mem. in Opp’n to Mot. for Prelim. Injunction (“Opp’n”) at 3, 17–19, 33–37, ECF No. 186. But judicial opinions state legal standards—they typically do not carry evidentiary value absent a court taking judicial notice of the facts established in them, and even then, a court must “reach its own, independent findings of fact” notwithstanding what other judges have said in prior cases implicating the same issues. Rimkus v. Islamic Republic of Iran, 750 F. Supp. 2d 163, 172 (D.D.C. 2010); see also Fed. R. Evid. 201(b). Because the government has not attempted to argue that the factual assertions in these cases are deserving of judicial notice, the Court affords no evidentiary weight to these citations.

5 States are also reevaluating their clinical guidance. Id. at 4. The government does not suggest that

the “debate” has resulted in medical consensus around any alternative treatment method, but

nevertheless claims—primarily through the declaration of Dr. Kaliebe—that it is better to treat

gender dysphoria with psychotherapy and psychotropic medications than with gender-affirming

care. AR at 2613–18, ECF No. 186–2. But see Kaliebe Tr. at 46–47 (144:9–145:4), ECF No. 179-

5 (admitting that there is no evidence showing that psychotherapy is efficacious in treating gender

dysphoria).

After becoming aware of this “new” evidence and the “debate” in the medical community,

the government concluded that it was necessary to revise its prior policy of providing gender-

affirming care to inmates diagnosed with gender dysphoria.

B. Factual Background & Procedural History

1. BOP’s Treatment of Individuals with Gender Dysphoria Prior to the EO

BOP is responsible for “the safekeeping, care, and subsistence of all persons charged with

or convicted of offenses against the United States.” 18 U.S.C. § 4042(a). BOP’s Health Services

Division is tasked with delivering “medically necessary health care to inmates effectively[,] in

accordance with proven standards of care[, and] without compromising public safety concerns

inherent to the Bureau’s overall mission.” Program Statement 6010.05 (June 26, 2014), Health

Services Administration § 1, ECF No. 36-2. “Providing health care within a correctional

environment presents unique challenges not encountered by practitioners elsewhere.” Id. § 2.

When there is an “incompatibility between medical and correctional guidelines,” conflicts “should

be resolved, as far as practical, in favor of medicine.” Id. The Health Services Division follows

certain “core principles,” including that all inmates “deserve medically necessary health care” that

is evidence based, meaning that it is “generally supported by outcome data.” Id.

6 Prior to the issuance of EO 14168, inmates in BOP’s custody diagnosed with gender

dysphoria received gender-affirming care when clinically indicated. Declaration of Dr. Cathy

Thompson (“First Thompson Decl.”), ¶ 33, Ex. B thereto (“2022 Transgender Offender Manual”),

and Ex. C thereto (“2023 Clinical Guidelines”), ECF No. 7-3. That care applied well-accepted

medical protocols, including the WPATH guidelines, to individualized patient need. See generally

2023 Clinical Guidelines, ECF No. 7-3. BOP first issued clinical guidelines concerning the care

of individuals with gender dysphoria in 2017 and periodically updated those guidelines to more

“closely align [them] with community standards.” Id. at i. The guidelines were developed in

response to the fact that transgender individuals in BOP custody were more likely to require

services to manage mental health crises than other inmates who are not transgender. First

Thompson Decl. ¶ 27, ECF No. 7-3. The guidelines were most recently updated in 2023 and

included the provision of hormone therapy, social accommodations, and surgical interventions

when clinically indicated.

In 2017, BOP issued the “Transgender Offender Manual,” which called for individualized

assessment for hormone therapy and other treatment in accordance with BOP’s clinical guidelines,

and also set forth the clothing and commissary policies applicable to transgender inmates. Id.

¶¶ 28, 32–38 and Ex. B thereto. To implement these policies, BOP’s Health Services Division

created a Transgender Clinical Care Team made up of physicians, pharmacists, and social workers.

Id. ¶ 33. BOP also created a Transgender Executive Council, which was the “decisionmaking

body on all issues affecting the transgender population.” Id. ¶ 31. That body included senior

correctional leaders from BOP’s Women and Special Populations Branch as well as BOP’s senior

psychologist, psychiatrist, security expert, and medical administrator. Id.

2. EO 14168 and the Original Implementing Memoranda

7 On January 20, 2025, President Donald J. Trump signed an executive order, which provides

in pertinent part:

Sec. 4(c): The Attorney General shall ensure that the Bureau of Prisons revises its policies concerning medial care to be consistent with this order, and shall ensure that no Federal funds are expended for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex.

*** Sec. 8(b): This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

Exec. Order 14168, Defending Women from Gender Ideology Extremism and Restoring

Biological Truth to the Federal Government, 90 Fed. Reg. 8615 (Jan. 20, 2025) (the “Executive

Order” or “EO”).

Pursuant to the command contained in Section 4(c), BOP began the process of

formulating a policy consistent with the Executive Order. On February 21, 2025, BOP issued an

implementing memorandum (the “First Implementing Memorandum”) which provided, in

relevant part, that “[n]o appropriated funds should be utilized to purchase any items that align

with transgender ideology (e.g., binders, stand-to-pee devices, hair removal devices, etc.)” and

that “[r]equests for clothing accommodations (e.g., issuance of smocks for male inmates and

undergarments that do not align with an inmate’s biological sex) will not be issued.” Compl.

Ex.1 thereto (“First Implementing Memorandum”), ECF No 1-1. On February 28, 2025, BOP

issued another implementing memorandum providing that “Consistent with Executive Order

(EO) 14168, . . . no Bureau of Prisons funds are to be expended for any medical procedure,

treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite

sex.” Compl. Ex. 2 thereto (“Second Implementing Memorandum”), ECF No. 1-2.

The three named plaintiffs in this case—transgender inmates who were diagnosed with

gender dysphoria by BOP medical staff, who were in BOP’s custody at the time that the Executive

8 Order and Implementing Memoranda were issued, and who remain in BOP custody today—

initiated this action on March 7, 2025. Compl. ¶¶ 1, 4, 24–26, ECF No. 1.

3. June 3, 2025 Preliminary Injunction

On March 17, 2025, Plaintiffs moved for a preliminary injunction and for class

certification. Mot. for Prelim. Injunction, ECF No. 7. On June 3, 2025, this Court certified a class

consisting of “all persons who are currently or will be incarcerated in BOP facilities with a current

diagnosis of gender dysphoria or who receive such a diagnosis in the future,” Mem. Op. at 27,

ECF No. 67, stayed the Implementing Memoranda pursuant to 5 U.S.C. § 705, and enjoined

Defendants from enforcing EO 14168 or the Implementing Memoranda, id. at 1–2. This Court

concluded that Plaintiffs were likely to succeed on the merits of their APA claim that the

Implementing Memoranda were arbitrary and capricious based, in part, on the lack of a reasoned

explanation for the policy. Id. at 20–23. As a result, this Court did not delve into the merits of

Plaintiffs’ Eighth Amendment claim. Id. at 23.

After the preliminary injunction issued, Defendants informed Plaintiffs’ counsel that BOP

would not produce an administrative record for the Implementing Memoranda, and would instead

produce an administrative record for the new policy it was working on when it issued. Li Nowlin-

Sohl Decl. ¶¶ 10–11, ECF No. 87–2. On February 19, 2026, BOP issued Program Statement

5260.01, titled “Management of Inmates with Gender Dysphoria.” Notice of New BOP Policy,

ECF No. 125. Like the Implementing Memoranda and the EO, the Program Statement is a near

total ban on gender-affirming care.

4. Program Statement 5260.01

At bottom, the Program Statement (or policy) seeks to provide only mental health services

and psychotropic medication to treat gender dysphoria. It prohibits gender-affirming surgery,

9 hormone therapy, and social accommodations, with exceedingly few exceptions. Id. §§ 5(a)-(c),

at 6–8.

The policy’s “Treatment” section purports to establish “individualized, treatment plans that

are tailored to the specific clinical needs of the inmate,” id. § 5(a), at 6, but goes on to state that

“[i]n general, identified medical and psychiatric comorbidities should be addressed before

treatment for [gender dysphoria] proceeds,” id. Indeed, the policy states that “[p]sychotherapy

should be prioritized,” and that further treatment for gender dysphoria may only “proceed once

these medical and psychiatric comorbidities are resolved or ruled out as the potential cause of”

gender dysphoria. Id. The policy then goes on to prohibit several modes of gender-affirming care

for individuals who have not already received them, and to “taper” off those who have.

To begin, BOP will no longer provide sex trait modification surgeries to treat gender

dysphoria. Id. § 5(b), at 7. For inmates who have already received these surgeries, medical care

will be provided to address complications and resulting conditions. Id. Additionally, BOP will

no longer provide social accommodations such as clothing and hair-removal devices to inmates

diagnosed with gender dysphoria. Id. § 5(d), at 8. “If the inmate currently has social

accommodations, the Bureau shall no longer provide the social accommodations and, when

practicable, [will] remove or confiscate the social accommodations.” Id.

Regarding the provision of hormone therapy, the Program Statement differentiates between

several groups of inmates diagnosed with gender dysphoria. For those who are not currently

receiving hormones, BOP will not provide hormone therapy to address gender dysphoria. Id.

§ 5(c)(i), at 7. For inmates who are currently receiving hormones, BOP will place “all such

inmates” on a “tapering plan” that considers “the appropriate factors such as the duration the

inmate has been receiving hormones to address [gender dysphoria], the initial rationale for

10 receiving the hormone intervention, the response by the inmate to the intervention, and whether

the inmate has undergone sex trait modification surgery.” Id. § 5(c)(ii), at 7–8. For those who

have “recently begun receiving hormones,” the tapering plan will include “a rapid discontinuation”

of hormones. Id. at 8. For inmates who have been receiving hormones “for an extended period of

time,” the tapering plan will include “an appropriately paced discontinuation of the hormone

intervention.” Id.

BOP places inmates who are (1) post-surgery or (2) have been receiving hormones for an

“extended period of time and develop severe physiological and psychological withdrawal effects

from tapering” in a category of their own. Id. (emphasis added). For these especially vulnerable

individuals, “it may not be appropriate in all cases for the initial tapering plan to include cessation

of hormones.” Id. However, even for these special groups, “tapering plans should be reevaluated

regularly with respect to cessation of hormones.” Id. Foreseeing that tapering may lead to

complications, the Program Statement notes that for all groups, “[t]apering plans may be adjusted

as necessary . . . but the adjusted tapering plans must still be consistent with the purpose of this

policy.” Id.

5. Administrative Record

On March 12, 2026, BOP filed a certified index of the administrative record associated

with the Program Statement, AR, ECF No. 151, and produced the entire 3,000-page administrative

record to Plaintiffs. Defendants represent that in revising its policy for the treatment of gender

dysphoria, BOP “conducted extensive reviews of, among other things, relevant medical studies,

state correctional policies, pertinent case law, prison administration and security concerns, and

expert medical opinions.” Opp’n at 7, ECF No. 186 (citing AR at 1–4, 5–47, ECF No. 186-1). Of

note, the AR includes a four-page memo on the administrative record itself (“AR Memo”), as well

11 as a 43-page policy memo (“Policy Memo”) explaining the agency’s reasoning for the new policy.

In sum, the agency concluded that due to new evidence of a debate in the medical community

regarding the efficacy of and risks associated with gender-affirming care, the benefits to inmates

of providing such care no longer outweighed BOP’s other security and prison-administration

concerns. See generally Policy Memo, AR at 5–47, ECF No. 186-1. As a result, BOP decided it

would no longer provide gender-affirming care and would instead use psychotherapy and

psychotropic medication to treat gender dysphoria. Id. at 29–30.

6. Motion for an Updated Preliminary Injunction

On April 29, 2026, Plaintiffs Alishea Kingdom, Solo Nichols, and Jas Kapule, on behalf of all

class members, filed a supplemental complaint to challenge the new policy, Supp. Compl., ECF

No. 182, and moved this Court for a preliminary injunction enjoining Defendants, their contractors,

employees, and agents (1) from enforcing Executive Order 14168 as applied to medical care and

social accommodations for people in BOP custody and from enforcing Program Statement

5260.01, and (2) to provide Plaintiffs and class members gender-affirming care in accordance with

BOP policy and practice in effect immediately prior to the issuance of the EO on January 20, 2025.

Mot. for Prelim. Injunction, ECF No. 179. Additionally, Plaintiffs moved for a stay of the Program

Statement pursuant to 5 U.S.C. § 705. Id. On May 13, 2026, Defendants opposed the motion and

filed a motion for summary judgment on all of Plaintiffs’ claims. Opp’n, ECF No. 186. On May

27, 2026, this Court held a hearing on the motion for preliminary injunction. Today, the Court

decides only that motion.

II. LEGAL STANDARDS

A. Preliminary Injunction

Preliminary injunctive relief is warranted if the movant meets its burden to show that (1) the

movant is likely to succeed on the merits; (2) the movant is likely to suffer irreparable harm unless

12 preliminary relief is granted; (3) the balance of the equities favors a preliminary injunction; and

(4) that a preliminary injunction is in the public interest. Winter v. Nat. Res. Def. Council, Inc.,

555 U.S. 7, 20 (2008). Courts in this Circuit have adopted a sliding scale approach to the

preliminary injunction analysis, whereby a relatively strong showing on one of these factors may

partially offset weakness in another, although some non-speculative showing of irreparable harm

is essential. CityFed Fin. Corp. v. Office of Thrift Supervision, 58 F.3d 738, 747 (D.C. Cir. 1995).

Where, as here, the government is a party, the latter two factors of the analysis merge into one,

because the interest of the government is taken to be identical to the interest of the public. Nken

v. Holder, 556 U.S. 418, 435 (2009). In evaluating these factors, a Court must bear in mind that

preliminary injunctive relief is an extraordinary form of relief that “should be sparingly exercised.”

Dorfmann v. Boozer, 414 F.2d 1168, 1173 (D.C. Cir. 1969) (cleaned up). A motion to stay agency

action pending review under 5 U.S.C. § 705 is governed by the same standard. Green Oceans v.

U.S. Dep’t of the Interior, No. 24-cv-141-RCL, 2024 WL 3104945, at *2 n.3 (D.D.C. June 24,

2024).

B. Judicial Review Under the APA

The Administrative Procedure Act provides for judicial review of final agency action. 5 U.S.C.

§§ 702, 704. A reviewing court must “hold unlawful and set aside agency action” that is, among

other defects, “arbitrary, capricious, . . . or otherwise not in accordance with law.” Id. § 706(2).

The APA generally limits judicial review to the administrative record. Theodore Roosevelt

Conservation P’ship v. Salazar, 616 F.3d 497, 514 (D.C. Cir. 2010). Moreover, “to the extent

necessary to prevent irreparable injury,” the APA authorizes courts to “postpone the effective date

of an agency action or to preserve status or rights pending conclusion of the review proceedings.”

Id. § 705. “The four-factor standard used by courts for a motion to stay agency action is the same

13 legal standard as that used in a motion for preliminary injunction.” Hill Dermaceuticals, Inc. v.

U.S. Food & Drug Admin, 524 F.Supp.2d 5, 7 (D.D.C. 2007).

III. DISCUSSION

A. The Court’s Jurisdiction to Enjoin Enforcement of the EO

Plaintiffs moved this Court for a preliminary injunction enjoining Defendants, their

contractors, employees, and agents (1) from enforcing Executive Order 14168 as applied to

medical care and social accommodations for people in BOP custody and from enforcing Program

Statement 5260.01, and (2) to provide Plaintiffs and class members gender-affirming care in

accordance with BOP policy and practice in effect immediately prior to the issuance of the EO on

January 20, 2025. ECF No. 179. Additionally, Plaintiffs moved for a stay of Program Statement

5260.01 pursuant to 5 U.S.C. § 705.

Defendants argue that this Court lacks jurisdiction to enjoin enforcement of the executive

order. Plaintiffs counter that the Court has already done so in this case. See Mem. Op. at 1–2,

ECF No. 67 (enjoining Defendants from enforcing the EO “as applied to medical hormone therapy

and social accommodations for people in the custody of BOP”). While that may be true, it is also

true that jurisdiction was not contested when this Court issued its June 3, 2025 preliminary

injunction. At this early stage of litigation and without more extensive briefing, the Court declines

to take up this question on an expedited basis. Instead, the Court grants Plaintiffs’ injunction with

the following modification:

Defendants, their contractors, employees, and agents are enjoined (1) from enforcing Program Statement 5260.01, and (2) are ordered to provide Plaintiffs and class members gender-affirming medications and social accommodations in accordance with BOP policy and practice in effect immediately prior to the issuance of the EO on January 20, 2025. Additionally, Program Statement 5260.01 is stayed pursuant to 5 U.S.C. § 705.

B. The Plaintiffs Are Likely to Succeed on the Merits of their APA Claim

14 Plaintiffs argue that the Program Statement violates the APA on multiple grounds. First,

because the APA requires courts to set aside unconstitutional agency action, and here the Program

Statement violates the Eighth Amendment. Second, because the Program Statement is arbitrary

and capricious based on its lack of reasoned decisionmaking. Dep’t of Com. v. New York, 588

U.S. 752, 773 (2019). The Court agrees that the Program Statement amounts to arbitrary and

capricious action and accordingly holds that Plaintiffs are likely to succeed on the merits of their

APA claim. The Court declines to reach Plaintiffs’ constitutional arguments at this time, and

accordingly does not take up this aspect of Plaintiffs’ APA claim.

“[A]s a matter of judicial restraint and ‘governance,’ courts generally should endeavor to

resolve cases on non-constitutional grounds and should entertain constitutional questions only

when necessary.” Uthman v. Trump, 486 F. Supp. 3d 350, 356 (D.D.C. 2020) (Lamberth, J.)

(quoting Ashwander v. Tenn. Valley Auth., 297 U.S. 288, 346 (1936)). It stands to reason that the

need for such “judicial restraint” is heightened in cases, such as the one at hand, where the factual

record is necessarily thin due to the procedural posture of the litigation. Therefore, because the

Court assesses that Plaintiffs are likely to prevail on their APA claim, the Court need not delve

into the merits of their Eighth Amendment claim at this time.

1. The Plaintiffs Are Challenging Final Agency Action

As a threshold matter, the Court must determine whether BOP’s actions constitute “final

agency action” susceptible to APA review. 5 U.S.C. § 704. Executive orders themselves are not

susceptible to APA review for the simple reason that “the President is not an ‘agency’ under” the

APA. Chamber of Comm. of U.S. v. Reich, 74 F.3d 1322, 1326 (D.C. Cir. 1996); see also League

of United Latin Am. Citizens v. Exec. Off. of President, 780 F. Supp. 3d 135, 171 (D.D.C. 2025)

(holding that because the President is not an agency, “the APA does not supply a cause of action

15 to challenge an executive order”). However, where the President delegates the implementation of

an executive order to an agency, that agency’s actions are not derivatively shielded from APA

review. See Tate v. Pompeo, 513 F. Supp. 3d 132, 142 (D.D.C. 2021) (holding that an “attempt to

bootstrap the nonreviewability of presidential actions to discretionary authority delegated to” an

agency did “not have support in precedent”); Gomez v. Trump, 485 F. Supp. 3d 145, 177 (D.D.C.

2020) (“To the extent Defendants contend that the court is foreclosed from reviewing agency

actions taken to implement [Presidential] Proclamations, they are wrong.”) (emphasis omitted);

O.A. v. Trump, 404 F. Supp. 3d 109, 147 (D.D.C. 2019) (“The Court . . . need not pause over the

fact that presidential actions are not themselves subject to APA review because it is the Rule, and

not the Proclamation, that has operative effect.”) (citation omitted).

Here, such a delegation plainly appears on the face of the Executive Order. See EO 14168

Sec. 4(c) (instructing the Attorney General and BOP to “revise[] [BOP’s] policies concerning

medical care to be consistent with this order”). Moreover, the Program Statement itself states that

the “Bureau will comply with . . . Executive Order [14168] unless compliance with the Executive

Order is prohibited by a court injunction or court order.” Program Statement § 5, at 5–6, ECF No.

125. As a result, BOP’s actions taken pursuant to this directive, including the Program Statement,

do not partake of the President’s exemption from APA review.

Having determined that the actions challenged here are those of an “agency,” the next

question is whether they are “final.” An agency’s action is final if it “mark[s] the ‘consummation’

of the agency’s decisionmaking process” and is “one by which ‘rights or obligations have been

determined,’ or from which ‘legal consequences will flow . . . .’” Bennett v. Spear, 520 U.S. 154,

177–78 (1997) (first quoting Chi. & S. Air Lines, Inc. v. Waterman S.S. Corp., 333 U.S. 103, 113

(1948), and then quoting Port of Bos. Marine Terminal Ass’n v. Rederiaktiebolaget Transatlantic,

16 400 U.S. 62, 71 (1970)). Both aspects of the Bennett test are met here. BOP’s mind was made up

as to its obligation to provide gender-affirming care by the time the Program Statement was issued

on February 19, 2026. The only reason the new policy has not yet taken effect is because of the

existence of this Court’s preliminary injunction that was first issued on June 3, 2025. So even

though the Program Statement has not yet been applied to class members, BOP’s “decisionmaking

process” undergirding the future termination of Plaintiffs’ gender-affirming treatments is

complete, which is all that Bennett requires. Moreover, the government does not dispute that the

Program Statement represents final agency action.

2. The Plaintiffs Have Demonstrated a Likelihood that BOP’s Action Was Arbitrary and Capricious

The APA provides that agency action may be set aside if it is “arbitrary” or “capricious.”

5 U.S.C. § 706(2)(a). Agency action is arbitrary or capricious if the agency “has relied on factors

which Congress has not intended it to consider, entirely failed to consider an important aspect of

the problem, offered an explanation for its decision that runs counter to the evidence before the

agency, or is so implausible that it could not be ascribed to a difference in view or the product of

agency expertise.” Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm Mut. Auto. Ins. Co., 463

U.S. 29, 43 (1983). “The scope of review under the ‘arbitrary and capricious’ standard is narrow

and a court is not to substitute its judgment for that of the agency.” Id. “A court simply ensures

that the agency has acted within a zone of reasonableness and, in particular, has reasonably

considered the relevant issues and reasonably explained the decision.” F.C.C. v. Prometheus

Radio Project, 592 U.S. 414, 423 (2021).

Plaintiffs contend that the Program Statement is arbitrary and capricious for several

reasons, including that BOP did not properly consider its own prior experience providing gender-

affirming care to inmates diagnosed with gender dysphoria, and because the Program Statement’s

17 prohibition on gender-affirming care is objectively unreasonable given the evidence before the

agency. For these reasons, Plaintiffs argue that the Program Statement was preordained, rests on

a pretextual basis, and is reverse engineered to implement the Executive Order. The government

disputes each of these claims and points to the 3,000-page administrative record as containing

ample evidence of its reasoned decisionmaking. For the reasons that follow, the Court agrees with

Plaintiffs and holds that the Program Statement amounts to arbitrary and capricious agency action.

(i) BOP Did Not Properly Consider Its Own Experience Providing Gender- Affirming Care Under the Prior Policy.

The D.C. Circuit has held that “an agency’s refusal to consider evidence bearing on the

issue before it constitutes arbitrary agency action within the meaning of § 706.” Butte Cnty., Cal.

v. Hogen, 613 F.3d 190, 194 (D.C. Cir. 2010). “This proposition may be deduced from case law

applying the substantial evidence test, under which an agency cannot ignore evidence contradicting

its position.” Id. Here, Plaintiffs contend that the government failed to consider critical

information it had in its possession when formulating the Program Statement: BOP’s own

experience providing gender-affirming care to inmates diagnosed with gender dysphoria for many

years under its prior policy. Based on the current record, the Court agrees that Defendants did not

adequately consider this experience.

The government states that in revising its medical policies on gender-affirming care, it

“considered the relevant issues,” including among other things: “extensive reviews of existing

research, medical expert opinions, medical journals, national media reports, recent medical studies,

state correctional policies, BOP’s prior policies, and pertinent case law.” AR Memo at 1, ECF No.

160-1. Based on this review, the government concluded that gender-affirming care is “unproven”

and “not medically necessary to treat gender dysphoria, especially in the correctional context,”

Policy Memo at 5, 9, 12, 20–21, ECF No. 160-2 (emphasis added). It also concluded that these

18 treatments pose “serious security and prison-administration concerns” within BOP facilities. Id.

at 14, 24. As a result, BOP decided that with very limited exceptions, it would no longer provide

gender-affirming care to inmates diagnosed with gender dysphoria.

These conclusions imply that the government considered evidence from the correctional

environment when formulating its new policy. Indeed, the government acknowledges that it

reviewed “five different state correctional policies (Florida, California, Kentucky, Oklahoma, and

Minnesota) to understand how those states address gender dysphoria in the correctional context.”

Opp’n at 8 (citing AR 3). To be sure, this evidence is relevant to BOP’s new policy. But the

government has other relevant evidence of the efficacy and safety of gender-affirming care in

correctional facilities—its own experience providing this care to inmates diagnosed with gender

dysphoria for nearly a decade.

Recall that BOP first issued clinical guidelines concerning the care of individuals with

gender dysphoria in 2017 and periodically updated those guidelines to more “closely align [them]

with community standards.” 2023 Clinical Guidelines at i, ECF No. 7-3. The guidelines were

most recently updated in 2023 and included the provision of hormone therapy, social

accommodations, and surgical interventions when clinically indicated. In addition, in 2017, BOP

issued the “Transgender Offender Manual,” which called for individualized assessment for

hormone therapy and other treatment in accordance with BOP’s clinical guidelines and also set

forth the clothing and commissary policies applicable to transgender inmates. First Thompson

Decl. ¶¶ 28, 32–44, 38 and Ex. B thereto, ECF No. 7-3. To implement these policies, BOP’s

Health Services Division created a Transgender Clinical Care Team made up of physicians,

pharmacists, and social workers. Id. ¶ 33, Ex. C thereto at 1. BOP also created a Transgender

Executive Council, which was the “decisionmaking body on all issues affecting the transgender

19 population.” Id. ¶ 31, Ex. B thereto at 4. That body included senior correctional leaders from

BOP’s Women and Special Populations Branch as well as BOP’s senior psychologist, psychiatrist,

security expert, and medical administrator. Id. ¶ 31.

And yet, the government does not meaningfully discuss this experience anywhere in the

43-page Policy Memo supporting the Program Statement. Despite providing gender-affirming

care to inmates in its custody for years, the government cites in the Program Statement zero

evidence from its own medical or mental health professionals to support its conclusions.

Moreover, the government does not point the Court to evidence that gender-affirming care was

ineffective or harmful to its own inmates diagnosed with gender dysphoria, or that providing this

care previously led to security concerns at BOP facilities.

In its opposition to Plaintiffs’ motion, the government argues that the APA does not require

it to scrutinize “any particular documents” concerning inmates’ treatment histories under the prior

policy, “especially here where many of the BOP senior officials who wrote, consulted[,] and

applied the previous BOP policy were also responsible for evaluating, implementing, and

ultimately formulating” the Program Statement. Opp’n at 32, ECF No. 186. The government

claims that “those officials” used their “experience with the prior policy to help formulate the 2026

Policy.” Id. at 31 (internal quotation marks omitted). But this claim is not supported by the Policy

Statement or the AR, and instead, it comes solely from the declaration of BOP Medical Director

Dr. Elizabete Stahl, which appears in the record for the first time as an attachment to Defendants’

opposition. See generally Stahl Decl., ECF No. 186-3.

Notwithstanding the fact that Dr. Stahl goes on to essentially concede that the government

did not consider its own experience, see id. ¶ 16 (attesting that the treatment histories of BOP

inmates would not be helpful because “there is not a vetted, or validated clinical instrument that

20 measures the success or failure of gender dysphoria treatment”), her declaration cannot be credited.

“It is a foundational principle of administrative law that judicial review of agency action is limited

to the grounds that the agency invoked when it took the action.” Dep’t of Homeland Sec. v. Regents

of the Univ. of Cal., 591 U.S. 1, 20 (2020) (internal quotation marks omitted). Post-hoc

rationalizations during litigation cannot replace the type of reasoned analysis the government must

undertake at the front end. See American Textile Mfrs. Inst., Inc. v. Donovan, 452 U.S. 490, 539

(1981) (stating that “the post-hoc rationalizations of the agency or the parties to this litigation

cannot serve as a sufficient predicate for agency action.”). Here, the government does not invoke

this evidence from Dr. Stahl anywhere in the administrative record. Moreover, Dr. Stahl’s

declaration is dated May 12, 2026—nearly three months after BOP formally announced the

Program Statement. Stahl Decl. at 7, ECF No. 186-3. Thus, Dr. Stahl’s post-hoc statements cannot

ameliorate the government’s failure to demonstrate that it meaningfully considered its prior

experience.

Accordingly, the Court finds that the Program Statement amounts to arbitrary and

capricious agency action because the government failed to seriously consider its own experience

providing gender-affirming care to inmates for years under its prior policy.

(ii) The Program Statement is Objectively Unreasonable Given the Evidence Before the Agency.

The Program Statement is separately arbitrary and capricious because it reaches a

conclusion “so implausible that it could not be ascribed to a difference in view or the product of

agency expertise,” as evidenced by its explanation, which “runs counter to the evidence before the

agency.” Evergreen Shipping Agency (Am.) Corp. v. Federal Mar. Comm’n, 106 F.4th 1113, 1117

(D.C. Circ. 2024) (quoting State Farm, 463 U.S. at 43). “Such illogical decisions are not rationally

21 connected to the facts and are thus arbitrary and capricious.” Markel v. Del Toro, 2025 WL

304875, at *6 (D.D.C. Jan. 27, 2025).

Instead of relying on BOP’s own medical or mental health professionals, the agency

supports its new policy with a declaration by a doctor it retained specifically for this litigation,

who has limited experience treating gender dysphoria, and who promotes a treatment for gender

dysphoria that he himself acknowledges is not evidence based. See Kaliebe Tr. at 9–10 (20:9–

21:10), ECF No. 179-5 (conceding minimal experience treating individuals diagnosed with gender

dysphoria); id at 46–47 (144:9–145:4) (admitting that no evidence supports psychotherapy as a

treatment for gender dysphoria). But as Plaintiffs have demonstrated, the evidence before the

agency suggests that denying gender-affirming care to patients for whom such care is medically

necessary can lead to a deterioration in mental health and increase depression, anxiety, and self-

harm rates. See First Karasic Decl. ¶¶ 39, 80–85, ECF No 7-2. And whereas the government

provides no support for its assertion that gender-affirming care could increase self-harm, Policy

Memo at 24, ECF No. 160-2, Plaintiffs’ experts—who unlike Dr. Kaliebe, have considerable

experience treating gender dysphoric patients—testify that this claim is unfounded, Third Karasic

Decl. ¶ 49, ECF No. 179-2; Second Thompson Decl. ¶ 29, ECF No. 179-4.

An agency’s judgment “must be based on logic and evidence, not sheer speculation.”

Council of Parent Att’ys and Advocates v. Devos, 365 F. Supp. 3d 28, 51 (D.D.C. 2019) (quoting

Sorenson Commc’ns Inc. v. F.C.C., 755 F.3d 702, 708 (D.C. Cir. 2014)) (cleaned up). Banning

evidence-backed care for an alternative that has no evidentiary support is an “implausible strategy”

to treat gender dysphoria, Bedford Cnty. Mem’l Hosp. v. Health & Hum. Servs., 769 F.2d 1017,

1022 (4th Cir. 1985), to say the least. Nor can the government’s attacks on the WPATH standards

of care overcome decades of research and clinical experience demonstrating the efficacy of gender-

22 affirming care. See Third Karasic Decl. ¶ 60, ECF No. 179-2. Thus, the government has not

demonstrated a reasonable basis to adopt a policy prohibiting this care. Because the Program

Statement does not follow from the evidence in the record, it is likely arbitrary and capricious.

(iii) The Program Statement is Pretextual and Reverse Engineered to Implement EO 14168.

Finally, Plaintiffs contend that the Program Statement violates the APA because it is

pretextual, preordained, and reverse engineered in response to this litigation to implement EO

14168’s directives. Mot. at 34–36, ECF No. 179-1. To support this claim, Plaintiffs point to

identical language contained in the Program Statement and the EO, BOP’s failure to consider its

prior experience, and the lack of a rational connection between the evidence and BOP’s new

policy. Id. Defendants counter that the Program Statement could not be pre-ordained because it

is the result of approximately 12 months of study, and in any event the policy is rationally

connected to the facts found during that time. Opp’n at 30–31, ECF No. 186. The Court is not

convinced.

When the record reveals that an agency “preordained [its] decision,” Miot v. Trump, 818

F. Supp. 3d 126, 175 (D.D.C. 2026), cert granted before judgment, 2026 WL 731087 (U.S. Mar.

16, 2026), and the agency merely “reverse engineered” a policy to justify the same outcome—

thereby engaging in a “pretextual” action, Saget v. Trump, 375 F. Supp. 3d 280, 361 (E.D.N.Y.

2019) (quoting Cowpasture River Pres. Ass’n v. Forest Serv., 911 F.3d 150, 176 (4th Cir. 2018)),

that is itself a violation of the APA. Based on the existing record, the Court finds that is the case

here.

Recall that the stated intent of the Program Statement “is for federal funds to not be

expended for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s

appearance to that of the opposite sex.” Program Statement 5260.01 § 8, at 9, ECF No. 125. That

23 language comes directly from EO 14168, a fact the Program Statement acknowledges directly. Id.

§ 5, at 5–6 (“Executive Order 14,168 . . . prohibits the Bureau from expending federal funds for

‘any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance

to that of the opposite sex’ . . . . The Bureau will comply with this Executive Order unless

compliance with the Executive Order is prohibited by a court injunction or court order.”).

Nevertheless, BOP insists that, even though the EO “supports this policy, the Bureau also adopts

this policy independently” of the EO. Id. § 5, at 6. As Plaintiffs say, “[t]he suggestion that BOP

happened to independently reach the same result as the one required by the EO is preposterous.”

Mot. at 36, ECF No. 179-1. It is more likely, given the record before the Court, that the government

disregarded significant evidence in its possession to reach the EO’s mandated result.

The Court’s conclusions in subsections (B)(2)(i)–(ii) provide further evidence of pretext.

If the government intended to form a policy based on the evidence, one would expect it to have

seriously considered its own experience providing gender-affirming care to inmates in its custody.

Moreover, the government would not have concluded that this care is “not medically necessary”

and “poses security and prison-administration concerns” despite ample record evidence to the

contrary. Plaintiffs theorize that after this Court enjoined BOP’s original Implementing

Memoranda for lack of even a basic explanation, the agency “cherry-picked” materials to support

the same predetermined policy choice. Mot. at 36, ECF No. 179-1 (quoting Afr. Communities

Together v. Noem, 2026 WL 395732, at *10 (D. Mass. Feb. 12, 2026)). The government disputes

this series of events. Instead, it argues that the new policy is more than a mere repacking of the

2025 Implementing Memoranda because it took nearly 12 months to create. This argument is

unavailing. No length of consideration can convince the Court that a policy is anything other than

pretext when the agency has not demonstrated that it considered the relevant evidence and drew a

24 reasonable conclusion from that evidence. Because the Program Statement appears to be

pretextual, it is arbitrary and capricious under the APA.

Having found that BOP’s prohibition on gender-affirming care is likely arbitrary and

capricious under the APA, the Court leaves Plaintiffs’ Eighth Amendment claims for another day.

C. The Plaintiffs Have Shown Sufficient Likelihood of Irreparable Harm

To obtain a preliminary injunction, Plaintiffs must demonstrate that irreparable injury “is

likely in the absence of an injunction.” Winter, 555 U.S. at 22 (emphasis omitted). Irreparable

harm results where damages cannot adequately compensate for the loss if the injunction is denied.

National Senior Citizens Law Center, Inc. v. Legal Services Corp., 581 F. Supp. 1362, 1372

(D.D.C. 1984).

Recall that all class members have “a current diagnosis of gender dysphoria or [will]

receive such a diagnosis in the future.” Mem. Op. at 27, ECF No. 67. Plaintiffs have put forward

evidence that gender-affirming care is the only effective treatment for gender dysphoria, and that

severe harms flow from the cessation of such care. While not every class member requires the

same treatment for their gender dysphoria, Plaintiffs argue that irreparable harm flows from the

government’s categorical ban on the only type of care that is effective at treating their condition.

On this record, the Court finds that Plaintiffs have carried their burden of showing irreparable

harm.

1. Efficacy of Gender-Affirming Care

Through their expert, Dr. Dan Karasic, Plaintiffs assert that a substantial body of research

and clinical experience has proven that gender-affirming care is effective in treating gender

dysphoria, and that this conclusion is widely held in the medical community. First Karasic Decl.

¶¶ 72–76, 78, ECF No. 7-2; Third Karasic Decl. ¶¶ 32–35, ECF No. 179-2. According to Dr.

25 Karasic, every major medical and mental health professional organization in the United States

recognizes the efficacy of gender-affirming care, including the American Medical Association, the

American Psychological Association, the American Psychiatric Association, and the Endocrine

Society. Third Karasic Decl. ¶ 33, ECF No. 179-2; see also id. ¶ 11 (opining that “social transition

and hormone therapy for the treatment of adults with gender dysphoria are not the subject of

controversy or debate within the medical and mental health fields” and that “[t]o the extent there

is any controversy about these treatments in public discourse, it is limited to the context of pediatric

patients with gender dysphoria”). Dr. Karasic further attests that, those “[f]or whom gender

affirming medical care is indicated, no alternative treatments have been demonstrated to be

effective.” First Karasic Decl. ¶ 70, ECF No. 7-2. “Denying patients with gender dysphoria the

ability to socially transition or obtain gender-affirming medical care where indicated predictably

will lead to significant deterioration in mental health.” Id. ¶ 82.

It's true that the government puts forward some evidence to contest these conclusions. See

Kaliebe Decl., ECF No. 160-3. There is, however, a clear winner in the battle of the experts. Only

Plaintiffs have put forward evidence attested to by medical professionals with meaningful

experience treating people with gender dysphoria. The government’s evidence comes principally

from Dr. Kaliebe, a psychiatrist hired by DOJ to be its “psychiatric expert.” Stahl Decl. ¶ 41, ECF

No. 186-3. As mentioned, Dr. Kaliebe has limited experience treating patients with gender

dysphoria. Kaliebe Tr. at 9–10 (20:9–21:10), ECF 179-5 (testifying that he has only ever treated

around 6 to 8 adult patients with gender dysphoria out of approximately 20,000 patients over the

course of his career). Similarly, BOP’s Medical Director, Dr. Stahl, who “consult[ed] with” Dr.

Kaliebe, also has little experience treating gender dysphoria. Stahl Decl. ¶¶ 13, 41, ECF No. 186-

3 (admitting that she treated a “small number of patients”).

26 What’s more, although the government acknowledges that gender dysphoria is a serious

disorder, the only treatment options it intends to provide are psychotherapy and psychotropic

medication—even though Dr. Kaliebe has previously admitted that there is no evidence showing

that psychotherapy is efficacious in treating gender dysphoria, Kaliebe Tr. at 46–47 (144:9–145:4),

ECF No. 179-5, and Dr. Stahl has acknowledged that psychotropic medication treats co-

morbidities, Stahl Decl. ¶ 6, ECF No. 186-3, not the condition of gender dysphoria itself, see also

Third Karasic Decl. ¶¶ 41–48, ECF No. 179-2 (agreeing that these treatments do not ameliorate

gender dysphoria).

The government also attempts to challenge the efficacy of gender-affirming care by

suggesting that there is a lack of “high quality” research backing these treatments. Opp’n at 8,

ECF No. 186 (citing AR at 1552). But Dr. Karasic explains that “high quality” research is a term

of art generally referring to randomized controlled trials, while all other types of research are

deemed “low quality” by comparison. Third Karasic Decl. ¶¶ 25–26, ECF No. 179-2. While

randomized controlled trials may be the gold standard, they are often infeasible or unethical, and

many widely accepted medical treatments are supported only by “low quality” evidence, such as

cross-sectional and longitudinal observational studies—the same type and quality of research

demonstrating the efficacy of gender-affirming care. Id. ¶ 25.

Based on this record, the Court concludes that Plaintiffs have demonstrated that gender

affirming care is the only effective treatment for gender dysphoria. The Court now turns to the

question of whether denying this medically necessary care gives rise to irreparable injury.

2. Consequences of Denying Gender-Affirming Care

The named plaintiffs, along with other class members, have described the harms they faced

when BOP previously denied them hormone therapy. Declaration of Alishea Sophia Kingdom

27 (“Kingdom Decl.”) ¶¶ 21–22, ECF No. 7-4 (experiencing symptoms including anxiety, panic

attacks, thoughts of self-harm and suicidal ideation when hormone therapy was withdrawn); Third

Declaration of Solo Nichols (“Third Nichols Decl.”) ¶ 3, ECF No. 179-7 (experiencing hot flashes,

rapid mood swings, insomnia, and “unreasonable sad[ness]”); Third Kapule Decl. ¶¶ 2–9, ECF

No. 179-8 (experiencing depression, anxiety, and worsening gender dysphoria); Declaration of

Rebecca-James Meskill (“Meskill Decl.”) ¶ 12–13, ECF No. 107-11 (experiencing worsening

mental health and “feeling diminished in every aspect of life” due to “re-masculinizing” body).

The government insists that this time will be different because it will provide class members with

“individualized” tapering plans for their hormone therapy, along with mental health counseling.

See Opp’n at 41–44, ECF No. 186. But even if the government’s tapering process mitigates severe

withdrawal symptoms, it will “not prevent the predictable serious harms of denying hormone

therapy to those who have a medical need for it.” Third Karasic Decl. ¶ 19, ECF No. 179-2. Put

simply, there is reason to believe, based on the record, “that withdrawing people from hormone

therapy they have been receiving to treat gender dysphoria”—regardless of the rate of tapering and

regardless of the availability of psychotherapy—will “cause[e] significant mental health distress.”

Id. ¶ 21. And the same is true of the government’s plan to confiscate class members’ social

accommodations. Id. ¶ 9; see also Supplemental Declaration of Solo Nichols (“Nichols Supp.

Decl.”) ¶ 6, ECF No. 56-1 (describing worsening mental health and gender dysphoria absent social

accommodations); Declaration of Grace Pinson (“Pinson Decl.”) ¶ 20, ECF No. 107-2 (same);

Declaration of Valerie Simpkins (“Simpkins Decl.”) ¶ 13, ECF No. 107-4 (same); Declaration of

Justine Finley (“Finley Decl.”) ¶ 11, ECF No. 107-6 (same); Declaration of Tiffany Larson

(“Larson Decl.”) ¶ 16, 107-12 (same); Declaration of Gigi Auliyaa (“Auliyaa Decl.”) ¶ 9, ECF No.

107-13 (same).

28 The government next argues that under Doe v. Blanche, 172 F.4th 901 (D.C. Cir. 2026),

the Court is required to make individualized findings of each class member’s risk. But in Doe, the

Circuit held that fact-finding was required because the plaintiffs in that case expressly disclaimed

the argument that BOP’s categorical ban on housing transgender women in women’s prisons was

unlawful as to every transgender woman in BOP’s custody. See id. at 916–18. Rather, the Doe

plaintiffs argued on appeal that they possessed certain characteristics that made them particularly

vulnerable to being housed in men’s facilities. Id. at 916. Here, Plaintiffs argue that the

government’s categorical ban—which precludes medical professionals from prescribing a gender-

affirming treatment plan based on an inmate’s unique needs—puts all class members at risk of

being denied medically necessary care. Unlike in Doe, the Kingdom class members are injured by

virtue of their gender dysphoria diagnosis alone, making individualized findings unnecessary for

irreparable harm purposes.

The record shows that denying class members gender-affirming hormone therapy and

social accommodations will cause irreparable injuries, including the exacerbation of their gender

dysphoria and increased risk of depression, anxiety, self-harm (including attempts to self-castrate),

and suicidality. First Karasic Decl. ¶¶ 72, 83–86, ECF No. 7-2; see also Third Karasic Decl. ¶¶ 18–

25, ECF No. 179-2 (detailing the harms associated with withholding medically necessary care to

treat gender dysphoria). Plaintiffs have therefore carried their burden of showing irreparable harm.

D. The Balance of the Equities and the Public Interest Favor an Injunction

Where, as here, “the Government is the opposing party,” the balance-of-equities factor and

the public-interest factor “merge,” Nken, 556 U.S. at, because “the government’s interest is the

public interest,” Pursuing Am.’s Greatness v. Fed. Election Comm’n, 831 F.3d 500, 511 (D.C. Cir.

2016). As this Court noted in its prior opinion, the “only deleterious public effect of the Court’s

29 injunction will be to require that, during the pendency of the litigation, [] BOP will continue to

shoulder” the “administrative cost” of gender-affirming care, which it had voluntarily “borne for

many years prior” to the commencement of this action. Mem. Op. at 26, ECF No. 67. The same

remains true today. Then, as now, the equities tilt in Plaintiffs’ favor because their interests in

receiving medically prescribed treatment outweighs the minimal cost to the government of

continuing such treatment. The government also emphasized its interest in effectuating the

administration’s agenda, Opp’n at 44, ECF No. 186, but that consideration is outweighed by the

public’s interest in the government’s adherence to the law.

Finally, the government raises the specter of prison safety, asserting that gender-affirming

care leads to security and prison-administration concerns. Id. at 37. Though the Court does not

discount the possibility that a highly feminized transgender woman faces threats to her safety in a

men’s facility (or that a highly masculinized transgender man faces the same in a women’s

facility), the government has not cited a single instance of gender-affirming care giving rise to

safety concerns despite having provided such care for many years. This failure is conspicuous.

The Court’s previous injunction has been in place for more than a year, yet the government

provides no evidence of gender-affirming care giving rise to prison safety issues during this time.

The balance of the equities therefore favor Plaintiffs.

E. No Bond Should Be Required

Federal Rule of Civil Procedure 65(c) provides that “[t]he court may issue a preliminary

injunction . . . only if the movant gives security in an amount that the court considers proper to pay

the costs and damages sustained by any party found to have been wrongly enjoined.” Fed. R. Civ.

P. 65(c). “Courts in this Circuit have found the Rule vests broad discretion in the district court to

determine the appropriate amount of an injunction bond, including the discretion to require no