Roy Mitchell, Jr. v. Kevin Kallas ( 2018 )


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  •                                    In the
    United States Court of Appeals
    For the Seventh Circuit
    ____________________
    No. 16-3350
    LISA MITCHELL,
    Plaintiff-Appellant,
    v.
    KEVIN KALLAS, et al.,
    Defendants-Appellees.
    ____________________
    Appeal from the United States District Court for the
    Western District of Wisconsin.
    No. 15-cv-108 — William M. Conley, Judge.
    ____________________
    ARGUED JANUARY 10, 2018 — DECIDED JULY 10, 2018
    ____________________
    Before WOOD, Chief Judge, HAMILTON, Circuit Judge, and
    BUCKLO, District Judge. *
    WOOD, Chief Judge. Lisa Mitchell is a transgender person
    who has identified as a woman her entire life. After an arrest
    in Wisconsin, officials from the state’s Department of Correc-
    tions (“DOC”) repeatedly prevented Mitchell from obtaining
    *Of   the Northern District of Illinois, sitting by designation.
    2                                                   No. 16-3350
    access to the treatments she needed to express her gender
    identity. It took DOC over a year to evaluate Mitchell’s candi-
    dacy for hormone therapy, and even then, nothing happened.
    Instead, DOC refused to provide Mitchell with the treatment
    its own expert recommended, on the ground that Mitchell
    was within a month of release from the prison. Although
    DOC’s Mental Health Director, Dr. Kevin Kallas, encouraged
    Mitchell to find a community provider to prescribe her hor-
    mones, DOC parole officers prevented Mitchell from follow-
    ing this advice. Still under state custody, the terms of Mitch-
    ell’s parole actually prohibited her from taking hormones or
    dressing as a woman.
    Mitchell sued, contending that the prison doctors and the
    parole officers violated her constitutional rights. It is well es-
    tablished that persons in criminal custody are entirely de-
    pendent on the state for their medical care. Estelle v. Gamble,
    
    429 U.S. 97
    , 103 (1976). Prison officials thus have a constitu-
    tional duty to provide inmates with the care they require for
    their serious medical needs. Prison staff cannot bide their time
    and wait for an inmate’s sentence to expire before providing
    necessary treatments. This affirmative obligation ends when
    imprisonment does, but state officials may not block a parolee
    from independently obtaining health care. The only limitation
    is that the condition be serious enough to trigger constitu-
    tional protection; otherwise the nature of the disorder is irrel-
    evant. Because the district court prematurely rejected some of
    Mitchell’s claims, we reverse in part.
    I
    In 2008, Mitchell received a diagnosis of gender dyspho-
    ria. A few years later, she was convicted of a crime and sent
    to Wisconsin’s Columbia Correctional Institution on October
    No. 16-3350                                                    3
    11, 2011, to serve her sentence. On November 25, 2011, Mitch-
    ell asked for hormone treatment. Her request initiated a mul-
    tistep process that DOC outlined in its then-new policy on
    Health Care Treatment of Gender Identity Disorder. That pol-
    icy was first implemented on December 19, 2011. Step one un-
    der the policy required Mitchell’s clinician to conduct a pre-
    liminary assessment. She did so, producing a written report
    about Mitchell on February 10, 2012. Next, the Gender Dys-
    phoria Committee reviewed the report and decided to refer
    Mitchell’s request for hormone therapy to its outside consult-
    ant, Cynthia Osborne. Osborne is a social worker and assis-
    tant professor at Johns Hopkins University, in Maryland; she
    specializes in providing gender-dysphoria evaluations. Since
    Osborne visited the Wisconsin facilities roughly every two
    months, Dr. Kallas informed Mitchell that she would meet
    with Osborne in April. That interview did not occur until May
    22, 2012, however, nearly six months after Mitchell’s initial re-
    quest for care.
    During the months leading up to and following the inter-
    view, Mitchell repeatedly inquired about her health care re-
    quest. She asked Dr. Dawn Laurent, the prison’s Psychologi-
    cal Services Unit Supervisor, for an update on April 8, 2012.
    Dr. Laurent did not respond. Instead, Mitchell’s assigned cli-
    nician wrote back, promising to follow up. Mitchell also wrote
    letters to Dr. Kallas. In his October 8 reply, Dr. Kallas in-
    formed Mitchell that Osborne’s report was “nearly complete”
    and should be finished “in a matter of days.” He explained
    that Osborne was just trying to get in touch with two people
    whom Mitchell named as references. Dr. Kallas recognized
    that “considerable time ha[d] passed” and thanked Mitchell
    for her patience.
    4                                                  No. 16-3350
    The long delay was not cost-free for Mitchell. While she
    waited, her psychological health was deteriorating. In
    May 2012, she reported feeling unsafe with silverware. A cli-
    nician’s notes from July reflect that she was “not doing well
    regarding gender identity disorder issues.” Though she was
    receiving periodic counseling services, the notes from these
    sessions suggest that they focused on her other mental health
    conditions, such as her post-traumatic stress (the result of a
    violent hate crime committed against her when she was 18).
    To the extent Mitchell’s gender dysphoria was discussed, the
    notes primarily refer to the harassment Mitchell experienced
    and her desire to know the status of her treatment request.
    Osborne did not submit a draft of her report until Novem-
    ber 15, 2012. Curiously, the report was dated September 27.
    Mitchell received a copy of the draft on November 28, and the
    report was finalized on December 2. Though Osborne’s con-
    clusions came a full year after Mitchell asked for hormone
    treatment, her recommendations strongly supported Mitch-
    ell’s request. Osborne concluded that Mitchell “is an excellent
    candidate for hormone therapy” and predicted that this treat-
    ment would very likely improve Mitchell’s “functional stabil-
    ity and sense of psychological well-being.” Osborne expected
    that hormones would help not only with Mitchell’s gender
    dysphoria, but also with her post-traumatic stress as well.
    Based on Osborne’s unequivocal recommendation, Mitch-
    ell resubmitted her request for hormone therapy the same day
    that she reviewed the draft report. Dr. Kallas turned her down
    on January 2, 2013. His letter explained that she was not eligi-
    ble for treatment because she was scheduled to be released
    that month. As a “point of information,” Dr. Kallas said, DOC
    starts inmates on hormone therapy only when they have at
    No. 16-3350                                                  5
    least six months left on their sentences, in order to allow for
    the several-month process of getting the person stabilized on
    the medication. Dr. Kallas encouraged Mitchell to seek hor-
    mone treatment upon her release; he even offered a copy of
    Osborne’s report and information about community provid-
    ers.
    But Mitchell was thwarted again after her release on Janu-
    ary 8, 2013. When she tried to follow up on Dr. Kallas’s sug-
    gestion, her parole officers flatly forbade her from seeking
    hormone therapy. Indeed, as a condition of her parole, she
    was required to dress and present as a man. Though Mitchell
    provided the agents with a copy of Osborne’s report and rec-
    ommendations, the officers did not relent.
    On February 18, 2015, Mitchell filed a pro se complaint in
    federal court against Dr. Kallas, Dr. Laurent, and DOC parole
    officers Joseph Ruhnke, Brittany Wolfe, and Nicole Raisbeck.
    (Mitchell also initially sued two DOC Secretaries, but she has
    not appealed the dismissal of these defendants.) The district
    court understood the suit as one under 
    42 U.S.C. § 1983
     alleg-
    ing deliberate indifference to a serious medical need. As re-
    quired by the Prison Litigation Reform Act (PLRA), the court
    began by screening Mitchell’s complaint. 28 U.S.C.
    § 1915A(a). It concluded that Mitchell failed to state a claim
    against the parole officers under the Eighth Amendment (as
    applied to the states through the Fourteenth Amendment),
    and so it dismissed them without prejudice. Though the court
    allowed the claims against Drs. Kallas and Laurent to pro-
    ceed, it later granted summary judgment for them. It deter-
    mined that neither one was deliberately indifferent to Mitch-
    ell’s gender dysphoria, and regardless, both were entitled to
    qualified immunity. Mitchell filed an earlier appeal in which
    6                                                  No. 16-3350
    she challenged some aspects of her parole, but we dismissed
    on the ground that it was moot. Mitchell v. Wall, 
    808 F.3d 1174
    (7th Cir. 2015). The merits are now before us, and as there is
    no mootness problem this time, we consider whether the dis-
    trict court properly dismissed Mitchell’s claims.
    II
    As we noted earlier, because a person is deprived of her
    liberty while incarcerated, she “must rely on prison authori-
    ties to treat [her] medical needs.” Gamble, 
    429 U.S. at 103
    . Un-
    able to call her own doctor or walk into a hospital, an inmate
    with medical problems will go without treatment unless the
    prison provides care. If prison medical staff exhibit deliberate
    indifference to an inmate’s serious medical condition, they
    subject her to unnecessary and wanton pain and suffering and
    thereby run afoul of the Eighth Amendment. 
    Id.
     at 104–05; Pet-
    ties v. Carter, 
    836 F.3d 722
    , 727–28 (7th Cir. 2016) (en banc).
    The state defendants do not dispute that Mitchell’s gender
    dysphoria is a serious medical condition or that she never re-
    ceived hormones while in DOC custody. They maintain, how-
    ever, that no jury could find that they were deliberately indif-
    ferent to her condition. To establish deliberate indifference, a
    plaintiff must show that the defendant “actually knew of and
    disregarded a substantial risk of harm.” Petties, 836 F.3d at
    728. Failing to provide care for a non-medical reason, when
    that care was recommended by a medical specialist, can con-
    stitute deliberate indifference. Perez v. Fenoglio, 
    792 F.3d 768
    ,
    778 (7th Cir. 2015). So too can inexplicable delays in treatment
    where the delays serve no penological purpose. Petties,
    836 F.3d at 730. The district court held that neither the 13-
    month delay in evaluating Mitchell’s request nor its ultimate
    denial constituted deliberate indifference. Moreover, the
    No. 16-3350                                                    7
    court determined, the defendants were entitled to qualified
    immunity because there was no clearly established right to
    hormone treatment when requested. We take a fresh look at
    the district court’s conclusions, viewing the record in the light
    most favorable to Mitchell. See Orlowski v. Milwaukee Cnty.,
    
    872 F.3d 417
    , 421 (7th Cir. 2017); Zimmerman v. Doran, 
    807 F.3d 178
    , 182 (7th Cir. 2015).
    A
    We start with Dr. Laurent. For a defendant to be liable un-
    der section 1983, she must be personally responsible for the
    alleged deprivation of the plaintiff’s constitutional rights. Wil-
    son v. Warren Cnty., 
    830 F.3d 464
    , 469 (7th Cir. 2016). The per-
    sonal-involvement requirement is satisfied if the constitu-
    tional violation occurs at a defendant’s direction or with her
    knowledge or consent. 
    Id.
     Here, the alleged deprivation of ad-
    equate medical care occurred because of the time it took to
    resolve Mitchell’s treatment request and the ultimate out-
    come—rejection. Dr. Laurent was not a member of the Gender
    Dysphoria Committee, nor did she take part in the decisions
    to get a consultation from Osborne or to deny Mitchell’s re-
    quest for hormones.
    Nonetheless, Dr. Laurent may be liable under section 1983
    if she acquiesced in the failure to provide necessary medical
    treatment. Minix v. Canarecci, 
    597 F.3d 824
    , 833–34 (7th Cir.
    2010). Dr. Laurent was the psychological services supervisor
    at the prison where Mitchell was housed. In that role, she
    signed treatment notes from sessions where Mitchell com-
    plained about her distress and the harassment she experi-
    enced as a result of her gender dysphoria. Though Dr. Lau-
    rent was not Mitchell’s assigned clinician, she did meet with
    Mitchell for one session. Additionally, in April 2012, Mitchell
    8                                                    No. 16-3350
    directly asked Dr. Laurent for an update on when she would
    meet with Osborne.
    Yet, even assuming that she knew about Mitchell’s dis-
    tress, there is no evidence that Dr. Laurent could have sped
    up Osborne’s evaluation or the Committee’s deliberations, or
    could have influenced the Committee’s final decision. In fact,
    there is evidence that as a psychologist, Dr. Laurent had no
    authority to order hormone therapy. Because Dr. Laurent was
    not sufficiently involved in the failure to provide hormone
    therapy, the district court properly granted summary judg-
    ment in her favor.
    B
    Next we turn to Dr. Kallas. As DOC’s Mental Health Di-
    rector and a member of the Gender Dysphoria Committee,
    Dr. Kallas was directly involved in Mitchell’s treatment. He
    contacted Osborne for a consultation and sat on the Commit-
    tee that ultimately denied Mitchell’s request.
    We begin with the question whether Dr. Kallas is entitled
    to qualified immunity. A prison official is immune from suit
    if the constitutional right at issue was not clearly established
    at the time of the violation, and thus a reasonable officer
    would not have known that his conduct was unlawful. Or-
    lowski, 872 F.3d at 421. In deciding whether a right was clearly
    established, it is essential to assess the case at the right level
    of specificity. White v. Pauly, 
    137 S. Ct. 548
    , 551–52 (2017). But
    this particularity requirement does not go so far as to mandate
    a mirror-image precedent from the Supreme Court or this
    court. Ziglar v. Abbasi, 
    137 S. Ct. 1843
    , 1866–67 (2017) (stating
    that the “very action in question” need not have been found
    to be unlawful (citation omitted)). As we put it recently, the
    No. 16-3350                                                    9
    Eighth Amendment duty “need not be litigated and then es-
    tablished disease by disease or injury by injury.” Estate of
    Clark v. Walker, 
    865 F.3d 544
    , 553 (7th Cir. 2017) (rejecting a
    highly specific framing of the right at stake); see also Estate of
    Perry v. Wenzel, 
    872 F.3d 439
    , 460 (7th Cir. 2017) (same).
    Dr. Kallas urges that he is entitled to qualified immunity
    because no binding decision guarantees inmates the right to a
    speedier gender dysphoria evaluation or short-term hormone
    therapy prior to release. That formulation, however, frames
    the right too narrowly. Dr. Kallas has conceded (consistently
    with other cases) that Mitchell’s gender dysphoria was a seri-
    ous medical need. See Fields v. Smith, 
    653 F.3d 550
    , 556
    (7th Cir. 2011); Maggert v. Hanks, 
    131 F.3d 670
    , 671 (7th Cir.
    1997); Meriwether v. Faulkner, 
    821 F.2d 408
    , 413 (7th Cir. 1987).
    The first question is thus whether a prison doctor would have
    known that it was unconstitutional never to provide a person
    with the appropriate treatment for her particular case (and for
    many others)—hormone therapy. Fields, 
    653 F.3d at 556
    .
    Prison officials have been on notice for years that leaving
    serious medical conditions, including gender dysphoria, un-
    treated can amount to unconstitutional deliberate indiffer-
    ence. E.g., Arnett v. Webster, 
    658 F.3d 742
    , 753 (7th Cir. 2011)
    (refusing to provide a prescribed treatment or to follow a spe-
    cialist’s advice can violate the Eighth Amendment); Fields,
    
    653 F.3d at 556
     (“Refusing to provide effective treatment for a
    serious medical condition serves no valid penological pur-
    pose and amounts to torture.”). An absence of treatment is
    equally actionable whether the inmate’s suffering is physical
    or psychological. See Meriwether, 
    821 F.2d at 413
    . Because cir-
    cuit precedent clearly established that a total absence of treat-
    10                                                  No. 16-3350
    ment for the serious medical needs created by gender dyspho-
    ria is unconstitutional, Dr. Kallas may not claim qualified im-
    munity for the denial of Mitchell’s request for care.
    The question remains, however, whether on this record
    such a total denial of care could be found by a jury. The facts
    in this respect are disputed. On the one hand, Mitchell never
    received the hormone therapy that Osborne, on DOC’s behalf,
    concluded that she needed. Instead, while Mitchell waited for
    a response to her plea, she got nothing but occasional visits
    with psychologists. Although Dr. Kallas argues that these vis-
    its were themselves “treatment,” the notes from those ses-
    sions indicate that they were not focused on her gender dys-
    phoria, but instead were primarily designed to deal with her
    post-traumatic stress and the harassment she faced. And more
    broadly, psychological visits are not automatically a substi-
    tute for other medical treatments. See De’lonta v. Johnson, 
    708 F.3d 520
    , 525–26 (4th Cir. 2013) (providing “some treatment”
    does not necessarily mean providing “constitutionally adequate
    treatment”); Fields, 
    653 F.3d at 556
    . No one would say that a
    psychologist could treat someone’s epilepsy, nor would we
    say that a counseling session is a substitute for high blood
    pressure medication, even though stress can have an adverse
    effect on blood pressure. In some cases, a psychological con-
    dition, such as bipolar disorder, should not be treated by
    counseling alone: medication can be essential. So it is with her
    gender dysphoria, Mitchell says. And even if the therapy ses-
    sions addressed Mitchell’s gender dysphoria to a degree, she
    may still recover if they did nothing actually to treat her con-
    dition. See Arnett, 
    658 F.3d at 751
    ; see also Fields, 
    653 F.3d at 556
     (“Although DOC can provide psychotherapy as well as
    antipsychotics and antidepressants, defendants failed to pre-
    sent evidence rebutting the testimony that these treatments
    No. 16-3350                                                   11
    do nothing to treat the underlying disorder [gender dyspho-
    ria].”). Given the opinions of the prison doctors and Osborne,
    Mitchell has presented enough evidence to move forward.
    To the extent that Mitchell may be complaining about the
    length of time it took for the assessment to be completed, as
    opposed to the lack of treatment, our answer is different. It is
    true that delays in care for “non-life-threatening but painful
    conditions may constitute deliberate indifference if the delay
    exacerbated the injury or unnecessarily prolonged an in-
    mate’s pain.” Arnett, 
    658 F.3d at 753
    ; see also McGowan v. Hu-
    lick, 
    612 F.3d 636
    , 640 (7th Cir. 2010). Yet prisons have limited
    resources, and that fact makes some delay inevitable. Petties,
    836 F.3d at 730. For a delay in treatment to qualify as deliber-
    ate indifference, we must weigh “the seriousness of the con-
    dition and the ease of providing treatment.” Id. As we have
    said, the serious nature of gender dysphoria is not disputed
    here. But the ease of evaluating the appropriateness of hor-
    mone therapy remains to be considered. There is little evi-
    dence about the typical length of these evaluations, either in
    prisons or in the community. The few courts that have con-
    sidered this question (some after the events in question) have
    determined that even longer delays in evaluating an inmate’s
    candidacy for hormone treatment did not amount to deliber-
    ate indifference. See Arnold v. Wilson, No. 1:13cv900, 
    2014 WL 7345755
    , at *6 (E.D. Va. Dec. 23, 2014) (24-month delay in
    prescribing hormones); Rowe v. Corr. Med. Servs., Inc.,
    No. 1:08-cv-827, 
    2010 WL 3779561
    , at *6–7 (W.D. Mich. Aug.
    18, 2010) (15-month delay). Because Dr. Kallas was not on no-
    tice that a 13-month evaluation would violate Mitchell’s
    Eighth Amendment right, he is entitled to qualified immunity
    on any possible claim of unreasonable delay.
    12                                                   No. 16-3350
    That is not to say that this delay cannot be criticized. Far
    from it. The lack of any sense of urgency, or even of the need
    for prompt follow-through, is quite disturbing. But on these
    facts, no clearly established law would have signaled to
    Dr. Kallas that this delay amounted to deliberate indifference.
    C
    With respect to Dr. Kallas, that leaves the question
    whether he was deliberately indifferent in failing to treat
    Mitchell’s condition during the entirety of her stay at DOC,
    even after Osborne recommended that Mitchell receive hor-
    mone therapy. Mitchell accuses Dr. Kallas of doing nothing
    while the evaluation process was ongoing, and then (through
    the Committee) denying her request because she was going to
    be released within a month. Dr. Kallas claimed that DOC had
    an unwritten rule that an inmate may start hormone therapy
    only if she has six months left on her sentence, and he denied
    her request on that basis. He later explained in an affidavit
    that this period was intended to allow time to figure out the
    proper hormone dosage while monitoring both physical and
    psychological side effects.
    The first problem is that this requirement appears no-
    where in DOC’s written policy on gender dysphoria. This
    conspicuous absence from DOC’s freshly-minted policy
    raises the factual question whether DOC actually had such a
    practice. Moreover, the question remains whether Dr. Kallas
    and the Committee exercised medical judgment in applying
    the policy to Mitchell’s request. Neither professional disa-
    greement nor medical malpractice constitutes deliberate in-
    difference. Cesal v. Moats, 
    851 F.3d 714
    , 721, 724 (7th Cir. 2017).
    Thus, if the trier of fact finds that there was such a policy and
    No. 16-3350                                                    13
    that Dr. Kallas and the Committee had a medical basis for de-
    ciding not to start Mitchell’s hormone treatments, then Dr.
    Kallas will not be liable. If the factfinder alternatively con-
    cludes that there was no such policy, or that Dr. Kallas failed
    to assess whether application of the policy was appropriate in
    Mitchell’s case, then it would follow that he did not exercise
    his medical judgment and was deliberately indifferent. “The
    denial of hormone therapy based on a blanket rule, rather
    than an individualized medical determination, constitutes de-
    liberate indifference in violation of the Eighth Amendment.”
    Hicklin v. Precynthe, No. 4:16-cv-01357, 
    2018 WL 806764
    , at *11
    (E.D. Mo. Feb. 9, 2018); accord Kosilek v. Spencer, 
    774 F.3d 63
    ,
    91 (1st Cir. 2014); De’lonta v. Angelone, 
    330 F.3d 630
    , 635
    (4th Cir. 2003); Allard v. Gomez, 9 F. App’x 793, 794–95 (9th Cir.
    2001).
    We have no reason to doubt that hormone therapy poses a
    health risk if not properly controlled. But the same could be
    said about medications for countless other conditions. It
    seems exceedingly unlikely that DOC would refuse to com-
    mence a course of treatment for an inmate who was about to
    leave, just because continuity of care protocols would require
    a hand-off to a different provider. Would it really refuse to
    address breathing problems, or cardiac problems, or even a
    broken leg, just because one doctor begins the treatment and
    another completes it? At this stage, the parties disagree about
    the critical question whether DOC could have provided
    Mitchell with something more than counseling services—per-
    haps a limited prescription for hormones—to bridge the gap
    between her release from custody and the time when she
    found a new provider in the community.
    14                                                  No. 16-3350
    In sum, there remain material disputes about whether
    Dr. Kallas and the Committee balanced the pros and cons of
    starting Mitchell on hormones, or if they just looked at the cal-
    endar and reflexively dismissed her request. The district court
    should not have granted summary judgment on Mitchell’s
    claim for the refusal to provide care.
    III
    Finally, we consider Mitchell’s argument that the parole
    officers were improperly dismissed from this case. The dis-
    trict court concluded that Mitchell failed to allege sufficient
    facts to support a finding that the parole officers were person-
    ally involved in making decisions about her gender dysphoria
    treatment or that they were obligated to provide her such
    treatment.
    Reading Mitchell’s pro se complaint in the light most fa-
    vorable to her, as we must, Perez, 792 F.3d at 776, we conclude
    that she did state a claim against the parole officers. Mitchell’s
    complaint did not suggest that her parole officers had a legal
    duty to arrange hormone therapy for her. Rather, her argu-
    ment was that the officers impermissibly forbade her from
    dressing as a woman and seeking hormone treatment on her
    own. She alleged that the agents had ample notice that a bar
    on taking hormones would harm her. They had a copy of her
    medical records and Osborne’s report, which even mentioned
    that hormone treatment would help ward off recidivism.
    We have not yet addressed whether parole officers can be
    liable for deliberate indifference to a parolee’s serious medical
    need, though we have found that their actions implicate the
    Eighth Amendment in some situations. See Hankins v. Lowe,
    
    786 F.3d 603
    , 606 (7th Cir. 2015) (holding that parolee stated
    No. 16-3350                                                    15
    an Eighth Amendment claim that her parole officer subjected
    her to restrictive conditions past the expiration of her term of
    parole). One district court has contemplated that parole offic-
    ers can be liable for deliberate indifference by placing condi-
    tions on a plaintiff that prevent her from taking the medically
    indicated course of care. Stewart v. Raemisch, No. 09-C-123,
    
    2009 WL 3754173
    , at *3 (E.D. Wis. Nov. 4, 2009) (entertaining
    a suit against a parole agent where parolee was required to
    seek employment but could not for medical reasons). And we
    have held that custodial prison staff violate the Eighth
    Amendment by interfering with or preventing necessary
    medical care. McDonald v. Hardy, 
    821 F.3d 882
    , 888 (7th Cir.
    2016); see also Gamble, 
    429 U.S. at
    104–05. Though parole of-
    ficers may have no duty under Gamble to provide a parolee
    with medical care or ensure that she receives it, they at least
    may be constitutionally obligated not to block a parolee who
    is trying to arrange such care for herself without any basis in
    the conditions of parole. See 
    429 U.S. at 105
     (deliberate indif-
    ference to a serious medical issue “[r]egardless of how evi-
    denced” states a cause of action under section 1983). From
    that perspective, Mitchell pleaded enough to proceed on the
    theory that the parole officers acted with deliberate indiffer-
    ence to her gender dysphoria by blocking her from getting
    care.
    In its ruling on Mitchell’s motion to reconsider, the district
    court offered an additional reason for dismissing the parole
    officers: it was concerned that the claims against the parole
    officers and those against the doctors were not sufficiently re-
    lated to continue in the same lawsuit. When screening prison-
    ers’ complaints under the PLRA, courts can and should sever
    an action into separate lawsuits or dismiss defendants who
    are improperly joined under Federal Rule of Civil Procedure
    16                                                  No. 16-3350
    20(a)(2). Owens v. Hinsley, 
    635 F.3d 950
    , 952 (7th Cir. 2011). A
    prisoner may join defendants in the same action only if the
    claims against each one “aris[e] out of the same transaction,
    occurrence, or series of transactions or occurrences … .”
    FED. R. CIV. P. 20(a)(2)(A); George v. Smith, 
    507 F.3d 605
    , 607
    (7th Cir. 2007).
    The question then is whether Mitchell’s claim against the
    parole officers should have been brought in a separate law-
    suit. Out of concern about unwieldy litigation and attempts to
    circumvent the PLRA’s fee requirements, we have urged dis-
    trict courts and defendants to beware of “scattershot” plead-
    ing strategies. E.g., Owens v. Evans, 
    878 F.3d 559
    , 561 (7th Cir.
    2017); Owens v. Godinez, 
    860 F.3d 434
    , 436 (7th Cir. 2017). We
    target for dismissal “omnibus” complaints—often brought by
    repeat players—that raise claims about unrelated conduct
    against unrelated defendants. E.g., Evans, 878 F.3d at 561;
    Hinsley, 
    635 F.3d at 952
    .
    Mitchell’s complaint stands in stark contrast to these scat-
    tershot suits. Mitchell has focused on a series of events stem-
    ming from one issue: her inability to get hormone therapy
    while she remained in state custody. One of the defendants’
    arguments underscores that Mitchell’s claims belong to-
    gether. In an attempt to disclaim deliberate indifference, Dr.
    Kallas stresses that he gave Osborne’s report to Mitchell,
    along with information about Wisconsin providers, so that
    she could seek hormone therapy in the community once she
    was released on parole. The parole officers, however, told her
    she was not allowed to follow through on Dr. Kallas’s advice.
    She thus suffered an ongoing denial of treatment arising out
    of one fundamental occurrence, well within the bounds of
    Rule 20(a)(2). The fact that Mitchell has different theories of
    No. 16-3350                                                  17
    liability against the different defendants does not diminish
    the fact that her claims are sufficiently related. “The two sets
    of claims are against different defendants, but they belong in
    the same suit because they arise out of the same set of con-
    nected transactions.” Terry v. Spencer, 
    888 F.3d 890
    , 894 (7th
    Cir. 2018). Given Mitchell’s allegations of a fairly continuous
    period in which two sets of defendants denied or interfered
    with her access to needed medical treatment, it is easy to im-
    agine that if the claims were tried separately, each set of de-
    fendants could try to shift blame to the other. Handling the
    claims against both sets of defendants in one case minimizes
    the risk of unfairness from such inconsistent defenses suc-
    ceeding in separate trials.
    The fact that the district court dismissed Mitchell’s claim
    against the parole agents without prejudice does not change
    our conclusion, nor does the fact that her claim probably
    would not be time-barred under Wisconsin’s generous six-
    year statute of limitations. See Kennedy v. Huibregtse, 
    831 F.3d 441
    , 442 (7th Cir. 2016). Mitchell was entitled not to split her
    claims against these two sets of defendants. On remand, she
    will be entitled to proceed against both Dr. Kallas and the pa-
    role officers.
    IV
    Punishment for Mitchell’s crimes cannot extend to the
    deprivation of the medical treatment she requires for her se-
    rious gender dysphoria. The Wisconsin DOC staff must ap-
    proach Mitchell’s request for treating gender dysphoria with
    the same urgency and care as it would any other serious med-
    ical condition. We AFFIRM the judgment in favor of Dr. Lau-
    rent, but we REVERSE with respect to Dr. Kallas and Parole
    18                                          No. 16-3350
    Agents Ruhnke, Wolfe, and Raisbeck, and REMAND for pro-
    ceedings consistent with this opinion.