Transgender and Gender Diverse Health Care in Correctional Settings (2020)
INTRODUCTION
Transgender people may face an array of risks to their health and well-being during incarceration, and are often targets of discrimination, physical assault, and emotional abuse. They may be assigned by custody and classification staff to correctional facilities according to their gender identity and presentation, or alternatively, according to their genitals and/or sex assigned at birth. Many have specific health needs related to gender dysphoria and other comorbid medical and mental health conditions. Health staff should be aware that transgender patients may be more likely to have experienced sexual and other forms of trauma, but that trauma experiences do not cause transgender identity or gender dysphoria. This special population has unique health needs and thus this position statement recommends the appropriate and responsible provision of health care as clinically indicated.
The screening, referral, evaluation, and management of medical and mental health care and consideration of hormonal treatment for gender dysphoria should follow accepted standards developed by professionals with expertise in transgender health. For transgender patients, determination of gender-affirmative treatment necessary should be on an individualized case-by-case basis, with the risks, benefits, alternatives, and other factors related to treatment carefully weighed and discussed with each patient. Ideally, health staff are trained in transgender health care. Alternatively, they should have access to consult with other professionals with such expertise to help determine appropriate evaluation and management and receive training on transgender-related care. Surgical interventions for incarcerated patients with gender dysphoria is a particularly complicated area and additional specialty consultation is highly recommended as clinically indicated.
DEFINITIONS
Gender identity refers to each person’s deeply felt psychological sense of self as male, female, or something else.
Transgender, as defined by the World Professional Association for Transgender Health (WPATH), “is an adjective to describe a diverse group of individuals who cross or transcend culturally defined categories of gender. The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth.” Transgender women are individuals whose birth sex was male but who understand themselves to be, and desire to live their lives as, women. Transgender men are individuals whose birth sex was female but who understand themselves to be, and desire to live their lives as, men. Transgender people may be male, female, neither, both, or another gender. Transgender people display a range of sexual orientations similar to those who are not transgender. Current evidence indicates that individuals cannot voluntarily change their gender identity; however, some individuals may experience shifts in how they express or experience their gender over the course of a lifetime. In this position statement, the term “transgender” is used to refer to individuals who are transgender and gender diverse (TGD) and those who present with gender dysphoria.
Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.
Gender dysphoria is a DSM-5 psychiatric disorder that was referred to as gender identity disorder (GID) in earlier DSM versions. Gender dysphoria refers to discomfort or distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). It should be noted that not all transgender people experience gender dysphoria symptoms or associated psychosocial impairments, or meet the DSM-5 diagnostic criteria for gender dysphoria. Transgender individuals are at risk for other mental health disorders with associated distress and impairment, such as major depression, anxiety disorders, and substance use disorders, especially in the community and in correctional environments.
ADOLESCENT/DEVELOPMENTAL ISSUES
Transgender youth have higher rates of depression, suicidality, self-harm, substance use, and eating disorders when compared with their peers. Adolescence is a time of immense physical and mental changes, including issues related to gender identity. The brain continues to develop during adolescence and for many adolescent youths, gender identity is an exploration and not a foregone conclusion. It has been demonstrated that adolescents should be allowed to express gender identities as they experience them, and that gender identities may be fluid and may change over time, and not all youth will persist in a transgender identity into adulthood. Review of community records and evaluation by a mental health professional experienced in working with transgender youth will help determine the youth’s current functioning, clinical stability, and the need for additional mental health treatments and interventions.
The diagnostic evaluation and consideration of initiation, continuation, or other adjustments to hormone therapy (e.g., pubertal suppression agents) and other treatment interventions for incarcerated transgender adolescents requires a multidisciplinary treatment team approach: youth psychoeducation and assent, parent/legal guardian involvement, ongoing communication and consent for minor youths for hormone therapy and/or psychotropic medication treatments (this may vary based on the youth’s age and legal requirements of the jurisdiction). Facilities that lack transgender expertise should consult with psychiatry, psychology, adolescent medicine, and endocrinology consultants as needed.
Research has found that transgender youth who receive appropriate hormone therapy have significantly improved mental health that continues into their adult life. This underscores the importance of appropriate care for these patients.
POSITION STATEMENT
Correctional leaders and health care and custody staff have a responsibility to ensure the physical and mental health and well-being of people in their custody; therefore, health staff should evaluate and treat transgender patients in a manner that respects their unique transgender, medical, mental health, and psychosocial needs. The National Commission on Correctional Health Care recommends that the following principles guide correctional health professionals in addressing the needs of transgender patients:
Health Management
1. All incarcerated people, including those who are transgender, must be treated with fairness, dignity, and respect in a gender-affirming environment.
2. All incarcerated people, including those who are transgender, should receive comprehensive health care that is clinically and developmentally appropriate (for adolescents in particular), culturally sensitive, and offered through a nonjudgmental, gender-affirming approach.
3. All incarcerated people should receive medical screening regarding sexual activity, sexual orientation, gender identity, and sexual abuse and other forms of trauma or victimization. This may already occur as part of standard PREA interviews but should also be explored by qualified health care professionals.
4. Confidential HIV and STI testing and care should be provided to all transgender patients.
5. Gynecological, family planning, and obstetrical care and routine primary preventive health care (e.g., mammograms, Pap smears) should be provided when clinically indicated, regardless of housing placement or gender identity. Health staff should be aware that such care may be particularly physically and/or emotionally stressful for some transgender patients. Consideration should be given to special nutritional needs of these patients.
6. Health staff should screen all incarcerated people, including transgender patients, for mental health issues (e.g., self-harm and suicide risks, depression, anxiety, PTSD), including those unrelated to sexual orientation or gender identity, and incorporate any identified concerns into the overall treatment plan. The presence of comorbid mental disorders associated with or separate from gender dysphoria should prompt timely mental health evaluation and treatment. Current mental health distress, impairment, and concerns should be addressed either prior to or concurrent with treatment for gender dysphoria.
7. Psychotherapy and other mental health treatment should be provided to transgender patients who are experiencing gender dysphoria, depressive disorders, PTSD, or anxiety disorders, or have experienced sexual trauma.
8. The clinical decision making to initiate or advance hormone medication treatment or candidacy for surgical interventions while incarcerated or upon release needs to be based on individual medical need, risks and benefits, analysis of alternatives, ruling out contraindications, accepted standards of care, and a thorough informed-consent process.
a. Transgender patients with gender dysphoria who have not received hormone therapy before incarceration should be evaluated by a health care provider qualified in the area of gender-related health care to determine their evaluation and treatment needs.
b. When determined to be medically necessary for a patient, after baseline laboratory studies are collected, hormone therapy or pubertal suppression should be initiated, and regular laboratory monitoring should be conducted according to accepted medical standards.
9. For transgender patients who received hormone therapy or pubertal suppression agents (with or without a prescription) before incarceration:
a. If the prescription hormone therapy is verified, it should be continued without interruption (without waiting for a medical evaluation).
b. If the patient took unprescribed hormones, decisions should be made on a case-by-case basis, with continuation of hormones when safe and appropriate.
c. If previous hormone use cannot be verified, the patient should receive a medical evaluation for hormone therapy as soon as possible to minimize disruptions, or to determine if consultation with or referral to a transgender specialist is warranted.
The continuation of prior hormone medication, dose, and schedule would take into account the patient’s medical risks and contraindications or other urgent medical reasons to the contrary. Ideally, hormone therapy would not be abruptly discontinued as this may result in a reversal of target physical characteristics, which could be a new stressor to the patient.
10. Evaluations to determine the medical necessity of gender-affirming surgical procedures will be performed on a case-by-case basis, applying a careful risk, benefit, and alternatives analysis. Gender-affirming procedures will be provided when determined to be medically necessary for a patient according to accepted medical standards.
11. Timely emergency treatment and specialty follow-up for genital mutilation or self-harm (e.g., penile, testicular, or other injury) or for other related complications should occur. Individuals who engage in any type of genital self-harm should be referred for further mental health evaluation and treatment.
12. Postoperative care, surgical follow-up, and medical housing for patients after gender-affirming surgery should be provided for as long as medically necessary for each patient and according to accepted medical standards.
13. Psychotherapy such as “reparative” or “conversion” therapy or attempts to alter gender identity should never be employed. Similarly, disciplining individuals solely for expressing their gender identity may have harmful health consequences.
14. Transgender patients should have access to services and support systems that address self-acceptance, disclosure of sexual orientation or gender identity, family relationships, peer support, healthy intimate relationships, and sexual decision making.
15. Correctional health care providers should provide transgender patients with patient education materials on gender dysphoria hormonal and supportive mental health treatments, transitioning, and gender affirmation options.
16. Health staff should recommend to custody leadership that commissary items and undergarments consistent with an individual’s gender identity are available, regardless of a gender dysphoria diagnosis, as well as any hygiene items needed due to anatomy, such as menstrual products.
17. Correctional health care providers should attempt to refer to transgender patients by the name and pronouns of the patients’ preference. Facilities may consider developing policies and procedures that address the use of legal versus preferred names in health documents/records (e.g., sick call requests, medication administration passes).
18. Correctional health care providers should be attentive to the unique biopsychosocial needs of adolescents who identify as transgender or present with gender dysphoria. This includes addressing physiologic aspects related to puberty and ongoing growth, neurodevelopmental and psychological aspects, and social issues, including family acceptance and youth/caregiver consent for treatment. Care delivered to adolescents identifying as transgender should be consistent with guidelines established by adolescent health professional societies, such as the American Academy of Pediatrics.
Patient Safety
19. Since transgender individuals are common targets for violence, health staff should work with custody staff to help identify appropriate safety measures regarding housing, recreation, and work assignments.
20. Transgender individuals should be placed in the least restrictive environment necessary to ensure their safety. Isolation, restrictive housing, or segregation should not be relied on exclusively or indefinitely to ensure safety.
21. Health staff may be asked to consult, participate, or provide input to custody and classification staff regarding custodial placement decisions of transgender patients, including potential impact on medical and mental health, overall adjustment and functioning, and risk of harm to self or others.
22. Health staff should periodically assess the safety of transgender patients. Staff must report all observed or self-reported incidents of harassment, discrimination, and abuse as per PREA and other mandated reporting requirements.
23. Health staff should encourage that transgender patients be given the opportunity to shower with physical and visual separation from other incarcerated people on a voluntary basis.
24. Custody staff should not search or physically examine a transgender individual for the sole purpose of determining genital status. If genital status is unknown, it may be determined during sensitive, confidential, and private health care encounters or interviews/conversations with the person; by reviewing medical records; or, if necessary, by learning that information as part of a broader medical examination conducted in private by a medical provider.
25. Health staff may be asked to participate or provide input on decisions regarding search procedures for transgender patients, including potential impacts on health. Current practices include asking whether the patient would feel safer being searched by female or male correctional staff or having all searches conducted by female staff (for adults) (see https://www.prearesourcecenter.org/node/3257).
Community Collaboration, Continuity of Care, and Discharge Planning
26. Transgender patients receiving hormone therapy should receive a sufficient medication supply upon release to last until a community provider assumes care. Referrals should be made to community-based organizations with sensitive and inclusive services for transgender people.
27. For discharges to a residential treatment facility, a signed release of information will facilitate health staff’s ability to share and forward discharge planning recommendations and to improve continuity of health care.
28. Correctional health care policies for evaluation and management of transgender individuals should be developed and implemented in partnership with local transgender communities, particularly people currently and formerly incarcerated, and transgender service providers when possible.
Training
29. Training of medical and mental health professionals competent to work with adults and adolescents who identify as transgender rests upon general clinical competence in the assessment, diagnosis, and treatment of medical and mental health concerns unrelated to gender identity. However, further training is necessary to recognize and diagnose medical and mental health conditions in transgender patients and to distinguish these from gender dysphoria, as well as to gain further knowledge about gender-nonconforming identities and expression and the assessment and treatment of gender dysphoria. Additional training and competence in adolescent developmental issues is particularly necessary for work with transgender youths.
30. Health staff should recommend to custody leadership that correctional staff receive training on transgender patients (as with other special populations) to gain awareness, understanding, and sensitivity to critical issues of health, mental health, and safety.
October 18, 2009 — adopted by the National Commission on Correctional Health Care Board of Directors
April 12, 2015 — reaffirmed with revision
November 1, 2020 — reaffirmed with revision
Resources
American Academy of Pediatrics. (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents (Policy Statement). https://pediatrics.aappublications.org/content/142/4/e20182162
American Psychological Association. (2015). Guidelines for Psychological Practice With Transgender and Gender Nonconforming People, Guidelines 5 & 10. https://www.apa.org/practice/guidelines/transgender.pdf
The Mental Health of Transgender Youth: Advances in Understanding. (2016). Journal of Adolescent Health and Medicine. https://doi.org/10.1016/j.jadohealth.2016.06.012
PREA Standards and Policy Development Guidelines for Lesbian, Gay, Bisexual, Transgender and Intersex Inmates. http://www.wcl.american.edu/endsilence/documents/LGBTIAdultWebinarFINAL.pdf
Prison Rape Elimination Act, 28 C.F.R. § 115.15 (e)
Prison Rape Elimination Act, 28 C.F.R. § 115.43 (a)
World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. https://www.wpath.org/publications/soc