Transgender and Gender Diverse Health Care in Correctional Settings | National Commission on Correctional Health Care

Transgender and Gender Diverse Health Care in Correctional Settings

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POSITION STATEMENT

The National Commission on Correctional Health Care recognizes that transgender and gender diverse (TGD) people are vulnerable to victimization in the carceral setting and have unique health care needs. Therefore, NCCHC recommends the following:

  1. Correctional facilities implement policies and procedures that promote a gender-affirming environment for people who identify as transgender and gender diverse and comply with applicable NCCHC standards.
  2. Correctional facilities provide training to all correctional staff on working with people who identify as TGD in accordance with applicable policies and procedures that address the unique safety concerns as well as medical and mental health needs of this population.
  3. Correctional staff treat all people who identify as TGD with dignity and respect in an environment free of stigma and discrimination.
  4. Correctional facilities implement policies and procedures that promote the safety and well-being of people who identify as TGD and comply with the Prison Rape Elimination Act (PREA) standards.
    a. Screen all newly admitted people for their vulnerability to sexual victimization during incarceration, including their gender identity, sexual orientation, and prior history of sexual abuse.
    b. Place people who identify as TGD in the least restrictive environment necessary that ensures their safety while refraining from exclusive or indefinite placement in isolation, restrictive housing, or segregation.
    c. Require staff reporting of all observed or self-reported incidents of harassment, discrimination, or abuse.
    d.Prohibit medical staff evaluations of transgender individuals solely for the purpose of determining genital status.
    e. Provide timely emergency care and mental health evaluation and treatment for self-harm incidents, including genital injuries.
    f. Ensure people who identify as TGD have access to educational, recreational, social accommodation (such as gender-conforming undergarments and hair removal products), and other programs and services that are available to the general population.
    g. Consult with health staff for decisions regarding custodial placement, work assignments, educational classes, and other programming for people who identify as TGD to ascertain potential impact on their medical and mental health and overall adjustment and functioning.
  5. Correctional health professionals implement evidence-based health care for patients who identify as TGD by providing the following:
    a. Employ an interdisciplinary health care team that provides clinically competent, trauma-informed, and culturally sensitive care, supported, when necessary, by other health care professionals with expertise in caring for patients who identify as TGD.
    b. Screen all people upon intake for their histories of gender-affirming medical needs, prior care, and current treatment plan.
    c. Screen all people who identify as TGD upon intake for mental health and substance use concerns, including gender dysphoria, self-harm and suicide risk, post-traumatic stress disorder (PTSD), anxiety, depression, and substance use disorders.
    d. Define the scope of gender-affirming health care services available to those who identify as TGD based on evidence-based clinical guidelines, evolving standards of care in the community, and applicable legal parameters.
    e. Make available patient education information on gender-affirming medical and mental health care treatment services and options.
    f. Develop individualized treatment plans that address the unique medical, mental health, and developmental needs of patients who identify as TGD.
    g. Continue hormone medications and age-appropriate pubertal suppression agents upon entry to the facility with the informed consent of the patient in accordance with state and federal laws and regulations, unless medically contraindicated.
    h. Initiate hormone medications during incarceration as clinically appropriate with the informed consent of the patient in accordance with state and federal laws and regulations.
    i. Provide mental health treatment for patients with gender dysphoria, anxiety disorders, depression, or other mental health conditions including past physical, emotional, or sexual trauma.
    j. Provide age-appropriate, sex, anatomy, and risk-based preventive health care that includes screening for sexually transmitted infections, screening for cancers, and administration of vaccinations.
    k. Provide treatment for conditions that disproportionately affect those who identify as TGD, such as substance use disorders, HIV infection, and hepatitis C.
  6. Correctional facilities implement policies and procedures that provide targeted discharge planning that addresses the unique needs of those who identify as TGD.
    a. Develop an individualized transition plan prior to discharge that includes assistance with health benefits applications, including Medicaid enrollment, as applicable.
    b. Provide referrals to a gender-affirming health care provider and an adequate supply of prescription medications to bridge care.
    c. Provide referrals for mental health care and treatment for substance use disorders, including medications for opioid use disorder and an adequate supply of prescription medications to bridge care.
    d. Facilitate access to interventions that prevent the acquisition of sexually transmitted infections, as clinically appropriate, including HIV pre-exposure prophylaxis (PrEP).
    e. Coordinate access to safe and nondiscriminatory housing.
    f. Assist with securing and updating personal identification documents, including legal support for gender marker change.
    g. Offer linkages to transgender community advocacy organizations and peer support networks.

DEFINITIONS

Gender-affirmative health care can include any single or combination of a number of social, psychological, behavioral, or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.

Gender diversity refers to variations in gender identity, expression, or gender role behavior (for example, in choices of clothing, hairstyle). It acknowledges a spectrum of gender identities.

Gender dysphoria is defined as distress or discomfort that may occur when gender identity and other biology are not strictly aligned. Not all transgender people experience gender dysphoria symptoms or associated psychosocial impairments or meet the diagnostic criteria for gender dysphoria.

Sexual orientation refers to an individual’s pattern of physical and emotional arousal and the gender(s) of people to whom an individual is physically, romantically, or sexually attracted (for example, gay/lesbian, straight, bisexual). Sexual orientation is separate from gender identity or expression.

Transgender, trans, and gender incongruence are umbrella terms used to describe individuals whose gender identity is not strictly aligned with the gender assigned to them at birth. Transgender and trans are used as adjectives (“transgender people”), not nouns (“transgender”).

Transgender man/transmasculine individual refers to a person with male gender identity who was recorded/designated female sex at birth.

Transgender woman/transfeminine individual refers to a person with female gender identity who was recorded/designated female sex at birth.

DISCUSSION

People who identify as TGD frequently experience social marginalization and stigma and disproportionately face discrimination, poverty, and homelessness. These stresses may lead to an increased contact with the criminal justice system from participation in illicit economies, such as substance use and sex work, as survival and coping strategies. The structural barriers and health care disparities faced by many people who identify as TGD also place them at higher risk for serious mental health conditions, suicidality, drug overdose, and poorly controlled or untreated medical conditions such as HIV and sexually transmitted infections (STIs). Incarceration may further worsen the physical and emotional well-being of people who identify as TGD due to social isolation, fear of personal safety and sexual victimization, inherent distrust in health care systems, and lack of competent, gender-affirming health care in some carceral settings.1,2

Correctional facilities can most fundamentally address the distress of incarcerated people who identify as TGD by promoting a culture that treats all people in the carceral setting with dignity and respect. Strategies for creating an environment free of stigma and disrespect include leadership role-modeling, mandatory training of correctional staff by knowledgeable educators with good communication skills, use of scenario-based staff training that mirrors day to day interactions with people who identify as TGD, and engagement with the TGD advocacy community to inform correctional policies, practices, and training.3

Correctional facilities can further address the distress of incarcerated people who identify as TGD by mitigating their risk of personal harm and sexual victimization. Strategies include sustaining a leadership culture of safety for people who identify as TGD, adopting uniform trauma-informed practices when engaging with people who identify as TGD, and effectively implementing PREA standards.3 Key PREA requirements for protecting people who identify as TGD include receiving screening requirements for assessing risk of victimization; reporting mandates for harassment, discrimination, or abuse; individual assessments for housing assignments; and access to emergent and supportive medical and mental health care.4 Correctional health professionals provide critical support to people who identify as TGD by identifying signs of physical, emotional, or sexual abuse during clinical encounters; providing effective medical and mental interventions for those experiencing victimization; and contributing relevant input to custody and classification staff related to housing, education, recreation, and work assignments.

Correctional facilities should address the unique health needs of people who identify as TGD by adopting policies that endorse gender-affirmative health care services per NCCHC standards including the continuation of gender-affirming hormone therapies (GAHT) in accordance with state and federal laws and regulations. Clinical care for patients who identify as TGD should be based on evidence-based recommendations from recognized adult and adolescent professional health organizations that are continually updated amid an evolving legal landscape.5-9

Patients who identify as TGD should be provided with health education that is consistent with the most current evidence-based medicine for gender-affirming care. Individualized treatment plans should integrate an informed consent model that empowers patients to make knowledgeable decisions.1 For example, patients who identify as TGD considering initiation of GAHT should be thoroughly apprised of the potential benefits of GAHT in improving overall emotional well-being, the physical changes that can be anticipated from GAHT that are reversible and irreversible, and the potential for significant side effects, including the impact on fertility.

Mental health evaluations should be included in the treatment plan for patients who identify as TGD, as clinically warranted, to diagnose and manage gender dysphoria, PTSD, anxiety, depression, and other serious mental health concerns. Treatment plans should also include the provision of age-appropriate preventive health care and access to treatments that disproportionately affect patients who identify as TGD, such as substance use disorders, HIV infection, and hepatitis C.1

Correctional health care administrators should ensure that patients who identify as TGD have access to competent health care staff to manage their medical and mental health conditions. Strategies for improving the quality of care for these patients include staff training through online and continuing medical education; employing or contracting with practitioners with expertise in caring for patients who identify as TGD; accessing subspecialists, such as endocrinologists, as needed; leveraging telehealth to facilitate health care access; and using telementoring technology to build workforce competencies.3

People who identify as TGD discharging from the carceral setting frequently face significant challenges, including alienation from families and other social supports; limited access to gender-affirming care, mental health services, and substance use disorder treatments; and need for social work and legal assistance for navigating health insurance coverage, housing, discrimination concerns, and name change services. Not adequately addressing these concerns can lead to serious risks upon discharge, including the emotional and physical effects of discontinuing gender-affirming hormone treatments and the potential for STI acquisition, drug overdose, suicide, self-injurious behaviors, and homelessness.3 People who identify as TGD should have an individualized discharge plan that addresses these potential risks, including assistance with health benefits applications, linkages to necessary health care services, an adequate supply of prescription medications to bridge care, and the provision of housing and psychosocial support services as needed. If available, peer navigators should be considered as an additional support as this strategy has proven effective in maintaining health care continuity.10

Adopted by the National Commission on Correctional Health Care Board of Directors: October 18, 2009

April 12, 2015 – reaffirmed with revision

November 1, 2020 – reaffirmed with revision

July 31, 2026 – reaffirmed with revision by the National Commission on Correctional Health Care Governance Board

resources

National Commission on Correctional Health Care. (2026). Standards for Health Services for jails and prisons.

REFERENCES

  1. Murphy, M., Rogers, B. G., Streed, C., Jr., Hughto, J. M. W., Radix, A., Galipeau, D., Napoleon S., Scott, T., Noh, M., Coats, C. S., Hubbard, L., Chan, P. A., Nunn, A., & Berk, J. (2023). Implementing gender-affirming care in correctional settings: A review of key barriers and action steps for change. Journal of Correctional Health Care, 29(1), 3–11. https://doi.org/10.1089/jchc.21.09.00
  2. Rastogi, A., Menard, L., Miller, G. H., Cole, W., Laurison, D., Caballero, J. R., Murano-Kinney, S., & Heng-Lehtinen, R. (2025). Health & wellbeing: Findings from the 2022 U.S. Trans Survey. Advocates for Transgender Equality. https://transequality.org/sites/default/files/2025-06/USTS_2022Health%26WellbeingReport_WEB.pdf
  3. Kendig, N. E., Cubitt, A., Moss, A., & Sevelius, J. (2019). Developing correctional policy, practice, and clinical care considerations for incarcerated transgender patients through collaborative stakeholder engagement. Journal of Correctional Health Care, 25(3), 277–286. https://doi.org/10.1177/107834581985711
  4. Bureau of Justice Assistance. (2025). Prison Rape Elimination Act (PREA) overview. https://bja.ojp.gov/program/prea/overview
  5. Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, L., Nahata, T. O., . . . Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, Version 8. International Journal of Transgender Health, 23(Sup1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644
  6. Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658
  7. Deutsch, M. B. (Ed.). (2016). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people (2nd). UCSF Gender Affirming Health Program, Department of Family and Community Medicine, University of California San Francisco. https://transcare.ucsf.edu/guidelines
  8. Rafferty, J., Committee on Psychosocial aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness, Yogman, M., Baum, R., Gambon, T. B., Lavin, A., Mattson, G., Wissow, L. S., Breuner, C., Alderman, E. M., Grubb, L. K., Powers, M. E., Upadhya, K., Wallace, S. B., Hunt, L., Gearhart, A. T., Harris, C., . . . Sherer, I. M. (2018,). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents [Policy statement, reaffirmed 2023]. American Academy of Pediatrics. Pediatrics, 142(4), e20182162. https://doi.org/10.1542/peds.2018-2162
  9. American Academy of Child and Adolescent Psychiatry. (2024). Policy statement on access to gender-affirming healthcare. https://www.aacap.org/AACAP/Policy_Statements/2024/Access_Gender-Affirming_Healthcare.aspx
  10. Cunningham, W. E., Weiss, R. E., Nakazono, T., Malek, M. A., Shoptaw, S. J., Ettner, S. L., & Harawa, N. T. (2018). Effectiveness of a peer navigation intervention to sustain viral suppression among HIV-positive men and transgender women released from jail: The LINK LA randomized clinical trial. JAMA Internal Medicine, 178(4), 542–553. https://doi.org/10.1001/jamainternmed.2018.0150