Crossing Over: Treatment Rights of Transgendered Prisoners

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)