Transgender patients face significant challenges in prison

Imagine that as a child you thought you had been born in the body of the wrong gender. If you were biologically male, in your mind you really thought of yourself as female. Likewise, if you were born in a girl’s body, you thought that you were actually a boy.

Yes, you were probably more interested in children’s role-playing games more often associated with the opposite gender as well, but the issue went much deeper than that. It was your core identity that was at stake. You knew that you were the other sex, at least in all ways except for the reproductive organs of your body.

You felt this way during childhood, but nobody seemed to understand or accept this about you. But you were dressed in the clothing of your biological gender and expected to participate in the activities stereotypically associated with it as well. Imagine that as your body matured in adolescence, you hated your penis if you had one, or likewise, you wanted to hide your developing breasts. You simply felt that you were trapped in the wrong body.

This experience is the gist of what transsexual or transgender persons face every day.

To some who have never met a transgender person, the concept itself may seem bizarre. I can assure you, though, that transgender people are not freaks; they are human beings who were born with a challenge that no person would choose to have.

Both in the community and in prisons, I have worked with several transgender patients over the years. They have taught me more about the challenges that they face every day than any book ever could have. Their life challenges, though, are magnified several-fold in jails and prisons.

The terms transgender and transsexual have approximately the same definitions, but transsexual is a medical term. However, please note that there is a great deal of debate and controversy about terminology that will be beyond the scope of this article. A brief overview can be found here.

Transgender does not imply anything about sexual orientation; it is all about gender identity.

Unfortunately, society can be a cruel place for anyone perceived as “different” from the norm. This issue could not be truer than in a prison environment.

Prisons in general are very black and white places. There are rules and regulations to handle different situations, and shades of gray tend to create confusion.

Men go to men’s prisons, and women go to women’s prisons. So, where do transgender people go?

Well, it depends. As far as I can tell, in most systems, those with a penis (present from birth or surgically constructed) go to men’s prisons. Those with a vagina go to women’s prisons. Sounds simple, right?

Not at all. First, assuming that the transgender person has not been taking hormones and has not had sex reassignment surgery (sex-change operation), he or she will likely have to psychologically endure being housed in an institution for those that the person perceives as being of the opposite sex.

What if a person with male genitalia who believes himself/herself to be female has started taking female hormones before the incarceration and has fully-developed breasts? Then, the person would likely end up in a men’s prison. That’s right, a penis and breasts, in jail with a bunch of men.

It is pretty easy to see how there are various possibilities that present challenges since transgender people do not easily fit into male and female categories.

Once incarcerated, regardless of the gender of their inmate peers, there are other challenges.

How can they avoid discrimination? My guess is that most security personnel in most institutions are not well-versed in working with transgender inmates. People often fear what they don’t understand, and there is a significant risk of these prisoners not being treated fairly. Likewise, I believe it’s rather obvious how transgender inmates potentially face significant harassment, intimidation, and violence from other inmates.

What about hormone treatment in prisons? Should inmates who are already receiving it on the outside be prescribed these medications in prison, too? What about sex reassignment surgery? Should taxpayers bear the burden of this for long-term prisoners? Some have argued that they should.

How should one address a transgender person: “he” or “she”? I’d suggesting asking them how they wish to be addressed. However, I will say that every transgender patient I’ve ever worked with wanted to be addressed as the sex they felt they really were, not as the gender into which they were born. This presents an interesting dilemma in a correctional environment because referring to any inmate as “she” in a men’s prison or vice versa elicits shocked and confused reactions from prison staff.

My purpose of this post is to raise awareness about challenges faced by transgender inmates, an issue that I rarely hear discussed and about which there is much ignorance. Transgender people deserve to be treated with dignity and respect just like anyone else. They deserve not to be discriminated against, and they deserve to be safely housed if incarcerated. However, there are many details involved in their custody and health care that will never be simple to solve.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc.

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  • The Happy Hospitalist

    Is there such a thing as don’t ask don’t tell in prison?

  • AnnR

    It would seem like if you were transgender and receiving hormones/surgery etc… that you would stay away from criminal behaviors because prison would be such a risky place.

    Changing sexes isn’t really an impulse activity. I would have thought that someone who’d put that much effort into changing their gender would not be prone to criminal actions.

  • Lockup Doc

    If my patients are gay or lesbian, I always advise them to keep it to themselves in prison (which they usually already know is smart). As for the transgender, most of the people I’m referring to in the above article stand out, and keeping it to themselves may be impossible (a person born with male parts who now has developed breasts from hormone treatment and has changed their name to a female name). For their own safety, inmates are always smart to keep as many of these things to themselves as they can, but often it’s just not possible.

  • Lockup Doc

    AnnR: I understand your logic, but it just doesn’t work that way. People with impulse control problems still may be able to plan very well for something of great importance to them. And, of course not all crime is impulsive. I don’t know the rate of criminality in the transgender compared with the rest of the population, but I do know from experience that transgender people still end up committing crimes and getting locked up. As counterintuitive as it may be…

  • JML

    >>I don’t know the rate of criminality in the transgender compared with the rest of the population, but I do know from experience that transgender people still end up committing crimes and getting locked up.>>

    I don’t know, either, but I’m guessing many imprisoned transgenders were convicted of either prostitution or drug offenses.

  • Zoe Brain

    My apologies beforehand for the length of the posts. But “challenges” perhaps under-estimates the situation.

    According to Judge Richman’s opinion, Giraldo self-identifies as a “male-to-female transgender person.” When she was taken into custody at North Kern State Prison, she was evaluated for placement for the duration of her sentence. She was classified as a Level III inmate with 36 points, which gave her a “primary placement recommendation” to be placed at California Medical Facility or California Men’s Colony, institutions with experience in handling transsexual inmates, where they “are relatively safer… than at other state prisons.” Despite this recommendation, she was sent to Folsom and put into general male population.

    “Within a week of her assignment to FSP, an inmate employed as a lieutenant’s clerk requested that plaintiff be assigned as his cellmate,” wrote Richman,” which request was granted. Beginning almost immediately, and lasting through late January, the cellmate ‘sexually harassed, assaulted, raped and threatened’ plaintiff on a daily basis.” Then this first cellmate introduced plaintiff to “his friend, another inmate, who in late January requested that plaintiff be transferred to his cell, which request was also granted.” Just weeks later, this second inmate “began raping and beating her, again daily.” Although Giraldo reported this abuse to prison officials and begged to be transferred to a different cell, her requests were ignored for several weeks.

    Finally, after suffering a rape and attack with a box-cutter by her cellmate on March 12, 2006, she was moved to “segregated housing.” This was just days after she had told a correctional counselor about the abuse to which she was being subjected, and pleaded to be moved to a different cell, pointing out that her original classification meant she was not supposed to have been assigned to Folsom. The counselor’s reaction was to tell her to be “tough and strong,” and the counselor discouraged her from taking any further action, returning her to the cell. Just two days before the final incident, she had also spoken with a medical employee, who noted the conversation in her file but took no steps to report the matter to authorities, because “I don’t want to get him into trouble.”

    Giraldo was moved to a unit for psychologically troubled inmates, but lived in constant fear that she might be sent back to general population and placed with another abusive cellmate. She was released on parole after filing her lawsuit, shortly before the trial of her claims was to take place.

    The state argued that there was no general duty under tort law for prison officials to protect inmates from attacks by other inmates.

  • Zoe Brain

    Inquiry into a death, Coroner J Abernethy, Wednesday 21 July 1999. Ref: W308 201/99 JI-D1.

    December 1997. After an appearance in a Local Court, bail was refused and Ms M. was remanded in custody. Late on 22 December she was transported to a remand and reception centre where that night and into the morning of December 23 she underwent induction assessment. She was identified as transgender by the welfare officer and it was determined she should go into a “protection” wing. Having spent December 24 in court Ms M. spent December 25 and 26 in “strict protection”. During this time she was brutally raped at least twice during daylight hours. The attacks were so vicious that two other prisoners took the unusual step of reporting the incidents and giving sworn evidence. On December 27 Ms M. was found dead in her cell hanging by a shoelace.

  • Zoe Brain

    Then there’s the many cases of Trans women who are awaiting trial being put in “administrative segregation” in punishment cells. No windows, cards, books, writing implements, allowed out once every 3 days for a shower. Sometimes for months. Many plead guilty after only a week of this treatment.

    A transgendered woman convicted of drug trafficking has been locked down in solitary confinement for the past six months in a Virginia jail because they feared she would be raped by fellow male prisoners, a jail official said.

    Maria Benita Santamaria, 35, pleaded guilty to trafficking 10 pounds of methamphetamine in August. She was arrested at a Lorton Comfort Inn in June and was held without bail.

    Central Virginia Regional Jail officials labeled Santamaria as a vulnerable victim and kept her out of the general male population where, Deputy Superintendent Susan Fletcher said, they believed she risked being raped.

    Despite that, “[Santamaria] has repeatedly tried to convince jail personnel that she is willing to risk being in general population,” court documents said.

    That’s because Santamaria “is treated no differently than inmates on punitive lockdown,” Alterman said. Santamaria is let out of her cell for one hour a day and allowed to shower every three days. Her solitary cell has no windows and Santamaria has considered suicide, Alterman said.

    Even after pleading guilty, they still kept her there for more months despite the court’s order that she be transferred to another facility. She’s now in a psychiatric ward, unresponsive to external stimuli.

    And then there’s the Wisconsin Sex Inmate Sex Change Prevention Act, which forbids any diagnostic examination for GID, as if it was diagnosed, the withholding of hormones (also forbidden) would be cruel and unusual punishment.

    Earlier, Kevin Kallas, a psychiatrist and mental health director for Wisconsin’s prisons, testified he opposed the law banning hormones.

    Kallas said patients who are taken off hormones typically need counseling, drugs and hospital stays instead, suicide treatments that are more expensive than the hormones, which cost $675 to $1,600 a year. Kallas said he did not know of any other medical treatment that the state Legislature has banned in prisons.

    Yes, it’s more expensive not to give treatment than to give it. Although as many complete suicide as the result, there may be savings long-term.

  • Zoe Brain

    I mustn’t exaggerate the scope of the problem: while it’s true that in some jurisdictions, being arrested (not convicted) amounts to a very messy death sentence, only 60% of trans people report being raped while in prison, not 100%.

    While I’m not transsexual, I am Intersexed. My documentation is inconsistent (a cause for arrest in itself), with a male birth certificate but female passport and anatomy. Unfortunately, while the majority of penal systems go by current anatomy, there are many where the original birth certificate is the over-riding document, even if it’s been changed.

    Intersexed people are treated worse, if anything, by the penal system than trans people. Many attract attention due to an unusual appearance, and using the wrong restroom because one has crossed a state or even county line – so one’s legal sex has changed – can lead to fatal consequences.

    “Taking this situation to its logical conclusion, Mrs. Littleton, while in San Antonio, Texas, is a male and has a void marriage; as she travels to Houston, Texas, and enters federal property, she is female and a widow; upon traveling to Kentucky she is female and a widow; but, upon entering Ohio, she is once again male and prohibited from marriage; entering Connecticut, she is again female and may marry; if her travel takes her north to Vermont, she is male and may marry a female; if instead she travels south to New Jersey, she may marry a male.”

    – Littleton v Prange

  • jsmith

    Thanks for the posts, Zoe. We docs could use some consciousness-raising on this issue.

  • Zoe Brain

    HI, Dr K.

    I think you’ll pass the word around.

    I give talks at the Australian National University on the subject, called in by professors of Medicine and Psychology to talk about both the science, and the social consequences.

    Talking about the science – I can recommend biologist Ronnie Drantz‘s presentations on the neurology, and Prof of Urology Sid Ecker’s Brain Gender Identity presentation he gave to the APA Annual Meeting.

    My sympathies to yourself and Lockup Doc. Being expected to make bricks without straw, having to do the psych equivalent of putting a band-aid on a sucking chest wound. in a prison environment.. I get that impression from ClinkShrink anyway… it must be hard on you both. But knowing that someone actually gives a damn is a huge help, according to a few former inmates I know.

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