What kind of basic healthcare coverage should we offer to prisoners?

I expect most of us agree that an incarcerated felon experiencing a heart attack should receive medical treatment, even if that treatment comes at taxpayers’ expense.  The same probably goes for more preventive measures—blood pressure pills, cancer screening tests and the like.  While serving out the sentence for their crimes, prisoners should not be forced to suffer from treatable and preventable illnesses without receiving appropriate medical care.  They can pay for their crime in other ways.  Making them suffer from medical illness seems cruel and inhumane.

But what about a prisoner whose mental health requires a sex reassignment operation: should taxpayers foot the bill for that?

In early September, a U.S. District judge ruled that Massachusetts prison officials have an obligation to provide sex reassignment surgery to Michelle Kosilek (formerly Robert).

Kosilek is already receiving hormonal treatment to enable her transition to womanhood.  But that transition won’t be complete until she receives the approximately $20,000 surgery.  Meanwhile, she has shown significant signs of suffering from her state of gender limbo, even trying to castrate herself once and attempting to kill herself more than once.  Transgender advocates have argued that these mental health problems are usually reduced dramatically by sex reassignment surgery.  Indeed, the American Medical Association has urged insurance companies to classify such procedures as part of basic health coverage.

I am not a gender disorders expert by any means.  But as the graduate of twelve years of Roman Catholic school, and as the big brother of a conservative Roman Catholic priest, I have to say this: my early life understanding of sex and gender was hopelessly naïve.  Medical school and medical practice taught me to see these issues in a much more nuanced fashion.

What are those facts?  Most of us are pretty solidly and traditionally male or female.  Most men bear XY chromosomes in every cell of their bodies (sperm excepted), and are sexually attracted to women.  Most women carry XX chromosomes and dig dudes.  But a large minority of people don’t fall into these two categories.  For example, some folks have XXY chromosomes.  Some have XX chromosomes in some cells of their body and XY in others—those rare, true hermaphrodites.

More common than these chromosomal variations are other variations in gender.  For instance, consider someone with XY chromosomes who will either experience low testosterone levels in utero (that is, while still inside Mamma’s womb) or who for some reason or other failed to transport that testosterone into its brain cells during that formative period.  Would it be surprising to find out that this person might have a male body and a female brain?  Could this explain why so many transgender people describe themselves as “a woman trapped in a man’s body”?

Once again, I am not an expert on variation in sexuality and gender.  Instead, I am a physician who’s seen enough variation across my own patients that I am inclined to trust the experts.  And the gynecologists, urologists and endocrinologists I have spoken with about this topic have consistently encouraged me to broaden my understanding of gender, and accept that not everyone can be placed into the two groups most of us have been taught to view as “natural.”

Nature is not interested in dichotomizing humanity.  Although it is important to debate what kind of basic healthcare coverage we should offer to prisoners, we shouldn’t allow outdated notions of gender to cruelly deny important medical care to people who, through natural circumstances beyond their control, don’t fit into easy categories.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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  • ELang11

    Typo? “For instance, consider someone with XY chromosomes who will either experience low testosterone levels in utero (that is, while still inside Mamma’s womb) or who for some reason or other failed to transport that testosterone into its brain cells during that formative period. Would it be surprising to find out that this person might have a male body and a female brain?” Yes, it would be surprising — I would expect a female body if the fetus experienced low testosterone levels in utero, a phenotypical female and genotypical male.

  • meyati

    There are many prisoners with mental conditions that mutilate their selves and have to be watched. this prisoner should be with them and be watched. Then I have to ask-what problems is this transgender causing in the prison-the cell block? —-I would not want to be a guard nor a prisoner with this person, just because of their unexpected strength and mental instability.
    While I have LG friends-and I never ask about transgender-I do not see a struggling prison system having to provide this type of surgery. One of the reasons is that there isn’t any guarantee that transgender patients would be able to get the surgery in the free world -the out side–probably couldn’t afford it. Prisoners should be allowed if they could afford it and pay for it. My heart goes out to the bi-polar and schizophrenic prisoners.

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