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. 2023 Feb 14;29(1):3–11. doi: 10.1089/jchc.21.09.0094

Implementing Gender-Affirming Care in Correctional Settings: A Review of Key Barriers and Action Steps for Change

Matthew Murphy 1,2,3,*, Brooke G Rogers 1,4, Carl Streed Jr 5,6, Jaclyn MW Hughto 7, Asa Radix 8, Drew Galipeau 1, Siena Napoleon 1, Ty Scott 1, Madeline Noh 1, Cassie Sutten Coats 3,7, Leigh Hubbard 3, Philip A Chan 1,3,7, Amy Nunn 1,3,7, Justin Berk 1,2
PMCID: PMC10081719  PMID: 36378847

Abstract

Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration, interpersonal violence, HIV and other sexually transmitted infections, substance use disorders, and suicidality. Little is known about successful approaches to improve health outcomes for TGD individuals impacted by incarceration. We review the barriers to providing gender-affirming clinical care in correctional systems in the United States, identify key knowledge gaps regarding the provision of gender-affirming care to incarcerated TGD populations, and highlight necessary steps to improve the health and safety of this highly vulnerable population. We also describe the components of a gender-affirming care model implemented in a state correctional facility, including support from correctional administrators, identifying a gender-affirming care provider, standardizing clinical care protocols, and adapting clinical services to TGD population needs. Similar models should be employed elsewhere to improve health outcomes for TGD populations during incarceration and on release.

Keywords: transgender, gender diverse, gender-affirming care, incarceration, implementation

Introduction

Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration and criminal justice (CJ) involvement (Grant et al., 2011; Jones, 2021; Kaeble & Cowhig, 2016; National Academies of Sciences, Engineering, & Medicine, 2020). TGD groups experience extreme social marginalization, homelessness, and poverty as a result of the interpersonal, social, and structural stigma they experience due to their gender identity and this stigma had been shown to contribute to health disparities for TGD people (Brown & Jones, 2016; Lefevor et al., 2019; Reisner et al., 2014; Su et al., 2016; White Hughto et al., 2016).

The stress associated with this marginalization also places TGD individuals at higher risk for stress-sensitive mental health conditions, including suicidality, substance use, and risk of drug overdose (James et al., 2016; Johns et al., 2019; Mak et al., 2020; Wansom et al., 2016; White Hughto et al., 2017, 2019; Wolfe et al., 2021) as well as physical health conditions, including HIV infection (Baral et al., 2013) and cardiovascular morbidity and mortality (Streed et al., 2021).

TGD individuals are also more likely to report activities that place them at increased risk of CJ involvement, including substance use and sex work, due to the structural disadvantages faced by this community (Garofalo et al., 2006; Nemoto et al., 2011; Sanders et al., 2022; White Hughto et al., 2018). Poor social support, intimate partner violence, and safety threats in public settings are linked to negative mental health outcomes for TGD individuals (Nemoto et al., 2011). Psychological stressors, in tandem with social phenomena including high rates of unemployment and discrimination in housing and the workplace, lead some TGD people to engage in illicit economies, including sex work and substance use for survival (Clark et al., 2022 (in review); White Hughto et al., 2018).

This, in turn, leads to not only vulnerability to incarceration but also poor health outcomes such as HIV acquisition and overdose (Nemoto et al., 2011). In addition to being disproportionately impacted by several social and structural issues affecting their health and well-being, TGD populations experience numerous barriers to accessing affirming and culturally congruent medical care (Puckett et al., 2018). These barriers include experiences of rejection from health care professionals, fear of mistreatment by clinical staff, and a lack of clinicians able to provide competent and compassionate health care including gender-affirming clinical care (Poteat et al., 2013; Puckett et al., 2018).

The term “gender-affirming clinical care” refers to the provision of culturally competent clinical care that affirms an individual's gender identity. This can include hormone therapy (e.g., administration of estrogen or testosterone via injection, gel, or patch), surgical procedures, and other medical interventions to assist an individual in having a gender presentation that is consistent with their internal gender identity (Reisner et al., 2016). Access to gender-affirming clinical care is particularly important during a period of incarceration given the known vulnerability of TGD populations in CJ settings (Malkin & DeJong, 2019; White Hughto et al., 2018).

In addition, with the disproportionate burden of suicidality, substance use disorders (SUD), and HIV acquisition among TGD populations (Johns et al., 2019; Mak et al., 2020; Wansom et al., 2016) and the specific risks of these conditions in the immediate period after release from incarceration (Binswanger et al., 2007; Gan et al., 2021; Stone et al., 2018), improving access to gender-affirming care with the goal of connecting individuals to care in the community on release is crucial to improving health outcomes for this uniquely vulnerable population (Keuroghlian et al., 2015; Levin et al., 2021).

Among the many unknowns related to the health of CJ-involved TGD populations, perhaps the most concerning is the lack of knowledge related to their health status on community reentry and the services needed to ensure their well-being after release. Although the general incarcerated population returning to the community is at a markedly increased risk of a drug overdose, suicide, homicide, and HIV acquisition during the period immediately following release (Binswanger et al., 2007; Gan et al., 2021; Stone et al., 2018), this risk is likely to be even greater among CJ-involved TGD people given their disproportional exposure to stigma and related poor health outcomes (Hughto et al., 2022; White Hughto et al., 2019).

Historically, TGD care guidelines required individuals to undergo extensive mental health screening to access gender-affirming hormones and such requirements still exist for accessing surgical therapy (Puckett et al., 2018). Although such rigorous psychological screening standards are applied to multiple types of presurgical evaluations (e.g., bariatric, organ transplant), to our knowledge, such screenings are not required for other routine and medically necessary outpatient procedures. Requiring such a high level of psychological evaluation and letters of support for gender-affirming surgery, therefore, creates unnecessary barriers to care for TGD people and particularly reduces access to care for those who lack the resources to access a mental health provider (Puckett et al., 2018).

In light of the barriers to accessing gender-affirming care, the World Professional Association for Transgender Health Standards of Care and other leading clinical practice guidelines in transgender health have called for the use of an informed consent model for the provision of gender-affirming care (Coleman et al., 2012). In this model, assessments, including mental and physical health evaluations, are conducted by health professionals (usually primary care providers), which reduces barriers to treatment (Coleman et al., 2012).

This informed consent model avoids the gatekeeping approach, attempts to destigmatize gender diversity and gender nonconformity, empowers TGD populations to make their own decisions related to their health, and encourages nonspecialist physicians, including primary care providers, to offer gender-affirming hormone therapy (Spanos et al., 2021). State Medicaid and insurance regulators are increasingly including gender-affirming medical and surgical care as part of their covered health services, increasing TGD people's access to care (Zaliznyak et al., 2021). Although incarcerated populations are legally required to receive the community standard of care (Hurst et al., 2019), access to gender-affirming care in correctional settings is frequently restricted (Jones, 2021).

Given the known variability in gender-affirming care implementation and health challenges facing incarcerated TGD populations (Table 1), this article reviews barriers to implementing an informed consent approach to providing gender-affirming clinical care in CJ settings and key action steps needed to improve the health and health care of TGD groups experiencing incarceration in the United States. The article then describes a gender-affirming care model that has been implemented in a Rhode Island correctional facility and discusses how a similar model can be used nationally to improve access to care and related health outcomes for TGD populations.

Table 1.

Key Health Challenges Facing Incarcerated Transgender and Gender-Diverse Populations

1. Multifactorial marginalization in the community
2. Disproportionate vulnerability to multiple health processes, including substance use disorders, HIV, and severe mental health disorders
3. Barriers to accessing clinical care, including gender-affirming care in the community and during incarceration
4. Lack of research characterizing effective approaches to improving health outcomes among incarcerated transgender populations
5. Potential vulnerability to death and HIV acquisition during the period of community reentry after incarceration
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Gender-Affirming Care Access in CJ Settings

Although there has been some improvement in expanding access to gender-affirming health care in the community (Poquiz et al., 2021), little is known about the status of implementing gender-affirming care in correctional settings. Notably, prior research found that TGD populations report insufficient access to gender-affirming care while incarcerated (Hughto et al., 2022; James et al., 2016; McCauley et al., 2018; White Hughto et al., 2018).

In a study conducted by Brown (2014), letters written by TGD incarcerated individuals (N = 129) and submitted to the Trans in Prison journal, a publication of the Gender Identity Center of Colorado, were qualitatively analyzed by content area and theme (Brown, 2014). TGD detainees wrote about a variety of topics; the top 10 included TGD health care issues, social, legal, physical abuse, gender dysphoria, sexual abuse, poverty, housing, suicidal ideation, and mental health problems. Of these, TGD health care was most frequently mentioned (55%) as a problem, highlighting the importance (and challenges) of receiving gender-affirming health care in CJ settings.

Prior research has attempted to quantify U.S. prison policies regarding access to hormones. A survey of over 27,000 TGD people found that 37% of those who had been incarcerated in the past year and were taking hormones prior to incarceration were not allowed to continue hormones while in a CJ setting (James et al., 2016). Access to this care has historically depended on the state and even the specific setting in which a person is incarcerated (Jones, 2021).

In a qualitative study by Clark et al. (2017), correctional health care providers (N = 20) completed individual, semi-structured interviews about their experience caring for incarcerated TGD people (Clark et al., 2017). Thematic analysis of interviews identified multi-level barriers to the provision of affirming and culturally sensitive care. At the structural level, restrictive policies and limited budgets for care were identified as barriers to the delivery of gender-affirming care. At the interpersonal level, custody staff biases toward health care providers and transgender individuals were reported to obstruct providers' ability to adequately care for their TGD patients.

Finally, at the individual level, the study found that lack of cultural and clinical competency, stemming from some providers' personal bias toward TGD people and/or their lack of knowledge and experience in caring for TGD patients, resulted in the inadequate and non-gender-affirming provision of care to incarcerated TGD people.

In a related study, White Hughto et al. (2018) conducted individual interviews (N = 20) with recently incarcerated (past 5 years) TGD women to document their health care experiences while incarcerated in men's correctional facilities. At the structural level, many study participants identified the challenges of living and receiving medical care in a sex-segregated facility as their feminine identity was routinely suppressed through the institution's rules and regulations and actions of custody staff and even health care providers.

For example, participants reported being subjected to restrictive policies that made it difficult for them to access hormone therapy unless they could provide documentation of their use prior to being incarcerated. This was particularly the case for TGD women who had accessed hormones outside of traditional care settings (i.e., “street hormones”). Participants also reported stigmatizing and uncomfortable interpersonal interactions with some health care staff whom participants perceived to either hold biases toward TGD people or lacked appropriate clinical and cultural knowledge about how to care for TGD people.

At the individual level, in an effort to avoid mistreatment by custody staff, health care providers, and other incarcerated people, some TGD women attempted to conceal their feminine gender expression and identity whereas others chose to not seek out hormones in an effort to not be identified as TGD within the correctional system. To address these multi-level issues, TGD women called for the more affirming treatment of incarcerated TGD people and increased education and cultural competency training for correctional health care providers.

Increasing Access to Gender-Affirming Care

The Federal Bureau of Prisons (BOP) has issued guidance on the clinical management of TGD people, which calls for the use of an informed consent approach to provision of medical and surgical gender-affirming health services (Federal Bureau of Prisons, 2016, 2022). Used as a reference for many correctional systems, this guidance provides resources for ensuring that informed consent is attained and documented, makes clinical recommendations for providers managing hormone therapy, and highlights the need for an integrated care approach to address the high mental health burden among incarcerated TGD populations (Federal Bureau of Prisons, 2016, 2022; National Center for Transgender Equality, 2018).

One way to improve physical and psychosocial health and well-being among TGD populations is to increase affirming medical support. Gender-affirming clinical care, particularly when integrated with wraparound services and connection to community support, is associated with several improved health outcomes and high patient satisfaction (Bränström & Pachankis, 2020; Coulter et al., 2019; Spanos et al., 2021; White Hughto & Reisner, 2016).

The informed consent model of gender care allows individuals to provide consent to primary care providers directly, thus reducing barriers to gender-affirming care. This approach aims at empowering individuals to make their own health choices related to their gender identity while avoiding requirements for mental health evaluations, which are often perceived as stigmatizing and can delay or limit the availability of clinical services, including general mental health care (Cavanaugh et al., 2016).

Key Action Steps to Improve CJ-Involved Gender Minority Health Policy and Guidance

The Prison Rape Elimination Act (PREA), signed into law in 2003, has been continuously updated to help eradicate rape in correctional facilities in the United States. The PREA instituted protections by developing and enforcing standards for the prevention and sanction of prison rape, including acts of sexual violence perpetrated by incarcerated individuals and staff (Bureau of Justice Assistance, n.d.).

As of 2015, PREA specifically addressed new protections for sexual and gender minority populations in correctional facilities through measures such as providing segregated pods or units for lesbian, gay, bisexual, transgender, queer+ people (National Center for Transgender Equality, 2015). In a thorough review of 21 states' policies for TGD people conducted by the Prison Policy Initiative, only one state's policies fully match PREA standards for TGD people (Oberholtzer, 2017).

Although PREA has instituted protections for sexual and gender minority populations, TGD people still experience a significant amount of stigma and violence while incarcerated (Hughto et al., 2022; Jenness, 2021; Sanders et al., 2022). The environment in correctional settings and further marginalization as a result of their gender identity have the potential to heighten the extreme social marginalization that TGD people experience in the community. Violence in correctional settings may also impact people's ability or comfort in seeking gender-affirming clinical care (Sanders et al., 2022; White Hughto et al., 2018).

Scholars in sexual and gender minority health have identified key challenges and opportunities for improvement for incarcerated TGD populations (Table 2). For example, Sevelius and Jenness (2017) identified victimization, housing placement, and health care provision as issues currently facing TGD detainees, specifically TGD women in the CJ setting.

Table 2.

Priorities for Improving the Health of Incarcerated Transgender and Gender-Diverse Populations

1. Using a gender-affirming framework in a “whole-incarceration-setting” approach (Brömdal et al., 2019)
2. Collect data on gender identity, in addition to sex assigned at birth
3. Increase access to gender-affirming clinical care
4. Address HIV, hepatitis C, substance use disorders, and other disease processes that disproportionately impact transgender populations
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First, they propose using a “gender affirmation” framework, which refers to an interpersonal, interactive process whereby a person receives recognition and support for their gender identity and expression. Second, they suggest collecting data on gender identity (in addition to sex assigned at birth) and considering it in determining housing placement. Third, they recommend gender-affirming health care, including addressing gender dysphoria, hormones, and gender-affirming surgeries and providing stage-appropriate support for individuals based on their needs. Providing this care is well established as beneficial for TGD people and can prevent morbidity and mortality associated with gender dysphoria, including depression and suicidality (Coleman et al., 2012).

Fourth, they assert the importance of HIV prevention and treatment and preventive medical and mental health care to provide support for well-being. TGD people, and specifically TGD women, are at an increased risk for HIV and STIs compared with the general population and should have access to this care in prison settings (Baral et al., 2013). Systemic discrimination and marginalization add an undue burden of stress (often termed “minority stress”) that makes TGD people more vulnerable to stress-sensitive disorders such as depression, anxiety, and suicidality (Bockting et al., 2013; Perez-Brumer et al., 2015). This holistic approach to providing affirming TGD care in CJ settings would go a long way to support the health and well-being of TGD people.

Safe Environment

Although the BOP's guidance is a crucial first step to ensuring TGD populations receive the clinical care that they need, it does not ensure that the lived environment during incarceration is conducive to safe, informed consent decision making, particularly in the context of the gender-binary organized CJ system. As a result, a “whole-incarceration-setting” approach has been underscored as key to ensuring a gender-affirming environment (Brömdal et al., 2019).

Informed by the “whole setting” approach to improving public health supported by the World Health Organization and the experience of the “whole-of-school” approach to improving the educational experience for TGD populations (Bartholomaeus & Riggs, 2017), implementing multi-level changes to facilitate a more gender-affirming space during incarceration offers the greatest opportunity for success. Central to implementing a “whole-incarceration-setting” approach is the organization of housing assignments and facilities that provide TGD people with safe, affirming, and nonpunitive means to express their gender identity.

One promising example is legislation recently passed in California that allows for housing TGD people in a facility that aligns with their gender identity (The Transgender Respect, Agency and Dignity Act, 2020). Although the implementation of this policy has yet to be studied, its passage provides an opportunity for incarcerated TGD people in California to gain access to environments that may be more affirming of their gender identity and it could lead other states to create similar policies as a means to improve the correctional environment for TGD people. In additional, engagement with community stakeholders has been employed to advance correctional policy around improved conditions for incarcerated TGD communities (Kendig et al., 2019).

Culturally Congruent Trainings for Medical Staff

One intervention area that is already being tested is the training of correctional security and health care providers in transgender cultural and clinical competencies. Although research in this area is limited, preliminary studies suggest that gender-affirming training of correctional staff is feasible (White Hughto et al., 2019) and effective in improving knowledge and the delivery of care (White Hughto & Clark, 2019). Cultural and clinical competency training also appears to reduce patient complaints related to their clinical care and overall experience while incarcerated, an important consideration for correctional leadership (Jaffer et al., 2016).

Data collection and analysis are important for developing effective interventions to protect and promote TGD population health, as well as a fundamental part of the monitoring and regulation of correctional facilities required to ensure that universal standards and safety for TGD people are met throughout the country's correctional institutions.

Although the National Commission on Correctional Health Care (NCCHC) has a position statement that supports creating gender-affirming correctional environments and an informed consent approach to gender-affirming clinical care (NCCHC, 2020), notably, NCCHC and the American Correctional Association have few tools at their disposal to ensure universal standards of practice for gender-inclusive and affirming environments and clinical care. Strengthening the credentialing process of correctional health services to ensure high standards of health care provision are met along with introducing national data reporting processes are potential approaches to standardize health care services for incarcerated TGD people.

Feasible Clinical Model for Gender-Affirming Care Delivery: A Case Example From the Rhode Island Department of Corrections

Rhode Island Department of Corrections (RIDOC) is a unified state correctional system with all pretrial and sentenced individuals housed on the same campus in Cranston, Rhode Island, under the same administrative and clinical leadership. The department housed roughly 2,150 people as of June 30, 2020. Of these, approximately 1,600 were sentenced and around 550 were pretrial (RIDOC, 2020). Roughly two-thirds of individuals were between the ages of 20–39 and the racial makeup was primarily White (49%), followed by Hispanic (25%) and Black (21%). Males made up 95% and 97% of pretrial and sentenced populations, respectively (RIDOC, 2020).

RIDOC has been at the forefront of developing innovative clinical programming to address the HIV and opioid epidemic, among other significant public health challenges facing populations experiencing incarceration (Clarke et al., 2018; Zaller et al., 2008). Important elements of these successful efforts include establishing screening protocols for specific pathological processes such as HIV or opioid use disorder shortly after entering into the CJ system, providing clinical care during incarceration, and then linking individuals to care in the community upon release.

In January 2021, RIDOC established a gender-affirming clinical care program under the leadership of a general medical provider with gender care clinical training who provides gender-affirming care in the community as well as in the CJ system. The clinical program was developed in response to requests from individuals seeking greater access to gender-affirming care while incarcerated at RIDOC. A systemwide clinical care protocol was developed under the supervision of RIDOC's medical director to reflect the community standard of care in Rhode Island such as the state's guidance for patients enrolled in Medicaid.

In addition, the protocol incorporated recommendations from the BOP, including the consenting process, hormone dosing parameters, and referrals for surgical affirmation during a period of incarceration. After receiving approval from the medical director, the standardized protocol was reviewed by RIDOC's health service administration and director's office, who finalized approval.

Since the protocol's implementation, all patients who request gender-affirming care are referred to a gender care provider through the electronic medical record for a comprehensive clinical intake, discussion of hormone and surgical therapies, and completion of a verbal and written informed consent process in line with BOP guidance. Screening for TGD individuals occurs as part of a standardized, nurse-led universal screening shortly after a period of incarceration begins. Referrals can also be generated from clinical staff throughout RIDOC in the pretrial and sentenced facilities.

The gender care clinical provider is responsible for overseeing the continuation of hormone therapy ordered by providers in the community as well as initiating TGD individuals on hormone therapy during their incarceration. As of September 2021, approximately 15 TGD individuals at RIDOC have been cared for as part of this program. In addition to standardizing the initiation of gender-affirming hormonal therapy, the clinical protocol allows for TGD individuals sentenced for longer than 12 months to be evaluated for gender-affirming surgery. Notably, the first person requesting affirming surgery at RIDOC has been referred for surgical evaluation per the approved protocol.

The RIDOC approach to gender-affirming care was developed in parallel to a long-standing, PREA-based housing assignment process that allows for individuals to petition to be housed based on their gender identity. A PREA committee, made up of clinical staff, social workers, security leadership, and RIDOC administrators, convenes for each housing petition of a TGD individual. Petitions are reviewed as a group with the petitioner able to present their case in person. The committee then votes on whether the request to be housed based on gender identity as opposed to sex assigned at birth should be granted.

Despite RIDOC receiving approximately 10 petitions annually, no individual has been housed in a facility that aligns with a gender identity distinct from their sex assigned at birth. Although the gender care provider participates in these PREA committee meetings as a voting member, the vote does not affect the initiation or continuation of gender-affirming care, including consideration of referrals for surgical affirmation.

Gender-affirming clinical care has also been integrated into pre-existing HIV, hepatitis C, SUD, and HIV pre-exposure prophylaxis (PrEP) care programs. The same gender care clinician provides general medical, hepatitis C, and PrEP care within RIDOC. Thus, clinical encounters often address an array of needs among TGD people. The gender care provider also works with discharge planners and case managers at RIDOC to ensure that gender care needs are met on community reentry. This includes preparations for continuing HIV treatment, prevention, hepatitis C, and other general medical care for TGD individuals during planning for linkage to gender-affirming providers after leaving RIDOC.

Although more research is needed on the effectiveness of this approach in the CJ setting, access to gender-affirming care is associated with greater adherence to antiretroviral medications (Sevelius et al., 2014) and improved SUD care outcomes (Wolfe et al., 2021). This is likely to be important for TGD people in the period immediately after release from incarceration.

Opportunities for Future Research and Practice

Although the limited preliminary research conducted with TGD populations in correctional settings provides important insights into the development of effective intervention, important knowledge gaps in the literature remain. These gaps include limited research on the impact of the BOP gender care guidelines, barriers to their implementation at different levels of carceral management, and their impact on health outcomes. Future research is needed to fully understand the current state of gender-affirming care access and utilization among TGD people in order to improve health outcomes for this highly vulnerability population during and after release from incarceration.

Identifying a gender care provider who works in both the CJ setting and the community can aid in connecting TGD people to clinical care on release and facilitate the medical discharge planning process (Shavit et al., 2017; Zaller et al., 2008). It may also facilitate communication among correctional staff to quickly address any gender care-related concerns that arise, ensure the continuity of gender care when TGD people enter correctional facilities, and facilitate the initiation of gender-affirming clinical care for people sentenced to a prolonged period of incarceration.

This provider may also be in the position to act as a public health champion, advocating for change within the correctional system to address the clinical care needs as well as the social and structural determinants of health for incarcerated TGD populations (Wood et al., 2020). Support from correctional and clinical leadership is key to the success of this approach.

Conclusion

TGD populations, particularly those involved with the CJ system, experience significant social marginalization and related poor physical and mental health and encounter a number of barriers to accessing gender-affirming clinical care. There are many unknowns related to the health status of TGD populations experiencing incarceration, and significant barriers remain to implementing tailored interventions to improve their health. Greater monitoring and regulation of CJ settings are needed to ensure basic health and safety standards are being met throughout the diverse correctional institutions in the United States.

In addition, more research is needed on effective approaches to improve the health of CJ-involved TGD populations, particularly during the vulnerable period of community reentry. The experience at RIDOC shows that expanding an informed consent approach to gender-affirming care is feasible within correctional systems. Key elements to this innovative approach (Table 3) to providing gender-affirming care can provide a framework for implementation in other contexts. Together, ongoing research paired with expanding gender-affirming care delivery services can help to better understand and improve the health and safety of CJ-involved TGD populations.

Table 3.

Key Elements to Implementing the Rhode Island Department of the Corrections Gender-Affirming Care Model

1. Respond to requests and stated needs of the incarcerated transgender population
2. Identify a correctional care provider with experience providing gender-affirming care in the community
3. Standardize processes through the development of a systemwide gender-affirming clinical care protocol
4. Obtain support from correctional leadership, including clinical leadership
5. Adapt to pre-existing correctional and clinical care activities
6. Integrate gender-affirming care with HIV, pre-exposure prophylaxis, hepatitis C, and general activities
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Authors' Contributions

All authors contributed to the drafting, editing, and formatting of the article.

Author Disclosure Statement

Drs. Murphy and Rogers are supported by a Gilead Sciences grant, IN-US-276-5463. The other authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

In addition to the Gilead Sciences grant, M.M. is supported in part by National Institutes of Health (Grants Nos. 1R25DA031608 and 1K23DA054003-01A1).

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