Developing Correctional Policy, Practice, and Clinical Care Considerations for Incarcerated Transgender Patients Through Collaborative Stakeholder Engagement

Abstract

Transgender persons are at increased risk of victimization during incarceration and have unique health care needs. We convened a symposium of 27 key stakeholders to develop consensus on correctional policy, practice, and clinical care considerations for incarcerated transgender persons. Participants included formerly justice-involved transgender persons, correctional leaders, government authorities, academicians, advocates, health care providers, and expert consultants. Consensus considerations were developed in four areas: correctional practices that promote safety and respectful interactions with transgender inmates, training of correctional staff, health care delivery, and reentry to the community. Gaps in knowledge and practice in these four areas were also identified. A collaborative stakeholder model is an effective strategy to convene disparate groups who infrequently communicate with one another to help advance correctional policies and clinical care.

Ensuring the safety, the respectful treatment, and the health of incarcerated transgender persons is a major challenge for U.S. correctional systems. Transgender persons are disproportionately victims of sexual assault during incarceration and may be treated disrespectfully by correctional staff (Beck, Berzofsky, Caspar, & Krebs, 2014; Jenness & Fenstermaker, 2016). The enactment of the Prison Rape Elimination Act (PREA) with its detailed standards has helped inform correctional policies to better protect transgender persons and provide them more respectful treatment (National PREA Resource Center, n.d.). Despite these policy advancements, however, a recent review of state correctional policies indicated that 40% of states continued to have at least one policy that conflicted directly with the transgender protections of PREA (Malkin & DeJong, 2018). Furthermore, the breadth of effective implementation of correctional policies intended to enforce PREA is still largely undetermined.

Beyond the requirements of PREA compliance, correctional health authorities must also navigate the rapidly evolving U.S. community standard of health care in transgender medicine to define the scope of health care services provided to their transgender patients (Baker, 2017). The actual provision of care to incarcerated transgender patients is further complicated by the broad lack of health care professional expertise in this evolving area of medicine. Incarcerated transgender patients cited access to adequate health care as their major concern in one qualitative analysis (Brown, 2014).

Compounding these policy and clinical care concerns, correctional systems are frequently faced with legislative initiatives and active litigation that directly affect their management of transgender persons. In consideration of these major challenges, we proposed a novel strategy for further informing public policy and clinical care in this arena. We convened a meeting of key stakeholders from disparate groups to establish meaningful relationships with one another and develop correctional policy, practice, and clinical care considerations for managing incarcerated transgender persons.

Method

We determined symposium priorities by the following: (1) conducting a comprehensive literature review to identify current research findings and gaps in knowledge; (2) surveying more than 40 directors of state correctional systems to determine their prioritized concerns; and (3) personally interviewing key stakeholders including leaders from transgender advocacy groups; authorities on PREA; formerly justice-involved transgender persons; health care providers with expertise in transgender medicine; and correctional leaders from local, state, and federal systems as well as accrediting organizations. The preplanning process reinforced the potential benefits of convening stakeholders at an academic medical center to discuss the management and care of incarcerated transgender persons. We identified four major areas of focus for the symposium: (1) identifying correctional policy and practice considerations for screening, searching, housing, and managing transgender persons that protect them from abuse and create a culture of safety; (2) training correctional staff to enhance respectful attitudes toward transgender inmates and transgender coworkers; (3) identifying clinical practice considerations for better defining medically necessary health care for transgender patients and improving their access to quality medical care; and (4) identifying effective reentry strategies for transgender persons returning to their communities.

We selected a broad spectrum of participants from across stakeholder groups, intentionally limiting the number of symposium participants to foster highly interactive discussions. The 27 invited participants had significant expertise in the fields of corrections and/or transgender care, many with national scopes of responsibility, and included two federal managers of transgender programs, three directors or assistant directors of state departments of corrections, one medical director of a state department of corrections, three jail authorities, one chief of probation, two correctional accreditation leaders, five university professors with expertise in transgender medicine and/or public policy, two experts from organizations focused on reducing jail and prison sexual assaults, three consultants with expertise in training correctional staff, and five leaders from the transgender advocacy community.

Additionally, three of these participants were physicians with collectively more than 70 years of experience in correctional medicine. Three of these participants were doctoral clinical psychologists with expertise in transgender mental health care. Two of these participants, including a board-certified endocrinologist, had long-standing clinical practices in managing the medical issues of transgender patients. Two of these participants were formerly justice-involved transgender persons. Six of these participants self-identified as transgender persons.

We established the following ground rules to foster meaningful dialogue: The 2-day meeting was a closed forum not open to the public; all stakeholders were asked to actively contribute and advocate for their organization or position, while respecting their colleagues; participant comments and opinions were not to be disclosed outside the meeting; and symposium findings would be published as a collective consensus without attribution to a specific person or organization.

The symposium convened for 2 days at the School of Medicine & Health Sciences, George Washington University in August 2018. The four major areas of focus for the symposium were presented in a panel format by subject matter experts followed by open discussion to determine group consensus on panel recommendations. Consensus was defined as 90% concurrence. Symposium consensus “considerations” were drafted from the live meeting discussions and then subsequently finalized through virtual feedback from participants in the ensuing 5 months after the meeting.

Results

Identifying Correctional Policy and Practice Considerations for Screening, Searching, Housing, and Managing Transgender Persons That Protect Them From Abuse and Create a Culture of Safety

Sound correctional policies are critical for safely managing transgender persons. PREA standards articulate specific policy requirements for screening and housing newly incarcerated inmates who may be vulnerable to sexual assault (National PREA Resource Center, n.d.). However, PREA standards do not specifically detail the operational procedures for screening newly incarcerated persons and designating their housing assignments. Housing decisions for transgender inmates are particularly complex. Discussions among stakeholders indicate that transgender women may or may not prefer to be housed in a women’s or men’s facility based on personal, facility, and safety considerations. In certain jurisdictions, transgender advocacy groups and correctional administrators jointly support housing transgender persons in a designated unit. Furthermore, there is a paucity of information to inform housing policies on the designation of transgender men. These observations support the need for case-by-case decision-making in housing transgender persons through a careful interdisciplinary assessment. Other correctional management practices also impact the sense of well-being of transgender persons, including the use of preferred pronouns by correctional staff, gender accommodations for pat or strip searches, and access to undergarments and commissary items consistent with the inmate’s gender identity. We developed consensus considerations for correctional officials who are implementing policies for managing transgender populations (Table 1). We also identified critical gaps in knowledge and practice that warrant further research and discussion.

Table 1.

Identifying Correctional Policy and Practice Considerations for Screening, Searching, Housing, and Managing Transgender Persons That Protect Them From Abuse and Create a Culture of Safety.

Consensus Considerations  Community engagement: Correctional systems should consider engaging transgender community members or advocates to help inform correctional policies and practices in managing transgender inmates.  Housing: Facility designation decisions for transgender inmates should be made on a case-by-case basis utilizing an interdisciplinary team that includes representatives from mental health, medical, security, and programming. When making these housing decisions, the team should consider relevant factors including, but not limited to, the inmate’s gender identity, history of living daily life in accord with that identity, physical characteristics, security level, criminal and disciplinary history, medical and mental health needs, vulnerability to sexual abuse, and facility-specific factors. Consideration should also be given to the individual’s own perception of where they would be safest. Facility designation decisions for transgender inmates should not be based solely on the genitalia or the sex assigned at birth.  Screening: Facilities should ensure that their existing risk screening tools initially identify transgender inmates and adequately assess these inmates’ vulnerabilities to victimization. Risk screening information should be communicated to correctional staff, modified as needed to protect the inmate’s privacy, and used throughout an inmate’s incarceration. To accomplish this, there needs to be adequate communication and “systems compatibility” with booking/intake, medical, mental health, classification, housing, and program staff.  Pronouns and names: Correctional agencies should encourage staff to use a transgender inmate’s preferred pronoun.  Searches: Transgender inmates should be given an opportunity to indicate a preference for the gender of the staff they would feel most comfortable with conducting pat or strip searches. Absent exigent circumstances, the correctional agency should honor this decision.  Commissary: Transgender inmates should have access to the same commissary items consistent with their gender identity and security classification. For example, a medium-security transgender woman who is housed in a men’s facility should have access to the same commissary items that are available to medium-security women housed in a women’s facility.  Undergarments: Transgender inmates should be permitted to have undergarments consistent with their gender identity, regardless of whether they are housed in a facility for men or a facility for women. Gaps in Knowledge and Practice  How can screening tools be evaluated and more thoughtfully constructed and administered to better identify safety risks for transgender persons?  Can a more thoughtful, multidimensional construct be developed to determine where transgender persons are optimally housed?  How can correctional agencies develop policies for managing transgender inmates that are Prison Rape Elimination Act compliant and develop quality measures that assess policy implementation and drive continuous improvement?  What are the pros and cons of adopting unisex commissaries and should they be more broadly implemented in correctional facilities?  How can corrections and the academic community better collaborate to evaluate correctional policies and practices related to the management of transgender persons? What is a prioritized research agenda?

Training Correctional Staff to Enhance Respectful Attitudes Toward Transgender Inmates and Transgender Coworkers

Correctional leaders prioritized the importance of training for all levels of correctional staff on appropriately engaging with transgender inmate populations and supporting transgender coworkers. This need was reinforced by the testimonies of formerly incarcerated transgender individuals who reported personal discrimination and disrespectful interactions with correctional staff in certain U.S. jails and prisons. More targeted training of correctional health care providers may also be warranted, since in certain settings, these staff lack the cultural competencies to provide gender-affirming health care to transgender patients (Clark, White Hughto, & Pachankis, 2017). Relevant training information is available to correctional officials from the National Institute of Corrections (n.d.) and other sources. Nevertheless, there was strong group consensus that the delivery of training content on respecting transgender inmates could be improved in most correctional settings. We developed practical considerations for correctional officials who are developing staff training curricula on professionally interacting with transgender inmates (Table 2). We also identified gaps in knowledge and practice that warrant further research and discussion.

Table 2.

Training Correctional Staff to Enhance Respectful Attitudes Toward Transgender Inmates and Transgender Coworkers.

Consensus Considerations  Correctional agencies should create and sustain a leadership culture of safety for transgender persons. Staff training should align with the agency’s vision, mission, and values and link to the agency’s leadership expectations for interacting with transgender persons.  Correctional agencies should develop training content, design, delivery, and evaluation methodologies that engage correctional staff in understanding their role in responding to transgender individuals in consideration of the following:   – Training content should be consistent with best practices and professional standards guiding correctional practice and the treatment of transgender individuals.   – Training design for supervisory, midlevel, and line staff should be skills-based and include scenario-based skill development and content.   – Training strategies should be tailored to the size and unique characteristics of the correctional facility. Examples of training strategies include accessing web-based resources, regional trainings, and the involvement of community organizations and advocacy groups.   – Training delivery should be consistent with adult learning theory and best practices in responding respectfully to transgender individuals. Key training concepts for consideration include the following:   – Select train-the-trainers using defined criteria that establish clear role expectations.   – Ensure trainers are knowledgeable and possess the communication skills to adequately convey key messages.   – Integrate, as feasible, transgender persons as trainers or contributors to the training curriculum, including available transgender correctional staff or transgender law enforcement peers from the local community.   – Support trainers with additional training materials including videos that provide access to subject matter experts and the experiences of justice-involved transgender persons.   – Conduct training that emphasizes the importance of respecting transgender persons as human beings in their routine activities within the correctional setting rather than solely focusing on Prison Rape Elimination Act compliance and sexual victimization.   – Provide correctional staff with confidential opportunities to communicate their concerns for managing transgender persons in compliance with policy. Proven strategies include submitting note cards with questions for a private response and engaging in volunteer meetings that provide a trusting environment, for example, chaplain prayer breakfasts. Gaps in Knowledge and Practice  What additional training resources on managing transgender populations would be most helpful to correctional agencies?  What hiring strategies would better identify correctional staff who will respect the human dignity and diversity of transgender coworkers and inmates?  What additional guidance can be provided to human resources departments to better support transgender correctional staff?

Identifying Clinical Practice Considerations for Better Defining Medically Necessary Health Care for Transgender Patients and Improving Their Access to Quality Medical Care

The recommended coverage of health care services for transgender patients in the United States is evolving rapidly yet remains inconsistent across public- and private-sector insurance plans (Baker, 2017). Therefore, defining medically necessary health care services for transgender patients is extremely challenging for correctional health care authorities. Fortunately, there are increasingly available high-quality evidence-based guidelines to inform transgender care, such as those from the Federal Bureau of Prisons (2016), the Endocrine Society (Hembree et al., 2017), the World Professional Association for Transgender Health (Coleman et al., 2012), and the University of California, San Francisco (Deutsch, 2016). However, effectively implementing these guidelines is complicated by the general lack of primary care provider expertise in transgender care and the paucity of available subspecialists in transgender medicine to support correctional health care. Considering these hurdles, ensuring the adequate delivery of medically necessary health care to transgender patients poses major risk management issues for correctional systems. We developed consensus considerations to help inform correctional health authorities who are developing policies and clinical practice guidelines for managing transgender patients (Table 3).

Table 3.

Identifying Clinical Practice Considerations for Better Defining Medically Necessary Health Care for Transgender Patients and Improving Their Access to Quality Medical Care.

Consensus Considerations  Correctional chief executive officers, health care authorities, and legal advisors should stay abreast of the evolving landscape of health care services coverage for transgender patients in both the public and private sectors.  Correctional health authorities should adopt clinical practice guidelines for managing transgender patients.  Chief medical officers and correctional health care administrators should recognize the wide range of health care services that are important to transgender patients that include, but are not limited to, hormonal treatments, surgical interventions, voice training, hair removal, and mental health care interventions.  Treatment plans should be patient centered (individualized) for transgender patients as mental health and medical needs are highly variable.  Hormonal treatments should be continued, and medically adjusted as clinically indicated, for newly incarcerated transgender patients who were on treatment at the time of incarceration. Patients without a documented prescription should be considered for continuation of hormonal treatment on a case-by-case basis as clinically warranted.  Hormonal treatments should be initiated for transgender patients who are deemed candidates for treatment by a qualified health care professional.  Surgical interventions for transgender patients should be considered on a case-by-case basis, while weighing the clinical importance of the intervention for the patient and other relevant factors.  Although gender-affirming surgical interventions can incur significant costs, these treatments can be cost-effective. Incarcerated transgender women with debilitating dysphoria related to their genital status can be costly to manage due to frequent hospitalizations, self-injurious behaviors, and associated litigation expenses.  As feasible, an interdisciplinary approach should be adopted to engage the entire health care team in transgender care with the support of subject matter experts as needed.  Mental health care staff, in certain settings, may need to take on the unusual role of patient advocate in coordinating an interdisciplinary health care treatment plan.  Correctional health care administrators should adopt one or more proven interventions for providing quality health care services for their transgender patients, which may include, but are not limited to:   – training primary care providers to gain competencies in managing transgender patients through residential and online continuing medical educational programs;   – employing or contracting subspecialists, for example, endocrinologists, to provide care for transgender patients;   – accessing transgender medicine expertise through telehealth options: teleconsultation, provider-to-provider case presentations by phone, televideo, provider to direct patient care or telementoring, subspecialist training to primary care providers through video case presentations.  Correctional health administrators should evaluate the adequacy of transgender care delivery as part of the health system’s plan to improve organizational performance. Gaps in Knowledge and Practice  How can access to quality care for transgender patients be improved through telehealth initiatives that have proven markedly successful in other health care arenas?  What quality improvement measures might be adopted to assess the quality of health care services provided to transgender patients to drive continuous improvement?

Identifying Effective Reentry Strategies for Transgender Persons

Community transitions for transgender persons releasing from jail or prison are complicated by multiple challenges specific to transgender populations, including the following: (1) transgender persons are frequently alienated from their families and must rely on public systems that may not be adequately prepared to support them; (2) transgender persons may be released to sex-segregated environments, such as shelters and residential treatment facilities, where they may be vulnerable to physical and emotional abuse and inadequate access to resources; (3) linkages to adequate medical and mental health care and substance use treatments may be difficult to secure; and (4) transgender persons may require legal assistance upon release from prison, including name change services, assistance navigating health care insurance coverage, and support in gaining access to nondiscriminatory housing and public accommodations. Not adequately addressing these unique reentry challenges for transgender populations can lead to health risks and psychological distress (if hormones are discontinued), substance use relapse, homelessness, personal safety risks, and possible recidivism. We developed consensus considerations for correctional officials who are implementing reentry programs for transgender populations (Table 4). We also identified related gaps in knowledge and practice that warrant further research and discussion.

Table 4.

Identifying Effective Reentry Strategies for Transgender Persons.

Consensus Considerations  Unique needs: Correctional agencies should recognize that transgender people are at high risk of recidivism and have unique reentry needs that warrant tailored release plans.  Safety: Reentry programs should ensure that transgender people are being connected to safe housing and support services.  Medications: Correctional agencies should have policies and procedures in place to ensure that transgender patients have access to prescription medications at the time of release. Ideally, at release, patients should have a referral to a health services provider who is culturally aware and clinically astute in caring for transgender patients.  Identity documents: A reentry priority for corrections should be providing legal support/referrals to transgender people for name and gender marker change on personal documents such as driver’s license, state ID card, and birth certificate to facilitate community reintegration.  Employment: Correctional agencies should provide tailored job training, formal education, and physical and mental health interventions to transgender people during incarceration to support their ability to gain employment upon release.  Parole: Correctional agencies should target parole locations, as feasible, that minimize housing and employment discrimination for releasing transgender people.  Community support: Linking transgender persons with community transgender support groups, peers, or advocates can be helpful during incarceration and facilitate release planning to appropriate community services. Connectivity can be fostered through in-person meetings and through virtual support groups. Gaps in Knowledge and Practice  What are the challenges faced by transgender persons navigating reentry, including their experiences with reentry planning and utilization of community resources upon reentry?  How can reentry coordination be strengthened among corrections, parole and probation, and other law enforcement agencies and advocacy groups?  How can we better identify community resources that are trans-informed and safe and communicate these resources to correctional officials?

Discussion

Managing transgender populations poses unique challenges for correctional officials, including ensuring inmate safety and respectful treatment during incarceration, providing access to adequate medical and mental health care services, and providing effective reentry planning. Published recommendations for managing transgender populations have helped inform advances in correctional policies in many states (National Center for Transgender Equality, 2018; National Commission on Correctional Health Care, 2015; National PREA Resource Center, n.d.; Sevelius & Jenness, 2017). A review of state correctional policies for managing transgender inmates, however, reveals inconsistent compliance with all PREA standards and a wide divergence in approaches to inmate classification and scope of approved health care services (Malkin & DeJong, 2018; Routh et al., 2017).

We found that collaborative stakeholder engagement could add further input to public policy recommendations and clinical care guidance for incarcerated transgender persons. Key stakeholders from disparate groups, who were vested in ensuring the health and safety of incarcerated transgender persons, respectfully engaged with one another in meaningful dialogue during a 2-day symposium at an academic medical center. This collaborative stakeholder engagement proved fruitful on multiple fronts: (1) participants gained new insights and perspectives from stakeholder groups other than their own; (2) personal networks were established for ongoing dialogue; and (3) consensus considerations for correctional policy, practice, and clinical care were developed to help advance the management and care of incarcerated transgender persons. Participant communication has continued since the symposium with a focus on addressing the identified gaps in knowledge and practice in the correctional management of transgender populations, training of correctional staff, the delivery of adequate health care services, and reentry planning. Since many of the symposium participants were correctional leaders with national scopes of responsibility, we believe this effort could positively impact the future management of transgender persons in U.S. jails and prisons. Collaborative stakeholder engagement is a thoughtful and effective way to advance public policy and should be more broadly embraced to evaluate other challenges faced by U.S. correctional systems.