Lived Experiences of Transgender Inmates in Barcelona Prisons: An Interpretative Phenomenological Study

ABSTRACT

Introduction

Incarceration significantly impacts inmates health, particularly marginalized groups like transgender persons, due to systemic oppression and inadequate healthcare. This study aims to understand transgender prisoners' health management experiences.

Methodology

An interpretative phenomenological approach was used. Data were collected through in‐depth interviews with eight transgender inmates in Barcelona, Spain, and analyzed using the seven‐step Colaizzi method.

Results

Three primary themes emerged: (1) Navigating Vulnerability in Healthcare Dynamics, which highlighted experiences of stigma and inadequate care; (2) The Quest for Wellbeing Amidst Uncertainty, underscoring concerns regarding treatment continuity; and (3) Negotiating a Landscape of Violence, revealing experiences of harassment and discrimination.

Discussion

This study highlights the need for culturally competent, person‐centered healthcare policies in prisons, particularly for transgender individuals. Addressing the specific health needs of transgender inmates is crucial for enhancing their overall well‐being. This emphasizes the importance of systemic reforms to improve care provision for transgender prisoners.

Clinical Relevance

Prison nurses must prioritize person‐centered approaches, ensure continuity of gender‐affirming treatments, and provide empathetic mental health support to enhance trust and improve the overall well‐being of transgender inmates.

1. Introduction

Imprisonment is a significant event for any individual, irrespective of the underlying reasons. Up to 31% of admissions to prison verbalize and express suicidal behavior and ideation, accompanied by stressors in the same environment; these stressors are unknown, but may include harassment, the deprivation of liberty itself and/or the socio‐affective rupture and estrangement (Favril 2021). Furthermore, it is important to note that the prevalence of comorbid mental health conditions such as major depression, dysthymia, substance abuse, psychotic syndromes, among others, is higher in this population than in the general population outside of prison (Fovet et al. 2020).

Given these heightened mental health risks, the United Nations Office on Drugs and Crime (UNODC 2009) identified some vulnerable groups who require a distinctive approach throughout their period of incarceration. These include those in pre‐trial detention, juveniles, women, individuals with disabilities, those with mental challenges, foreign nationals, ethnic minorities or indigenous communities, older individuals, those with substance dependence, and those who are terminally ill, as well as members of the LGBTQIA+ community.

Among these vulnerable groups, many transgender individuals face distinct challenges that further exacerbate their health risks during incarceration. It has been evidenced that up to 7% of incarcerated transgender individuals had experienced isolated admissions to cells or departments, simply because they were incarcerated (Van Hout et al. 2020). These isolations were found to be more prevalent among black or Latino transgender individuals. This form of oppression can have a significant impact on the health of transgender individuals and has been associated with increased risks of suicide and depression (Drakeford 2018). The term “transgender” (or “trans”) is used to describe individuals whose gender identity differs from the sex assigned to them at birth (United Nations 2024).

To contextualize the experiences of transgender inmates, it is essential to examine the broader literature on their treatment and challenges within prison systems globally. In the United States, the National Transgender Discrimination Survey reported high rates of violence and harassment experienced by incarcerated transgender individuals (Grant et al. 2011). Specifically, 16% of respondents reported having faced physical violence, 15% reported having experienced sexual violence, and over a third reported having been subjected to harassment by both prison staff and fellow inmates.

However, these challenges are not unique to the United States; similar patterns have been documented in other countries. The United Kingdom has experienced difficulties in providing adequate housing and healthcare for transgender inmates, leading to the implementation of policy reforms to address these concerns (Gorden et al. 2017). In Australia and New Zealand, recent reviews have identified ongoing challenges pertaining to placement, identity recognition, and access to gender‐affirming healthcare (Lymch and Bartels 2017). Despite efforts to align policies with human rights standards, discrimination and rights violations continue to affect transgender inmates across jurisdictions (Winter 2023). In light of this global trend, the United Nations Office on Drugs and Crime (UNODC 2009) has emphasized the necessity for the implementation of tailored policies that address the specific needs of the LGBTQIA+ community within the context of prisons. These policies should prioritize the social integration of transgender women and the prevention of victimization.

In parallel with policy reforms, the approach to transgender healthcare itself is undergoing significant transformation, moving away from traditional paradigms that have historically categorized transgender health primarily through biomedical and psychiatric lenses. This shift acknowledges the diverse and individual nature of transgender experiences and healthcare needs. While some medical interventions can be beneficial when appropriately applied, there is a growing recognition that a more holistic, person‐centered approach is necessary (Grau 2017). The international network Stop Trans Pathologization has advocated for the World Health Organization (WHO) to reconsider the classification of transgender healthcare in the International Classification of Diseases (ICD) viewing it as a non‐pathological process (Marcus and Hatters 2019). This evolving perspective aims to balance the potential benefits of certain medical interventions with a broader understanding of transgender experiences. It recognizes that while some people may benefit from medical treatments, others may not require or desire them. The goal is to move towards a more inclusive, respectful, and individualized approach to transgender healthcare, both within and outside of prison settings.

Alongside these shifts in clinical understanding, there is growing agreement on the need for institutional policies that safeguard the dignity and rights of transgender people in prisons (Kendig et al. 2019; Miller et al. 2020; Coleman et al. 2022). It is recommended that states establish protection measures for all prison inmates who are vulnerable to violence or abuse because of their gender identity and/or expression. These measures must not result in further restrictions on the rights of those experienced by the general population of the prison.

In addition to these policy recommendations, it is crucial to address the primary and additional health needs of transgender inmates to ensure comprehensive care. The National Center for Transgender Equality's (NCTE 2018) guide Policies to Increase Safety and Respect for Transgender Prisoners identifies the following as the primary health concerns of transgender individuals incarcerated in correctional facilities: the provision of HIV care and treatment, the management of anxiety and post‐traumatic stress, and the administration of abuse and patient confidentiality. These issues are often precipitated or exacerbated by harassment, violence, and deficiencies in mental health approaches within prison institutions (NCTE 2018).

Comprehensive care for transgender inmates should encompass not only immediate medical needs but also preventive, mental health, and gender‐affirming services (Murphy et al. 2023). Furthermore, holistic care for gender dysphoria is a critical component of their well‐being. Gender dysphoria, experienced by some transgender people, is characterized by significant distress resulting from the incongruence between one's experienced gender and the sex assigned at birth. Addressing this condition often involves a combination of social gender transition—such as changes in name, gender expression, and social role—and medical interventions like hormone therapy, which may or may not include surgical procedures (Sevelius and Jenness 2017). When optimal treatment for gender dysphoria is not provided, the resulting physical and mental health consequences can be severe, effectively compounding the punitive aspects of incarceration. In light of these complex needs, it is also vital that public sector employees receive training focused on non‐discrimination and respect, equipping them to respond to and prevent harassment, violence, and abuse within correctional settings (Kendig et al. 2019; NCTE 2018).

Despite these recommendations, there remains a significant gap in the literature regarding the lived experiences and specific needs of transgender individuals in prison. The existing evidence is limited and primarily quantitative, underscoring the critical necessity for a comprehensive and specific understanding of the social, labor, and health requirements of institutionalized transgender individuals, which would empower these individuals and their subjectivities. Furthermore, it is essential to gain an understanding of the experiences of transgender people in relation to the management of their health within a complex environment and context where vulnerabilities are navigated through a significant thickness of intersecting axes and a hypermasculine law and subculture prevail. This context simultaneously surrenders to social hierarchies and is part of them. Addressing this gap is essential for developing effective, culturally competent nursing interventions. Accordingly, the present study aims to understand the experiences of transgender people who are or have been incarcerated in Catalan prisons regarding the management of their health.

2. Methodology

The study employs a qualitative methodology with an interpretative phenomenological approach and an intersectional perspective (Polit and Beck 2020). This perspective is essential for understanding the complex interplay of multiple forms of oppression experienced by participants. This approach recognizes that the experiences of transgender individuals in prison are shaped not only by their gender identity but also by intersecting factors such as race, ethnicity, socioeconomic status, and immigration status (Wyatt et al. 2022).

Semi‐structured interviews were conducted with eight transgender individuals who have been or are currently incarcerated, lasting between 30 and 50 min each. The interviews were conducted in order to elicit the participants' personal narratives regarding the management of their health. The interview guide, which was created through constant critical reflective discussions among the researchers and verified by external experts, covered two key areas: firstly, the perception of the management of their health once they enter prison; and secondly, the perception of the management of their health throughout the time in prison.

Catalonia is unique within Spain for having fully integrated its prison healthcare system into the regional public health service since 2014. As a result, inmates in Catalan prisons receive healthcare from the same professionals, under the same protocols, and with coordinated medical records as the general population, which ensures continuity of care and access to specialized services (Fernandez Náger 2017). The Catalan penitentiary system, administered by the Department of Justice of the Generalitat de Catalunya, currently houses 7713 inmates across nine closed‐regime centers, four open‐regime centers, and one penitentiary hospital (Idescat 2024). Upon admission, all inmates undergo multidisciplinary evaluation, including health assessment. For transgender inmates, Instruction 1/2019 is applied, allowing them to declare their gender identity, preferred name, and the facility in which they wish to serve their sentence (male or female), thus formalizing gender recognition and placement procedures (Generalitat de Catalunya 2019). This integrated and rights‐based approach contrasts with most other Spanish regions, where prison healthcare remains under national management and is not linked to the regional health system.

The study was carried out in one of the penitentiaries designated for inmates subject to closed regimes. However, the transgender individuals who participated had previously been incarcerated in various centers throughout Catalonia. The prison is located in the province of Barcelona (Spain) and is one of the largest in the country, with over a thousand inmates.

One of the researchers (JS), a social educator and gender issues referee within the Penitentiary Service in Catalonia (Spain), was responsible for conducting the interviews. After providing all study details, addressing any doubts, and obtaining informed consent, JS proceeded with the interviews. His role in conducting the interviews was crucial due to the established rapport and trust he had developed with the inmates. This pre‐existing relationship was instrumental in fostering an environment where participants felt comfortable sharing their experiences openly, without feeling constrained by hierarchical or power imbalances that could potentially influence the study's outcomes. The choice of JS as the interviewer was deliberate, leveraging his positive relationship with the inmates to enhance the credibility and authenticity of the data collected.

The interviews were conducted in 2022 within the educational, sports, or cultural areas of the prison, utilizing private and safe spaces for both the interviewer and interviewee. These spaces were meticulously chosen to ensure isolation from noise, intimacy, and the absence of interruptions. The creation of an atmosphere of sensitivity, safety, and genuine presence was crucial for establishing rapport with participants, with a focus on both verbal and non‐verbal communication details (Horsfall et al. 2021). The tone of voice, communicative accompaniment, silence, and pauses served as primary tools for approaching the participants in a sincere and close manner.

The life stories expressed during the interviews were marked by a range of emotions, including memories, tears, fears, sadness, loneliness, and uncertainty, as well as laughter, empowerment, resilience, initiatives, pushes, struggles, and a sense of pride. This emotional climate necessitated a reflective debriefing within the research team to identify barriers and facilitators, as well as to discuss how to implement bracketing without compromising rapport (Moustakas 1994). Bracketing, as employed in this study, refers to the reflective process of setting aside researchers' preconceptions and biases to fully engage with participants' lived experiences (Moustakas 1994). This was achieved through regular debriefing sessions within the research team, where we critically examined our assumptions and discussed how to maintain an open and empathetic stance during interviews. These sessions also helped us identify potential barriers to rapport and ensured that participants' narratives were authentically represented.

The data was analyzed using the six‐step method proposed by Colaizzi (1978). This method permitted the researchers to collect and comprehend the experiences of the participants, while enhancing the quality of the results in favor of the development of policies and person‐centered interventions and their healthcare. In analyzing the data, was applied an intersectional lens was applied to understand how these various axes of identity and oppression interact to create unique experiences and challenges for the participants (Abrams et al. 2020).

The data were analyzed in Spanish, the language of the interviews, to preserve the nuances and cultural context of participants' narratives. For reporting purposes, a bilingual team member translated the interpretations and illustrative quotes into English. These translations were then back‐translated and reviewed by a native English speaker fluent in Spanish. This meticulous process aimed to maintain the authenticity of the data while addressing linguistic challenges inherent in cross‐language qualitative research (Khilji and Jogezai 2024).

While collecting and analyzing data simultaneously, it was necessary to gain a general sense of the experience and to generate information directly relevant to the phenomenon under study. Therefore, it was essential to read the transcripts several times and take reflective notes to capture their emerging thoughts, doubts, and impressions. Regular debriefing meetings of the entire research team contributed to the identification and interpretation of hidden meanings within the context of the phenomenon and to the identification of experiences common to all informants. Then, all interview notes and transcripts were critical for detecting fundamental meanings. Once this was achieved, identified and formulated meanings were grouped into common themes among all participant narratives; researchers were able to generate a prototype of an interpretative explanation of the phenomenon under study. Subsequently, all transcripts were subjected to a second round of analysis with the objective of condensing the themes into a concise and comprehensive report of the essential elements of the phenomenon under study. Finally, participants and qualitative methodology experts were invited to confirm the findings and ensure that the interpretations were an accurate reflection of the original experience (Colaizzi 1978).

Participation in the study was entirely voluntary, with no financial or other form of incentive offered. All participants were given comprehensive oral and written explanations of the study and were offered the option to discuss any questions they may have before signing the informed consent form. It was made clear at the outset of the interview that the topic under study might evoke strong emotions and that, should such a reaction occur, the interview would be terminated, and the necessary support provided. In practice, however, this did not happen. All identifying data was eliminated from the interviews. Data was treated confidentially, limiting access to the research team and stored in a secure digital space accessible only with a password. Participants were able to abandon the study at any time, with no further implications, although none did so. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used in this study (Tong et al. 2007).

3. Findings

Saturation was determined when no new themes or insights emerged from the data, indicating that the collected information sufficiently captured the phenomenon under study (Saunders et al. 2018). This was achieved after conducting eight interviews, during which recurring patterns and themes became evident. The iterative process of data collection and analysis ensured that the findings were comprehensive and reflective of participants' diverse experiences.

The sample included eight participants who self‐identified as transgender women (n = 5), transsexual women (n = 2), and one individual who identified as gender‐fluid (n = 1). Participants' ages ranged from 21 to 56 years. A transgender woman refers to an individual whose sex assigned at birth was male, but who identified as a woman. The term transsexual applied to individuals who pursued bodily modifications to align their physical characteristics with their affirmed gender identity; however, this terminology is evolving and may be viewed as outdated or stigmatizing in some contexts and thus was used only when explicitly claimed by the individual. Gender‐fluid identity describes a gender experience that could shift over time, encompassing multiple gender expressions rather than a fixed identity (American Psychiatric Association 2015). None of the participants reported a current diagnosis of gender dysphoria, which is characterized by psychological distress arising from incongruence between an individual's gender identity and their sex assigned at birth (American Psychiatric Association 2013).

Among the eight participants, only three were Spanish nationals, while the remainder were migrants from Spanish‐speaking countries. Their socioeconomic backgrounds revealed engagement in precarious, low‐skilled occupations within underground economies prior to incarceration. Six participants disclosed involvement in sex work, with five experiencing exploitation through extortion networks or human trafficking. All participants reported a history of domestic violence during childhood and adolescence and indicated that they had faced sexual harassment from fellow inmates while incarcerated. Suicidal ideation was prevalent among all participants, with six reporting a lack of family or social support during their imprisonment, resulting in economic dependence on the limited income generated from prison labor.

Three themes emerged across participant narratives: (1) Navigating Vulnerability in Healthcare Dynamics, which included reports of stigma and inadequate care; (2) The Quest for Wellbeing Amidst Uncertainty, reflecting concerns some participants had regarding treatment continuity; and (3) Negotiating a Landscape of Violence, with several participants describing experiences of harassment and discrimination (Table 1).

TABLE 1.

Themes, subthemes and codes.

Themes	Subthemes	Codes
Navigating Vulnerability in Healthcare Dynamics	Feeling lonely	Communication deficits
		Lack of support
		Transition process according to prison rules
	Random professional care	Lack of sensitivity
		They don't know how to care for us
		Professional disinterest
		Consolidating stigma and stereotypes
		Ideology bias
	Something positive	Prison sentence according to gender expression and identity
		Healthcare card using new name
The Quest for Wellbeing Amidst Uncertainty	Conditioned Health	Uncertainty about transitioning while in prison
		Lack of trans* care
		Insufficient mental health care
		Inadequate sexual health
		Double, triple… discrimination
Negotiating a Landscape of Violence	Intrafamily	It conditioned my social relations
		Difficulties for stablishing personal/social bounds
	Sex work	It shaped my life
		Human trafficking
		Social exclusion
		Revictimization
		Marginalization
	Institutional violence	Determinant of health
		Creating a hostile environment
	Preventive isolation	False protection
		Traumatic experience
	Self‐directed violence	Recurrent suicidal ideation

3.1. Navigating Vulnerability in Healthcare Dynamics

The eight participants reveal a pattern of maladaptive processes throughout their childhood and adolescence. These experiences included feelings of loneliness and helplessness at the beginning of the development of their identity, as well as a lack of social, family, or health support. This lack of support was mainly attributed to the precariousness and nonexistence of health systems in the countries of origin, as well as a lack of specialized health services. Two interviewees acknowledged the satisfactory, punctual, positive, and motivating professional individualism, which they simultaneously experience as anecdotal. Most of the participants perceived distant and stigmatizing treatment as the prevalent and expected norm.

I only remember a psychologist. My father made me see her because he thought she could cure me and make me feel attracted to women. I didn't want to see her. The first thing she said to me was, “You are a woman. It won't be easy, but you have to be strong and have both feet on earth.” She really helped me. The rest [of healthcare professionals] were useless (Participant 3).

Once incarcerated, participants faced several challenges in establishing their identity. This process was often hindered by a lack of effective communication and treatment from health professionals. Narratives frequently highlight the prevalence of communication deficits on the part of professionals. These deficits were often attributed to a lack of awareness and attention to difference and diversity, as well as a lack of interest in the individual in front of them. This mostly resulted in the consolidation of stigmas and stereotypes, as well as an ideological bias in professional practice. All participants acknowledged that the positive and empathetic bond between health professionals and transgender people has a beneficial impact on the well‐being of the person being cared for, reinforces the trust placed and empowers the transgender person to maintain a stable follow‐up and contact with health services.

The doctor never called me by my preferred name, and the nurses and other professionals called me whatever they wanted. Sometimes they used my legal male name and sometimes my preferred name, which made me feel very insecure. (Participant 5)

I was fortunate to have a nurse on the module who always called me by my name. She was a great listener, and I could open up to her. She was interested in my life and cared about me. She treated me as a woman and told me I was beautiful. She brought me women's things like nail polish. When she left, all that great care was over. (Participant 8)

When I got my health card with my chosen name I cried; I remember the press came and took a photo; it was the first time I saw my name on a document. (Participant 6)

Three of the participants initiated or resumed their transition process upon entering prison. Their narratives indicate that the development of their identity was influenced by the circumstances of incarceration. This situation makes the transition process subject to penitentiary laws, which restrict access to clothing, access to the medical center, and other necessities that align with gender expression and identity. These limitations are imposed on the participants during specific times and in designated spaces. The entry of packages of clothing and accessories is permitted according to the regulations of the center. In the cell, inmates are permitted to possess a limited number of articles of clothing, however the specific number of items permitted depends on the nature of the accessories and necessities that are subject to specific authorizations.

It seems that prison healthcare professionals have this idea that transgender women need to have big breasts, a big butt, and be very feminine. People in prison don't know that it's a process. Neither mental health professionals, doctors, nor nurses understand this. They always start by telling me that I don't dress like a woman. Of course I don't! because most of the time stupid regulations do not let me do so! (Participant 5)

3.2. The Quest for Wellbeing Amidst Uncertainty

The issue of health expectations at the time of admission to prison has been a consistent theme throughout the interviews, with almost all respondents repeatedly citing concerns about the continuity of treatments that had already been initiated. These concerns relate to the uncertainty surrounding the availability of support, monitoring, and surgical interventions during the transition period.

I was linked to a gender clinic before going to prison. I told the nurse I needed hormones. She said I had to wait because the treatment needed approval. She just asked why I wanted an operation, nothing else. I feel like I'm losing my transition (Participant 6).

Sometimes I've been without hormone treatment because they [health care professionals] say they ran out of it. I had to beg them for it […] They do give out condoms, but not lubricant or specific advice. Once I even had to push to get a blood test because I had a risky practice, and they were obsessed asking me about what I did. It was not necessary! (Participant 2)

The experience of feeling unsupported and unaccompanied by a health professional was a common theme among the interviewees. This lack of support was mainly attributed to various processes and situations, including consultations regarding hormone treatment, psychological monitoring, and transitioning processes. This experience of lack of support was also linked to the arbitrary nature of specialized health services, for example, sexual health or mental health, which were conditioned by prison idiosyncrasies and insufficient transcultural training.

To many health professionals it's all the same, the same [repeats angrily] about our health, very few care. They just want to give you pills to keep you calm. It was very complicated; it made me want to attack them. A whole life suffering abuse and transphobia and inside prison you are psychologically mistreated. Really? Again? […] I just wanted to scream, express who I am, my rights. (Participant 1)

When I ask questions about hormones, I feel like they're laughing at me instead of explaining things (Participant 3).

All participants concurred that mental health is of paramount importance for those incarcerated. However, access to mental health services was experienced as a constant challenge due to the difficulties of navigating and maintaining a transgender identity in a highly cisheteropatriarchal environment. This vindication implies the necessity of specialized and empathetic mental health care that is open to proactively addressing long‐term specific transgender health needs. Such care must be receptive and protective of the prevalent hostility present in prison towards a cultural group that is extremely vulnerable. All participants demanded a health care approach that responds to the individual fragility to face destabilizing and isolating situations while being in prison, which is a fundamental piece for preventing mental health complications and suicide.

Professionals don't put themselves in the place of the other. I've cried sometimes, and some doctors have told me things like, “Come on, don't cry. You're tough. You've been through a lot, and that's nothing for you [pats her back].” If I were a doctor, I would stand by the patient's side and simply listen. (Participant 4)

I've never had a psychologist, or a professional come to me and say, “I'd like to talk to you. I'd like to know how you're doing with this or that.” I've never been asked how I'm feeling or what's going on with me. They only talk to me about my blood tests (Participant 7).

Mental health, here, there isn't much of that. Only direct health, but mental health, someone coming to see you, there isn't that, I don't know why. They don't come and ask if you're okay, or how they can help […] I think for our mental health, we suffer a lot, a lot, we are very sensitive, we need more understanding and help from professionals towards us, because many things happen in prison. (Participant 5)

The data indicates a dearth of sexual health care within the prison. Despite six of the interviewees admitting to having been sex workers at some point in their lives, none of the eight recognize themselves in this practice within the prison. However, they pointed out that this condition was often presupposed for them, which limits and restricts their sexual freedom and health. Regarding the participants' sexual practices, all of them indicated that they lacked interest and even modesty in discussing sexual matters openly and freely. All of them considered sexual freedom to be an inherent right of the individual, yet they also noted that in the penitentiary environment, all the agents involved supervise, judge, and presuppose their sexual practices, mostly from a punitive and limiting perspective.

If you ask for lube from a healthcare worker, they're probably going to think you're a hooker or something. They don't have any clue. They're not trained to talk about sex with inmates. Or maybe they just don't want to help us. Who knows? But it is important! Accessing lubricants will help us from getting diseases and yes [shouts] to get more pleasure! What's wrong with it? (Participant 8).

3.3. Negotiating a Landscape of Violence

Most of the participants recalled violent episodes in almost all stages and moments of their lives with a combination of emotional and reflective intensity. All eight participants suffered domestic violence in their childhood. Parents, siblings, and significant others in their immediate environment exercised extreme violence on all of them. This fact has conditioned the way they relate to each other, from socio‐ and sex‐affective parameters to obvious discrepancies with authority figures, such as health professionals, security forces, and prison workers, among others. They exhibited resistance to the structural omnipotence of the prison system, and some claimed it from the need to protect themselves and avoid rediscovering traumatic memories of the past.

My dad hit me a lot. Every time I played or made a girly gesture or spoke like a woman, my dad hit me hard, really hard. He hit me so hard that social workers took me out of the house and put me in a children's center. It wasn't a girls' center, though. I don't know what was worse. I think this is why I don't get along with rigid rules and punishing styles. Just imagine how many pauses I must take every day to avoid getting into trouble here [prison] (Participant 2).

I was abused by my dad for four years, until I was 13. He even tried to kill me just for being who I am. (Participnat 5)

Since I was little, I'd wear my mom's heels and put on lipstick, and my dad would beat the hell out of me [cries]. He was in the military, and to him, I was a disgrace (Participant 7)

As previously stated in the preceding theme, the participants' lives have been inherently impacted by the practice of sex work. However, it is crucial to acknowledge that in no instance has this been a voluntary activity. Six of the participants have disclosed that they were compelled into sex work, often without any form of guarantee, which has significantly shaped their life trajectories.

I'm from a tiny province in my country. When I left, I had no choice but to become a sex worker. I started working with a madam who only took my money and didn't protect me. When I was raped, she ignored it (Participant 1).

I had to get a package at a post office, or my pimp would've hit me. When I got there, the police were already waiting for me. I got a nine‐year sentence. The guy who was running the operation wasn't caught (Participant 3).

Participants perceived the prison as a hostile and violent space, even those that have been located at some point in women's centers. They questioned the punitive function of punishment, extending beyond their personal circumstances, and justified this by claiming that intra‐institutional violence is part of the system's inherent idiosyncrasy, which is flawed. They also claimed that everyone, including themselves, bears responsibility for this perceived institutional violence.

I've experienced a lot of negative things, including insults, harassment, physical abuse, and verbal abuse. I became insecure and distrusted of others. I don't trust anyone, so I tend to isolate myself. This isn't just about them; it's also about me. I feel like I'm stuck in a rut, facing a lot of oppression (Participant 5).

Guys in prison are such a pain in the ass. It's like being trans makes you some kind of fantasy, like you're easy, like you're supposed to take it all. I've been physically attacked, insulted, groped… but I don't feel like anyone's gonna do anything about it. And you know how I am (Participant 6).

Being a trans woman in prison is anything but easy. I've been attacked by men, I've fought them, I've done all sorts of things. I felt like I had to act tough just to carve out a space for myself (Participant 7)

Three participants reported having been placed in isolation cells or units, not as a disciplinary measure, but purportedly for their own protection from the general prison population. All indicated that staff justified this decision by citing potential disruptions that might arise from housing a transgender person in a standard unit and asserted that segregation was in the inmates' best interest. The interviewees described this as harmful, citing victimization and blame as well as the generation of fear and negative expectations of a traumatic process. Additionally, they perceived a lack of socialization and participation, which they consider essential, given their self‐perception as extremely in need of bonds. They also asserted that the institution itself must understand and be responsible for their positive integration.

When I first went to prison, I was kept isolated for a few days, with the explanation that it was for my own good. However, I found it very difficult to cope alone. I didn't speak to anyone for days on end. I had no idea what would happen next. I was scared (Participant 7).

Several participants indicated that self‐directed violence was a recurrent phenomenon within the group. In particular, some described the emergence of suicidal ideation as a coping mechanism during significant life events. Within the prison context, three interviewees specifically reported experiencing active suicidal ideation. A range of emotions, including hopelessness, anxiety, and fear, were pervasive among them. The absence of protective factors, such as the lack of familial support, uncertain expectations for the future, and complex administrative situations, among others, greatly influenced the exposure to suicidal thoughts.

When I was in the isolation cell, they said it was for my own good. I just kept thinking, “Is this going to be like this for the rest of the sentence?” I didn't like it at all. I didn't want to be isolated. I started thinking, “Is it worth it? Should I keep fighting, or is it better to end it all?” [suicide]. I was really sad. t was a really rough time for me. It was devastating (Participant 2)

I've tried to end it a bunch of times while locked up. Shit's been rough in here. But I keep going 'cause what choice do I have, right? I've been on hormones for three years now, just trying to be me. I just wanna be the woman I know I am. But if they won't let me live as myself… then what the hell am I supposed to do? (Participant 5)

4. Discussion

The findings of this study reveal that transgender people's experiences of healthcare in Barcelona prisons are mainly shaped by a complex interplay of factors, including healthcare dynamics, the pursuit of well‐being amid uncertainty, and the ongoing negotiation of violence within the prison environment. These findings reveal how intersecting vulnerabilities—stemming from both gender identity and systemic barriers—shape the lived experiences of transgender inmates, suggesting the urgent need for targeted reforms.

As shown, the cumulative effects of trauma, loneliness, and rejection experienced during childhood and adolescence continued to influence transgender inmates' health and identity development while incarcerated. These early life experiences should therefore be considered a post‐traumatic axis when seeking to understand and address the needs of transgender inmates. It is well established that incarceration itself carries significant social stigma, which can hinder subsequent social, occupational, and economic reintegration (Favril 2021; Fovet et al. 2020). For transgender individuals—who often experience stigma even prior to imprisonment—incarceration further amplifies these disadvantages, leading to heightened vulnerability during reentry into society (Constant 2022).

Given the cultural diversity within prison environments, it is imperative to adopt a comprehensive, theory‐informed approach to address the complex health and social needs of transgender individuals in custody (Christensen 2014). In this regard, some nursing theories collectively offer actionable frameworks that can be operationalized to facilitate culturally competent and person‐centered care. Specifically, Campinha‐Bacote's Model of Cultural Competence conceptualizes cultural competence as a dynamic, ongoing process encompassing awareness, knowledge, skill, encounters, and desire (Campinha‐Bacote 2002), which is particularly relevant in prison settings where continuous staff training, reflective sessions, and structured workshops can serve to reduce bias and enhance culturally safe communication. Furthermore, Papadopoulos et al. (1998) position cultural competence within an anti‐discriminatory and equity‐focused framework; therefore, its implementation in prison healthcare can include policy reviews through a human rights lens, the involvement of transgender advocates in institutional reform, and the development of interdisciplinary care teams equipped to challenge structural transphobia.

Communication also emerged as a critical area for improvement, both in verbal and non‐verbal interactions. Our findings reinforce the urgent need for prison health services that actively recognize and respond to diversity. Transgender inmates consistently highlight the importance of secure, supportive, and affirming environments to safely express their identities and manage their health needs (Van Hout et al. 2020). Therefore, addressing these needs requires not only structural changes in the healthcare environment but also ongoing, specialized training for staff to ensure culturally competent and inclusive care (Hochdorn et al. 2018; Nass 2019).

The findings of this study revealed that participants experienced significant difficulties in accessing gender‐affirming care while incarcerated. In the future, prison health services must be equipped to support transgender individuals holistically, addressing all aspects of their lives—including sports and physical activity, diet, and leisure—rather than focusing narrowly or reinforcing stigmatized lifestyles (Nass 2019). Regarding identity, transition, and healthcare, challenges in accessing hormonal treatments were a recurring issue in both this study and the broader literature (Sevelius and Jenness 2017). Facilitating timely and supportive access to these treatments can enhance adherence, promote well‐being, and support a satisfactory transition process. Conversely, resistance or barriers to gender‐affirming care can undermine well‐being, disrupt the transition process, and contribute to distress, mistrust, and frustration among transgender inmates (Van Hout et al. 2020; Maycock 2022; Tripathy et al. 2023).

Another key finding is the prevalence of isolation and solitary confinement among trans inmates, often justified as protective but experienced as deeply traumatic. The available evidence indicates that between 65% and 85% of imprisoned transgender people have been confined and/or isolated, alone, without access to activities (Lydon et al. 2015; Chesnut and Peirce 2024). This dynamic is justified under the protective fallacy, which aims to prevent the transgender person from being punished by the rest of the population for their gender expression, alleged and reprehensible sexual activity, and/or possible grievances (Emmer et al. 2011). It is important to note that confinement is a traumatic experience with significant mental health implications (White Hughto et al. 2018). Transgender individuals incarcerated in correctional facilities frequently report experiences of harassment, violence, and victimization, not only from other inmates but also from correctional staff and the institution itself. In 2014, 21% of the 1118 LGBTIQ individuals surveyed in US prisons reported disrespectful treatment by the institution's health professionals (Brown 2014).

This study also indicates the lack of an adequate culturally competent approach to the mental health care of transgender people in prison. It is observed that a tendency exists among a large part of mental health professionals to pathologize transsexuality, facilitating stigmatization and perpetuating diagnoses that allow for the relevant psychopharmacological intervention, leaving aside a more adapted and appropriate care based on listening and monitoring, from a transcultural and intersectional approach where a series of health‐related disciplines can take the relevant actions (social work, social education, community nursing, sexology, gynecology, among others) (Coulter et al. 2019; Sevelius and Jenness 2017).

The findings regarding the experiences of transgender people and self‐directed violent behavior and suicidal ideation are particularly noteworthy. The limited and scarce scientific literature recognizes and relates the extreme vulnerability of transgender people and suicidal ideation (Brown 2014). Data from a meta‐analysis show that transgender inmates have a higher risk of depression, post‐traumatic stress disorder, and suicide attempts while incarcerated than controls (OR = 3.07, 95% CI = 1.33–7.06; OR = 2.23, 95% CI = 1.46–3.43; OR = 2.25, 95% CI = 1.46–3.49, respectively) (Marchi et al. 2024). As stated in this study, the thought of giving up or leaving this life in order not to suffer and not to experience feelings of loneliness, helplessness, among others, is recurrent.

Transgender inmates experience disproportionately high rates of trauma, PTSD, depression, and suicide risk compared to the general prison population, largely due to stigma, discrimination, and violence within correctional settings (Marchi et al. 2024). Trauma‐informed care (TIC) models tailored for gender minority people emphasize creating safe, affirming environments that acknowledge the unique stressors faced by this population, including misgendering, isolation, and lack of access to gender‐affirming healthcare (McKinnish et al. 2019; Elze 2019). Studies demonstrate that implementing TIC in prisons for transgender inmates reduces psychological distress and suicidal ideation by fostering supportive interactions with staff and peers and by addressing trauma through gender‐affirming interventions (Malek et al. 2023).

The Council of Europe's European Prison Rules and other prison standards have begun incorporating guidelines to protect transgender prisoners' rights and mental health, aligning with TIC principles by promoting dignity, non‐discrimination, and access to appropriate healthcare (O'Connell et al. 2021). Furthermore, the American Nurses Association (2016), in its Declaration of Ethics and Human Rights, described and emphasized the obligation, responsibility, and commitment of nurses to integrate into their professional practice the principles of social justice that are inherent to their function and, consequently, guarantors of health policy (American Nurses Association 2015). Similarly, the International Council of Nurses (2021) recommends educators and researchers to include in curricula the defense of social rights as an important and essential part of nursing content.

Despite the existence of progressive policies in Catalonia—such as the integration of prison healthcare into the public health system and the formal recognition of gender identity—our findings reveal persistent misalignments between policy and practice. Transgender inmates continue to experience stigma, inconsistent access to gender‐affirming care, and inadequate mental health support, highlighting gaps in staff training and institutional culture. These challenges are consistent with recent international studies, which show that even in settings with inclusive policies, transgender prisoners often face barriers to appropriate healthcare and protection from discrimination (Murphy et al. 2023). Bridging this gap requires not only policy reform but also ongoing staff education, robust monitoring, and mechanisms for accountability to ensure that rights and care standards are upheld in daily prison life.

This study has some limitations that should be considered when interpreting the findings. The sample size was relatively small and focused on a single area of Barcelona, Spain. As a result, the findings may not be generalizable to other socio‐cultural contexts and should be cautiously transferred to similar settings. Next, the study sample reflects the fluidity of gender and transitioning experiences, which were situated within a global, hierarchical, institutionalized, and hypermasculinized context. This complex social and cultural environment must be considered when interpreting the results. Moreover, participants in the study recognized themselves as individuals who have experienced significant emotional and psychological damage. The memory and manifestation of traumatic situations were placed in a space of affective security, protected by close, empathetic relationships. However, the participants also exhibited resistance, limitations, and desires not to continue certain discourses related to their experiences. Finally, the data was collected and analyzed in Catalan or Spanish and then translated to English using professional bilingual services. This process may have resulted in some misinterpretation of the data due to translation issues.

5. Conclusion

The health experiences of imprisoned transgender individuals in Barcelona, Spain, are primarily characterized by three key factors: navigating vulnerability within healthcare systems, seeking well‐being in an uncertain environment, and navigating a landscape of violence.

The findings regarding the experiences of transgender individuals, self‐harm, and suicidal thoughts highlight the elevated vulnerability of this community. It is therefore evident that healthcare and rehabilitation professionals have a vital role to play in the delivery of continuous gender‐affirming care, compassionate surveillance, therapeutic connections, and proactive measures to ensure fair treatment for this vulnerable group. In order to provide compassionate, transcultural, and patient‐focused nursing care that empowers transgender individuals and allows them a voice within the highly gender‐segregated correctional system, it is vital to gain a comprehensive and targeted understanding of their social, occupational, healthcare, and cultural needs.

To address the gaps identified in this study, we recommend three key actions to improve healthcare for transgender inmates. First, all prison staff should receive mandatory, ongoing training in trans‐inclusive cultural competence to reduce stigma and improve care quality. Second, independent oversight committees—including healthcare professionals, legal experts, and LGBTQIA+ representatives—should be established to monitor and advocate for gender‐based healthcare needs, ensuring accountability and continuity of care. Third, protective housing policies must avoid isolating transgender inmates; instead, individualized assessments and access to gender‐congruent, non‐isolative housing should be prioritized to support safety and mental health. Implementing these measures can help bridge the gap between policy and practice, promoting safer and more equitable prison environments.

Ethics Statement

The study was approved by the Ethical Board of the Generalitat de Catalunya.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.