Abstract
Background: Many jurisdictions globally have no specific prison policy to guide prison management and prison staff in relation to the special needs of lesbian, gay, bisexual and transgender (LGBT) prisoners despite the United Nations for the Treatment of Prisoners Standard Minimum Rules and the updated 2017 Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity. Within LGBT prison groups, transgender people represent a key special population with distinct needs and rights, with incarceration rates greater than that of the general population, and who experience unique vulnerabilities in prisons.
Aims/Method: A scoping review was conducted of extant information on the transgender prison situation, their unique health needs and outcomes in contemporary prison settings. Fifty-nine publications were charted and thematically analyzed.
Results: Five key themes emerged: Transgender definition and terminology used in prison publications; Prison housing and classification systems; Conduct of correctional staff toward incarcerated transgender people; Gender affirmation, health experiences and situational health risks of incarcerated transgender people; and Transgender access to gender-related healthcare in prison.
Conclusions: The review highlights the need for practical prison based measures in the form of increased advocacy, awareness raising, desensitization of high level prison management, prison staff and prison healthcare providers, and clinical and cultural competence institutional training on transgender patient care. The review underscores the need to uphold the existing international mandates to take measures to protect incarcerated transgender people from violence and stigmatization without restricting rights, and provide adequate gender sensitive and gender affirming healthcare, including hormone therapy and gender reassignment.
Keywords: Health, LGBT, prison, scoping review, transgender, violence, trans, human rights
Background
A total of 10 million men, women and children are incarcerated across the world (Penal Reform, 2019), with almost a 20 percent increase observed between 2000 and 2015, despite the reduction in global crime trends (Penal Reform, 2018). The prison population is not homogeneous, with several key groups identified by the United Nations (UN) as having needs requiring special consideration within the prison setting. These include pretrial detainees, children in conflict with the law, women, people with disabilities, mental health needs, foreign nationals, people belonging to ethnic and racial minorities or indigenous communities, older people, those with drug dependence, terminal illness, and lesbian, gay, bisexual and transgender (LGBT) people (UNODC, 2009, 2016). LGBT prisoners are especially vulnerable in certain countries where same sex relationships are criminalized under sodomy laws or under the abuse of morality laws (International Commission of Jurists, 2006; WHO, 2014). Grant et al. (2011) found that 7% of their transgender sample had been held in a cell solely due to their gender identity. If the individuals were Black or Latino, the rates rose dramatically to 41% and 21%, respectively. Further to this, LGBT prisoners, which include sex workers, men who have sex with men, and transgender women housed in male prisons, have unique vulnerabilities exacerbated by the prison environment (Arnott & Crago, 2009; Baral et al, 2013; The Global Fund, 2017). They can be marginalized on the basis of sexual orientation or gender identity, subjecting them to increased risk of violence, ill-treatment or physical, mental or sexual abuse by other prisoners as well as officers. The impact that this form of victimization can have on the prisoner can cause or exacerbate mental health issues leading to depression, suicide ideation, and the potential for auto-castration and auto-penectomy (Brown & McDuffie, 2009). Furthermore, there is a distinct increased risk and vulnerability between transgender and non-transgender prisoner vulnerabilities. For example in 2015–2016, 0.04% of the general US population experienced sexual assault in prison (Bureau of Justice Statistics, 2020; United States Census Bureau, 2020; Wagner & Sawyer, 2018), whilst Grant et al. (2011) found that 38% of their transgender sample had been harassed during incarceration, 9% physically assaulted, and 7% sexually assaulted.
States are obliged to protect all prisoners under their care and supervision, in addition to supporting their social integration (UNODC, 2009). Many jurisdictions globally have no specific prison policy to guide prison management and prison staff in relation to the special needs of LGBT prisoners (UNODC, 2009). This is despite the 2016 Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules) mandating prison administrations to “take account of the individual needs of prisoners, in particular the most vulnerable categories in prison settings” (Rule 2(2)) (United Nations General Assembly, 2016, p. 8). The 2006 and updated 2017 Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, principle 9 further mandates the right to treatment with humanity while in detention (International Commission of Jurists, 2007; Yogyakarta Principles, 2006). The extreme vulnerability of LGBT, especially transgender people, within closed settings requires dedicated policies to supporting their needs, encouraging social integration and prevent victimization (UNODC, 2009, 2016). Standards of care mandated in the Standard Minimum Rules for the Treatment of Prisoners, the Prison Elimination Act (PREA; Beck, 2015) and the 2017 Yogyakarta Principles as well as well-established research that will be analyzed in this paper such as Brown and McDuffie (2009), work to ensure that placement in detention avoids further victimization by identifying inadequacies in prison policies and providing human rights agendas that institutions can comply to. Furthermore, they advocate for the provision of adequate access to medical care and counseling appropriate to the needs of those in custody, recognizing any particular needs of persons on the basis of their sexual orientation or gender identity, including with regard to reproductive health, access to HIV/AIDS information and therapy, access to hormonal or other therapy, and access to gender-reassignment treatments where appropriate, as outlined in the World Professional Association for Transgender Healthcare Standards of Care (WPATH SOC; 2012) section XIV (UNODC, 2009, 2016).
We refer specifically to incarcerated transgender people in this review. Transgender is a term that “describes a diverse group of people whose internal sense of gender is different than that which they were assigned at birth” (WHO, 2020). It is not a diagnostic term and does not imply a medical or psychological condition or any specific form of sexual orientation. It is an umbrella term which includes a broad range of experiences and identities. It includes individuals who undergo medical treatment or are in the process of transitioning their physical appearance to conform to their internal gender identity, as well as those who live in accordance with their gender identity without seeking any medical treatment. As prisons are segregated by gender, the actual number of incarcerated transgender individuals across different countries is unknown (Clark et al., 2017). Two countries which document rates of transgender people in prisons are the United States (US) and the United Kingdom (UK). In the US, Grant et al. (2011), estimated that 16% of transgender individuals have been imprisoned at some point, in comparison to up to 0.7% of the whole US population (Prison Policy, 2020). In the UK, in 2016, 0.8% (n = 70) of incarcerated individuals reported being transgender (Ministry of Justice, 2016a). In 2018, this increased to 125 people across England and Wales (Reality Check Team, 2018) and then in 2019 it was reported that the figure had risen to 1,500 out of 90,000 (1.6%) of the general incarcerated population (Hymas, 2019).
Transgender health and social disparities even prior to detention or incarceration are well documented in the literature, and underpinned by their experience of pervasive stigma, humiliation, sexual assault, exploitation and violence, barriers to employment and housing, exclusion from legitimate economies and their participation in street economies (for example the sex work industry and drug dealing) (Fletcher et al., 2014; Grant et al., 2011; Nadal et al., 2012; Reback & Fletcher, 2014; White Hughto et al., 2015; Wilson et al., 2009). Garofalo et al. (2006) highlighted that 59% of their transgender women sample, reported a lifetime history of sex work. Reasons for this significance include economic hardship as a consequence of transphobic discrimination (Wilson et al., 2009), family rejection (Fuller & Riggs, 2018), and poor school attendance and dropout rates resulting from peer harassment (Grossman & D’Augelli, 2006). When transgender individuals then enter into sex work, they are at a significantly increased risk of acquiring HIV, as well as being arrested and detained (Brown & Jones, 2016; Poteat et al., 2014; 2015; Wilson et al., 2009).
Experiences of such prejudices are further amplified within the prison context (International Commission of Jurists, 2006; UNDP, 2013; WHO, 2014), as transgender individuals are vulnerable to sexual abuse and rape when they do not conform to gender expectation, and are also at risk of developing or exacerbating existing mental health issues, engaging in high risk substance use whilst inside, all of which compound their risk of self-harm and suicide (Bradford et al., 2013; Penal Reform, 2019; Stotzer, 2009; UNDP, 2013; UNODC, 2009, 2016; Yang et al., 2015). The hostile prison environment for transgender people also includes unsanitary and violent conditions that impede rehabilitation; widely used sanctions by prison staff against them, solitary confinement and forms of torture or degrading treatment (Penal Reform, 2019). The Association for the Prevention of Torture (APT) has identified a ‘Don’t Ask, Don’t Tell’ policy for LGBT people in prison settings, where they ‘render themselves invisible’, therefore allowing authorities to breach their human rights and deny their dignity, including in prisons (Blanc, 2018).
Given the increased recognition of transgender incarcerated people as a key population with specific needs and rights within the prison setting, we conducted a scoping review to extensively map extant literature on their prison situation, their unique health needs and outcomes in contemporary prison settings.
Method
Scoping reviews are a research synthesis which map literature on a particular topic or research area and provide an opportunity to identify key concepts and evidence to inform practice, policymaking, and technical guidance (Levac et al., 2010). They are particularly useful as they include a wide range of data across identified sources and designs, and are used to raise awareness, and inform policy and practice (Daudt et al., 2013; Levac et al., 2010). The underpinning research question for this scoping review was: ‘What is known in the literature about the health situation and health experiences of incarcerated transgender people?’ The term ‘prison’ was defined and adopted as representing facilities housing both on-remand transgender prisoners (including jails, police holding cells, and other detention centers) and convicted transgender prisoners representing facilities housing both on-remand young people and convicted adult prisoners (Van Hout & Mhlanga-Gunda, 2018).
The scoping review method is deemed rigorous and transparent in terms of its step by step protocol to identify and analyze all relevant available sources of information (Daudt et al., 2013; Levac et al., 2010). The five-stage iterative process was closely adhered to and consisted of (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarizing and reporting the results (Arksey & O’Malley, 2005). Detailed search terms were subsequently generated by the team. The general search strategy is illustrated in Table 1.
Table 1.
Search strategy.
| Search | Search terms |
|---|---|
| #1 | (Prison* OR detention* OR incarcerat* OR custod* OR jail OR gaol OR "correction* facilit*" OR "correction* setting*" OR “correction* service*” OR "detain* setting*" OR “Her Majesty* Prison” OR HMP OR probation OR confinement OR penitentiar* OR penal OR imprison*) |
| #2 | (Prisoner* OR detainee* OR offender* OR criminal* OR inmate* OR felon OR custodial OR cellmate* OR convict*) |
| #3 | (Transgender* OR “transgender men” OR transmen OR transman OR transmale OR “trans man” OR "trans men” OR “trans male” OR "transgender women" OR LGBT* OR trans OR "gender identit*" OR “trans* identit*” OR “Female to Male” OR “Male to Female” OR transsexual OR transexual OR transvestite OR intersex OR “gender reassignment” OR “sex reassignment” OR “gender minority” OR “sex change” OR “gender change” OR “gender dysphoria” OR transsexualism OR “gender identity disorder*”) |
| #4 | (Health OR “health situation” OR “health experience*” OR “health service*” OR “health service* availability” OR “health management” OR transphob* OR homophob* OR “quality* of life” OR “mental health”) |
The search was conducted using the university databases at Liverpool John Moores University, PubMed Clinical Queries and Scopus (exploratory search with selected references downloaded for the purpose of clarifying search terms). Comprehensive searches were subsequently conducted in the Web of Science, Medline, PsycINFO, Google and CINAHL, and restricted to the time period 2000–2019. The search was confined to the English language. In order to ensure full coverage of current knowledge and perspectives relating to incarceration and the transgender health experience, health management and situation in worldwide prisons; we included international and national policy briefs, handbooks, documents and reports, country situational assessment reports, conference proceedings, news reports, commentary pieces and editorials, in addition to empirical peer-reviewed scholarly literature.
Citations were managed using the bibliographic software manager EndNote, with duplicates removed manually. Records included both reference to transgender people (male-to-female; female-to-male) and prison official perspectives in their management within prisons or other closed settings. Follow-up search strategies included hand searching of reference listings. Hand searches were conducted on international aid and development organizational websites, law enforcement, correctional, social, health, medical and human rights related databases, and websites of country governments and non-governmental bodies. Key LGBT and trans organization websites were also searched. Figure 1 reflects the screening and filtering process of the resulting studies.
Figure 1.
Flowchart of screening and filtering process.
All records warranting inclusion were procured for full text review. Eligibility criteria for inclusion in the review were based on whether citations mentioned transgender prisoners’ health experiences, unique transgender prison healthcare needs and healthcare outcomes or contained health related content directly relating to transgender people in prisons worldwide. Records were also excluded if the transgender population was solely under 18 years of age and found not to meet the eligibility criteria.
The remaining records were charted and thematically analyzed, as per scoping review protocols (Daudt et al., 2013; Levac et al., 2010). This involved the creation of a spreadsheet used to chart relevant data (data collection categories were the year of publication, author, location, method and aim, key guidance points). The team conducted a trial charting exercise of five records as recommended by Levac et al. (2010), followed by a joint consultation to ensure alignment with the scoping question and its purpose. Based on this preliminary exercise, the team developed prior categories which guided the subsequent extraction and charting of the data from the records. The charted data was analyzed and systematized by thematic manual coding, which organized the data, and structured it into themes through patterns in associated categories. Disagreements around theme allocation were resolved through team discussion.
Results
From the database and hand searches, 59 publications were included in the final sample (Figure 1). From the searches, we reviewed empirical studies (n = 23), commentaries (n = 23), literature reviews (n = 8), reports (n = 2), a book chapter, case study and a set of conference slides. The searches were not limited by country, yet only the US (n = 47), the UK (n = 6), Australia (namely the state of New South Wales; n = 3), Brazil, Canada, Hong Kong and Italy (n = 1), are represented (Table 2). Three articles focused on the global perspective, with some referring to more than one country. A further 45 documents were identified through grey literature searches and were used to inform the results as well as throughout the discussion (Table 3). Types of documents included reports (n = 23), legal rulings (n = 9), newspaper articles (n = 4), websites (n = 4), a bulletin, framework, guidelines, a policy document and a policy review (n = 1). Table 4 identifies results by country, highlighting the various policies and attitudes toward transgender rights in prison.
Table 2.
Article results from database and hand searches.
| Authors | Article details | Type | Location | Method and Gender Included (M2F & F2M) | Key Themes | Findings |
|---|---|---|---|---|---|---|
| Alexander, R. and Meshelemiah, J. C. A. | Gender Identity Disorders in Prisons: What Are the Legal Implications for Prison Mental Health Professionals and Administrators? Prison J; 2010; 90 (3); pp. 269-286 | Journal article | US | A literature review of recent cases and lawsuits of both M2F & F2M |
|
The article focuses on transgender case law in the US. In most cases cited, the discourse focuses on GD and if it is a mental disorder. Guidelines provided by WPATH SOC, state that mental health professionals should evaluate and counsel individual’s around treatments options and then determine eligibility for hormone treatment or SRS. One of the main issues in the US is the restrictive insurance policies, which will not cover SRS. Due to this, WPATH SOC state that SRS should only be considered when ‘medically necessary’. In the courts the term ‘medically necessary’ is regularly disputed with claims made that denial of a basic level of specialized care, is viewed as a violation of the Eighth Amendment. |
| Bacak, V., Thurman, K., Eyer, K., Qureshi, R., Bird, J. D. P., Rivera, L. M. and Kim, S. A. | Incarceration as a Health Determinant for Sexual Orientation and Gender Minority Persons; Am J Public Health; 2018; 108 (8) pp. 994-998 | Commentary | US | Both M2F & F2M |
|
Authors comment on how transgender inmates should be considered based on how they self-identify as they have unique health risks in correctional facilities that other inmates do not have. Authors note however, if they self-identify as a sexual minority in prison, they are at an even higher risk of harm or victimization. Authors highlight the need for additional mental health support before and after incarceration for transgender people, with focus on social support and sexual and gender minority communities. The paper stresses the obstacles faced with many prisons refusing access to transition-related care. Authors discuss the problem with housing based on inmates’ birth sex or external genitalia, noting an increased risk to mental and physical health. Authors argue inmates should be assigned based on their chosen gender identity. |
| Bashford, J., Hasan, S. and Marriott, C. | Inside Gender Identity: A report on meeting the health and social care needs of transgender people in the criminal justice system (2017) | Report | UK | Cross sectional survey Research. Data collected using Interview, documents/records; analyzed using thematic analysis both M2F & F2M |
|
Report highlights transgender populations experience high levels of stigma, discrimination, victimization and harassment. With prison staff overlooking transphobic. Males prisons, place of isolation and fear, with inmates at an increased risk of self-harm and suicide. Transgender inmates are not only treated unfairly by other inmates but also by professionals and the wider criminal justice system. The report finds reluctance among healthcare professionals to prescribe hormone therapy. Report highlights consequences hormone withdrawal including higher likelihood of auto-castration, depression, dysphoria or suicide. Some UK prisons allow transgender inmates to pursue gender affirmation by accessing clothing, makeup and prosthetics, others have found it more difficult. While some prisons in UK allocate to preferred gender prison, others are still determined by birth gender. Lack of knowledge around transgenderism is cause. |
| Beckwith, C., Castonguay, B. U., Trezza, C., Bazerman, L., Patrick, R., Cates, A., Olsen, H., Kurth, A., Liu, T., Peterson, J. and Kuo, I. | Gender Differences in HIV Care among Criminal Justice-Involved Persons: Baseline Data from the CARE + Corrections Study; PLoS One; 2017; 12 (1); p. e0169077 | Journal article | US (Washington) | N = 110 Self-reported adult HIV + ve inmates. Data collected computer-assisted personal interview and blood samples; analyzed using inferential statistics considered M2F only |
|
The study found transgender women were more likely to have a healthcare provider prior to incarceration compared to men and women. Given this, they were more likely to have participated in drug treatment programs than men (90% versus 61%) and women (90% versus 50%). More impressively, 94.7% (n = 18/20) of transgender women took HIV treatment during incarceration and at baseline, 80% of transgender women achieved HIV viral suppression (<200 copies/mL). |
| Beckwith, C. G., et al., | Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: Data from the Seek, Test, Treat, and Retain Harmonization Initiative; PLoS One; 2018; 13 (5); p. e0197729 | Journal article | US (Washington; California; Illinois) | Retrospective study pooling data from three US studies. inferential statistics used to analyze data, using only M2F sample |
|
Analysis found risky behavior in population including, 42% of transgender women classified as hazardous drinkers and more likely to report crack and cocaine use compared to general population (40% and 16% respectively), more likely to use multiple (more than two) substances (74% vs. 62%). They reported higher rates of condomless sex (58%) than the general population (64%) and they were significantly more likely to have more than one sexual partner. Although riskier sexual behaviors, there was no difference between transgender women and the general population in taking ART or in regard to adherence, achieving viral suppression or lowered CD4 counts. |
| Brömdal, A., Clark, K. A., White Hugho, J. M., Debattista, J., Tania M. Phillips, T. M., Mullens, A. B., Gow, J. and Daken, K. | Whole-incarceration-setting approaches to supporting and upholding the rights and health of incarcerated transgender people; International Journal of Transgenderism; 2019; 20 (4); pp. 341-350 | Journal article | Global | Review and recommendations. Both M2F & F2M |
|
Editorial reviewing existing literature, providing a key set of recommendations and calling for a ‘whole-incarceration-setting approach’ to support incarcerated transgender people. The article describes the global incarceration of transgender populations; lived experiences of incarcerated transgender people; violence, abuse, and harassment toward incarcerated transgender people; lack of adequate gender-affirming medical care; solitary confinement and prolonged “protective custody”; health consequences of discrimination and violence for incarcerated transgender people and the whole-incarceration-setting approach. |
| Brömdal, A., Mullens, A. B., Phillips, T. M. and Gow, J. | Experiences of transgender prisoners and their knowledge, attitudes, and practices regarding sexual behaviors and HIV/STIs: A systematic review; Int J Transgend; 2019; 20 (1); pp. 4-19 | Journal article | Global | Scoping review. Data collected using narrative analysis and document/records. Analyzed using Thematic Analysis of both M2F & F2M |
|
The article reports on the sexual and violent assaults of transgender inmates, assaults reported when sexual advances were turned down and examples of homophobic discrimination from other inmates. Plus, experiences of interpersonal violence, including sexual assault, lack of respect and sensitivity, discrimination, mistreatment, harassment, or stigma from prison staff. Impact of such experiences are significant. HIV-infected report hiding HIV medications or transgender status to protect self. Vulnerability and heightened mental health issues associated with self-treatment, self-harm and sometimes suicide. An example of self-castration was observed as a means to cope with gender dysphoria. High levels of transactional condomless sex. Lack of general medical assessment and treatment including HIV care management and gender affirming care, with challenges to accessing medication and treatment also being discussed. Lack of knowledge and understanding regarding gender diversity and how gender identity and expression is related to yet distinct from sexual orientation was also reported. Transgender inmates housed in specific units as they were deemed 'at risk'. This was a designated are for men who have sex with men and transgender women only in a men’s central jail to ensure their safety from the male general population. |
| Brown, G. R. | Recommended Revisions to the World Professional Association for Transgender Health's Standards of Care Section on Medical Care for Incarcerated Persons with Gender Identity Disorder; Int J Transgend; 2009; 11 (2); pp. 133-138 | Commentary | US | Discussion relating to M2F & F2M |
|
Author discusses significant levels of depression, exacerbation of other mental illnesses, sexual and violent abuse as well as suicides. The authors argue treatment should be tailored to the individual but note current lack of access to healthcare (consequences include mental illnesses, suicidal thinking and behavior, auto-castration and/or auto-penectomy). Authors note some institutions base housing arrangements on the appearance of external genitalia rather than considering the gender role, thus causing greater distress to the inmate. |
| Brown, G. R. | Autocastration and autopenectomy as surgical self-treatment in incarcerated persons with gender identity disorder; Int J Transgend; 2010; 12 (1); pp. 31-38 | Journal article | US | Content analysis of three written accounts of M2F inmates |
|
The article outlines the journey of three transgender inmates who displayed gender dysphoria symptoms, mental health issues and requested evaluation for gender identity disorder. A result of failure to evaluate, diagnose and treat the inmates resulted in hunger strikes, being moved to maximum security prison to access services, access transition related treatment continued to be denied, resulting in all three inmates self-treating with auto-castration. Following this, one inmate was treated for comorbid conditions including psychosis, another eventually transferred and given hormones, another placed in solitary confinement on suicide watch. Following litigation, one has been allowed cross-sex hormone therapy and was able to gender affirm but still denied access to GD treatment. |
| Brown, G. R. | Qualitative analysis of transgender inmates' correspondence: implications for departments of correction; J Correct Healthcare; 2014; 20 (4); pp. 334-341 | Journal article | US | N = 129 documents and records of both M2F & F2M transgender prisoners analyzed thematically |
|
Findings include 42% of inmates reported abuse while in prison, with '23% reporting physical abuse or harassment and 19% relating that they had been sexually mistreated or abused by other inmates, corrections officers (COs), or both'. One inmate was allowed to have sex-reassignment surgery and 14% used hormone therapies. However, access to transgender healthcare is limited, leading to 2% having attempted and 3% completing auto-castration. |
| Brown, G. R. and McDuffie, E. | Health care policies addressing transgender inmates in prison systems in the US; J Correct Healthcare; 2009; 15 (4); pp. 280-290 | Journal article | US | N = 46 Department of Correctional documents and reports and were thematically analyzed; Thematic Analysis to consider both M2F & F2M |
|
Findings detail three different options available for transgender inmates in relation to hormone therapy: the continuation of hormones for inmates, ‘‘freeze-frame’’ or initiation of hormonal treatment de novo under appropriate clinical circumstances. Most inmates were able to continue to use hormones as this required extensive documentation proving diagnosis and existing care pathway. However, only one state did not rule out sex reassignment surgery as a treatment option in prisons. Illinois states that the prison system will allow it but only under extreme circumstances. Due to this, auto-castration was observed and reported by the authors. furthermore, 12 (71%) states base housing on external genitalia with only four states having more lenient policies based on sexual orientation. |
| Chianura, L.., Di Salvo, G., and Giovanardi, G. | Clandestine transgender female convicts in Italian detention centers: a pilot inquiry; Ecol della Mente; 2010; 33; 219-238 | Journal article | Italy; Brazil | Discussion relating to M2F & F2M |
|
The article, cited by Hochdorn et al. (2018), states that Italy has protected sectors for transgender inmates which has 'improved the situation either of the transgender prisoners, who suffered less violence and discrimination, or of the prison workers, who received special courses for interacting in an appropriate manner with these inmates'. It takes a systemic approach, discussing a binary system to housing and gender identification. Some form of rehabilitation services available to Italian transgender inmates, with particular reference to drug and alcohol use. These changes are highlighted to originate from the 1980s onwards that look to 'humanise the penitentiary system'. Training programs are offered to staff to understand the situation (Hochdorn et al. 2018) |
| Clark, K. A., Hughto, J. M. W. and Pachankis, J. E. | What's the right thing to do? Correctional healthcare providers' knowledge, attitudes and experiences caring for transgender inmates; Soc Sci Med; 2017; 193; pp. 80-88 | Journal article | US (New England) | N = 20 practitioners using Grounded Theory and analyzed using Thematic Analysis M2F & F2M |
|
The article reported that gender affirmation was unacceptable due to lack of transgender training and therefore confusion among staff; lack of knowledge/experience, prison culture, clinical incompetency, and personal bias. Clinical incompetency was largely seen through mental health issues with GD and custody staff biases toward healthcare and transgender inmates. Treatment ceased for inmates without documentation when inmates entered prison. Healthcare budget explanation for lack of treatment. |
| Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. | Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7; 2012; Int. J. Transgenderism; 13: 165-232 | Commentary | US | Discussion relating to M2F & F2M |
|
Whilst there is no direct mention of prisons, the commentary draws on the WPATH SOC. The main points include the need for more understanding and evidence-based from across the world as currently sources used to inform the SOC are predominantly from North America and Western Europe; discussion on the definition of gender dysphoria and therefore evaluation and diagnosis as well as wider treatment options. |
| Colopy, T. W. | Setting gender identity free: expanding treatment for transsexual inmates; Health Matrix Clevel; 2012; 22 (1); pp. 227-271 | Commentary | US | Discussion relating to M2F & F2M |
|
Authors discuss literature regarding high levels of reported sexual and violent assault and need for inmates to receive a continuation of treatment. Authors note how inmates diagnosed after incarceration should also be provided with treatment and while other treatment options are available, these do not necessarily lead to 'adequate care'. Authors note need for healthcare professional training to effectively evaluate, assess and provide 'sound medical diagnosis without discrimination.' Often officers have full discretion on the treatment of inmates, this is an issue due to bias or inappropriate reasoning. Authors call for more appropriate prison officials to act as decision makers and to house inmates on their subjective gender rather than their physical sex, although the risks are noted. Alternatively a more progressive (but controversial) strategy would be to have transgender specific prisons. |
| Culbert, G. J. | Violence and the perceived risks of taking antiretroviral therapy in US jails and prisons; Int J Prison Health; 2014; 10 (2); pp. 94-109 | Journal article | US (Illinois) | Ethnography of N = 42 HIV-infected male and male to-female transgendered adults. Data analyzed using Thematic Analysis |
|
The study found more than a third of transgender inmates were diagnosed with HIV in prison. Some did not disclose their status for the entirety of their sentence as HIV disclosure was seen by officers as a bid for special treatment. Thus, treatment was not provided. Nearly half initiated ART while in prison. However, many reported missing doses or sustained treatment interruptions lasting weeks or months due to delayed prescribing, out-of-stock medications, and intermittent dosing. Those diagnosed in prison reported suicidal thoughts increased violence widespread stigma and homophobia. Numerous institutional barriers were reported to accessing HIV care including 'physical isolation, interpersonal violence, actions for controlling violence, CO apathy or unwillingness, and fees for health services'. |
| Disspain, S., Shuker, R. and Wildgoose, E. | Exploration of a transfemale prisoner’s experience of a prison therapeutic community; Prison Serv. J; 2015; 219, 9-18. | Case study | UK | Discussion relating to M2F & F2M |
|
The case study discusses the role of prison therapeutic communities (TC). Literature highlights high levels of assault, lack of knowledge from officers, sexual violence and overall bias. Little evidence of delivering treatment to offenders. Four elements to TG inmates situation: identity, understanding, openness and coping at the TC. We need to bridge the gap between supporting needs and knowing how to practically. TCs allowed a positive experience to engage with situation and treatment. |
| Drakeford, L. | Correctional Policy and Attempted Suicide Among Transgender Individuals; J Correct Healthcare; 2018; 24 (2); pp. 171-181 | Journal article | US | Cross-sectional survey of N = 500 organizations, Inferential statistics used to analyze data of M2F & F2M |
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The study reports states which provide high levels of transgender-related medical services were significantly less likely to report their transgender inmates attempting suicide. Yet, there was a strong correlation between gender-based victimization and lifetime suicide attempts in transgender inmates. Mental health issues were reported and were seen to be interchangeable with suicide. |
| Edney, R. | To keep me safe from harm-transgender prisoners and the experience of imprisonment; Deakin. L. Rev; 2004; 9; 327. | Commentary | US | Discussion relating to M2F & F2M |
|
The commentary discusses sexual violence, disproroptionate punishment and the differing levels of medical treatment. A major source of contention, which is highlighted in the article, is the failure of correctional facilities to differentiate between sex and gender. |
| Emmer, P., Lowe, A. and Marshall, R. | This Is a Prison, Glitter Is Not Allowed: Experiences of Trans and Gender Variant People in Pennsylvania's Prison Systems; Hearts on a Wire Collective; 2011 | Report | US (Pennsylvania) | Discussion relating to M2F & F2M |
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The report discusses the varied levels of housing and methods of classification; difficulty of bathrooms and showers with reports of rape and humiliation from officers; unfair solitary confinement; different levels of hormone use; general healthcare access with specific reference to HIV/STIs care and management; institutionalized discrimination and violence and risky sexual behavior. The report provides recommendations that include expanding options for housing placement; tailoring healthcare to address health needs; education and training programs; gender-based policy change as well as increased accountability and advocacy. |
| Erni, J. N. | Legitimating Transphobia: The legal disavowal of transgender rights in prison; Cult Stud; 2013; 27 (1); pp. 136-158 | Commentary | US; Hong Kong | Discussion relating to M2F & F2M |
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Authors describe rape of transgender inmates as sexual terrorism. Prison officials see two genders placing transsexuals at high risk as housing based on the appearance of external genitalia. |
| Garcia, N. | Starting with the Man in the Mirror: Transsexual Prisoners and Transitional Surgeries Following Kosilek v. Spencer; Am J Law Med; 2014; 40 (4); pp. 442-462 | Journal article | US | Discussion relating to M2F & F2M |
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The article reports on the deterioration of inmate mental health and inmates being at risk of assault and rape, stating that it can be caused from the housing of inmates based on genitalia. Authors note the refusal of gender transitional care, is deemed a violation of an individual’s Eighth Amendment right as it is viewed as a form of 'cruel and unusual punishment'. |
| Glezer, A. , McNiel, D. E. and Binder, R. L. | Transgendered and incarcerated: a review of the literature, current policies and laws, and ethics; J Am Acad Psychiatry Law; 2013; 41; pp. 551-558 | Commentary | US | Discussion relating to M2F & F2M |
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Authors report on the violence against transgender inmates, noting that it is significantly higher than that of the general population. One study reported that 59% of GD inmates in a Californian prison were sexually assaulted. According to WPATH SOC, to proceed with surgery the individual must have had continuous 12 months’ worth of hormones and real-life experience. The classification of housing inmates was also reported on. |
| Green, R. | Transsexual legal rights in the US and UK: employment, medical treatment, and civil status; Arch Sex Behav; 2010; 39 (1); pp. 153-159 | Commentary | US; UK | Discussion relating to M2F & F2M |
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Authors report on the US prison’s denial of transition related treatment. Under the federal Bureau of Prisons, if the inmate can provide documents of hormone use prior to incarceration, there is a greater chance of continued therapy. However, in most cases this is not practiced and abruptly stopping treatment can be extremely dangerous. In contrast, in the UK, inmates have received surgeries while imprisoned. This is more likely to happen if inmates have gender affirmed or are on hormones. The extent to which inmates are allowed to cross dress differs by prison given concern for prisoner safety and housing is allocated by birth gender unless undergone surgery. |
| Halbach, S. | Framing a narrative of discrimination under the eighth amendment in the context of transgender prisoner healthcare; J Crim Law Criminol; 2016; 105 (2); pp. 463-497 | Commentary | US | Discussion relating to M2F & F2M |
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The article discussed the commonality of additional mental health problems if the inmate is denied hormones or surgery. The authors stated that a physician must diagnose an inmate with GD using the DSM and then must deem hormones or surgery to be a necessity. It states that by denying an inmate access to an evaluation and subsequent treatment, prisons are violating the Eighth and Fourteenth Amendments. |
| Harawa, N. T., Amani, B., Rohde Bowers, J., Sayles, J. N. and Cunningham, W. | Understanding interactions of formerly incarcerated HIV-positive men and transgender women with substance use treatment, medical, and criminal justice systems; Int J Drug Policy; 2017; 48; pp. 63-70 | Journal article | US (California) | N = 19 M2F formerly incarcerated HIV positive participants interviewed with data analyzed using Thematic Analysis |
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Findings include intense HIV stigma experienced by inmates, resulting in many not disclosing HIV status. Many were marginalized and denied benefits that they would normally be entitled to. Some hid their HIV status to other prisoners as well as healthcare professionals and so would forgo their treatment altogether for the duration of their sentence. Alcohol, drug use and mental were treated in prison but symptoms would cease on release. Some inmates had self-medication regimes, but the majority were processed through electronic databases and used pill-call allowing for almost complete adherence. Some misused prescribed medication while incarcerated. |
| Harawa, N. T., Sweat, J., George, S. and Sylla, M. | Sex and condom use in a large jail unit for men who have sex with men (MSM) and male-to-female transgenders; J Healthcare Poor Underserved; 2010; 21 (3); pp. 1071-1086 | Journal article | US (California) | Mixed methods with N = 109 M2F & F2M |
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Sex is commonplace in prisons. 32% of inmates were HIV positive and 24% had received a positive STI diagnosis during their last incarceration period. Most people would not disclose if they are HIV positive as they want to continue having sex while incarcerated. 25% had sex with women during incarceration; two-thirds had oral sex and 53% anal sex. 13% had exchange sex, this was evident more in transgender inmates than men (28% vs. 10%) and 75% reported at least one act of unprotected anal sex. Condoms were distributed once per week. Custody staff were aware of sexual activity but chose not to do anything about it. In relation to housing, if homosexual or transgendered M2F pre-sex reassignment surgery, inmates are dubbed ‘K6G’ and segregated from general population. |
| Hochdorn, V., Faleiros, P., Valerio, P. and Vitelli, R. | Narratives of Transgender People Detained in Prison: The Role Played by the Utterances “Not” (as a Feeling of Hetero- and Auto-rejection) and “Exist” (as a Feeling of Hetero- and Auto-acceptance) for the Construction of a Discursive Self. A Suggestion of Goals and Strategies for Psychological Counseling Alexander; Frontiers in Psychology; 2018; Volume 8; Article 2367 | Journal article | Italy; Brazil | N = 23 in-depth interviews with transgender women detained in either female or male prison contexts in Italy and Brazil. |
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The article contrasts the current treatment of transgender inmates in Brazil and Italy. In Brazil, there were reports of self-harm, sexual violence and assault as well as maltreatment by officers. Transgender inmates are not considered separate or different from the general inmate population and so they must dress and cut their hair the same as cis-gender men and are not allowed hormone treatment. In contrast, Italy allows individual or private cells with a maximum of 3 people, each with a toilet. No uniforms are required to be worn and inmates are allowed real life experience and gender affirmation. Hormonal treatments are allowed, these are partially supported by local health policies. |
| Jenness, V., Sexton, L. and Sumner, J. | Transgender inmates in California’s prisons: an empirical study of a vulnerable population. The California Department of Corrections and Rehabilitation Wardens’ Meeting; 2009 | Conference slides | US (California) | Discussion relating to M2F & F2M |
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The Powerpoint slides were presented at the Californian Department of Corrections and Rehabilitations Warden's meeting in 2009. They reference the Detention Elimination Act regarding sexual abuse among transgender inmates. They report that sexual assault rates are significantly higher in transgender populations. It highlights that more research is needed on perceptions and opinions of staff and other inmates. Furthermore, they make reference to high profile cases such as Farmer v. Brennan and legislative mandates e.g. PREA, SADEA and AB382 of the penal code. Housing and expressed preference for classification were also considered. |
| Jones, L. and Brookes, M. | Transgender offenders: A literature review; Prison Service Journal; 2013; 206; 11-18. | Journal article | US; UK | Literature review relating to M2F & F2M |
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The book chapter literature review identifies the significance of the 2004 Gender Recognition Act as allowing transsexual people to have legal recognition of their new gender. It also highlights that the majority of literature on transgender offenders is conducted in the US, which are more advanced than the UK guidance documents. It identifies that transgender inmates are extremely vulnerable from sexual violence as they have a unique set of health issues that can be a problem for the system. The article points out that the legal system has not informed prisons on how they should treat transgendered inmates. In the UK, there is no official monitoring within the prison system for gender identity, with only one study published at the time of the review. The comorbidity rates for psychological problems in transgender inmates are greater than in other groups. There was further discussion on treatment by officers, medical treatment and gender affirmation. The review concludes that more research is needed in the UK due to difficulty in engaging in effective therapeutic interventions. |
| Kendig, N. E., Cubitt, A., Moss, A. and Sevelius, J. | Developing Correctional Policy, Practice, and Clinical Care Considerations for Incarcerated Transgender Patients Through Collaborative Stakeholder Engagement; J Correct Healthcare; 2019; pp. 1-9 | Journal article | US | Stakeholder Focus Groups analyzed using discourse analysis considering M2F & F2M |
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Findings from focus groups include recommendations of a tailored approach to healthcare through counseling. This approach should be carried through transition related care with hormone therapy to be recommended, continued and medically adjusted if required. If no prior hormone therapy or documentation is available, inmates should be assessed, and treatment initiated. Medical officers should recognize and understand the range of medical services that are important and necessary in order to provide good standards of care to transgender inmates. Knowledge and training of correctional staff should be implemented. The article also discusses the role of specific units to address the housing and classification complex and also acknowledges that it could be down to the choice of the inmate by tailoring the decision making of housing transgender individuals through interdisciplinary assessment. |
| Lamble, S. | Rethinking Gendered Prison Policies: Impacts on Transgender Prisoners; The Howard League for Penal Reform: Early Career Academics Network Bulletin; 2012; 16; 7-12. | Commentary | UK | Discussion relating to M2F & F2M |
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UK-based commentary that discussed gender segregation in prisons. Until recently, regardless if an individual has a Gender Recognition Certificate, they are housed based on their birth gender. This changed when a M2F won a case v Ministry of Justice after they ignored the certificate. This was in breach of Article 8 of the European Convention of Human Rights. The Equality Act of 2010 also offers transgender inmates greater protection. Other issues discussed in the commentary include unsolicited solitary confinement, denial to trans-specific healthcare such as make-up, hormones and surgery, with many stopping the transition once they enter prison. Harassment, assault and abuse was also discussed. Furthermore, it identified that the PSI 2011 issues. The Care and Management of Transsexual Prisoners guidelines in compliance with the Equality Act 2010 |
| Lea, C. H., GDeonse, T. K. and Harawa, N. T. | An examination of consensual sex in a men's jail; Int J Prison Health; 2018; 14 (1); pp. 56-61 | Journal article | US (California) | N = 17 M2F Participants Interviewed and data Thematically Analyzed |
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This paper examined sexual behaviors of consensual sex and the enhanced provision of condom distribution in a specialist protective custody unit. Transgender women felt they were not attractive to men in some units who were homosexuals and attracted to men, so felt slightly safer in the segregated unit where they can live as a woman. However, they still witnessed and engaged in high levels of sexual activity regularly. They reported how condom use was poor as most prisoners in the unit already had HIV and it was prison policy for only one condom to be issued each week – this was even when men were having sex several times a night. In the new condom distribution program, more condoms were issued and some prisoners took lots of condoms and gave these out to others who were not on the program. |
| Levine, S. B. | Reflections on the Legal Battles Over Prisoners with Gender Dysphoria; J Am Acad Psychiatry Law; 2016; 44 (2); pp. 236-244 | Commentary | US | Discussion relating to M2F & F2M |
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Personal commentary exploring existing paradigms of GD and how they are used in legal battles. Further exploration by author into general experiences of transgender prisoners and the treatment of GD using hormones and SRS. |
| Mann, R. | The treatment of transgender prisoners, not just an American problem: A comparative analysis of American, Australian, and Canadian prison policies concerning the treatment of transgender prisoners and a ‘‘universal’’ recommendation to improve treatment; 2006; 15; pp. 91-133 | Commentary | US; Australia (New South Wales); Canada | Discussion relating to M2F & F2M |
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This paper notes the high levels of violence and abuse experienced in prison, as well as the severe side effects of coming off hormone treatment. The paper focused mainly on the issues of hormone treatment and surgery, authors highlight the disparity of treatment across countries but, in the main, if a prisoner has not started treatment prior to incarceration, it is unlikely they will be issued it in prison. Authors discuss housing of prisoners and how this is a difficult process when considering the risk to the transgender prisoner and the potential risk to other prisoners (usually females). Prisons allocate prisoners by sex at birth although some prisons are moving transgender prisoners to pods or specialist units. Authors note the trend to of prisons to use segregation units, but note the significant consequences for MH, ability to socialize etc. |
| Maruri, S. | Hormone therapy for inmates: a metonym for transgender rights; Cornell J Law Public Policy; 2011; 20 (3); pp. 807-831 | Commentary | US | Discussion relating to M2F & F2M |
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This paper highlights the problem with a diagnosis from the DSM-IV for GD means that prisoners are often viewed as sick or abnormal in some way |
| McCauley, E., Eckstrand, K., Desta, B., Bouvier, B., Brockmann, B. and Brinkley-Rubinstein, L. | Exploring Healthcare Experiences for Incarcerated Individuals Who Identify as Transgender in a Southern Jail; Transgender Health; 2018; 3 (1); pp. 34-40 | Journal article | US (Florida) | Use of screening questionnaire and Interview N = 10 M2F inmates of color, data analyzed using Thematic Analysis |
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Participants report a significant lack of access to healthcare resulting in an increase in mental health symptoms during imprisonment. Imprisonment in and of itself was reported to trigger MH episodes and symptoms. Sexual and violent assaults are regularly experienced along with routine harassment. The mental health implications mean transgender prisoners feel dehumanized have low levels of self-worth, self-esteem and self-stigma. Participants experienced disruption in their treatment (hormone therapy) which had consequences in terms of negative side effects. In terms of housing, participants reported the use of segregation in solitary confinement for long periods to deal with the prisons housing issue. Participants were sometimes moved to specialized wings with people who have significant vulnerabilities or problems, but they did not feel protected in these wings, at times felt more at risk, as participants describe rapists targeting them in the showers. Solitary confinement is used to punish people and so being sent there was very hard, many reported wanting to commit suicide. Participants noted issues with being placed in a female jail too in that they were just as at risk of abuse and violence there and wanted to be placed in a transgender unit. |
| Okamura, A. | Equality behind bars: improving the legal protections of transgender inmates in the California prison systems; Hastings Race Poverty LJ; 2011; 8; 109 | Commentary | US (California) | Discussion relating to M2F & F2M |
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The commentary outlined the legal protections for transgender inmates in California, US. It discussed sexual assault and prison rape; lack of adequate healthcare (citing Estelle v Gamble), which itself is underfunded for the general population; identified that between 60-80% of transgender inmates are HIV + ve; classification, housing and segregation; PREA; Detention Elimination Act, SADEA and the concept of deliberate indifference and duty to protect through the Eighth Amendment. |
| Osborne, C. S. and Lawrence, A. A. | Male Prison Inmates With Gender Dysphoria: When Is Sex Reassignment Surgery Appropriate?; Arch Sex Behav; 2016; 45 (7); pp. 1649-1662 | Commentary | US | Discussion relating to M2F & F2M |
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Authors discuss eligibility criteria for SRS. They note inmates are disadvantaged as the a) are unable to document persistent and well documented GD b) do not have access to full information or comprehend the challenges, consent is an issue c) can not always get a diagnosis of MH and keep it under control in prison; d) cannot always live in preferred gender for minimum of 12 months while possible in prison. Post SRS, authors note transgender women should be housed in a women's prison automatically after surgery, but there are issues e.g. some men opting out of SRS even when they medically need it, or when transgendered women have engaged in violence against women |
| Peek, C. | Breaking Out of the Prison Hierarchy: Transgender Prisoners, Rape and the Eighth Amendment’; Santa Clara Law Review; 2004; 1211-1248 | Commentary | US | Discussion relating to M2F & F2M |
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The legal commentary covering the following topics: evaluation and diagnosis; lack of understanding of GD and what it means to be transgender; housing and placement; surgery; rape, sexual abuse and coercive sex; the 'modern' Eighth Amendment in the context of Farmer v Brennan and deliberate indifference. |
| Poole, L., Whittle, S. and Stephens, P. | Working with transgendered and transsexual people as offenders in the Probation Service; Probation Journal; 2002; 49 (3); 227-232 | Journal article | UK | Discussion relating to M2F & F2M |
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Research study that interviewed officers as part of their sample. The article that discusses officers understanding and existing bias toward transgender inmates. Officers stated that transgender inmates were much like general population and so their offending behavior needed to be challenged regardless of their gender, therefore no discrimination either way. It discussed the need for hormones in order to control sexual needs and that officers needs better education and training. |
| Poteat, T. C., Malik, M. and Beyrer, C. | Epidemiology of HIV, Sexually Transmitted Infections, Viral Hepatitis, and Tuberculosis Among Incarcerated Transgender People: A Case of Limited Data; Epidemiol Rev; 2018; 40 (1); pp. 27-38 | Journal article | Global | Systematic literature review studies including M2F & F2M |
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This systematic review found very few studies detailing the HIV, STI, viral hepatitis and TB status among transgender inmates. They found 1 HIV prevalence study and one TB study that support the view that prevalence of HIV and related infections are high amongst this population. Likewise, they found limited prevention programs as a result of facilities fearing the promotion of sexual activity in prison. |
| Reisner, S. L., Bailey, Z. and Sevelius, J. | Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S; Women Health; 2014; 54 (8); pp. 750-766 | Journal article | US | Survey Research of N= 6456 M2F transgender participants analyzed using Inferential statistics |
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Study found 19.3% of transgender women had previously been incarcerate and were more likely, when compared to others in the survey to be women of color, have a low income, education, be uninsured. Black transgender women were three times more likely to have been imprisoned. Transgender participants had disproportionate health disadvantages when compared to others including smoking, use of substances, HIV positive status, sex work, experiencing physical and sexual assault. When in prison, this population reported greater victimization and mistreatment and denial of healthcare was reported by 24.5%. These women were more likely to report daily cigarette smoking, substance use, suicide attempts compared to those not in jail. |
| Routh, D., Abess, G., Makin, D., Stohr, M. K., Hemmens, C. and Yoo, J. | Transgender Inmates in Prisons: A Review of Applicable Statutes and Policies; Int J Offender Ther Comp Criminol; 2017; 61 (6); pp. 645-665 | Journal article | US | Systematic review of US statutes considering M2F & F2M |
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Authors found 37 states allow for counseling services for transgender prisoners; over half of states do not allow to obtain treatment after incarceration; 13 states allow for initiation, or beginning of hormone treatment, 21 states allow continuation of hormone therapy and 20 states do not allow. Only 7 states allow for SRS. They also found that some states use DSM-5 for gender identity disorder or gender dysphoria and this then dictates treatment pathways, but this is not consistent across all 50 states reviewed. |
| Schneider, D. | Decency, Evolved: The Eighth Amendment Right to Transition in Prison; Wis L Rev; 2016; 4; pp. 835-870 | Commentary | US | Discussion relating to M2F & F2M |
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Author discusses the physical and psychological consequences of stopping hormone treatment on arrival to prison, which is often experienced by inmates. The commentary highlights how not all states in the US have formal policies requiring the provision of medical treatment to transgender inmates and that the Standards of Care do not appear to be routinely applied. Although, some prisons have worked flexibly, not all have and as a result law suits have followed. The author also notes the risk of harm to male to female prisoners who remain housed in male prisons. Authors advise a case by case approach has been adopted in many states |
| Sevelius, J. and Jenness, V. | Challenges and opportunities for gender-affirming healthcare for transgender women in prison; Int J Prison Health; 2017; 13 (1); pp. 32-39 | Commentary | US (California) | Discussion relating to M2F & F2M |
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Authors note how left untreated the mental health outcomes for people with GD can be significant resulting in suicide and depression. Transgender women are most likely to be living with HIV experience serious MH conditions and as such should be regularly assessed for these conditions and offered support. Authors also discuss housing in prison and highlight the range of policies in prisons and detention centers that now consider the gender identity of the prisoner rather than their gender at birth. Consideration is given to place transgender women in female units as the policy recognizes the greater risk of victimization this group face and thus, aim to reduce this. The authors also note it remains unclear if this type of housing addresses the victimization of transgender women. |
| Sexton, L., Jenness, V. and Sumner, J. M. | Where the Margins Meet: A Demographic Assessment of Transgender Inmates in Men's Prisons; Justice; 2010; 27 (6); pp. 835-865 | Journal article | US (California) | Mixed methods using N = 316 M2F & F2M transgender inmates |
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This study found transgendered prisoners a highly victimized population with 61.1% experiencing physical assaults outside of prison and 85.1% physically assaulted in lifetime. 60-80% have HIV. 40.2% had to engage in sexual acts against their will outside of prison, 52.7% had done sexual acts they would rather not have done outside prison, and 70.7% had engaged in sexual acts against will in lifetime. 21.0% were homeless right before their most recent incarceration, 47.4% had ever experienced homelessness. 66.9% report mental health problems since being incarcerated and 42% participated in sex work. The sexual and gender identity of transgender prisoners are complex in prison. Often a conflation of identity and sexuality occurs, in that transgender prisoners are viewed homosexual. |
| Simopoulos, E. F. and Khin, E. K. | Fundamental principles inherent in the comprehensive care of transgender inmates; J Am Acad Psychiatry Law; 2014; 42 (1); pp. 26-35 | Commentary | US | Discussion relating to M2F & F2M |
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This discussion paper reports how transsexualism or Gender Identity Disorder (GD)/Gender Dysphoria has been criticized for its use as a labeling tool that serves to add to already stigmatized group. Authors note the criteria for diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), is under much debate. They note issues with diagnosis, many people are not being diagnosed, or wrongly diagnosed – resulting in no medical treatment. Authors note transgendered prisoners have greater healthcare needs are at increased risk of MH, suicide, HIV infection. The authors discuss the binary nature of prison classification that does not accommodate transgender inmates, often placed in segregation or vulnerable wings. This housing strategy does not mean conditions are any safer or in cases of F2M where inmates are placed in male prisons, are arguably greater risk. Management of inmates in terms of record keeping is inconsistent. |
| Stotzer, R. L. | Law enforcement and criminal justice personnel interactions with transgender people in the US: A literature review; Aggress Violent Behav; 2014; 19 (3); 263-276 | Journal article | Global | Literature review discussing M2F & F2M |
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This literature review found transgendered prisoners are denied basic care and access to hormone treatment. When living out in the community, transgender people report being treated as criminal suspects by correctional staff in the community, experience high arrest rates, and face harassment and assaults from police. When in prison they face abuse and harassment by staff including physical and sexual assaults. They feel they are treated unfairly by staff compared to other inmates and when correctional staff respond to complaints of abuse these are undermined. Sentencing of transgender prisoners appear to receive longer sentences and less conditional release options. |
| Sultan, B. A. | Transsexual prisoners: how much treatment is enough?; New Engl Law Rev; 2003; 37 (4); pp. 1195-1229 | Commentary | US | Discussion relating to M2F & F2M |
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This paper details legislation and strategies relevant to transgender prisoners in the Commonwealth of Australia. Authors note how transgender prison policies typically focus on four domains: identification, classification and placement, health services/treatments, and ‘every day’ living issues. Authors note the rights of transsexuals v. the rights of other prisoners as well as the need to administer justice and punishment. The author notes transsexual inmates do not “deserve” more treatment or concern than non-transsexual inmates. The author highlights the costs of surgery and treatment. Individuals need to pay privately, although low-income transgender people can usually not afford this – the author highlights, if treatment/gender reassignment surgery was made available in prisons, transgender people would commit crime just to get into prison. The author further notes that society would be dissatisfied if transgendered inmates received better treatment than non-transgendered inmates. That it is not the role of prison staff to make inmates happy. |
| Sumner, J. and Jenness, V. | Gender Integration in Sex-Segregated U.S. Prisons: The Paradox of Transgender Correctional Policy; 2014; New York: Springer | Book Chapter | US | Systematic review of documents and records; Thematically Analyzed examining M2F & F2M |
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This book chapter outlined findings from a systematic review that analyzed a range of US correctional policies, court opinions, etc. Authors present issues with medical treatment in terms of diagnosis, surgery, and gender affirming treatment, as well as the rationale for using segregation to house transgender inmates. They first note the problem with the varying definitions making diagnosis a challenge. Authors highlight how use of inmates preferred name has become part of correctional policy under the recognition that prisoners have the right to be treated with respect, impartially and fairly by all employees. Likewise, wearing gender appropriate clothing is also now recognized in policy with the aim to ensure dignity and respect. However, in some operation/healthcare manuals, gendered specific clothing are not tolerated and often seen as contraband e.g. women's bras, cosmetics. In practice policy is not yet fully implemented. Historically, people with Gender Dysphoria had been loosely classified as "effeminate homosexuals" and classification very rarely occurs on the basis of sexual preference. While there have been legal challenges to housing decisions, inmates continue to be segregated even though this is usually for the purpose of punishment. While, male to female prisoners are less victimized when placed in female prison, authors note how female inmates may be at greater risk of violence, or at the least have their privacy violated. In some US prisons screening for transgender status is taking place, and prisoners are housed in wards or pods for gay inmates, where gendered housing is provided, developments have been noted |
| Tarzwell, S. | Gender lines are marked with razor wire: addressing state prison policies and practices for the management of transgender prisoners; Columbia Hum Rights Law Rev; 2006; 38; 167-219 | Commentary | US | Discussion relating to M2F & F2M |
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The legal commentary focuses on 'hyper-gendered systems' and 'sex-segregated facilities where traditional gender roles are strictly enforced' (p. 177). The article also discusses safety concerns; victimization and stigma; solitary confinement; mental health; denial of gender affirming medical care and hormone therapy. It places the challenges in the context of Eighth Amendment Jurisprudence, 'deliberate indifference to serious medical need' (p. 181), citing key legal cases throughout. The article concludes, 'Transgender advocates must pressure prisons to voluntarily adopt policies embodying concrete reforms that will improve the daily lives of transgender prisoners.' (p. 219) |
| von Dresner, K. S., Underwood, L. A., Suarez, E. and Franklin, T. | Providing counseling for transgendered inmates: a survey of correctional services; Int. J. Behav. Consult. Ther; 2013; 7; 38-44 | Commentary | US | Discussion relating to M2F & F2M |
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Commentary describing the high rates of sexual assault, risk taking behavior and STI/HIV transmission among transgender inmates. Transgender inmates are also at considerable risk of relapsing or increasing psychological symptoms. It discusses the main treatment for TG inmates, 'freeze-framing' in that they should maintain status quo of their appearance and current treatment when they enter into a correctional facility. However, this does not account for those that have not been previously diagnosed with GD. Mental health assessment and services should therefore be working with transgender and potential transgender inmates to abide by SOCs. Other areas addressed include housing and provisions, such as gender affirmation and tailored services |
| Wall, B. W. | Commentary: gender nonconformity within a conformist correctional culture; J Am Acad Psychiatry Law; 2014; 42 (1); pp. 37-38 | Commentary | US | Discussion relating to M2F & F2M |
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The author highlights the nature and risk of violence/abuse, mental health, and medication/treatment for transgender inmates. How the binary nature of prison system presents issues of bias and prejudice. Authors refer to the principles as outlined by Simopoulos and Khin could serve to improve healthcare in prisons. Authors note that a need for openness and sensitivity to gender concerns is called for as well as approaching transgender prisoners as individuals with individual needs. |
| White Hughto, J. M. and Clark, K. A. | Designing a Transgender Health Training for Correctional Healthcare Providers: A Feasibility Study; Prison J; 2019; 99 (3); 329-342 | Journal article | US | Seven stage evaluation of previous intervention |
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The article describes the authors’ research study that piloted a transgender health training for correctional healthcare provider. Key topics include the integrating gender affirming language such as preferred pronouns; exposure to stories from transgender inmates; hormone provision; surgical considerations and mental health therapies. 'Providers indicated that the training provided them with the required cultural competencies to provide care to transgender patients and basic competencies for affirming clinical interactions' (p. 6) |
| White Hughto, J. M., Clark, K. A., Altice, F. L., Reisner, S. L., Kershaw, T. S. and Pachankis, J. E. | Creating, reinforcing, and resisting the gender binary: a qualitative study of transgender women's healthcare experiences in sex-segregated jails and prisons; Int J Prison Health; 2018; 14 (2); pp. 69-87 | Journal article | US | N = 20 M2F former inmates interviewed, data analyzed using Thematic Analysis |
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Participants fear violence and abuse in male prisons, some participants complied with male norms and did not disclose transgender status. Participants report inadequate healthcare e.g. not being able to access hormone treatment, as a result of them using street hormones and not officially prescribed drugs prior to incarceration; the state would not recognize their need for continued treatment without official prescriptions. Some health providers use the argument that if prisoners used hormone treatment they would be at increased risk of violence. Poor knowledge amongst treatment providers along with transphobic attitudes was reported, this meant some prisoners would simply conform to male norms or exert their gender and behave more feminine. |
| White Hughto, J. M., Clark, K. A., Altice, F. L., Sari, L. R., Kershaw, T. S. and Pachankis, J. E. | Improving correctional healthcare providers’ ability to care for transgender patients: Development and evaluation of a theory driven cultural and clinical competence intervention; Soc Sci Med; 2017; 195; pp. 159-168 | Journal article | US (Massachu-setts; Connecticut) | Mixed methods exploration of N = 34 health practitioners discussed M2F & F2M |
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This study discussed methods to improve healthcare provisions rather than document prisoner’s experiences. Authors note that interventions are needed to not only improve the knowledge, attitudes and skills of healthcare providers, but to encourage a willingness to provide gender-affirming care also. However, authors report how healthcare providers do not feel equip or skilled to give gender affirming care. |
| Wilson, M., Simpson, P. L., Butler, T. G., Richters, J., Yap, L. and Donovan, B. | ‘You’re a woman, a convenience, a cat, a poof, a thing, an idiot’: Transgender women negotiating sexual experiences in men’s prisons in Australia; Sexualities; 2017; 20 (3); pp. 380-401 | Journal article | Australia (New South Wales) | N = 7 M2F Inmates interviewed |
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Participants reported experiencing sexual abuse in prison, including rape, assaults, witnessing rape and assaults and sexual harassment. Personal strategies to cope in prison were discussed including (stand up and fight getting support from other prisoners, affiliating with ethnic groups for support, being in female prison). While hormone treatment was not discussed by participants, reference was made to prisons appearing to know nothing of hormone treatments. New South Wales policy takes a case management approach, they consider the offense, risk to others in the prison and risk to the transgender prisoner before determining which gender prison to allocate them too. |
| Yap, L., Richters, J., Butler, T., Schneider, K., Grant, L. and Donovan, B. | The Decline in Sexual Assaults in Men’s Prisons in New South Wales: A “Systems” Approach; Journal of Interpersonal Violence; 2011; 26, 15; 3157-3181 | Journal article | Australia (New South Wales) | Interviews with N = 33 men and N = 7 M2F in a New South Wales prison |
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The study from New South Wales, Australia, reported that prison rapes and sexual violence was occurring less frequently than previous decades. One participant believed that this is due to generational differences, who are now less violent and more open-minded. It is also effected by reduced drug supply, demand and harm reduction progams. However sexual violence is still present, and can turn violent if not reciprocated. The study calls for new programs to be implemented that support the changing environments of correctional facilities |
Table 3.
Additional grey literature results.
| Author | Title, year and other details | Location | Type of publication | Definition of transgender synonym | Findings/key points |
|---|---|---|---|---|---|
| American Psychological Association | Guidelines for psychological practice with transgender and gender non-conforming people. Am. Psychol; 2015; 70; 832-864 | US | Guidelines | Transgender and gender nonconforming (TGNC) people are those who have a gender identity that is not fully aligned with their sex assigned at birth. | Guidelines that focus on the psychological aspect of transgender incarceration, including addressing issues such as harassment, abuse and victimization. Also discussing the role of mental health professionals. |
| Arnott, J. and Crago, A. | Rights Not Rescue: A Report on Female, Male, and Trans Sex Workers’ Human Rights in Botswana, Namibia and South Africa; 2009; New York: Open Society Institute | South Africa | Report | Not mentioned | The report namely discusses South Africa (SA) where, 'trans sex workers are systemically submitted to violence by being locked in jail with men' (p 40). Also, no condoms are distributed in prisons in SA. Police will also encourage other prisoners to harm trans inmates. 'Hormone replacement for trans women and other trans-specific medical treatment is not available in South African prisons because it is not considered primary healthcare.' (p 50). |
| Blight (2000) | Transgender Inmates. Trends and Issues in Crime and Criminal Justice; Australian Institute of Criminology | Australia | Report | According to The New South Wales Anti-Discrimination Act a transgender person as someone who: • identifies as a member of the opposite sex by living, or seeking to live, as a member of the opposite sex • has identified as a member of the opposite sex by living as a member of that sex • being of indeterminate sex, identifies as a member of a particular sex by living as a member of that sex, and includes a person being thought of as a transgender person, whether the person is, or was, in fact a transgender person. | The report covers different Australian province prison policy, discrimination protection and birth/sex recognition. It discusses housing based on self-choice; self-harm, sexual assault and surgery. |
| Blazer and Hutta (2012) | Transrespect versus Transphobia Worldwide: A Comparative Review of the Human-rights Situation of Gender-variant/Trans People; 2012; Transrespect | Global | Report | Not mentioned | Report on the international transgender situation. E.g. 1. Uganda - inmates gender identity denied and suffered assaults from other inmates and prison wards (p 35); E.g. 2. Thailand and Philippines - ' In Thailand and the Philippines, penal laws also do not recognize transpeople’s gender identity…Many transpeople in the Philippines try to circumvent the law’s limitations by securing identification documents that reflect their identity through sometimes illegal but mostly creative means (i.e., black-market passports, credit-card or bill statements declared in their preferred names, fake IDs, etc.)' (p 82). |
| Bassichis and Spade (2007) | It's War in Here: a Report on the Treatment of Transgender and Intersex People in New York State Men's Prisons. Sylvia Rivera Law Project; 2007; New York | US | Report | Not mentioned | The report is affiliated to the Sylvia Rivera Law Project, which was opened in 2002. The Project has 'provided free legal services to over 700 intersex, transgender, and gender non-conforming people'. Includes: assault, sexual violence, stigma and discrimination, denial of treatment, housing, lack of medical care, HIV/STI and gender affirmation. Other topics covered in the report include showers, lack of privacy and searches. Recommendations put forward include to improve safety and treatment of transgender inmates, enhance grievance procedures and ensure access to healthcare. |
| Beard (2018) | Briefing Paper: Transgender Prisoners; 2018; House of Commons Library | UK | Report | Not mentioned | In regards to classification of transgender inmates, the UK are slightly more progressive stance through the 2016 Prison Service Instruction (set of policy guidelines). In Scotland, policy guidelines state that the social gender in which the prisoner is living should be fully respected, regardless of whether or not they have a GRC. The Northern Ireland Prison Service has no recent record of any prisoners who have self-identified as transgender. |
| Beck, A. J. | Prison Rape Elimination Act of 2003: PREA Data Collection Activities; 2015; US Department of Justice | US | Report | Not mentioned | The report comments on abuse in prisons as well as maltreatment of transgender inmates by correctional officers. |
| Carr et al. (2016) | Out on the Inside: The Rights, Experiences and Needs of LGBT People in Prison; Irish penal reform Trusts; 2016; The Community Foundation for Ireland. | Ireland | Report | Not mentioned | Report commissioned by the Irish Penal Reform Trust. It is based on research and international models of practice, looking at Irish policy and placement of TG prisoners; access to medical treatment; the need for privacy during searches and showers; methods of rehabilitation; and identifies current discrimination, harassment and abuse, sexual violence and treatment from officers with the use of segregation. |
| Committee on Economic, Social and Cultural Rights | The right to the highest attainable standard of health, E/C.12/2000/4, General Comment No. 14, paragraph 34; 2000 | Global | Legal Rule or Regulation | Not mentioned | Set of principles outlining the individual’s right to the highest attainable standard of health. |
| Federal Bureau of Prisons (2016) | Medical management of transgender inmates (Clinical guidance); 2016 | US | Report | Transgender; gender dysphoria; gender identity disorder TRANSGENDER (TG) individuals are those whose gender identity is different from their biological sex. GENDER DYSPHORIA (GD), previously known as GENDER IDENTITY DISORDER (GID), is the discomfort or distress caused by a discrepancy between a person’s GENDER IDENTITY and that person’s GENDER assigned at birth. Not all TG will be diagnosed with GD, and a diagnosis of GD is not required for access to services | The official government report details the experiences of transgender inmates such as stigma, discrimination and victimization as well as classification, treatment by correctional officers, evaluation and diagnosis, counseling, general care, transition related care, hormone, surgery and gender affirmation. It concludes with providing solutions such as individualized treatment, education and informed consent. |
| Government Publishing Office | Prison Rape Elimination Act of 2003; 2003; Authenticated U.S. Government Information; U.S. 108-79 | US | Legal Rule or Regulation | Not mentioned | The complete legal rule of the Prison Rape Elimination Act of 2003. |
| Grant, J. M. Mottet, L. Tanis, J. E. Harrison, J. Herman, J. Keisling, M. | Injustice at Every Turn: a Report of the National Transgender Discrimination Survey; National Center for Transgender Equality; 2011 | US; Columbia; Puerto Rico; Guam and the US Virgin Islands | Report | Transgender ‘Those who transition from one gender to another (transsexuals), and those who may not, including genderqueer people, cross-dressers, the androgynous, and those whose gender non-conformity is a part of their identity’ | The report outlines findings of 6,450 transgender and gender non-conforming people across the US, Columbia, Puerto Rico, Guam and the US Virgin Islands. The report found discrimination was experienced by the entire sample. Race and ethnic minorities face worse situations in contrast to their white counterparts. 41% of the sample reported attempted suicide. 16% of respondents reported physical abuse when in prison and 15% reported sexual assault. |
| Harris (2017) | In historic 1st, transgender inmate wins transfer to women's prison; 2017; CBC News; Canada; 21st July 2017 | Canada | Newspaper article | Not mentioned | The article reports on the first transfer of transgender inmate to an institution based on gender identity rather than physical anatomy. |
| Harris (2018) | Canada's prison system overhauls transgender inmate policy; 2018; CBC News; Canada; 7th February 2018 | Canada | Newspaper article | Not mentioned | The article reports on Canada's prison system and how it has overhauled its policies around transgender inmates, now housing inmates based on their gender identity. |
| Human Rights Watch (2018) | Living at Risk: Transgender Women, HIV, and Human Rights in South Florida; 2018 | US | Report | Not mentioned | Human Rights Watch reports on the current provisions in place to protect the negative experiences currently held by transgender inmates in the US, 'Withdraw revisions to the Bureau of Prisons Transgender Offender Manual that weaken protections for transgender prisoners'. |
| Lambda Legal (2015) | Transgender Incarcerated People in Crisis; 2015 | US | Report | Not mentioned | The report discusses the experiences of transgender inmates, discussing abuse, stigma, discrimination and victimization as well as classification, transition related care, surgery and hormones, with reference to PREA, Farmer v Brennan, 1994 and the Eighth Amendment. |
| Lydon, J., Carrington, K., Low, H., Miller, R. and Yazdy, M. | Coming Out of Concrete Closets: a Report on Black and Pink's LGBTQ Prisoner' Survey; Black and Pink; 2015; Boston, MA | US | Report | Not mentioned | LGBTQ report identifying lack of disclosure of GID, lack of evaluation and diagnosis upon entry. It also reports that 44% of transgender inmates are denied access to hormones when requested, and only 21% are allowed real life experience and gender affirmation while in prison. Housing, strip searches and treatment by officers also discussed. |
| McLemore (2018) | US Bureau of Prisons Policy Change Endangers Transgender Prisoners: Transgender Prisoners Face Alarming Rates of Abuse in Detention; 2018 | US | Webpage | Not mentioned | The website provides further information and updates on the classification of transgender inmates, citing that 'The Trump administration’s decision to change the policy of the federal Bureau of Prisons (BOP) for housing transgender prisoners is dangerous, wrongheaded, and unnecessary.' |
| Ministry of Justice (2016b) | Review on the Care and Management of Transgender Offenders; 2016 | UK | Report | Not mentioned | The reports discuss the importance of diagnosis and evaluation as well as the abuse experienced by transgender inmates such as interrogation and isolation. Finally, it provides solutions such as additional training and necessary policy review. |
| The Nation (2017) | Prison system sets up new accomodations for LGBT inmates; 2017; Thailand News; Thailand; 22nd March 2017 | Thailand | Newspaper article | Not mentioned | The newspaper article discussing the arguments for and against special units designed specifically for transgender inmates. |
| National Centre for Transgender Equality (2018a) | Ending abuse of transgender prisoners: a guide to winning policy change in jails and prisons; 2018 | US | Report | Not mentioned | National Center for Transgender Equality published a series of guidelines based on PREA for treatment of transgender inmates. The report advises correctional officers to understand current attitudes, practice and policies. It provides solutions in the form of workshops, interventions, training, media and messaging. |
| National Centre for Transgender Equality (2018c) | Policies to increase safety and respect for transgender prisoners: A guide for agencies and advocates; 2018 | US | Report | Not mentioned | The report advises to limit the use of segregation and handle case by case. It offers solutions such as tailoring services, prisoner education, policy dissemination and implementation. The report also comments on gender affirmation; general treatment in the form of equal access to care and transition related care and finally it discusses the need for greater attention on showering and restroom practices, searches and language (pronouns etc). |
| National Centre for Transgender Equality (2018b) | LGBTQ People Behind Bars: A Guide to Understanding the Issues Facing Transgender Prisoners and Their Legal Rights; 2018 | US | Report | Not mentioned | Drawing on the PREA Act of 2003 and PREA Standards 2012, the Eighth Amendment Equal Protection Clause, the report discusses treatment options as well as treatment from correctional officers, classification of transgender inmates and other issues such as searches, privacy, equal treatment regarding visitation and opportunities |
| National Institute of Corrections (2013) | Policy Review and Development Guide: Lesbian, Gay, Bisexual, Transgender, and Intersex Persons in Custodial Settings; 2013; US Department of Justice | US | Report | Transgender or transexual A transgender or transsexual person has a gender identity that is different from his/her assigned sex at birth. Gender identity disorder; gender dysphoria the levels of stress that transgender people experience results in depression, anxiety, low self-esteem, and even suicide ideation. | US Department of Justice's policy review and development guide outlining the necessity of medical and mental healthcare; risk, housing and classification; constitutional law; sexual abuse and violence and the need for additional privacy and safety. The review states that classification is still based on inmates genitalia or assigned sex at birth, placing inmates at high risk of abuse and vulnerability. This is in violation of the Eighth, Fifth and Fourteenth Amendments. |
| NCCHC (2015) | Transgender, transsexual, and gender nonconforming healthcare in correctional settings (Position statement); 2015 | US | Webpage | Transgender Transsexual is an older term that originated in the medical and psychological communities. It is still preferred by some people who have permanently changed-or seek to change-their bodies through medical interventions (including but not limited to hormones and surgeries). Transsexual is not an umbrella term. It is best to ask which term an individual prefers. For the purposes of this statement, the term transgender includes those who identify as transsexual as well as gender nonconforming individuals. | The website outlines the current state of transgender inmate healthcare including counseling, diagnosis and evaluation, hormone, surgery. It refers to PREA as well as World Professional Association for Transgender Health (WPATH). |
| Penal Reform International & Association for the Prevention of Torture (2013) | LGBTI Persons Deprived of Their Liberty: A Framework for Preventative Monitoring; 2013; London; Penal Reform International | Global | Framework | Transgender defined according to the Yogyakarta Principles ‘to refer to each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms.’ | The report details the risk factors faced by transgender persons in the criminal justice system. Some of these include inappropriate interrogations; housing and allocation; body searches; violence; abuse; isolation and solitary confinement and discrimination. It uses examples from Honduras and New Zealand to set precedence for future policies. Recommends training such as knowledge building around sexuality and gender identity. |
| Prisons & Probation Ombudsman for England and Wales (2013) | Sexual Abuse in Prisons; 2013; London | England; Wales | Bulletin | Not mentioned | Bulletin outlining sexual abuse in prisons. Case studies presented include a transgender prisoner stating that she was not treated respectfully. The Ombudsman report upholds guidelines and in this specific case, recommended additional training for staff for the care and management of transgender prisoners. It states that ' Prisons need to ensure they conform with the Equalities Act 2010, specifically in relation to transgender prisoners' (p 6). |
| Public Health England (2018) | Gender Specific Standards to Improve Health and Wellbeing for Women in Prison in England | UK | Report | Not mentioned | Public Health England Standards that discuss rights of all women in prisons, including TG inmates. It states that 'NHS England will be undertaking work to develop standards of transgender people in prison' (p 8). It advises on 'informed gender-sensitive training' and that TG women needs should be 'assessed and appropriate services available' (p 38). |
| Ryan (2016) | Transgender issues in the criminal justice system; 2016; Legal Action Group | UK | Webpage | Not mentioned | The website details the experiences of abuse, stigma, discrimination and victimization, citing that the 'UN Special Rapporteur on Torture reported as long ago as 2001 that transgender prisoners (particularly trans women) are at ‘great risk’ of physical and sexual abuse'. It discusses classification, treatment by correctional officers and quotes the Prison Service Instruction, 'The English and Welsh policy on The care and management of transsexual prisoners (Prison Service Instruction (PSI) 07/2011) provides that trans prisoners should be able to live in their affirmed identity regardless of which type of prison they are in. However, prisoners frequently report having to battle for basic items and face a challenge as ‘security’ issues outweigh equality rights.' |
| The Scottish Centre for Crime and Justice Research (2019) | Safety of, from or including transgender people in prison?; 2019 | Scotland | Webpage | Not mentioned | The Scottish website highlights the experiences of transgender inmates to include abuse, stigma, discrimination and victimization, mental health, classification and treatment by correctional officers. |
| Scottish Prison Service (2014) | Gender Identity and Gender Reassignment Policy for those in our Custody; 2014 | Scotland | Report | Gender dysphoria Is distress, unhappiness and discomfort experienced by someone about their biological sex not fully matching their gender identity. | The report details the procedures around gender reassignment surgery before, during and after operation. It also touches upon treatment, evaluation and diagnosis, surgery and classification as well as rubdowns, search, shower and changing facilities for transgender prisoners. |
| Thompson (2017) | California funds 1st US inmate sex reassignment; New York Times; 2017 | US | Newspaper article | Not mentioned | Newspaper article discussing prison sex reassignment surgery. |
| Transgender Europe (2016) | Malta Prison Policy (August 2016); 2016 | Europe | Policy document | Trans Trans refers to people (sometimes referred to as ‘transgender’) whose psychological self (‘gender identity’) differs from the social expectations for the physical sex they were assigned at birth. ‘Trans’ is also an umbrella term for transgender, transsexual, crossdressers, gender queer, gender fluid, and people who identify as neither female nor male. | The policy document addresses the issues of classification, gender affirmation, treatment of correctional officers and the additional training required and the positive impact that using different pronouns may have as well as turning consideration to searches, shower and changing facilities and gender-based activities. |
| United Nations General Assembly | United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) | Global | Legal Rule or Regulation | Not mentioned | Set of rules ‘recalling all standards and norms in crime prevention and criminal justice developed at the request of the Commission on Crime Prevention and Criminal Justice and adopted or recommended by the General Assembly, or adopted by a United Nations congress on the prevention of crime and the treatment of offenders, and recognizing that the Universal Declaration of Human Rights’. |
| United Nations General Assembly | First United Nations Congress on the Prevention of Crime and the Treatment of Offenders UN Doc. No. A/CONF.6/L. 17; 1955 | Global | Legal Rule or Regulation | Not mentioned | The report details the Standard Minimum Rules for the Treatment of Prisoners according to the first UN Congress on the Prevention of Crime and the Treatment of Offenders. |
| United Nations General Assembly | Basic principles for the treatment of prisoners, Res. 45/111. UN Doc. No. A/RES/45/111; 1990 | Global | Legal Rule or Regulation | Not mentioned | Eleven basic principles for the Treatment of Prisoners as Adopted and proclaimed by General Assembly resolution 45/111 of 14 December 1990. |
| United Nations General Assembly | UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Expert consultation on access to medicines as a fundamental component of the right to health, UN Doc. No. A/HRC/17/43, 16 March 2011, paragraph 44 | Global | Legal Rule or Regulation | Not mentioned | The report ‘report contains a summary of the discussions held and the recommendations made at the expert consultation on access to medicines as a fundamental component of the right to health, held in Geneva on 11 October 2010, in accordance with the Human Rights Council resolution 12/24′. |
| United Nations Human Rights Committee | Communication No. 1020/2001, UN Doc. No. CCPR/C/78/D/1020/2001, para 7.7.; 2003 | Global | Legal Rule or Regulation | Not mentioned | Legal ruling and communication, dated 6 July 2001, by Carlos Cabal and Marco Pasini Bertran ("Pasini"), currently under detention in Port Philip maximum security prison awaiting extradition to Mexico. They claim to be victims of violations of articles 7, 10, paragraphs 1 and 2 (a), and 14, paragraph 2, of the International Covenant on Civil and Political Rights, by Australia. The prisoners are appealing due to their experiences of violence and negative health outcomes as a consequence of being incarcerated. |
| Universal Declaration of Human Rights | Universal Declaration of Human Rights; G.A. Res. 217A (III). Art 25.1; 1948 | Global | Legal Rule or Regulation | Not mentioned | ‘Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction’. |
| UNODC | Handbook on Prisoners with Special Needs; 2009; Criminal Justice Handbook Series; Vienna | Global | Report | Transgender Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies that diverge from the normative gender role (man or woman) commonly, but not always, assigned at birth, as well as the role traditionally held by society. | The UN report from Vienna, highlights transgender inmates experiences such as abuse, stigma, discrimination and victimization; treatment by correctional officers with inappropriate strip searches; transition related care, hormone, surgery and the role of Yogyakarta Principle 9. |
| WHO | Prisons and Health; 2014 | Global | Report | Not mentioned | The WHO report details the role of the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity and the right to treatment with humanity while in detention |
| Kosilek v. Maloney | 221 F. Supp. 2d 156 (D. Mass. 2002); 2002; US District Court, D. Massachusetts; CIV.A.92-12820-MLW | US | Legal Rule or Regulation | Not mentioned | The legal rule and case of Kosilek v Maloney, 2002. |
| WPATH | Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People; 2012 | US | Report | Not mentioned | The complete Standard of Care put forward by the WPATH. |
| Yogyakarta Principles | The Yogyakarta Principle: additional principles and state obligations on the application of international human rights law; 2006; Geneva | Global | Report | Gender expression '‘gender expression’ as each person’s presentation of the person’s gender through physical appearance – including dress, hairstyles, accessories, cosmetics – and mannerisms, speech, behavioral patterns, names and personal references, and noting further that gender expression may or may not conform to a person’s gender identity' | The report outlines the complete Yogyakarta Principles. It details 29 principles, including rights to universal enjoyment of human rights, life, fair trial, work, education, movement and accountability. |
| Yogyakarta Principle plus 10 | The Yogyakarta Principle plus 10: additional principles and state obligations on the application of international human rights law; 2017; Geneva | Global | Report | Gender expression '‘gender expression’ as each person’s presentation of the person’s gender through physical appearance – including dress, hairstyles, accessories, cosmetics – and mannerisms, speech, behavioral patterns, names and personal references, and noting further that gender expression may or may not conform to a person’s gender identity' | The report builds on the existing set of principles to include a further nine additional principles based: state protection, legal recognition, bodily and mental integrity, discrimination, protection from poverty, sanitation, human rights, truth and cultural diversity. |
Table 4.
Country specific results and policies.
| Country* (Number of articles**) | Country policy toward TG*** inmates | Overall climate toward TG inmates (positive/negative/neutral) |
|---|---|---|
| Australia (4) | Multiple anti-discrimination legislation across territories, with general uniformity. Definition of TG differs per territory and therefore when a TG person enters the criminal justice system, their treatment depends on their location. Very limited knowledge of treatment of TG inmates.a | Neutral – needs more research to be conducted to understand attitudes |
| Brazil (2) | Reports of self-harm, sexual violence and assault as well as maltreatment by officers. Transgender inmates are not considered separate or different from the general inmate population and so they must dress and cut their hair the same as cis-gender men and are not allowed hormone treatment.b | Negative – gender binary is maintained, with no acknowledgement to TG |
| Canada (3) | Correctional Service Canada (CSC) policy was updated in 2017 The changes enforce that TG inmates will be afforded the same protections, dignity and treatment as other. Inmates housed based on their gender identity rather than physical anatomy.c,d | Positive – new policy changes reflect equal rights and protection |
| Hong Kong (1) | ‘Transgender inmates who have not undergone reassignment surgery do not have the right to serve their time in prisons for the gender they have chosen’. They are therefore subject to strip and cavity searches amongst the general population. Many TG inmates experience sexual harassment while in custody.e | Negative – policy changes required |
| Ireland (1) | There is currently no policy regarding the housing and treatment of TG inmates in Ireland. However, if individuals have had SRS + before entering prison, they are provided with a new birth certificate to reflect the physical changes.f | Negative – policy changes required |
| Italy (2) | There are protected sectors for transgender inmates and the situation has seen improvements recently, in regard to less violence and discrimination from other inmates as well as prison officials. Prison workers receive tailored courses and training programs for interacting with TG inmates in an appropriate manner.g | Positive – changes originate from the 1980s onwards that look to ‘humanise the penitentiary system’ |
| South Africa (1) | It is reported that no condoms are distributed in prisons. Police will also encourage other prisoners to harm trans inmates. 'Hormone replacement for trans women and other trans-specific medical treatment is not available in South African prisons because it is not considered primary healthcare’.h However, changes are taking place as in 2019, a transwoman won the right to express her gender identity in the male prison that she is housed.i | Neutral – albeit lagging behind some countries, changes are taking place |
| Thailand (1) | Transgender is recognized as a third gender in Thailand. However, the UNDP conducted an audit of the rights of TG inmates in Thai prisons in 2018 and found that they ‘experience challenges in accessing basic services, as well as sexual harassment by other inmates’ and ‘that correctional officers often lack knowledge of transgender issues, resulting in increased stigma and stereotyping of transgender inmates’.j | Neutral – state and prison policy needs to reflect the recognition of TG that is embedded in Thai culture |
| UK (13) | TG inmates are allowed to dress in line with their gender identity and they have access to gender-related healthcare. However, housing is decided on a case-by-case basis and so there can be a delay in processing and searches remain to be conducted as an individual was housed.k | Positive – changes are ongoing and are more liberal than other countries |
| US (65) | Under the Trump administration, protective policies have been rolled back after prisoners have challenged policies and human rights.l Similar to Australia, policies vary depending on States. For a breakdown of state specific policies toward TG inmates see Routh et al. (2017). | Negative – there has been a regression in progress of TG rights |
| Europe (1) | ||
| Global (17) |
Countries do not equate to the total number of sources (n = 58) as some sources cover multiple countries.
Total literature found during all searches (database, hand and grey literature).
TG = transgender.
SRS = sex reassignment surgery.
aLynch and Bartels (2017).
bHochdorn et al. (2018)
cHarris (2017).
dHarris (2018).
eLau (2018).
fIrish Penal Reform Trust (2016).
gChianura et al. (2010).
hArnott and Crago (2009).
iVenter (2019).
jUNDP Thailand (2019).
kPrison Reform Trust (2016).
lReuters (2018).
The thematic analysis of charted publications found several areas of commonality, interest and importance, as well as some gaps in the literature. Five key themes that consistently emerged and featured across sources included: transgender definition and terminology used in prison publications; prison housing and classification systems; conduct of correctional staff toward incarcerated transgender people; gender affirmation, health experiences and situational health risks of incarcerated transgender people; and transgender access to gender-related healthcare in prison.
Transgender definition and terminology used in prison publications
The review underscores the complexity of the transgender definition within the prison setting. Not all sources in this review outline or define with clarity the terminology of the term transgender, see Table 2. The original Yogyakarta Principles (2006, p. 6) understand gender identity as “each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth”. They state that one’s gender identity is integral to their “dignity and humanity and must not be the basis of discrimination or abuse”. Of note, definitions varied between those that define transgender, for example Gender Disorder (GD) is “usually accompanied by (a) the belief that one is born the wrong gender, and/or (b) a preoccupation with the surgical removal/altering or hormonal change of one’s primary and secondary sex characteristics” (Alexander & Meshelemiah, 2010, p. 273) or a less medical explanation of transgender as outlined by Brömdal et al. (2019b, p. 5) who cite the UN Program on HIV/AIDS definition that “transgender is an umbrella term to describe people whose gender identity and expression does not conform to the norms and expectations traditionally associated with their sex at birth”. However, others attempt to generate clarity on the differences between terms such as transgender and GD. The main point made by authors is that GD is a medical diagnosis, whereas transgender is an umbrella term (Brown, 2009). Other examples include Garcia (2014) who outlines the difference between transgenderism and transsexualism. Garcia (2014, p. 444) states that transgender is as “an umbrella term that encompasses many different gender identities including cross-dressers, drag kings and queens, and intersex persons with disorders of sex development” whilst transsexualism refers to “someone who feels as though his or her body is not equipped with the sexual organs and other physical manifestations of gender that reflect the transsexual’s desired gender expression.” Some authors spent considerable time discussing the variations and problems with academic definitions (Routh et al., 2017), detailing medical terminology such as in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and more broader definitions as found in the WPATH SOC (Mann, 2006; Sevelius & Jenness, 2017; WPATH, 2012). However, what is apparent is the inconsistency and lack of consensus of what transgender is, in these prison based records, with definitions ranging from a broad and all-encompassing umbrella term, to a narrow and medicalised definition (Jones & Brookes, 2013; Peek, 2004; Sexton et al., 2010).
Prison housing and classification systems
The review identifies five key sub themes in relation to the housing of transgender incarcerated people across the included publications. These include: a) the continued use of a binary classification system resulting in inappropriate housing; b) inappropriate housing resulting in increased risk of violence and harm to the incarcerated transgender individual; c) inappropriate housing potentially placing other prisoners (usually women) at risk of harm; d) frequent use of segregation or solitary confinement as a solution to housing of transgender incarcerated people and e) the development of a case by case approach and use of specialized wings in prisons.
It appears commonplace in countries such as the US, UK, Canada, Australia and Ireland, that entry into a male or female prison is determined by the individual’s external genitalia and/or assigned sex at birth. Classification is binary allowing only male or female selection (Tarzwell, 2006). For most post-operative incarcerated people, this is less of an issue, however, the majority of incarcerated transgender individuals are pre-operative or non-operative (Erni, 2013), and as such, are placed in prison matching their physical genitalia (Bacak et al., 2018; Garcia, 2014; Green, 2010; Mann, 2006; Simopoulos & Khin, 2014). Very rarely are prisoners given the option to choose their prison placement, however some US, UK, Canadian and Australian institutions practice a case-by-case approach where prisoners’ preferred gendered housing is offered to the individual (Bashford et al., 2017; Mann, 2006; Sevelius & Jenness, 2017; Sumner & Jenness, 2014). Indeed, this was a recommendation by Brömdal et al. (2019a) as well as PREA (Beck, 2015), whereby an individual’s gender identity is taken into consideration alongside their overall safety when placed in a closed setting.
The review highlights that the key issue when placing transgender individuals in a gender-based system is that it can result in an inappropriate classification (not the preferred option of the transgender individual), placing the transgender person at risk of harm, or placing other prisoners at risk of harm from the transgender person. One of the most cited US legal cases, Maloney v. Kosilek (2002), saw Michelle (then Robert) Kosilek, a transgender female serving a life sentence for strangling her wife (Osborne & Lawrence, 2016; Schneider, 2016; Sultan, 2003), placed in a male prison and subjected to violent harm (Colopy, 2012) and “sexual terrorism” (Erni, 2013, p. 6; Garcia, 2014). While it is rare for pre-operative transgender female incarcerated people to be placed in a male prison due to the potential risk (Simopoulos & Khin, 2014), many transgender women report experiencing vulnerabilities and at risk of violence in women only prisons (Brömdal et al., 2019b).
The review illustrates that a common solution used by prison and correctional authorities when faced with decisions around the appropriate placement and safety of housing a transgender individual, is to place them in segregation wings or in solitary confinement (Lamble, 2012). While prison officials argue this is to protect the transgender individual from harm, the social and psychological deprivation experienced by solitary confinement, a tool used for punishment, is arguably inhumane. This situation is even more prevalent with race as Lydon et al. (2015) found that Black, Latino, mixed‐race, and Native American/American Indian transgender incarcerated people were twice as likely to be placed in solitary confinement. Yet, many prisons in the US, Australia and Canada opt for this solution (Colopy, 2012; Mann, 2006; McCauley et al., 2018; Simopoulos & Khin, 2014; Sumner & Jenness, 2014). More progressive responses in some US, UK, Canadian and Australian prisons include the placement of incarcerated transgender people onto specialist wards or pods, that are then able to address the needs of transgender prisoners (Bashford et al., 2017; Mann, 2006; Sumner & Jenness, 2014). Yet in practice such specialist wings are used to house ‘all’ prisoners with vulnerabilities and problems, and incarcerated transgender people report feeling equally vulnerable in these facilities (McCauley et al., 2018).
Conduct of correctional staff toward incarcerated transgender people
Experiences of transgender people in the prison environment are also directly impacted by prison and correctional staff attitudes and behaviors toward them. Brömdal et al. (2019b) observed a lack of understanding by prison and correctional staff in regard to how gender identity and expression is related to, yet distinct from, sexual orientation. Examples include where continual requests by transgender individuals for evaluation have been ignored or they have experienced a cessation in hormone therapy whilst in prison. Prison staff have been described as having ‘deliberate indifference’ as evidence in several legal challenges in the US, which by law is a violation of the Eight Amendment and deemed as ‘cruel and unusual punishment’ (Alexander & Meshelemiah, 2010). For example, Brown (2009) reported that in one case of auto-castration in the prison, the officers believed that the threats of auto-castration were a form of manipulative behavior.
Many sources from the US and the UK documented victimization and abuse by prison and correctional staff toward incarcerated transgender people (Alexander & Meshelemiah, 2010; Bashford et al., 2017; Clark et al., 2017). Alexander and Meshelemiah (2010, p. 279) in the US, described how officers called transgender people in prison; “freak,” “sicko,” and “that thing”. This was reported to subsequently cause multiple issues for the individual with the prison officers’ bias contributing to the further overlooking of transphobic abuse, discrimination and victimization of them by other prisoners (Bashford et al., 2017). This has the repercussion that treatment decisions and access to treatment fall to the discretion of the prison and correctional staff themselves (Colopy, 2012; Garcia, 2014). Clark et al. (2017) and Poole et al. (2002) reported that even healthcare professionals working at US and UK prisons respectively, recalled how officers’ bias was an obstacle in providing adequate care to their transgender patients. Direct assault, physical and sexual, from prison and correctional staff to incarcerated transgender people was also documented in other US sources (Brömdal et al., 2019b; Brown, 2014; Stotzer, 2014).
Of the few solutions proposed to support integration and acceptance, Kendig et al. (2019) believe that an incarcerated transgender individual’s sense of wellbeing can be increased by prison and correctional staff using the correct pronouns, such as they or them. In order to achieve this, Colopy (2012) and Clark et al. (2017) stated that in order to overcome bias and provide better treatment, staff need frequent training and require certain decisions to be made by more qualified members of staff. White Hughto et al. (2017) and White Hughto and Clark (2019) piloted a transgender health training for prison and correctional healthcare providers in the US. The novel intervention used an education curriculum grounded in behavioral change theory. It sought to improve correctional healthcare providers’ transgender cultural and clinical competencies as well as a willingness to care for transgender patients, encourage subjective norms and provide gender-affirming care in a correctional environment. The curriculum included lectures, discussions, role playing and case studies, which addressed being trans in the criminal justice system, healthcare interactions and tailored medical care. Key topics included the integrating gender affirming language such as preferred pronouns; exposure to stories from incarcerated transgender individuals; hormone provision; surgical considerations and mental health support. When examined, “providers indicated that the training provided them with the required cultural competencies to provide care to transgender patients and basic competencies for gender affirming clinical interactions” (White Hughto & Clark, 2019, p. 6).
Gender affirmation, health experiences and situational health risks of incarcerated transgender people
A core element of the overall experience of incarcerated transgender people is the ability to gender affirm when inside. Although it can be classed as a treatment to GD, gender affirmation is a lived experience for an individual and was thoroughly documented across all publications. UK-focused publications documented recent progressive changes within prison reform, as some UK prisons allow incarcerated transgender people to pursue gender affirmation by accessing clothing, makeup and prosthetics (Bashford et al., 2017), which in turn has led to increased access to gender affirming hormone treatment and surgery (Green, 2010). Italy were reported to be leading the way in reform as they allowed transgender incarcerated people to live a real life experience and gender affirm while in detention (Chianura et al., 2010; Hochdorn et al., 2018). In contrast, other articles based in the US, discussed how in some cases gender affirmation was prohibited in prison settings due to lack of respective training, confusion among staff or not acted upon by individuals in a bid to protect themselves from personal safety (Clark et al., 2017; Osborne & Lawrence, 2016).
One of the dominant issues across most publications is the risk of sexual and physical violence to transgender people in the prison setting. This was apparent across all countries and contexts. While the rates of reported abuse vary across studies, the publications that discussed the situation in the US, UK, Canada, and Australia, consistently reported how incarcerated transgender people are sexually and physically victimized at a far greater rate than the general prison population (Bacak et al., 2018; Brömdal et al., 2019a, 2019b; Brown, 2010, 2014; Colopy, 2012; Culbert, 2014; Disspain et al., 2015; Edney, 2004; Erni, 2013; Glezer et al., 2013; Mann, 2006; Reisner et al., 2014; Sexton et al., 2010; Stotzer, 2014; von Dresner et al., 2013; Wall, 2014; White Hughto et al., 2018; Wilson et al., 2017). In a Californian prison Jenness et al. (2007) reported that sexual assault was 13 times more prevalent for incarcerated transgender individuals, than others, and with 59% having experienced a sexual assault while in prison. Colopy (2012) documented in their paper, that as many as 59% of incarcerated transgender individuals reported experiences of sexual assault whilst in prison, compared with 4% of the general prison population. Furthermore, the incidence rates of sexual and physical abuse of black and ethnic minorities were proven to be much higher than their white counterparts (Grant et al., 2011).
The review highlights that this high-risk environment, and the risk of harm to oneself whilst in the prison setting impacts the mental health status of incarcerated transgender people. This is well documented across included publications. Incarcerated transgender people regularly arrive to prison with existing mental health issues, which appear to be exacerbated by the hostilities encountered in prisons, their experience of incarceration, violence, poor care and/or withdrawal from hormone treatment (Bashford et al., 2017; Brown, 2009, 2010, 2014; Drakeford, 2018; Garcia, 2014; Halbach, 2016; Harawa et al., 2017; Jones & Brookes, 2013; Maruri, 2011; McCauley et al., 2018; Reisner et al., 2014; Sexton et al., 2010; Simopoulos & Khin, 2014). Relatedly, incidents of suicide and self-harm within this population in US and UK prisons are significant, with rates increasing following periods of solitary confinement (Bashford et al., 2017; Brömdal et al., 2019b; Brown, 2009, 2014; Drakeford, 2018; Reisner et al., 2014; Simopoulos & Khin, 2014).
Risk taking behaviors among incarcerated transgender people are well documented in the included publications. These include high levels of problematic substance use, with studies in the US reporting on high rates of hazardous drinking and use of multiple substances (Beckwith et al., 2017; 2018; Harawa et al., 2017; Reisner et al., 2014). Entry to prison is often pre-dated by existing low self-worth due to significant societal stigmatization (Brömdal et al., 2019b; McCauley et al., 2018; Sexton et al., 2010); self-reports of engaging in sex work as a means of securing finances (Reisner et al., 2014); and homelessness (Sexton et al., 2010). This furthers the point that incarcerated transgender people have significant vulnerabilities on entry, are extremely vulnerable to exploitation and have unmet specific health (and mental health) needs when incarcerated. Three studies referred to instances of auto-castration in US prisons (Brown, 2009, 2010, 2014).
Transgender access to gender-related healthcare in prisons
Records documented the health needs and experiences of the transgender people in prison from a range of different stakeholder perspectives, using various methodological approaches, and across multiple geographic locations including the US, UK, Canada, Australia, South Africa, Thailand, Italy, Brazil, Hong Kong and Ireland. The review is unable to provide any comprehensive scale or quantifiable scope of the health profile of the transgender population when in prison. However, we can detail the nature of the health situation of incarcerated transgender people, due to identified consensus across publications, which report on the poor health situation and standards of care for this key prison population, compared to general prison populations. It is worth noting that as the majority of studies are based in the US, those from lower socio-economic backgrounds outside of prison, will have even greater difficulty paying for general healthcare, irrespective of their gender-related needs (see Table 4) (Lydon et al., 2015). The review underscores that transgender people in prison continue to be a significantly vulnerable and disadvantaged group with complex and multiple health and social care issues, requiring unique prison healthcare and treatment needs (Jones & Brookes, 2013).
Access to gender-related assessment and healthcare for incarcerated transgender people is described as highly problematic and controversial in all publications. Three dominant healthcare problems are repeated regarding diagnosis, healthcare and gender affirming surgeries (GAS). Firstly, across prison settings the use of the DSM (American Psychological Association, 2015) is used to determine and classify a transgender persons GD status (clause V). There are many academic debates regarding the classification and diagnosis of DSM-V, outside of this setting. Whilst some transgender people may reject a diagnosis of GD arguing the label is stigmatizing in that it suggests the person is sick or abnormal in some way (Maruri, 2011), others require it in order to access appropriate medications and hormones to alleviate their symptoms (Brown, 2010). Access to a diagnosis while in prison is, however, problematic due to the intensity of resources required, existing stigmatized attitudes among prison healthcare professionals and other people in prison, as well as a general lack of medical knowledge. In turn, this may result in incarcerated transgender people not receiving an initial evaluation or diagnosis, being wrongly diagnosed, and subsequently not receiving the correct medical treatment (Simopoulos & Khin, 2014). Indeed due to the significant discrimination experienced by incarcerated transgender individuals by prison staff and prison healthcare professionals, a diagnosis of GD remains uncommon (Colopy, 2012).
Secondly, the WPATH SOC require prisons and other closed settings to provide medical hormone treatment to incarcerated transgender people (WPATH, 2012). Failing to do so, or abruptly stopping hormone treatment, is likely to have detrimental effects on the physical and psychological state of the person, such as carrying out auto-castration, depression, dysphoria or suicide (Bashford et al., 2017; Green, 2010; WPATH, 2012). To support this, principle 12 of the National Commission on Correctional Healthcare’s position statement declares, “Transgender patients who received hormone therapy with or without a prescription prior to incarceration should have that therapy continued without interruption pending evaluation by a specialist, absent urgent medical reasons to the contrary. Hormone therapy should not be discontinued precipitously as this will likely cause depression and anxiety” (NCCHC, 2015). Sources in the US draw light on the concerning situation that many prison and state policies do not support the continued use of hormone treatment for transgender prisoners (Routh et al., 2017; Stotzer, 2014). In a study of 50 US states, 30 prohibited counseling consults for incarcerated transgender people, 27 did not initiate hormone treatment, 20 discontinued hormone treatment, potentially causing irreparable damage, and only eight states allowed GAS (Routh et al., 2017). While some prisons do support the use of hormone treatment, they require the transgender person to provide evidence of an official diagnosis and evidence of legitimate hormone prescriptions prior to incarceration (Clark et al., 2017; Mann, 2006). However, prior to incarceration, many transgender people are only able to secure hormone treatments through the black market due to the high cost of prescriptions, thus are unable to demonstrate a treatment history and diagnosis on entry to prison (Brown, 2009; White Hughto et al., 2018). Furthermore, when appropriate treatment is provided in prison, continuity of care is not always sustained. Transgender people in US prisons have reported interruptions due to delayed prescribing, out of stock medications, transfers to different wings, and intermittent dosing, even for treatments such as anti-retroviral treatment for HIV infection (Culbert, 2014; Lea et al., 2018; McCauley et al., 2018). The actual HIV prevalence rate, as well as that of other communicable diseases such as sexually transmitted infections (STIs) and tuberculosis (TB), in transgender prison populations are further unknown and undocumented (Brömdal et al., 2019b; Emmer et al., 2011; Poteat et al., 2018); although Okamura (2011) reported that 60-80% of transgender incarcerated people in a Californian prison were HIV positive. Transgender people in prison may also choose not to engage with healthcare facilities due to stigma and potential risk should they disclose any health status (Harawa et al., 2018).
Thirdly, while access to hormone treatment is sporadic, GAS is rarely offered as a treatment option within prisons. Sources highlight how refusal to provide access to treatment and GAS for incarcerated transgender individuals has regularly been challenged in the US courts as a violation of the Eighth and Fourteenth Amendment (Garcia, 2014). One of the challenges when considering GAS for legal and medical professionals is the medical and developmental paradigms in which GD exists. Levine (2016) reflected that while GD is a serious medical concern as outlined in the DSM-V, healthcare professionals who believe that GAS is an inevitable treatment plan must confirm that GAS would prevent death or further complications for the patient, relieve pain and improve capacity to function. However, other healthcare professionals believe that GD is more of a developmental issue in which biological, social, psychological and cultural factors interplay and so surgery may not be appropriate. While all transgender people in prison are entitled to adequate levels of care that is medically necessary, including GAS (Halbach, 2016), meeting the eligibility criteria for GAS while incarcerated is difficult (Osborne & Lawrence, 2016). Incarcerated transgender people may find it difficult to evidence their symptoms, such as continual thoughts of altering genitalia, genital harm and mental health co-morbidities (Brown, 2009), as many transgender prisoners minimize and hide symptoms in prison due to stigma and discrimination. They may find it difficult to give full consent (gauging a person’s ability to consent, having access to all information and being aware of the possible complications is unrealistic); demonstrate they have control of any co-morbid conditions; and evidence that they have lived as their preferred gender (gender affirmation) for a minimum of 12 months (Osborne & Lawrence, 2016). Compounding these issues in prison are the political and resourcing challenges that inform and dictate clinical decisions.
Discussion
The scoping review represents a unique and first step toward mapping extant literature on the global health situation of incarcerated or detained transgender people in prisons and other closed settings. The review reflects a dearth of academic publications on the topic, perhaps reflective of the hidden nature of this vulnerable group, notwithstanding the bureaucratic barriers in conducting such sensitive prison health research, gaining access to incarcerated transgender people and obtaining data due to general lack of transparency within correctional institutions. Strengths of the review are based on its robust and comprehensive method in searching and charting extant literature, despite the huge gaps in research globally. While the issues raised across sources are detailed and varied, there are several limitations within included studies. These include the sample size and geographical range of the articles and a lack of global research on the situation of transgender incarcerated people, with the literature heavily weighted on Western countries. For example, studies were dominated by discussion and analysis of prison policy, practice and experiences of transgender prisoners within a limited number of States within the US (see Tables 2–4). Only a few studies solely examined the transgender prison experience, which themselves were small and localized to specific issues or geographical location such as one jail in the US state of Florida (McCauley et al., 2018), or prisons in New South Wales, Australia (Yap et al., 2011). We further recognize the limitation in language, with only English records included. The review highlights the lack of consensus and application of diverse definitions of transgender, the seeking of gender affirmation, the hostile prison environment and risk to health, as well as barriers to access of appropriate medical care, across the included prison publications.
The review highlights concerning breaches of human rights when incarcerated. Gender affirmation is restricted, with slight progressive changes observed only in Italy and the UK. For example, the 2006 and updated 2017 Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, state that one’s gender identity is integral to their “dignity and humanity and must not be the basis of discrimination or abuse” (Yogyakarta Principle 32, The Right to Bodily and Mental Integrity). Standards of care appropriate to the special vulnerabilities of transgender people appear to be breached in many of the publications included in this review. Failure by prison health authorities to provide a diagnosis for the transgender individual should be considered as a breach of the Yogyakarta Principle 9 which mandates the right to treatment with humanity while in detention (International Commission of Jurists, 2007; Yogyakarta Principles, 2006). Other Yogyakarta Principle potentially breached include 2 (The Rights to Equality and Non-Discrimination), 3 (The Right to Recognition before the Law), 17 (The Right to the Highest Attainable Standard of Health), 31 (The Right to Legal Recognition) and 33 (The Right to Freedom from Criminalization and Sanction on the Basis of Sexual Orientation, Gender Identity, Gender Expression or Sex Characteristics). Further, the Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules) mandate prison administrations to “take account of the individual needs of prisoners, in particular the most vulnerable categories in prison settings” (Rule 2(2)) (United Nations General Assembly, 2016). As transgender individuals may enter detention facilities during their gender transition, there should be culturally sensitive psychological and social support or services in place to guide them through the process, thus also preventing or reducing significant negative impact on their mental health. The WPATH SOC (2012) are deemed to apply to all transsexual, transgender, and gender-nonconforming people, irrespective of their housing situation. Yet, the results have shown that in some countries incarcerated transgender people continue to experience discrimination, stigma, a lack of consideration of their health needs, and are ostracized by other prisoners, prison officers, managers and decision makers. Furthermore, the victimization of those from deprived backgrounds as well as Black and ethnic minority groups is even more exacerbated than white transgender people within correctional facilities, as they experience higher rates of physical and sexual abuse as well as spells of solitary confinement during their sentence.
Guiding principles impacting on the rights of transgender people in prison include the right to health, where like all persons, prisoners are entitled to enjoy the highest attainable standard of health and human treatment with equal right to services and medicines (Committee on Economic Social & Cultural Rights, 2000; United Nations General Assembly, 2011; United Nations Human Rights Committee, 2003; Universal Declaration of Human Rights, 1948). The protection of human rights, and the rights to health and equivalence of care are mandated by several international instruments which include the United Nations Standard Minimum Rules for the Treatment of Prisoners, Basic Principles for the Treatment of Prisoners, and the Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment (United Nations General Assembly, 1955, 1990, 2011). Healthcare for transsexual, transgender, and gender-nonconforming people living in prisons and other closed settings should be equivalent to that which is available to them in the community. For those on hormone therapy on entry to prison, continued access to therapy is required, and similarly if GAS is available in the community, it should also be available to transgender incarcerated individuals (WHO, 2014; WPATH, 2012). This refers to access to medical treatments, expertise of prison health staff, access to outside consultation from knowledgeable professionals, treatment of co-exisiting morbidity, the continuation of hormone therapy and appropriate housing and showering facilities for transsexual, transgender, and gender-nonconforming people. Prison healthcare policy and provision in the US for example, is impacted by the country’s refusal to acknowledge transgender prisoners’ gender identity and subsequently refuse hormone treatment and GAS (Emmer et al., 2011; Pemberton, 2013). Some US courts however have ruled that it is necessary medical treatment to provide hormone therapy for transgender prisoners, for example California Medical Facility, Vacaville and Kosilek v. Maloney (2002). There have also been additional rulings to allow prisoners GAS such as in the case of Quine v. Beard (2016) and Edmo v. Corizon (2019). Structural barriers to providing sufficient healthcare to incarcerated transgender people appears grounded in lack of prison based resources and support and the lack of both clinical and cultural competence of prison health providers (Clark et al., 2017; White Hughto et al., 2017; 2018; White Hughto & Clark, 2019).
Of grave concern is that the denial of necessary healthcare for incarcerated transgender people is associated with depression, non-suicidal self-injury, auto-castration, and death by suicide (Brown, 2010, 2014; Brown & McDuffie, 2009; Coleman et al., 2012; Routh et al., 2017). Despite the relatively low yield of included publications, this review further underscores how the transgender incarceration experience may result in particularly negative health outcomes and higher morbidity and mortality rates. Incarcerated transgender people are highly stigmatized within the closed setting, according to the UN Special Rapporteur on Torture, they are particularly at risk of human rights violations including verbal harassment, physical and sexual violence and exposure to HIV, and lack of access to psychological and HIV-related services, hormones or gender affirming health services (UNDP, 2013). Such hostile unsafe environments, stigma-based discrimination and violence compounds mental health conditions such as depression, anxiety, and suicidality (White Hughto et al., 2015). These unique vulnerabilities directly relate to the breach of mandates stipulated in the Yogyakarta Principles 5 (The Right to the Security of the Person); 9 (The Right to Treatment with Humanity while in Detention); 10 (The Right to Freedom from Torture and Cruel, Inhuman or Degrading Treatment or Punishment); 18 (Protection from Medical Abuses); and 27 (The Right to Promote Human Rights). Recognizing transgender identities and respecting individuals’ decisions improves their vulnerable health situation. Whilst strides are being made in changing the use of language and better understanding of gender-affirming action in countries such as the UK, US and Australia, sexual and physical violence of transgender incarcerated people warrants significantly greater attention. These types of violence were only briefly mentioned in many of the articles but in depth research outlining the phenomenon, depicting the complete picture on a global scene, especially highlighting differences between the general prison population and that of transgender incarcerated individuals, is an essential area for future research. Due to the challenges that researchers face in accessing both prisons and transgender prisoners, researchers should look to engage collaboratively with transgender activist communities to access these hard to reach groups, so that they can co-produce, design and deliver projects or interventions tailored to the specific needs of transgender prisoners. This approach will ensure that the complete research team is diverse in itself, which would provide recognition of the complex intersections of transgender incarcerated individuals.
The complexities around suitable housing and the prevention of harm and isolation are highlighted in this review. Transgender prisoners are generally placed in male or female facilities according to their genitalia (Sevelius & Jenness, 2017) or housed in solitary confinement in a single-sex housing unit, ward, or pod due to staff concerns for prisoners’ protection. For example in the US, the general policy is to house according to birth assigned sex or genital configuration, whereby, post-operative transgender men are placed in women’s prisons. The US revoked its position in 2018, and reverted to using a gender and sex binary model for housing transgender people (Caspani, 2018). However, some progress is still being made to promote transgender rights in prisons in the US, for example in the Keohane v. Jones (2018) case, which was concluded four months after the policy changes, the defendant was permitted to gender affirm by wearing female clothing and accessing female items. Other countries such as the UK, Australia and Canada have more promising housing allocation for transgender people in prison. There is movement globally to improve housing conditions for transgender prisoners so that they are placed according to their gender identity rather than their genitalia. It is worth noting that some transgender incarcerated people believe they should be given the choice of where they should be housed, for example women’s prisons have been perceived as vicious and harmful (Bashford et al., 2017; Mann, 2006; Sevelius & Jenness, 2017; Sumner & Jenness, 2014).
In March 2013, the Shadow report on the International Covenant on Civil and Political Rights, Hong Kong activists called on the Human Rights Committee “to ask the government to account for its failure to set up regulations for treating transgender prisoners with humanity and respect” (UNDP, 2013, p. 10). In September 2018, a national workshop in Thailand facilitated by the Department of Rights and Liberty of the Ministry of Justice and United Nations Development Program (UNDP), called for new standards to manage incarcerated transgender people and combat sexual harassment in prisons. Some countries such as the UK have adapted and developed their technical guidance for prisons and other closed settings to incorporate a holistic approach that gives transgender prisoners the same access to safety, health, dignity and rehabilitation as other prisoners, wherever they are housed (Brömdal et al., 2019a; Ministry of Justice, 2011, 2017; Public Health England, 2018). Others have developed dedicated prison units for transgender prisoners, for example in the US, Canada and Australia (Bashford et al., 2017; Mann, 2006; Sumner & Jenness, 2014). Brömdal et al. (2019a) provided comprehensive recommendations in relation to the appropriate housing of individuals to include, implementing a case-by-case housing policy, considering gender identity and preference; reassessment of housing circumstances twice per year (including protective custody and segregation); and potentially establishing same cell or units for transgender incarcerated people. These changes, alongside others already recommended, would significantly impact incarcerated transgender people by reducing vulnerability; create transparent policies across all levels of the prison setting; support the wellbeing of incarcerated transgender people; and encourage rehabilitation. However, in order for this to occur, significantly more research is required in the field, particularly in Europe, Africa, South America and across Asia. Research must be internationally credited at the same time as tailored to country-specific environments.
Conclusion
The review has shown that physical and sexual violence; compromised mental health; lack of access or denial to specific healthcare; susceptibility to substance use; and likelihood of auto-castration or suicide, are exacerbated in prison settings for transgender people. Whilst some countries have instigated positive prison reforms, there is a need for countries to uphold international human rights mandates, such as the WPATH SOC, taking measures to protect incarcerated transgender people from violence and stigmatization without restricting rights, and to provide adequate gender sensitive and gender affirming healthcare, including hormone therapy and GAS. Increased advocacy, awareness raising, de-sensitisation of all prison staff, greater intensity of clinical and cultural competence training, updated prison policies and general support of prisons in providing gender affirming medical care, safe detention conditions and informed detention placement for transgender people is warranted.
Conflict of interest
The authors declare that they have no conflict of interest.
Disclosure statement
No financial interest or benefit has arisen from the direct applications of the research. This article does not contain any studies with human participants or animals performed by any of the authors.
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