Trans inmates need access to gender-affirming care. Often they have to sue to get it

This story is part of a series looking at transgender inmates in the U.S. and the challenges they face in confinement and upon release. The series focuses on topics such as being incarcerated in prisons that do not reflect the inmate's gender identity, the medical hurdles faced behind bars, and rehousing after being released. The series includes dozens of interviews with inmates, experts and public officials.

Note: This story contains graphic details of incidents of self-harm.

Ashley Diamond thought her battle against the state of Georgia was over — until she was arrested again.

She had fought Georgia's prison system in a lawsuit over her treatment in prison and lack of access to medical care, which resulted in a major legal settlement in 2016. That case highlighted the conditions she faced as an incarcerated transgender woman who was denied hormone treatments she had been taking for 17 years for her gender dysphoria.

But when she was arrested again in Georgia in 2019, she faced the same problems.

"Imagine being a trans woman and a Black trans woman on top of that, and you're trying to assert these rights that you were promised and guaranteed in your first case," she said. When she brought up complaints with prison officials, she said it was like talking to a wall.

Diamond's difficulty accessing medical care in prison is not unusual.

Health experts and attorneys for civil rights groups, as well as incarcerated and formerly incarcerated individuals, told NPR that getting reliable gender-affirming care in prison seems to often come only after threats of lawsuits or an all-out legal fight. Prisons that do provide gender-affirming care can often still be inconsistent, regardless of policies on the books.

"Prisons oftentimes refuse to treat transgender people consistent with their gender. And they also refuse to provide medically necessary health care," Taylor Brown, a staff attorney at the American Civil Liberties Union, told NPR. Gender-affirming care can include "puberty suppression, hormone therapy, and gender-affirming surgeries among others," according to the World Professional Association for Transgender Health.

Access to this care is considered medically necessary to treat gender dysphoria. Without it, individuals can struggle severely with mental health issues such as heightened anxiety and depression, with some turning to self-harm and suicide.

Civil rights groups, such as Lambda Legal and the ACLU, have been involved in lawsuits in recent years on behalf of transgender inmates struggling to access gender-affirming medical care.

A woman known by the pseudonym Sonia Doe, who was imprisoned in New Jersey, and Reiyn Keohane, who is still incarcerated in a men's prison in Florida, have successfully sued. Those lawsuits were filed in 2019 and 2016, respectively, against their state departments of corrections over access to gender-affirming care.

Adree Edmo, a transgender woman in Idaho, won the ability to get gender-confirmation surgery after a yearslong battle against the state. In 2020, she underwent her surgery, according to the National Center for Lesbian Rights. It's a rare occurrence for trans inmates, despite this surgery being a proven medical treatment for gender dysphoria.

Diamond's first case against Georgia is settled

Diamond filed her first lawsuit in 2015, three years into a sentence related to charges of burglary and theft. At the time, she said she was denied hormone treatments that she had been consistently taking for almost two decades to alleviate her gender dysphoria.

Diamond was paroled later that year and reached her major legal settlement with the Georgia Department of Corrections in 2016, with the help of the Southern Poverty Law Center.

In addition to an undisclosed monetary payout from the state, she also received assurances that Georgia prisons would make changes to policies on trans inmates. That included staff training on the treatment of trans inmates, adopting a new sexual assault prevention policy and improved access to hormone treatments, according to the Southern Poverty Law Center.

But in 2019, Diamond violated the terms of her parole by traveling out of state. She said she traveled to Florida to receive treatment for PTSD and other issues at a trans-friendly center. Then, she was rearrested.

She reentered the custody of the Georgia Department of Corrections in October of that year, department records show. Despite her landmark legal case against Georgia prison officials, she faced the same problems that she had thought were resolved when she arrived at Savannah's Coastal State Prison after her parole violation.

"They made it very difficult," she told NPR.

She got back in touch with her attorneys at the Southern Poverty Law Center. In November 2020, the organization and its partners at the Center for Constitutional Rights announced that they had filed another lawsuit against Georgia prison officials, saying Diamond's gender-affirming health care needs were routinely ignored.

The U.S. Justice Department even weighed in on this case.

In a statement of interest, the Justice Department said: "Prison officials also have an Eighth Amendment obligation to provide all prisoners with adequate medical care for serious medical conditions. ... This duty includes the treatment of gender dysphoria."

Not getting care can be 'catastrophic'

Diamond's lawsuit states that she was not given hormone treatment medication for weeks at a time. Additionally, the officials' "refusal to provide Ms. Diamond anything beyond sub-therapeutic hormone therapy is so wholly inadequate that it is tantamount to no treatment at all," according to the lawsuit.

She was also informed at intake that she would not be getting women's clothing.

"I was told that from the very beginning — 'That's never gonna happen,'" she said.

These are critical components of medical care for people who experience gender dysphoria, Randi Ettner, a psychologist who specializes in treating transgender individuals, told NPR. Ettner works with the World Professional Association for Transgender Health to help establish the organization's standards of care, which are used by institutions around the globe.

(Ettner was also retained by Diamond's attorneys for her 2020 lawsuit. Ettner provided an analysis of Diamond's treatment for gender dysphoria while in the care of the Georgia Department of Corrections.)

As a result of the GDC's health care denials and the frustration she felt at not being heard, Diamond said that she experienced severe physical and mental anguish. She said it was "catastrophic" to go without hormone treatment on a regular basis.

Getting medication sporadically "plays on your mind and your mental health," she explained. "You're also dealing with the ramification of withdrawals: You're sick and you're vomiting, and you're not seeing the changes that you should be seeing."

She told NPR that the depth of loneliness and self-loathing "is just a reality when you get fed up and when you're hurting, and when you're sick and when no one is listening."

Diamond repeatedly tried to castrate herself while incarcerated. Her attorneys said in a court document that this was "a desperate form of self-treatment that has led to severe medical complications such as difficulty urinating."

Diamond said these attempts occurred during an incredibly low time for her, after a year back in custody. She explained to NPR where her mind was during one of those attempts: She said she thought at the time that this piece of her body "is why people hate me. Then why don't I just cut this off? Then what?"

Extreme measures like this are not uncommon when trans women don't receive sufficient gender-affirming health care, according to Ettner.

"I have seen far too many individuals engage in auto-castration, auto-penectomy, as attempts to 'surgically self-treat,'" Ettner said. She described it as a "desperate and often deadly attempt to remove the testosterone that kindles the dysphoria."

In response to NPR's request for comment on Diamond's 2020 lawsuit, a representative for the GDC declined to speak specifically about her allegations.

"The lawsuit between Ms. Diamond and the GDC remains pending, and so we cannot offer specific comments on the statements she made to you. However, the GDC believes that the Court was satisfied that the evidence produced so far demonstrated that her medical and mental health needs were met during her incarceration," said Jennifer Ammons, the general counsel for the Georgia Department of Corrections, in a statement.

Prison policies on the books can be lacking

A major survey highlights the problems that trans inmates like Diamond have in accessing medical care.

In the 2015 U.S. Transgender Survey, 58% of respondents who were incarcerated in the prior year had been taking hormones before being imprisoned. Of those, 82% had a prescription for hormones. More than one-third (37%) of respondents who had been taking hormones before their incarceration said they were banned from continuing to take their hormones once in custody.

The reported experience of transgender inmates shows that hormones are less available than state corrections departments suggest in their policies. Most state corrections departments explicitly say access to hormone therapy will be provided to transgender inmates, if proved medically necessary. But some legal cases indicate that facilities act differently in practice, like in Diamond's situation.

Prison policies on trans health care are inadequate, according to Ettner.

"Some states still have 'freeze frame' policies — requiring proof of care prior to entering prison and maintaining that dose throughout an individual's incarceration, even if it was a low, introductory dose," she said.

Most states require inmates requesting hormone therapy to show health records to continue hormone access behind bars, or they require approval from a doctor, a committee specially designated to handle issues affecting trans inmates and sometimes a warden.

Showing prior medical records sometimes "proves an insurmountable blockade" because there are trans prisoners entering correctional institutions who don't have a prior prescription for hormones from a physician, Ettner said. Individuals who earned their living from sex work, drug sales or other underground work were more likely to turn to unlicensed sources for hormones, according to the U.S. Transgender Survey.

The legal fight continues

The ACLU won a major victory this year against the Federal Bureau of Prisons (BOP).

The BOP settled a case, initially filed in 2020, by a federal inmate named Cristina Nichole Iglesias. She won the ability to be evaluated for gender-affirming surgery. When she was approved by the BOP, she became one of the first incarcerated individuals in federal custody to be granted this medical procedure.

Brown, the ACLU staff attorney, was part of this federal case. It mirrors the same trends happening at the state level, she said.

When individual cases are brought to court, judges often side with the prisoner's right to access gender-affirming care, Brown said.

"We have seen a number of courts come down against prisons across the country and ordered them to stop violating transgender prisoners' constitutional rights and provide them with the health care that they need," Brown said. "So while we're winning these victories in court for individual plaintiffs, that doesn't change the reality for many transgender people who are incarcerated."

Many trans inmates are facing a continuing legal battle to access gender-confirmation surgery. Some states don't have an explicit policy regarding granting inmates access to this surgery, according to medical care policies collected by the Transgender Law Center and reviewed by NPR.

In cases specifically related to gender-confirmation surgery, courts have varied widely on whether a prison's refusal to provide this type of care violates an inmate's constitutional rights. For example, a study reviewing decisions by U.S. Circuit Courts of Appeals in cases filed by incarcerated trans women found that courts differed about whether there is a medical necessity for gender-confirmation surgery.

Diamond was released this summer but said she is still working to bring her story to light.

She's writing a memoir and music to help make that happen.

"Every day I worry about the people that have been left behind. I worry about the trans women still there," she said. "Some cases will never get the attention that this case got, and so I've got to use it to empower the community and to educate people."

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