Michelle’s Case She was supposed to be the first person to receive sex-reassignment surgery inside an American prison. The prison had other plans.

Michelle-Lael Norsworthy lay on her back on the top metal bunk, her arm hanging off the side, holding a long rod of tightly rolled newspapers. She aimed it at the TV she’d bought at commissary and poked the up button: NBC . Down: Fox. Behind a sheet, her roommate filled the sink, lifted water to his armpits, lathered, and rinsed. Michelle lingered on the Channel 2 Evening News, volume on low, and her eyes drifted to the wall beside the TV. There, next to a blessing in Hebrew, she’d taped the paperwork from her pending lawsuit, including the complaint she wrote in the law library: Michelle-Lael B. Norsworthy v. Jeffrey Beard, Secretary of the California Department of Corrections and Rehabilitation, et al. Suddenly, Michelle heard her name on the TV. “Did you hear that?” she asked her roommate. “I did!” “Did she say what I think she said?” “I don’t know, try another channel?” ABC News didn’t mention her. Neither did NBC . Then, two hours later, on the 10:00 p.m. news, she heard it again. “A federal judge has ordered the state corrections department to provide a sex-change surgery for a transsexual inmate,” the newscaster said. “The inmate is 51-year-old Michelle-Lael Norsworthy.” Michelle dropped the newspaper rod, and it rolled under the bed. Oh my gosh, she thought. I won. The judge’s ruling, announced that night in April of 2015, came as transgender rights were entering the national conversation. Caitlyn Jenner’s transition was just about to break, and the White House was on the verge of announcing its new gender-neutral bathroom. But Michelle’s case broke ground in more ways than one. No trans person has ever received sex-reassignment surgery inside of an American prison; Michelle would be the first. Even more, the judge’s ruling introduced a new precedent: that sex reassignment is medically necessary and to deny a prisoner access to it is cruel and unusual, a violation of her constitutional rights. Incarcerated transgender people, in California and nationally, could point to her case in future lawsuits. Michelle knew all of this. She thought about the operating table. She thought about the other girls on the yard. But that night, flipping through news channels, she didn’t account for the parole notice sitting on the shelf, the one her correctional counselor handed her nine months earlier. The board had moved up her next hearing by nearly two years, the counselor told her, because of “a change in circumstances or new information.” She’d been denied parole just a year before. The day she got the new parole notice, she handed it to a lifer friend on the yard and asked: “What do you think this means?” He took a long look at the paper and said, “It means they’re trying to get out of giving you a vagina.”

By the time she saw herself on the news, Michelle had been in prison for 28 years. In 1987, Michelle — who then went by her given name, Jeffrey — was sentenced to 17 to life after shooting and killing an acquaintance during a drunken fight outside a bar in Orange County. Her first ten years inside were a blur of write-ups and disciplinary notices: She made booze out of oranges and sugar packets, got into fights on the cellblock, refused to go to work as a porter. Twice, prison staff found her with a Bic razor blade to her arm. Twice, they wrote her up for “Violence: Self-Mutilation.” Then, in 1994, Michelle took a job in the chapel. She is Jewish, but she liked the quiet, and, besides, the Torah is in the Old Testament. Instead of mopping bathrooms, she spent her days at a wooden desk with a yellowing word processor, typing out the hymn lyrics for Sunday Mass-goers. Her supervisor was the priest, Father John Moore. Together they drank black coffee and smoked cigarettes, and before long, she felt like she could tell him anything: about the panic she felt when she woke up at night, sweating and breathless. About having sex with men, but not really feeling gay. How she used to sneak into her mom’s closet as a kid and dress up in her bra and white pantsuit. She loved how powerful and peaceful the shoulder pads and flared legs made her feel. One Thursday morning, Father John looked up from his desk. “Jeff, have you ever heard of the term transsexual?” he asked. “It’s some kind of fag, right?” “No, not quite. I want you to go home tonight and look up that word.” Walking out of the office that day, Michelle slipped the Webster’s dictionary off the shelf and tucked it under her arm. That evening, cross-legged on the top bunk, she read and reread the one-sentence definition: “A person with a psychological urge to belong to the opposite sex that may be carried to the point of undergoing surgery to modify the sex organs.” She began to cry. A few months later, when Michelle was transferred to a lower-security yard for good behavior, she introduced herself as a queen. No more Jeffrey, she thought. You can call me Michelle-Lael.

Four years after Michelle started living as a woman, her correctional counselor recommended she be moved to the only prison with a medical clinic specifically dedicated to transgender women. The Gender Clinic at California Medical Facility, a men’s prison in Vacaville, had been established in 1998. (California prisons today treat nearly 400 transgender patients with hormone-replacement therapy.) Michelle saw a therapist, who diagnosed her with gender identity disorder (now called gender dysphoria), and she began seeing a nurse every Friday. She’d pull down her pants and clench her teeth as a syringe delivered hormones into her bloodstream: one set to block the male hormones and another to supply the female ones. Within several weeks, her leg hair stopped growing back after she shaved. The little facial hair she had disappeared, except for a few patches on her chin and upper lip. Small, sensitive lumps grew behind her nipples — what the other queens called knots. Within a few months, the knots relaxed into breast tissue. Her muscles and affect mellowed; for the first time, she started feeling like it was OK not to be tough. She learned to rub a red colored pencil on a towel and swab her cheeks for blush. She got glasses with purple rectangular frames and let her hair grow to her shoulders, her bangs cut straight across. At the law library, Michelle read everything she could about trans rights in prison. She learned that the guards aren’t allowed to strip-search trans women in front of men, and she learned to write formal grievances. She requested a bra, got denied, wrote an appeal, and won. In the day room, she sat with the other girls — Heather or Cupcake — and taught them to write grievances of their own: Speak factually, she told them. Take the emotion out of it. But about two years after she began transitioning, Michelle stopped noticing new changes. She realized the hormones weren’t going to fix her, make her penis fall off or something. She cried in therapy, feeling like half a person, stuck in between. Then, in 2009, nine male inmates gang-raped Michelle in her cell. They knocked her glasses off, held her face into a pillow, and took turns for six hours while she prayed for them to finish. Transgender women held in male prisons are 13 times more likely to be sexually assaulted than their cisgender (as in, nontrans) counterparts. Many end up in “administrative segregation,” a type of solitary confinement intended to protect them. The only trans woman ever moved from a male to a female facility in California had self-castrated. After the rape, Michelle’s panic attacks got worse. A dentist had to fit her for dentures to replace the front row of teeth her attackers had kicked in. A few weeks after the assault, she tested positive for Hepatitis C, a sexually transmitted disease that makes the liver susceptible to irreparable damage. In 2012, Michelle’s psychologist wrote that “clinical medical necessity suggest and mandate a sex change medical operation before normal mental health can be achieved.” But Michelle did not receive the surgery. After her psychologist made his opinion known, the prison removed Michelle from his care. Over the next year and a half, Michelle filed complaints and appeals to increasingly higher levels of the prison system. Each level denied her request. Finally, on Valentine’s Day of 2014, Michelle filed a lawsuit claiming that the prison’s refusal to give her gender reassignment constituted cruel and unusual punishment. With that, whether Michelle deserved surgery became a question of her constitutional rights. The Eighth Amendment entitles every prisoner to necessary medical treatment, but whether sex-reassignment surgery fits the definition of “medically necessary” for inmates has been the subject of a decades-long debate. For many years, insurance companies and government health care categorized sex-reassignment surgeries as “experimental” and “elective.” The surgeries can cost from $7,000 to $50,000 or more and can range from the removal of the penis, testes, breasts, uterus, or ovaries to the construction of a vagina, phallus, or breasts. By the time Michelle filed her suit in 2014, the American Medical Association, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association had all agreed that the surgery can be medically necessary. About a third of trans people in the United States have had some kind of gender-confirming surgery (the term preferred by many in the trans community), which has been shown to alleviate distress when hormone therapy isn’t enough.

Three doctors testified that Michelle’s anxiety and panic attacks would not subside with anything less than a surgical change to her genitalia. One doctor added that, without surgery, Michelle’s vulnerable liver would be further damaged by her high dose of hormones. Surgery would significantly reduce her required dosage. The state countered that the medical services available had adequately treated Michelle’s dysphoria. One doctor, who also testified in a similar case in Massachusetts, claimed surgery is “always an elective procedure. There’s no immediacy to it.” The state said that after completing the genital surgery, Michelle couldn’t stay in a male prison, but it argued her criminal history meant she couldn’t safely live with women, either. The federal judge disagreed with the state. Judge Jon Tigar ordered the prison to give Michelle the surgery immediately. But only weeks later, she would have her parole hearing.

Michelle’s fellow lifers were as surprised by the sudden hearing as she was. It became a joke on the yard: Wanna get out of prison? Ask for a vagina. The hearing took place in May, a month after Michelle heard her name on the news. She woke at 3 a.m., brushed her teeth in the metal sink, and shaved the few remaining spots of stubble from her chin. She pulled her long brown hair into a tight ponytail and drew out her eyebrows with a black grease pencil. Michelle had already been denied parole five times. Each verdict cited a combination of reasons — lack of self-help, no parole plans, too many disciplinary records. Each spoke extensively of Michelle’s crime: When she was 17, Michelle started working as a confidential informant for the Buena Park Police Department. She’d always wanted to be a cop. In 1985, after a stint in the military, Michelle ran into a guy she had helped bust on a drug deal at a bar in Orange County. This was the first time they’d seen each other in years. They started to argue at the bar, both intoxicated. The man followed Michelle out to the parking lot, and Michelle went to her car and got a loaded rifle. They struggled over the gun, and she fired three times, nicking his femoral and carotid arteries. According to prison records, Michelle began dressing his wounds and called for help. He died six weeks later. On her bunk, Michelle scanned through the details of her crime in the parole transcripts. She knew how she would respond to questions about it: “I own that responsibility for the remainder of my existence on this planet.” She picked other questions the commissioner usually asked during the hearing and practiced her answers facing the mirror over the metal sink, trying a different inflection with each repetition, hoping to appear softer. Midsentence, Michelle heard a knuckle on the steel door. “We got the call,” a voice said. Michelle crossed the yard, where hundreds of her fellow inmates walked laps around the perimeter, did layups, push-ups, or dealt a hand of rummy. A lifer sitting at a concrete picnic table looked up from his hand of cards. Good luck, he nodded in her direction. Michelle had steeled herself for a four-hour interrogation, but after only 90 minutes of questioning and a short deliberation, the commissioner looked up from her papers and said, “All right. This panel finds you suitable for parole today.” Michelle stayed still, her hands frozen in her lap. Her first thought was: They’re kicking me out of my home.

“Transgender convicted murderer, 51, seeking sex-­reassignment surgery whilst in jail will now be RELEASED from prison,” a headline from the Daily Mail read the day her parole was finalized. The same day, the California Department of Corrections and Rehabilitation ( CDCR ) filed paperwork to drop Judge Tigar’s order, arguing that because Michelle was going home, the order was irrelevant, which would also mean the potential precedent it set was moot. Michelle’s attorneys — a co-counsel between the Transgender Law Center and Morgan, Lewis, and Bockius — believed the prison released Michelle before her surgery on purpose. “It didn’t seem plausible that this was just a coincidence,” said one of her attorneys, Ilona Turner. Attorney General Kamala Harris contended: “None of the defendants were involved in any aspect of the parole proceedings.” But the Ninth Circuit, which had been set to hear Michelle’s case, disagreed: “We are not so convinced,” the majority wrote, saying that the coincidences in timing imply “there was at least some chance that the defendants influenced the parole process.” Similar cases in Virginia and Georgia may have added to this suspicion. In 2011, Ophelia De’lonta, a transgender woman in a Virginia prison, filed a lawsuit demanding access to sex-reassignment surgery. Though De’lonta had been living as a woman for most of her life, the prison had initially denied her hormone treatments. She had attempted to self-castrate on multiple occasions. Before a decision could be made in her case, however, the Virginia Department of Corrections released her. She had completed 30 years of a 73-year sentence for rob­bery. Anoth­er trans woman, Ashley Diamond, who was in a Georgia prison, filed a lawsuit in February 2015 de­manding ­hormone-replacement therapy. Her case drew the attention of Elton John, the actress Laverne Cox, and even the Obama administration, which issued a warning to the state of Georgia. Two months later, after a surprise parole hearing, Diamond was released — three and a half years into her 12-year sentence for burglary. “I think they let me go to escape liability, to rid themselves of my health care,” Diamond told The New York Times.

On the morning of August 12, 2015, Michelle stepped out of the Reception and Release Center onto a gravel path. She held a clear tub of her belongings with both hands: underwear, court documents, medical records, and $200 of “gate money.” Missing were her hormones. Every California parolee is promised a 30-day supply of medications, but Michelle’s release happened too quickly, she says. A silver SUV idled at the end of the gravel path. Inside sat three of Michelle’s attorneys. (Michelle’s family, whom she hadn’t heard from in two decades, had moved to Tennessee.) Her attorneys had brought her the pantsuit she’d asked for — slacks and a matching blazer — and drove her to a strip-mall diner for her first breakfast. She ate a plate of scrambled eggs and ham. She threw up in the restaurant bathroom. Even though Michelle was out, her legal team was still at work, gathering evidence to prove the prison had released her to avoid the surgery. In the meantime, her lawyers had represented another trans woman, Shiloh Quine, who sued for reassignment surgery just four months after Michelle. The same week that the CDCR paroled Michelle, it came to a settlement with Quine. In the agreement, however, Quine would be the only inmate to receive surgery; there would be no precedent set. Michelle’s case was different: If her lawyers could prove that the prison had deliberately paroled her to avoid the surgery, the precedent would stand. After breakfast, the attorneys took Michelle to a transitional house, where she would stay for at least the next six months — the first place Michelle would live with women as a woman. The director showed her to a small room on the third floor, with a twin bed pushed against the wall. Michelle hesitated at the door and stepped slowly onto the linoleum floor. On the bed, on top of a bag of sheets, were bottles of shampoo and conditioner, a bar of soap, and deodorant. She picked up the Lady Speed Stick and rolled it over in her hand. This is awesome, she thought. She’d never had women’s deodorant before. Things that are awesome about coming home after nearly 30 years: tuna melts, Google, the best coffee you have ever tasted at Starbucks. An old lady selling neon popsicles out of a refrigerated cart in the park. Opening a bank account. Not awesome: having $43 in that account. Filling out Medi-Cal paperwork after your coverage was canceled. Having to complete HIPAA forms without a computer or any idea what HIPAA is. Attaching your prison résumé to job applications. Knowing your housing could run out in months. At 52, Michelle is older than most of her 60-some housemates. The dining hall is on the first floor, and the girls yell and reach over Michelle’s plate as she eats. She has to get permission to leave the house. She goes to Fisherman’s Wharf to watch the seals, or to see the doctor. A form Michelle filled out at the doctor’s recently: “Over the last two weeks how often were you: Feeling bad about yourself or that you are a failure? Nearly every day. Not being able to stop worrying? Every day. Feeling afraid as if something awful is going to happen? Every day. Describe your social contact, social support, friends, family, colleagues: None to note.” In one appointment, a specialist told her the hormones have left her with severe fibrosis of the liver. In another, a nurse showed her to a room with an exam table with stirrups, the kind used for gynecological exams. Just take off your clothes and put on this gown, the nurse told her. Michelle explained that there had been a mistake. She doesn’t have a vagina, at least not yet. Michelle lives in a state whose Medicaid theoretically covers gender-reassignment surgery, and she has already accomplished Medi-Cal’s checklist of requirements: live for a year as a transgender person (she has 22 years under her belt), see a therapist for at least 12 months (22 years as well), and have recommendations from two independent psychologists (she has five). But the process of signing up for coverage, finding a surgeon willing to accept Medi-Cal’s low reimbursement rate, submitting her materials for approval, and waiting to hear has taken months. Finally, eight months after Michelle’s release, a surgeon — the same one who approved her surgery while incarcerated — called to talk her through the procedure. The surgeon starts by removing the scrotum, a sensitive swath of skin that becomes the lips of the labia and the back wall of the new vaginal canal. But there’s a problem: the hair. Before surgery, electrolysis will remove most of Michelle’s pubic hair, but a good surgeon will scrape every follicle off the scrotal skin that becomes the vagina. It’s a thing Michelle worries about. Like, what if he misses two? The surgeon then unwraps the skin of the penis, preserving the tip, careful not to sever too many blood vessels, those precious nerves. The head will become the clitoris, the body inverted into the walls of the vagina. In the best-case scenario, the surgeon told her, Michelle will be able to have clitoral orgasms. Once insurance is squared away, she’ll be able to make the appointment. Shouldn’t take more than two weeks.

Michelle pulls open the glass door of a Krispy Kreme in a suburb of San Francisco. She has been wanting to go to this shop for more than a decade, ever since she saw the doughnuts on an episode of Will & Grace in jail. She’d never heard of them, but the short-timers knew all about them, warm and glazed. “Wow,” she says, watching the conveyor belt carry rows of golden-brown doughnuts through the fryer. “Are all the Krispy Kremes like this?” She orders two cheesecake doughnuts, two double dark chocolate, two blueberry. “Don’t worry,” she tells the pubescent cashier, “these are for dinner, too.” She tears off a piece of a cheesecake one and puts it in her mouth. “Oh my gosh,” she says, eyes rolled back. “You know how Jewish people, we pick our house based on where the temple is? I’m gonna pick my house based on where the Krispy Kreme is.” With crumbs in her lap, Michelle takes out her cellphone to call the doctor’s office. Four weeks after the initial call, she hasn’t heard anything. Voicemail. She leaves a message. Calls back. Then a third time. The fourth time, a receptionist answers. Michelle vibrates her head in excitement. “Hi, yes, my name is Michelle Norsworthy. About four weeks ago I had a telephone consultation with Dr. Crane. He said within a few weeks I would be contacted?” The receptionist doesn’t have her insurance card on file. “Wait, you don’t already have it? OK, um,” Michelle looks right to left, as if someone could give her an answer. “You have to excuse me. I just spent 30 years in prison. Should I bring it in?” The clinic is an hour and a half away by bus. The receptionist coaches Michelle through taking a photo of the card and emailing it to the medical office. She’ll get back to her in a few weeks. Michelle hangs up the phone. “How does that make me feel?” she says. “Like an idiot.” At moments like this, Michelle thinks about the prison yard. She misses knowing where everything is. She misses how she felt when she won a bra and helped the girls with their grievances. She considers what she would have to do to go back. And she thinks about the Golden Gate Bridge — it’s not far, and it’d be easy. One recent night, she dreamed of the rape, her most vivid dream yet. Her therapist told her that as she gets more comfortable in her life outside, her dreams might get worse. She has other nightmares: the knife that went through a guy’s back on the yard, pushed through his chest, and tented his T-shirt. How blood splattered her face after a guard shot a man next to her in the chow hall. But there’s another thing she dreams about, too: her own transitional house, one for trans people coming home from prison. They would have their own rooms, pre- and post-operation. At night, she’d come home and watch TV with her boyfriend and complain about her long day. She’s not sure what she’d call the house, but on the bottom floor, she says, there’d be a conveyor belt with Krispy Kremes for everyone.