When she was 17, Ophelia Azriel De’lonta tried to rob a bank with a 9-millimeter handgun, but as she was driving away, the dye pack exploded. Unable to breathe, she pulled over and began to run, dollar bills streaming out the open car doors. Police quickly caught her, and a judge sentenced De’lonta to 73 years in a maximum-security prison.

For the next three-and-a-half decades, she lived among the most dangerous men in Virginia. “It was a nightmare,” she recalls. “I had long hair, soft skin and a female body, minus the breasts.” She was raped repeatedly. “I lost track after the tenth time,” she says.

De’lonta, 54, is a transgender woman with high cheekbones and big, sparkling eyes. Born as Michael Stokes, she realized she was really a female at the age of 8, and soon began to dress like one. She robbed the bank to get money to fly out to San Francisco—she’d heard the city was a refuge for people like her. Instead, prison nearly destroyed her. De’lonta’s story illustrates the uniquely horrifying experience of being transgender in prison—not only the repeated physical violence but also the lack of access to treatment.

Ophelia Azriel De’lonta, a transgender woman, served 35 years in a maximum-security prison in Virginia

Last week was an important one for transgender inmates. For the first time, the Department of Justice went on record saying that prisoners who have “gender dysphoria” (the clinical term for folks who experience extreme distress about their biological sex) should be treated just like anyone else who has a health condition — just like, say, diabetics or HIV patients. This entitles them to “individual assessment and care,” including hormone therapy, improved housing, choice of pronoun, and expressing gender identity through “dress” and “grooming.” States can still challenge that interpretation, but it was noteworthy that the federal government articulated it. Recently, courts in California and Boston have gone even further, insisting that taxpayers should pay for gender-reassignment surgery.

Transgender men and women are disproportionately represented in prisons. A recent survey says that one in six will be incarcerated at some point in their lives, and for African-Americans like De’lonta, the rate triples. Once inside, transgender women are typically placed with men, and as a result, about 60% of them are sexually assaulted. In cellblocks, they tend to make up a tiny minority of the general population, and often have few allies. De’lonta, for instance, says she was the only transgender inmate in the roughly eight prisons in which she lived. “I didn’t have a friend,” she says. “There’s no one to protect you. All you can do is fight back. I stabbed four people.”

Even worse than the constant danger of being assaulted, De’lonta says, was the state’s refusal to cover what proved to be a medical necessity: the operation that would physically make her a woman. On several occasions over the course of her imprisonment, De’lonta tried to castrate herself. “But I could never make it through,” she remembers. “I’d pass out from a loss of blood.”

De’lonta’s first attempt at self-castration was in the mid-80s, after she’d been locked up for several years. At the time, the Virginia Department of Corrections provided a minimal amount of counseling, but otherwise she was forced to live as a man. In 1999, she sued the state, allegeing cruel and unusual punishment. Four years later, after an extended legal battle, De’lonta was permitted to undergo hormone therapy and to receive psychological counseling; she also was allowed to dress as a woman.

But even with these improvements, her symptoms persisted, and then worsened. Her treatment team included a psychologist, but oddly not a gender identity specialist. She notified prison officials that her counseling sessions were causing her “extreme distress.” In the summer of 2010, she was again hospitalized for attempting self-castration. She desperately appealed to officials, explaining that the only way she could keep from harming herself was sexual-reassignment surgery.

Rate of suicide attempts (%)

For people in De’lonta’s position, the World Professional Association for Transgender Health, an advocacy group, recommends sexual reassignment surgery when hormone therapy and the opportunity to experience some semblance of life as a woman don’t provide sufficient relief. De’lonta’s continued attempts at castration suggested she was a good candidate for the surgery. But her request was denied.

In 2011, De’lonta filed another lawsuit, which prompted another prolonged legal battle. Three years later, she began to make headway. But then, in the midst of the proceeding, De’lonta came up for parole and, in January 2014, Virginia released her from prison. As a result, the state didn’t have to pay for a medical procedure that could have cost up to $24,000. De’lonta does not think this is a coincidence.

Once out of prison, she went to live with her niece in Landover, Maryland. Soon after, Medicaid paid for the removal of her testicles—the first phase of the sex reassignment process. “I feel free,” De’lonta says. “Really free. But I’ve got issues with people. I’ve got some scars I’m going to have to carry for a long time.”