Valerie Navarrete

A new study by Yale researchers examines the reasons behind deficiencies in treatment for transgender inmates.

A collaboration between Yale and UCLA, the study extends previous research on the conditions of transgender inmates and takes a critical look at the role of health care providers in the correctional system. Led by Kirsty Clark from UCLA’s Fielding School of Public Health and Jaclyn Hughto ’17 and John Pachankis from Yale’s School of Public Health, the study was published in the November issue of the journal Social Science & Medicine.

“In some cases, providers had existing biases towards transgender people, which played out in their care,” Hughto said. “In other cases, providers wanted the best for transgender patients but lacked the training and education to do so.”

The researchers interviewed 20 health care providers in Connecticut state prisons and identified three barriers preventing adequate care of transgender individuals: structural prison policies that maximize physical security over mental health, interpersonal dynamics between health care providers and the rest of the prison staff, and individual lack of cultural and clinical competency on the part of mental health workers. The paper advocates for a combination of structural reforms and professional retraining in order to provide greater care for incarcerated transgender individuals.

The study noted that transgender inmates often do not receive mental or physical health care in prison, including, in some cases, losing access to hormonal therapy that started before incarceration. Additionally, the lack of adequate care is evidenced by the rarity of intensive therapies like gender affirmation surgery. According to the paper, only seven states permit inmates to receive this surgery; the first and only documented case occurred in California this year.

The study concluded that health care providers often find their authority at odds with that of the guards and prison administrators, who are collectively known as the custody staff. When combined with what the study calls an “overarching prison culture that prioritizes physical safety and security over treatment,” providers fear that “advocacy for any patient could lead them being labeled as an ‘inmate lover’ by custody staff.” One worker interviewed in the study said custody staff did not refer to a trans woman in a men’s prison as “he,” but simply as “it.”

Nonetheless, Hughto said prisons can offer unique health care opportunities for transgender inmates.

“It’s the first time, when many people are detained, that they actually have access to health care in a way they didn’t when they were out on the streets,” she explained.

Hughto has designed a program to retrain providers to understand the cultural and clinical significance of transgender issues. A separate study is due for release in Social Science & Medicine in the coming weeks. Along with other researchers, Hughto uses four surveys to quantify the efficacy of retraining prison health care providers in Connecticut and Massachusetts.

Hughto emphasized that inadequate care for transgender inmates is not a new issue.

“Transgender people have been in jails and prisons for as long as there’s been jails and prisons,” she said.

Although she expressed optimism about her program, Hughto said other issues facing the prison system, like endemic sexual assault, can make any catch-all reform problematic: In addition to misgendering, the current system of classifying prisoners’ gender “by the waist down” places trans women in men’s prisons at greater odds of sexual assault, she said. But, she added, under an affirmed-gender placement, trans men in men’s prisons may face the same heightened risk.

The study’s discussion lists several limitations to its results: Its data are limited to prisoners in Connecticut medium-to-high security facilities and the sample size of health care providers interviewed is limited. Even this small pool may be self-selecting and self-censored, the authors acknowledge, given the knowledge that the interviews would be published.

Roughly one in six transgender Americans has been to prison, according to Lambda Legal.

Jack Kelly | jack.kelly@yale.edu