In 2015, Trimble, who is serving a life sentence for murder, was assaulted by another inmate in her unit, she said. While trying to get herself separated from her assaulter, she started writing letters to every LGBTQ organization for which she could find an address, asking for help in advocating for herself. None could help her relocate, but one did send her a pamphlet called “Still We Rise.” That’s where she first read the definition for “gender dysphoria.” As Trimble recalls, “I'm reading that, and I'm like ‘my God... that explains my life.’"

Before going to prison, Patricia Trimble didn’t know what it meant to be transgender. “In fact, for many years, I just introduced myself as, ‘OK, I'm a gay man,’ because that's all I knew,” she said over the phone from Jefferson City Correctional Center, a maximum security prison in Missouri’s capital.

Through this letter-writing network, Trimble is helping other trans people across Missouri's Department of Corrections (MDOC) better understand their own identities, what kinds of treatment they need—and how they can advocate for it from the inside. “You have a bunch of psychologists and therapists talking to us that really have no clue,” Trimble said. “So we kind of have to educate one another.”

Alongside her bed sits a metal footlocker with hundreds of photocopied pages of literature related to trans issues. In the hours before work, she might write letters to LGBTQ associations across the state (“carpet-bombing,” as she calls it) for help weaving through the bureaucracy standing between her fellow inmates and diagnoses or legal name changes. She then mails texts from her archive to other incarcerated trans women, transcribing them on a typewriter first because the corrections department doesn’t allow her to exchange personal property—which sometimes includes photocopies—with fellow inmates.

After a lifetime spent in the dark about the reality of gender dysphoria, Trimble, now 59, answers more questions than she asks. On a typical day, she gets up at 5 A.M. and does her make-up—before recent policy changes allowed cosmetics in, she’d make it herself with hot water and Crayola pencils. She skips breakfast in favor of a few cups of coffee, and, with the morning news playing on the TV in her cell, looks through her mail.

“You have a bunch of psychologists and therapists talking to us that really have no clue, so we kind of have to educate one another.”

In visits with her psychiatrist, Trimble pushed for a diagnosis, which she finally got in 2016, but it wasn’t until last year that she was given a prescription to Estradiol and testosterone blockers. Until recently, a “freeze frame” policy in Missouri made it impossible for anyone in the state’s prisons to start hormone therapy unless they’d been on it before starting to serve their sentence.

But most inmates are held in state prisons , not federal ones. According to a 2014 study in the Journal of Correctional Health Care, “a number of highly publicized lawsuits in the last 10 years have resulted in court orders that compelled prisons to allow the prescribing of hormones pursuant to physician recommendation.” In 2019, it’s still a “state by state battle,” said George R. Brown, the study’s author and a professor of psychiatry at East Tennessee State University.

It’s unclear just how common freeze frame policies are in America’s prisons. The Bureau of Prisons rejected them on a federal level in 2011, writing in a memorandum that “treatment options will not be precluded solely due to level of services received, or lack of services, prior to incarceration.”

Hicklin soon began her hormone therapy in the form of testosterone blockers and estrogen pills. A few months later, the same court struck down the freeze frame policy, the effects of which soon trickled down to other transgender inmates, including Trimble. An MDOC spokesperson estimated that there are “about 50 to 60” transgender inmates in the MDOC’s custody, out of a prison population of roughly 30,000. Fourteen of them are on hormone therapy, according to a spokesperson at Corizon.

Hicklin, 40, is serving a life sentence for murder at Potosi Correctional Center, a two-hour drive from Jefferson City; she will be eligible for parole next year due to a state law passed in 2016 granting leniency to convicts who committed their crimes as juveniles. She, too, was kept from adequate medical care because of the department’s freeze frame policy. With the help of Lambda Legal, a legal non-profit focused on LGBTQ rights, she successfully sued the MDOC and its private health care provider, Corizon Health, for treatment. Last year, a federal district court directed the defendants to provide Hicklin “with care that her doctors deem to be medically necessary treatment for her gender dysphoria, including [...] hormone therapy, access to permanent body hair removal, and access to ‘gender-affirming’ canteen items,” according to a court document .

A 2017 analysis by the Prison Policy Initiative, a nonprofit organization that studies and advocates against mass incarceration, found that, of the 21 state correctional departments studied, four had policies against providing hormone therapy to inmates who weren’t on them before their prison terms. “Two of them, Alabama and Oklahoma, have changed those specific policies,” according to Harper Jean Tobin, director of policy at the National Center for Transgender Equality (a spokesperson for Alabama’s Department of Corrections conceded this was once the case; another at Oklahoma’s Department of Corrections said in an email that “no one here is aware of any previous ‘freeze frame’ policy,” and the document linked to by the Prison Policy Initiative does allow for care if a “medical provider determines hormone treatment is medically necessary”).

In a Florida case, the ACLU is suing the state’s Department of Corrections on behalf of a transgender woman seeking medical care. According to an amicus brief in the case filed by Lambda Legal and co-written by Jessica Hicklin’s lawyer, they and other organizations “have received hundreds of requests for assistance from incarcerated transgender people nationwide.”

Brooke Santina, a spokesperson at the Nevada Department of Corrections, tells VICE that “right now, that's the case. However, I know that we're going to be making a lot of change in the near future,” she said. “This is just one more step in our rehabilitation as a department, really.”

Transgender prisoners suing for treatment have succeeded in California, Georgia, and Wisconsin.

But in Missouri, Hicklin said, getting hormone therapy and gender-affirming items like clothing, chest binders, or make-up still depends on where a trans inmate happens to be incarcerated, and how well they’ve made their case for diagnosis. “If you’re just a person who’s slightly removed from the dialogue, it looks like everything’s roses,” Hicklin said. “‘Look, we’ve won, it’s over, hooray, everybody gets to be who they are.’ And that’s not the reality of the situation yet.”

Trimble said she teaches her therapist more about transgender issues than the other way around. But it was through him that she first heard about Hicklin’s case. She reached out—"all I need is their name, their register number, and what institution they're in," Trimble said—and they quickly bonded through weekly letters, which soon became just a part of the overall correspondence they kept with people around the state. “She's a mom and I'm a mom,” Hicklin said. “That's probably the shortest way of putting that. We both try and help each other and everybody else.”

Hicklin is in touch, at least occasionally, with about 20 other inmates. Her court victory is cause for cautious optimism for Jay Livingston, a trans man serving 16 years for first degree robbery at Missouri’s Chillicothe Correctional Center. “I love hearing things from her, and it actually does help me,” Livingston, 31, said about the pen-pal relationship. “Because it shows that even though things are not happening right now the way I want them to, I know eventually things will happen.”

Livingston said he hasn’t been diagnosed with gender dysphoria—a problem he chalks up to an uninformed psychiatrist—but is seeking to be addressed appropriately by prison staff, wear his hair the way he wants, and get access to chest binders, masculine clothes, and hormone treatment. (A spokesperson at Corizon maintains that “every patient is treated as an individual in consideration of his or her unique health needs and specific circumstances.” A spokesperson at the MDOC said items that are “normally available” in women’s facilities are available in men’s prisons, and vice versa, but that “transgender offenders can’t necessarily get items that aren’t normally available in either type of facility.”)