AUSTIN - Transgender inmates in Texas' prisons now are able to begin hormone therapy while incarcerated, a shift in state policy that advocates call positive but far from ideal.

The decision by the Texas Department of Criminal Justice to update its policy regarding transgender inmate health care was uncharacteristic of a wider trend in Texas, where there are few laws to protect access to housing, employment or health care.

Advocates, however, said the step, while positive, was small, and raised concerns that prison officials have ensured the process is onerous enough that transgender inmates could have to wait months, even years, to receive treatment.

"We're hearing from people that, for example, if they're not close to the point where they're going to try to perform surgery on themselves, or commit suicide or something like that, that their needs for treatment are not being taken seriously," said Demoya Gordon, an attorney at Lambda Legal, a national law firm that specializes in lesbian, bisexual, gay and transgender issues. "By no means has this issue been resolved."

Under TDCJ's previous policy, only inmates who came into the system already taking hormones could continue doing so. The change, which went into effect last August, allows transgender inmates who already are incarcerated to begin receiving hormone therapy behind bars.

TDCJ spokesman Jason Clark played down the change, saying Texas' policy remained "among the most conservative in the nation."

"Offenders are prescribed hormone therapy only after going through a rigorous process that includes being reviewed by a gender dysphoria specialist, an endocrinologist, and having an affirmative diagnosis," Clark said. "Only then would it be considered medically necessary and require the minimum level of treatment which is hormone therapy."

Gordon said she was heartened by the change, but added that transgender inmates still must jump through too many hoops.

"Texas seems to have, I don't know, some sort of vested interest in not being seen as respecting the constitutional rights of transgender people. I don't really understand it," she said.

Texas does not offer sex reassignment surgery to its inmates. According to the Marshall Project, a non-partisan nonprofit focused on criminal justice issues, some states, like California, provide "ready access" to hormone therapy for transgender inmates, some provide it on a case-by-case basis and some do not provide any access at all.

In August, TDCJ counted 212 inmates in prisons who self-identify as transgender, a term that broadly refers to someone who identifies as a different gender than their sex at birth. Of those 212 inmates, 21 are receiving hormone therapy, 10 of whom started while in prison, according to Clark.

Lou Weaver, transgender programs coordinator for the LGBT-rights group Equality Texas, said hormone therapy is a simple process. For transgender men, it often involves getting recurring testosterone shots, usually once a week. Transgender women often take estrogen pills, one or two a day.

Older inmates and those who require them for medical reasons already have access to hormones, so making them available to transgender inmates should not be such an onerous step," Weaver said. "Gay and transgender Texans need to have access to medical care the way anyone else does."

In a document explaining TDCJ's decision to begin classifying transgender and intersex inmates at intake, it says the change was made "to ensure offender and staff safety" and to comply with federal prison and jail standards aimed at reducing inmate rapes.

TDCJ initiated the policy just months after the state of Georgia lost a legal challenge from a transgender inmate who sued to receive hormone therapy while in prison. After claiming there was no record Ashley Diamond had been taking hormones previously, state prison officials refused to continue her therapy, housing her with male inmates.

The U.S. Department of Justice intervened on Diamond's behalf, after which the state reversed course and agreed to begin providing hormone therapy to transgender inmates on a case-by-case basis, according to the Marshall Project.

It is unclear whether the Georgia case informed Texas' decision to change its policy.

Clark said Texas' policy was updated "to reflect community standards of care" after the American Psychiatric Association updated its manual of mental disorders to include "gender dysphoria" as a diagnosable condition.

Per the APA, gender dysphoria is defined as feeling a marked difference between the one's expressed/experienced gender and the gender others would assign him or her that continues for at least six months.

"Dysphoria is a general term that means a sense of unease. It's like the opposite of euphoria," said Dr. Jack Drescher, a psychiatrist and psychoanalyst who helped the APA develop its definition and also works with the World Health Organization on issues related to sexual disorders and health. "Gender dysphoria is a feeling of unease about one's gender."

To be diagnosed with gender dysphoria, someone must meet two of six conditions including a wish to rid oneself of sexual organs or sexually-identifying characteristics, such as a beard or breasts, wishing to have the sexually-identifying characteristics of the opposite gender of one's birth, or wishing to be treated like that other gender.

Many doctors have stopped requiring people to be diagnose with gender dysphoria to receive hormones.

According to Drescher, continuing to mandate such a diagnosis before providing hormones is "not necessarily rational" under today's evolving medical standards.

"The fact that they're willing to provide the service at all, I think, is a good thing," Drescher said. "And I think what usually happens in these cases, is that as the people providing the service get more comfortable with the idea of doing it ... then it's possible they will develop a more contemporary standard."