Societal trends that occur in the community at large are seen eventually in our correctional facilities. Among the trends now being dealt with in prisons, large urban jails and occasionally in smaller suburban jails is transsexualism.

In 1989 the American Medical Association defined transsexualism as a "rare psychiatric disorder in which a person feels persistently uncomfortable about his or her anatomical sex." Transsexuals identify with a core gender identity that society believes is not congruent with their external genitalia.

Conflict over gender does not mean the person is homosexual. Some transsexuals are homosexual and some are heterosexual. Furthermore, sexual identification does not always influence the desire to physically change gender.

Those who have identified the need to change their bodies, also known as gender reassignment, do not progress to that stage without many evaluations and behavioral health assessments. Those considering the physical change are required to live as the sex they wish to become and deal with day-to-day life for at least two years. Males who choose to become females begin to dress in public daily as women and often change their names.

With behavioral health sessions continuing (but perhaps less frequent), the person is ready to work with a medical provider. Hormone therapy may begin, and some people choose to get breast implants. If transitioning transsexuals cannot get the necessary hormones from a physician, many will purchase them on the black market or the Internet.

Complex Issues
People who feel transgendered often face many difficulties in dealing with it, such as ridicule from family, friends and coworkers, and trouble fitting in with others.

The transsexual’s life is complex enough in the free world. When he or she becomes incarcerated, the issues multiply and many of them must be dealt with by corrections, medical and behavioral health staff. When transsexuals enter the correctional environment, the first thing we must do is remain nonjudgmental and treat them in a humane manner. Here are some specific recommendations for corrections, medical and behavioral health.

Correctional Considerations
Correctional staff must take care to ensure transsexual patients’ safety but not go overboard and keep them locked down continuously. The bottom line is to treat them like the other inmates as much as possible.

The classifications department needs to be intricately involved in the placement of transsexual inmates. First, it must be decided whether to place the inmate in a male or female housing unit. This question is usually one for prisons or lengthy confinement situations.

It’s a tough question and the answer depends on the transitional phase of the transsexual person. In general, decide based on findings from the physical examination. If the person looks primarily female with full breast growth (or implants) and has no appearance of functional male genitalia, a woman’s facility may be appropriate.

Beyond that, transsexuals should be housed in general population whenever that’s feasible based on physical appearance and the ability to maintain their safety. Privacy for hygiene must be accommodated, and the inmate should be offered a single cell on the housing unit when possible. The inmate should be provided appropriate clothing as needed, including a bra. If the inmate must share a cell on a male housing unit, careful consideration should be given to the choice of the cellmate.

Medical and Behavioral Care
Medical staff must be very involved in the care and development of a treatment plan for transsexuals. The intake nurse should get complete information about prior medical care and names of medical providers, and obtain a signed release for medical records. Detailed history should include any previous surgical procedures, including dates and location. During the physical examination the physician must document in detail previous care and treatment (medical and behavioral health), including current hormone therapies.

The physician also must document physical features—just because someone appears female does not mean he doesn’t have functional male genitalia—to assist the correctional classifications department.

Medical’s role is to provide needed palliative care and to prevent loss of current changes based on past care and treatment. A hormone therapy regimen should be ordered as soon as possible. Maintenance of such therapy will prevent the side effects of withdrawal from sudden stoppage or reduction of therapy. Sudden stoppage of high levels of hormonal therapy can result in an inmate who becomes out of control (tearful, moody, aggressive, psychotic and a discipline problem).

Also, it is unethical to cease needed medical therapeutic hormonal therapy on an incarcerated transsexual person based on personal biases. The patient need not be followed in chronic care, necessarily, but the hormone therapy must be continued.

To get an idea of free-world hormone therapy regimens, let’s look at male-to-female preoperative transsexuals. (Postoperative transsexuals continue their preop routines at a maintenance dose.) As seen in the table below, pre-op transsexuals take much higher doses than normal hormone therapy in order to suppress testosterone levels and to facilitate physical changes (breast growth, less facial hair, muscle mass changes).

In a correctional setting, hormone therapy should be as close as possible to previous levels, but they can be lower. The recommended therapy during short-term incarceration is estradiol at 2 mg to 4 mg.

Behavioral Factors
Transsexualism is not a psychiatric disorder but a gender identification disorder. Since it is not a mental health issue, transsexual patients do not need routine care by behavioral health staff unless it’s clinically identified or indicated. If the patient has underlying mental health issues or asks to continue therapy, a referral should be generated and behavioral health professionals should determine their need of involvement.

Unsettled Questions
In prisons, the classification and the policy and procedure departments should determine what to do with transsexual inmates, taking into consideration their time of sentence and their current transitional stage. But the issue may need revisiting, since there has been some debate over whether prisons should continue higher doses of hormonal therapy to help the transsexual person move toward post-op readiness.

Prisons also have faced the question of providing gender reassignment surgery. While such surgery cannot be viewed as merely cosmetic, the debate must weigh elective vs. clinical need. Also, there have been cases concerning prisons’ possible deliberate indifference in housing and safety, but, to date, not about completing the surgical process of transsexual transitioning. Surely this issue will be seen in the courts.