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Judge orders us bureau of prisons to find surgeon for transgender inmate’s gender-affirming surgery.

A federal judge in Illinois on Monday ruled that the US Bureau of Prisons (BOP) has to immediately find a qualified surgeon so that a transgender prisoner, Cristina Nichole Iglesias, can receive gender-affirming surgery, court documents show.

Earlier in the case, the district court had ordered the BOP to evaluate Iglesias for gender-affirming surgery, but the BOP sought to postpone any referral to a surgeon for months, court records show. The BOP “employed tactics similar to the game of Plinko on The Price is Right,” Chief Judge Nancy Rosenstengel said in Monday’s ruling, comparing their tactics to a game of “whack-a-mole.”

This week’s order from the court now requires the BOP to provide a detailed timeline for Iglesias’s surgery, including providing the court with a list of all surgeons within the United States who are qualified to perform gender-affirming surgery, the ruling states.

“I am hopeful that I will finally get the care I need to live my life fully as the woman I am,” Cristina Iglesias said in a statement provided to CNN by the ACLU of Illinois. The “BOP has denied me gender-affirming surgery for years – and keeps raising new excuses and putting new obstacles in my way. I am grateful that the court recognized the urgency of my case and ordered BOP to act.”

Related article A transgender female inmate received her gender confirmation surgery after a three-year court battle

“For years, Cristina has fought to receive the health care the Constitution requires. The court’s order makes clear that she needs gender-affirming surgery now and that BOP cannot justify its failure to provide this medically necessary care,” Joshua Blecher-Cohen, an ACLU of Illinois staff attorney who represents Iglesias, said. “We hope this landmark decision will help secure long overdue health care for Cristina – and for the many other transgender people in federal custody who have been denied gender-affirming care.”

According to the ACLU, while the BOP has more than 1,200 transgender people currently in its custody, Iglesias is now expected to be the first federal prisoner to ever receive gender-affirming surgery.

Iglesias has been in federal custody for 28 years and is currently housed in a BOP residential reentry center in Florida, the ACLU said.

When reached for comment, the BOP told CNN it doesn’t comment on “pending litigation or matters subject to legal proceedings,” nor on “the conditions of confinement for any individual or group of inmates.”

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Federal Court Orders Bureau of Prisons to Schedule First-Ever Gender-Affirming Surgery

CHICAGO — For the first time in its history, the federal Bureau of Prisons (BOP) has been ordered to immediately secure a qualified surgeon so that a transgender prisoner, Cristina Nichole Iglesias, can receive gender-affirming surgery. The federal court’s order follows three years of litigation in which Ms. Iglesias sought this medically necessary surgery but faced repeated delays, denials, and deception from BOP. The court’s latest order requires BOP to provide a detailed timeline for Ms. Iglesias’s surgery, including undertaking a nationwide search to identify a qualified surgeon.

Earlier in Ms. Iglesias’s case, the district court issued the first-ever decision ordering the federal Government to evaluate a transgender prisoner for gender-affirming surgery. BOP then recommended Ms. Iglesias for gender-affirming surgery in January 2022, but sought to postpone any referral to a surgeon for months. The court’s order this week requires BOP to immediately locate a qualified surgeon and begin the process of scheduling Ms. Iglesias’s gender-affirming surgery.

“I am hopeful that I will finally get the care I need to live my life fully as the woman I am,” said Cristina Iglesias. “BOP has denied me gender-affirming surgery for years—and keeps raising new excuses and putting new obstacles in my way. I am grateful that the court recognized the urgency of my case and ordered BOP to act.”

The court’s ruling responds to BOP’s pattern of delays, noting that Ms. Iglesias “is suffering from gender dysphoria, and time is running out.” Chief Judge Nancy Rosenstengel ordered BOP to make weekly reports to the court that lay out a timeline to ensure Ms. Iglesias receives surgery and recovers before her sentence ends in December 2022. These reports will continue until Ms. Iglesias’s surgery occurs and will allow the court to monitor BOP’s compliance.

The court also ordered high-level officials from BOP and the Department of Justice, including the Principal Deputy Assistant Attorney General, to appear at a hearing and justify federal government officials’ repeated misconduct during Ms. Iglesias’s litigation, including violations of previous judicial orders. As one example, Judge Rosenstengel noted that BOP spent seven weeks promising to set up a surgical consult for Ms. Iglesias, then knowingly sent her to a doctor who does not perform the surgery she needs.

“For years, Cristina has fought to receive the healthcare the Constitution requires. The court’s order makes clear that she needs gender-affirming surgery now and that BOP cannot justify its failure to provide this medically necessary care,” said Joshua Blecher-Cohen, an ACLU of Illinois staff attorney who represents Ms. Iglesias. “We hope this landmark decision will help secure long overdue healthcare for Cristina—and for the many other transgender people in federal custody who have been denied gender-affirming care.”

While BOP has more than 1,200 transgender people currently in its custody, no federal prisoner—past or present—has ever yet received gender-affirming surgery. With this court order, Ms. Iglesias is now expected to be the first.

Ms. Iglesias has been in federal custody for 28 years and currently lives in a BOP residential reentry center in Florida. BOP has known that Ms. Iglesias is transgender since she first arrived in federal custody in 1994 and identified as a woman. Since then, she has been denied basic medical care to treat her gender dysphoria and was housed in men’s facilities for over two decades, where she experienced severe physical and sexual violence. In May 2021, this lawsuit resulted in Ms. Iglesias being one of the few transgender people ever moved to a federal prison that aligns with her gender. Ms. Iglesias has been seeking gender-affirming surgery since at least January 2016.

Ms. Iglesias is represented by a legal team that includes counsel from the ACLU of Illinois, the American Civil Liberties Union, Winston & Strawn LLP, and Feirich/Mager/Green/Ryan.

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Prisons agency agrees to pay for first gender surgery for trans inmate

Cristina iglesias will become the first inmate in federal custody to get gender-affirming surgery, her lawyers say..

11:22 AM on Jun 1, 2022 CDT — Updated at 6:41 PM on Jun 8, 2022 CDT

It was a different world for transgender people when Cristina Iglesias was first locked up.

Back in the early-1990s, there were no mainstream trans celebrities. Even the word — “transgender” — was only beginning to enjoy more widespread use.

Iglesias didn’t think she would be accepted as female in that world, especially not in small-town Florida where she grew up. So she kept acting out, kept breaking the law, she said, to stay in the one place where the men around her treated her like a woman — behind bars.

“I did stuff to stay in prison because I was afraid to come out,” Iglesias, a transgender woman, said.

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“Being around guys and being called a girl,” she added, “it felt comfortable.”

Over nearly three decades, Iglesias said she spent time in more than a dozen prisons, from Florence, Colorado to Fort Worth. In that time the world changed — and so has Iglesias. Now there are trans stars like Janet Mock and Laverne Cox. Caitlyn Jenner is out. And while violence against trans women is rampant , public opinion has shifted radically on LGBT rights.

After years of hormone therapy, Iglesias will become the first inmate in federal custody to receive gender-affirming surgeries , according to her lawyers with the ACLU of Illinois. Under a settlement agreement approved this week, the U.S. Bureau of Prisons will pay for her vaginoplasty, facial feminization, breast augmentation and laser hair removal.

If all goes to plan, she will be finished with her recovery by the time she is released in December. The agreement could also provide a blueprint for other federal inmates seeking gender-affirming care.

In an exclusive interview with The Dallas Morning News , Iglesias said she doesn’t feel like a pioneer for suing the government to access the medical care she says she needs. She’s ready to reenter the world and hopes to do so as the woman she’s always felt like inside.

“I made some very bad decisions in my life that haunted me for 28 years,” she said. “I just want a second chance at life and to prove that I have changed.”

Threatening letters

Iglesias was barely an adult when she committed the first crime to land her in federal custody. It was 1993 and she was already locked up for stealing a car and thieving items from the local jail’s evidence locker.

Being behind bars up was scary, she said. It could be violent. But it was also a place she felt feminine, where she said the men around her called her by her chosen name — “Cristina” for the woman she felt she was inside; “Iglesias” after the first boyfriend to ever love her.

It was then that she made the decision to stay locked up, Iglesias said.

From her cell in Hernando County, Florida, she penned a series of threatening letters to an Oklahoma judge who had recently been in the news. Iglesias did not know John Amick and had no reason to terrorize him.

“My whole life I just wanted to be like my sister and have a boyfriend and be a girl,” Iglesias, now 47, told The News this month in a video interview from a halfway house. Her blonde hair tied in a low ponytail, Iglesias’ silver aviators were set off by matching hoop earrings.

“I couldn’t do that in my home environment. So when I went to prison, I automatically got referred to as a girl, had a boyfriend. And so I was living my life in prison as a woman and being treated as a woman,” she explained.

Related: Transgender inmate in Texas recommended for consult on gender-affirming surgery, prisons bureau says

At the time, the crimes puzzled Iglesias’ mother. She believed her child had mental health issues but none of the psychiatrists they’d seen had solved or even identified the problem.

“I’ve written some more letters, Mom. I don’t know why I did,’” her mother said, recalling what her child told her in an interview with The Tampa Bay Times in 1994. “I think I’m going crazy.’”

Despite the aggressive language and scores of exclamation points, Iglesias’ letters didn’t worry Amick much, according to reports from the time. He’d received more serious threats before, plus, this one was signed by a teenager who was already in jail halfway across the county, he told The Times in 1993.

But prosecutors noted that sending death threats to a judge was a grave offense. Iglesias was convicted and sentenced to 52 months in federal prison.

When Iglesias was set to be released, she issued another threat, this time sending fake anthrax to the British Foreign and Commonwealth Office in London. She was indicted for threatening to use a weapon of mass destruction and making threats through the mail. She got 20 years.

Iglesias told The News the threats were hollow.

“I’m not violent at all,” she said, throwing up her hands, nails adorned with a French tip manicure. “Every time I would come close to getting out, I would write a letter and it would get me new time and I would rack my sentence up.”

Gender dysphoria

Iglesias felt like a girl at a young age. As a child, she said her father pulled a gun on her when he caught her wearing girl’s clothes.

But she wasn’t diagnosed with “gender identity disorder,” now an outdated term, until she was first taken into federal custody at age 19. Her diagnosis was later updated to gender dysphoria, which is the feeling of discomfort or distress that can occur in people who identify as a gender that is different from the gender or sex assigned at birth.

While prison could provide her with a place she felt affirmed, it also put her in harm’s way. Her traditionally effeminate mannerisms made her a target for sexual violence, she said. And while the prison system recognized her as trans, Iglesias was housed in men’s prisons for 21 years before she was approved for hormones.

This meant two decades of fashioning eyeliner out of grease pencils and makeshift breasts made out of water-filled latex gloves. It meant years of self harm, even thoughts of castration — what she said the trans girls behind bars call “self treatment.”

“Gender dysphoria is a living nightmare. Suicide is very real,” she said.

Iglesias said her time in prison made her inured to verbal and physical abuse. She became steely. In some facilities, she avoided reporting violence altogether.

“Your heart becomes kind of hard,” she said. “You can’t cry. You can’t go talk to staff because [other inmates will] think you’re a snitch. They’ll kill you.”

Iglesias wasn’t moved to a women’s prison, a facility in Fort Worth, until last year. There, for the first time, she could don earrings and dye her hair, the simple trappings of womanhood banned in men’s prisons.

But one thing is still missing: the female body she’d wanted since she was a child.

Gender affirming surgery

On May 27, Iglesias’ lawyers reached a settlement in which the Bureau of Prisons agreed to facilitate and fund the surgery and related gender-affirming care. According to a court order issued Tuesday, the bureau will pay for these treatments even if Iglesias is released prior to receiving the full retinue of care by depositing funds into an escrow account for her use.

Her lawyers called the settlement a “landmark win.”

“Cristina will be the first person to receive gender-affirming surgery from BOP,” Joshua Blecher-Cohen, a staff attorney with the ACLU of Illinois, said in a statement. “We hope this victory will pave the way for other transgender people in federal custody to get the care they need.”

Iglesias doesn’t feel like a trailblazer. She knew no one had been approved for gender-affirming surgery when she sued the prison department to get it. She said she did it because she had no other options.

“The status quo is unacceptable. It’s a death sentence,” she said. “I’m not brave. I’m not courageous. I’m just living my life.”

Now she knows gaining access to this care could open the door for other trans prisoners: “I am just doing this for my brothers and sisters — and honestly for myself.”

About 1,200 federal inmates, less than 1% of the total population, identify as transgender, according to the U.S. Justice Department. The prisons bureau approved another inmate for the procedure in October, according to court filings in Iglesias’ case.

But it is unclear when that person will receive the surgery, and the bureau did not answer questions about the prisoner’s identity, medical status or housing location, citing “privacy, safety and security reasons.”

Nearing middle age, Iglesias is now starting life anew. She plans to go back to school to be a psychologist and to advocate on behalf of others with gender dysphoria. And she wants to fulfill the last hope of her mother: to come home and to be happy.

“To just stay free and try to live my life and heal from all the torture I’ve put myself through,” Iglesias said. “I am doing everything I possibly can to stay free in her honor.”

Lauren McGaughy . Lauren is an investigative reporter focused on state politics and policy. Her expertise areas include courts, criminal justice, ethics and LGBTQ issues. She previously covered Texas politics for The Houston Chronicle and Louisiana politics for The New Orleans Times-Picayune. She loves cats, cemeteries and comic books, and cooks a mean steak.

California OKs first-ever sex reassignment surgery for trans inmate

Sidestepping broader constitutional questions, the California Department of Corrections and Rehabilitation (CDCR) has agreed to pay for a transgender inmate’s sex reassignment surgery — the first in the nation.

The decision, announced on Friday, settles a lawsuit brought by 56-year-old Shiloh Quine, who argued that California’s refusal to provide medically necessary treatment for her gender dysphoria violated the Eighth Amendment’s protection against cruel and unusual punishment. If she goes through with it, Quine -- who is serving life without parole for murder -- will be the first inmate in the country to receive sex reassignment surgery while incarcerated.

“After so many years of almost giving up on myself, I will finally be liberated from the prison within a prison I felt trapped in, and feel whole, both as a woman and as a human being,” said Quine in a statement released by the Transgender Law Center, which has been representing her. “I’m just overwhelmed, especially knowing that this will help so many other people. I know I can never truly make amends for what I’ve done in the past, but I am committed to making myself a better person, and to helping others so they don’t have to struggle the way I have.”

RELATED:  Appeals court blocks sex reassignment surgery for transgender inmate

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gender dysphoria as “clinically significant distress” arising in people whose gender assigned at birth differs from the one with which they identify. As treatment, the DSM-5 recommends a broad set of options including counseling, cross-sex hormones, social and legal transition to the desired gender, and sex reassignment surgery.

But for transgender inmates, options are limited. In 2009, Quine, formerly known Rodney James Quine, was diagnosed with gender dysphoria and began taking feminizing hormone treatment. The prison system, however, would not allow her to legally change her name or transfer her from Mule Creek State Prison, a male facility where California sends transgender women. According to legal filings , Quine has repeatedly attempted suicide and reported once instance of attempted self-castration.

“Based on my examination of Ms. Quine’s medical and mental health records and my clinical interview, I have determined that genital sex-reassignment surgery is appropriate and medically necessary treatment for Ms. Quine,” concluded Dr. Richard Carroll, a clinical psychologist hired by the CDCR in June. “Sex-reassignment surgery is medically necessary to prevent Ms. Quine from suffering significant illness or disability, and to alleviate severe pain caused by her gender dysphoria. In addition, sex-reassignment surgery is likely to significantly reduce Ms. Quine’s other mental-health conditions, which include depression, anxiety, and risk of suicide attempts.”

RELATED:  Does the LGBT movement ignore inmates?

Under the 1994 Supreme Court case of Farmer v. Brennan , prisoners can hold prison officials accountable for “deliberate indifference” to their safety. Though Friday’s settlement means that the federal judiciary won’t be using Quine’s case to settle the question of whether denying access to sex reassignment surgery constitutes “deliberate indifference” to an inmate’s medical needs, her attorneys believe the decision will still have a broad impact on the national stage.

“While this isn’t ‘precedent-setting’ in the general sense, other jurisdictions can look to California and, in particular, to this case to develop policies that are compliant with the constitutional requirement to provide medical care to inmates,” Flor Bermudez, detention project director at the Transgender Law Center, told msnbc. “The settlement agreement itself is a public document that can be cited by other inmates seeking redress from the courts.”

“In other words,” she added, “by settling this case, the state of California is acknowledging that this is what they have to do.”

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Judge orders Wisconsin to provide inmate with long-sought gender confirmation surgery

A federal judge has ordered the state to provide long-sought gender confirmation surgery to a transgender female inmate, which would make her the first in Wisconsin to have the procedure while in state custody.

"The rights of transgender persons and sex reassignment surgery remain politically controversial, even outside the prison context," wrote U.S. District Judge James Peterson.

"And some members of the public are outraged at any effort to improve the health and well being of inmates," he wrote. "But the true public interest lies in alleviating needless suffering by those who are dependent on the government for their care."

Peterson's order followed a three-day bench trial in March in the case of Nicole Campbell. Also known as Mark Campbell, who in 2007 began serving a 34-year-sentence for sexual assault of a child.

The Department of Corrections agrees that Campbell, 49, suffers from gender dysphoria, and has made some accommodations: she has received hormone treatment, counseling and is allowed to wear some women's clothing at Racine Correctional Institute, a men's prison.

But it had denied her reassignment surgery, which she first sought in 2013. Not everyone with gender dysphoria wants or needs surgery for treatment, or meets the strict medical requirements to be recommended for surgery.

Peterson found that Campbell has the most severe form of gender dysphoria, in which  the presence of male genitalia on her body causes particularly severe anguish.

He noted that it could take a year to schedule an appointment with the one qualified surgeon in the state, and suggested DOC could move Campbell to the main women's prison in the meantime.

The DOC took the position that Campbell met all the criteria for gender confirmation surgery except having practiced living as a woman in "real life," which it said was impossible while residing in a men's prison.

Peterson said denying the surgery by summarily citing policy amounted to deliberate indifference of her serious medical needs, a violation of the Eighth Amendment.

He gave particular consideration to the testimony of Cynthia Osborne, a social worker and sex therapist who has evaluated more than 200 inmates of gender dysphoria. She concluded the 'real life experience' requirement before surgery may not be so important or relevant for someone like Campbell, who had experienced it before prison, has done all that she can to successfully live as a woman for several years in prison, and faces many more years of incarceration.

Peterson noted that the DOC had requested that, if Peterson ordered surgery, he first require Campbell to live for a year at Taycheedah Correctional Institution, the state's largest women's prison first.

"That request came as a surprise, because previously the DOC designated any inmate with a penis to a male prison, regardless of gender identity or expression," Peterson wrote.

"I decline to impose any further prerequisites on Campbell’s sex reassignment surgery; she has waited long enough."

That doesn't mean surgery will happen soon though. According to Peterson's order, there's only one surgeon in Wisconsin qualified to perform the operation, and it could be a year before Campbell's surgery. Ultimately, the surgeon must also agree that the procedure is necessary. 

Campbell was represented for free by lawyers from Husch Blackwell, led by Tom Henegen. 

Earlier in the case, the U.S. Court of Appeals for 7th Circuit had ruled that the prison officials could not have anticipated that denying Campbell the surgery might violate her rights, and therefore were immune from damages.

The same court in 2011 upheld a judge's ruling that struck down a Wisconsin law that tried to ban even hormone treatments for transgender inmates . 

Contact Bruce Vielmetti at (414) 224-2187 or [email protected] . Follow him on Twitter at @ProofHearsay.

Our subscribers make this reporting possible. Please consider supporting local journalism by subscribing to the Journal Sentinel at jsonline.com/deal .

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The trans prison experience

Trans inmates need access to gender-affirming care. often they have to sue to get it.

Jaclyn Diaz

Transgender inmates who don't get proper gender-affirming care in prison can experience serious anxiety, depression and suicidal ideation. One individual said the experience was "catastrophic." Jasjyot Singh Hans for NPR hide caption

Transgender inmates who don't get proper gender-affirming care in prison can experience serious anxiety, depression and suicidal ideation. One individual said the experience was "catastrophic."

This story is part of a series looking at transgender inmates in the U.S. and the challenges they face in confinement and upon release. The series focuses on topics such as being incarcerated in prisons that do not reflect the inmate's gender identity , the medical hurdles faced behind bars, and rehousing after being released. The series includes dozens of interviews with inmates, experts and public officials.

Note: This story contains graphic details of incidents of self-harm.

Ashley Diamond thought her battle against the state of Georgia was over — until she was arrested again.

She had fought Georgia's prison system in a lawsuit over her treatment in prison and lack of access to medical care, which resulted in a major legal settlement in 2016. That case highlighted the conditions she faced as an incarcerated transgender woman who was denied hormone treatments she had been taking for 17 years for her gender dysphoria.

But when she was arrested again in Georgia in 2019, she faced the same problems.

"Imagine being a trans woman and a Black trans woman on top of that, and you're trying to assert these rights that you were promised and guaranteed in your first case," she said. When she brought up complaints with prison officials, she said it was like talking to a wall.

Diamond's difficulty accessing medical care in prison is not unusual.

Health experts and attorneys for civil rights groups, as well as incarcerated and formerly incarcerated individuals, told NPR that getting reliable gender-affirming care in prison seems to often come only after threats of lawsuits or an all-out legal fight. Prisons that do provide gender-affirming care can often still be inconsistent, regardless of policies on the books.

"Prisons oftentimes refuse to treat transgender people consistent with their gender. And they also refuse to provide medically necessary health care," Taylor Brown, a staff attorney at the American Civil Liberties Union, told NPR. Gender-affirming care can include "puberty suppression, hormone therapy, and gender-affirming surgeries among others," according to the World Professional Association for Transgender Health .

Access to this care is considered medically necessary to treat gender dysphoria. Without it, individuals can struggle severely with mental health issues such as heightened anxiety and depression, with some turning to self-harm and suicide.

Civil rights groups, such as Lambda Legal and the ACLU, have been involved in lawsuits in recent years on behalf of transgender inmates struggling to access gender-affirming medical care.

A woman known by the pseudonym Sonia Doe , who was imprisoned in New Jersey, and Reiyn Keohane , who is still incarcerated in a men's prison in Florida, have successfully sued. Those lawsuits were filed in 2019 and 2016, respectively, against their state departments of corrections over access to gender-affirming care.

Adree Edmo, a transgender woman in Idaho, won the ability to get gender-confirmation surgery after a yearslong battle against the state. In 2020, she underwent her surgery, according to the National Center for Lesbian Rights. It's a rare occurrence for trans inmates, despite this surgery being a proven medical treatment for gender dysphoria.

Minnesota recognizes she's a woman. She's locked in a men's prison anyway

Diamond's first case against georgia is settled.

Diamond filed her first lawsuit in 2015, three years into a sentence related to charges of burglary and theft. At the time, she said she was denied hormone treatments that she had been consistently taking for almost two decades to alleviate her gender dysphoria.

Diamond was paroled later that year and reached her major legal settlement with the Georgia Department of Corrections in 2016, with the help of the Southern Poverty Law Center.

In addition to an undisclosed monetary payout from the state, she also received assurances that Georgia prisons would make changes to policies on trans inmates. That included staff training on the treatment of trans inmates, adopting a new sexual assault prevention policy and improved access to hormone treatments, according to the Southern Poverty Law Center.

But in 2019, Diamond violated the terms of her parole by traveling out of state. She said she traveled to Florida to receive treatment for PTSD and other issues at a trans-friendly center. Then, she was rearrested.

Ashley Diamond fought Georgia's prison system in a 2015 lawsuit that highlighted the conditions she faced as an incarcerated transgender woman who was denied hormone treatments she had been taking for 17 years. Ashley Diamond hide caption

Ashley Diamond fought Georgia's prison system in a 2015 lawsuit that highlighted the conditions she faced as an incarcerated transgender woman who was denied hormone treatments she had been taking for 17 years.

She reentered the custody of the Georgia Department of Corrections in October of that year, department records show. Despite her landmark legal case against Georgia prison officials, she faced the same problems that she had thought were resolved when she arrived at Savannah's Coastal State Prison after her parole violation.

"They made it very difficult," she told NPR.

She got back in touch with her attorneys at the Southern Poverty Law Center. In November 2020, the organization and its partners at the Center for Constitutional Rights announced that they had filed another lawsuit against Georgia prison officials, saying Diamond's gender-affirming health care needs were routinely ignored.

The U.S. Justice Department even weighed in on this case .

In a statement of interest, the Justice Department said: "Prison officials also have an Eighth Amendment obligation to provide all prisoners with adequate medical care for serious medical conditions. ... This duty includes the treatment of gender dysphoria."

Not getting care can be 'catastrophic'

Diamond's lawsuit states that she was not given hormone treatment medication for weeks at a time. Additionally, the officials' "refusal to provide Ms. Diamond anything beyond sub-therapeutic hormone therapy is so wholly inadequate that it is tantamount to no treatment at all," according to the lawsuit.

She was also informed at intake that she would not be getting women's clothing.

"I was told that from the very beginning — 'That's never gonna happen,'" she said.

These are critical components of medical care for people who experience gender dysphoria, Randi Ettner, a psychologist who specializes in treating transgender individuals, told NPR. Ettner works with the World Professional Association for Transgender Health to help establish the organization's standards of care, which are used by institutions around the globe.

(Ettner was also retained by Diamond's attorneys for her 2020 lawsuit. Ettner provided an analysis of Diamond's treatment for gender dysphoria while in the care of the Georgia Department of Corrections.)

As a result of the GDC's health care denials and the frustration she felt at not being heard, Diamond said that she experienced severe physical and mental anguish. She said it was "catastrophic" to go without hormone treatment on a regular basis.

Getting medication sporadically "plays on your mind and your mental health," she explained. "You're also dealing with the ramification of withdrawals: You're sick and you're vomiting, and you're not seeing the changes that you should be seeing."

She told NPR that the depth of loneliness and self-loathing "is just a reality when you get fed up and when you're hurting, and when you're sick and when no one is listening."

Diamond repeatedly tried to castrate herself while incarcerated. Her attorneys said in a court document that this was "a desperate form of self-treatment that has led to severe medical complications such as difficulty urinating."

Diamond said these attempts occurred during an incredibly low time for her, after a year back in custody. She explained to NPR where her mind was during one of those attempts: She said she thought at the time that this piece of her body "is why people hate me. Then why don't I just cut this off? Then what?"

Extreme measures like this are not uncommon when trans women don't receive sufficient gender-affirming health care, according to Ettner.

"I have seen far too many individuals engage in auto-castration, auto-penectomy, as attempts to 'surgically self-treat,'" Ettner said. She described it as a "desperate and often deadly attempt to remove the testosterone that kindles the dysphoria."

In response to NPR's request for comment on Diamond's 2020 lawsuit, a representative for the GDC declined to speak specifically about her allegations.

"The lawsuit between Ms. Diamond and the GDC remains pending, and so we cannot offer specific comments on the statements she made to you. However, the GDC believes that the Court was satisfied that the evidence produced so far demonstrated that her medical and mental health needs were met during her incarceration," said Jennifer Ammons, the general counsel for the Georgia Department of Corrections, in a statement.

Health Care

How gender-affirming care may be impacted when clinics that offer abortions close, prison policies on the books can be lacking.

A major survey highlights the problems that trans inmates like Diamond have in accessing medical care.

In the 2015 U.S. Transgender Survey , 58% of respondents who were incarcerated in the prior year had been taking hormones before being imprisoned. Of those, 82% had a prescription for hormones. More than one-third (37%) of respondents who had been taking hormones before their incarceration said they were banned from continuing to take their hormones once in custody.

The reported experience of transgender inmates shows that hormones are less available than state corrections departments suggest in their policies. Most state corrections departments explicitly say access to hormone therapy will be provided to transgender inmates, if proved medically necessary. But some legal cases indicate that facilities act differently in practice, like in Diamond's situation.

Prison policies on trans health care are inadequate, according to Ettner.

"Some states still have 'freeze frame' policies — requiring proof of care prior to entering prison and maintaining that dose throughout an individual's incarceration, even if it was a low, introductory dose," she said.

Most states require inmates requesting hormone therapy to show health records to continue hormone access behind bars, or they require approval from a doctor, a committee specially designated to handle issues affecting trans inmates and sometimes a warden.

Showing prior medical records sometimes "proves an insurmountable blockade" because there are trans prisoners entering correctional institutions who don't have a prior prescription for hormones from a physician, Ettner said. Individuals who earned their living from sex work, drug sales or other underground work were more likely to turn to unlicensed sources for hormones, according to the U.S. Transgender Survey.

The legal fight continues

The ACLU won a major victory this year against the Federal Bureau of Prisons (BOP).

The BOP settled a case, initially filed in 2020, by a federal inmate named Cristina Nichole Iglesias. She won the ability to be evaluated for gender-affirming surgery. When she was approved by the BOP, she became one of the first incarcerated individuals in federal custody to be granted this medical procedure.

Brown, the ACLU staff attorney, was part of this federal case. It mirrors the same trends happening at the state level, she said.

When individual cases are brought to court, judges often side with the prisoner's right to access gender-affirming care, Brown said.

"We have seen a number of courts come down against prisons across the country and ordered them to stop violating transgender prisoners' constitutional rights and provide them with the health care that they need," Brown said. "So while we're winning these victories in court for individual plaintiffs, that doesn't change the reality for many transgender people who are incarcerated."

Many trans inmates are facing a continuing legal battle to access gender-confirmation surgery. Some states don't have an explicit policy regarding granting inmates access to this surgery, according to medical care policies collected by the Transgender Law Center and reviewed by NPR.

In cases specifically related to gender-confirmation surgery, courts have varied widely on whether a prison's refusal to provide this type of care violates an inmate's constitutional rights. For example, a study reviewing decisions by U.S. Circuit Courts of Appeals in cases filed by incarcerated trans women found that courts differed about whether there is a medical necessity for gender-confirmation surgery.

Diamond was released this summer but said she is still working to bring her story to light.

She's writing a memoir and music to help make that happen.

"Every day I worry about the people that have been left behind. I worry about the trans women still there," she said. "Some cases will never get the attention that this case got, and so I've got to use it to empower the community and to educate people."

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Gender Reassignment Surgery, Prisoners, and the 8th Amendment

• September 22, 2021 September 27, 2022

By: Bill Watt

Advancements in technology have created new legal questions for federal courts to address. Is it a violation of the Eighth Amendment’s “Cruel and Unusual Punishment” clause to deny gender-reassignment surgery to a person in prison who experiences gender dysphoria? [1]

In the medical field, gender reassignment surgery (“GRS”) is a technological innovation that has become increasingly common. [2] Gender dysphoria, a condition that leads to GRS, is referred to as discomfort or distress caused by a mismatch between a person’s gender identity and that person’s sex assigned at birth. [3] The global market for GRS was $202 million in 2017. [4] GRS has an estimated growth rate of 25.1% annually through 2024 – when the market will reach a projected valuation of $968 million. [5]

Before the first half of the 20th century, gender reassignment surgeries did not occur at all or were extremely rare. [6] One of the early recipients of sex reassignment surgery is Lili Elbe. [7] Ms. Elbe, a German, began transitioning from a male to a female in 1930. [8] In 1931, she died from surgical complications three months after a vaginoplasty and uterus transplant. [9] In 1952, Christine Jorgensen, a famous cultural icon and United States citizen, traveled to Denmark and began a series of operations for sex reassignment surgery. [10] The first male-to-female GRS in the United States occurred in 1966. [11]

Circuit courts have come up with different rationales and holdings in deciding whether denying GRS violates the Eighth Amendment. In deciding Edmo v. Corizon, Inc. , (2020), the Ninth Circuit, which presides over district courts located on or near the Pacific Coast, mandated that states pay for and provide sex-reassignment surgery to a prisoner when it is a medical necessity. [12] The Court focused on a standard created by the World Professional Association for Transgender Health (WPATH) to determine if sex-reassignment surgery is medically necessary. [13] An inclusion criterion for genital surgery includes age, mental health, and 12 months of continuous hormonal therapy. [14] Even though the plaintiff suffered from extreme mental distress and attempted suicide, a surgeon did not provide her with GRS. [15]

The First, Fifth, Seventh, and Tenth Circuit courts ruled that sex-reassignment surgery is not a necessity. [16] These federal circuit courts have used different rationales to arrive at this conclusion. In Kosilek v. Spencer (2014), the First Circuit recognized the existence of WPATH but did not heavily rely on it in their decision to reverse a district court’s grant for injunctive relief. [17] The Court determined that the current treatment for the plaintiff was enough and that security in prison would be problematic post-surgery. In Gibson v. Collier (2019), the Fifth Circuit said that there was medical disagreement over the necessity of sex-reassignment surgery. [18] The surgery could not definitively be called a necessity. Further, the Court said it is not “cruel and unusual punishment” to withhold medical treatment that prisons have never given in the past. [19]

[1] Jacklyn Gunn, Is Denying Sex-Reassignment Surgery to Prisoners a Violation of the Eighth Amendment? , Sunday Splits (July 11, 2021), http://sundaysplits.com/2021/07/11/is-denying-sex-reassignment-surgery-to-prisoners-a-violation-of-the-eighth-amendment/.

[2] Universitätsspital Zürich, Gender reassignment surgery , YouTube (Aug. 5, 2020).

[12] Jacklyn Gunn, Is Denying Sex-Reassignment Surgery to Prisoners a Violation of the Eighth Amendment? , Sunday Splits (July 11, 2021),  http://sundaysplits.com/2021/07/11/is-denying-sex-reassignment-surgery-to-prisoners-a-violation-of-the-eighth-amendment/.

[14] Universitätsspital Zürich, Gender reassignment surgery , YouTube (Aug. 5, 2020).

[15] Jacklyn Gunn, Is Denying Sex-Reassignment Surgery to Prisoners a Violation of the Eighth Amendment? , Sunday Splits (July 11, 2021),  http://sundaysplits.com/2021/07/11/is-denying-sex-reassignment-surgery-to-prisoners-a-violation-of-the-eighth-amendment/.

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Transgender Inmate Receives Gender Affirming Surgery After Yearslong Battle

An Idaho inmate has become the second incarcerated person in the U.S. to receive gender affirming surgery while in prison, following a legal dispute that went to the U.S. Supreme Court.

Last year , the 9th Circuit Court of Appeals ruled that Idaho Department of Corrections (IDOC) must provide medically necessary gender affirming surgery for Adree Edmo, 32, a transgender woman, after she filed a lawsuit in 2017 against the state of Idaho and the IDOC’s health care provider, Corizon Health Inc., in which she argued that depriving her of gender affirming treatment violates the constitution’s ban on “cruel and and usual punishment.”.

That ruling was issued by a three-judge panel — U.S. Circuit Judge Mary Margaret McKeown, U.S. Circuit Judge Ronald Gould, and U.S. District Judge Robert Lasnik — who are all Clinton appointees. Idaho Gov. Brad Little attempted to appeal the case to the U.S. Supreme Court, but it declined to take up the case and permitted the lower court ruling to stand.

"The hard working taxpayers of Idaho should not be forced to pay for a prisoner's gender reassignment surgery when individual insurance plans won't even cover it," Little had argued , despite having used taxpayer dollars himself to fight the legal action. "We cannot divert critical public dollars away from our focus on keeping the public safe and rehabilitating offenders."

An online petition opposing Edmo’s case had reached nearly 6,000 signatures last year.

In 2012, prison doctors diagnosed Edmo with gender dysphoria, a term that describes the disconnect between a person’s gender identity and the sex they were assigned at birth. The Idaho Press reported that Edmo received the surgery on July 10, according to Deborah Ferguson, Edmo’s lawyer.

According to a spokesman for the Idaho Department of Correction, Edmo is at the Idaho Correctional Institution-Orofino for post-surgical medical care and will be transferred to the Pocatello Women's Correctional Center “once it is medically appropriate to do so."

Nearly one in six transgender Americans — and one in two Black transgender people — has been to prison, according to a 2012 survey conducted by Lambda Legal. A February report by NBC News found that incarcerated transgender Americans are often placed in prisons based on the sex they were assigned at birth, research that was based on documents received through public records requests and interviews with 18 current and former transgender prisoners.

Transgender and gender nonconforming people face higher rates of violence and discrimination in prison, which tends to be worse in places that are separated by sex, such as county jails, immigration facilities and prisons, according to the Lambda Legal Defense and Education Fund , an organization that focus on the civil rights of the LGBTQ+ community, as well as people living with HIV/AIDS.

In a statement last year following the successful ruling, Edmo said that she was “relieved and grateful” the court recognized her right to necessary medical treatment. “I hope my case helps the State of Idaho understand that they can’t deny medical care to transgender people.”

Edmo is scheduled to complete a prison sentence in 2021 after serving a 10-year sentence for the 2011 sexual assault of a 15-year-old boy when she was 22.

A California inmate named Shiloh Heavenly Quin e, became the first transgender prisoner to receive gender affirming surgery in 2017. Quine is serving a life sentence for the for the 1980 robbery, kidnapping and murder of 33-year-old Shahid Ali Baig in downtown Los Angeles.

In 2015, California prison officials agreed to fund Quine’s surgery after years of opposition, making the state the first to successfully allow transgender inmates to apply for gender affirming surgeries. A total of seven inmates in California have undergone gender affirmation surgery as of 2019, according to the Washington Blade .

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California pays for inmate's gender reassignment surgery

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Van Gogh's Starry Night recreated as park in Bosnian hills

Amid the green hills and meadows of central Bosnia, a local businessman has realised his long-held dream: recreating one of Vincent van Gogh's most famous paintings, The Starry Night, in the form of a nature park.

Beginning gender change in prison is a long shot 

Bradley Manning may want to live as a woman, but the young man sentenced to prison this week for leaking hundreds of thousands of secret government documents will face a difficult — if not impossible — task of beginning to switch his gender behind bars.

Manning, 25, announced through his lawyer on TODAY Thursday that he intends to request hormone therapy while at Fort Leavenworth prison. 

"I am Chelsea Manning. I am female," the Army private wrote in a statement read on TODAY Thursday. 

Throughout Manning's court-martial for divulging government papers to the website WikiLeaks, the soldier’s gender confusion was a factor used by the defense.

The move raises a host of questions about Manning, about transgender inmates in the U.S. -- and about the treatment itself. Here are answers from experts and advocates familiar with sex-change issues.

Can Manning get   hormone   therapy   in a U.S. military prison?  

Manning is being held at the military prison in Fort Leavenworth, Kan., where the now discharged soldier is expected to serve at least seven years and up to the full sentence of 35 years. 

“The Army does not provide hormone therapy or sex-reassignment surgery for gender identity disorder,” Kimberly Lewis, a spokeswoman for the prison, told NBC News. 

Manning's lawyer, David Coombs, told TODAY that he's "hoping" Fort Leavenworth "would do the right thing" and provide hormone therapy for Manning. "If Fort Leavenworth does not, then I'm going to do everything in my power to make sure they are forced to do so."

Coombs said that Manning hasn't discussed whether to pursue sex-reassignment surgery while in prison.

Why would he need such treatment?

Manning reportedly expressed ongoing distress over gender confusion and created an identity dubbed “Breanna” while deployed, and now identifies as a "she" named "Chelsea." She was diagnosed with gender dysphoria, the preferred term for gender identity disorder, or GID, according to Dr. David Moulton, the defense’s expert on forensic psychiatry. It’s a rare condition in which people feel that their physical gender does not match who they are on the inside.

In a statement read on TODAY, Manning wrote: "Given the way that I feel, and have felt since childhood, I want to begin hormone therapy as soon as possible. I hope that you will support me in this transition."

Have other prisoners received hormone therapy or sex-change surgery?

No inmates have received sex-reassignment surgery while in U.S. prisons, though dozens of lawsuits have forced changes at the state and federal level that have opened the door to such treatment, said Jennifer Levi, director of the Transgender Rights Project for the Gay & Lesbian Advocates and Defenders, or GLAD.

In the highest-profile case so far, a Boston judge told Massachusetts officials to grant the procedure last year to a transgender prisoner, Michelle Kosilek. Kosilek, formerly known as Robert, is facing a life sentence for the 1990 murder of wife Cheryl Kosilek. Kosilek's doctors have said that surgery is the only treatment that will fully address her gender identity disorder; she attempted castration and tried to commit suicide twice while held in an all-male prison. That court decision is pending on appeal. Kosilek has already received hormone therapy and laser hair removal.

Other inmates have received hormone therapy and other care for transgender issues. Under old rules, transgender inmates housed by the federal Bureau of Prisons were treated only for their existing conditions when they were admitted to prison. If they took hormones, for instance, that was maintained. But in 2010, after a lawsuit, the prison bureau changed its policy to allow treatment and care for problems diagnosed after incarceration. “Treatment options will not be precluded solely due to the level of services received, or lack of services, prior to incarceration,” the new policy states. That opens the door to new options, including surgery.

Very little is known about transgender inmates in military prisons, advocates say. Manning's request may even be unprecedented.

How often does this happen?

No one knows how many of the nearly 2.3 million prisoners in the U.S. are identified as transgender. A 2010 study by the California Department of Corrections identified more than 330 transgender inmates in a population of about 160,000, equal to about 0.2 percent. But the National Center for Transgender Equality estimates that the actual figure may be much higher. When that group surveyed transgender people in 2011, officials found that 16 percent of nearly 6,500 respondents reported that they’d been jailed at some time in their lives.

Why is this the   prison's problem?

Doctors who treat transgender people and advocates who lobby on their behalf say that inmates are legally entitled to health care while incarcerated -- including services for gender identity issues.

“Treatment for people with severe gender dysphoria is medically necessary,” said Dr. Sherman Leis of the Philadelphia Center for Transgender Surgery, who performs sex-change operations three days a week.

Just as diabetics need insulin and people with heart problems need surgery, inmates with gender identity-related health problems require the most appropriate treatment, said Mara Keisling, executive director of the National Center for Transgender Equality.

“This is America; we do not deny prisoners health care,” Keisling said. “What happens if they break a leg while they’re in custody? What happens if they develop schizophrenia? It is illegal to withhold those treatments.”

What kind of ‘treatment’ are we talking about? 

For those in and out of prison, switching genders is a protracted, complicated process that involves years of psychiatric counseling, hormone therapy and -- sometimes, but not always -- surgery, experts say.

Male-to-female transgender people typically take the female hormone estrogen in sufficient doses to influence the development of breasts and other secondary sex characteristics. They must receive adequate regular doses for the rest of their lives to maintain their new gender. They often also undergo laser hair removal.

If surgery is indicated, it can involve a range of procedures including removal of the original sex organs and reconstruction of new genitals. Other surgeries can include removing or augmenting breasts and reshaping facial contours, Leis said. 

Coombs, Manning's lawyer, told TODAY that his client's final goal is not necessarily surgery. 

"No, I think the ultimate goal is to be comfortable in her skin and to be the person that she never had an opportunity to be," Coombs said.  

How much does it cost? And who pays?

Cost ranges widely from $12,000 to $30,000 or more for surgery with ongoing costs of up to $200 a month for hormone therapy and more for psychotherapy.

If a prisoner receives care while incarcerated, the taxpayers would foot the bill, advocates say.

Can   this be a ploy  for men to get into a women' s prison?

GID is diagnosed by a doctor and the life-altering treatment must be prescribed. Besides, prisons usually go by birth gender when assigning inmates, so even after gender reassignment, a newly female prisoner could end up in a male population— or in isolation for her own protection.

Fort Leavenworth spokesman George Marcec told the Associated Press that Manning would need to petition for a transfer to a federal prison to receive hormone treatment. In addition, the prison staff can separate high-risk prisoners from the general population based on the level of security risk to the inmate and others, he added.

Officials with the United States Disciplinary Barracks said that they have procedures to ensure that Manning and any other transgender inmates are protected from abuse and assault while in custody. 

"The USDB has implemented risk assessment protocols and safety procedures to address high risk factors identified with the Prison Rape Elimination Act," the agency said in a statement. 

Getting Hormones and Surgery for Transgender Prisoners

The Army's blanket denial of hormone therapy and gender reassignment surgery to Chelsea Manning may not be the final word on the matter.

Yesterday, one day after the whistleblower formerly known as Pfc. Bradley Manning was sentenced to 35 years in prison for leaking thousands of classified documents, Manning announced that she has embraced her true gender identity and would like to live out the rest of her sentence—and the rest of her life—as Chelsea Manning, a woman. So how does the criminal justice system care for the health and well-being of transgender prisoners?

Access to transition-related healthcare services, such as hormone therapy and sex reassignment surgery, has been a major concern for transgender prisoners and advocates. Before 2010, it was the policy of the U.S. Bureau of Prisons to provide hormones at whatever level was maintained prior to the incarceration. After a 2010 lawsuit, however, the bureau reformed those regulations to include transgender women who did not begin hormone therapy until after their incarceration—and today, for the most part, transgender prisoners are able to access necessary hormone therapy. When Pfc. Manning mentioned in her statement that she would like to begin hormone therapy “as soon as possible,” the Army quickly released a statement saying that it “does not provide hormone therapy or sex-reassignment surgery for gender identity disorder.”

“It seems odd that the Army would make a determination on Manning’s healthcare needs before they’ve even had an assessment,” says Masen Davis, the Executive Director of the Transgender Law Center. “Manning has the right to access necessary medical care while she is in prison, which may include estrogen. That should be determined by a doctor and the patient, not by bias.”

Although transgender inmates are not currently able to receive sex reassignment surgery while incarcerated, in 2012 a U.S. District Judge ordered Massachusetts prison officials to provide sex reassignment surgery to Michelle Kosilek, a transgender woman serving life in prison for murder, on the basis that the surgery would meet Kosilek’s “serious medical need.” The Massachusetts Department of Correction is currently appealing the decision, but according to Jennifer Levi, Director of the Transgender Rights Project for the Gay and Lesbian Advocates and Defenders (GLAD), the decision opens the door to the possibility that transgender inmates might be able to access sex reassignment surgery.

In the past, transgender prisoners were assigned to either a men’s prison or a women’s prison based on whether or not they had already undergone gender reassignment surgery prior to the incarceration. Prisoners who had not had gender reassignment surgery, such as Pfc. Manning, were placed in prison according to the gender they were assigned at birth, regardless of how long they had been living as their true gender or how many previous transitional medical treatments or surgeries they had already undergone. This practice attracted particular controversy in 1994, when the Supreme Court ruled that prison officials had violated the cruel and unusual punishment clause of the Eighth Amendment after Dee Farmer, a male-to-female transgender prisoner who had already received breast implants but not yet had genital reassignment surgery at the time of her incarceration, was repeatedly raped at the men’s prison to which she had been assigned. Fortunately, though, the Department of Justice’s 2012 Prison Rape Elimination Act took landmark steps to protect all prisoners, including transgender prisoners, from sexual assault.

“The new guidelines require a case-by-case consideration for housing transgender inmates in either male or female facilities,” Davis says. “There is no longer a one size fits all approach—instead, it’s based on an individual assessment of what would make the most sense for that person.” Davis added that these guidelines do not currently apply to military prisons. Manning has been assigned to a men’s military prison.

Transgender prisoners, and especially transgender women, are also at a much higher risk of violence and sexual assault. Historically, transgender prisoners have been placed in “non-punitive administrative segregation”—a euphemism for solitary confinement—for their own protection. Although that practice sometimes did succeed in keeping transgender prisoners away from potentially violent fellow inmates, it was also socially isolating, precluded transgender prisoners from participating in social and recreational activities, and had serious consequences for inmates’ mental and emotional health. The 2012 DOJ guidelines include limits on the extent to with protective segregation can be used on transgender inmates, although Mara Keisling, the founding Executive Director of the National Center for Transgender Equality, says there has not yet been an audit to measure how successfully those measures have been implemented.

“The reality is that every credible medical organization has recognized gender identity disorder as a legitimate medical condition, and that the appropriate standard of care includes hormone therapy and surgery,” Levi says. As for Pfc. Manning, transgender advocates say that the Army’s decision to deny her access to hormone therapy will likely be challenged.

“It is illegal in the U.S. to withhold legitimate medical treatment from prisoners,” Keisling says. “What the Army said today about Private Manning’s care is not the last word on the issue.”

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Supreme Court Won’t Block Surgery for Transgender Inmate

The prisoner, Adree Edmo, said Idaho’s failure to provide the procedure violated the Eighth Amendment’s ban on cruel and unusual punishment.

By Adam Liptak

WASHINGTON — The Supreme Court on Thursday turned down a request from Idaho prison officials to block court-ordered sex reassignment surgery for a transgender prisoner.

The court’s brief order, which gave no reasons, let stand a ruling from the United States Court of Appeals for the Ninth Circuit, in San Francisco, in favor of the prisoner, Adree Edmo, a transgender woman.

Justices Clarence Thomas and Samuel A. Alito Jr. said they would have granted the prison officials’ request for a stay of the Ninth Circuit’s ruling.

Ms. Edmo, who was convicted of sexually assaulting a sleeping 15-year-old boy, is scheduled to be released next year. She has been treated for gender dysphoria, the psychological distress caused by incongruence between experienced gender and that assigned at birth, with hormone therapy and counseling.

A prison psychiatrist, Dr. Scott Eliason, denied her request for surgery notwithstanding two attempts by Ms. Edmo at self-castration. Ms. Edmo sued, saying that the failure to provide the surgery violated the Eighth Amendment’s ban on cruel and unusual punishment.

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Has the Biden administration made gender-affirming surgery accessible for federal prisons? Officials won’t say.

Donna Langan has become the first transgender person to undergo gender-affirming surgery in a federal prison, but the White House won’t comment on its policies.

Candice Norwood , Kate Sosin

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Cristina Nichole Iglesias was supposed to be the first. Last June, the American Civil Liberties Union of Illinois announced that the federal government would finally make good on something it had been legally required to do for years: provide gender-affirming surgery to a transgender person in federal prison.

Iglesias won what advocates hailed as a landmark settlement against the Bureau of Prisons after decades of being denied health care for her gender dysphoria.

“We hope this victory will pave the way for other transgender people in federal custody to get the care they need,” Joshua Blecher-Cohen, an ACLU of Illinois staff attorney who represented Iglesias, said in a statement at the time.

But nine months later, Iglesias is still waiting for her surgery, scheduled for this spring. In the meantime, another transgender woman in federal prison has received that care. President Joe Biden’s administration won’t say if the two cases mark a change in policy for the federal government, which has long denied transition-related surgeries to detainees even after publicly announcing broader accessibility. State prisons and jails are also required to follow federal guidelines for detaining transgender people, but many states have neglected to enforce the policies.

Donna Langan, a transgender woman incarcerated in a federal prison in Texas, became the first federal prisoner to receive gender-affirming surgery in December 2022, according to her lawyer Moira Meltzer-Cohen. 

“Ms. Langan is not alone in enduring decades of anguish resulting from the Federal Bureau of Prisons’ functionally blanket denial of this medically necessary, life-saving care,” Meltzer-Cohen said in a statement.

According to Meltzer-Cohen, it took 16 years of requests before the Bureau of Prisons allowed Langan to have hormone replacement therapy in 2012. In 2016, she was transferred to a women’s prison and spent four years petitioning for gender-affirming surgery. 

• Biden administration releases new transgender federal prison policy

‘They couldn’t understand me’: One woman’s plea for transgender surgery in prison

Federal law requires that state and federal prisons place transgender people on a case-by-case basis, taking into account where each detainee feels they will be safest. 

LGBTQ+ legal scholars, backed by major medical associations, have argued denying treatment for gender dysphoria amounts to cruel and unusual punishment.

However, prisons have largely denied transgender people affirming housing and medical care. 

“Implementation of these good, well-intended efforts is abysmal at best,” said Julie Abbate, who worked for 15 years in the civil rights division of the Department of Justice and who is now the national advocacy director for Just Detention International, an organization that seeks to end sexual abuse for people in detention. “There are really amazing professionals in the BOP who are dedicated to providing the services that are required by the population that they lock up. And chaos ensues nonetheless in the implementation.”

Before taking office, Biden promised reform. His campaign website promised to “ensure all transgender inmates in federal correctional facilities have access to appropriate doctors and medical care —including OBGYNs and hormone therapy.” 

Biden noted that when he was vice president, the Obama administration had “issued a Transgender Offender Manual , requiring gender identity be considered when making housing assignments.”

That manual was rolled back during Donald Trump’s presidency, but Biden reinstated it last year. The latest version of the manual says that surgery for incarcerated transgender people is “generally considered only after one year of clear conduct and compliance with mental health, medical, and programming services at the gender-affirming facility.” 

Requiring a minimum one-year waiting period before providing gender-affirming care is common both in and out of correctional facilities, Olivia Hunt, the policy director for the National Center for Transgender Equality, told The 19th.

“It’s unfortunate, but it’s a common kind of requirement that you hear in almost every circumstance, whether it be a surgeon who will not consider transition-related care until a person has ‘lived in their affirmed gender for a year,’ or an insurance company that won’t cover transition-related surgery unless a patient has been receiving hormone therapy for a year,” Hunt said.

Mandating a waiting period can make the transition process more difficult from an emotional and safety standpoint, particularly in prison, where a transgender woman might be transferred to a woman’s facility before she has obtained her necessary medical care.

According to the BOP manual, after one year a person interested in surgery can submit a request to their warden for surgical consideration.

The request is then supposed to be passed on to the bureau’s Transgender Executive Council, which assesses whether the criteria for surgical consideration have been met. After TEC, the case is then given to the agency’s medical director to determine “whether surgery is medically appropriate for referral to a gender-affirming surgeon.” But the timeline of this process and the specific reasoning behind why a surgery request might be denied remains unclear.

The Biden administration has signaled support for gender-affirming care behind bars outside of the manual. In 2021, the Department of Justice filed a statement of interest in support of Ashley Diamond , a transgender woman incarcerated in a Georgia state prison at the time, who sued twice for access to gender-affirming care. 

• People face a ‘desperate’ reality after leaving prison. Two Atlanta women are pushing to change that.
• A woman’s calls sustained her incarcerated grandson. Now a law in her name will lower prison phone rates.
• Mental health of incarcerated LGBTQ+ youth is understudied — but new analysis shows kids are in crisis

But the administration will not confirm that BOP has provided the first gender-affirming surgery, nor whether it will shift to providing broader access to surgery in the future.

Randilee Giamusso, a spokesperson for the Bureau of Prisons, declined an interview and cited the Transgender Offender Manual when asked to confirm that Langan was the first transgender person in BOP custody to receive surgery. Tom Shea, a spokesperson for the Department of Justice, likewise declined to comment. 

When asked whether the administration has moved to make gender-affirming care more accessible, Kevin Munoz, assistant White House press secretary, sent The 19th its own article about the Transgender Offender Manual being reinstated last year. Munoz did not respond after reporters pointed out that the manual dated back to the Obama administration but had not previously prompted the federal government to grant gender-affirming surgeries. 

Advocacy groups told The 19th that Langan’s surgery is a big moment in the years-long effort to secure medical care for transgender people in prisons. However, her case highlights how major action from the BOP in providing surgical procedures has come only after lawsuits, said Amy Whelan, a senior staff attorney at the National Center for Lesbian Rights.

“I wish that the BOP didn’t have to be sued to make this progress, but you’ll notice that Donna Langan and Cristina Iglesias both had active lawsuits. And the BOP hasn’t provided surgery, as far as I know, to somebody who doesn’t have a lawsuit,” Whelan said. 

Major medical groups and researchers deem gender-affirming care, which includes surgery, to be medically necessary, and the BOP’s readoption of the Transgender Offender Manual last year signals the Biden administration’s recognition of this. 

But gender-affirming care is “absolutely not” being treated on the same level as other medical needs, Abbate said. “Because if [Donna Langan] is the first time a transgender person in BOP custody has received the gender-affirming surgery that they need, then they’re not being treated the same as other folks.”

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Incarcerated trans women won sweeping prison reforms in colorado. it could be a model for other states., biden will not use private federal prisons. prison reform advocates want him to do more., white house says it opposes gender-affirming surgery for minors.

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Watch CBS News

Idaho must pay for transgender inmate's surgery, court rules

By Caitlin O'Kane

August 27, 2019 / 10:24 AM EDT / CBS News

A federal  appeals court has ruled  that the state of Idaho must pay for a transgender inmate's sex reassignment surgery. The state says it will appeal the case to the U.S. Supreme Court.

Inmate Adree Edmo has been living as a woman for years, but has been housed in a men's prison,  CBS Idaho affiliate KBOI-TV reports . Deborah Ferguson, an attorney representing Edmo,  said in January  that her client was at risk of self-harm if the surgery was postponed.

Edmo, 31, was diagnosed with gender dysmorphia in 2012. Ferguson argued that the state's refusal to provide the surgery was unconstitutional.

"They certainly would treat a prisoner with cancer, they treat a prisoner with diabetes, or other chronic conditions," Ferguson said, according to KBOI-TV. "So, we have a medically recognized condition that's very treatable and we have been trying to get her the treatment that she very much needs."

Earlier this year, the state of Idaho was put on a court-ordered deadline to pay for the surgery by mid-June. The state, however appealed that decision — a process it says has already cost more than $325,000.

On Friday, the court of appeals agreed with the federal judge that denying the surgery amounted to cruel and unusual punishment, a violation of the U.S. Constitution.

Idaho Governor Brad Little, however, said he intends to appeal the decision to the U.S. Supreme Court.

"The court's decision is extremely disappointing," Little said in a statement obtained by KBOI-TV. "The hardworking taxpayers of Idaho should not be forced to pay for a convicted sex offender's gender reassignment surgery when it is contrary to the medical opinions of the treating physician and multiple mental health professionals."

Edmo, a convicted sex offender who is expected to be released from prison in 2021, is not the only inmate in the state requesting surgery. Five other requests have been submitted since the beginning of 2019, according to the Idaho Department of Correction .

Caitlin O'Kane is a New York City journalist who works on the CBS News social media team as a senior manager of content and production. She writes about a variety of topics and produces "The Uplift," CBS News' streaming show that focuses on good news.

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CIRCUIT COURT DYSPHORIA: THE STATUS OF GENDER CONFIRMATION SURGERY REQUESTS BY INCARCERATED TRANSGENDER INDIVIDUALS

Samantha braver*.

Incarcerated transgender individuals with gender dysphoria have increasingly turned to the courts to seek medical relief in the form of gen­der confirmation surgery (GCS). These claims generally allege that prison officials’ denials of GCS amount to deliberate indifference, which is forbidden under the cruel and unusual punishment provision of the Eighth Amendment. To date, the First, Fifth, and Ninth Circuits have been the primary federal appellate courts to address whether to grant requests for GCS under the Eighth Amendment. The Fifth Circuit’s legal reasoning enables prisons to institute categorical bans on GCS without considering an incarcerated individual’s factual circumstances and the evolution of medical knowledge on gender dysphoria. This Note suggests that instead, courts should adopt the legal approach of the First Circuit and Ninth Circuit, or the “ Kosilek–Edmo framework,” to better vindi­cate the constitutional right to medical care of incarcerated transgender individuals and adhere to Eighth Amendment precedent. The framework urges courts to examine the subjective prong of deliberate indifference on a case-by-case basis of medical need, rely on experts familiar with the World Professional Association for Transgender Health Standards of Care, and apply increased scrutiny when considering the security con­cerns prison officials may have in granting GCS requests or other accom­modation requests by incarcerated transgender individuals.

The full text of this Note can be found by clicking the PDF link to the left.

* J.D. Candidate 2021, Columbia Law School. The author would like to thank Professor Brett Dignam for her guidance and the staff of the Columbia Law Review for their diligent, insightful, and gracious edits. The author would also like to thank former Columbia Law Review editor Justice Ruth Bader Ginsburg for her pioneering work on gender discrimination in the law.

Introduction

Vanessa Lynn is a pre-operational male-to-female transgender individual residing in a correctional facility in Texas. 1 1 This Note refers to Vanessa Lynn by her preferred name and pronouns, although the Fifth Circuit refers to her by her assigned name, Scott Gibson, and by male pronouns. See Gibson v. Collier, 920 F.3d 212, 216 (5th Cir. 2019), cert. denied, 140 S. Ct. 653 (2019) (mem.). ... Close Lynn, who has gender dys­phoria, has lived openly as female for several decades. 2 2 Id. at 217–18. ... Close Officials, however, have provided Lynn with only limited treatment, such as hormone therapy, to aid her suffering from gender dysphoria while in prison. 3 3 Id. ... Close A lack of fuller medical treatment, which would entail gender confirmation surgery (GCS) through modification of one’s primary and/or secondary sex char­acteristics, 4 4 See infra section I.A.1. This Note refers to “sex reassignment surgery” by its newer classification and identification, “gender confirmation surgery (GCS).” See Loren S. Schechter, ‘Gender Confirmation Surgery’: What’s in a Name?, Huffington Post (Apr. 20, 2012), https://www.huffpost.com/entry/gender-confirmation-surgery_b_1442262 [https://perma.cc/28PG-JJ8G] (last updated Feb. 2, 2016) (explaining how “gender confirmation surgery” is the most accurate label for the plastic surgery that takes place); see also Gender Confirmation Surgeries, Am. Soc’y of Plastic Surgeons, https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries [https://perma.cc/3LMM-WWXQ] (last visited Sept. 1, 2020) (describing the surgical options available for transgender patients). ... Close has caused Lynn to experience immense anguish. In an attempt to accommodate her own medical needs, Lynn has inflicted severe harm upon herself, including tying a tight string around her testicles, repeatedly cutting herself, and attempting suicide three times while incarcerated. 5 5 Petition for Writ of Certiorari at 4, Gibson , 140 S. Ct. 653 (No. 18-1586), 2019 WL 2711440. ... Close Lynn swears that without GCS, she will castrate herself or commit suicide. 6 6 Gibson , 920 F.3d at 217. ... Close Despite her self-harm and continued mental pain, the Texas Department of Criminal Justice (TDCJ) has categorically refused to evalu­ate Lynn for GCS. 7 7 Id. at 217–18. ... Close Believing this denial violated her Eighth Amendment right to be free from cruel and unusual punishment, Lynn filed a pro se complaint in 2016 in the U.S. District Court for the Western District of Texas, alleging violations of her rights under 42 U.S.C. § 1983. 8 8 Gibson v. Livingston, No. W-15-CA-190, 2016 U.S. Dist. LEXIS 195724, at *19–20 (W.D. Tex. Aug. 31, 2016). ... Close She argued that TDCJ’s system-wide ban on GCS constituted deliberate indifference to her gender dysphoria. 9 9 Id. at *22–23. ... Close The district court granted TDCJ’s motion for summary judgment. 10 10 Id. at *34. ... Close

Much scholarship has been written in the past about the difficulties of obtaining relief for incarcerated transgender individuals with gender dysphoria under the Eighth Amendment’s cruel and unusual punishment framework. 11 11 See, e.g., Susan S. Bendlin, Gender Dysphoria in the Jailhouse: A Constitutional Right to Hormone Therapy?, 61 Clev. St. L. Rev. 957, 974 (2013) (describing how “bias against transgender individuals and misunderstandings about [g]ender [d]ysphoria may influence the outcome”); Lindsey V. Gilbert, Comment, Crossing the Line: Examining Sex Reassignment Surgery for Transsexual Prisoners in the Wake of Kosilek v. Spencer , 23 S. Cal. Rev. L. & Soc. Just. 29, 55–56 (2013) (explaining how some are opposed to GCS as a treatment option because they view it as medically controversial, costly, and unnecessary for individuals who are supposed to face punishment for committing crime); Lindsey Ruff, Note, Trans-Cending the Medicalization of Gender: Improving Legal Protections for People Who Are Transgender and Incarcerated, 28 Cornell J.L. & Pub. Pol’y 127, 144–45 (2018) (“For many plaintiffs, satisfying both parts of the ‘deliberate indifference’ inquiry proves to be an insurmountable hurdle.”). ... Close In particular, scholars have focused great attention 12 12 See, e.g., Bethany L. Edmondson, Note, Trans-lating the Eighth Amendment Standard: The First Circuit’s Denial of a Transgender Prisoner’s Constitutional Right to Medical Treatment, 51 Ga. L. Rev. 585, 594–96 (2017). ... Close on the first federal circuit court case to have decided this issue, Kosilek v. Spencer (Kosilek IV) . 13 13 This final decision, Kosilek v. Spencer ( Kosilek IV ), 774 F.3d 63 (1st Cir. 2014), was composed of an en banc court that ultimately reversed the initial appellate decision. See Kosilek v. Spencer ( Kosilek III ), 740 F.3d 733, 736 (1st Cir. 2014). ... Close In Kosilek IV , the First Circuit ruled that the incarcerated individual’s particular factual circumstances did not support a finding of deliberate indifference for a prison’s failure to provide GCS. 14 14 774 F.3d at 96. ... Close No other circuit court tested or contested this outcome for years.

In March 2019, the Fifth Circuit ruled on a similar Eighth Amendment claim by an incarcerated transgender individual. 15 15 Gibson v. Collier, 920 F.3d 212, 218 (5th Cir. 2019), cert. denied, 140 S. Ct. 653 (2019) (mem.). ... Close In Gibson v. Collier , the Fifth Circuit agreed with the First Circuit in its holding, affirming the district court’s decision that the denial of GCS to Lynn did not violate the Eighth Amendment’s deliberate-indifference standard. 16 16 Id. at 228. ... Close Mere months after Gibson , the Ninth Circuit disagreed with the Fifth Circuit’s ruling and the First Circuit’s outcome, holding in Edmo v. Corizon that when officials deny medically necessary GCS to an incarcerated transgender individual, the responsible officials are indeed deliberately indifferent. 17 17 935 F.3d 757, 797 (9th Cir. 2019). “Medically necessary” under the Eighth Amendment generally means a medical need so obvious that an ordinary person would recognize that it warrants treatment by a doctor. See Gaudreault v. Municipality of Salem, 923 F.2d 203, 208 (1st Cir. 1990); Laaman v. Helgemoe, 437 F. Supp. 269, 311 (D.N.H. 1977); infra section I.B.1 (discussing how courts determine what treatment is medically necessary). ... Close In coming to their decisions, the First and Ninth Circuits relied on a fact-specific approach to determine the plaintiff’s medical need for GCS, in contrast to the Fifth Circuit’s categorical ban on GCS. 18 18 See infra section II.C. ... Close The proper standard for determining what amounts to deliberate indifference by prison officials now remains in question for incarcerated transgender individuals seeking surgical relief for gender dysphoria.

This Note argues that despite the outcome-determinative split between the First and Fifth Circuits in opposition to that of the Ninth Circuit, the real circuit split exists between the First and Ninth Circuits’ similar interpretations of deliberate indifference in Kosilek IV and Edmo and the Fifth Circuit’s unprecedented interpretation of deliberate indif­ference in Gibson . Of these approaches, the Note ultimately proposes that courts should follow the Kosilek – Edmo framework, which aligns most soundly with how other courts have interpreted deliberate indifference in the past for incarcerated individuals (transgender and others alike) and best upholds their constitutional right to medical care under the Eighth Amendment. 19 19 See infra Part III. ... Close Part I of this Note provides medical background infor­mation on gender dysphoria and an overview of Eighth Amendment jurisprudence on claims by incarcerated transgender individuals. Part II considers the competing legal applications of deliberate indifference among the Kosilek IV , Gibson , and Edmo courts and describes how the Kosilek – Edmo framework lies in contrast to the Gibson court’s approach. Part III recommends that courts adopt the Kosilek – Edmo framework and offers jurisprudential recommendations for how courts can standardize their deliberate-indifference analyses on these types of claims in the future.

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Court: Transgender people in prisons can get gender-affirming care

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After a five-year legal battle, the U.S. District Court recently ruled that transgender people incarcerated in Connecticut prisons are entitled to gender-affirming health care. 

Veronica-May Clark originally filed the case in 2019, and the American Civil Liberties Union offered her representation in 2021. Clark, who has been in custody since 2007, alleges that after a diagnosis of gender dysphoria — a medical diagnosis for someone who experiences distress that can occur when their true gender does not match with their outward appearance and/or the sex they were assigned at birth — her treatment from the Department of Correction was inconsistent. 

“At the end of the day, she just wants health care,” Elana Bildner, Clark’s attorney with the CT ACLU, told The Connecticut Mirror. “She wants the health care to be consistent, to be adequate, to be appropriate [and] to be able to rely on the fact that she will get this health care that she needs for the long term.”

As a result of the DOC’s continued delay of her requests, she says, her symptoms worsened, and she experienced serious self-harm and hospitalization. 

Unheard requests for care 

In July 2009, Clark was sentenced to an effective life sentence, 75 years, in Connecticut prison for beating his estranged wife’s boyfriend to death with a pipe. 

According to Bildner, Clark “had lived publicly as a woman” on and off throughout her life but had never tried to access transitional care. When sentenced, Clark chose to present as a cisgender man for her safety in prison. 

Seven years later, in April 2016, Clark requested treatment, including hormone therapy and gender-affirming surgery, and stated that she believed she had gender dysphoria. A month later, a DOC health care provider diagnosed Clark with gender dysphoria, but she was not provided any gender-affirming treatment, according to the lawsuit. 

Clark turned to self-harm in an effort to treat herself. According to the memorandum and witness testimony, Clark attempted to castrate herself in her cell.  

Following the incident, a DOC psychologist assessed Clark and affirmed that she had gender dysphoria and was undergoing a “high level of psychological distress.” Clark again filed a request for treatment consistent with the diagnosis. 

According to Bildner, the DOC had an “informal policy” that “if you didn’t come into prison having received transitional care, you could not get it in prison.” 

“She was fighting against something that she couldn’t see,” Bildner said. “The DOC said ‘Yes, you do [have gender dysphoria], and then refused her any transitional care on the basis of this unwritten policy.” 

In the months after her hospitalization, Clark continued to request hormone therapy and gender-affirming surgery. She described her situation as “simply intolerable” and DOC’s treatment of her as “cruel and unusual.”

[RELATED: CT: ‘Safe haven’ for transgender youth? For some, not safe enough]

Later, in September 2017, Clark saw an endocrinologist at University of Connecticut Health. Her physician prescribed her a low “starter dose” of spironolactone and estradiol: two drugs used for hormone therapy. The physician requested a follow-up in three months with Clark to track her progress and increase her dosage to a therapeutic level. 

Clark did not see the doctor again until August 2019. 

The inconsistent care, despite her requests, led Clark to sue the DOC for violating her Eighth Amendment right to freedom from cruel and unusual punishment and her Fourteenth Amendment right to equal protection under the law in April 2019, according to the complaint.

The Connecticut ACLU joined her team in 2021.

Bildner said the lawsuit occurred in two phases. The first, which was presided over by now-retired Justice Vanessa Bryant, was meant to “convince the court that if prisons have to provide health care, gender affirming care is health care. Therefore, prisons have to provide gender affirming care.” 

On Sept. 15, 2023, the U.S. District Court issued summary judgment in favor of Clark. The court concluded that DOC employees were “deliberately indifferent to Ms. Clark’s serious medical needs.” 

After that first decision, the case moved into its second “trial phase,” according to Bildner. This second phase took place throughout July 2024.

“[In] the trial phase, the DOC was trying to convince the judge [to] ‘forget about what had happened in the past,’ because they were now on top of it and no judicial intervention was required.” 

The DOC presented evidence that since the September 2023 ruling, they were making an increased effort to give Clark the treatment she requested. 

Justice Victor Bolden, however, was unconvinced and ultimately ordered an injunction on July 26 to ensure Clark’s constitutional rights were continuously upheld. 

“Although DOC has made progress in providing gender-affirming medical treatment to Ms. Clark in recent months, such efforts have not yet cured the ongoing Eighth Amendment violation,” Bolden wrote. “And, the Court has determined that an injunction is necessary to ensure that Ms. Clark receives appropriate medical care for her gender dysphoria and does not suffer additional irreparable harm.” 

The injunction requires continuous status reports on Clark’s care to both her lawyers and the court. 

The Department of Corrections Public Information Office said it was still reviewing the decision and was unable to comment.

“With that said, the DOC strives to provide quality healthcare to all those under our supervision,” DOC Public Information Officer Andrius Banevicius said.

A precedent-setting case 

The favorable injunction stretches beyond securing gender-affirming health care for just Clark, Bildner said. 

The case was the first of its kind in the Second Circuit, which includes Connecticut, New York and Vermont. 

“I really do think it answers the question of the prison system’s responsibility to gender-diverse people to provide health care for them that is multifaceted and that is individualized,” Bildner said. 

Often, prisoners have to secure this health care through litigation, according to Bildner. Prisons that do provide gender-affirming care can often still be “inconsistent or inadequate” like Clark’s, she said. 

The hope for the ACLU legal team is that the Connecticut DOC moves forward with this acknowledgment and no further prisoners turn to legal action in an effort to receive this type of care. 

“She’s relieved and grateful,” Bildner said about Clark following Justice Bolden’s ruling. “This healthcare for her is life-saving. Getting a hormone injection, she said in court, feels absolutely life-saving to her. And knowing that she can progress in a transition is really all she’s ever wanted.” 

Kaitlyn Pohly

Kaitlyn is CT Mirror’s General Reporting Intern. A member of Yale’s Class of 2026, she majors in History on the “Politics, Law, and Government” track. Additionally, Kaitlyn is receiving a certificate in Energy Studies and pursuing the Yale Journalism Initiative scholar distinction. She previously served as the student life reporter for the YaleDailyNews and now serves as the paper’s Sports Editor.

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Gender-Affirming Surgery Rare Among Transgender Children in US

In 2019, no transgender and gender diverse (TGD) children aged 12 years and younger underwent gender-affirming procedures in the United States (US). These findings were published in JAMA Network Open .

Gender-affirming health care procedures are aimed at aligning one’s physical appearance with their gender identity for TGD individuals. However, these procedures can also include breast reduction for cisgender men and boys with gynecomastia.

Recent US legislative efforts have attempted to restrict gender-affirming health care to TGD individuals. Although supporters of these legislations often site concerns about TGD children, the number of TGD children undergoing gender-affirming procedures is expected to be low.

Investigators from the Harvard T.H. Chan School of Public Health conducted a cross-sectional study sourcing data from the Inovalon Insights database. Among a cohort of 47,437,919 adults and 22,827,194 children and adolescents, the rates of gender-affirming procedures in 2019 were assessed on the basis of gender and age. Surgery for other indications, such as cancer or injury, were excluded from the analysis.

Among children and adolescents, 16.8% were aged 15 to 17 years, 11.9% were aged 13 to 14 years, and 71.3% were aged 12 years and younger.

The rate of gender-affirming surgery among TGD individuals was 5.3 per 100,000 adults, 2.1 per 100,000 adolescents aged 15 to 17 years, 0.1 per 100,000 adolescents aged 13 to 14 years, and 0 among children aged 12 years and younger.

Most gender-affirming procedures were chest-related among adults (59.7%) and children and adolescents (96.4%). Of all gender-affirming breast reductions among adults and children/ adolescents , 80% were performed on cisgender men and 97% were performed on cisgender boys.

The major limitation of this study was the reliance on diagnostic coding, which may have resulted in misidentification of the clinical justification for TGD or cisgender identities, and the exclusion of patients without insurance and patients who self-paid for gender-affirming surgery.

The study authors concluded that “these findings suggest that concerns around high rates of gender-affirming surgery use, specifically among TGD minors, may be unwarranted. Low use by TGD people likely reflects adherence to stringent standards of gender-affirming care.”

This article originally appeared on Endocrinology Advisor

References:

Dai D, Charlton BM, Boskey ER, et al. Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Netw Open . Published online June 27, 2024. doi:10.1001/jamanetworkopen.2024.18814

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Fact Check: Walz Did NOT Approve Legislation That Overrules Existing Protocols On Age For Gender-Affirming Surgeries

• Aug 9, 2024
• by: Uliana Malashenko

Did Minnesota Gov. Tim Walz sign a bill "allowing gender reassignment surgery for children"? No, that's not true: No state law sets a specific minimum age for gender-affirming surgical interventions, a Minnesota lawmaker told Lead Stories. Major health care providers do not operate on people under 18. One bill signed into law protects youth access to those services discussed in broad terms, but doesn't address a specific age.

The claim reproduced a frequent misconception about gender-affirming care: It ignores that such care is not limited to surgeries and includes many other treatments such as mental health services, puberty blockers and hormone therapies.

The claim appeared in a post (archived here ) on X, formerly known as Twitter, on August 6, 2024, by @BRICSinfo. It said:

Tim Walz, the VP selection for Kamala Harris, signed a bill allowing gender reassignment surgery for children and a bill requiring schools to stock tampons in boys' bathrooms. Donald Trump says he will ban gender reassignment surgery for children in all 50 states.

This is what the post looked like on X at the time of writing:

(Source: X screenshot taken on Wed Aug 7 15:37:05 2024 UTC)

What are the laws?

Rep. Leigh Finke (archived here ) who sponsored several key bills concerning gender-affirming care in Minnesota, told Lead Stories via email on August 8, 2024:

No law in Minnesota has been passed addressing the age of receiving gender affirming care, including surgery. We simply protected access to gender affirming care as it already existed for those who require it ... Standards of care in Minnesota follow the national and international guidelines for gender affirming care. Like all heathcare decisions, gender affirming care is highly personal and individualized. Families, patients, and doctors are best able to make those decisions, not the government. Minnesota's largest providers of gender affirming care do not perform any surgeries on individuals under 18.

Neither legislation about youth transgender health (archived here ), sometimes referred to as the "trans refuge" law (archived here ), nor the Governor's Executive Order on "Protecting and Supporting the Rights of Minnesota's LGBTQIA+ Community Members to Seek and Receive Gender Affirming Health Care Services" (archived here ) contains any provisions overriding existing medical protocols or sets a specific minimum-age bar for what the post called "gender reassignment surgery."

Both pieces of legislation went into effect in 2023. They discuss gender-affirming care in general terms to ensure that those who need care recognized as medically necessary (archived here ) by the Centers for Disease Control and Prevention, can safely access it.

Neither define such care exclusively as surgery. In reality, gender care can be many other things (archived here ). The transgender refuge law doesn't even explicitly mention surgical interventions -- it focuses on mental health services and other aspects of gender-affirming care.

Finke, a member of the Minnesota Democratic-Farmer-Labor Party, added:

In 2024, I carried a bill to require gender affirming care coverage among certain health care plans in the state of Minnesota. This law also did not address standards of care, including age. At no point has Minnesota legislature in the past two years passed legislation to change the standards of gender affirming care--including the age at which surgery could be conducted-- in Minnesota.

In June 2023, the Minnesota Reformer news website reported (archived here ) that "most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or 'top,' surgery."

In the spring of 2024, as Minnesota's gender care legislative actions made the news, Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children's Minnesota, told MPR (archived here ), a local public radio station, that the state does not perform gender-affirming surgeries on patients under 18 years old.

Lead Stories searched Minnesota statutes, laws and rules , but did not find anything that would explicitly set a minimum age for gender-affirming surgeries.

What are the surgeries?

" Gender (or sex) reassignment surgery " (archived here ), as the post on X calls it, is an outdated term (archived here ). It was once used primarily to refer to the medical interventions that change a person's genitalia.

The World Professional Association for Transgender Health (WPATH) manual (archived here ) -- one of the most authoritative sources of evidence-based gender care recommendations -- suggests on page 59 the term "gender-affirming surgeries," instead, . The current term incorporates several more interventions, and not all of them concern genitalia or the chest area, according to the appendix , attached to Chapter 13.

The newer term and its definition are consistent with the wording used by Minnesota's Department of Human Services (archived here ).

Who counts as a child?

In Minnesota, a child, or a minor, is any person younger than 18 (archived here ). After that, a person is generally considered an adult for many legal purposes. Though certain restrictions are still applicable (archived here ), that does not include required parental consent when it comes to health care (archived here ).

For gender-affirming care, however, "child" is not a blanket term for anyone under 18: People go through several developmental stages between birth and adulthood, and health care professionals consider that while deciding what is appropriate and medically necessary.

For example, the WPATH guidelines (archived here ) differentiates between children, pubescent youth and adults, as seen on page 67:

Unlike pubescent youth and adults, prepubescent gender diverse children are not eligible to access medical intervention (Pediatric Endocrine Society, 2020); therefore, when professional input is sought, it is most likely to be from an HCP [health care professional] specialized in psychosocial supports and gender development.

While WPATH suggests that there might be some benefits if vaginoplasty is performed before the age of 18, that appears to offer some flexibility -- not a blanket recommendation. At the same time, the organization still strongly advises against phalloplasty before that age.

The Minnesota Department Human Services (archived here ) prohibits one particular surgery -- phalloplasty -- before 18. In any case, the agency requires authorization for any other gender-affirming surgery, listing additional requirements for those younger than that age.

Trans youth and genital surgeries

Lead Stories was not able to locate any Minnesota-specific data about gender-affirming surgeries performed on people under 18, but available national statistics confirmed that genital surgeries in that age category are incredibly rare.

For example, a 2022 Reuters story (archived here ), citing an analysis of insurance claims for roughly 330 million U.S patients over five years, reported that:

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021.

A 2023 study (archived here ) published by the American Medical Association's JAMA Network Open, a peer-reviewed medical journal, read:

... breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

A 2024 article in JAMA Network Open (archived here ) found that among minors who had gender-affirming surgeries in 2019, 96.4 percent -- or 82 out of 85 cases -- were chest-related procedures, not genital surgeries.

Lead Stories contacted Minnesota Gov. Walz about the claim that is the target of this fact check. If we get a response, the article will be updated as appropriate.

About @BRICKinfo

The same account on X that posted the claim that is the focus of this fact check previously published a misleading statement about President Joe Biden before he dropped out of the presidential race. Lead Stories debunked it here .

Further reading

Lead Stories previously debunked false claims about transitions in toddlers here . Other Lead Stories fact checks concerning claims about transgender issues can be found here . Fact checks of claims about the 2024 U.S. presidential election are here .

Uliana Malashenko is a  New York-based freelance writer and fact checker. Read more about or contact Uliana Malashenko

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A trans history of the united states: books.

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Trans Metadata

• Trans metadata collective The Trans Metadata Collective is a group of dozens of cataloguers, librarians, archivists, scholars, and information professionals with a concerted interest in improving the description and classification of trans and gender diverse people
• Homosaurous This vocabulary is intended to function as a companion to broad subject term vocabularies
• A History of Classifying Trans Subjects at the Library of Congress before 1963 An article by Beck Shaefer
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Subect Headings

"subject headings" refer to a controlled vocabulary assigned to books by librarians, when they are being entered into the library catalog. The cool thing is that using one of these phrases when you search by subject will help you to have very specific results. The less cool thing is that these subject headings map to many of the biases of white, heteronormative, patriarchal, colonial, western culture. Lot's of librarians are doing good work to push against this. Here's a list though of many of the current Subject Headings that relate to trans and gender diverse content.

African American transgender people

African American transsexuals

Bible–Transgender interpretations

Children of transgender parents

Children of transsexual parents

Christian transgender people

Christian transsexuals

Church work with transgender people

Conversion therapy

Female-to-male transsexuals

Female-to-male transsexuals in art

Gender-affirming care

Gender binary

Gender dysphoria

Gender dysphoria–Religious aspects–Christianity

Gender dysphoria–Religious aspects–Islam

Gender dysphoria in adolescence

Gender dysphoria in children

Gender euphoria

Gender expression

Gender expression–Law and legislation

Gender identity

Gender identity–Law and legislation

Gender identity–Religious aspects–Buddhism

Gender identity–Religious aspects–Catholic Church

Gender identity–Religious aspects–Christianity

Gender identity–Religious aspects–Church of Jesus Christ of Latter-day Saints

Gender identity–Religious aspects–Hinduism

Gender identity–Religious aspects–Islam

Gender identity–Religious aspects–Judaism

Gender identity–Religious aspects–Mormon Church

Gender identity–Religious aspects–Neopaganism

Gender identity–Religious aspects–United Methodist Church

Gender identity in advertising

Gender identity in art

Gender identity in children

Gender identity in comics

Gender identity in dance

Gender identity in education

Gender identity in literature

Gender identity in mass media

Gender identity in motion pictures

Gender identity in music

Gender identity in science

Gender identity in sports

Gender identity in the Bible

Gender identity in the Qur’an

Gender identity in the theater

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Gender identity on television

Gender-neutral toilet facilities

Gender-nonconforming children

Gender-nonconforming children in literature

Gender-nonconforming people

Gender-nonconforming people–Identity

Gender-nonconforming people in library science

Gender-nonconforming people’s writings

Gender-nonconforming people’s writings, American

Gender-nonconforming people’s writings, Czech

Gender-nonconforming people’s writings, Russian

Gender-nonconforming prostitutes

Gender-nonconforming woodworkers

Gender-nonconforming youth

Gender nonconformity

Gender nonconformity–Religious aspects–Catholic Church

Gender nonconformity–Religious aspects–Christianity

Gender nonconformity–Religious aspects–Hinduism

Gender nonconformity–Religious aspects–Islam

Gender nonconformity–Religious aspects–Judaism

Gender nonconformity–Religious aspects–Lutheran Church

Gender nonconformity–Religious aspects–Neopaganism

Gender nonconformity–Religious aspects–United Church of Canada

Gender nonconformity in literature

Gender nonconformity on television

Gender reassignment surgery

Gender transition

Gender transition–Hormone therapy

Gender transition–Law and legislation

Gender transition in literature

Gender transition (Jewish law)

Jewish transgender people

Jewish transsexuals

Legal assistance to transgender people

Libraries and transgender people

Libraries and transsexuals

Libraries–Special collections–Gender identity

Libraries–Special collections–Transgender people

Male-to-female transsexuals

Minority transgender women

Names, Personal–Law and legislation

Older transgender people

Older transsexuals

Parents of gender-nonconforming children

Parents of transgender children

Parent of transsexuals

Restrooms–Law and legislation

Social work with gender-nonconforming youth

Social work with transgender people

Social work with transgender youth

Subject headings–Gender nonconformity

Subject headings–Transsexuals

Top surgery (Gender reassignment surgery)

Trans-exclusionary radical feminism

Transgender artists

Transgender athletes

Transgender children

Transgender college students

Transgender college teachers

Transgender Day of Remembrance

Transgender journalists

Transgender legislators

Transgender librarians

Transgender men

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Transgender musicians

Transgender parents

Transgender people

Transgender people–Employment–Law and legislation

Transgender people–Identity

Transgender people in art

Transgender people in library science

Transgender people in literature

Transgender people in mass media

Transgender people in motion pictures

Transgender people in popular culture

Transgender people’s writings

Transgender people’s writings, American

Transgender people’s writings, Canadian

Transgender people’s writings, Spanish American

Transgender police officers

Transgender prisoners

Transgender singers

Transgender students

Transgender superheroes

Transgender teachers

Transgender veterans

Transgender women

Transgender youth

Transmisogyny

Transphobia

Transphobia in medical care

Transphobia in schools

Transphobia in the military

Transphobia–Law and legislation

Transsexual college students

Transsexual librarians

Transsexual parents

Transsexual students

Transsexual youth

Transsexualism

Transsexualism–Religious aspects–Catholic Church

Transsexualism–Religious aspects–Christianity

Transsexualism–Religious aspects–Hinduism

Transsexualism–Religious aspects–Islam

Transsexualism–Religious aspects–Judaism

Transsexuals

Transsexuals–Identity

Transsexuals in literature

Transsexuals in motion pictures

Transsexuals’ writings

Transsexuals’ writings, American

Two-spirit people

Two-spirit people in literature

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