United States Gender-affirming healthcare According to
Masen Davis of the
Transgender Law Center, LGBT people in prisons often face barriers in seeking basic and necessary
medical treatment, exacerbated by the fact that prison health care staff are often not aware of or trained on how to address
those needs. and incarcerated transgender people can assert legal challenges under the 8th Amendment to access gender-affirming and gender-transition-related care under the framework first articulated in
Estelle v. Gamble. or under a
Bivens action to address deliberate indifference and denial of healthcare in federal prisons. Some courts in the US have ruled that
hormone replacement therapy is a necessary medical treatment to which transgender prisoners are entitled. In the early 2000s, California Medical Facility, Vacaville, provided this medical treatment for male-to-female prisoners. Additionally, access to psychological counseling and to supportive underclothing like bras can help individuals live as the gender with which they self-identify. In 1992, UC Irvine researchers published an article detailing medical experiments performed on every trans female inmate in the California state prison system, ending with all subjects being indefinitely taken off hormone therapy. The authors wrote: "withdrawal of therapy was also associated with adverse symptoms in 60 of the 86 transsexuals. Rebound androgenization, hot flashes, moodiness, and irritability or depression were the most frequent complaints." At the time, no right to access gender appropriate care existed in
California state prisons. In June 2019,
Layleen Polanco, a Black transgender woman, died of an epileptic seizure in solitary confinement on New York City's
Rikers Island. Guards had noticed that she was unresponsive but waited 90 minutes to seek help. A year later, it was reported that 17 corrections officers would be disciplined as a result of the incident.
Defining gender-affirming care Gender-affirming care can be understood as encompassing both medical (non-surgical), social, and surgical interventions. Under the World Professional Association of Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People," gender-affirming healthcare is broadly defined as "primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments." Gender-affirming healthcare is widely regarded as a "life-saving practice" both by physicians and members of the transgender and nonbinary community. Medical scholarship also recognizes that this "treatment is critical to maintain the health and safety of inmates, as without it, transgender prisoners may fall into deeper depression and have greater risk of life-threatening autocastration". Several U.S. Circuit Court of Appeals have held that the prison's duty to treat serious illnesses includes the treatment of gender dysphoria. Other Circuits have held that prison bans on hormonal therapies constitute deliberate indifference in violation of the 8th Amendment. There is some disagreement among Circuits as to whether denial of gender confirmation surgery constitutes deliberate indifference. Some lower courts have affirmed that prohibitions on gender-affirming healthcare are also unconstitutional. These unconstitutional standings rely primarily on the subjective applications of the
Eighth Amendment, particularly the application of "deliberate indifference." The application of protections and protection of rights for transgender incarcerated individuals is commonly referred to with discussion from the
Supreme Court in
Farmer v. Brennan (1994). The ratification of this amendment was intended to protect incarcerated individuals and the fairness of criminal proceedings. The subjective nature of "cruel and unusual" punishments remains frequently analyzed by the Supreme Court and court circuits.
Farmer v. Brennan 114 S. Ct. 1970 (1994), is a case that involves the subjective application of "cruel and unusual" punishment. This case involves the development of "deliberate indifference" to establish infraction upon a person's Eighth Amendment rights. Dee Farmer, a transgender woman, was imprisoned in an all-male federal facility for credit card fraud. At a previous federal prison she was placed in protective segregation due to safety risks because of her gender presentation. Upon transfer to the United States Penitentiary in Terre Haute, Indiana, she was initially held in administrative segregation, but was soon moved to the general prison population. Within two weeks after the removal from administrative segregation, Farmer was beaten and raped by another inmate. Farmer then filed a Bivens lawsuit (a lawsuit against government officers for violating constitutional rights) stating that prison officials had violated the Eighth Amendment's "cruel and unusual punishments" clause. She argued that officials knew that her feminine appearance increased her vulnerability to sexual assault, but still placed her in the general population, demonstrating deliberate indifference to her safety. In the lawsuit, Farmer sought both damages and an injunction (a court order that directs someone to do or stop something) to prevent similar future confinement conditions. The
United States District Court for the Western District of Wisconsin ruled that officials could be liable only if they acted with "criminal recklessness" and the
Seventh Circuit Court of Appeals upheld that decision without issuing a written opinion. ultimately holding in contradiction to the United States District Court and the Western District Court of Wisconsin that prison officials' failure to prevent sexual assault or harm is infringing upon Eighth Amendment rights. There are two stipulations to this holding that must be met in order to prove constitutional violation. The first being the denial should be "sufficiently serious." The second involves the rationale of prison officials furthering the subjective application of the Eighth Amendment. Because the Court recognizes that "prison conditions may be 'restrictive and even harsh,'" however prison officials still must commit to the protection of inmates from other incarcerated individuals. which recognized that incarcerated
LGBTQ+ individuals, especially transgender women, face disproportionately high rates of sexual assault and inadequate institutional protection. There have been cases in which gender identity disorders were not addressed by the courts. Courts have sometimes directly avoided evaluating whether gender identity disorder constitutes a "serious medical need." Instead the cases have been dismissed on the grounds of lack of evidence of prisoners suffering or disagreements. One such example is the decision of the
Tenth Circuit Court in
Spicer, a.k.a Alexis R. Bell v. Terhune et al. (2003). Spicer sued the prison doctor for stopping hormone treatment for her gender identity disorder stating that this falls under deliberate indifference. The doctor's argument included that the
hormone treatment was stopped because she had gained 29 pounds in six weeks. In this decision, the court ruled that deliberate indifference could not be cited if prisoner's opinions do not coincide with medical expert opinions, especially because Spicer was unable to provide corroborating expert opinions. When systemic failures risk the physical safety of incarcerated individuals extend beyond that to include the evaluation and provision of gender-affirming care to be included in cruel and unusual punishment. Under the
Eighth Amendment, denial or delay of medically necessary treatment, including for conditions such as
gender dysphoria, has been found to cause severe psychological and physical harm, ranging from depression and anxiety to self-harm and suicide. a group of transgender inmates in
Wisconsin challenged
Act 105, a state law that banned hormone therapy and gender-confirmation surgery for incarcerated individuals. Before the law, these inmates had been receiving hormone therapy to treat
gender identity disorder (GID), a medically recognized condition and had the right to start new treatments when medically necessary. Some people with GID describe the experience as "being born into the wrong body, since they were born with the anatomy typically associated with one gender, but identify with the other." Medical experts agree that preventing hormone therapy and denying gender-affirming care can lead to life-threatening conditions. Dr Kallas from the
American Medical Association affirmed an individual-by-individual assessment standard, stating "'it seems so obvious to me, that it's important that doctors are able to use their clinical judgment with respect to conditions that are significant, especially when it pertains to medically necessary treatment.'" The Court reasoned that by categorically banning hormone therapy and surgery, the state intentionally disregarded the medical needs of transgender inmates. Furthermore the statute's blanked denial of care was medically unjustifiable and caused unnecessary suffering. This landmark ruling also sets the stage for future cases. Following
Fields v. Smith (2011), courts began to apply the Eighth Amendment's subjective "deliberate indifference" not only to physical safety in prisons, but to also include medical neglect involving gender-affirming care. De'lonta sued for violation of her Eighth Amendment rights as her treatment was denied. However, court documents state that "De'lonta's own allegations contradict the conclusion that Appellees are 'persistently denying her treatment,' since De'lonta acknowledges that VDOC has provided mental health consultations, hormone therapy, and cross-dressing allowances in accordance with
the Standard of Care." Initially the judge dismissed the case based on that argument and following De'lonta's appeal, an
amicus brief (when a third party submits additional information on law or policy that may have greater implications) was submitted by the ACLU of Virginia. The second factor that was considered is the subjective side of deliberate indifference where the intentional actions of the VDOC officials must be shown. Ultimately, the Fourth Circuit stated that the refusal for evaluation of surgery was an instance of deliberate indifference and emphasized that meeting the medical needs of inmates includes not only providing treatments for partial solutions such as hormone therapy and gender-affirming dressing but must include and address the inmates serious medical needs as well. The impact of this decision includes the standing that prison authorities must also "consider advanced or specialized medical interventions." If a prisoner feels as though they are receiving inadequate medical care for a serious condition, they can sue under Section 1983 for violating constitutional rights. The
Massachusetts Department of Correction (DOC) doctors recommended that Kosilek get sex reassignment surgery and stated that it was the only adequate and medically necessary treatment. Despite the recommendations of the doctors, the DOC Commissioner Kathleen Dennehy refused to approve the surgery. The state argued that the sex reassignment surgery would create "insurmountable" security problems with Dennehy arguing, "Kosilek would be at risk for sexual assault if she were to remain in a male prison, and housing her in a female prison would come with its own host of problems." With the two-pronged Eighth Amendment legal standard in order to win her claim, she would have to show 1.) she had a serious medical need and 2.) the treatment denial was deliberately indifferent, meaning that officials knew of her condition and disregarded the risk. The court ultimately found that both of the prongs were satisfied as her gender identity disorder had caused her extreme depression, self-harm, and suicidal tendencies. Furthermore, Dennehy ignored medical advice for non-medical reasons including fear of public backlash and personal bias. For an
injunction, Kosilek had to prove a higher bar including 1.) she had a serious medical need 2.) sex reassignment surgery is the only adequate treatment 3.) officials know she faces serious risk without it 4.) the denial was not for legitimate prison-related reasons 5.) the unconstitutional conduct would continue. Legal scholars state, "the implications of this holding are ambiguous." Some courts took the decision to mean that sex reassignment surgery is thus never medically necessary and never required under the Eighth Amendment, therefore blanket bans on gender-affirming surgery are constitutional. On the other hand, some courts interpret this holding as a case-specific analysis only saying that it was not medically necessary for Kosilek specifically, not that surgery is never medically necessary for anyone. Furthermore, legal scholars state that the blanket ban prohibiting sex reassignment surgery's constitutionality created a split among the Ninth and Fifth Circuits and both sides of the debate still relied on Kosilek to set their precedents and defend their claims. Following Kosilek, courts continued to disagree on how to apply the "deliberate indifference" standard to gender-affirming surgery. In 2025, the First, Fifth, and Ninth Circuits are the primary federal appellate courts which have addressed granting gender confirmation surgery under the Eighth Amendment. In
Edmo v. Corizon, Inc. (2019), the
U.S. Court of Appeals for the Ninth Circuit contradicted the decision of the Fifth Circuit, holding that denying a prisoner of gender confirmation surgery was in fact cruel and unusual punishment and was illegal under the Eighth Amendment. Adree Edmo was a prisoner in the Idaho Department of Corrections (IDOC) since 2012 and since a young age identified as a female. She consistently lived as a woman while incarcerated. Soon after becoming incarcerated, a psychiatrist diagnosed her with gender dysphoria and she began her social transition, legally changing her name and sex marker. She was eventually prescribed hormone therapy which provided some relief, but remained distressed about having male genitalia. Edmo attempted self-castration on two different occasions, describing the severe and psychological pain driving those actions. Dr. Scott Eliason, the
psychiatrist that initially diagnosed her, evaluated her for gender-confirmation surgery (GCS), after one of the attempts. Dr. Eliason advised against GCS, stating counseling and hormone therapy were sufficient, however admitting that this was not in harmony with any
standard of care or
medical consensus. In 2017, Edmo filed her own complain in federal court asking for an injunction which would require the IDOC to provide the GCS, stating that the Eighth Amendment was violated. The district court reviewed the testimony of multiple medical experts and used the
WPATH Standards of Care as the prevailing medical framework for treating gender dysphoria. The District Court found that there was a serious medical need and Edmo's gender dysphoria clearly met the threshold. Secondly, the District court had to come to a decision on if this was a case of deliberate indifference, with the central issue being if denial of surgery appropriately reflected accepted
medical practice. Medical experts who
testified said that surgery was necessary in this situation and that the IDOC's denial fell far outside accepted medical treatment. Thus, the district court concluded that IDOC's denial of GCS was inadequate care and met the subjective deliberate indifference standard. Ultimately, the court ruled in favor of Edmo and ordered IDOC to provide the surgery. Following this decision, Idaho appealed the ruling but the Ninth circuit upheld the injunction. The Ninth Circuit affirmed that this case clearly demonstrated serious medical need, IDOC was aware of the situation and severity, and medical evidence strongly supported the necessity of surgery. A follow-up request for rehearing was denied and the U.S. Supreme Court declined to review the case. Vanessa Lynn Gibson, a transgender woman, was incarcerated in Texas and had been formally diagnosed with gender dysphoria. She sought gender confirmation surgery but the Texas Department of Criminal Justice (TDCJ) rejected the request because its official treatment policy did not include GCS. Gibson subsequently filed a lawsuit stating that the policy prevented the TDCJ from seeing if the surgery for medically necessary which constituted as deliberate indifference. The TDCJ director sought dismissal on the case based on qualified and
sovereign immunity, which essentially means that the government can not sue the government itself unless the government has agreed to be sued and also protects government employees from being sued personally for money damages unless they violated a clearly established constitutional right and a reasonable official would have known their action was unconstitutional. The District Court denied the immunity defenses, but still ruled against Gibson on the Eighth Amendment claim. Gibson appealed, the Fifth Circuit appointed a counsel and ultimately affirmed the dismissal. The legal reasoning behind this was that the Fifth Circuit accepted that Gibson had a serious medical condition but saw that she could not prove deliberate indifference. The decision relied on
Kosilek, stating that the decision to treat and provide GCS is a permissible medical choice rather than a constitutional violation. Judge Barksdale first argued that the case should have been passed back down to a lower court because the district court mishandled summary-judgement procedures. According to the judge, the TDCJ had the burden to show that there was no factual dispute that existed about whether surgery was medically necessary and the TDCJ did not meet that standard. The judge in their
dissent also criticized the majority of the inclusion of evidence from
Kosilek, saying that it was a different case, rather than relying on the actual record of the parties involved. Lastly, the claim that GCS should be viewed as medically permissible should be rejected according to Judge Barksdale dissent because there is no constitutional requirement that a treatment standard has to be "universally" endorsed. In their dissenting opinion, Judge Barksdale stated, "Tellingly, the majority provides no citation to any caselaw regarding this universal acceptance standard..." This case represents the broader implications of both procedural defects and a misunderstanding of established medical science. If Gibson seeks further review, she would have extensive scientific support showing that gender-affirming surgery can be medically necessary. According to legal experts at the Harvard Law Review, this case highlights the growing divide between courts and contemporary medical knowledge, and raises questions about how the Eighth Amendment should be adapted to current understanding of gender dysphoria and its treatment. Under these policies, trans inmates may not start or expand their treatment while incarcerated. As a result, even a state that is legally bound to offer gender-affirming healthcare to trans inmates may deny that healthcare to someone who was not transitioning before being incarcerated. In other words, freeze-frame policies are much more common than outright bans on hormone therapy for incarcerated people. These policies continue to exist in several U.S. states and have been repealed in others. One obstacle in challenging these policies is that prison policy is determined largely at the state level; as a result, freeze-frame policies have been repealed piecemeal in each state in response to individual lawsuits. Several important cases have challenged freeze-frame policies in the Federal Bureau of Prisons, Georgia, and Missouri. Critics note that these policies rely on the assumption that transness and one's desire or comfort in seeking gender-affirming healthcare is static and fixed. Ending freeze-frame policies, however, does not guarantee that incarcerated trans people will receive gender-affirming healthcare. Rather, the decisions in each of the cases challenging freeze-frame policies require that prisons conduct individualized assessments of inmates experiencing gender dysphoria. Hormone therapy is not always the treatment offered or deemed necessary following these assessments. In cases challenging these policies, the trans plaintiffs experienced severe mental health crises as a result of being denied care; courts weighed this risk of suicide and self-harm in determining whether hormone therapy was medically necessary for the plaintiffs. Additionally, trans inmates who do receive hormone therapy still do not have control over their healthcare decisions, as prison healthcare officials set dosages and treatment plans for inmates. On the whole, courts ending freeze-frame policies only intervene to ensure that prison policy does not constitute cruel and unusual punishment, leaving a significant gap between constitutionally permissible healthcare and healthcare that enables trans inmates to flourish and act with
self-determination. One of the earliest challenges to a freeze-frame policy came in 2011 in
Adams v. Federal Bureau of Prisons. Vanessa Adams, a trans woman incarcerated in a federal prison, was diagnosed while incarcerated with Gender Identity Disorder (GID). Each of her 19 requests for treatment were denied under the BOP's freeze-frame policy. As a result, Adams attempted suicide and self-harm multiple times. In 2009, the National Center for Lesbian Rights, Gay and Lesbian Advocates and Defenders, Florida Institutional Legal Services, and Bingham McCutchen LLP challenged the policy in court. In 2011, the Obama administration settled with Adams. The settlement ended freeze-frame policies in all federal prisons, ensuring that trans inmates would receive individualized assessments and treatment plans for gender dysphoria. In 2015, Ashley Diamond, a trans woman incarcerated in Georgia, sued the state for failing to provide hormone therapy under a freeze-frame policy and for failing to protect Diamond from sexual assault while incarcerated. She was represented by the Southern Poverty Law Center. Diamond had been undergoing hormone therapy for 17 years prior to her 2012 arrest, but because her intake forms failed to identify her as trans, the Georgia DOC's freeze-frame policy disqualified her from continued treatment. The conditions of her incarceration resulted in multiple self-harm and suicide attempts.
Diamond v. Owens was significant because for the first time, the federal government stepped in to comment on states' legal requirements to provide gender-affirming healthcare. The U.S. Department of Justice released a statement in support of Diamond, stating that in Diamond's case, gender dysphoria required medically necessary treatment. Notably, the DOJ did not state unequivocally that prisons must provide hormone therapy. Rather, the DOJ argued that "proscriptive freeze-frame policies are facially unconstitutional under the Eighth Amendment because they do not provide for individualized assessment and treatment." Within a week of the DOJ intervention, Georgia ended its freeze-frame policy, committing instead to individually assess inmates' gender dysphoria and provide treatment accordingly. The court case, during which prison officials used incorrect pronouns in reference to Diamond, continued after this announcement, resulting in the Georgia DOC adopting a sexual assault prevention policy. Jessica Hicklin, a trans woman from Missouri, was incarcerated at the age of 16 and sentenced to life in prison. At the age of 37, Hicklin challenged the Missouri Department of Corrections freeze-frame policy, claiming that it violated the 8th Amendment cruel and unusual punishment clause; Lambda Legal represented Hicklin in
Hicklin v. Precynthe. Hicklin noted that at 16, she did not know what gender dysphoria was or have the resources to begin transitioning. In 2018, a federal court sided with Hicklin and ordered the Missouri DOC to provide Hicklin with gender-affirming healthcare in the form of hormone therapy, as well as other commissary products to help Hicklin socially transition.
Hicklin v. Precynthe effectively ended Missouri's freeze-frame policy, giving incarcerated trans people greater access to gender-affirming care across the state.
Canada On August 31, 2001, the
Canadian Human Rights Tribunal concluded that Sections 30 and 31 of the Correctional Service of Canada contained discrimination on the basis of sex and disability in
Canadian Human Rights Act after
Synthia Kavanagh, a trans woman sentenced for life in 1989 for 2nd-degree murder, was sent to an institution for males. This institution assignment occurred despite the trial judge's recommendation that Synthia, as a trans woman, serve her sentence in a facility for women. Further, Synthia was denied
sex reassignment surgery and
hormones. The institutional policy, at the time, only facilitated cases which addressed conditions in which, reasonably, the plaintiff would seek sexual reassignment after the period of incarceration. Due to Synthia Kavanagh's life sentence, this was not a foreseeable option. "The decision to discontinue hormones in 1990 seems to have been based on the complainant's life sentence which made her, according to Dr. R. Dickey, apparently ineligible for ultimate reassignment. ... the diagnosis of transsexualism has been clearly established in this case" by expert witness testimony, throughout her trial, "She [had] responded well to feminizing effects of cross-gender hormones and has experienced no significant side effects. As established by legal precedent and confirmed by policy in Canadian and British Columbia Corrections Service, the complainant was entitled to continue her hormone treatment".
Mental healthcare Within US prisons, the mental health of LGBTQ persons has been shown to suffer, with a higher rate rate of mental illness and a lower likelihood of seeking healthcare, according to a 2016 survey. Efforts have been made to connect the prevalence of housing loss due to family rejection with correlated increased mental health issues and a higher rate of incarceration in Federal and State prisons.
Hungary Hungary has compulsory HIV testing, which is part of the Ministry of Health regulations, which requires prostitutes, homosexuals, and prisoners be tested for HIV. When prisoners are found to be HIV positive they are taken to a special unit in Budapest. Units for HIV positive prisoners are staffed with individuals who are trained and who understand the problems of HIV. Specialized treatment of HIV are only available at one hospital in Budapest. HIV treatment for prisoners is paid for by the state-owned National Health Insurance Fund. These prisoners have their own cells with their own showers, a community room with games, and a social worker available to them. Post test counseling is also provided.
New Zealand In a study in New Zealand, Transgender people in prisons were shown to be more likely to have previous experience with abuse, and a higher rate of incarceration. However, the NZ government has declared support for gender affirming healthcare for incarcerated persons, as well as gender-affirming clothing. NZ Researchers have attempted to connect gender dysphoria to mental health issues amongst transgender persons in prison as described by the
Minority stress model often used in the study of LGBTQ mental health issues, which describes the intersectionality of minority issues and their impact on a group's mental well-being. == LGBTQ youth prisoners in the United States ==