Creating, reinforcing, and resisting the gender binary: a qualitative study of transgender women’s healthcare experiences in sex-segregated jails and prisons

• Date: 11 June 2018
• Published date: 11 June 2018
• Pages: 69-88
• DOI: https://doi.org/10.1108/IJPH-02-2017-0011
• Author: Jaclyn M. White Hughto,Kirsty A. Clark,Frederick L. Altice,Sari L. Reisner,Trace S. Kershaw,John E. Pachankis
• Subject Matter: Health & social care,Criminology & forensic psychology,Prisoner health,Sociology,Sociology of crime & law,Public policy & environmental management,Policing,Criminal justice

Creating, reinforcing, and resisting the

gender binary: a qualitative study of

transgender women’s healthcare

experiences in sex-segregated jails

and prisons

Jaclyn M. White Hughto, Kirsty A. Clark, Frederick L. Altice, Sari L. Reisner, Trace S. Kershaw

and John E. Pachankis

Abstract

Purpose –Incarcerated transgender women often require healthcare to meet their physical-, mental-, and

gender transition-related health needs; however, their healthcare experiences in prisons and jails and

interactions with correctional healthcare providers are understudied. The paper aims to discuss these issues.

Design/methodology/approach –In 2015, 20 transgender women who had been incarcerated in the

USA within the past five years participated in semi-structured interviews about their healthcare experiences

while incarcerated.

Findings –Participants described an institutional culture in which their feminine identity was not recognized

and the ways in which institutional policies acted as a form of structural stigma that created and reinforced the

gender binary and restricted access to healthcare. While some participants attributed healthcare barriers to

providers’transgender bias, others attributed barriers to providers’limited knowledge or inexperience caring

for transgender patients. Whether due to institutional (e.g. sex-segregated prisons, biased culture) or

interpersonal factors (e.g. biased or inexperienced providers), insufficient access to physical-, mental-, and

gender transition-related healthcare negatively impacted participants’health while incarcerated.

Research limitations/implications –Findings highlight the need for interventions that target multi-level

barriers to care in order to improve incarcerated transgender women’s access to quality, gender-

affirmative healthcare.

Originality/value –This study provides first-hand accounts of how multi-level forces serve to reinforce the

gender binary and negatively impact the health of incarcerated transgender women. Findings also describe

incarcerated transgender women’s acts of resistance against institutional and interpersonal efforts to

maintain the gender binary and present participant-derived recommendations to improve access to gender

affirmative healthcare for incarcerated transgender women.

Keywords Transgender women, Health in prison, Violence, Prison staff, Correctional health care,

Prisoners, Mental health

Paper type Research paper

Introduction

Transgender women, individuals assigned a male sex at birth who now have a feminine gender

identity or expression, experience pervasivestigma in the USA (White Hughto et al., 2015). Stigma

restricts accessto resources for transgender women,including employment and housing, leading

some to turn to street economies, such as survival sex work, or substance use to cope with

mistreatment; these activities then place transgender women at risk for arrest and incarceration

(Garofalo et al., 2006; Grant et al.,2011;Nemotoet al., 2011; Mizock and Mueser, 2014).

Received 28 February 2017

Revised 27 April 2017

Accepted 22 June 2017

The authors affiliations can be

found at the end of this article.

DOI 10.1108/IJPH-02-2017-0011 VOL. 14 NO. 2 2018, pp. 69-88, © Emerald Publishing Limited, ISSN 1744-9200

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Biased policing and sentencing practices also contribute to high rates of incarceration among

transgenderwomen (Wolff and Cokely, 2007;Grant et al., 2011). Lifetime estimatesof incarceration

range from19 to 65 percent among transgender women(Reisner et al.,2014;Garofaloet al., 2006;

Clements et al., 1999; Grant et al., 2011), compared to less than 3 percent of the US general

population(Glaze and Kaeble, 2014). Once incarcerated,transgender women are typically housed

in sex-segregatedfacilities accordingto their genitalia; thus, transgender women who have not had

gender confirmation surgery are placed in male facilities where they are at risk for mistreatment

(Jenness et al.,2009;Emmeret al., 2011; Lydon et al.,2015).

Due to the stigma attached to their feminine gender identity and/or expression, transgender

women incarcerated in male facilities are especially at risk for verbal harassment, physical

violence, and sexual assault (Jenness et al., 2007, 2009; Emmer et al., 2011; Lydon et al., 2015).

While victimization often occurs at the hands of inmates, transgender women also report being

victimized by jail and prison staff. For example, a US study of 6,450 transgender individuals found

that among 749 transgender women in the sample who had been incarcerated, 38 percent had

been harassed, 9 percent had been physically assaulted, and 7 percent had been sexually

assaulted by facility staff (Grant et al., 2011). While research points to mistreatment by custody

staff, a dearth of empirical research explores the nature of transgender women’s interactions with

healthcare providers (e.g. doctors, nurses, psychologists, counselors).

Like all detainees, incarcerated transgender women may need to access physical and mental

health servicesto meet their preventative, chronic,and urgent healthcare needs;some transgender

women also require medical care in order to “transition”or medically affirm their gender. Medically

affirmingones gender can include theuse of exogenous hormone therapy(e.g. estrogen) or surgery

(e.g. medicalconfirmation surgery) to feminizethe body, with hormone therapyoften being the first

and sometimes onlygender transition-related intervention sought (Coleman et al., 2012).Hormone

therapy is an essential component of healthcare delivery for some transgender people, as it

alleviates the psychological distress of gender dysphoria (APA, 2008; Coleman et al.,2012),and

has been linked to improved mental health outcomes (e.g. reduced depression and anxiety) and

quality of life(White Hughto and Reisner, 2016;Murad et al., 2010). Given that transgender women

may require a varietyof health services while incarcerated,access to supportive medical providers,

who are knowledgeable about transgender individuals and their healthcare needs, is essential to

ensuring the health of incarcerated transgender women.

The extent to which transgender women are able to access quality, gender-affirmative general

and gender transition-related care while incarcerated is not well-documented in the empirical

literature. Prior qualitative research in non-criminal justice settings highlights providers’lack of

training on how to provide gender-affirmative care to transgender patients, and transgender

women consistently report provider bias and limited transgender-specific healthcare knowledge

as a barrier to receiving adequate healthcare (Lurie, 2005; Poteat et al., 2013). In regards to

healthcare in criminal justice settings, a 2014 survey of 1,118 lesbian, gay, bisexual, transgender,

and queer (LGBTQ) detainees from across the USA found that 21 percent of respondents were

treated disrespectfully by correctional medical staff and/or therapists; however, the report did not

define the term “disrespect”and the experiences of transgender respondents were not reported

separately from non-transgender respondents. Similarly, a 2009 survey of 59 transgender and

gender-variant inmates in Pennsylvania found that 42.4 percent of the sample believed their

needs were not taken seriously by medical staff, however, the survey did not report the

experiences of transgender women separately from the full sample. Like the national study, the

Pennsylvania study relied primarily on quantitative methods, which precluded the nuanced

exploration of unique participant experiences. Further, a dearth of empirical research qualitatively

explores key interpersonal or provider-level factors that may shape the delivery of care, such as

provider comfort, attitudes, and knowledge about transgender people or their care.

While interpersonal factors may contribute to access to care barriers, structural or institutional

factors (e.g. culture, norms, practices, and policies) may also shape the delivery of care for

incarcerated transgender women. In terms of transgender-specific correctional policies, an

investigation found that only 16 out of the 26 US states surveyed had explicit policies enabling

transgender individuals to continue hormone therapy once incarcerated and only four states had

clear policies allowing transgender inmates to initiate hormones under certain circumstances

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