The Experience of Transgender Women Prisoners Serving a Sentence in a Male Prison: A Systematic Review and Meta-Synthesis

Abstract

Due to social exclusion and direct and indirect discrimination, there is a disproportionate representation of transgender individuals in prison. The aim of this article is to report the findings of a systematic review and meta-thematic synthesis to understand the experience of transgender women who have served a sentence in a male prison. The review identified 14 papers, and the thematic synthesis identified five themes. The themes are discussed within a contemporary socio-ecological model, developed by White Hughto and colleagues to support transgender healthcare in prison, and to explore if this model is applicable for the wider prison environment.

Keywords

transgender prison gender dysphoria systematic review

Introduction

Transgender is a widely used term for people whose gender identity, expression, and behavior are different from their biological sex assigned at birth (Drescher & Pula, 2020).

The medical diagnostic label is gender dysphoria (American Psychiatric Association, 2013), which identifies being transgender as a recognizable condition with treatable symptoms. Treatments for gender dysphoria may include psychological counseling, psychotherapy, and medical interventions to promote physical changes such as hormonal therapy, permanent hair removal, chest/breast surgery, and genital removal, or reconstructive surgeries (National Health Service, 2020).

Due to the fluid nature of gender identity and the sensitivity and stigma associated with identifying as transgender, the available estimates of transgender populations are often tentative and from data which are unreliable (Zucker, 2017). The World Health Organisation/Europe (WHO, 2020) estimated 0.3 to 0.5% of the global population identify as transgender, which is approximately 25 million people. A contemporary report from the United States (US) has estimated1.6 million people aged 13 and older identify as transgender, an estimation of almost 0.5% of the population (Herman et al., 2022), although previously prevalence has been estimated to be between 0.39% and 2.7% of the total US population (Nolan et al., 2019; Zucker, 2017). In the UK, there are currently no official figures, but it has been estimated by the Government Equality Office (2018) that between 200,000 to 500,000 people identify as transgender. Globally, there are two key trends observed in relation to transgender prevalence: an increase in the prevalence of people self-identifying as transgender and a higher prevalence of self-identification among younger generations (Nolan et al., 2019). These trends are not due to an increase in prevalence of transgenderper se but rather a result of an increase in confidence to express gender identity or to seek support, and improved reporting (Zucker, 2017).

Transgender individuals have reported experiencing social exclusion throughout their childhood and adult lives, resulting in inequalities in access to further education, housing, health care, and employment (Cruz, 2014; Grant et al., 2011; Jaffee et al., 2016). Social exclusion, stigma, and inequalities increase a transgender individual's risk of developing severe mental health conditions (Grant et al., 2011; Greene et al., 2014; McDermott et al., 2017). For example, transgender women are nearly six times more likely to experience depression than the general US population (McCann & Brown, 2017).

The impact of higher rates of depression, discrimination and inequalities leave transgender individuals at a greater risk of criminal prosecution due to homelessness, participating in sex work, and drug dealing, especially in relation to the distribution of hormones (Grant et al., 2011; Fletcher et al., 2014; Sylvia Rivera Law Project, 2007). Due to social exclusion, direct and indirect discrimination, abuse, and harassment, there is a disproportionate representation of transgender individuals in prison (Lenning & Buist, 2012).

Discrimination of transgender individuals continues in prison settings, through racism, victimization, and physical and sexual abuse by fellow prisoners, jail, and prison staff (Grant et al., 2011). Discrimination also prevents access to hormones and feminine products, such as clothing and make-up, all of which support their gender identity and expression (Emmer et al., 2011; Lydon et al., 2015). Furthermore, there remains a lack of understanding and recognition of transgender prisoners which leads to further discrimination through normative gender binarism and segregation by sex that continues across all prison services (Dziewanska-Stringer et al., 2019; Erni, 2013). In many countries, transgender prisoners are identified as male or female depending on their genital status, which dictates if the prisoner is placed in a male or female prison (Sevelius & Jenness, 2017).

The phrase “double-punishment” has been applied to describe transgender women in a male prison, due to the impact of gender binary sex-segregated prisons, which denies gender recognition and the inability to gender-affirm (Van Hout & Crowley, 2021). However, the impact of gender binary sex-segregated prisons also ignores the sexual violence that occurs in male prisons towards transgender women prisoners (Rodgers et al., 2017). The heteronormative values of gender binary sex-segregated prisons also creates a stratified hierarchy of prisoners (Fleisher & Krienert, 2009); this places sex offenders and non-normative identities, including transgender at the bottom of this hierarchy, leaving them open to abuse (Jenness & Fenstermaker, 2014; 2016). A further lack of understanding is identified through the frequent use of solitary confinement for the protection of transgender women prisoners, which is otherwise widely regarded as punishment and a form of isolating high-risk prisoners form the general prison population (Emmer et al., 2011; Grant et al., 2011; Lydon et al., 2015; Read & McCrae, 2016).

The treatment of and risk to transgender prisoners has begun to be recognized, for example, in the England and Wales Prison Service, a Prison Service Instruction in 2016, following a broad review of the care and treatment of transgender prisoners was conducted by the Ministry of Justice (2016). In 2020, the Ministry of Justice and HM Prison and Probation Service (HMPPS) published operational guidance on the care and management of transgender individuals, with the aim to “provide staff with clear direction in the support and safe management of transgender individuals, including managing risks both to and from transgender individuals” (p.4). However, there remains the need for a greater understanding of transgender prisoners” experience of serving a prison sentence. Transgender women in male prisons appear to be the most susceptible to discrimination, harassment, sexual, and physical abuseand consequential self-harm tendencies. Therefore, the aim of this systematic review is to explore the experience of prison for transgender women who have or are serving a prison sentence in a male prison.

In this article, the phrase “transgender women prisoner/s” has been applied throughout to describe the population, whose experience is the focus of this research. However, this term has only been applied to improve readability and transparency and not dehumanize those who identify as transgender and are serving a sentence within a correctional facility.

Method

The search strategy included searching the following electronic databases: CINHAL, Medline, PsychINFO, PubMed, Science Direct and Web of Science from inception to 31^st December 2019 and updated to identify any further papers published in the English language on 1^st June 2022. Search strategies were tailored for each database with the inclusion of recognized Medical Subject Headings (MeSH), and Boolean operators of AND/OR. The following search string was applied to both CINAHL and PsychINFO databases (transgender or transsexual or transsexual or gender variant or gender non-conforming) AND (prison or jail or incarceration or imprisonment or correction facilities).The search strategy also included “hand searching” prominent prison journals, and “manual searching” of the reference lists of all papers identified. Studies were included if they explored the experience of transgender women prisoners over 18 years of age, and who have or were serving a sentence in a male prison.

A meta-thematic synthesis was completed by adhering to the three stages of a meta-synthesis as described by Thomas and Harden (2008). The first phase commenced with coding of the text, which was independently completed by three authors, followed by discussion and the development of descriptive themes that reflected the extracted data; and finally, an interpretative phase of the development of analytical themes.

Findings

A total of 1,126 papers were identified, following the removal of duplicates,831 papers were screened, a number of papers were excluded following the reading of titles (n = 701) and abstracts (n = 89). Following this process, full papers were obtained (n = 41), of which 14papers met the inclusion criteria and were included in the analysis.

The majority of studies were completed in the US (Brown, 2010; 2014; McCauley et al., 2018; Rosenberg & Oswin, 2014; Sumner & Sexton, 2016; White Hughto et al., 2018), although four papers reported data from one comprehensive mixed methods multi-site study (Jenness & Fenstermaker, 2014; Jenness & Gerlinger, 2020; Jenness et al., 2019; Sexton & Jenness, 2016). The remaining were completed in Latin America (Johnson et al., 2019), England (Nulty et al., 2019), Australia (Wilson et al., 2017) and Scotland (Maycock, 2020), Refer to Table 1 for more details of each study.

Table 1.

Overview of Included Studies.

Author	Aim	Participants	Results
Brown 2010 USA	Inmates experiences of attempting or completing surgical self-treatment (SST) due to their gender dysphoria	- Prisoners with gender dysphoria (n = 18); Engaged in SST (n = 8); Considering SST (n = 5); provision of consent for analysis of letters (n = 5)	-SST was preceded by substantial efforts, both verbal and written, at obtaining psychiatric and medical care for gender dysphoria
Brown 2014 USA	To understand the range of concerns of transgender inmates from their experiences in prison from unsolicited letters	Participants (n = 129) - male-to-female transsexual (48%) - male-to-female transgender (49%) - female-to-male transgender (<1%) - intersex (2%)	The top five concerns:transgender healthcare (56%); social issues (31%); legal concerns (30%); physical abuse (23%); gender dysphoria (22%); sexual abuse (19%)
Jenness 2014 USA	To explore how gender is accomplished by transgender prisoners in prison.	Participants (n = 315) - transgender women in a prison for men in California	Themes from a focus on the pursuit of the “real deal” whilst in prison: the importance of acting like a lady; and competition among the ladies
Jenness 2020 USA	To explore the self-perceptions of femininity of transgender women in prisons for men and the impact of sexual victimization by other prisoners.	Participants (n = 315) - transgender women in a prison for men in California	Transgender women perceived themselves as more feminine in prison and self-perceptionof femininity increased more than four times if they also reported sexual victimization
Jenness 2019 USA	An exploration of transgender women in prisons for men experiences of relationships, sexual assault and sexual victimization.	Participants (n = 315) - transgender women in a prison for men in California	Reported physical assault (80.3%), sexual acts against their will (58.5%),sexual acts “rather not do” (69.4%). Reasons for allowing abuse an appeasement strategy, bargaining tool and, protection from other prisoners
Johnson 2019 Latin America	To address the inequalities of transgender women in prisons, in Latin America.	Participants (n = 5) transgender women in prison in Latin America: - Nicaragua (n = 3) - El Salvador (n = 2)	Identified themes included: societal prejudice, family experiences, reasons for incarceration, experiences in prison, roles of state actors
McCauley 2018 USA	To document the health-related experiences and needs of prisoners who self-identified as transgender women.	Participants (n = 10) -transgender women of color in prison	Identified themes: use of special housing and use the of solitary confinement, treatment of mental health issues and difficulties with the continuation of medications
Maycock 2020 Scotland	An exploration of where transgender people in prison would like to be housed based on their current experiences	Participants (n = 13) - transitioning from male to female (n = 11) - transitioning from female to male (n = 2)	Views on a specific wing for transgender women:support and a shared experience of transitioning, but‘segregation” from mainstream prisoners, and a lack of social transitioning
Nulty 2019 England	An exploration of transgender women experiences within a male prison.	Participants (n = 3) - transgender women prisoners	Themes identified:participants experience of transitioning;challenges of presenting as female; fighting the system due to daily struggles against harassmentand discrimination
Rosenburg 2015 USA	To examine the experiences of transgender prisoners.	Participants (n = 23) - prisoners in a male prison, who identified as transgender or transsexual or as a women or genderqueer	Participants reported:laughed at/called names (n = 19), denied treatment (n = 14), physically hurt (n = 13), sexual abuse (n = 11). All participates reported extreme gender regulation
Sexton 2016 USA	The application of collective identity efficacy to examine the overlapping communities of transgender women in prisons for men experience prison life	Participants (n = 315) - transgender women in a prison for men in California	Transgender inmates report relatively high levels of both collective identity and perceived collective efficacy with regard to the transgender inmate reference group
Sumner 2016 USA	To examine the pursuit of safety and security in a sex-segregated prison of transgender prisoners through the stance of the: “dilemma of difference”	Participants - interviews with transgender prisoners (n = 10); focus group with mainstream prisoners (n = 27); interviews and focus groups with staff members (n = 20)	Themes identified:identifying the difference; understanding the difference; dealing with difference -the consequences of the difference
White Hughto 2018 USA	An exploration of the healthcare experiences of transgender women in prison	Participants - transgender women who had served a prison sentence (n = 20)	Structurallevel: the institution's role in creating gender binary; Interpersonallevel: provider's role in reinforcing gender binary; Individuallevel: transgender women's agency in resisting gender binary
Wilson 2017 Australia	To examine the sexual experiences of transgender women in men's prisons with a focus on negotiating sexual safety	Participants (transwomen n = 7) - Australian Aboriginal (n = 2) - Anglo-Australian (n = 5)	Themes included: sexual violence and violent assault; everyday harassment and coercion; diversity and ambiguity of sex; personal strategies to keep safe; and placement in a women's prison as a policy for safety

Transgender women prisoners within and across the included studies were not a homogenous group, with diversity including sexual orientation, “outness” within prison, stage of transitioning, as well age and ethnicity. The classification of transgender women prisoners varied across all studies; eight studies included participants who self-identified as transgender, transsexual, women or gender queer (Brown, 2014; Johnson et al., 2019; Maycock, 2020; McCauley et al., 2018; Nulty et al., 2019; Rosenberg & Oswin, 2014; White Hughto et al., 2018; Wilson et al., 2017), one paper applied the term gender dysphoria (Brown, 2010). Four papers from the same dataset applied four criteria to identify transgender prisoners, which included self-identifies as transgender and/or presents as female, transgender, or feminine inside or outside prison and/or receives treatment for gender dysphoria and/or participating in groups for transgender prisoners (Jenness & Fenstermaker, 2014; Jenness & Gerlinger, 2020; 2019; Sexton & Jenness, 2016). One study applied three of these four criteria, and their last criteria were receiving any special considerations rather than the inclusion of receiving treatment for gender dysphoria (Sumner & Sexton, 2016).

Five themes were identified from the extracted data and included: femininity in a male prison; friendships and relationships; harassment, sexual abuse and physical violence; and solitary confinement and housing.

Femininity in a Male Prison

Prisons remain sex-segregated institutions, with a focus on prisoner's anatomical sex rather than their gender identity (White Hughto et al., 2018), restricting the ability of transgender women prisoners to “pass” as women when placed in a male prison, as all prisoners have been identified as male (Jenness & Fenstermaker, 2014). Many transgender women prisoners lived and “passed” as women prior to entering prison, and people respected them automatically as a woman (Jenness & Gerlinger, 2020). When transgender women prisoners were placed in a male prison, this removed their femininity and acceptance of being a woman (Johnson et al., 2019). The response to this loss by transgender women prisoners was a desire to enhance their femininity, which included their appearance and determination to try and “pass” as a woman (Jenness & Gerlinger, 2020). Acting and presenting as a woman was felt to be very important by transgender women prisoners, both as an expression of self, and a way of gaining respect (Jenness & Fenstermaker, 2014; Nulty et al., 2019).

In defiance of gender binary prison policies, US transgender women prisoners reported enhancing their femininity by growing their hair long, altering prison-issued uniforms, creating bras and applying make-shift cosmetics, shaving their legs and underarms, sculpting their eyebrows, and re-training their voices (Jenness & Gerlinger, 2020). Prison institutions opposed the defiance of transgender women prisoners by removing their feminine clothes, forcing them to cut their hair and nails, and prohibiting them from shaving, alongside the implementation of disciplinary charges (Jenness et al., 2019; Rosenberg & Oswin, 2014). Similarly, the restrictive policies on feminine expression in UK prisons included the banning and removing of items essential for transgender women prisoners to present as their identified gender (Nulty et al., 2019). Thus, prison institutions create a culture that reinforces the abnormality and stigma of feminine expression by transgender women prisoners (Nulty et al., 2019; Rosenberg & Oswin, 2014; White Hughto et al., 2018).

Friendships and Relationships

Friendships and relationships between transgender women prisoners and non-transgender prisoners occurred. Friendships between transgender women prisoners were important for safety, conversation, and support (Nulty et al., 2019; Rosenberg & Oswin, 2014; Sexton & Jenness, 2016). These relationships were not without difficulties, and transgender women prisoners reported competition, distrust and jealousy of others who looked and acted more like a woman. One transgender women prisoner explained: “It's odd. You want friends (other transgender women), but you don’t want the hassle, the drama that comes with them. I’m torn. I want them around, but I don’t want them around. It's good and bad.” (Jenness & Fenstermaker, 2014, p. 23). Transgender women prisoners suggested these friendships were more of a sense of community and support during their time in prison, but these were not friends who would necessarily intervene if you were in trouble (Nulty et al., 2019; Rosenberg & Oswin, 2014; Sexton & Jenness, 2016).

Transgender women prisoners formed and were involved in committed relationships with other prisoners, to whom they referred to as their “prison husband”, which provided them with an element of protection and care (Jenness & Fenstermaker, 2014; Jenness & Gerlinger, 2020; Jenness et al., 2019). The feminine ways of transgender women prisoners provoked idealized responses from the male prisoners towards them as women, supporting and providing for them, which they identified and appreciated. Transgender women's interactions with their prison husbands, which they recognized as real men, supported them to be respected and identified as a woman (Jenness & Fenstermaker, 2014; Jenness & Gerlinger, 2020). Prison husbands however often demanded regular sex and were reported to be possessive and jealous, which lead to violence and sexual assault (Jenness et al., 2019; Sumner & Sexton, 2016). Transgender women prisoners engaged in these relationships as they recognized this prevented some of the continuous sexual and physical harassment, abuse, and violence from other prisoners (Johnson et al., 2019; Wilson et al., 2017).

Harassment, Sexual Abuse and Physical Violence

The gender binary approach of prison institutions had an overwhelmingly negative impact on transgender women prisoners, which included harassment, physical violence, and sexual abuse. Transgender women prisoners” experiences of harassment included being “looked down upon”, subjected to intense security, disrespected, hated and resented by both fellow prisoners and staff (Johnson et al., 2019; Sumner & Sexton, 2016). The constant harassment demeaned transgender women prisoner's identities, making them feel different and diseased, and, on occasion, ashamed (Rosenberg & Oswin, 2014). Transgender women prisoners felt their harassment was worse than that towards homosexuals, as fellow prisoners and staff believed being transgender was a “life style” choice, and therefore they had the capacity to make better choices (Sumner & Sexton, 2016).

Sexual abuse in prison was a common experience for transgender women prisoners in a male prison (Brown, 2014; Jenness et al., 2019; Johnson et al., 2019; Nulty et al., 2019; Rosenberg & Oswin, 2014; Sumner & Sexton, 2016; Sexton & Jenness, 2016; Wilson et al., 2017), and was described as “a way of life” (Jenness & Gerlinger, 2020). Transgender women prisoners identified the constant sexual abuse was due to other prisoners” identifying them as “prison whores”, as one transgender women prisoner explained: “They think I’m a slut because I have breasts. We’re prison whores. That's how we’re seen, especially if we have breasts.” (Sexton & Jenness, 2016, p. 561). The wider prison community interpreted transgender women prisoner's behavior through a sexual rather than a gender lens that lead to their behaviors being interpreted asexually promiscuous (Nulty et al., 2019). Therefore, transgender women prisoners received constant unwanted sexual advances, which they felt was to “wear them down” to provide sexual services (Wilson et al., 2017).

Many transgender women prisoners disclosed being violently raped or witnessing a rape (Johnson et al., 2019; Nulty et al., 2019; Wilson et al., 2017), leading to a sense of fatalism, that it was better to allow sexual advances and non-consensual sex, as a refusal could end in a physically violent assault (Jenness et al., 2019: Johnson et al., 2019; Wilson et al., 2017). However, transgender women prisoners developed strategies to repel or cope with sexual abuse through ignoring it, using put-downs and swearing, or even with a flirtatious response (Nulty et al., 2019). Transgender women prisoners also reported taking “time out” from “being a lady” and responded to sexual harassment with physical violence, as they believed this gained them some respect, and reduced further incidents (Jenness & Fenstermaker, 2014; Sumner & Sexton, 2016; Wilson et al., 2017). Non-transgender prisoners were surprised transgender women prisoners could be physically violent, as they were viewed as being” a girl”, with no testosterone (Jenness & Fenstermaker, 2014; Sumner & Sexton, 2016).

Solitary Confinement and Housing

Transgender women prisoners reported being placed in solitary confinement or to “special units” at some point during their incarceration, as a punishment or for protection (Brown, 2010; Maycock, 2020; McCauley et al., 2018; Rosenberg & Oswin, 2014). Transgender women prisoners were placed in solitary confinement from a minimum of 14 days, which occurred on many occasions to indefinitely, although the average length of placement in one study was 1.8 years (Rosenberg & Oswin, 2014). Reasons for solitary confinement included: arguing with prison officers, accusations of having a sexual relationship with another prisoner, and other prisoners being uncomfortable around a transgender woman (McCauley et al., 2018). Transgender women prisoners reported they were still not safe in solitary confinement (Rosenberg & Oswin, 2014), and solitary confinement was described as a trigger for mental illness (McCauley et al., 2018).

Transgender women prisoners were sometimes housed within “special units” with prisoners who identified as LGBT or diagnosed with a mental illness or a physical disability, or who had committed sexual offences (McCauley et al., 2018; Nulty et al., 2019). Transgender women prisoners described being placed with sex offenders as very uncomfortable, and they feared abuse from these prisoners who constantly harassed them; prison officers just dismissed these concerns when they were raised (McCauley et al., 2018). Transgender women prisoners” reporting being housed in special units does not decrease their level of sexual harassment and abuse from fellow prisoners or public strip searches by prison officers, or the unfair or unprovoked disciplinary charges (Rosenberg & Oswin, 2014).

A transgender woman who had spent time in a women's prison believed this protected her to some extent against sexual harassment and violence (Wilson et al., 2017). However, other transgender women in a male prison had concerns that women prisoners may be cruel and intrusive (McCauley et al., 2018). Some transgender women felt that being housed with other transgender prisoners in a specialized prison unit would be the most appropriate solution (McCauley et al., 2018). Only one paper explored transgender women prisoners” views and experiences of being placed on a transgender-specific wing (Maycock, 2020). However, while there was no clear consensus, positive elements of this approach included support and a shared experience of transitioning in custody, and explicit support prior to entering either a women's prison with proposals of a non-binary or intersex wing, but with a caveat that prisoners could still access the relevant mainstream prison population. However, other transgender women prisoners identified a transgender specific wing as just another form of segregation: “I think a separate wing would be highly inappropriate because it is segregation again which we outlawed years ago.” (Maycock, 2020, p. 36). Further concerns were the assumption that transgender individuals would naturally get along, which is not always the case. Finally, the need to be able to socially transition would not be possible if living only with other transgender prisoners (Maycock, 2020). There was no clear delineated belief by transgender women prisoners regarding being housed only with other transgender prisoners, as one transgender women prisoner explained: “It's hard. I want the company of men, but I feel safe around transgenders. I like women friends.” (Sexton & Jenness, 2016, p. 565).

Limited to no Access to Transgender Healthcare

The majority of transgender women prisoners within the included studies experienced a lack of access to hormone medication at some point during their incarceration. This led to a deterioration in their mental health and occasionally surgical self-treatment to achieve gender realignment (Brown, 2010; 2014; McCauley et al., 2018; Rosenberg & Oswin, 2014; White Hughto et al., 2018). Transgender women prisoners blamed the lack of access to hormone medication on the beliefs and attitudes of healthcare professionals, who they believed attempted to maintain the gender binary approach of prison institutions (White Hughto et al., 2018). Healthcare professionals were reported to apply male pro-nouns to transgender women prisoners that they believed was a deliberate attempt to reinforce gender binary of the prison, and demonstrated a lack of respect towards them:“The nurse, she makes it a point to defeminise you. They say things like, “you’re not a girl, you’re a he”.” (White Hughto et al., 2018, p. 77), and persistently being called a he was described as “like a knife to your side” (McCauley et al., 2018, p. 37). Transgender women prisoners also believed healthcare professionals lacked knowledge and understanding of gender dysphoria, which placed the burden on them to explain the importance of hormone therapy and gender identity treatment (White Hughto et al., 2018).However, transgender women prisoners also recognized and understood healthcare professionals feared the violence they would experience if hormone medication was provided (White Hughto et al., 2018).

A common barrier reported in obtaining hormone medication was the need to provide a previous prescription or a proof of diagnosis of gender dysphoria. However, many of the transgender women prisoners had obtained hormones illicitly (McCauley et al., 2018; Rosenberg & Oswin, 2014). Transgender women prisoners therefore experienced withdrawal of hormone medication, evoking physical symptoms and a sense of despair and frustration that the transition process was not only stalling but reversing. The lack of hormone medication significantly affected transgender women prisoner's mental health, as they expressed feelings of low self-worth and worsening of pre-existing mental health issues (McCauley et al., 2018). One transgender women prisoner who was unable to obtain hormone medication explained how she felt: “I’m depressed most of the time, not being able to express my true self and still being in the wrong body, not being comfortable in my appearance. I have crying fits often for no reason, and I forgo eating so I won’t have to be around other people because I’m ashamed of my looks.” (Rosenberg & Oswin, 2014, p. 9). When hormone medication was prescribed, transgender women prisoners were unable to receive a dose 4 times a day; they believed healthcare professionals were being deliberately obstructive, as this was possible for other medications (White Hughto et al., 2018).

An analysis of unsolicited letters to the Trans in Prison journal identified ten unaddressed needs of transgender women prisoners, of which the most important element was access to transgender healthcare, which a lack of led to suicidal ideation and mental health problems (Brown, 2014). In the US, transgender women prisoners have filed lawsuits regarding a lack of access to transgender healthcare and named the department of correction as the defendant; a number of these cases were successful (|Brown, 2010; 2014). In a small number of cases, the response to a lack of gender identity treatment by healthcare professionals involved transgender women prisoners” engaging in surgical self-treatment (SST) (Brown, 2010; 2014). Transgender women prisoners completed autocastration and/or autopenectomy, life threatening events due to a lack of referral for gender identity treatment (|Brown, 2010; 2014). Following these events, gender identity treatment was not forthcoming; one transgender woman prisoner was placed in solitary confinement on suicide watch (Brown, 2010). These unsolicited letters demonstrate the need for gender identity assessment and treatment, and the devastating impact if this is not provided or continued in prison.

Discussion

The themes identified in this systematic review of transgender women prisoners” experience of serving a sentence in a male prison included: femininity in a male prison; friendships and relationships; harassment, sexual abuse and physical violence; solitary confinement and housing; and limited to no access to transgender healthcare.

The themes femininity in prison, harassment, sexual abuse and physical violence, and solitary confinement and housing will be discussed within a contemporary model, developed by White Hughto et al. (2018), who applied a socio-ecological approach of addressing gender binary at multiple levels within healthcare delivered within prisons. Therefore, the theme limited to no access to transgender healthcare in prison will not be discussed further. A further rationale for our choice is that transgender healthcare has been explored in a contemporary scoping review (Van Hout et al., 2020).

Our aim is to explore and apply this model to understand if it will support the development of a framework to address the current gender binary environment of prisons. The socio-ecological approach recognizes the importance of acknowledging multiple levels -including structural (institutional structure, policies, culture, norms), interpersonal (provider interactions with transgender women prisoners), and individual(beliefs and behaviors of transgender women prisoners).Due to the complexities of the gender binary prison environment, one element from each theme will be chosen to explore at the structural, interpersonal, and individual level.

Femininity in a Male Prison

Structural– prison institutions continue to reinforce a gender binary culture through the banning of feminine expression by prisoners in a male prison. The experiences of transgender women prisoners within this review included the removal of feminine clothes and products, and the enforcement of maintaining short hair and nails. In the UK, this is beginning to be addressed, with the most recent policy by HMPPs in 2019, alongside operational guidelines in 2020. Both reinforce the right of transgender women prisoners to wear clothing and buy items to express their gender. The clothing and items must meet the rules of the prison, and have been approved following assessments such as risk for the individual, others, security and the possible disruption at an operational level (HMPPS, 2019; 2020).

Interpersonal – the development of institutional level policies and operational guidelines are an important progression in supporting transgender women prisoners, but these need to be implemented and disseminated to address the lack of understanding by staff and minimize their mistreatment of transgender women prisoners. A reoccurring element of the development of improving provider interactions at the interpersonal level is the training of staff to challenge their preconceptions and support their understanding of transgender women prisoners (Kendig et al., 2019). The development and delivery of training programes needs to be relevant and applicable to the prison environment, and include insight and support from transgender individuals, who may be correctional staff or wider law enforcement peers (Kendig et al., 2019).

Individual – The acknowledgement of gender identity at an institutional and interpersonal level, such as the ability for and individual to present themselves in alignment with the gender they identify is essential to support their own self-respect and to gain self-respect from others. The support of transgender women to live in prison as their “real” self, enables and empowers them to be respected as a woman, and removes the need to be defiant of the rules and disrupt the operationalization of a prison.

Harassment, Sexual Abuse, and Physical Abuse

Structural – this review highlighted the discrimination, harassment, and victimization of transgender women prisoners by fellow prisoner, staff, and the institution. In the UK, Equality Act (2010), which extends into prisons, describes discrimination as a process that occurs when a person is treated less favorably than another because they have the protected characteristic of identifying as transgender. HMPPS (2019; 2020) has identified the need “to promote and develop trans inclusion and to proactively address discrimination, harassment, and victimisation across the establishment”. Further guidance is required to support this broad well-meaning approach and the equity of how and to what extent this is proactively being implemented across and within prisons.

Interpersonal –the overarching structural aims of preventing harassment, discrimination, and victimization need to explicitly address and prevent transgender women prisoners” expressions of femininity being understood by staff and prisoners as expressions of sexuality, and the perception of them as the “prison whore”, when their expressions of femininity are an expression of their gender. As previously acknowledged, education and training of staff are essential to address these preconceptions and enable them to address the actions of prisoners who hold these preconceptions (Kendig et al., 2019). Education and training programes have begun to be developed for healthcare professionals working within prison environments (White Hughto & Clark, 2019), but these need to be adapted and developed for prison staff and all professionals working with transgender prisoners.

Individual – this review highlighted the constant sexual harassment of transgender women prisoners demeaned their identity and made them feel different, diseased, and ashamed. There remains a need for structural and interpersonal level changes to address this issue, which includes the identification of sexual harassment, abuse and rape of transgender women prisoners, and the continuation and frequency of this abuse. However, there is a need to understand how to change the culture within male prisons that enables this abuse, as in the US this abuse continues despite the Prison Rape Elimination Act of 2003 (Jenness, 2021).

Solitary Confinement and Housing

Structural –this review highlighted the three approaches to housing transgender women prisoners that have been implemented: integration (within the general male prison population), segregation (with sex offenders, LGBT prisoners, and those with physical or mental health difficulties), and isolation (solitary confinement). Traditionally, prisons worldwide have only been able to house prisoners in one of these three approaches. Therefore, there is a need to challenge the traditional culture and gender binary approach of prisons. The use of solitary confinement for transgender women prisoner has been justified as a method to ensure their safety and protection (Jenness, 2021; Lydon et al., 2015). Due to the detrimental impact of this approach on individuals, this needs to be challenged. Only one study in this review explored specific housing for transgender women prisoners (Maycock, 2020). However, the practicalities of this approach involved moving transgender women prisoners away from their families and friends and isolating them from the general prison population – although this was compensated to a degree by the sense of community and safety (Maycock, 2020).

Interpersonal – Many transgender women prisoners discussed the experience of solitary confinement or being placed in a special unit that not reduce sexual harassment, abuse, or strip searches by staff, due to a lack of understanding of their “life-style” (as many believed this to be a choice). When transgender women prisoners were placed in special units with sex offenders, the sexual harassment and abuse continued. Even when this was reported, the incidents were not identified or addressed by prison staff. As highlighted previously, staff discriminatory approaches to transgender women prisoners needs to be addressed through education and training (Kendig et al., 2019).

Individual –transgender women prisoners within this review highlighted the negative impact of solitary confinement on their mental health, which was identified as a trigger for a relapse. The negative psychological and physical impact of solitary confinement has been well-documented (Shalev, 2014), more recently the need to eliminate solitary confinement for some groups of prisoners and greatly reduce for others (Haney, 2018). This review highlights the need for individual risk assessments, with the inclusion of gender identity prior to the consideration of the use of solitary confinement, and this is an approach that should not be evoked to support a transgender women prisoner's safety.

Limitations

A possible limitation of this review concerns the inclusion of four papers from the same date set , although this was a comprehensive mixed methods multi-site study in the US, and each paper explored different elements of the data set (Jenness & Fenstermaker, 2014; Jenness & Gerlinger, 2020; Jenness et al., 2019; Sexton & Jenness, 2016). A further limitation is the inclusion of two studies that reported the analysis of unsolicited letters to a journal (Brown, 2010; 2014). Lastly, the majority of studies were conducted in the US which may be a limit to the generalization of the results of this review to other countries, where laws, policies, and protocols may differ.

Conclusion

There remains a clear need to address the gender binary environment and culture within prisons that currently reinforces the abnormality of gender dysphoria. The application of the contemporary socio-ecological model developed by White Hughto et al. (2018) to the wider prison environment captures the essential elements which need to be addressed at the structural, interpersonal, and individual level to begin the process of addressing and changing the gender binary culture of prison environments. In the UK, a number of structural elements are beginning to be addressed, but without identifying and including the comprehensive experiences of transgender women prisoners, as explored in this paper, these alone will not be sufficient. There remains a need to develop an in-depth framework inclusive of the three levels for each of the themes identified within this article.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article

Author Biographies

Joanne M. Brooke, PhD, is professor of nursing and director of the Birmingham City University Centre of Social Care Health, and Related Research. Her research focuses on the inequities and inequalities in healthcare provision, exploring access in prison settings, supporting older prisoners, those with dementia, and those who identify as LGBTQ.

Karolina Biernat, PhD, is a research assistant with the Birmingham City University Centre of Social Care, Health, and Related Research. She is a public health nutritionist with research experience in community and third-sector organizations, GP practices, and schools.

Nina Shamaris, BSc, is an adult nurse, specializing in prison nursing and supporting patients with complex physical and mental health needs alongside healthcare management and delivery in this setting. She is a lecturer who has supported the development of an undergraduate nursing module that includes mental health in prisons.

Victoria Skerett, MA, is a mental health nurse specializing in forensice health nursing. A senior lecturer at Birmingham City University, she is the lead for the forensic mental health pathway for post-qualifying nurses. Her work also includes the development and support of an undergraduate nursing module with a focus on mental health in prisons.

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