Health-Related Experiences,Needs,and Challenges of Transgender People in Prisons: A Systematic Review

Abstract

Despite transgender people being a vulnerable group, many jurisdictions lack an appropriate prison policy for transgender prisoners. We examined five databases for studies published in English between 2010 and December 2022. After screening, a total of 18 articles were included for review, highlighting four significant issues: (1) incorrect housing classification; (2) barriers to gender-affirming commodities; (3) healthcare services; and (4) gender-based violence and discrimination against transgender inmates by other inmates and prison officials. The study recommends appointing an interdisciplinary transgender committee in prisons and enhancing gender sensitivity among corrections officials to meet the transgender inmates’ needs.

Keywords

prisoner health transgender inmates discrimination gender identity

Introduction

Transgender is an umbrella term for persons whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth. Gender identity refers to a person's internal sense of being male, female, queer, nonbinary; gender expression refers to how a person communicates gender identity to others through behavior, clothing, hairstyles, voice, or body characteristics (American Psychological Association, n.d.). The Global Gender Identity Report states that over 2% of the respondents from 27 countries identified themselves as transgender. Around 3% of the population in Germany and Sweden are transgender (Statista, 2023). Another recent 2022 report shows that more than 1.6 million adults (aged 18 and older) and young people (aged 13–17) identify themselves as transgender in the US alone, and one in five people who identify themselves as transgender are aged 13–17 (Jody et al., 2022). Similarly, a systematic analysis of papers from 2009 to 2019 indicated that Transgender population ranged from 0.5% to 4.5% of the adult population. However, there is a lack of good quality empirical evidence and data (like from census) quantifying the true proportion of the transpopulation (Zhang et al., 2020).

Due to this population underestimation, transgender people, or gender-diverse people worldwide usually have less access to health care than the general population. However, access to healthcare services is even more daunting for those transgender people who are imprisoned due to various issues, including stigma, discrimination, and legal barriers. Additional to the health challenges (Reisner et al., 2016), transgender prisoners also face discrimination and physical, sexual, and psychological assault in prison environments, perpetrated by prison officials, staff, or other inmates (Alfonsín et al., 2020; Lamble & College, 2012). Additionally, they lack proper access to gender-specific medical care and counseling centered on their gender identity or sexual orientation, including access to care for reproductive health, access to hormone therapy, and treatment options for gender transition (Van Hout et al., 2020). Because of the anxiety brought on by this alienation, TGD individuals are more at risk of physical ailments like HIV infection as well as psychological disorders including suicide risk, drug abuse, and the likelihood of drug overdose (Global Prison Trends 2021, n.d.). As a result, the World Health Organization, the United Nations Office of Drugs and Crime, and the National Standard to Prevent, Detect and Responds to Prison Rape: Final Rules in the United States of America identified these transgender (LGBT) prisoners as “vulnerable” (Gatherer et al., 2014). Unfortunately, the information about the LGBTQ population remains piecemeal among most prison authorities in many countries owing to a lack of research and inadequate prison policies. Due to the insufficient evidence, the total number of LGBTQ+ inmates in prisons is often underestimated, and the actual number of Transgender detainees is surprisingly higher among the prison populations than the reported data.

But still, despite their vulnerabilities, many jurisdictions lack an appropriate prison policy framework for transgender prisoners related to their special needs of housing, gender-specific basic and health needs despite the United Nations for the Treatment of Prisoners Standard Minimum Rules and the updated 2017 Yogyakarta Principles on the Application of International Human Rights Law about Sexual Orientation and Gender Identity ( Yogyakartaprinciples.org – The Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, n.d. ). Following the 2022 report entitled “Lost Identity: Transgender Persons Inside Prisons,” released by the Commonwealth Human Rights Initiative and the University of Dundee, transgender people in and outside the prison system continue to be invisible among the vulnerable populations, with their dignity and rights as citizens being ignored due to their minority population and the structural stigma associated with being a transgender (Ghosh & Dhanuka, 2020). According to the Yogyakarta Principles, medical services for transgender prisoners should be coordinated in strong collaboration with the public health administration. These services must include hormonal treatment and gender-affirming care, therapeutic interventions for HIV and other STIs, TB, and other infectious, noncommunicable diseases, and mental health services (United Nation office on Drug and Crime, n.d.). However, the provision of access to these services in prisons is still neglected by the correctional systems. Considering the known vulnerability and invisibility of incarcerated TGD populations, this article examines the special needs, challenges, and healthcare needs of imprisoned transgender people.

Method and Materials

Search Strategies and Selection Criteria

Five computer-based literature indexes (PubMed, Scopus, Embase, ProQuest, Science Direct) were searched for publications between January 1, 2010, and November 24, 2022, in order to update the existing information on the topic (Van Hout et al., 2020) using systematic review methodology. Initially, 602 articles from PubMed, 856 articles from Scopus, 25 articles from Embase, 608 articles from ProQuest, and 25 articles from Science Direct were discovered. A total of 2116 articles were found (Figure 1 PRISMA flow).

Figure 1.

PRISMA flowchart for included studies.

The search terms applied were “transgender,” “LGBT,” “Non-binary,” “Two-spirit Persons,” “transgender person,” “transsexual,” and “third gender” along with “prisoner,” “prison,” “inmates,” “jail,” “goal,” “criminal,” “confinement,” “detainee,” “felon,” “correctional facility,” “penal institution,” and “offender.” We used search terms separately as well as in conjunction with Boolean operators “AND” or “OR.” MeSH terms were applied to find relevant publications based on the study's title (Supplementary fileS1). To expedite the review process, articles were exported to Rayyan, a freely available online software to conduct systematic review faster and convenient. The selection of relevant articles was made in two stages. The articles were primarily screened based on title and abstract. In the second stage, full-text secondary screening was done. We settled the disagreements between authors through discussion and mutual consensus at each screening step.

Inclusion and Exclusion Criteria

We included only the quantitative, qualitative, and mixed-method studies published in English that identified the gender-specific needs, challenges, and healthcare-related experiences among transgender prisoners. Studies that are not primary articles, not included transgender people as prisoners, or did not have an outcome of interest (challenges, needs, and health-related experiences) were excluded from the study.

Data Extraction and Synthesis

For every eligible study, one author independently extracted information, and another cross-checked the information. Data were extracted on a preformed data extraction sheet under the following parameters: year, author, country, study title, study type, study participants, no. of participants, data collection method, analysis method, and key findings. The health, needs, and challenges of transgender prisoners were analyzed systematically.

Data Analysis

Prisma guidelines were followed for investigating and reporting the search results. Thematic synthesis was used to analyze the findings. After reading the studies several times, the authors (SN and ST) identified the meaning units as well as potential themes. Following that, the two reviewers discussed the findings of each study. A single reviewer then reviewed the results line by line (SN). Categories were inductively developed using the MAXQDA 2022 (free trial) Analytical Pro (VERBI Software, Berlin, Germany) to capture the significance of the findings. After all, the potential similarities and discrepancies between such categories and their relationship were considered. Whenever it was possible, categories were combined to create overarching themes. For the quantitative data, descriptive statistics were employed to describe them due to the lesser number of quantitative studies.

Quality Assessment

One author independently conducted the risk of bias assessment using the Mixed Method Assessment (MMAT) tool of the selected articles based on scoring system. A score of 1 was assigned to a yes response, while a score of 0 was assigned to a no and can't tell response. Each study was classified based on sum scores as “low” (sum score = 2), “medium” (sum score = 3 or 4), or “high” (sum score of 5). Table 1 represents the results of the quality assessment of each article included in the study.

Table 1.

Quality Assessment of Studies—MMAT Tool.

Author/Year	Study type	Is the sampling strategy relevant to address the research question?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research question?
White Hughto et al. (2022)	Quantitative	Yes	Yes	Yes	Can't tell	Yes

	Qualitative	Is the qualitative approach appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from the data?	Is the interpretation of results sufficiently substantiated by data?	Is there coherence between qualitative data sources, collection, analysis and interpretation?
Hochdorn et al. (2018)	Qualitative	Yes	Yes	Yes	Yes	Yes
Jaffer et al. 2016	Qualitative	Yes	No	Yes	Yes	Yes
Jenness et al. 2019	Qualitative	Yes	Yes	Yes	Yes	Yes
Rosenberg and Oswin 2015	Qualitative	Yes	Can't tell	Yes	Yes	Yes
Maschi et al. 2016	Qualitative	Yes	Yes	Yes	Yes	Yes
Maycock (2020)	Qualitative	Yes	Can't tell	Yes	Yes	Yes
Sumner and Sexton (2016)	Qualitative	Yes	Yes	Yes	Yes	Yes
Wilson et al. 2017	Qualitative	Yes	Yes	Yes	Yes	Yes
Smoyer et al. 2021	Qualitative	Yes	Yes	Yes	Yes	Yes
Brown (2014)	Qualitative	Yes	No	Yes	Yes	Yes
Maycock (2022) (	Qualitative	Yes	Yes	Yes	Yes	Yes
Chotchun et al. 2021	Qualitative	Yes	Yes	Yes	Can't tell	Yes
Johnson et al. (2020)	Qualitative	Yes	No	Yes	Yes	Yes
McCauley et al. 2018	Qualitative	Yes	Yes	Yes	Yes	Yes
White Hughto et al. 2018	Qualitative	Yes	Yes	Yes	Yes	Yes
Phillips et al. 2020	Qualitative	Yes	Yes	Yes	Yes	Yes

	Mixed Method	Is there an adequate rationale for using a mixed methods design to address the research question?	Are the different components of the study effectively integrated to answer the research question?	Are the outputs of the integration of qualitative and quantitative components adequately interpreted?	Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?	Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?
Jenness et al. 2019	Mixed Method	Yes	Yes	Yes	Can't tell	Yes

Results

Study Characteristics

After repeated articles were removed, the database search yielded 856 articles. According to the eligibility criteria, 1,111 papers were rejected based on their title and abstract information. As a result, 149 articles were sought to be collected. However, only 142 were available as full texts and were considered for inclusion. A total of 18 were utilized in the resulting synthesis. Table 2 contains comprehensive information about each study, including the author details, study setting, and study sample. Sixteen qualitative, one quantitative, and one mixed-method study comprising 1,571 subjects were included in this review. Although we did not apply any country or geographical restrictions on search; however, the studies found eligible to inclusion criteria were from United States (n = 11), Switzerland (n = 1), England (n = 1), Australia (n = 1), Scotland (n = 2), Latin America (n = 1), and Thailand (n = 1). Eleven (61.1%) studies included only transgender women inmates, while transgender men and women were included in three (16.6%) studies. The remaining four (22.2%) were conducted among LGBTQI+ inmates.

Table 2.

Characteristics of included Studies.

Author/Year	Country	Study title	Study type	Study participants	No. of participants	Data collection method	Analysis method	Key findings
Jaffer et al. 2016	United States	Improving Transgender Healthcare in the New York City Correctional System.	Qualitative	Transgender males (n = 2) and females (n = 25)	27	Survey method	Descriptive	Hormone therapy, familiarity and sensitivity, housing issues
Hochdorn et al. 2018	Switzerland	Narratives of Transgender People Detained in Prison	Qualitative	Transgender women	23	In-depth interviews	Lexicometric analysis	Psychosocial dimensions, masculine-driven behavior, transphobia
Brown (2014)	United States	Qualitative analysis of transgender inmates’ correspondence: implications for departments of correction.	Qualitative	Male-to-female transgender (49%), female-to-male transgender 1%	129	Letter	Thematic analysis	Cross-sex hormone use, Sexual abuse, physical abuse
Maschi et al. 2016	United States	“Coming Out” of Prison: An Exploratory Study of LGBT Elders in the Criminal Justice System.	Qualitative	LGBT	5	Interview (qualitative)	Thematic analysis	Discrimination, survival, suicidal, incarceration
White Hughto et al. 2022	United States	Victimization Within and Beyond the Prison Walls: A Latent Profile Analysis of Transgender and Gender Diverse Adults	Quantitative	Transgender men (n = 184), women (n = 141) and nonbinary (n = 249)	574	Online survey	Latent class analysis and Logistic Regression	Depression, anxiety, somatization,
Chotchun et al. (2021)	Thailand	Causes of Committing Crime and Life in Prison: A Case Study of Transgender Woman Offenders in Thailand Prisons	Qualitative	Transgender women	60	In-depth interviews	Content analysis	Ineffective treatment, no sexual healthcare, vocational training
Smoyer et al. 2021	United States	Masculine Embodiment Among Sexual Minorities in a Women's Prison	Qualitative	Transgender men and women	15	Interview (qualitative)	Thematic analysis	Surveillance, harassment, Correctional Officers, peers
Johnson et al. 2020	Latin America	An Exploratory Study of Transgender Inmate Populations in Latin America	Qualitative	Transgender women	5	Interview (qualitative)	Thematic analysis	Early childhood discrimination, survival behaviors, and incarceration
Jenness et al. 2019	United States	The Feminization of Transgender Women in Prisons for Men: How Prison as a Total Institution Shapes Gender	Qualitative	Transgender women	315	Mixed methods	Thematic analysis	Heterosexual, femininity, pettiness
Phillips et al. 2020	United States	We don’t recognize transsexuals and we are not going to treat you: Cruel and Unusual and the lived experiences of transgender women in US prisons	Qualitative	Transgender women	5	Interviews	Thematic analysis	Gender identity, misfits, abrupt cessation
Jenness et al. 2019	United States	Sexual victimization against transgender women in prison: Consent and coercion in context	Mixed Method	Transgender women	315	Interviews	Thematic analysis	Against my will, sexual victimization, strip club, suicidal
McCauley et al. 2018	England	Exploring Healthcare Experiences for Incarcerated Individuals Who Identify as Transgender in a Southern Jail	Qualitative	Transgender women	10	Semistructured interviews, questionnaire	Thematic analysis	Abuse, solitary confinement, discrimination
White Hughto et al. 2018	United States	Creating, reinforcing, and resisting the gender binary: a qualitative study of transgender women's healthcare experiences in sex-segregated jails and prisons	Qualitative	Transgender women	20	Semistructured interviews	Grounded Theory	Conversion Therapy, Femininity, physically harmed
Wilson et al. 2017	Australia	You are a woman, a convenience, a cat, a poof, a thing, an idiot: Transgender women negotiating sexual experiences in men's prisons in Australia	Qualitative	Transgender women	7	Interviews and IDI	Thematic analysis	Prize, Sexual violence, sexual interactions
Sumner and Sexton (2016)	United States	Same Difference: The Dilemma of Difference and the Incarceration of Transgender Prisoners	Qualitative	Transgender women	10	IDI With Transgender, FGD with Random prisoner		Sexual preference, Inmate Culture, regular homosexuals
Rosenberg and Oswin 2015	United States	Trans embodiment in carceral space: hypermasculinity and the US prison industrial complex	Qualitative	Transgender women	23	In-depth interviews and arts-based inquiry	Thematic analysis	Physical hurt, raped, sexually assaulted, humiliating
Maycock (2020)	Scotland	I want the male and the female wings. I don't want a special trans wing for people. Transgender people in custody in Scotland's views about transgender-specific facilities within prisons	Qualitative	Transgender women (11) and men (2)	13	Semistructured interview	Thematic analysis	Intersex wing, community, custody
Maycock (2022)	Scotland	The transgender pains of imprisonment	Qualitative	Transgender men and women	13	Semistructured interview	Inductive thematic analysis	Misclothing, transphobia, sexual commenting hormone therapy, social support

From the thematic analysis of included studies, two major themes emerged:

Challenges/barriers to the establishment of self-identity within the prison

Coping strategies and suggestions to uphold identity within the prison

Challenges/Barriers to the Establishment of Self-Identity Within the Prison

Subtheme I: Inappropriate Housing Assignment

The housing assignment for detained transgender inmates in United States, England, Latin America, and Scotland is based on the sex-segregated structure of prisons. As a result, transgender people are usually imprisoned in a male or female facility depending on their genitalia or birth-assigned sex (Jenness & Gerlinger, 2020; Johnson et al., 2020; Maycock, 2022; White Hughto et al., 2018). A transgender inmate revealed in a study that the court had justified her placement in a cell with men because she has male genitalia, so she should be treated as such.

Even though other transgender prisoners were incarcerated in the same institution, they were not housed together since prison officials regarded them to be men (Johnson et al., 2020). This further suppressed their drive to express their gender identity and gave them a great deal of anguish and struggle because they had never experienced being housed in rooms with their biological gender while in the community (Maycock, 2022). A transgender incarcerees narrated how the jail institutions ignore their female gender presentation, stating:

“They don't care if you got a feminine personality. If you got male genitalia, you would stay in men's jail” (White Hughto et al., 2018)

The transgender inmates found it particularly difficult to socially transition while living in jails that corresponded to the birth-assigned sex rather than their lived gender. They continually believed that the only prisoners with whom they could socially transition were those of their own lived gender (Maycock, 2022).

On the other hand, another study conducted in men's prison of southern region of England reported on specific housing allocations, segregation, or isolated imprisonment for transgender inmates. Participants reported being allocated or reassigned to a special cell where inmates who are LGBT, have psychiatric disorders, have committed sex offenses, or have disabilities were confined together, which transgender incarcerated persons found to be neither safe nor comfortable (McCauley et al., 2018).

Subtheme II: Challenge in Accessing Basic Commodities

The housing misclassification in prison caused significant challenges for transgender inmates. They reported feminine clothing being confiscated during the admission process because officials felt it would attract male convicts. Transgender women allocated to male housing were made to undress and trim their hair and fingernails (Johnson et al., 2020). Furthermore, access to basic needs such as gender-appropriate clothes, makeup, beauty products, jewellery, and restrooms, which transgender people frequently utilized to express their gender identity, were restricted or unavailable in male prisons (Maycock, 2022; White Hughto et al., 2018). A transgender woman in US jail elaborated,

“When I go outside, I dress in feminine clothes and use the female restroom. “But there is no female clothing or toilets here.” (Jenness & Gerlinger, 2020)

Similarly, transgender men in women's prison in the U.S. Northeast face difficulty maintaining physical behaviors reflecting their masculine identities (Smoyer et al., 2021).

“Boxers are not permitted in a women's jail; therefore, I have to wear panties instead of my belt, footwear, and other clothing.” (Smoyer et al., 2021).

Subtheme III: Challenge in Accessing Healthcare

According to one study from Switzerland (Hochdorn et al., 2018), 24.5% of transgender incarcerated women reported being denied medical care. However, another study from Thailand found that while primary medical care was available for transgender inmates, it was ineffective. The imprisoned transgender persons frequently received medications that did not match the symptoms of their condition and were primarily painkillers and antipyretics (Chotchun et al., 2021).

Access to hormones was one of the most significant concerns across all studies (Chotchun et al., 2021; Jaffer et al., 2016; Maycock, 2022; McCauley et al., 2018; Phillips et al., 2020; Rosenberg & Oswin, 2015; White Hughto et al., 2018; Wilson et al., 2017) The inability to access hormone therapy accounted for over 70% of the medical concerns made by transgender inmates (Jaffer et al., 2016). Inability to access hormones results in withdrawal symptoms for certain individuals, including hot flashes, breast pain, and facial hair growth, and mental health problems such as sadness, suicidal thoughts, and emotional instability (Chotchun et al., 2021; McCauley et al., 2018; Phillips et al., 2020; Rosenberg & Oswin, 2015). This consequently impacted the transgender offender's ability to maintain their gender identity and sexual health.

Contrastingly, another study from USA and England revealed that hormone therapy was only made available to transgender inmates who had a prescription from a licensed doctor before imprisonment. This was especially challenging for transgender people who were homeless, uninsured, or using nonprescribed hormone therapy before incarceration (McCauley et al., 2018; White Hughto et al., 2018).

Additionally, even those with verification documents had to wait longer to receive hormone therapy (White Hughto et al., 2018). They believed that by putting up barriers to accessing feminizing hormones, healthcare providers attempted to perpetuate the gender binary inside jails. Several claimed that healthcare professionals ignored hormone therapy's value, resulting in substandard healthcare. They further alleged that providers’ beliefs that hormone therapy lacks a vital health benefit and a lack of knowledge of the physical and psychological advantages of hormone therapy are responsible for the lack of access to hormonal treatment and the preference for other medicines (Maycock, 2022; White Hughto et al., 2018; Wilson et al., 2017).

Besides a lack of access to hormone therapy, participants described dealing with psychological problems, not having access to proper psychiatric care, and their symptoms worsening while incarcerated. Many spoke of long-standing mental health problems before imprisonment, while others described how the experience of being imprisoned exacerbated or sparked these problems (Maycock, 2022; McCauley et al., 2018).

Subtheme IV: Gender-Based Violence and Discrimination

In the research from United States, England, Scotland, and Australia, transgender inmates claimed they were mistreated, discriminated against, and treated poorly by the corrections personnel and the other inmates. According to some transgender interviewees, other prisoners’ attitudes toward transgender inmates often border on “hatred” and “resentment,” which frequently lead to “dehumanizing” behavior (Brown, 2014; Sumner & Sexton, 2016). Transgender prisoners reflected on the instances where prison officials critiqued their justifications for transitioning by making derogatory remarks (Maycock, 2022; Phillips et al., 2020).

Participants described receiving solitary confinement as a punishment for gendered actions deemed unacceptable. Nearly all studies found that 42% of transgender inmates reported experiencing physical abuse, rape, or sexual abuse, humiliating strip searches in front of other inmates, verbal harassment, destroyed personal items, or unfair or unwarranted disciplinary actions because of their gender identification (Hochdorn et al., 2018); 19% of respondents said that other prisoners, correctional officers (COs), or both had sexually mistreated or abused them (Brown, 2014). Nine investigations found that being a transwoman rendered unwanted sexual advances from other inmates a typical aspect of the jail experience, which, if not reciprocated, leads to physical violence or sexual abuse. To avoid being personally attacked, many people succumbed to any sexual advances made (Brown, 2014; Johnson et al., 2020; Maschi et al., 2016; Maycock, 2022; Phillips et al., 2020; Smoyer et al., 2021; Sumner & Sexton, 2016; Wilson et al., 2017).

On the other hand, few participants from jails of England reported sexual victimization that began as a consensual relationship and evolved over time or in an instant to sexual assault and physical abuse (Maycock, 2022). In addition, many disclosed being subjected to sexual assault and other forms of sexual victimization to obtain gender-affirming goods (Jenness et al., 2019). However, not every inmate experiences sexual or physical violence; instead, most report regular verbal abuse from COs and other inmates in the form of threats, taunting, name-calling, and transphobia (Brown, 2014; Johnson et al., 2020; Maschi et al., 2016; Maycock, 2022).

“'The COs said they would cut my balls, and then they would hang me. They are reprimanding me for being a transgender. Saying it was unnatural” (Brown, 2014)

In some cases, transphobic comments were rather severe, with threats of violence and comments about shooting transgender people (Maycock, 2022; McCauley et al., 2018). In addition, all respondents experienced being approached for sex, which they regarded as near continual verbal harassment (Phillips et al., 2020; Wilson et al., 2017). They acknowledged that abuse and discrimination during incarceration harmed their mental health (McCauley et al., 2018). However, for all individuals who had been victims of transphobia, informing might result in unwanted attention; thus, the transgender inmates minimized their complaints to make life easier (Maycock, 2022; Smoyer et al., 2021).

Coping Strategies and Suggestions to Uphold Identity Within the Prison

Subtheme I: Housing Classification Based on Self-Identity

Regarding housing classification, most research underlined the necessity for transgender housing, with 96% agreeing that the criterion should be based on self-identity (Jaffer et al., 2016; Maycock, 2020; McCauley et al., 2018). Participants who had not received gender reassignment believed that prison assignments could be problematic and unique for each person if they did not fit into the gender criteria of the correctional system. Some said they would prefer to live in facilities in congruence with their genitalia. In contrast, others said they would rather live in female facilities, which is in accordance with their gender identity. Some recommended creating a distinct nonbinary or transgender wing, and many said it was difficult because neither seemed entirely right. Thus, all transgender inmates in the studies underlined the significance of consulting the individual while choosing a facility (Maycock, 2020; McCauley et al., 2018; Wilson et al., 2017).

Subtheme II: Bargaining for Basic Commodities

The research revealed many tactics in which transgender prisoners reinforced their gender identity while incarcerated. The US transgender women prisoners reported defying prison rules by keeping their hair long, wearing bras, using make-shift beauty products, shaving their underarms, carving their eyebrows, modifying their government apparel, and displaying gender-specific mannerisms, including retraining their voices. On the other hand, transgender men displayed their masculinity by keeping their hair short or wearing baggy clothes. This displayed a dedication to one's real self-identified gender identity that is as necessary as irrefutable (Jenness & Gerlinger, 2020; Smoyer et al., 2021). However, they were only allowed to wear these outfits and cosmetics in their unit and not in the prison's open spaces, unlike cisgendered women who were allowed to do so in open spaces (Maycock, 2022; Smoyer et al., 2021). Those unable to acquire gender-appropriate necessities, particularly from Australian and California prison systems, reported resorting to commercial sex with male inmates or correctional authorities to trade for essential commodities. Although transgender women do not always wish to engage in such behavior, it enables them to obtain personal items (Jenness et al., 2019; Jenness & Gerlinger, 2020; Wilson et al., 2017). A transgender woman narrated:

I perform oral sex on other prisoners when I'm running out of shampoo, lotion, and hygiene products (Jenness & Gerlinger, 2020).

However, on the whole, incarcerated transgender women believed that their experiences behind bars have made them more feminine than they were before (Jenness et al., 2019; Jenness & Gerlinger, 2020).

Subtheme III: Gender-Sensitive Healthcare

Transgender incarcerated persons suggested specific ways to improve the poorly accessible and biased correctional healthcare in the prison system. Several cited the need to improve easy access to quality healthcare, particularly hormone therapy on request (Johnson et al., 2020). Participants also suggested that training healthcare workers and other correctional staff in cultural sensitivity or hiring qualified transgender healthcare providers across all prisons might enhance healthcare access and the treatment of imprisoned transgender people. This emphasizes the importance of cultural sensitivity training.

“Teach cultural sensitivity…. allowing some things, like calling somebody a fucking freak, is a disrespect.” (White Hughto et al., 2018)”

It was also highlighted that interaction with transgender persons and their narratives could play a critical part in educational initiatives to strengthen the cultural sensitivity of caregivers (Jaffer et al., 2016; White Hughto et al., 2018).

Subtheme IV: Coping Strategies Against Gender-Based Violence and Discrimination

Across the studies, various coping mechanisms were applied by transgender inmates to protect themselves from abuse. Regarding sexual and gender identity in prison, participants identified three coping strategies: fight, flight, or out of sight. The “fight” was described as defending their right to gender identity. Several described being outspoken, rude, or building up their strength to fight. Flight, on the other hand, was described as separating oneself from one's gender identity in prison or avoiding inmates. One of the individuals enrolled in college classes to demonstrate model conduct. Out of sight was defined as carefully disclosing one's LGBT orientation to fewer trusted people in prison (Maschi et al., 2016; Rosenberg & Oswin, 2015; Smoyer et al., 2021; Sumner & Sexton, 2016). On the other hand, the most common strategy adopted by several transgender women whose gender status was disclosed to all was forming a relationship with the strongest male offenders or offenders serving a life sentence for protection from other male offenders (Chotchun et al., 2021; Wilson et al., 2017). Furthermore, few seek protection by associating themselves with the ethnic or gender minority group within the same cell (Wilson et al., 2017).

Discussion

Our study draws attention to the needs, experiences, and healthcare-related challenges transgender inmates confront when incarcerated. The findings of our systematic review highlight four significant issues: incorrect housing classification in prison due to the binary gender-based classification policy of the correctional system, barriers to accessing gender-affirming commodities, barriers to healthcare services as well as gender-based violence and discrimination against transgender inmates by other inmates and staff members in the various prisons in the research.

Transgender inmates are typically held in male or female facilities depending on their genitalia or in isolated custody in some countries with no or limited access to gender-essential commodities. It has been discovered that prisons run on a cisgender system overlook and disregard the transgender inmates’ pursuit of gender identity and are associated with increased violence and mental health problems among transgender people. Additionally, although segregation and isolation address the problem of social vulnerability, it is challenging for isolated inmates to access education, training, leisure, employment, and other support services, thus subverting their mental and physical health. It is vital to recognize that some transgender inmates feel they should have a say in where they are kept. Different strategies are being applied by many nations, including the United States, Argentina, Columbia, Scotland, Sweden, and Australia, to address the needs of transgender inmates. These strategies include blanket policies versus case-by-case policies, general public housing versus segregation, and solitary units versus shared units (Jenness et al., 2019).

Healthcare is a common challenge faced by inmates of all genders. However, it is worrisome that incarcerated transgender people are denied basic and gender-affirming healthcare more than cisgender prisoners (Brömdal et al., 2019; United Nations Development Programme, n.d.; Van Hout et al., 2020; Van Hout & Crowley, 2021). Given the fewer included articles, this review revealed how a lack of healthcare services could affect the health of transgender incarcerated persons. Stopping hormone therapy abruptly or not having access to hormone therapy for transgender people, particularly those with Gender Identity Dysphoria, has been linked to depression, self-injury, self-penectomy, and suicide (Phillips et al., 2020; White Hughto et al., 2018). Furthermore, male prisoners’ violent and stereotyped behavior makes them more vulnerable to gender-based assault, which may result in sexually transmitted diseases and exacerbate preexisting psychological issues. These outcomes demonstrate the pressing need to develop policies and strategies to close the disparity in the healthcare services provided to transgender prisoners.

Within the confines of carceral spaces, transgender people face significant stigma. According to the United States Transgender Survey, transgender people are ten times more likely than their fellow inmates to be sexually abused and five times more likely to be sexually raped by the authorities tasked with their care (Police, Jails & Prisons, n.d.). Besides, a complicated sexual interaction in which coercive and transactional sex were used to facilitate survival as an adaptation to and to cope with weaknesses was also found (Jenness et al., 2019; Jenness & Gerlinger, 2020; White Hughto et al., 2018; Wilson et al., 2017). Such unfriendly, hazardous situations, discrimination, and violence are severe breaches of human rights. They have been linked to exacerbating health outcomes such as sexually transmitted diseases/HIV, depression, anxiety, substance abuse, and suicidality (Donohue et al., 2021; White Hughto et al., 2018). This suggests the importance of promoting transgender prisoners’ rights and responding to gender-based abuse and triggering factors within the prison system.

In terms of quality, most studies (61.1%) were classified as “high” quality, while 38.8% were classified as “medium” quality. The studies’ strengths typically included appropriate sampling strategies, data analysis methods, and measure descriptions. The limitations of others were typically related to adequacy of data collection method to address research question, the resolution of divergences and inconsistencies between quantitative and qualitative results in a mixed-method study, and a lack of information regarding the risk of no response bias in a quantitative study.

Based on the findings of the 18 included studies in our systematic review, we offer a few recommendations. Firstly, transgender prisoners must be included in decisions about their prison accommodation. Access to gender-neutral clothing and personal goods must be made available. Where such gender-neutral options are unavailable, a substitute method of purchasing commodities must be supplied. According to Ledesma and Ford (2020), the transgender prison committee in Washington is composed of a physician, a mental health specialist, a prison superintendent, a senior caseworker, and a volunteer from the transgender community who has been certified by the Corrections Department (Ledesma & Ford, 2020). Similarly, transgender prison administration requires the formation of multidisciplinary transgender committees to address the housing assignment issues. Second, prison officials and healthcare personnel must be trained in gender sensitivity skills and collaborate with relevant community groups to support the health requirements of transgender prisoners. Before entering prison, individuals on a hormone treatment program should be allowed to pursue the same or similar medicines and be closely monitored. All verification criteria for prior hormone treatment should be waived in recognition that transgender occasionally obtains hormones without a physician's prescription. Nevertheless, several US courts (California Medical Facility at Vacaville Prison) have recognized hormone therapy for transgender prisoners as a medically necessary treatment (Ledesma & Ford, 2020). Transgender convicts are more susceptible to mental health issues than ordinary inmates. Thus, prison psychosocial support services must be made available through multidisciplinary case management systems. Besides that, more research into the experiences of transgender people will be necessary to inform appropriate, effective interventions.

Strengths and Limitations

This systematic review supports future prison policies that encourage the provision of gender-appropriate housing, clothing, and evidence-based health care and support that is responsive, sensitive, and suitable to transgender people's needs while incarcerated. However, a few shortcomings have also been noted. The authors tried to conduct a thorough search; however, there is a possibility for subjectivity and bias. The majority of the studies identified were conducted in Western nations, which restrict the applicability of findings to non-Western nations. Besides that, carceral environments differ significantly internationally. Thus, it is crucial to understand that transgender inmates may have different perspectives and experiences, depending on geography. The incorporation of qualitative method designs with quantitative tools enhances the study's rigor, bringing critical depth and perspective to a body of research that is predominately quantitative. Thus, the strengths of one method can compensate up for the shortcomings of the other when quantitative and qualitative data are combined (Levitt et al., 2018). Therefore, the authors considered qualitative, quantitative, and mixed-method studies for inclusion; however, most studies were qualitative in nature. Although qualitative results might be as valid as mixed method and quantitative method, we might not anticipate that these results will be replicated. Moreover, all the investigations were cross sectional in nature. Thus, there is room for prospective research that tracks the needs of LGBTQ+ inmates in prison, how well or poorly those needs are recognized and addressed, and its influence on their health outcomes. Furthermore, the majority of studies in this review focused on the experiences of imprisoned transgender women, which limits its generalizability to transmen and other gender-diverse inmates. Thus, it highlights the need to conduct in-depth research to understand the specific requirements and experiences of transgender men as well as other gender-diverse incarcerees.

Conclusion

Because of their lack of visibility in correctional systems’ darkest spaces and inadequate legal representation, transgender inmates remain ignored in criminal justice policies as well. Our analysis identified gender-based violence, access to necessities, healthcare access, and misclassification as the most frequent problems this vulnerable prison population confronts worldwide. It is strongly recommended that an interdisciplinary transgender committee be appointed in correctional settings to enhance gender sensitivity among prison officials and to meet the needs of transgender incarcerated persons.

Supplemental Material

sj-pdf-1-tpj-10.1177_00328855231208015 - Supplemental material for Health-Related Experiences, Needs, and Challenges of Transgender People in Prisons: A Systematic Review

Supplemental material, sj-pdf-1-tpj-10.1177_00328855231208015 for Health-Related Experiences, Needs, and Challenges of Transgender People in Prisons: A Systematic Review by Snehasish Tripathy, Sapna Negi, Elakeya Udhaya, Mirza Adil Beig, and Dilip Kumar in The Prison Journal

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.

Supplemental material

Supplemental material for this article is available online.

Author Biographies

Snehasish Tripathy, BDS, MPH, is a research consultant and public health professional with interests in prisoner health research.

Sapna Negi, BSc Nursing, MPH, works as a research associate at the Indian Law Society's Centre for Mental Health Law and Policy. Her research interests include gender-based violence, suicide prevention, and qualitative research methods.

Elakeya Udhaya, BSc Physician Assistant, MPH, is a public health professional passionate for conducting impactful research to address public health issues and provide evidence-based solutions for improved health outcomes.

Mirza Adil Beig, MPH, PhD, is a passionate professional who is committed to improving the health of marginalised communities through innovative approaches and data-driven methods.

Dilip Kumar, BPT, MPH, is a dedicated public health professional with a strong desire to improve healthcare outcomes through commitment to equitable access and evidence-based practices.

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