Commentary: Gender Nonconformity Within a Conformist Correctional Culture

Simopoulos and Khin¹ have made a valuable contribution to the literature in presenting fundamental principles for the comprehensive care of transgender inmates. They provide basic definitions and terms that relate to transgender and gender-nonconforming people, review case law that is presently shaping correctional system policies on such people, and propose a standardized, comprehensive care approach toward transgender people, to ensure that institutional safety, inmate housing, and medical and mental health care are properly addressed.

Health professionals began conceptualizing the term transgender and identifying the treatment needs of such people in the 1960s.² The assimilation of transgender and gender-nonconforming people has always been difficult, regardless of the environment. Despite the difference between sexual orientation and gender identity, the gay and lesbian subculture was historically the place where transgender and gender-nonconforming people were socially accepted, particularly when legal and medical transitioning was virtually impossible. Acceptance within the gay and lesbian subculture was complicated, however, because, like the rest of society, gays, lesbians, and bisexuals in the Western world did not generally distinguish between sexual orientation and gender identity until the 1970s.³ Instead, they commonly viewed transgender and gender-nonconforming individuals as homosexuals who behaved in a gender-variant way instead of being gender variant outright. As gays and lesbians continue to achieve greater civil rights in the current era, transgender and gender-nonconforming people still struggle to be included in rights protections.

Societal bias and discrimination toward transgender and gender-nonconforming people lead to social and economic marginalization, which, in turn, affect housing, employment, and access to competent health care. When accessing health care, transgender and gender-nonconforming people frequently experience disrespect and harassment and even violence and denial of service.⁴ Such individuals may turn to sex work and have higher rates of mental illness and substance abuse, all of which puts them at greater risk of arrest and imprisonment. For example, many male-to-female transgender people turn to sex work because they face extreme employment discrimination. Transgender and gender-nonconforming people are also at higher risk of contracting HIV.⁵ Discrimination against transgender and gender-nonconforming people, as well as provider ignorance about the health care needs of this small population, can cause these people to avoid seeking or receiving good health care.

The problems that surround psychological classification, stigma, and treatment become more complex when transgender and gender-nonconforming people are incarcerated. The authoritarian prison environment's central mission is containment and security, whereas correctional medical services, while required, are peripheral. Correctional professionals, including officers and administrators, have an authoritarian basis for their relationship with inmates as they enforce rules, regulations, and sanctions.⁶ Such authoritarianism, combined with stigma, can result in discrimination toward transgender and gender-nonconforming people. In contrast to the approach of correctional professionals, health care providers often seek to negotiate treatment adherence, which inmates perceive to be more respectful. Even then, health care providers may lack basic knowledge of transgender challenges, and those who seek help from these professionals often educate the professional rather than receive the needed help. Because of authoritarian attitudes, gender-based stigma, and lack of medical knowledge about transgender and gender-nonconforming people, these inmates are especially vulnerable to the hardships of confinement.

Fortunately, rulings in a handful of important cases that Simopoulos and Khin review have improved treatment approaches for transgender and gender-nonconforming people. As with providing care to any person in a correctional environment, decisions about the type of treatment that transgender and gender-nonconforming people need in a correctional environment require an interdisciplinary team review with individualized approaches. The overall environment must be conducive to treatment, and such inmates must have access to knowledgeable and empathic caregivers. Improvements in care can be achieved, even if individual members of an interdisciplinary team have differences in values and beliefs about the treatment of transgender and gender-nonconforming people on the basis of their individual education, training, and cultural experiences.

There is widespread diversity within the transgender community, and so the individualized approach to assessment, treatment, and housing of transgender and gender-nonconforming inmates is important to emphasize. For example, even mental health professionals who profess to know about transgender concerns may believe that transitioning from one sex to another is the best or only solution. This solution may be correct for many transsexual people, but it is not the solution for all, particularly gender queer people (those who lack an exclusively male or female identity). Instead, mental health professionals should support inmates in whatever steps they choose to take toward transition, or support their decision not to transition, while addressing the inmate's sense of congruence between gender identity and appearance.

Improving approaches to the treatment of transgender and gender-nonconforming people becomes a medical, mental health, interpersonal, and environmental challenge within the correctional setting. Correctional administration must endeavor to minimize bias, and medical staff must be educated enough to provide a broad range of sensitive and competent care and treatment. Correctional systems must be open to changing the behavior of the correctional staff and the inmates, when housing and managing transgender and gender-nonconforming people.

Openness and sensitivity to gender concerns, as well as the provision of appropriate services to transgender and gender-nonconforming people, increase the likelihood that medical services will enhance the overall mission and organization of a correctional environment. The principles Simopoulos and Khin promulgate can assist caregivers and corrections in minimizing risk and liability while enhancing health services.

• © 2014 American Academy of Psychiatry and the Law