Editor:
I thank Drs. Robinson, Dupré, Nesbit Huselid, and Burke for their article “The Present State of Housing and Treatment of Transgender Incarcerated Persons.”1 The authors gathered important information and presented it clearly and thoughtfully. I respectfully suggest, however, that the article’s content does not support some of their conclusions.
The authors defer to the World Professional Association for Transgender Health (WPATH) standards and characterize the January 2022 Bureau of Prisons revised Transgender Offender Manual as “progress” (Ref. 1, p 236). In the article’s abstract, they claim that “an increase in federal enforcement and consistency is needed to ensure the humane treatment and protection of TGD inmates” (Ref. 1, p 236).
The authors’ framework thus implies that WPATH’s guidance is good medical practice in carceral settings. No data were presented to substantiate the effectiveness of WPATH’s recommended approach in this setting or to compare it with other options. Furthermore, WPATH appears to have misled professionals and the public regarding the safety and efficacy of the treatments it supports and WPATH has interfered with the publication of systematic reviews it has commissioned.2 In light of these revelations, it appears prudent to reassess whether WPATH is capable of creating trustworthy clinical guidance.
Increased access to hormones or surgical treatment has arguably been achieved through litigation and politics utilizing the minority rights paradigm.3 Yet hormonal and surgical interventions for transgender-identifying persons have mixed, low-quality supporting evidence,4,5 with minimal data from prison settings. Thus, we require more discussion regarding whether, or in what circumstances, these treatments may be considered a “right.”
The second debate is whether, or under what circumstances, it is prudent to place males into female prisons. The intended justification would be to improve the safety and reduce the psychological distress of transgender female inmates. Any benefits from this policy, however, must be weighed against the potential physical harm and increased psychological distress of female prisoners. Without data regarding systematic effects, clinical outcomes, and the effects on female inmates, including the possibility of rape and sexual assault of female inmates, calling these efforts humane is premature.
It is important that we acknowledge that we know little about clinical outcomes and the unidentified ripple effects of following through with WPATH’s recommended clinical approach in carceral settings. The same is true regarding federal enforcement of new institutional policies on gender. Clinicians and policymakers minimally bear these risks, but these debates affect the lives of incarcerated people and can cause harm. Given the opaque nature of the risks involved, I suggest an open-minded and cautious approach.
Footnotes
Disclosure of financial or other potential conflicts of interest: I have been retained as an expert witness by three states that are defendants in lawsuits opposing legislation placing restrictions on medical and surgical care for gender-distressed youth, participated as an expert for the defense of a school system and in another school-related case involving gender-distressed youth, and been retained by the defense in two lawsuits related to gender-affirming care for incarcerated individuals. My expenses were paid, and I received an honorarium from The Society for Evidence-Based Gender Medicine to participate at their 2023 conference. A portion of my expenses were paid to participate in the Genspect Conference in September 2024. No funding was received regarding the creation of this manuscript.
- © 2024 American Academy of Psychiatry and the Law
