On September 17, a federal judge halted the Indiana Department of Correction (IDOC) ban on gender-affirming surgery for people in its custody. After IDOC implemented the ban in 2023, the ACLU of Indiana sued on behalf of Autumn Cordellioné, a transgender woman currently in the IDOC men’s prison system.
The court issued a preliminary injunction on the grounds that Cordellioné had sufficiently demonstrated that surgery was a medically necessary treatment for some gender dysphoria patients, and that she was one such patient. By withholding necessary treatment, IDOC is in violation of both the Eighth Amendment and the Equal Protection Clause of the Fourteenth Amendment, and must therefore provide Cordellioné her surgery without delay.
A diagnosis of gender dysphoria is the prerequisite for accessing trans health care in the United States. If you need treatment, you have to be sick, right? Many trans rights activists are focused on depathologizing—moving away from the idea that being trans is a form of mental illness. I understand the spirit of this. But when it comes to the letter of the law, I’m actually in favor of pathologizing.
Getting treatment for gender dysphoria requires producing a very, very thorough body of evidence showing that you’re mentally ill. That you’re sick. And in prison, if you’re sick then the department of corrections is legally obligated to provide treatment.
Over the decade-plus I spent incarcerated in Georgia Department of Corrections (GDC) men’s facilities, I filed five lawsuits against the department primarily related to violating my rights as a transgender woman in custody. I was the first person in the men’s system to get the female property package (underwear; toiletries); to receive facial laser hair removal; and to leave the hair on my head to grow long.
I was in the middle of my fifth lawsuit when GDC released me on parole. Though we can’t prove it, it’s the strong opinion of my attorney and myself that the reason I’m free today is that if I’d remained in prison, I was going to be the first person in GDC custody to receive gender-affirming surgery.
It’ll take several months at minimum just to be diagnosed as gender dysphoric.
If you’re pursuing gender-affirming care from prison, you start by putting in a “sick call” request to see medical and notify them of your gender dysphoria symptoms. You essentially have to play into the narrative that your identity is a mental illness: Here’s a male patient who’s so confused and unwell he thinks he’s a woman.
Then you get escalated to mental health. Like in the free world, in prison there’s a total separation of medical health care from mental health care. Once you do get a consultation to see a counselor, they’ll schedule you to see a psychologist. The psychologist will basically push back against your conception of your identity, to establish that it’s not fleeting or misguided. They’ll then kick you over to a psychiatrist, who’ll examine you to see something else like a personality disorder could explain the symptoms. Then back to the psychologist to answer some more questions.
There are waiting periods in between each step, so it’ll be several months at minimum just to be diagnosed as gender dysphoric. If you came into the prison system without a documented history of receiving or seeking gender-affirming care, and if you don’t already present yourself in a way that fits staff’s conception of what a trans person looks like, it’ll likely take longer.
Now that you have your diagnosis, you go back to medical and request hormone replacement therapy. They’ll schedule you with an endocrinologist. Getting that prescription might take another month or two. They like to say you’re getting the medically sound dosage, but really they cap you at a low dose that’s appropriate for people just starting on hormones.
For me, and the other trans women I know who pursued similar care while in GDC, this meant generic estradiol (a form of estrogen) capped at 10 mg tablets. The highest dose I got to while incarcerated was 12 mg injections every two weeks. GDC refused to allow anyone to progress to Premarin, the brand name for a mix of several different estrogen hormones that for many produces more noticeable results.
The assistant attorney general pointed out that, what with all this other pending litigation, GDC probably didn’t want to do risk me filing for even more damages.
I never got Premarin while in custody, but the more my transness was medicalized the more evidence I had to move into uncharted waters. If it seemed like facial laser hair removal shouldn’t have been a big deal for GDC, it made more sense after the invoice for one of my eight sessions was accidentally mailed to me rather than to the medical department. The bill was for $900. A similar laser session in the free world costs maybe $150.
Though I sought a restraining order to keep GDC from cutting my hair, I wasn’t able to show that it would cause irreparable harm if my hair was cut, since hair of course grows back. But by this time my fourth lawsuit was underway, and there was such a strong body of evidence backing me that I was exempted from GDC’s hair-length restrictions on hair anyway. We had a reasonably decent assistant attorney general who pointed out that, what with all this other pending litigation, GDC probably didn’t want to do something that could result in my filing for even more damages.
My fifth lawsuit was rendered moot in September 2023 when I was released. Had it moved forward, GDC would have had to either settle or go to trial. Settling would have meant providing, at minimum, breast augmentation surgery. If we went to trial, all the evidence suggests we would have won, which would have meant GDC providing breast augmentation, facial feminization surgery and genital reconstruction surgery.
More than just the price tag of the surgery, the real blow to GDC would have been surgery setting a precedent. It would have opened the door for a whole other slew of complaints around classification and housing. You can’t justify housing someone in the men’s system based on biological sex markers if those markers no longer indicate “male.” It’s easier to grant parole to one person than to fix something systemic.
Image (cropped) via Virginia Joint Legislative & Audit Review Commission
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