User login
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
REPORTING FROM THE AAPL ANNUAL MEETING