GUIDELINES FOR TREATMENT OF PRISONERS WITH GENDER ISSUES

Draft Document For The Department Of Corrections

Providing safe treatment for those identifying as Transsexual or questioning their gender
Providing treatment that will assist in the rehabilitation of individual Transsexual inmates

Processes of Transition within Prison:

If an inmate approaches health workers or officers with their gender issues or Officers and health workers consider that an inmate may have a gender issue then it can be helpful to both the inmate and the prison staff to have contact with outside transgender support agencies
Inmates may have drug and alcohol abuse problems associated with the gender issues, these need to be addressed before any issues surrounding gender can be successfully addressed

If gender questioning creates emotional problems then counselling is recommended to create some stability, either at the same time or following counselling, psychological assessment by a psychologist with experience of differently gendered people should be conducted to find just where the inmate truly sees themselves and to give direction toward possible further treatment

At this point, if it is considered by all parties that hormone treatment should begin then the first priority should be blood testing by an Endocrinologist to establish a baseline for all future treatment with hormone medication. This is the most important factor in providing safe hormone treatment and is considered vital within the international standards of care for GID (Gender Identity Disorder). Another vital aspect to take into account at this time is the education of the inmate that will be taking the hormones, they need to fully understand the changes that will occur to their bodies and emotional feelings. They also need to be fully aware of all the possible complications. Once the endocrinologist establishes a hormone regime then the prison doctor may continue to prescribe as per the endocrinologist's recommendation. This should continue with blood tests, ideally for the first year on a 3 monthly basis then 6 monthly for the second year and provided there are no complications, annually after that time.
Often people may enter prison already taking hormone medication. This needs to be continued, however experience shows that blood testing should still be conducted as some may be self dosing and taking unsafe levels of hormones or particular hormones that may create adverse effects in the individual's body. Even though they may have obtained hormones outside prison they still may have little or no idea of the full effects of the hormones on their bodies and their time in prison is an opportunity to provide them with accurate information on hormonal effects. Often having a fuller understanding of the effects can give the inmate the opportunity to reassess their own treatment.
The final treatment that anyone can undergo is surgery. As most inmates would not be able to travel overseas following release then surgical options are limited to what is available within New Zealand and by what the Corrections Department will allow.
- For Male to Females the first option is an orchidectomy (removal of the testes) which removes the need for taking anti androgen hormones by ceasing the production of testosterone, this is a comparatively simple surgery that can be carried out in most hospitals in New Zealand. Secondly, some may wish to have breast enhancement surgery. This is purely cosmetic surgery and again can be performed in most parts of New Zealand. Finally, genital surgery can be performed, however there is currently only one surgeon in New Zealand conducting such operations and the technique that he uses, unlike the most commonly used technique overseas, penile inversion, is far more complex using a section of the lower intestine to create a neo vagina and can have more complications than the penile inversion surgery.
- For Female to Males there is currently only 2 successful surgeries available in New Zealand. Firstly, a radical mastectomy which totally removes both breasts and depending on the skill of the surgeon creates a more masculine chest. Secondly, a hysterectomy can be performed. Both these surgeries are available throughout New Zealand hospitals. There is no full genital surgery for female to males available within New Zealand. There have been cases where testicular implants have been attempted but not always successfully due to the body rejecting the implants.
If any inmate is considering these surgeries then they also need to consider that they will be required under current Corrections Policy to pay for the surgery themselves and may also be required to pay for a security guard while in hospital.
Whether an inmate transitions after entering prison or has begun prior to imprisonment then it is important to their emotional well-being to be allowed to wear clothing appropriate to their gender of identification, while in some circumstances this may not always be possible it should be considered as the preferred manner in which to manage the inmate. They should at all times be addressed with the pronouns consistent with their gender identity i.e. She, her, him, he, etc. Chosen names should also be used wherever possible. Receiving respect for their gender will increase dialogue with officers and is likely to increase rehabilitation options. It is also preferable that other inmates directly in contact with a transsexual inmate be helped to understand the issues faced by transsexuals and that they also be encouraged to use correct names, pronouns, etc.

Blood Tests:
Blood studies should include a broad profile in order to evaluate all organ systems, therefore liver, thyroid, and kidney profiles should be done as well as a lipid profile, baseline pituitary gonadotropin levels, serum prolactin, serum testosterone levels, blood sugar and calcium and phosphorus evaluations. In female to male transsexuals estrogen and progesterone testing are not necessary, however there is a very definite need for cholesterol determinations and liver enzymes as baseline comparisons.

The effects of Hormones:
For the female to male transsexual:
They experience all the changes that normal males experience during puberty, the voice gets deeper due to thickening of the vocal folds, beard growth starts, and body hair growth increases. They get good muscle development as well. They may also experience acne and male pattern baldness as a result of the testosterone they take. These changes are irreversible because the addition of testosterone to the system excites all the androgen receptors that are already there but dormant. In effect, they go through puberty all over again, but this time their body is differentiating as a male's would. The main side-effects to look for are hypertension if it is already present, phlebitis can cause some problems, liver enzyme changes are a small possibility, but the major risk is of cardiac disease if the FtM has a family history of cardiac disease, is overweight, and/or diabetic, if there are problems with blood pressure and they smoke and exercise little they are heading for early onset of arteriosclerosis, which leads to heart attack and possibly a stroke.

Emotional changes can include an increase in anger, libido and in some individuals, in aggression.

For the male to female transsexual:
Adding estrogens in an attempt to feminize the male body doesn't always achieve the desired results and some things are immune to change once the male has been through puberty. For example: estrogens will not alter a males voice, they will not cause significant changes in bone structure, facial hair growth may slow but will not stop and rarely will it restore hair on the head. The MtF must understand that the process of change is slow and is not increased by taking higher doses, i.e. maximal breast growth can take at least 2 years and because of our genetic differences some people get more development than others do. Suppression of testosterone will diminish libido and diminish erections. After a time the effect is the same as if the male has been castrated. It will also cause some loss of muscle mass and that means loss of body strength most noticeable in the upper body. Other effects include a softening of body contours, fat redistribution to below the waist, decrease in bodily hair growth and stabilisation of a receding hairline. Negative side effects can include phlebitis and pulmonary embolism. Water retention is also an effect, which can raise blood pressure to dangerous levels. Forming a prodigious amount of body fat in a short period of time can also tax the heart. All these effects are related to dose levels. There is good evidence that smaller doses can be just as effective with fewer side effects. Another area that is becoming a concern for MtF transsexuals is monitoring for breast cancer. Breast cancer in males not on hormones is rare but not unknown. Adding estrogenic agents to your system may actually trigger breast cancer cells into activity. If somebody wishes to have breast development they need to be willing to accept the responsibilities and consequences and undergo periodic breast examinations and ideally mammograms.

Emotional changes can include an increase of tears and sadness, loss of male libido (dependant on medication regime).

Tattoos:
While there is much debate on the issue of tattoo removal, within the corrections system, as an aid to rehabilitation, we consider that removal of tattoos for transgender prisoners is a vital aspect of their rehabilitation. For any prisoner with tattoos it is very difficult to successfully rehabilitate, but to be an ex-prisoner, transgender and have tattoos compounds the problems.

On leaving prison:
As part of increasing chances of successful rehabilitation it is most important that the inmate be given assistance in finding suitable medical support in the area in which they will be living. If ongoing counselling or psychological evaluation is required they should be placed in contact with professionals knowledgeable on transgender issues. If contact with a transgender support network has not been established at this time, then it is suggested that contact be made so as to provide closer individual support. It is extremely difficult for anyone coming out of prison to reintegrate positively into the community, it is always too easy to slip back into former negative habits, being transgender makes this doubly hard and every effort must be made to aid these people in becoming worthwhile contributors to our society.