HMPS guideline proposals for transsexual prisoners
By Kate More
June 1996
Proposals for the HM Prison Service
Review of Guidelines relating to Transsexual Prisoners
Prepared by Kate More M.Sc., B.A.(Hons), L.R.P.S
Gender and Sexuality Alliance
Box 8, St Mary’s Centre
Corporation Road
Middlesborough TS1 2RW
June 1996
Foreword
by Press for Change
The report which follows was prepared at the invitation of the Home Office, as part of a proposed review of Prison Service Guidelines relating to the treatment of Transsexual Prisoners.
Remember, when you read of current practice in this report, that it deals with the treatment of UK citizens in their own country, diagnosed with an internationally classified medical condition. Think too of the marginalisation and abuse which has more often than not played a large part in some transsexual people resorting to the desperate behaviour that got them jailed in the first place. Consider how you might act if denied both health service treatment and the means to pay for your own private care. Wonder how it feels to be rejected by friends and family, and driven into the hands of exploitationists.
In February 1996, Anne Widdecombe MP assured the House of Commons …
".. No formal guidelines have been issued to Prison Service establishments on the care, management and treatment of transsexuals in prison. Clinicians have, however, always been able to call on advice from the Prison Service’s directorate of health care to assist them in dealing with individual cases … The general principles were set out in letters to you (Dr Lynne Jones MP) of 29th June 1994 and 22nd May 1995, from the former director general, copies of which will be placed in the library of the House.
… The directorate of health does intend to draw up some formal guidelines … [but] … I cannot say when the work will be completed."
Bear the blandness of that assurance in mind as you read this report. And ask yourself this question :
If the people in this report were treated thus because of skin colour, or ethnicity, or religion do you think there would be the deafening silence which you hear now?
So are transsexual people in prison doubly indicted? Once for a crime which more often than not stems from their rejection and brutalisation within society .. and then a second time just for being?
Are we outlaws of the state just for existing?
1.0 Prefatory Notes : The following analysis and recommendations are based on our experience visiting mostly male-to-female prisoners, on the testimony of prisoners given at face-to-face interviews or via correspondence, which we have taken at face value. This should therefore be seen as a partial document in support of the prisoner’s case.
1.1 Although we need to be aware of the needs and responsibilities of short-term and remand prisoners, for reasons outlined below we are only able to deal with the issue of long-term prisoners from first-hand knowledge.
2.0 Background Information : It is quite clear that transsexuals face considerable discrimination world wide, but it is also clear that the UK is not immune. Following the cases of Corbett v Corbett, White v British Sugar and R v Tan it would seem that UK transsexuals face the most legalised discrimination in Europe. And while this is beginning to be addressed, e.g. by the cases P v Cornwall County Council and hopefully with Sheffield v UK, the central issue of privacy has not found redress. Another factor we recognise is that there is an absence of support mechanisms; the gay community for instance is protected in most regions by equal opportunities policies, this is not so for the transsexual, nor are the other minority groups supportive, the women’s movement and gay rights movement in effect being the most hostile.
2.1 According to the 3 year longitudinal study conducted by the National Gender Identity Clinic at Charing Cross Hospital and published in 19921, 1-in-5 male-to-female transsexuals have received in-patient treatment in a Psychiatric Hospital, and 52% of male-to-female transsexuals and 43% of female-to-male transsexuals admit to having been victims of violent crime - this is in the wider Society. These are vulnerable people even without the stresses of transition and the isolation of prison life.
2.2 Gender Reassignment surgery has up to a 97% success rate2, it is therefore one of the most successful treatments available on the NHS. However, a number of studies3 have shown that it is also one of the most controversial practices within the medical profession, transsexuals often being seen as ’psychotic’ or ’morally-depraved’ when a more accurate picture might use words like "guilt-ridden", "having low self-esteem" "abused and angry." Because of these "moral and/or religious" viewpoints NHS staff generally are often badly informed and hostile. It is worth stressing that this is a recognised medical disorder which can be treated, not a whim or perversion. Refusal to treat would be a moral decision akin to decisions for instance, surrounding abortion. Prisoners have a right to appropriate medical treatment.
2.3 Throughout the rest of the world transsexuals have one of the highest incidence of HIV (as percentage) of any marginal community4, they are also amongst the most difficult groups to engender behavioural change in. Key to this seems to be peer group pressure5. The UK has some of the most discriminatory legislation (via case law) of any country in Europe, appalling levels of unemployment and poverty and consequently an extremely high level of prostitution. There seems to be only one factor preventing a major disaster in the UK - NHS provision of treatment. Anecdotally speaking, given that the sexual role is the only female role male-to-females are often permitted, these transsexuals are some of the highest risk people in the whole prison estate.
3.0 Size of the Problem : Lifers need to address certain issues, or ’risk factors’ before release. Transsexuals [such as ’M’ and ’S’] are often told to address their gender issues - yet this would seem to require medical treatment, meaning that they can never be released. We don’t actually know of a lifer who has been released. This will mean that this issue can only increase.
3.1 If we take the figure of 30,000 transsexuals in Britain6, we would expect there to be a minimum of 20 TS prisoners in the UK7. Transsexuals are believed to have the largest percentage of involvement in sex work of any UK community. Over half of Charing Cross Hospital’s m-to-f transsexual clients had criminal records, though not all of these would have been in custody. We have talked to 18 prisoners/ex-prisoners already. Therefore we say ’minimum’, because abused minorities are usually disproportionately represented in prison. There is clearly a great deal of self-censoring from transsexuals in prison; we know of no short term transsexual prisoners, in spite of the fact that most transsexuals are arrested for minor offences like prostitution. Either they are keeping quiet about their status, or the prison service is telling them to be silent. We can therefore only find out useful information from long-term prisoners.
3.2 One transsexual who was diagnosed in 1980 and was at that time refused treatment by the Home Office, decided to wait until she was released. However in 1996 she was told that she would never be released and so started up her campaign once more; the Governor was shocked knowing nothing about this. This was one of four transgendered patients at Gartree, seemingly a large number for one prison. The Governor, Mr Perry, felt that one of these clients had transferred to a prison where press reports had indicated favourable treatment and it would seem likely that two others - knowing that a patient was being treated with some modicum of respect - felt able to be open about their condition, hence the clustering at Gartree. We might presume therefore as an upper range, that for each client open about their condition there are perhaps two others in hiding. Mr Perry was, we felt, very supportive of the TS he had inherited from his predecessor, and who had been on hormone therapy, calling her ’she’ - the only person in the prison service we heard using the appropriate pronoun - but he did not believe the ones without therapy were real transsexuals. He felt this was a coincidence, he knew these particular prisoners better than we did.
4.0 Transsexuals within the Prison Estate : A whole series of problems arise from the practice of segregating prisoners in terms of their biological sex - as it has now been acknowledged that sexual acts between same-sex couples are not an issue within the prison system,8 the need for segregation is presumably to do therefore with either pregnancy or control. Pregnancy should not be an issue if transsexuals are placed on hormone therapy. This is normal practice on diagnosis - even if mild doubts are entertained. These issues are sometimes obvious such as the sex-segregation, the real-life test (which requires living in the opposite role, clothes etc), the realities of scapegoating and prejudice, but there are also more subtle issues such as the fact that transsexuals always self-diagnose. This means in practice that their diagnosis will always be doubted, especially in a regime without hormones or the possibility of a real life test, where the endemic belief is that if one does not look female, one is necessarily a male rebelling against authority.
4.1 Although some transsexuals are refused access to other prisoners under the 1992 policy which states that people whose transsexuality is obvious should be placed on a Segregation Wing, in the Health Care Centre or in a Vulnerable Prisoner Unit, at least one prisoner has been told that she is unique, there are no other transsexual prisoners and as such everything she asks for is setting new precedents.
4.2 Concern has been expressed about Vulnerable Prisoner status being given to TS prisoners to avoid periodic review by Prison Visitors. If a vulnerable Prisoner asks to see the Board of Visitors they are considered to be troublemakers. Quite clearly such reviews are a major part of the campaign for treatment TS prisoners need to wage.
4.3Several prisoners have been moved to new prisons being told that they were finally going to be assessed or receive treatment - the new prison knows nothing and they have to begin their campaign from the start once more. Enough people have mentioned this for it to appear to be deliberate.
4.4 Prisoners are refused access to case conferences at which decisions about them are made - these often by people who have little knowledge of the condition. Nor do prisoners seem to have access to their medical records which would help back their case up in the fight for treatment.
4.5 Not only is there no unified policy across the prison system, but some prisoners in the same prison receive different standards of care [instance: Gartree Prison - ’D’, ’S’, ’M’ and ’J’, the latter received the universal support of the staff and was granted hormone treatment by her prison doctor 6 years ago, the three former prisoners received neither]. In the outside world male-to-females can be placed on hormones after their first meeting with the psychiatrist, and often receive surgery after just two years, whereas ’D’ was diagnosed 16 years ago and still hasn’t been placed on hormones. A number of other campaigns have been waged: A hunger strike was unsuccessful. One prisoner felt she received hormone therapy by waging a dirty protest against Prison Officers. Every time she heard them call her "he" or by her male name she threw slops - faeces and urine over them. She was moved several times and then was given treatment. She is now very well behaved, scared that treatment will be withdrawn.
4.6 We know of no one who has been allowed surgery or even to cross-dress in company though the belief is that moving onto the hospital wing will enable this (’J’ at Gartree is allowed to wear make-up and female underwear in her cell - this would seem to be more to do with fetishisation than a useful medical test).
4.7 Attitudes vary dangerously. Officials at Frankland prison seem to openly state that prisoners will never receive treatment whilst there, yet at Parkhurst outside experts were invited in and paid to train prison staff - even if this was financed by the local health authority. An indication of official attitudes to transsexuals can be gleaned from the fact that most prison officers refer to male-to-females as ’he’ even when a prisoner has achieved full breast development. One prisoner suggested that if she called the more effeminate prison officers ’she’ they would have a right to object, and clearly if this were an issue surrounding race, universal practice in the prison service could only be seen as racist. This would seem to be led from the top - even after a prisoner has legally changed her name by deed poll, the Home Office breaks the law by referring to that prisoner by their previous (male) name. This is without what one prisoner described as her experience of staff’s increasing levels of prejudice, verbal abuse, physical molestation and emotional warfare. As one prisoner in a Health Care Unit says, "When you consider that I get more respect from inmates…"
4.8 There are a number of places where HMPS clearly breaks the law: where a prisoner changes their surname by deed poll, [as in the cases of ’M’ and ’S’] they must use and receive post with their old name in brackets - in effect the new name is not recognised, and if you do not include your previous name your post is returned - even though this is against the law. Other court cases are clearly indicated over the lifer tarif’s risk factors mentioned at 3.0 above and over the refusal to provide medical treatment (at 4.4).
4.9 Strip searches and rub downs are a big issue, male-to-female transsexuals being searched by men and female-to-males by women9. There have been some serious mistakes in the past which have tempted Prison Officers to abuse their position and this is another potential flash-point. We recall the statement of an ex-prisoner at a women’s prison who after receiving surgery, asked for hormone treatment and found herself transferred to Winchester, a male prison. She was then refused both hormones and use of her female name. She was referred to as he, and when experts were called in to advise that she did indeed need hormones and to use regular dilatation of her new vagina if it were not to cause her permanent damage, the governor agreed to let her perform her dilation - if watched by two male members of the prison staff. Eventually one officer stated that she needed the real thing and raped her. She was found the following morning having tried to strangle herself with a bed-sheet. She retreated within psychologically, and although released shortly after, she is still, several years later, clearly traumatised by the experience.
4.10 It would be foolish to deny that rape happens in male prisons, there are well attested texts on the issue. Do we presume that someone who lives as a woman in a male prison will be at lower risk? No, clearly they will be the highest risk.
4.11 There is little or no understanding of transsexualism amongst staff, several transsexuals complain of having to educate the staff about the difference between transvestism, transsexualism and homosexuality. One officer at Whitemoor assumed that transsexualism was a sexual offence and redirected me towards the sexual offenders’ wing, where thankfully no transsexuals were present. Another seemed to believe that it was just a ruse to escape the system, either to the Health Care Unit, to a mental health hospital outside of the prison system, or to eventual release. This begs the question….
4.11 Why do transsexuals, on the contrary, seem to have such an abnormally long stay in prison10? We have written about lifer’s tarifs. Is this due to prejudice? You may recall that the vast majority of women on death row in Florida are lesbians11. It is universally recognised, even by transsexuals’ most hostile critics12 that gender dysphoria is one of the most disturbing of medical conditions, and yet is never seemingly considered as a mitigating factor during the judicial process. Given the rightful use of other mitigating factors such as pre-menstrual syndrome to reduce murder to manslaughter, or to reduce actual sentences to a few years, a case such as that of ’D’s, in which we’re told she killed an uncle who had abused her both as a child and finally over her desire for gender reassignment, surely these circumstances apply. She was sentenced to life in 1974 at age 27, was then diagnosed as a transsexual in 1980 by two consultants visiting Long Lartin, but was refused treatment subsequently and 16 years later at age 49, has been informed that she will never be released.
4.13 Transsexuals need to fight to receive hormone treatment even if they were formerly prescribed this outside and even post-operatively, when not to receive it would lead to a rapidly worsening form of osteoporosis.
4.14 Prisoners often have to fight to be removed from ’Normal Location’ to the hospital wing where they can be allowed to live in role. In some cases this is denied even after initial diagnosis, even though transsexualism is a recognised medical condition under DSM IV and ICD 10. It is not clear that confidentiality is maintainable on a hospital wing. Male-to-female transsexuals who need electrolysis and heavy make-up to cover shaving rash, stubble etc often have an ungainly transition. This aside, the sudden appearance of a female prisoner in a male prison always gives the game away. This is clearly not a suitable arrangement - it leaves vulnerable prisoners prey to the ridicule of badly-informed staff and sometimes sexually-abusive fellow inmates.
4.15 There is a strong belief amongst prisoners that different treatment is meted out to those who first declare themselves to be a transsexual in prison and those committed with a diagnosis already - those already inside believed they were considered to be mentally ill, or disruptive, or were kept inside for longer, or were less likely to receive medical treatment, or all of these things.
4.16 In talking to the Home Office it is clear that the feeling is that m-to-fs cause HMPS more problems - although we are told of one female-to-male who has been transferred to a male prison,13 we believe that f-to-ms prefer female prison - nor do f-to-ms have the same level of urgency: they can be 60 before they transition and still pass perfectly; if an m-to-f doesn’t receive treatment in their 20s or early 30s they are likely to experience serious problems passing and may never be accepted by society.
4.17 When a case receives publicity, as did that of ’K’ at Parkhurst, where the prisoner had no part in an article about her in the Mail on Sunday, but parts of her medical file were seemingly sold to the papers by a member of staff, this seems to dramatically improve the material conditions of the prisoner such as provision of a cell with an en suite shower, speech therapy and electrolysis; but also removes her from favour and presents her with considerable difficulties in terms of confidentiality, becoming a plaything of politicians and also with staff. In this case she was told that not only would she never receive gender reassignment surgery but nor would any transsexual within the prison estate. She sought judicial review of the minister’s decision, but was then told that no decision had been taken! She was also told that the Home Office’s review, for which this document is a submission, was designed with the sole purpose of preventing transsexuals from getting surgery. When she asked to be allowed to put forward her views she was told that it was not appropriate for transsexual [prisoner]s to have input into this process. Interestingly the spokesperson for HMPS, responding to the media hyperbole, stated that they offer the same treatment as that of the NHS.
Recommendations
5.0 This report has been hastily prepared on the basis of hearsay evidence. We have had in fact just three weeks to produce this ’after hours.’ We know of no concrete information on this issue. HMPS itself doesn’t have ballpark figures for total numbers14. Clearly this suggests that a fuller report be produced. We would be very happy to be involved in this.
6.0 Arguments Against Integration : The key issue is the sheer variety of situations that transsexuals can find themselves in. At one level male-to-females may be ’completed’ - indistinguishable from other women, but female-to-males are unlikely to be able to find successful surgery in the UK, and so are likely to remain in a hybrid condition - men with beards and vaginas. Again prisoners vary from the acceptably feminine-looking male-to-female to someone who would always be a focus for ridicule; from first-stage transitional m-to-f, for whom a male prison might be appropriate, to a post-operative m-to-f woman for whom it would not. Again there are people that everyone can ’see’ to be a transsexual and others for whom even the experts have doubts. In terms of treatment, people need to cross-live, and be put on hormone therapy; this is the basis of diagnosis in more complicated cases. Yet this puts some of these people in danger - whichever prison you put them in - whilst taking people’s medication away can also endanger them. The complexity of this situation makes the construction of a coherent policy extraordinarily complex and a compromise is the only solution.
6.1 If policy - as stated by the Home Office spokesman - is to provide an equivalent service to that outside of prison - this is not happening. We know of no one allowed surgery and levels of provision for less radical treatments vary from good at Gartree and Parkhurst to nil at some other prisons. This does not appear to be a function of individual Health care officials, though they will be a factor. For example officials at Frankland Prison have been quite open about their policy of refusing treatment, but now care is provided via the NHS, and the attitude remains hostile.
6.2 Giving individual prisons autonomy to deal with individual cases in whatever way seems appropriate has therefore led to gross inequalities and this strategy has clearly failed. The inability to successfully integrate all groups has in our opinion, led to an alternative strategy based on suppression - if we suppress the problem, it doesn’t become a problem. The divide is almost non-existent between denial and punishment. We would go further, arguing that integration and medical treatment cannot co-exist within a prison environment.
6.3 Although we are conscious of the argument that we shouldn’t stigmatise, ghettoise or reward a specific group of prisoners, we do recommend that a specialist unit be set up, rather than simply placing people in a hospital wing. This is because of the issue of sexual abuse - hospital wings have, reportedly, a higher incidence of sex offenders and also a higher incidence of rape. The policy at Frankland seems to include a censoring of the library books transsexuals may receive - nothing at all about transsexualism. We discount the argument of a few older psychiatrists that putting transsexuals in contact with each other will allow them to school themselves in appropriate symptoms - transsexuals always in effect self-diagnose and there are many descriptions of the syndrome available in prison. Even in the outside world, isolating the most isolated is closer to psychiatric abuse than psychiatric probity. This will not always be what the prisoner wants, it is in effect a denial of choice, even if such a denial is almost definitive of the penal system.
6.4 The Category A prisoner system that might be raised as an objection to this specialist unit only applies to male prisoners, as women only make up 4% of the prison population and it would seem that small numbers enable women’s prisons to cope with their high security prisoners. Transsexuals of course make up a far smaller percentage again, but the unit could be attached to a women’s prison
6.5 Control over transsexual prisoners would not be an issue within a separate unit - where there would be a fear that therapy would be withdrawn.
7.0 Recommended Treatment of Prisoners : There is very poor information provided to inmates. Clearly there needs to be a code of practice or rigorously applied guidelines which are both consistent and available across the prison system, and freely given to every prisoner who self-diagnoses. There is a role for the Board of Visitors as well as outside groups such as ourselves in the monitoring of such guidelines.
7.1 Because of the inappropriate involvement of morality, it is important to pick staff who are well-informed and experienced in dealing with the issue. Given the costs of providing training for large numbers of staff, this would seem to suggest that either a specialist team be available to travel around the country or that prisoners be moved to a separate unit as being the most practical arrangement possible.
7.2 After self-diagnosis, prisoners should be kept in hospital units prior to clinical diagnosis. A small amount of training would, ideally, be needed - perhaps of the 100+ Principal Medical Officers. They would then be sent to the specialist unit where surgery would be a possibility (after the normal two years on hormones) - clearly one would need to dissuade non-transsexuals.
7.3 There needs to be a clarification of risk factors connected with lifer’s tarifs, though this will probably be the subject of a class action in the courts. Such a court case would be expected to provide the right to surgery and to cross-live in prison.
7.4 It would seem that there is enough leeway within the Prison’s Act to allow Governors discretion over strip-searches that we find at Parkhurst.
Kate More
Gender & Sexuality Alliance
Box 8, St Mary’s Centre, Corporation Rd,
Middlesbrough, TS1 2RW
References
- Tully, Bryan Accounting for Transsexualism and Transhomosexuality, Whiting & Birch, London, 1992 - these figures are drawn from Appendix 2, pp. 261-7
- Green & Fleming (1990) "Transsexual Surgery Follow-up: Status in the 1990’s (in the Annual Review of Sex Research, ed J Bancroft, vol 1, 1990 pp. 163-174. Also Pfafflin & Junge, (1992) Geschlecht-umwandlung Schattaver (Stuttgart/New York)
- Studies on medical attitudes include famously Green, Stoller and MacAndrew "Attitudes towards sex transformation procedures" (in Archives of General Psychiatry: 15, pp 178-82, 1966) and its follow up, Franzini & Casinelli, "Health Professionals Factual Knowledge and changing attitudes towards transsexuals" (in Social Science and Medicine, 22(5) pp. 535-9, 1986) which, although 20 years apart, both found that 57% of US medical practitioners considered that clients asking for gender reassignment were either "psychotic or morally-depraved"
- Studies include Rekart ML; Manzon LM; Tucker P, "Transsexuals and Aids" (Int Conf Aids 9(2), 1993 Jun 6-11 p734 abstract no. PO-C21 3101) and Alan D; Alexander R; Monroe J, "Transsexuals - don’t think about them and they go away… and die!" (Int Conf Aids 8(2), 1992, Jul 19-24, pp D452, abstract no. PoD-5391).
- e.g. see Ratnam KV "Efficacy of Health Education programmes on awareness of Aids among transsexuals" (Singapore Medical Journal 31(1), Feb 1990, pp33-7)
- This figure was used by a number of authorities including the Guardian Newspaper, and the European Commission’s recent Colloquium on Transsexualism and the Law).
- Based on the end of April prison population of England and Wales of 54,202 people.
- This change was clearly signalled recently by the provision of condoms in all male prisons.
- Except at Parkhurst where a prisoner with developed breasts is searched, top by a female officer, bottom by a male! This seems to be an insurance policy regarding charges of assault.
- A number of lifers have written to us who have exceeded or are about to exceed their tarifs (minimum recommended sentences) with no expectation of being released in the near future. One prisoner stated that her transsexuality meant that she would never be released.
- Study as reported in the Pink Paper, September 1995
- e.g. by supporters, Harry Benjamin, John Money, Richard Green, Russell Reid, Louis Gooren, and by critics: Janice Raymond, Bryan Tully, John Randall, Sheila Jeffreys etc
- This does not seem to be the rule!
- From telephone conversations with Mr Stevens and David Hillier at Cleland House.
