©2013, ALL RIGHTS RESERVED ISSN: 1555–7855 38 INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2013, VOL. 7, NO. 4 Providing Counseling for Transgendered Inmates: A Survey of Correctional Services Kara Sandor von Dresner1, Lee A. Underwood2, Elisabeth Suarez2, and Timothy Franklin3 1Harvard Medical School Department of Psychiatry, 2Regent University School of Psychology and 3Argosy University Along with the rise of the multicultural move- ment, growing interest in transgender treatment has spread through the mental health and criminal justice community. Over the past 20 years, research has focused on the etiological aspect of transgen- derism. Yet, almost no attention has been directed toward practice and policy standards for this pop- ulation in correctional facilities. While thousands of individuals experience distress or dysphoria concerning their gender identity each year, little progress has been made in achieving standards of care, effective treatment models and programs for training correctional administrators and providers. Individuals with transgender needs (assessment, housing, and treatment) have been largely ignored despite that they remain a key minority population at risk to experience suicide, depression, and hate crimes (Lev, 2004). Many of these individuals are marginalized into areas with high rates of crime, poverty, and drug dealing and abuse. Consequently, transgenders have an increased risk of getting in- volved in the criminal justice system and commit- ted to correctional facilities (Blight, 2000). Although there is no reliable estimate of the per- centage of prison inmates currently requiring trans- gender or transsexual treatment, there is a signifi- cant correlation with criminal behavior (Peterson, Stephens, Dickey, & Lewis, 1996; Walinder, Lund- strom, & Thuwe, 1978), specifically among those experiencing gender dysphoria (Peterson et al.). Other researchers suggest this correlation is a “con- sequence” due to social intolerance in conjunction with comorbid pathological symptoms (Shaylor, 2009, Peterson et al, 1978). As such, an estimated 40 percent of transsexual individuals have been in- volved with prostitution (Hoenig, Kenna, & Youd, 1970; Blight, 2000). Criminal justice administrators and mental health providers are faced with the challenges that arise when dealing with individuals with transgender concerns. Although the literature addressing assess- ment, housing and treatment needs of transgen- dered inmates is limited, administrators and pro- viders must be systematic in their responses. There is a realistic expectation on the criminal justice sys- tem to ensure effective services for transgendered inmates while in correctional facilities. This creates a burden on the corrections system as these admin- istrators and providers are hampered by non-sys- tematic approaches and practices for managing and treating this population (Richard, 2000). Despite literature which correlates criminal be- havior and gender identity disorders (transsex- ual, transgender) with disproportionately high prevalence rates of transsexuals within the cor- rectional system, few studies have been conduct- ed to suggest appropriate models of treatment for transgendered inmates. Numerous studies report transgendered inmates suffer considerably more problems than general population inmates. These include rape (Banbury, 2004), blackmail (Banbury, 2004; Knowles, 1999), contraction of HIV or other sexually transmitted diseases (Stephens, Cozza, & Braithwaite, 1999), relapse or increase of psycho- logical symptoms (Banbury; Knowles; Peterson et al., 1996), lack of social support, limited or inade- quate mental health treatment, denial of hormonal therapy (HRT) (Peterson et al, 1996), and death due to hate crime (Knowles, 1999). Yet the population remains virtually ignored by current researchers. Corrections play a significant role in coordinating treatment services for transsexual and transgender inmates. When inmates with transgender issues are committed to correctional facilities, these in- stitutions should be required to provide effective, adequate, and compassionate care. Sufficient care requires the application of empirically support- ed interventions; however there are few empirical studies which demonstrate best practices for the clinical management of transgendered persons con- fined in correctional facilities. This study surveyed the current assessment, hous- ing and mental health treatment provisions provid- ed to transsexual inmates within state correctional facilities. The literature reviewed epidemiology, prevalence, assessment, and current standards of care. Implications for correctional administrators and mental health providers as well as recommen- dations for future research are provided. � Epidemiology and Prevalence Epidemiology Although several studies seek to estimate the prevalence of transgenderism, there have been no national or world-wide efforts to determine the actual rates of transgenders. Although inter- national estimates differ, several studies indicate approximately 1:40,000 male to female (MtF) and 1:100,000 female to male (FtM) transgen- ders in the general population (Blight, 2000). Information provided by the DSM-IV-TR (2004) confirms these studies however; this estimate excludes transsexuals in early stages of develop- ment who have not fully actualized their gender identity and those who feel they can live as the opposite sex without undergoing surgery. This indicates that the actual numbers of transgenders and transsexuals may be understood. According to Shaylor, (2009) there was an estimated 50,000 post-operative MtF transsexuals within the Unit- ed States. Research indicates there is a higher prevalence of anatomically male transsexuals than female around 3:1 (Meyer, et al, 2001). It is hypothesized that be- cause FtM transsexuals do not receive the same social stigma as MtF, they less often seek treatment and are not accurately accounted for in estimates. Harry Benjamin reports in the Standards of Care for Gender Identity Disorders, Sixth Version, that FtM transsexuals tend to “be relatively invisible to culture, particularly to mental health professionals and scientists” (Meyer et al., 2001, p. 3). Evidence contrary to this ratio is reported in countries out- side the United States. International studies from Europe and Australia indicate that the ratio may be approximately equal (Beemer, 2006). Common Co-morbid Pathology Even the earliest literature pertaining to trans- genderism (Benjamin, 1964; Shively & DeCec- co, 1977; Stroller, 1978; Pauly, 1968) addresses the impact of co-occurring mental health and substance abuse issues.. Bockting and Coleman (1972) stress that it is imperative to distinguish co-occurring symptoms from gender-specific symptoms and that the efficacy of therapy de- pends on treatment of respective pathology. Co-occurring disorders commonly associated with transgender concerns include anxiety, de- pressive, substance-related, personality (Amer- ican Psychiatric Association, 2000), and eating disorders (Sumner, 2010). There are also high prevalence rates of autogynephilia, HIV infec- tion, and suicide attempt among the transsexual population (American Psychiatric Association, 2000). The potential severity of such comorbid pathology further illustrates the importance of provider competency, comprehensive assess- ment, and efficacious treatment. � Interrelated Terms Transgender According to Meyer et al. (2001), the term trans- gender was introduced between the publications of the DSM-III and DSM-IV. It is an umbrella term that refers to individuals who “have gender identities, expressions, or behaviors not tradi- tionally associated with their birth sex” (Gender Education & Advocacy, 2001). Transsexuals only account for a small percentage of the transgen- der population as the term also encompasses transgenderists (individuals who live part or full –time as the opposite sex but do not desire sexu- al reassignment surgeries), and intersex (patients born with atypical chromosomes, genitalia, or reproductive systems), and transvestites (Ke- nagy, Moses, & Ornstein, 2006). Many transgen- der individuals are MtF or FtM, however, some COUNSELING FOR TRANSGENDERED INMATES 39 ©2013, ALL RIGHTS RESERVED ISSN: 1555–7855 identify their gender as both male and female or neither male nor female. Gender Identity Disorder In 1994, the Subcommittee on Gender Identi- ty Issues replaced the DSM-III-R diagnosis of Transsexualism with the broader diagnosis of Gender Identity Disorder in the DSM-IV (Mey- er et al., 2001). According to the committee, the term Gender Identity Disorder (GID) was de- signed to suggest and allow for a “spectrum of gender dysphoria rather than discrete levels of symptoms” and should replace and encompass the DSM-III-R diagnoses of Gender Identity Disorder of Childhood, Gender Identity Dis- order of Adolescence or Adulthood, Nontrans- sexual Type, and Transsexualism (Bradley, et al., 1991; Vitale, 2006). Current diagnoses avail- able to consider when assessing an individual with gender identity or dysphoric issues in the DSM-IV-TR include Gender Identity Disor- der in Children (302.6), Adolescents or Adults (302.85), and Not Otherwise Specified (302.6; DSM-IV-TR, p. 582; Meyer et al., 2001). While a large percentage of empirical literature available pertains to the entire spectrum of GID presen- tation, the focus of the research in the paper will be on specifically on the pathology, adjustment, assessment, and treatment of MtF transsexuals. Transvestite Since the 1900s, the term transvestite has been specified to refer to a person who dresses or represents themselves as a member of the op- posite sex, but identifies as their biological sex. The Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (American Psychi- atric Association, 2000) offers the diagnosis of Transvestic Fetishism, which is described as a paraphilia that “involves cross-dressing by a male in a women’s attire” (p. 574). Transvestites, by definition, are heterosexual men, whose re- current sexual fantasies or urges to cross-dress cause them clinically significant distress or im- pairment in functioning (DSM-IV). Transsexual The term transsexual was used to refer to an individual who wanted to live as a member of the opposite sex. In 1980, Transsexualism was listed as a diagnosis in the Diagnostic and Statis- tical Manual of Mental Disorders – Third Edition (American Psychiatric Association, 1980) “gen- der dysphoric individuals who demonstrated at least two years of continuous interest in trans- forming the sex of their bodies and their social gender status” (Meyer et al., 2001). The term transsexual is currently understood as a person who identifies opposite of their anatomic sex, feels betrayed by their body, and often seeks to make their anatomic sex align with their gender identity through various surgical procedures and therapies. Vitale (2006) offers the definition “a state of existence in which one’s sense of gen- der identity differs markedly from that assigned at birth” (p. 2). Transsexualism is opposite to transvestism on the transgender spectrum proposed by Benjamin (Bullough, 2000; Benja- min, 1964) and differs greatly in motivation: a transvestite is a man who is sexually aroused by dressing in women’s clothing and a transsexual is a biological man who feels and believes he is a woman trapped in a man’s body. The terms (MtF) and (FtM) are used to denote respectively an individual’s anatomic sex to gender identity. � Assessment and Interventions When diagnosing individuals referred for trans- gender concerns, assessments are primarily completed through both observation and inter- view which is focused on both current clinical presentation and developmental history. Col- lateral sources may also be consulted or inter- viewed to verify criteria, including caretakers, family members, social workers, and medical/ mental health professionals. Although assess- ment is generally considered to be an ongoing process, the initial interview should also be used to screen for history of abuse, suicidality, and co- morbid pathology common to transgenderism, including anxiety, depression, social phobia, eat- ing disorders, and substance abuse. While sexual orientation and gender identity are considered separate issues in assessment, Harry Benjamin (1977) developed a Gender Disorien- tation Scale of six types based on Kinsey’s Sexual Orientation Scale. His model provides an insight- ful outline of typologies and presentation for prac- titioners to consider. According to Benjamin, the Type One patient (Pseudo Transvestite) identifies and lives as a male, but may find sexual arousal in occasionally cross-dressing. The Type Two patient (Fetishistic Transvestism) also lives and identifies as a man, but dresses more often as a woman and might wear female garments underneath male clothing. The Type Three patient (True Transves- tism) identifies as male, but with less conviction. He dresses consistently as a woman and may live accepted as female. He may seek hormonal or psychological therapy and may assume a double personality. The Type Four patient (Nonsurgical Transsexual) is often undecided about his gender identity. He dresses as a woman as often as possi- ble, but this does not effectively decrease his gender discomfort. He may be interested in gender reas- signment surgery (GRS), but does not request or admit it. The Type Five patient (Moderate Inten- sity True Transsexual) identifies as female, feels as if he is a female trapped in a male body, and often lives and works as a woman. He requests both GRS and hormonal therapy, but frequently rejects psy- chotherapy unless a condition to surgery. The Type Six patient (High Intensity True Transsexual) has urgently requested and obtained gender re-assign- ment surgery and identifies fully as female. He is usually receptive to psychotherapy and risks sui- cide or self-mutilation if he does not receive sur- gery (Benjamin, 1977). In addition to the Gender Disorientation Scale, Benjamin developed the Gender Identity Screening Tool, focused on the differentiation of transvesti- tism and transsexualism. It provides information on four axes and is, to date, the only widely-used assessment tool available to practitioners. It should be noted that the Gender Identity Screening Tool is used only for MtF transsexuals who are attracted to males and may be biased towards those who have had the resources to undergo electrolysis, hormone replacement therapy (HRT), or GRS (Benjamin, 1977). Although gender identity specific assessment tools have not proven necessary to accurately determine the presence of DSM-IV-TR or ICD-10 criteria, many mainstream tools may be used in research or to aid in more accurately identifying symptom- otology if needed. Some of these include: the Ror- schach (Exner System), the Minnesota Multiphasic Personality Inventory, and the Coolidge Person- ality and Neuropsychological Inventory, which contains a six-item gender identity disorder scale based on DSM-IV-TR criteria (Coolidge, Thede, & Young, 2002). It is also suggested that the Gender Disorientation and Gender Identity Screening Tool be adminis- tered to help define recommendations for treat- ment if indicated. Inmates exhibiting or reported comorbid pathology should complete personality traditional to correctional settings such as the Ror- schach or MMPI. Providers should be sensitive of issues more common to transgendered individuals such as: anxiety, identity disturbance, autogyne- philia, poor or distorted body image, family dis- cord, trauma history, and suicidality (Blight, 2000). Comorbid pathology should be treated separately with the most efficacious interventions available while keeping the overall mental health issue of gender dysphoria in mind. When conducting as- sessments, providers should maintain awareness of Axis II pathology, specifically antisocial personality disorder, and be careful not to provide a parasitic inmate with information needed to feign addition- al symptoms. � Treatment of Transgendered Individuals within the Community Current Standards of Care Treatment of transgendered individuals requires a comprehensive bio-psycho-social approach often employing a team of multidisciplinary caregivers, including a general physician, en- docrinologist, plastic surgeon, psychiatrist, psy- chologist, electrologist, and social worker. The most widely referenced protocol of treatment for individuals with transgender issues was devel- oped by the Harry Benjamin International Gen- der Dysphoria Association (HBIGDA). Harry Benjamin (1885-1986) was a German sexologist and gerontologist who began treating transsex- ual clients with HRT before gender identity dis- order was recognized by mental health profes- sionals when gender dysphoric individuals were mainly diagnosed with schizophrenia (Benja- min, 1977). HBIGDA released the first version of the standards of care (SOC) in 1979 and continued integration of practice, research, and public policy into revisions published in 1980, 1981, 1990,, and 1998. The most current version (sixth, 2001) of the SOC includes sections ad- VON DRESNER, UNDERWOOD, SUAREZ, & FRANKLIN40 dressing: Introductory Concepts, Epidemiolog- ical Considerations, Diagnostic Nomenclature, The Mental Health Professional, Assessment and Treatment of Children and Adolescents, Psychotherapy with Adults, Requirements for Hormone Therapy for Adults, Effects for Hor- mone Therapy in Adults, The Real-Life Expe- rience (RLE), Surgery, Breast Surgery, Genital Surgery, and Post-Transition Follow-up. These sections can be grouped into five major clinical areas that should be addressed throughout the course of treatment: diagnostic assessment, psy- chotherapy, real-life experience, hormonal ther- apy, and surgical therapy (Lev, 2004). The SOC lists an “overarching treatment goal” of “psycho- therapeutic, endocrine, and surgical therapy” for individuals with transgender needs in order to promote “lasting personal comfort with the gendered self ” and to “maximize overall psycho- logical well-being and self-fulfillment” (Meyer et al., 2001, p. 2). The authors specify that, while the SOC provides guidelines for the spectrum of treatment modalities, not all individuals will re- quire physical therapy or surgery and treatment planning should be determined on an individual basis. Mental Health Individuals strongly identifying with the oppo- site sex, experiencing gender dysphoria, or liv- ing as a transsexual may benefit from an array of mental health services ranging from assess- ment to psychoeducation to intense psycho- therapy. Although the SOC specifies “psycho- therapy is not an absolute requirement for the provision of triadic therapy” (RLE, HRT, and GRS) or effective treatment of individuals with transgender issues, mental health intervention is needed to complete the first three clinical areas outlined (diagnostic assessment, psycho- therapy, and RLE) along with letters of recom- mendation from mental health professionals are required for HRT and GRS (Meyer et al., 2001, p. 13). Mental health services vary depending on the individual’s severity of dysphoria, develop- ment of identity, age of onset, and progression in treatment. Given the frequent occurrence of pathology comorbid to transgender concerns, such as anxiety, depression, substance abuse, personality disorders (DSM-IV-TR), and eating disorders(Shaylor, 2009), treatment may be con- tinued on a long-term basis even after GRS has been competed and the individual is living fully as their identified gender. Referral for Treatment Referral for mental health care of individuals with transgender concerns is often made during childhood by family members who worry that their feminized behavior and interests will have a negative impact on their lifespan development or the family’s reputation. Often parents are un- aware of the distinction between sexual orien- tation and gender identity believe their son is gay and needs to be “fixed,” whereas others seek supportive therapy or treatment for comorbid pathology associated with gender discomfort. Late-onset clients are usually self-referred, al- though some are referred by spouses or life part- ners who are disturbed by their cross-dressing behaviors or lack of interest in the traditional husband role. Transgender-Specific Models of Therapy With the understanding that gender identity issues do not function independent of comor- bid symptomotology, many providers rely on traditional techniques of treating anxiety or de- pression (such as psychodynamic or cognitive behavioral therapy) and attempt to extend these interventions to address or their client’s struggle with gender identity. The SOC indicates effec- tive psychotherapy should provide education, clarify options of transgendered living, improve relationships, explore identity, provide informa- tion about medical and legal resources, support and educate family and loved ones, and facilitate transition, in addition to decreasing problemat- ic symptomotology (Meyer et al., 2001; Rachlin, 2002). These requirements, in conjunction with the need of proficient, detailed knowledge of psychological, medical and psychosocial com- ponents of the transgender experience (Brown, 2001), raise the question of whether traditional theoretical orientations allow for comprehensive treatment. Since the early 1990s, four promis- ing transgender specific models of therapeu- tic treatment have been proposed, including; Harry Benjamin’s model proposed in the SOC (2001), Bockting and Coleman’s comprehen- sive five-task model (1992), Devor’s 14 Stages of Transsexual Identity Formation (2004), and Lev’s Stages of Transgender Emergence (2004). These models of treatment are based on years of clinical experience, treating transgender clients. Because they are only recently available to the mental health community, providers have inte- grated them into practice but no formal empiri- cal research has been published supporting their efficacy. Pharmacological Interventions Of the literature reviewed, no studies directly ex- amined the affects of pharmacological interven- tions on gender dysphoria or transgender issues. The consensus among transgender researchers and health care providers is to refer to main- stream literature for the most effective interven- tion strategies and integrate them into therapy utilizing standard protocol and considerations. Thus, if a client was exhibiting depressive symp- toms, the provider may suggest integrating an antidepressant into treatment, or if the client was experiencing clinically significant anxiety, a benzodiazepine may be considered. However, it is imperative for providers treating transgen- dered individuals to consider contraindications involved with these therapies. For example, hor- monal fluctuations or medications associated with HRT and GRS may negatively impact the effectiveness of traditional psychotropic med- ication (Israel & Tarver, 1997). As transgender specific treatment models become more widely applied and researched, literature concerning the affects of pharmacotherapy should also be addressed. � Current Treatment of Incarcerated Transsexuals Issues and Risks Specific to Inmates with Transgender Needs Recent research identified a significant link be- tween transsexualism and criminality, suggest- ing transsexual inmates are up to 10 times more likely to have committed multiple offenses in the general population (Peterson, Stephens, Dickey, & Lewis, 1996). Many studies correlate gender identity disorders with criminal behavior (Peter- son, Stephens, Dickey, & Lewis, 1996; Walinder, Lundstrom, & Thuwe, 1978), specifically among those experiencing gender dysphoria (Peterson, Stephens, Dickey, & Lewis, 1996). Disregard- ing etiological reasons for the development of antisocial tendencies among the transgender population, there is an apparent proportional need for housing and treatment of those who are committed to correctional facilities. Those creating models for treatment and housing must first assess risk-factors specific to the population that should be addressed. Although all inmates are at a risk of sexual assault, rape, and contracting HIV through sexual contact, the prevalence of sexual assault, sexual promiscu- ity, and associated risk-taking behaviors are con- siderable higher among transgendered inmates. A recent study by Stephens, Cozza, and Braithwaite (1999) examined a population of 153 inmates, 31 of which identified as transgendered. Transgendered inmates were found to be 5.8 times more likely to report having multiple sex partners in prison, two times more likely to have been tattooed while in prison, four times more likely to have received treatment for STDs while in prison, and two times as likely to have used injection drugs while in prison. Additionally, a separate study suggests an estimate of 40 percent of transgendered individu- als have been involved with prostitution (Hoenig, Kenna, & Youd, 1970). In addition to rape (Banbury, 2004), blackmail (Banbury, 2004; Knowles, 1999), contraction of HIV or other sexually transmitted diseases (Ste- phens, Cozza, & Braithwaite, 1999), transgendered inmates are also at a particularly high risk of re- lapse or increase of psychological symptoms (Ban- bury, 2004; Knowles, 1999; Peterson, Stephens, Dickey, & Lewis, 1996). Lack of social support, lim- ited or inadequate mental health treatment, denial of hormonal therapy (Israel, 2002; Peterson, Ste- phens, Dickey, & Lewis, 1996), psychosis, self mu- tilation (Israel, 2002), and death due to hate crime (Knowles, 1999) add to the list of problems to be considered by correctional management. Whether a transgendered inmate is perceived as attractive, weak, victimized, or is using her gender as a sur- vival mechanism, prison officials must account for COUNSELING FOR TRANSGENDERED INMATES 41 these occurrences and provide adequate housing, treatment, and supervision. Current Provisions within Correctional Facilities The term “freeze-framing” is largely the current paradigm of treatment for transgendered inmates. It is argued that inmates should maintain status quo of their physical presentation upon incarcer- ation for several reasons, including: prisons are artificial environments that do not accurately re- flect the outside community, it is difficult to assess symptomotology of transgenderism due to need for protection and possible malingering, and the difficulty of conducting an accurate real life test in an all-male, controlled setting (Peterson, Stephens, Dickey, & Lewis, 1996). While many argue Dickey’s freeze-frame policy provides the most protection and order while allowing those who have already begun HRT to maintain treatment, it condemns transgendered inmates with life sentences who were not previously diagnosed with gender iden- tity disorders to a life without adequate treatment. In addressing current treatment issues and pro- visions allowed to transgendered inmates Gianna Israel (2002) writes: Most prisons do not provide hormones, and some go to great lengths to avoid providing any treatment to transsexual inmates. Most trans- gendered inmates are not receiving appropriate medical and psychological care. Many repeat- edly seek medical treatment, often for years, while enduring administrative harassment and difficult court battles in the pursuit of basic medical and civil rights. Prisons that do pro- vide frequently have policies which allow for the treatment of those who were treated prior to incarceration, but fail to address the medi- cal needs of those who develop gender identity disorder during incarceration or who have no documented proof of their pre-incarceration transsexualism. [Prison officials] sometimes maintain that the prison does not afford the opportunity for the real life experience…conve- niently ignoring the fact that many MtF trans- sexual inmates consistently maintain their female identity year after year in an all male facility (p. 2). Based on the self-report of inmates and relating case law review, Israel projects a grim, but ac- curate, portrait of treatment of transgendered inmates in most correctional facilities. In the provision of safe housing and effective men- tal health treatment for transgenders, many aspects must be considered, including; single cell housing, maintenance of hormonal therapy, possible place- ment in female facilities, provision of clothing and undergarments, differing hygienic needs, protec- tion or seclusion from sexually aggressive inmates, and gender identity disorder-specific psychological and pharmacological treatment. Because treatment in correctional facilities is guided by litigation, of- ficials are reluctant to publish studies or release in- formation concerning policies or guidelines of the treatment of transgendered inmates. Of the research reviewed, only one study directly addressed policies within correctional settings. In 1996, Peterson, Stephens, Dickey, and Lewis pub- lished Transsexuals within the Prison System: an International Survey of Correctional Services Poli- cies, a study focused on the European community, as well as Australia, Canada, and the United States. Of the 103 15-item questionnaires sent out, 64 us- able questionnaires were returned, resulting in a re- sponse rate of 63%. The study concluded that only 20 percent of the 64 corrections departments sur- veyed used a formal model of policy for the treat- ment and housing of transsexual inmates. When questioned how a diagnosis or classification of transgender is obtained, 21 of the 64 respondents reported they used self-report as criteria, 29 report- ed assessment within the correctional facility, 24 reported they referred to previous diagnosis within the community, and 13 reported they used external gender consultants for assessment and diagnosis. Twenty nine respondents indicated they would continue previous HRT, 26 reported they would decide appropriateness of provision on a case by case basis, and 9 reported they would not continue HRT treatments. Fifty three jurisdictions reported GRS would never be considered and 11 indicated it might be an option in specific circumstances. With regard to mental health services and hous- ing, 52 of the 64 respondents indicated they would provide standard counseling available to the entire prison population and only 12 reported they of- fered specialized mental health services for trans- gendered inmates. As for placement based on the inmate’s security, 52 respondents endorsed they would provide housing on a case by case basis, 25 of these considering placement in the general pop- ulation. Only 22 indicated protective custody as on option in deciding appropriate housing needs. The study reflects consistent difficulty in the assess- ment of transgendered inmates, suggesting num- bers presented to not reflect an accurate percentage of inmates with transgender concerns. Respon- dents (60%) who indicated they had no formal pol- icy based this decision on the premises that trans- gendered inmates would receive more adequate care if determined on an individual basis. Those who indicated they would deny transgendered in- mates HRT largely expressed doing so would make the inmate more feminine and a greater risk of physical or sexual assault. Across the board, place- ment was based on the inmate’s genital sex at the time of assessment; however, several jurisdictions indicated they would transfer inmates who under- went GRS to a female facility. The authors stress the confirmation of their hypothesis that almost all correctional facilities reported they provide no spe- cialized counseling or supportive therapy. � Method Procedures Surveys were mailed to 50 mental health direc- tors of each state’s correctional department. The mailing list was compiled by obtaining phone numbers from each state’s website and then calling the mental health department to obtain a current mailing address. In many cases, the acting director was available by telephone. Fifty questionnaires were mailed, including pre-ad- dressed and stamped envelopes. Two months later, a follow up letter was sent, containing a second copy of the questionnaire. Of the 21 re- sponses received, 18 were fully completed ques- tionnaires. The other 3 responses indicated that the states were not able to respond due to on- going litigation concerning transgender issues. No further information was provided. Surveys were sent exclusively to state-level mental health services departments rather than individual prisons or jails. One state forwarded copies of the questionnaire to each facility in an effort to compile the most accurate information. Participants Participants in this study included 18 out of 50 state mental health directors of correctional sys- tems. The majority of the mental health directors were psychologists, however, in some states the psychology department is a division of general health services and the surveys were completed by physicians. The survey included open and closed ended questions and was administered to the mental health directors as they reported on assessment, housing, treatment and training practices and then expressed their opinions on best practices. Additionally, they were invited to share further information they felt should have been addressed by the questionnaire and if they could be contacted. No items required information that could be used as identifiers to link participants to the survey, maintaining an anonymous study in an effort to received higher response. Informed consent ensuring anonymi- ty and confidentiality, as well as instructions on how to complete and return the survey was in- cluded in the survey material. � Research Design Measures A 16-item survey was developed to obtain in- formation about current methods of treatment and policies used by correctional facilities. The survey was comprised of 12 binary response (yes or no) questions with follow-ups for fur- ther explanation depending on the question, in addition to three free form questions. All text responses were coded and categorized. The bi- nary and categorized responses were then ana- lyzed descriptively to find trends by examining every binary data point and free form question for quantitative association between addressing special needs against lower risk factors. Issues addressed by the survey were determined to be need-based through discussions with mental health providers within a southeastern Department of Corrections and review of current literature ad- dressing norms and legal precedent. Items included general, housing, assessment, and treatment issues specific to transgendered inmates, using both open and closed questions. The survey also included an item that encouraged respondents to share in- formation which they felt should have been more adequately addressed by the survey, to which eight clinical directors responded. VON DRESNER, UNDERWOOD, SUAREZ, & FRANKLIN42 Results A total of 50 questionnaires were sent out and 18 usable were received with a response rate of 42%. Of the 18 states that provided usable responses, 45% reported they had no inmates who meet full criteria for gender identity disorders in any facil- ities. Of the 10 states that indicated incarcerating transsexual inmates, 6 states reported less than 5 inmates with transgender issues; 1 state report- ed awareness of seven inmates with transgender concerns, and 3 states reported awareness of be- tween 14 and 20 inmates with transgender con- cerns. 45% of respondents indicated they were aware of several additional inmates who met partial criteria of gender identity disorder or had not yet been formally diagnosed. Out of these 8 states, 5 indicated they could not estimate a number, 1 estimated over 15, another estimat- ed over 50, and the last estimated over 200. This accounts for an estimate 81 inmates who meet full criteria of gender identity disorder within 10 states and another estimated 265 inmates who meet partial criteria or have not yet been diagnosed within 3 states. Despite the fact that 10 states reported housing transsexual inmates, only 6 states endorsed having general guidelines specific to the assessment, treatment, and man- agement of transgendered inmates. Results concerning housing of transgendered in- mates indicated the extent of options was limited to single cells. 9 respondents (50%) reported that their state offered no housing provisions for inmates di- agnosed with gender identity disorder, 7 respon- dents (39%) reported their state offered single cells determined by safety needs on a case to case basis, and 2 respondents (11%) reported their states pro- vided housing on segregation units. Additionally, 1 state that provided single cells also provided the opportunity for transgendered inmates to shower separately from the general population. 12 states (67%) indicated they have no inmates diagnosed with gender identity disorders housed in mental health units (MHUs), 4 states (22%) indicated they housed between two and three transgendered in- mates in MHUs, and 2 states (11%) indicated they housed transgendered inmates in MHUs tempo- rarily as needed for acute symptoms or comorbid disorders. Every state that responded to the survey indicated they had no transgender specific or spe- cial housing units for transgendered inmates, one indicating that many transgendered inmates are housed on a special management unit. Concerning assessment and diagnostic procedures, 2 states indicated they had salaried employees whom they considered “transgender specialists” and 2 states (11%) indicated they worked with psy- chologists in private practice who have experience in transgender issues on a consulting basis. Of the 14 states (78%) that indicated they have no staff or consultant mental health professionals proficient with assessment and treatment of transgender con- cerns, one respondent reported his state consults with a university based endocrinologist for clients who receive HRT. 4 states (22%) indicated they had conducted between 2 and 10 evaluations to assess a diagnosis of transgender concerns, however, every state that responded denied having a standard bat- tery or assessment tool used in evaluation. 14 states indicated they do not administer or refer transgen- der specific evaluations. Regarding treatment, 17 states indicated they have no transgender specific programs or treatment methods. One state indicated there is transgender specific therapy available at every DOC facility in the state, but did not elaborate on what type of treatment or program was offered. 13 states denied providing provisions (such as female undergar- ments or hygiene products) to transgendered in- mates, one of which indicated such provisions were currently under consideration. 4 states indicated providing female undergarments or support bras and the last state indicated any provision would be provided if deemed “medically necessary” by a licensed psychologist or psychiatrist. 12 states reported providing HRT, 2 more states than indi- cated having inmates with transgender issues. Of these 12 states, 2 provide HRT to one inmate, 4 pro- vide HRT to between 2 and 5 inmates, one provides HRT to more than 5 inmates, one provides HRT to more than 25 inmates, and 4 did not provide a specific number. Overall, the most prominent obstacles reported by respondents were issues of housing, staff education, and treatment. 11 states (61%) indicated difficulty assessing the need for and providing single cells. Often, in these cases, transgendered inmates re- portedly end up placed in a higher security level than required or in a segregation unit with little social contact or privileges. Deciding whether to house a MtF transgendered inmate with breasts in a female or male facility and sexual activity were also raised as housing security issues. 8 states (44%) reported obstacles concerning the education of mental health staff, nurses, and correctional offi- cers about transgender specific concerns and relat- ed needs or pathology. Many of these states sited a “lack of understanding” as a significant issue, in- dicating controversy over the existence of the dis- order and frequent reports of verbal abuse by staff members. 7 states (39%) raised concerns about the efficacy of treatment provided to transgendered inmates, explaining that mental health staff is not familiar with transgender specific models of care or effective interventions. 5 states reported that they did not complete the questionnaire due to ongoing litigation, listed lawsuits and legal restraints as sig- nificant obstacles to providing adequate transgen- der treatment. Respondents were asked to list any intervention that had been effective in their facilities, which would be beneficial for other states to implement. Responses included: completing one-on-one con- sultations with medical staff and administration members to explain the criteria and treatment op- tions for individuals with transgender concerns; providing transgendered inmates with individual therapy to address comorbid personality disorders; building a consultation team composed of behav- ioral health psychologists, directors of nursing, medical doctors, health services directors, and oth- er site specific staff to consult regarding interven- tions and plans; acknowledging inmates who have transgender concerns closely monitoring them for persecution and retaliation; and continuing to provide HRT to inmates diagnosed and treat- ed for these concerns prior to incarceration. Four respondents (22%) recommended states should enhance transgender specific training available to staff members, including correctional officers and work supervisors. 5 of the 8 respondents stressed the issue of need- ing evidenced-based guidelines for the treatment of transgendered inmates that could be feasibly applied in a correctional setting, two of which sug- gested states should share their current policies of assessment, treatment, and management. � Discussion The purpose of this study was to survey the current assessment, housing and mental health treatment needs of transsexual inmates within state correctional facilities. The literature re- viewed epidemiology, prevalence, multiple uses of terms, assessment, and current standards of care. The results of the survey indicated not only a lack of psychological and physiological treat- ment, but also a consistent acknowledgement of discomfort with the lack of understanding about transgender specific issues. Fortunately, prison officials appear to be increasingly open to pro- viding services to transgender and transsexual inmates who require special consideration. . Re- sponses also indicated a need for standardized quality of care, education for staff interacting with transgendered inmates, and general physi- ological and mental health guidelines pertaining to specific psychological and medical therapies. � Assessment and Mental Health Services Mental health professionals working with trans- gendered individuals in correctional facilities should complete the 10 tasks outlined by the SOC. Basic standardized national level protocol would provide resources currently unavailable in some state institutions. Such protocols would allow states to share and develop groundbreak- ing methods in an age of limited resources. Tasks one and two (accurate diagnosis of the individ- ual’s gender disorder and comorbid pathology) should be addressed in a basic assessment pro- cess as discussed in the previous section. Task three (counseling the individual about treat- ment options and their implication) may be en- tirely limited by the providing institution. How- ever, if an inmate is found eligible or in need of psychotherapy (task four), the mental health professional providing treatment should discuss with the inmate what interventions and provi- sions are available within the facility. If deemed reasonably necessary for safety or health, it may be appropriate to transfer the inmate to an insti- tution better equipped to handle the treatment of gender identity disorders. Frequent lawsuits from transsexual and transgen- der inmates about reasonable standards of care make it reasonable for states to observe task five (ascertaining eligibility and readiness for hormone or surgical therapy) when providing treatment to COUNSELING FOR TRANSGENDERED INMATES 43 transsexual inmates. Again, the SOC eligibility cri- teria require a documented real life experience or extensive psychotherapy prior to hormone admin- istration. Readiness criteria also require consol- idation of gender identity during RLE or therapy, stable mental health with control of sociopathy, substance abuse, psychosis, and suicidality, and demonstrated evidence that the inmate will take hormones in a responsible manner. � Housing and Provisions The research determined that the largest trans- gender issue faced by corrections facilities is housing. Research indicates that transgender/ transsexual inmates face a greater risk in- mate-on-inmate physical and psychological harm when housed in the general population. However, because not all facilities offer single cell housing, transgender/transsexual inmates are often forced into mental health units, seg- regation, or special assignment units. This leads to a lower quality of life and a greater chance for comorbid symptoms because of the lack of services, social interaction, fewer privileges, and peer interaction. While the development of transgendered units seemingly solves several problems of safety and treatment, it also causes many others. First, trans- gender inmates may prefer to live in the general population, however, their motivations for doing so must be assessed (drugs, prostitution, etc). But, creating special units may attract malingerers and psychopaths who seek special privileges thereby creating a need for exceptional screening to be ac- cepted to a transgender unit. Also, states should de- velop more than one unit located in facilities of var- ied security levels across the state for transfer issues (enemies, institutional infractions, need to be clos- er to family, incident of being attacked or attacking others, level change, etc.). Until topics of housing have been further researched, states should provide the most protective and least restrictive arrange- ment available keeping in mind realistic budgetary and legal constraints. Several respondents also expressed frustration with lack of training and awareness for prison officials, correctional officers, mental health, and support staff about transgender issues. Seemingly all liter- ature stressed the importance of psychoeducation and training. A curriculum of awareness, budget planning, intervention, and identity specific issues should be researched further and presented to all prison staff during diversity trainings. Until trans- gender specific training for correctional settings is developed, mental health directors should assure that staff is familiar with the etiology, epidemiol- ogy, treatment, and management, Because screen- ing and assessment of individuals with transgen- der concerns understandably limited, these issues should be addressed at all levels of the corrections community; city, county, state, and federal. � Implications for Further Areas of Research Because research on the transgender population is in such an infantile stage, any well-conduct- ed, ethical research would be an appropriate addition to the current bed of literature. How- ever, analysis revealed several gaps which may be detrimental to the development or provision of “best care” practices to incarcerated transgen- dered individuals. Clearly, a training model and curriculum for cor- rectional staff concerning transgender issues is an immediate need. Information provided should in- clude the criteria of GID and how gender identity differs from sexual orientation, current etiologi- cal research, and assessment/treatment methods. Training should also address treatments available to transgendered individuals within the commu- nity, as well as, those which are offered within state facilities. Although correctional officers and support staff may not require as in depth clini- cal training as mental health professionals, they should understand RLE and be overtly sensitive to situations which could potentially put any inmate at risk of harm. Most correctional facilities train all employees to be cognizant of transference and countertransference issues when interacting with criminals and psychopaths. The transgender train- ing curriculum should equally address these issues with transsexual inmates. Staff should be encour- aged to explore any transference or counter trans- ference issues with supervisors or mental health staff with no fear of reprisal. Social implications of accepting transgender/trans- sexual inmates reach far beyond prison walls. Ar- guments can be made that prisons and detention centers are not places for social or political exper- iment. However, the reality is that larger popula- tions of inmates are presenting with issues beyond the normally seen. In this case, transgender and transsexual communities, who have long been out- cast, are now integrating into prison populations which forces prison management to address the psychosocial and medical needs of these individ- uals. Once taboo and relegated as an afterthought, this expanding community forces corrections staff, at all levels, to re-examine the safety and security for this group as it would for any other. But, be- cause research is in short supply, more articulate examination must be completed. Because this study had limitations, including a small sample population, and few respondents, similar surveys should be conducted to include individual prisons and jails rather than state level mental health executives. Future surveys should be designed to allow a greater response rate and more specific report of information. There is an emergent need for researchers to estimate a realistic preva- lence of gender identity disorders within correc- tional systems. Also, more research is needed to address the prevalence, assessment, and treatment of comorbid pathology. Studies should include the application of the SOC within correctional facilities and favorable revision should be tested and suggested where needed. Sim- ilarly, further research is needed on the feasibility and effects of embarking on the RLE while incar- cerated. Case studies should be documented and any effective related interventions should be shared nationally. 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