Health Implications of Housing Assignments for Incarcerated Transgender Women

Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women

BACKGROUND

Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants.

METHODS

Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots.

RESULTS

In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color.

CONCLUSIONS

The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Where do incarcerated trans women prefer to be housed and why? Adding nuanced understandings to a complex debate through the voices of formerly incarcerated trans women in Australia and the United States

Background

Incarcerated trans women experience significant victimization, mistreatment, barriers to gender-affirming care, and human rights violations, conferring high risk for trauma, psychological distress, self-harm, and suicide. Across the globe, most carceral settings are segregated by sex assigned at birth and governed by housing policies that restrict gender expression-elevating 'safety and security' above the housing preferences of incarcerated people.

Aim/methods

Drawing upon the lived experiences of 24 formerly incarcerated trans women in Australia and the United States and employing Elizabeth Freeman's notion of chrononormativity, Rae Rosenberg's concept of heteronormative time, and Kadji Amin's use of queer temporality, this paper explores trans women's carceral housing preferences and contextual experiences, including how housing preferences challenge governing chrononormative and reformist carceral housing systems.

Findings

Participants freely discussed their perspectives regarding housing options which through thematic analysis generated four options for housing: 1) men's carceral settings; 2) women's carceral settings; 3) trans- and gay-specific housing blocks; and 4) being housed in protective custody or other settings. There appeared to be a relationship between the number of times the person had been incarcerated, the duration of their incarceration, and where they preferred to be housed.

Conclusions

This analysis contributes to richer understandings regarding trans women's experiences while incarcerated. This paper also informs the complexities and nuances surrounding housing preferences from the perspectives of trans women themselves and considers possible opportunities to enhance human rights, health and wellbeing when engaging in transformative approaches to incarceration.

Identifying and Treating Incarcerated Women Experiencing Substance Use Disorders: A Review

While research on substance use disorder (SUD) treatment among justice-involved populations has grown in recent years, the majority of corrections-based SUD studies have predominantly included incarcerated men or men on community supervision. This review 1) highlights special considerations for incarcerated women that may serve as facilitating factors or barriers to SUD treatment; 2) describes selected evidence-based practices for women along the cascade of care for SUD including screening and assessment, treatment and intervention strategies, and referral to services during community re-entry; and 3) discusses conclusions and implications for SUD treatment for incarcerated women.

Correctional staff knowledge, attitudes and behaviors toward incarcerated trans people: A scoping review of an emerging literature

Background: Trans people are incarcerated at disproportionately high rates relative to cisgender people and are at increased risk of negative experiences while incarcerated, including poor mental health, violence, sexual abuse, dismissal of self-identity, including poor access to healthcare. Aims: This scoping review sought to identify what is known about the knowledge, attitudes, and behaviors of correctional staff toward incarcerated trans people within the adult and juvenile justice systems. Method: This scoping review was conducted in accordance with the five-stage iterative process developed by Arksey and O'Malley (2005), utilizing the PRISMA guidelines and checklist for scoping reviews and included an appraisal of included papers. A range of databases and grey literature was included. Literature was assessed against predetermined inclusion and exclusion criteria, with included studies written in English, online full text availability, and reported data relevant to the research question. Results: Seven studies were included with four using qualitative methodologies, one quantitative, and two studies employing a mixed methods approach. These studies provided insights into the systemic lack of knowledge and experience of correctional staff working with trans people, including staff reporting trans issues are not a carceral concern, and carceral settings not offering trans-affirming training to their staff. Within a reform-based approach these findings could be interpreted as passive ignorance and oversights stressing the importance of organizational policies and leadership needing to set standards for promoting the health and wellbeing of incarcerated trans persons. Conclusions: From a transformational lens, findings from this study highlight the urgent need to address the underlying structural, systemic, and organizational factors that impact upon the knowledge, attitudes, and behaviors staff have and hold in correctional, and other health and community settings to meaningfully and sustainably improve health, wellbeing, and gender-affirming treatment and care for trans communities, including make possible alternative methods of accountability for those who do harms.

Trans architecture and the prison as archive: "don't be a queen and you won't be arrested"

Most incarceration settings around the world are governed by strong cisnormative policies, architectures, and social expectations that segregate according to a person's legal gender (i.e. male or female). This paper draws on the lived experiences of 24 formerly incarcerated trans women in Australia and the U.S. to elucidate the way in which the prison functions according to Lucas Crawford's theory of trans architecture, alongside Jacques Derrida's notion of archive fever. The paper displays how the cisnormative archive of the justice system and its architectural constructs impact trans women in men's incarceration settings, including how trans women entering the incarceration setting are able to embody gender in a way that is not reified by the insistences of those normative structures. In light of this, this paper advances a theoretical understanding of the prison as an archive and as an architectural construct, providing a new means of understanding how incarcerated trans persons may use and perform gender to survive carceral violence.

Improving Access to Legal Gender Affirmation for Transgender Women Involved in the Criminal-Legal System

Transgender women of color experience interlocking systems of oppression rooted in racism and transphobia, which fuel economic vulnerability and overrepresentation in the criminal-legal system. Legal gender affirmation, which refers to changing one's name and gender marker on official documents, has the potential to mitigate these issues by improving access to employment, housing, education, health care, and social services. These services are particularly important for transgender women of color with criminal records, a history of incarceration, or other legal infractions; however, 23 states have policies that restrict access to legal gender affirmation for these individuals. Alongside eliminating restrictive policies to obtain legal gender affirmation, medical-legal partnerships in these states may address recidivism and health inequities among transgender women of color.

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Housing and health in vulnerable social groups: an overview and bibliometric analysis

Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.

The LGBTQ+ communities and the COVID-19 pandemic: a call to break the cycle of structural barriers

The COVID-19 pandemic has disproportionately impacted LGBTQ+ communities. Many disparities mirror those of the HIV/AIDS epidemic. These health inequities have repeated throughout history due to the structural oppression of LGBTQ+ people. We aim to demonstrate that the familiar patterns of LGBTQ+ health disparities reflect a perpetuating, deeply rooted cycle of injustice imposed on LGBTQ+ people. Here, we contextualize COVID-19 inequities through the history of the HIV/AIDS crisis, describe manifestations of LGBTQ+ structural oppression exacerbated by the pandemic, and provide recommendations for medical professionals and institutions seeking to reduce health inequities.