A transgender woman serving time in federal prison could become the first inmate to receive gender-affirming surgery under a recent ruling by a federal judge.
The judge ordered the US Bureau of Prisons this week to provide a detailed timeline showing how it will ensure that Cristina Nichole Iglesias receives by year’s end the gender-affirming surgery she has been seeking throughout several years of litigation.
“This is something that’s long overdue,” said Alexis Rangel, policy counsel for the National Center for Transgender Equality, based in Washington, DC “We recognize that trans folks who are incarcerated have a fundamental right to appropriate care, and they shouldn’t have to jump through hoops to access that care while on the inside.”
Gender-affirming care, particularly in regard to youth, has been increasingly under attack by lawmakers out of concern that young people might make life-aging decisions they might come to regret. Federal prisons are required to cover the costs of all necessary health care treatments for inmates under the US Constitution.
Joshua Blecher-Cohen, an ACLU of Illinois staff attorney who represents Iglesias, said the directive represents “a real first step” toward Iglesias’ finally getting gender-affirming surgery.
“This case has been full of delays and denials, as this opinion recognizes,” Blecher-Cohen said. “We are excited, but there is more work to be done toward actually making this happen.”
In her order, US District Judge Nancy Rosenstengel of Illinois’ Southern District ordered the prisons bureau to conduct an immediate nationwide search for a qualified surgeon while providing detailed evidence of its efforts.
The judge also asked the bureau to demonstrate why it should not be issued sanctions or held in contempt for previous delays and violations of court orders that have repeatedly postponed the procedure. She ordered that high-level officials and staff representing the bureau and the US Department of Justice appear at a future hearing to justify the misconduct.
For example, in December, the court ordered the Bureau of Prisons’ Transgender Executive Council to evaluate Iglesias’ readiness for gender-affirming surgery, the first time the bureau had ever been mandated to do so by judicial order. The council is a group of senior-level administrators that include two psychiatrists, a psychologist and a pharmacist, according to court records.
For weeks the council said it would set up a surgical consult but ultimately referred Iglesias to a surgeon unable to perform the necessary vaginoplasty, a surgery in which a vagina is constructed. Subsequent consultations with other surgeons then fell through.
The judge’s latest order, issued Monday, directs the bureau to file weekly reports detailing its search for a qualified physician who can conduct the procedure before Iglesias’ scheduled release from federal custody in December 2022.
A Bureau of Prisons spokeswoman said the bureau “does not comment on pending litigation or matters subject to legal proceedings, nor do we comment on the conditions of confinement for any individual or group of inmates.”
In a statement issued by the ACLU, Iglesias, 47, said she hoped the order meant she would “finally get the care I need to live my life fully as the woman I am.”
“(The bureau) has denied me gender-affirming surgery for years and keeps raising new excuses and putting new obstacles in my way,” she said. “I am grateful that the court recognized the urgency of my case.”
A history of resistance
Gabriel Arkles, senior counsel for the Transgender Legal Defense and Education Fund, said the federal government, along with numerous states, has long resisted providing necessary surgical care for transgender inmates.
“Everyone in custody has a right to the health care they need,” Arkles said. “It is unconstitutional and immoral to withhold healthcare because of someone’s gender or because the care they need is stigmatized.”
An estimated 1,200 transgender individuals are in the federal prison system, or about .07% of the overall inmate population of about 156,000.
Iglesias, previously housed at a federal prison facility for women in Fort Worth, Texas, is now an inmate at a residential reentry facility in Miami. She pleaded guilty in 2005 to sending an envelope to British officials that she falsely claimed contained anthrax.
At the time, she was in a federal prison and listed the detention center as the return address.
“No threat was carried out in any way,” wrote her public defender, Kathleen Williams, in asking for a more lenient sentence. She noted Iglesias’ history of bipolar disorder and the crime’s consistency with Iglesias’ decade-long history of sending such letters.
Iglesias ultimately received a 20-year sentence. She has been in the federal prison system since 1994, where until recently she was housed mostly in men’s facilities, subject to physical and sexual abuse. According to court documents, she experienced gender dysphoria so extreme that she considered self-castration and was placed under suicide watch numerous times.
“She is at risk for suicide, and her psychological condition will continue to deteriorate,” the judge wrote in her order.
Gender dysphoria is a medical condition marked by mental distress brought on by an incongruity between a person’s gender identity and their sex assigned at birth, which can cause anxiety and depression if left untreated. Not all transgender people experience gender dysphoria, and for those who do surgery isn’t always necessary.
Advocates note that treatment options are developed over a years-long process involving patients, parents, physicians and mental health professionals.
Protocols for transgender care have been set by the World Professional Association for Transgender Health (WPATH) and endorsed by groups such as the American Medical Association, American Psychiatric Association, American Academy of Family Physicians and World Health Organization.
Those guidelines call for individuals to live in their identified gender role for at least one continuous year before proceeding with surgery, a procedure that should be supported by their primary care provider with referrals from two mental health professionals.
‘We still have a long way to go’
Iglesias did not receive hormone therapy until 2015 and by the following year had informed prison health officials that she wanted gender confirmation surgery, court documents said. She requested transfer to a women’s prison facility, both to fit her identity and because of harassment from male prisoners.
Eventually, the ACLU took on her case and in May 2021, she became one of the few transgender inmates ever moved to a federal prison aligned with their gender identity.
Blecher-Cohen said he hoped that the judge’s order finally compels the prisons bureau to provide Iglesias with the care she needs.
“The court’s order makes clear that she needs gender-affirming surgery now and that BOP cannot justify its failure to provide this medically necessary care,” he said. “We hope this landmark decision will help secure long overdue healthcare for Cristina—and for the many other transgender people in federal custody.”
Rangel, of the National Center for Transgender Equality, noted that the prisons bureau recently updated guidelines governing management of transgender inmates to streamline identification, tracking and placement of those individuals.
“We’re in a place now where the federal government is catching up,” Rangel said. “There’s some movement, but we still have a long way to go to make sure that trans folks receive the care that they need.”