The best argument medical for the provision of hormones to a transgender person in prison (based on the 8^th amendment right to care for diseases) is that GID is a mental illness for which there are established diagnostic criteria, established treatment protocols that have been used for decades, known benefits of treatment, and known dangers of depriving people of such treatments.

The American Psychiatric Association is the medical professional specialty association that deals with mental illness. The APA publish two pertinent texts that set the recognized standards for diagnosis and treatment of mental illness. The diagnostic text is the Diagnostic and Statistical Manual of Mental Disorders (DSM.)¹ The DSM describes in it the diagnosis Gender Identity Disorder (GID.)

The APA's treatment text is Treatments of Psychiatric Disorders.² Within Treatments of Psychiatric Disorders, The Harry Benjamin International Gender Dysphoria Association's 'Standards of Care' are recognized as the guidelines used by “most responsible professionals” in the field of transgender medicine. In addition, the text stresses the risks of non-treatment of patients with GID which it states can result in “disastrous consequences” including depression, substance abuse, suicidality, and genital self-mutilation.

With regard to hormone treatment, Treatments of Psychiatric Disorders states:

“Cross-sex hormonal treatments play an important role in the psychological and anatomic gender transition process for properly selected adult patients with GID. Internationally recognized standards of care indicate that such treatments are 'medically necessary' for rehabilitation in the new gender and that they improve quality of life and limit psychiatric comorbidities which may accompany lack of treatment. Others have noted that these treatments should no longer be considered experimental and are now a component of acceptable medical practice for GID.”

With regard to alternative treatments to hormones (such as counseling or worse, reparative therapy,) Treatments of Psychiatric Disorders states:

“Contrawise, gender dysphoric patients treated only with psychotherapy and antidepressants may fail to respond, as the source of their depression is rooted more in the primary diagnosis of GID than in the secondary diagnosis of major depressive disorder.”

With regard to transgender people in the criminal justice system, Treatments of Psychiatric Disorders states:

“Persons with GID are often economically disadvantaged as a result of legal discrimination in the workplace and inability to access appropriate medical and psychiatric health care. Some patients resort to prostitution or other illicit activities in an attempt to obtain funds for hormones and surgical treatments. Others have committed serious crimes unrelated to their gender status. ...Once incarcerated pre-operative transsexuals are often housed with inmates of the same anatomic sex, which can lead to many distressing and potentially dangerous situations. Continuation of hormonal treatment for those in transition is often problematic. Many patients have been abruptly discontinued from their estrogen treatment and become depressed, anxious, and possibly suicidal. The author is familiar with several occasions of attempted autocastration in prison related to the denial of estrogens by prison officials. The policy of the United States Bureau of Prisons (US Department of Justice Program Statement 1994) states that medical providers can “maintain a transsexual inmate at the level of change existing upon admission” provided that the inmate supplies “appropriate documentation from community physician/hospitals” and the Medical Director approves. ...The Standards of Care state that treatment should not be denied on the basis of incarceration but should be provided on the basis of medical and psychiatric needs as established by an assessment. Psychiatrists may be asked to consult in the prison setting either to determine appropriatenesses of treatment (or review denial or treatment) or to provide emergency psychiatric consultation for suicidal, depressed, or self-harming transsexual inmates. Psychiatric comorbidity on the basis of either lack of appropriate psychiatric support or lack of medically necessary hormonal treatments is not uncommon and may require extensive intervention.”

The HBIGDA SOC³ that is referenced extensively in Treatments of Psychiatric Disorders states:

“Hormone Therapy and Medical Care for Incarcerated Persons. Persons who are receiving treatment for gender identity disorders should continue to receive appropriate treatment following these Standards of Care after incarceration. For example, those who are receiving psychotherapy and/or cross-sex hormonal treatments should be allowed to continue this medically necessary treatment to prevent or limit emotional lability, undesired regression of hormonally-induced physical effects and the sense of desperation that may lead to depression, anxiety and suicidality. Prisoners who are subject to rapid withdrawal of cross-sex hormones are particularly at risk for psychiatric symptoms and self-injurious behaviors. Medical monitoring of hormonal treatment as described in these Standards should also be provided. Housing for transgendered prisoners should take into account their transition status and their personal safety.”

Moreover, in addition to the known risks of discontinuation of medically indicated hormonal therapy following recognized standards of care, the safety of hormonal treatment of persons with GID has been demonstrated in a large study of over a thousand transgender patients followed for over ten thousand patient years of life that demonstrated no increase in the morbidity and mortality of transgender people compared with the cisgender population.⁴