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 (Bockting et al. 1998; Tsakris et al. 1997). Others have committed serious crimes unrelated to their gender status. Character pathology and other comorbid disorders (e.g., substance dependence) appear to be associated with repeated incarcerations. Once incarcerated, preoperative transsexuals are generally housed with inmates of the same anatomic sex, which can lead to many distressing and potentially dangerous situations. Continuation of hormonal treatments for those in transition is often problematic. Many patients are abruptly discontinued from their estrogen treatment and become depressed, anxious, and possibly suicidal. The author is familiar with several cases of attempted autocastration in prison related to the denial of estrogens by prison officials. The policy of the United States Bureau of Prisons (U.S. 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 physicians/hospitals” and the Medical Director approves.

Postoperative transsexuals should be maintained on adequate doses of estrogen to support secondary sexual characteristics, usually half the dose required before orchiectomy as noted above. Allegedly, this policy has been inconsistently applied and is in litigation by several inmates who are being denied hormonal and/or qualified psychiatric treatment in the federal prison system (Dee Farmer v. Hawk 1992; Yolanda Burt v. Hawk 1996/1998). 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 (Levine et al. 1998). Psychiatrists may be asked to consult in the prison setting either to determine appropriateness of treatment (or review denial of 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 treatment is not uncommon and may require extensive intervention. In any case, the prison environment is a challenging setting in which to provide any type of gender-related treatment and clinical complications with these inmates are common.