Trans people in WA prisons say gender-affirming care lacks, despite court-backed improvement plan

Content warning: This story contains descriptions of suicide and self-harm.

When Alexandra first arrived at a Washington prison nearly a decade ago, she’d already made up her mind to come out as transgender.

“I had decided that I wasn’t going to be able to survive my time in prison if I had to continue lying to myself and everybody else about who I was,” she said.

Alexandra is her middle name. KUOW has agreed not to publish her full name due to safety concerns.

She said getting what she needed — clothing, hormone therapy, surgery, and safe housing free from harassment and assault — wasn’t easy. While she had theoretical access to much of it, she ran into red tape in the form of psychiatric testing, requirements to meet with people who never responded to messages, and other bureaucratic hurdles.

Such barriers are why Disability Rights Washington sued the Washington State Department of Corrections on behalf of trans and non-binary people in prisons, saying they are effectively being denied their right to gender-affirming care due to bureaucratic barriers.

In October 2023, the agency and advocates leading the lawsuit signed a consent decree binding DOC to a plan to improve conditions. Now efforts to implement that plan — and to hold the corrections department accountable when it fails — are playing out as the Trump administration attempts to limit access to gender-affirming care.

About 300 people currently incarcerated in Washington have told the state corrections department they’re trans or non-binary. KUOW interviewed six of them for this story. Prior to the consent decree, their access to medical care and the means of self-expression was often denied, or delayed for months or years.

Care delayed, or denied

Alexandra, who was released from prison in late 2024, said when she first requested women’s clothes, it took months to get them. Then, since she was on hormone treatment, her bra size changed, but a male prison officer wouldn’t give her new bras unless her old ones were falling apart.

“So I would have to cut holes in my undergarments when I no longer needed them, because otherwise he wouldn’t exchange them,” Alexandra said.

On top of that, she added, she had to try on the new bras in front of the officer and in full view of the prison’s main thoroughfare.

The lawsuit shows these incidents were not limited to Alexandra.

“DOC has … systematically provid[ed] bras that are too small for the individual wearer and not adjusted for breast growth,” the consent decree reads.

KUOW spoke with several incarcerated trans people who said they were constantly fighting to keep their hormone prescriptions. Sometimes, the prescriptions would lapse entirely, and they’d get menopause-like symptoms of hot flashes, mood swings, and difficulty concentrating. Some people who were already on hormone therapy before being incarcerated waited more than a year to access hormones while in Washington state custody, according to the consent decree.

Getting surgery can be even more difficult. Alexandra requested breast augmentation as soon as the option became available in 2019.

Then, she said, “I had to start seeing mental health again, to prove that I really needed it.”

The consent decree notes that the corrections agency “routinely required transgender patients seeking gender-affirming surgery to undergo formal personality and psychiatric profiling, … requirements [that] were out-of-step with any evidence-based standards of care.”

Alexandra languished for months without responses in between various required meetings and screenings, she said, despite filing multiple grievances.

The delays were so long it meant she’d have to redo labs, since they only last a year — but getting those done was a hassle too.

“It was just on and on and on,” she said.

Mental health effects

Interviewees all told similar stories — and in each case, they said the delays and runarounds harmed their mental health.

One woman, Ashley Raelynn, started having panic attacks.

“I was just freaking out. I didn’t know what to do. They just kept refusing to give me hormones,” she said.

One panic attack was so bad she stopped being able to breathe normally or control her limbs, and she was taken to the emergency room. A little while later, records show, she tried to cut off her own testicles.

“DOC providers have discouraged people from seeking … hormone replacement therapy, gender-affirming surgery, and other medically necessary treatments and services,” the consent decree reads. “These practices have prolonged and worsened patient symptoms, resulting in significant outcomes including major depression, self-harm, and suicidality.”

Pharaoh Grayson, who identifies as gender non-conforming and has been in prison for more than two decades, echoed that statement. “I’ve seen it happen with a lot of girls over the years, my cellie included,” they said. “Suicidal ideation is prevalent in our community, especially after delays in medical care.”

A constitutional right to medical care

Some people question if it should be taxpayers’ responsibility to pay for gender-affirming medical care for people in prison. But numerous professional organizations, including the World Professional Association for Transgender Health and the National Commission of Correctional Health Care, have argued that the same standards of care outside of prison should apply for trans people inside of them.

AD Lewis, an attorney who advocates for incarcerated trans people, said treatments like hormone therapy and surgery are often medically necessary, just like cancer treatments and blood pressure medication. And, he said, “the U.S. Constitution requires prison officials not to be deliberately indifferent to people’s medical needs.”

The consent decree facing Washington’s corrections department also relies on the Constitution, including the Eighth Amendment, which protects people from cruel and unusual punishment.

A lack of adequate medical care should never be part of a prison sentence, Lewis told KUOW.

“The punishment is the removal of your liberty,” he said. “The punishment is not that the government gets to force you to be a certain gender or to not get medical care.”

Lewis said there are essentially three “buckets” of U.S. states in terms of their treatment of trans people in prison. Some states forcibly detransition people, denying them medical care, enforcing rules about clothing and hair length, and even taking away any gender-affirming items people might have.

“There’s another bucket that’s kind of in the middle, where people likely have access to gender-affirming hormones and might have access to gender-affirming hygiene supplies, but don’t have any access to gender affirming surgery unless … they’ve sued to get it,” Lewis said.

And then, in states like California and Washington, people have what Lewis calls “formal access” — or access on paper — to the full gamut of gender-affirming health care and personal items. But, he said, “There’s another question, which is, ‘Is it adequate medical care? … Is it matching the standards that we would expect in the community?’”

“It’s very tricky to be like, yes, [California and Washington] are leaders. Technically, [they] are leaders,” Lewis said. “And it is still falling so short of the baseline standards of care. It’s probably still unconstitutional.”

In the October 2023 consent decree, Washington’s corrections department agreed to a long list of concrete changes to bring what’s available inside the prisons in line with what’s available to people in the wider community.

“If Washington DOC complied with the settlement agreement as written, it would be among, if not the leading prison system for observing and ensuring trans civil rights and trans medical care access in the United States,” Lewis said.

Cheyenne Webb’s story

At Stafford Creek Corrections Center in Aberdeen, a trans woman named Cheyenne Webb spent years trying to get gender-affirming bottom surgery. Her friends said she was one of the first women to ask for it, but it seemed like she was always getting passed by or overlooked.

Mikailah Sweetgrass-Turner was Webb’s cellmate and close friend.

“The responses she was getting were always the same — ‘You contact this person or contact that person,’” Sweetgrass-Turner said. “And then she would contact that person, and that person would be like, ‘Oh, you’ve got to file this paper or you got to contact this person.’ [They were] always passing the ball somewhere else.”

After the consent decree, change didn’t come fast enough for Webb.

“Eventually she’d had enough, because I went to yard at 10 o’clock, and when I came back at 11, I found her hanging in the cell on the end of [the] bed,” Sweetgrass-Turner said.

That was in July 2024, six months after the consent decree.

For the trans people KUOW interviewed, Webb’s suicide is a symbol of the corrections agency’s continued inattention to their needs, and to how access to gender-affirming care can be a matter of life or death.

Like Sweetgrass-Turner, the state’s fatality review also noted Webb’s history of gender dysphoria and her frustration receiving related care in prison. It recommended that the corrections agency take steps to reassure trans people that care will continue to be available, and suggested that the prisons restart the support groups that were suspended during the pandemic.

The corrections department wrote in an email that they have let everyone in prison know what gender-affirming care is available, and they’re working to provide timely access to that care.

Changes since the consent decree

Pharaoh Grayson has been in prison for 25 years; they’re currently at Stafford Creek. Grayson came out as gender nonconforming to Washington’s corrections agency about five years ago and asked for hormone treatment and several gender-affirming surgeries.

The consent decree required the agency to hire an ombuds to help people like Grayson navigate the system.

Grayson and KUOW’s other interviewees said that ombudsperson is very helpful.

“She kind of walked me through all the things that I could expect, and I was really pleased with that interaction, and who they hired to do that,” Grayson said.

An agency spokesperson said in an email that trans people in Washington’s prisons now have “what amounts to personal case management to facilitate their gender-affirming care.”

People who spoke with KUOW said access to hormones has also gotten better.

But access to gender-affirming undergarments hasn’t, they said; those can still take months to get, and are sometimes insufficient.

“I have two pairs of bras and two pairs of panties, and I wash them by hand every time I shower, because I’m not able to put them in the laundry,” said Amber Kim, who’s in prison for life. “[If] I put them in the laundry, they won’t ever come back to me.”

Also, most trans people are still incarcerated with people who share their sex assigned at birth, not their gender identity.

Access to electrolysis for hair removal is another problem. Outside of gender-affirming care, electrolysis can be viewed as a luxury. But for trans women, facial hair removal can be essential to their gender presentation, and body hair removal is a prerequisite for some genital reconstruction surgeries, to avoid grave complications afterwards.

People in more than one Washington state prison told KUOW they did not receive electrolysis for more than six months last year, and that it is still not available as frequently as they need it.

“Without electrolysis providers, that means that people [who] want to have these gender-affirming procedures can’t have them, and people then either aren’t having surgeries that they medically need, or they’re making other choices for surgical interventions, which can have really significant impacts as well,” said Adrien Leavitt, a lawyer with the ACLU who represents a trans person incarcerated in Washington.

A spokesperson for the corrections department said in an email that they no longer have an in-house provider doing electrolysis, and transporting people outside the prisons has led to delays in treatments. She said the agency is looking for providers who can work inside the prisons.

The consent decree establishes timelines between when people request certain procedures, and when the corrections department has to schedule them.

But Ashley Raelynn, who’s been trying to get surgery for years, said that’s not working as intended.

“That’s all well and good, but, you know, 90% of those got cancelled,” Raelynn said.

A corrections department spokesperson wrote in an email that any delays or difficulties with scheduling could be due to the fact that “providers of atypical procedures can be rare, especially in rural areas where many of our prisons are located.”

Advocates say there’s still a long way to go before actual access to gender-affirming care mirrors what’s available outside prison.

This article was originally published by KUOW.