Earlier this fall, Florida officials ordered transgender women in the state’s prisons to submit to breast exams. As part of a new policy for people with gender dysphoria, prison medical staff ranked the women’s breast size using a scale designed for adolescents. Those whose breasts were deemed big enough were allowed to keep their bras. Everyone else had to surrender theirs, along with anything else considered “female,” such as women’s underwear and toiletry items.
The examinations came after people who had been diagnosed with gender dysphoria by the prison system’s own providers were brought into meetings at the end of September and told of the prisons’ new policy, which would make it nearly impossible for them to get hormone therapy and other gender-affirming medical care, according to interviews and emails with more than a dozen transgender women who said they attended the meetings.
Josie Takach, who is incarcerated in a men’s facility south of Tallahassee, said a male doctor told her to lift up her shirt, then glanced at her breasts and wrote something down without saying a word. When she tried to ask a question, a nurse “told me not to ask any questions and to just shut up and do what I’m told,” she recalled.
“It felt like I was being treated less than human,” she said.
The state’s chapter of the ACLU sued Florida’s Department of Corrections, which operates the prisons, in late October, calling the policy draconian and arguing it amounts to an unconstitutional ban on gender-affirming care. The new policy is the latest maneuver in the culture war around transgender people’s civil rights in the Sunshine State. Florida Gov. Ron DeSantis championed a raft of anti-trans legislation, including a law passed last year that prohibited children with gender dysphoria from accessing treatments like puberty blockers and hormone therapy. A similar law in Tennessee was the subject of arguments in a case before the U.S. Supreme Court last week.
In Tallahassee Monday, a federal judge held a preliminary hearing in the ACLU case. The state had asked the judge to dismiss the lawsuit altogether, and the ACLU asked him to stop the state from enforcing the new rules. The judge is expected to issue a ruling on these questions in the coming weeks.
The Florida Department of Corrections’ media office did not respond to multiple emails and phone calls with detailed questions, but in court papers responding to the ACLU’s lawsuit, the department’s lawyers argued that the new rules are “a carefully crafted policy that creates an individualized course of treatment for each inmate based on scientific evidence and clinical judgment.”
Under the new policy, the Department of Corrections stated that the prisons will only provide those with gender dysphoria with psychotherapy — and not cross-gender hormones — except “in rare instances … if necessary to comply with the U.S. Constitution or a court decision.” The policy argues that “unaddressed psychiatric issues and unaddressed childhood trauma could lead to a misdiagnosis of gender dysphoria,” and that cross-gender hormones “may be requested by persons experiencing short-termed delusions or beliefs which may later be changed and reversed.”
Florida has the country’s third-largest state prison system, with more than 87,000 people incarcerated at the end of September. Of those, 181 have been identified by the department as transgender, and about 100 received hormone treatment, according to documents state officials filed with the courts in the ACLU case.
The new policy was announced in meetings in several prisons across the state at the end of September. Transgender women who attended the meetings said they were told by officials that everyone identifying as transgender would be “re-evaluated” to assess whether they can have continued access to the care and accommodations they had been receiving, such as permission to grow their hair long. Officials have not told the women whether and under what circumstances they will be allowed to stay on the hormones they have been receiving.
Since then, more than a dozen transgender people said corrections officers ordered them to cut their hair. Mariko Sundwall told The Marshall Project that she was given a disciplinary infraction and spent 10 days in solitary confinement for refusing to cut her hair before officers put her in handcuffs and led her to the prison barber where her hair was cropped short.
“[Before] my hair was long enough for a ponytail. Now I have a buzz cut,” said Jada Edwards, incarcerated in Dade Correctional Institution south of Miami. “I’m very sad and depressed. I feel like they’re taking away my identity.”
Scores of women also had their breasts examined, according to filings in the suit and interviews with some of the women. A medical provider for the state assigned each transgender woman a rating on the Tanner scale, a system used by pediatricians to assess the development of adolescents during puberty. Several of the women said they weren’t told what stage was required for permission to keep their bras, but that almost everyone they knew had theirs taken away.
Some report hiding bras or sewing makeshift underwear — although now women’s undergarments are considered contraband and could result in disciplinary charges — because they feel naked and exposed without them.
“I feel like I’m 12 years old again, sneaking around wearing a bra,” said Takach, after her female undergarments were confiscated.
The new policy, which requires psychotherapy to treat underlying issues rather than treating the dysphoria, “comes off like conversion therapy,” says Daniel Tilley, the lead attorney from the ACLU of Florida. “We’re trying to change your fundamental nature to get you to stop being who you are.”
Sarah Maatsch, who is incarcerated in a men’s prison south of Orlando, said she was told that the gender dysphoria diagnosis she received from corrections department doctors in 2019 would now be considered a serious psychiatric illness. If she wants to continue her treatment, she said she was told, she would have to move to a more restrictive prison with more psychiatric services, but fewer work and programming opportunities.
“We are all devastated,” said Maatsch. “There are good days, bad days and the very bad days where a part of you hopes you have a heart attack.”
The new policy is the latest change in health care for transgender people in Florida after a 2023 law said any “governmental entity” in Florida “may not expend state funds … for sex-reassignment prescriptions or procedures.” It did not name prisons specifically, but the Department of Corrections’ new policy says it “shall comply” with this law.
Shortly after DeSantis’ anti-trans bills were passed, transgender people in state prisons began reporting that medications were abruptly changed or delayed with little or no explanation.
Courts have held that prisons are required under the U.S. Constitution to provide gender-affirming hormones as needed. Dan Karasic is a psychiatrist at the University of California, San Francisco who helped develop international standards for treatment of transgender people and who has testified against bans on gender-affirming care in Florida and elsewhere. He read Florida’s new guidelines at The Marshall Project’s request and called them “a fig leaf on their efforts to ban gender-affirming care. They are really trying to skirt the law, as determined by multiple courts, that gender-affirming medical and surgical care must be provided when medically necessary.”
The Florida prison system’s program to treat prisoners with gender dysphoria began in 2017, after Reiyn Keohane sued the state. The federal judge in the case said that the Department of Corrections’ refusal to provide Keohane with hormones and social accommodations, like women’s clothing and haircuts, caused her “to continue to suffer unnecessarily and poses a substantial risk of harm to her health.” During the course of the lawsuit, the state began providing gender-affirming hormone therapy, access to makeup, women’s clothing and other social accommodations within its prisons.
Behind the scenes, Danny Martinez, the state prison system’s medical director, began revising the state’s gender-affirming care program in 2020, he said in a court declaration in response to the ACLU’s recent lawsuit. As many as one-third of the people on hormones in Florida’s prisons were not attending group or personal therapy sessions, he said. “I observed no decrease, and in fact an increase in grievances to the medical and mental health staff from inmates receiving hormone therapy, indicating to me that the treatment solely based on hormone therapy without additional mental health treatment produced limited success,” he wrote. An email to Martinez seeking comment was not returned.
Martinez said he designed the new program based on a 2022 report by Florida’s Medicaid organization that found “insufficient evidence” that medical interventions for gender dysphoria are safe or effective. The report led to the state’s Medicaid program banning coverage of gender-affirming medical care. But a federal judge, in striking down the Medicaid ban last year, found that the report was “a biased effort to justify a predetermined outcome, not a fair analysis of the evidence,” and the report’s conclusion was “not supported by the evidence and was contrary to generally accepted medical standards.”
So far, none of the transgender women incarcerated in Florida have reported being taken off their hormones, but the looming threat has led to widespread anxiety.
“If they took away my hormone therapy treatment, I would be ready to end my life. I’m at that point,” said Sasha Mendoza, who is incarcerated in a men’s prison near Miami, in a declaration filed in the ACLU case. “It may sound drastic. But FDC just let me start my transition and I was doing so well, and now they are making me stop. I’m halfway there and halfway not there.”
