Court: Transgender people in prisons can get gender-affirming care

After a five-year legal battle, the U.S. District Court recently ruled that transgender people incarcerated in Connecticut prisons are entitled to gender-affirming health care.

Veronica-May Clark originally filed the case in 2019, and the American Civil Liberties Union offered her representation in 2021. Clark, who has been in custody since 2007, alleges that after a diagnosis of gender dysphoria — a medical diagnosis for someone who experiences distress that can occur when their true gender does not match with their outward appearance and/or the sex they were assigned at birth — her treatment from the Department of Correction was inconsistent.

“At the end of the day, she just wants health care,” Elana Bildner, Clark’s attorney with the CT ACLU, told The Connecticut Mirror. “She wants the health care to be consistent, to be adequate, to be appropriate [and] to be able to rely on the fact that she will get this health care that she needs for the long term.”

As a result of the DOC’s continued delay of her requests, she says, her symptoms worsened, and she experienced serious self-harm and hospitalization.

Unheard requests for care

In July 2009, Clark was sentenced to an effective life sentence, 75 years, in Connecticut prison for beating his estranged wife’s boyfriend to death with a pipe.

According to Bildner, Clark “had lived publicly as a woman” on and off throughout her life but had never tried to access transitional care. When sentenced, Clark chose to present as a cisgender man for her safety in prison.

Seven years later, in April 2016, Clark requested treatment, including hormone therapy and gender-affirming surgery, and stated that she believed she had gender dysphoria. A month later, a DOC health care provider diagnosed Clark with gender dysphoria, but she was not provided any gender-affirming treatment, according to the lawsuit.

Clark turned to self-harm in an effort to treat herself. According to the memorandum and witness testimony, Clark attempted to castrate herself in her cell.

Following the incident, a DOC psychologist assessed Clark and affirmed that she had gender dysphoria and was undergoing a “high level of psychological distress.” Clark again filed a request for treatment consistent with the diagnosis.

According to Bildner, the DOC had an “informal policy” that “if you didn’t come into prison having received transitional care, you could not get it in prison.”

“She was fighting against something that she couldn’t see,” Bildner said. “The DOC said ‘Yes, you do [have gender dysphoria], and then refused her any transitional care on the basis of this unwritten policy.”

In the months after her hospitalization, Clark continued to request hormone therapy and gender-affirming surgery. She described her situation as “simply intolerable” and DOC’s treatment of her as “cruel and unusual.”

[RELATED: CT: ‘Safe haven’ for transgender youth? For some, not safe enough]

Later, in September 2017, Clark saw an endocrinologist at University of Connecticut Health. Her physician prescribed her a low “starter dose” of spironolactone and estradiol: two drugs used for hormone therapy. The physician requested a follow-up in three months with Clark to track her progress and increase her dosage to a therapeutic level.

Clark did not see the doctor again until August 2019.

The case

The inconsistent care, despite her requests, led Clark to sue the DOC for violating her Eighth Amendment right to freedom from cruel and unusual punishment and her Fourteenth Amendment right to equal protection under the law in April 2019, according to the complaint.

The Connecticut ACLU joined her team in 2021.

Bildner said the lawsuit occurred in two phases. The first, which was presided over by now-retired Justice Vanessa Bryant, was meant to “convince the court that if prisons have to provide health care, gender affirming care is health care. Therefore, prisons have to provide gender affirming care.”

On Sept. 15, 2023, the U.S. District Court issued summary judgment in favor of Clark. The court concluded that DOC employees were “deliberately indifferent to Ms. Clark’s serious medical needs.”

After that first decision, the case moved into its second “trial phase,” according to Bildner. This second phase took place throughout July 2024.

“[In] the trial phase, the DOC was trying to convince the judge [to] ‘forget about what had happened in the past,’ because they were now on top of it and no judicial intervention was required.”

The DOC presented evidence that since the September 2023 ruling, they were making an increased effort to give Clark the treatment she requested.

Justice Victor Bolden, however, was unconvinced and ultimately ordered an injunction on July 26 to ensure Clark’s constitutional rights were continuously upheld.

“Although DOC has made progress in providing gender-affirming medical treatment to Ms. Clark in recent months, such efforts have not yet cured the ongoing Eighth Amendment violation,” Bolden wrote. “And, the Court has determined that an injunction is necessary to ensure that Ms. Clark receives appropriate medical care for her gender dysphoria and does not suffer additional irreparable harm.”

The injunction requires continuous status reports on Clark’s care to both her lawyers and the court.

The Department of Corrections Public Information Office said it was still reviewing the decision and was unable to comment.

“With that said, the DOC strives to provide quality healthcare to all those under our supervision,” DOC Public Information Officer Andrius Banevicius said.

A precedent-setting case

The favorable injunction stretches beyond securing gender-affirming health care for just Clark, Bildner said.

The case was the first of its kind in the Second Circuit, which includes Connecticut, New York and Vermont.

“I really do think it answers the question of the prison system’s responsibility to gender-diverse people to provide health care for them that is multifaceted and that is individualized,” Bildner said.

Often, prisoners have to secure this health care through litigation, according to Bildner. Prisons that do provide gender-affirming care can often still be “inconsistent or inadequate” like Clark’s, she said.

The hope for the ACLU legal team is that the Connecticut DOC moves forward with this acknowledgment and no further prisoners turn to legal action in an effort to receive this type of care.

“She’s relieved and grateful,” Bildner said about Clark following Justice Bolden’s ruling. “This healthcare for her is life-saving. Getting a hormone injection, she said in court, feels absolutely life-saving to her. And knowing that she can progress in a transition is really all she’s ever wanted.”