In 2019, Cristina Iglesias filed a lawsuit that changed the course of treatment for herself and other transgender inmates in federal custody.<\/p>\n
Iglesias, a trans woman who had been incarcerated for more than 25 years, was transferred from a men\u2019s prison to a women\u2019s one in 2021. And in 2022, she reached a landmark settlement<\/a> with the Federal Bureau of Prisons to receive gender-affirming surgery, which the agency said it had never provided for anyone in its custody.<\/p>\n By the time she got the surgery 10 months later, another federal inmate had also received a procedure to align their body with their gender identity. No other such surgeries for people in federal custody are publicly documented, although some people in state prisons have also received gender-affirming surgery, including at least five in Illinois<\/a> and 20 in California<\/a> within a U.S. prison population that tops 1.25 million people<\/a>.<\/p>\n Still, those procedures loomed large in the 2024 presidential election. Political advertising for President Donald Trump and other Republicans included $215 million on anti-trans ads<\/a>, according to media tracking firm AdImpact. One such ad declared that Democratic presidential nominee Kamala Harris supported \u201ctaxpayer-funded sex changes for prisoners,\u201d and concluded, \u201cKamala is for they\/them. President Trump is for you.\u201d Some Democrats bemoaned the ads<\/a> as having<\/a> helped tip<\/a> the election.<\/p>\n In the run-up to the Nov. 5 election, 55% of voters felt support for trans rights had gone too far, according to VoteCast, a survey by The Associated Press and partners including KFF, the health policy research, polling, and news organization that includes KFF Health News.<\/p>\n On Inauguration Day, Trump issued a flurry of executive orders that included a directive<\/a> to bar federal spending on gender-affirming care in federal prisons and to \u201censure that males are not detained\u201d in federal women\u2019s facilities.<\/p>\n \u201cPresident Trump received an overwhelming mandate from the American people to restore commonsense principles and safeguard women\u2019s spaces \u2014 even prisons \u2014 from biological men,\u201d White House spokesperson Anna Kelly wrote in an email. \u201cForcing taxpayers to pay for gender transition for prisoners is the exact sort of insanity that the American people rejected at the ballot box in November.\u201d<\/p>\n But for Iglesias, 50, Trump\u2019s order was a shocking reversal.<\/p>\n \u201cIt puts someone\u2019s life in danger being in a men\u2019s prison as a trans woman,\u201d she said from Chicago, where she\u2019s lived since her release in 2023. \u201cIt\u2019d be like putting sheep in a hyenas\u2019 den.\u201d<\/p>\n Iglesias said she faced emotional and physical abuse from her father for her desire to be female. When she was 12, she said, he put a gun in her mouth after finding her wearing her sister\u2019s clothes. Iglesias said she ran away from home, stole checks, cars, and jewelry, and ended up in jail.Lockup was not fun, Iglesias said, but it was the first place she got to be treated as a woman. So, she said, she wanted to stay. In 1994, she landed in federal prison after writing threatening letters to federal judges and prosecutors, according to court filings. In 2005, records show, she pleaded guilty to sending a letter to British officials that she falsely claimed contained anthrax. She told investigators she hoped to get extradited<\/a>.<\/p>\n \u201cI was reading these things where they were allowing trans females to start living with females,\u201d Iglesias said.<\/p>\n She said her outlook changed after the death of her mother in 2010, which prompted her to get serious about having a life outside of prison, and about improving her life inside it.<\/p>\n She began requesting hormone therapy in 2011 and was approved for it in 2015, according to court records. The 2019 lawsuit that led to her transfer to a women\u2019s prison and her surgery was initially handwritten and prepared with the help of only another inmate.<\/p>\n \u201cThe lawsuit was the foundation for everything that I am today,\u201d Iglesias said. \u201cFor the first time in my life, instead of digging myself in these holes, I was digging myself out.\u201d<\/p>\n Along with her settlement, Iglesias received a commitment<\/a> from the Federal Bureau of Prisons to create a timeline for considering other inmates\u2019 requests for gender-affirming care, and to recognize permanent hair removal and gender-affirming surgery as medically necessary treatments for gender dysphoria \u2014 a medical condition<\/a> in which the discrepancy between a person\u2019s gender identity and their sex assigned at birth causes significant distress.<\/p>\n In February, in response to Trump\u2019s executive order, the bureau issued new guidelines<\/a> requiring prison staffers to refer to inmates\u2019 \u201clegal name or pronouns corresponding to their biological sex,\u201d and ending clothing requests \u201cthat do not align with an inmate\u2019s biological sex.\u201d The guidelines end referrals for gender-affirming surgery but allow inmates already receiving treatment, such as hormone therapy, to continue.<\/p>\n However, in a lawsuit filed March 7<\/a>, a trans prisoner alleged the hormone therapy she had been receiving since 2016 was stopped on Jan. 26.<\/p>\n Spokespeople for the bureau did not respond to requests for comment.<\/p>\n The bureau spent $153,000<\/a> on hormone therapy in fiscal year 2022, its former director told Congress, 0.01% of its total spending on health care.<\/p>\n The new guidelines on trans inmates say that Trump\u2019s executive order \u201cdoes not supersede or change\u201d the obligation to comply with federal regulations. But the executive order calls for amending them to prevent trans women from being housed in women\u2019s prisons.<\/p>\n \u201cIt hurt my heart when I seen that because I do know other girls that are still in prison,\u201d said Iglesias, who spent more than 25 years in male facilities. \u201cFemale prison is safe for a trans woman, and you can be who you are. You\u2019re not penalized because you\u2019re feminine.\u201d<\/p>\n But requesting a transfer to a facility matching inmates\u2019 gender identity had not been easy<\/a>, and few prisoners had been moved before the order. A 2025 government court filing<\/a> said that federal prisons house 2,198 trans prisoners out of over 155,000 inmates<\/a>. Of those, the filing said, 22 are trans women housed in female facilities, and one is a trans man in a men\u2019s facility. Although courts have blocked attempts to move that small subset of trans prisoners after the order, a trans prisoner not included in those suits had been relocated, The Guardian<\/a> news outlet reported.<\/p>\n A Department of Justice report from 2014 estimated that trans inmates in state and federal prisons were 10 times<\/a> as likely<\/a> as other prisoners to report incidents of sexual victimization.<\/p>\n Iglesias said she experienced such violence firsthand. Included in her suit was a copy of a 2017 psychological report that said Iglesias reported being the victim of sexual misconduct or abuse in 1993, 2001, 2013, 2015, 2016, and 2017. Later filings included allegations of having been raped in 2019 and 2020, and a series of rapes, threats, and other abuse<\/a> in 2021 before she was transferred to a female facility. Iglesias said she faced more abuse than she officially reported.<\/p>\n \u201cJust because you commit a crime doesn\u2019t mean you deserve to have violence against you,\u201d said Michelle Garc\u00eda, deputy legal director of the ACLU of Illinois<\/a> and one of the attorneys who ultimately represented Iglesias.<\/p>\n Federal law requires all inmates to be protected from abuse. A 1994 Supreme Court decision<\/a> acknowledged trans inmates as particularly vulnerable to attack. Regulations from the Prison Rape Elimination Act<\/a>, passed unanimously by Congress in 2003, contain specific provisions for trans inmates<\/a>, including allowing them to shower separately from other inmates and requiring prison officials to consider their health and safety when deciding whether to house them in male or female facilities.<\/p>\n Courts also have ruled<\/a> that \u201cdeliberate indifference\u201d to an inmate\u2019s \u201cserious medical needs\u201d violates the Eighth Amendment\u2019s ban on \u201ccruel and unusual\u201d punishments. The quality of overall medical care for federal prisoners has come under scrutiny<\/a> amid reports<\/a> of inmates going without needed medical care and preventable deaths.<\/p>\n Iglesias successfully argued in court that gender-affirming surgery was necessary for her gender dysphoria. She was diagnosed with what was then called \u201cgender identity disorder\u201d soon after entering federal custody in 1994, according to court filings. Her diagnosis was updated to gender dysphoria in 2015.<\/p>\n Iglesias\u2019 court filings documented her having been assessed for the risk of suicide 33 times and placed on suicide watch 12 times, as well as an attempt at self-castration in 2009.<\/p>\n \u201cDefendants are aware of Iglesias\u2019s suffering, but have delayed her treatment without evaluating her medically,\u201d the judge in her case wrote<\/a>.<\/p>\n Garc\u00eda called the Trump administration\u2019s targeting of care for trans inmates cruel, unnecessary, and illogical.<\/p>\n \u201cThey\u2019re not assessing the constitutional rights of people,\u201d Garc\u00eda said. \u201cThey\u2019re making choices because this is a vulnerable community that they can rally people behind to hate.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. 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