Before going to prison, Patricia Trimble didn’t know what it meant to be transgender. “In fact, for many years, I just introduced myself as, ‘OK, I'm a gay man,’ because that's all I knew,” she said over the phone from Jefferson City Correctional Center, a maximum security prison in Missouri’s capital.
In 2015, Trimble, who is serving a life sentence for murder, was assaulted by another inmate in her unit, she said. While trying to get herself separated from her assaulter, she started writing letters to every LGBTQ organization for which she could find an address, asking for help in advocating for herself. None could help her relocate, but one did send her a pamphlet called “Still We Rise.” That’s where she first read the definition for “gender dysphoria.” As Trimble recalls, “I'm reading that, and I'm like ‘my God… that explains my life.’"
In visits with her psychiatrist, Trimble pushed for a diagnosis, which she finally got in 2016, but it wasn’t until last year that she was given a prescription to Estradiol and testosterone blockers. Until recently, a “freeze frame” policy in Missouri made it impossible for anyone in the state’s prisons to start hormone therapy unless they’d been on it before starting to serve their sentence.
“You have a bunch of psychologists and therapists talking to us that really have no clue, so we kind of have to educate one another.”
After a lifetime spent in the dark about the reality of gender dysphoria, Trimble, now 59, answers more questions than she asks. On a typical day, she gets up at 5 A.M. and does her make-up—before recent policy changes allowed cosmetics in, she’d make it herself with hot water and Crayola pencils. She skips breakfast in favor of a few cups of coffee, and, with the morning news playing on the TV in her cell, looks through her mail.
Alongside her bed sits a metal footlocker with hundreds of photocopied pages of literature related to trans issues. In the hours before work, she might write letters to LGBTQ associations across the state (“carpet-bombing,” as she calls it) for help weaving through the bureaucracy standing between her fellow inmates and diagnoses or legal name changes. She then mails texts from her archive to other incarcerated trans women, transcribing them on a typewriter first because the corrections department doesn’t allow her to exchange personal property—which sometimes includes photocopies—with fellow inmates.
Through this letter-writing network, Trimble is helping other trans people across Missouri's Department of Corrections (MDOC) better understand their own identities, what kinds of treatment they need—and how they can advocate for it from the inside. “You have a bunch of psychologists and therapists talking to us that really have no clue,” Trimble said. “So we kind of have to educate one another.”
Trimble’s strongest ally in her activism is Jessica Hicklin, a fellow inmate without whom she likely wouldn’t have gotten access to hormone therapy.
Hicklin, 40, is serving a life sentence for murder at Potosi Correctional Center, a two-hour drive from Jefferson City; she will be eligible for parole next year due to a state law passed in 2016 granting leniency to convicts who committed their crimes as juveniles. She, too, was kept from adequate medical care because of the department’s freeze frame policy. With the help of Lambda Legal, a legal non-profit focused on LGBTQ rights, she successfully sued the MDOC and its private health care provider, Corizon Health, for treatment. Last year, a federal district court directed the defendants to provide Hicklin “with care that her doctors deem to be medically necessary treatment for her gender dysphoria, including […] hormone therapy, access to permanent body hair removal, and access to ‘gender-affirming’ canteen items,” according to a court document.
Hicklin soon began her hormone therapy in the form of testosterone blockers and estrogen pills. A few months later, the same court struck down the freeze frame policy, the effects of which soon trickled down to other transgender inmates, including Trimble. An MDOC spokesperson estimated that there are “about 50 to 60” transgender inmates in the MDOC’s custody, out of a prison population of roughly 30,000. Fourteen of them are on hormone therapy, according to a spokesperson at Corizon.
It’s unclear just how common freeze frame policies are in America’s prisons. The Bureau of Prisons rejected them on a federal level in 2011, writing in a memorandum that “treatment options will not be precluded solely due to level of services received, or lack of services, prior to incarceration.”
But most inmates are held in state prisons, not federal ones. According to a 2014 study in the Journal of Correctional Health Care, “a number of highly publicized lawsuits in the last 10 years have resulted in court orders that compelled prisons to allow the prescribing of hormones pursuant to physician recommendation.” In 2019, it’s still a “state by state battle,” said George R. Brown, the study’s author and a professor of psychiatry at East Tennessee State University.
A 2017 analysis by the Prison Policy Initiative, a nonprofit organization that studies and advocates against mass incarceration, found that, of the 21 state correctional departments studied, four had policies against providing hormone therapy to inmates who weren’t on them before their prison terms. “Two of them, Alabama and Oklahoma, have changed those specific policies,” according to Harper Jean Tobin, director of policy at the National Center for Transgender Equality (a spokesperson for Alabama’s Department of Corrections conceded this was once the case; another at Oklahoma’s Department of Corrections said in an email that “no one here is aware of any previous ‘freeze frame’ policy,” and the document linked to by the Prison Policy Initiative does allow for care if a “medical provider determines hormone treatment is medically necessary”).
According to Tobin, Maine and Nevada “appear to maintain a freeze frame model based on written policies.”
Brooke Santina, a spokesperson at the Nevada Department of Corrections, tells VICE that “right now, that's the case. However, I know that we're going to be making a lot of change in the near future,” she said. “This is just one more step in our rehabilitation as a department, really.”
In a Florida case, the ACLU is suing the state’s Department of Corrections on behalf of a transgender woman seeking medical care. According to an amicus brief in the case filed by Lambda Legal and co-written by Jessica Hicklin’s lawyer, they and other organizations “have received hundreds of requests for assistance from incarcerated transgender people nationwide.”
But in Missouri, Hicklin said, getting hormone therapy and gender-affirming items like clothing, chest binders, or make-up still depends on where a trans inmate happens to be incarcerated, and how well they’ve made their case for diagnosis. “If you’re just a person who’s slightly removed from the dialogue, it looks like everything’s roses,” Hicklin said. “‘Look, we’ve won, it’s over, hooray, everybody gets to be who they are.’ And that’s not the reality of the situation yet.”
Trimble said she teaches her therapist more about transgender issues than the other way around. But it was through him that she first heard about Hicklin’s case. She reached out—"all I need is their name, their register number, and what institution they're in," Trimble said—and they quickly bonded through weekly letters, which soon became just a part of the overall correspondence they kept with people around the state. “She's a mom and I'm a mom,” Hicklin said. “That's probably the shortest way of putting that. We both try and help each other and everybody else.”
Hicklin is in touch, at least occasionally, with about 20 other inmates. Her court victory is cause for cautious optimism for Jay Livingston, a trans man serving 16 years for first degree robbery at Missouri’s Chillicothe Correctional Center. “I love hearing things from her, and it actually does help me,” Livingston, 31, said about the pen-pal relationship. “Because it shows that even though things are not happening right now the way I want them to, I know eventually things will happen.”
Livingston said he hasn’t been diagnosed with gender dysphoria—a problem he chalks up to an uninformed psychiatrist—but is seeking to be addressed appropriately by prison staff, wear his hair the way he wants, and get access to chest binders, masculine clothes, and hormone treatment. (A spokesperson at Corizon maintains that “every patient is treated as an individual in consideration of his or her unique health needs and specific circumstances.” A spokesperson at the MDOC said items that are “normally available” in women’s facilities are available in men’s prisons, and vice versa, but that “transgender offenders can’t necessarily get items that aren’t normally available in either type of facility.”)
Hicklin has sent Livingston the World Professional Association for Transgender Health (WPATH)’s Standards of Care—a document backed by organizations including the American Psychological Association, and that Corizon’s spokesperson said the company follows—to inform his efforts at receiving health care. “I have her in my corner,” he said about Hicklin.
Trimble has reached out to Livingston, too, getting to know him through letters and sending book recommendations for him to better understand trans issues.
“I cried for about three days, but then I came out. And I've been out ever since.”
Sometimes, the information-sharing doesn’t even need to happen through letters. Jasmyne René Cooley, who was recently released from prison, realized she was trans while sharing a cell with Trimble. “I didn't really talk too much about it,” she said about her dysphoria. “I didn't even know this was an actual thing.”
When she moved into Trimble’s cell, Cooley, 55, started sharing pieces of her past. “She told me she had some things I needed to read,” Cooley said. “And what she gave me to read were medical stuff from, you know, the DSM–5.”
The DSM–5, or Diagnostic and Statistical Manual of Mental Disorders, describes gender dysphoria as “a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.”
Its entry in the catalog is sometimes contentious in the trans community. Some believe that it unnecessarily pathologizes the trans experience. But it’s also an asset for those seeking treatment, allowing them to access hormone therapy, hair removal or surgery.
Reading the manual’s definition was Cooley’s deliverance from the feeling that her pain was different, irreparable, and wrong. “That was pretty much what did it,” she said. “I cried for about three days, but then I came out. And I've been out ever since.”
Trans Americans are more likely to end up in prison, and to be physically and sexually abused once there. The National Center for Transgender Equality’s 2015 U.S. Transgender Survey found that a fifth of incarcerated correspondents reported being sexually assaulted by facility staff or other inmates. “This rate was five to six times higher than the rates of sexual assault by facility staff or other inmates reported by the U.S. incarcerated population”, according to the survey.
Government data points to a higher rate. About a third of trans inmates reported “one or more incidents of sexual victimization involving another inmate or facility staff in the past 12 months,” according to Department of Justice survey data. That fraction is much greater than for the general prison population.
Despite these numbers, trans inmates are unlikely to find allies in the current administration. Last year, the Trump administration rolled back Obama-era guidelines to consider an inmate’s gender identity when making housing determinations. “The designation to a facility of the inmate’s identified gender would be appropriate only in rare cases,” the Transgender Offender Manual said.
The medical field, however, is clear on the importance of treatment for people with gender dysphoria. The U.S. Transgender Survey found that 40% of respondents had attempted suicide in their lifetime, making the suicide rate for transgender Americans almost nine times higher than that of the overall population. Studies have shown, however, that treatment such as hormone replacement therapy hugely decrease both depression and suicidality.
"She's my rock. What she's doing, she's doing not just for herself."
That possibility was once all too real for Patricia Trimble. “Every time I look in the mirror, I hate what I see,” she said shortly after her diagnosis with gender dysphoria. “I've attempted suicide a number of times in the past, and I was absolutely to the point to where, ‘look, we're either going to fix this or I'm going to fix this. This has got to stop. There's gotta be some relief—somewhere.’ And that's why I asked them for help.”
An MDOC spokesperson said that “gender is becoming more and more of an issue going forward, as we look into policies and training and making sure everyone's getting the kind of treatment they need.” They would not acknowledge whether these changes were due to the judge’s ruling in Hicklin’s case against the MDOC.
Brown, the psychiatrist, was actually hired to advise Corizon in its case against Hicklin. But he was “pleased with the outcome” after her victory. Once juries and judges hear “what it's like and hear what people's experiences are, they start to understand more about the condition and realize that it does require treatment.”
If Trimble has accepted that she’ll never regain her freedom, she could never do the same for her relief from gender dysphoria, which has come only after long and deliberate demands for it. Before she was granted access to hormone therapy, a treatment plan advised her to deal with her crippling dysphoria by making use of “coping skills such as deep breathing, communicating with outside transgender agencies, and communicating with fellow transgender offenders.”
In one respect, the plan got it right. Communicating with trans people like Hicklin has kept Patricia Trimble going. “She's my rock,” Trimble said of her friend. “What she's doing, she's doing not just for herself. She recognizes that. She's doing it for all of us.”