Gender Dysphoria: Healthcare for Inmates with

Idaho
Department of
Correction

Standard
Operating
Procedure
Title:
Gender Dysphoria: Healthcare for Inmates
with

Page:
1 of 9

Control Number:
401.06.03.501
Version:
4.0
Adopted:
10/31/2002

Ashley Dowell, chief of the division of prisons, approved this document on 10/05/2018.
Open to the public: Yes
SCOPE
This standard operating procedure (SOP) applies to all Idaho Department of Correction
(IDOC) inmates who request or are evaluated for and/or diagnosed with Gender Dysphoria;
Prisons Division administrators, employees, contract medical providers and subcontractors;
and limited IDOC staff such as facility heads, security staff, deputy attorneys general (DAG)
who represents the IDOC, and the director of the IDOC.
Revision Summary
Revision date (10/05/2018) version 4.0: Reformatted, updated terminology; provided
clarification regarding inmates with gender dysphoria including how they are to be addressed,
appearance, commissary, and various other issues.
TABLE OF CONTENTS
Board of Correction IDAPA Rule Number 401 ...................................................................... 2
Policy Control Number 401................................................................................................... 2
Purpose ................................................................................................................................ 2
Responsibility ....................................................................................................................... 2
Standard Procedures ........................................................................................................... 2
1. Initial Reporting ............................................................................................................ 2
2. Referral and Placement of the Inmate for Evaluation Purposes ................................... 3
3. Evaluation of the Inmate .............................................................................................. 3
4. Evaluation Findings, Diagnosis, and Reporting ............................................................ 3
5. Chief Psychologist’s Review ........................................................................................ 4
6. Management and Treatment Committee (MTC) Meeting.............................................. 4
7. Administrative Review Committee (ARC) Meeting ....................................................... 5
8. Final Approval of the Management and Placement Plan .............................................. 5
9. Implementation of the Management and Placement Plan ............................................ 5
10. Respectful and Safe Conduct Related to Appearance .................................................. 6
11. Subsequent Reviews and Evaluations for GD .............................................................. 7
Control Number:
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Definitions ............................................................................................................................ 7
References ........................................................................................................................... 9
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBER 401
Clinical Services and Treatment
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish guidelines for the
diagnosis, treatment, management, and placement of inmates diagnosed with Gender
Dysphoria (GD) to ensure inmate safety and access to appropriate and necessary medical
and mental health treatment. This SOP defines the extent and general limits of healthcare
services provided to inmates identified as meeting the criteria for diagnosis of GD as
outlined within the most current Diagnostic and Statistical Manual of Mental Disorders
(DSM).
RESPONSIBILITY
The chief of Prisons Division is responsible for the implementation of this SOP and for
designating appropriate personnel to develop and implement procedures in conjunction with
this SOP.
STANDARD PROCEDURES
1. Initial Reporting
Information about all services available within the correctional system, including those to
meet the needs of inmates with GD, will be made available to inmates while in the
Reception/Diagnostic Unit (RDU). Upon the inmate’s request, information about all services
will be available throughout the inmate’s incarceration. Until an inmate who is suspected of
having GD completes the RDU process, security staff and other relevant staff will review
whether to escort and transport the inmate separately to avoid the risk of physical or sexual
assault by other inmates in transit.
Inmates may be evaluated for GD at any point during their incarceration. When the inmate
has a prior diagnosis, or is suspected of having GD or accompanying/supporting information
(i.e., collateral information) is received pertaining to the suspicions of GD, any of the
following may request an initial or subsequent evaluation for GD:
• Inmate – Requests (in writing) health assistance in accordance with SOP
401.06.03.037, Non-emergency Healthcare Requests and Services or SOP
401.06.03.087, Healthcare for Inmates Housed in Non-Idaho Department of
Correction Facilities.
• Healthcare Staff – prepares a referral in accordance with SOP 401.06.03.037 or
401.06.03.087 and forwards to the chief psychologist.
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Subsequent Evaluations
Also see section 11.
2. Referral and Placement of the Inmate for Evaluation Purposes
The chief psychologist will take the necessary action to transfer an inmate who is scheduled
to be evaluated for GD to the appropriate facility for evaluation if a move is needed.
When determining appropriate placement, the chief psychologist will consider factors such
as the inmate’s diagnostic needs, prior institutional adjustment, and safety and/or security
concerns. In consultation with the warden, unless there are overriding security and/or safety
concerns for the inmate, the chief psychologist will place the inmate (who either requests a
GD evaluation or is diagnosed with GD) in a correctional facility consistent with the inmate’s
primary physical sexual characteristics.
The evaluation process will commence within 30 days from the date a written request, or
referral from medical staff for evaluation, is received by the chief psychologist.
3. Evaluation of the Inmate
Once the inmate has been moved to the appropriate housing unit, the inmate will be
evaluated by the Qualified GD Evaluator. The chief psychologist, at his direction, may
require that a consultant perform this initial evaluation.
Note: Any consultant involved with the diagnosis of GD must be a qualified GD evaluator
and contracted by the IDOC.
This evaluation will include a comprehensive history, mental status evaluation, and clinical
interview. Documentation of any claim by the inmate of prior GD diagnosis, treatment, or
transgender lifestyle will be obtained as part of the evaluation process. An inmate’s refusal
to provide written authorization to access medical records relating to prior diagnosis or
treatment of GD may be considered a factor for a non-GD finding by the evaluator.
The diagnosis of GD will be based on the most current Diagnostic and Statistical Manual of
Mental Disorders. If the IDOC evaluator believes it is necessary, they may contract a
medical or mental health consultant to assist in the evaluation process. Any diagnoses by
the evaluators should include consideration of the consultant’s report.
Throughout the evaluation process, the chief psychologist or clinical supervisor will monitor
the progress of the evaluation to ensure the GD evaluation is completed as soon as
practicable. Absent extenuating circumstances, the GD evaluation will be completed within
60 days from the date the evaluation process commences as described in section 2.
4. Evaluation Findings, Diagnosis, and Reporting
The GD evaluator conducting the evaluation will prepare independent written reports
detailing their findings, diagnosis, and recommended treatment options. These independent
written reports will include dates of contact, instrumentation utilized, collateral data obtained,
and the consultant’s report, if applicable. The reports will also include a diagnosis and a
summary of the information and impressions that support the diagnosis and recommended
treatment options. These written reports will be forwarded to the chief psychologist.
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In cases where an inmate was receiving (prior to incarceration) feminizing or masculinizing
hormones from a licensed medical professional as treatment for GD, the prior treatment will
be continued and incorporated into the inmate’s individualized medical treatment plan,
unless hormone replacement therapy is subsequently contraindicated based on the
assessment and findings by the inmate’s treating physician.
5. Chief Psychologist’s Review
Upon receipt of the evaluators’ reports, the chief psychologist reviews the findings and
convenes the Management and Treatment Committee (MTC). The chief psychologist may,
at his discretion, request an additional evaluation by a consultant who will provide an
independent diagnosis and report. If differences in opinions between evaluators exist, the
chief psychologist will—based upon his review of all available information, including the
reports of the evaluators and any consultant—issue a report resolving any differences of
opinions concerning diagnosis and/or treatment, including his own findings. All reports
generated by the evaluators, consultants, or the chief psychologist will be placed in the
inmate’s medical file.
Findings Not Supported
In incidences in which the diagnosis of GD is not supported by the evaluation process,
the chief psychologist may, at his sole discretion:
• Request an additional evaluation by a consultant who will provide an independent
diagnosis.
• Refer concerns about the inmate’s security or housing needs to the operations and
security staff at the inmate’s assigned facility so they can determine appropriate
housing.
6. Management and Treatment Committee (MTC) Meeting
When convened, the MTC will develop and recommend a plan for the management and
placement of the inmate. Copies of all reports authored by the evaluators will be provided to
the MTC.
The MTC will develop and recommend an individualized Management and Placement Plan
for each inmate diagnosed with GD, which implements the treatment plan developed by the
treating medical and mental health providers.
The treating physician may also initiate hormone replacement therapy when such therapy
has been prescribed as part of the treatment plan. When initiated by the treating physician,
the hormone replacement therapy may commence prior to and independent of the
Administrative Review Committee’s (ARC) review. The chief psychologist may initiate mental
health services recommended as part of the treatment plan prior to and independent of the
ARC review.
Management and placement recommendations for inmates with GD will take into account
both treatment and security needs, with a goal of least restrictive placement. As provided in
section 2, facility placement will be based upon the inmate’s primary physical sexual
characteristics.
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The MTC will forward its recommendation for management and placement to all ARC
members.
7. Administrative Review Committee (ARC) Meeting
Convening Responsibility
After receiving the MTC’s report and recommendations, the chief of the Prisons Division
will convene a meeting of the ARC.
Review of Management and Placement Plan
The ARC will review the Management and Placement Plan recommended by the MTC
and, at its discretion, consult with members of the MTC in an effort to address concerns
and/or questions related to the proposed plan.
Upon approval of the MTC’s proposed Management and Placement Plan, the ARC will
submit its recommendation for management to the director of the IDOC within 15
working days of meeting.
8. Final Approval of the Management and Placement Plan
The director of the IDOC will review the ARC’s recommendation, and in his sole discretion
take into consideration existing security concerns within the facility and available space in
the facility identified in the Management and Training Plan and either:
• Send the recommendation back to the ARC or the MTC for additional findings or
information, or
• Retain consultants to address any concerns or questions with the recommendation,
or
• May accept (in writing) the ARC’s recommendation.
9. Implementation of the Management and Placement Plan
Inmates diagnosed with GD will be:
• Managed pursuant to the Management and Placement Plan approved by the director
of the IDOC.
• Treated in accordance with their medical and mental health treatment plan.
Inmates requesting evaluation for (or diagnosed with) GD will not be placed in administrative
segregation based solely upon their request or diagnosis.
Hormone replacement therapy will be provided as needed, but only when medically
indicated and consistent with the inmate’s treatment plan. An inmate who was receiving
hormone replacement therapy at the time of incarceration will continue on those
medications, unless current treating medical providers determine there is a medically
compelling reason to discontinue treatment. An inmate who is initially diagnosed with GD
while incarcerated at the IDOC will be eligible to receive hormone replacement therapy if
medically necessary and as identified in their treatment plan. The inmate will be required to
provide their informed consent (see SOP 401.06.03.070, Informed Consent) to ensure the
inmate understands and accepts the risks associated with any prescribed treatment for GD.
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10. Respectful and Safe Conduct Related to Appearance
Inmates diagnosed with gender dysphoria will be allowed to maintain their appearance in a
way that is consistent with their identified gender. This means that inmates housed in a male
facility, who identify as female and have been diagnosed with gender dysphoria, will be
allowed to wear makeup and wear their hair in traditionally feminine hairstyles and present
as female. Similarly, inmates housed in a female facility, who identify as male and have been
diagnosed with gender dysphoria, will be allowed to wear their hair in traditionally male
hairstyles and present as male.
However, to avoid a sexually charged atmosphere in IDOC facilities, and to foster an
environment of respect for all persons housed there, the following guidelines will be in place:
• No provocative or sexually charged clothing or behavior will be permitted.
o Examples of inappropriate clothing include, but are not limited to: clothing
that is too tight, too short, transparent, shows cleavage or the midriff.
o Examples of inappropriate behavior include but are not limited to:
gestures or mimicking of sexual behavior, behavior or actions that are
provocative, kissing, or similar conduct.
• A single commissary list will be used for inmates who have been diagnosed with
gender dysphoria. There will be no distinction or restriction of products by gender as
to what can be ordered.
o This includes undergarments such as male/female underwear and bras.
o Inmates who are indigent, and diagnosed with gender dysphoria, and do
not have the funds to purchase undergarments will be provided state
issued undergarments per SOP 320.02.01.001, Property: State-issued
and Inmate Personal Property.
• Gender neutral references will be used by IDOC staff when speaking to or referring
to inmates diagnosed with gender dysphoria.
o For example: Use the inmate’s name or use gender neutral pronouns for
reference such as “they, them, or their”.
• Medical and mental health staff will refer to inmates diagnosed with gender
dysphoria by their preferred pronoun.
• Inmates diagnosed with gender dysphoria will be treated by staff in a manner
consistent with policy 201, Respectful Workplace. (i.e., Staff members must maintain
a respectful and professional demeanor, and refrain from harassing inmates due to
their gender/sex, etc.)
• Inmates diagnosed with GD will be provided access to the full range of services and
programs available within the IDOC to the same extent as other inmates.
Searches of inmates diagnosed with GD will be conducted in a manner that is consistent
with SOP 317.02.02.001, Searches: Cell/Living Unit, and Inmate.
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11. Subsequent Reviews and Evaluations for GD
In the event that additional observations or information concerning the inmate’s purported
GD becomes available, a subsequent evaluation (i.e., a re-evaluation) may be requested.
Inmates who have requested to be evaluated for gender dysphoria, and who have not been
assessed as meeting criteria for that diagnosis, may reinitiate the evaluation process via a
Health Services Request one year after the date of the initial evaluation.
The decision to allow a re-evaluation will be within the discretion of the chief psychologist
based upon his review of all available information. If a re-evaluation is denied, the basis for
the denial must be documented in the inmate’s healthcare record.
DEFINITIONS
Administrative Review Committee (ARC): A committee comprised of the chief of the
Prisons Division; a deputy chief of the Prisons Division; and a deputy attorney general who
is assigned to the Idaho Department of Correction (IDOC) and will act as legal advisor. The
committee reviews recommendations of the Management and Treatment Committee (MTC).
The ARC may, in its discretion retain a consultant versed in the treatment, management, and
placement of persons with gender dysphoria (GD). Recommendations of the ARC, together
with the recommendations of the MTC, will be submitted to the director of the IDOC for final
consideration.
Chief Psychologist: The chief psychologist must be a doctoral level psychologist licensed
in the state of Idaho and employed by the IDOC and will be responsible for overseeing the
delivery of all IDOC mental health services provided by state of Idaho and/or contract
providers. If the chief psychologist is not a qualified GD evaluator, he must engage and rely
upon a consultant who must be a qualified GD evaluator.
Consultant – GD: A medical or mental health professional, qualified by virtue of their
training and experience to make non-binding recommendations regarding the diagnosis and
treatment of inmates with gender dysphoria (GD). Any consultant involved with the diagnosis
of GD must be a qualified GD evaluator.
Diagnostic and Statistical Manual of Mental Disorders (DSM): The standard manual of
psychiatric diagnoses, as published and amended by the American Psychiatric Association
from time to time.
Facility: A building or residence (including the property and land where the building or
residence is located) owned, leased, operated, or managed by the Idaho Board of
Correction or Idaho Department of Correction (IDOC).
Facility Head: The person primarily responsible for overseeing, managing, or operating an
Idaho Department of Correction (IDOC) facility.
Gender Dysphoria (GD): A psychiatric disorder that is defined in the most current
Diagnostic and Statistical Manual of Mental Disorders (DSM). A person with this condition
reports marked incongruence between the gender they were born with and their identified or
expressed gender causing clinically significant distress or impairment in functioning.
Hormone Replacement Therapy: A medical treatment in which hormonal medications are
administered to individuals diagnosed with gender dysphoria for the purpose of more closely
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aligning their physical characteristics with their gender identity. The goal of this treatment is
feminization or masculinization.
Level of Care (LOC): An acuity based system utilized by the Idaho Department of
Correction (IDOC) in which inmates with mental health issues are assigned a LOC based
upon the severity of their mental illness and degree of treatment needs.
Management and Placement Plan: A written plan devised by the Management and
Treatment Committee (MTC) that includes a review of the treatment plan from the treating
medical and mental health providers, outlines referrals for treatment and includes
recommendations regarding facility placement and housing and special accommodations or
support services. The Management and Placement Plan is forwarded to the Administrative
Review Committee (ARC) for their review and approval.
Management and Treatment Committee (MTC): A multidisciplinary committee that is
composed of representatives from the medical, mental health, security and operations staff.
This committee reviews the treatment plan from the treating medical and mental health
providers and generates a management and placement plan. The committee is led by the
IDOC Chief Psychologist.
Inmate: A person under the legal care, custody, supervision, or authority of the Idaho Board
of Correction, including a person within or out of the state of Idaho pursuant to an
agreement with another state or contractor.
Primary Physical Sexual Characteristics: Genitalia and reproductive organs.
Qualified Gender Dysphoria Evaluator: A trai ned mental health professional who is either
an IDOC or contract medical employee, with competence to work with adults with gender
dysphoria and has:
1. A master’s degree, or more advanced degree, in a behavioral health field and
appropriate licensure in or credentials
2. Competence in using the DSM for diagnostic purposes
3. The ability to recognize and diagnose coexisting mental health concerns
4. Documented supervised training and competence in counseling
5. Is knowledgeable about gender non-conforming identities and expressions and the
assessment and treatment of gender dysphoria
6. Continuing education in the assessment and treatment of gender dysphoria
7. Cultural competence to facilitate work with individuals with gender dysphoria
Reception/Diagnostic Unit (RDU): Initial housing for newly committed inmates (except
those under sentence of death) where orientation, screening, assessment, and classification
occur.
Sexual Reassignment Surgery: The surgical alteration of the physical appearance of an
individual’s genitalia so the person’s genitals more closely match that of their identified
gender. Sexual reassignment surgery will not be considered for individuals incarcerated
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within the Idaho Department of Correction (IDOC), unless determined medically necessary
by the treating physician.
Sexual Reassignment Treatment: Treatment for a person diagnosed with gender
dysphoria (GD) in which hormone replacement medications, surgical procedures, or both
are utilized to alter a person’s physical appearance so that the person appears more like
their identified gender.
Treatment Plan: A series of written statements specifying a patient’s particular course of
treatment and the roles of qualified healthcare professionals in carrying it out.
REFERENCES
IDAPA 06.01.01, Rules of the Board of Correction, Section 302.05, Medical, Dental,
Psychological and Psychiatric Care
IDAPA 06.01.01, Rules of the Board of Correction, Section 401, Medical Care
Policy 201, Respectful Workplace
Standard Operating Procedure 317.04.02.001, Searches of Inmates
Standard Operating Procedure 401.06.03.037, Non-emergency Healthcare Requests and
Services
Standard Operating Procedure 401.06.03.070, Informed Consent
Standard Operating Procedure 401.06.03.087, Healthcare for Inmates Housed in Non-Idaho
Department of Correction Facilities
Standard Operating Procedure 327.02.01.001, Mental Health Services System

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