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Russell Webster

Russell Webster

Criminal Justice & substance misuse expert and author of this blog.

Transgender people in the criminal justice system

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Inside Gender Identity: meeting the health and social care needs of transgender people in the justice system.

Inside Gender Identity

Community Innovations Enterprise has published an important report: Inside Gender Identity: meeting the health and social care needs of transgender people in the criminal justice system.

I missed it when it was first published some months ago, but am indebted to yesterday’s Clinks Health & Justice Bulletin for bringing my attention to it.

The report sets out the findings from a review of the health and social care needs of transgender people in the criminal justice system. Although it focuses on offenders, the report states at its outset that trans people are more often victims of crime than perpetrators. However, for those who are offenders in the criminal justice system there is increasing awareness of their health and social care needs, especially mental health needs and the risk of self-harm or suicide. There are particular concerns about trans people in the prison system and there have been some recent tragic and
preventable deaths.

A new Prison Service Instruction (PSI 17/2016 – see my blog post) has brought much needed clarity to decision-making
processes about where to place trans offenders in the prison system and how to ensure that they are treated with dignity and respect for their gender identity. However, there has been less focus on the health and social care needs of trans offenders and how the identification of health and social care needs and offender health care pathways can be improved.

The review was commissioned by NHS England to assess the evidence base on meeting the health and social care needs of trans people in the criminal justice system with the intention of informing policy and practice in the offender health system, taking into account all ages and the range of provision. This includes an evaluation of the way in which the needs of transgender individuals are incorporated in offender health and social care needs assessments and the implications for service provision and practice.

Trans Health

In assessing the health and social care needs of the trans population it is important to recognise the limitations of the available research base and the relative lack of inclusion of trans people in population based health and social care needs assessments. This is largely a result of research and surveys failing to include identification of trans people in data collection and analysis. Lack of clarity and consistency in the use of terms to describe transgender also adds to the challenge of interpreting data. Nevertheless, there is a large and growing body of evidence that trans people experience a wide range of significant health and social care needs that are directly associated with being a trans person. These include:

Poor healthcare

Engagement with health services may be a factor that impacts on the health and wellbeing of trans people. For example: 

  • Trans people are known to experience negative attitudes and discrimination from health professionals that may result in avoidance of health services and neglect of health problems.

  • Gender specific health needs such as for age related cancer screening programmes, might be masked or neglected due to trans peoples’ poor experience of healthcare and subsequent lack of engagement with health services.

Poor physical health

Trans individuals are more likely to report their health as being poor, this is in comparison not only to general population self reported health but also with respect to Lesbian, Gay and Bisexual populations.

  • For trans people taking regular, long term hormonal therapies there are particular risks with respect to morbidity and mortality, for example, cardiovascular disease, cancer and osteoporosis.

  • 62% of trans people may be dependent on alcohol or engaging in alcohol abuse.

  • Trans people are up to four times more likely to be HIV positive than those in the general population and are thought to be less likely to be tested for HIV.

Poor mental Health

Mental health problems are known to be higher amongst trans individuals. This may be part of gender incongruence experienced as a result of being trans and/or in response to the high levels of stress and anxiety that can be caused by the experience of stigma and discrimination associated with being trans.

  • 56% of transgender people had been diagnosed with depression at some point in their lives, four times the rate for the general population.

  • Trans women on average are more likely than trans men to report paranoid ideation, interpersonal distrust, anxiety, depression, and obsessive-compulsive complaints.

  • More than half of trans people have self-harmed at some point and more than a third have considered suicide.

  • Three quarters of trans young people have self-harmed and over a quarter (27%) are currently purposely self- harming.

 High social risks 

  •  1 in 4 trans young people experienced physical abuse at school.
  • 22% of trans people were not permitted to use the appropriate toilet after coming out at work.

  • 58% of trans people were reported to have a disability or chronic health condition, including 8.5% who were deaf and 5% who were visually impaired.

  • Transgender people may be more likely than the general population to have an autistic spectrum disorder.

  • 57% of transgender adults have experienced family rejection.

  • 1 in 5 transgender people reported having experienced homelessness at some time in their lives because of discrimination and family rejection.

Recommendations

The report makes 9 recommendations:

  1. Equality and diversity training for healthcare providers in the justice system.
  2. There is a need for concise, evidence based practice guidance on working with gender diverse individuals in the offender healthcare system.
  3. There is a need to concentrate expertise in a way that is accessible across the offender healthcare system by creating expert champions in the area of trans offender health and social care needs.
  4. NHS England needs to work collaboratively, internally and with external partners and providers, to ensure that trans individuals in the criminal justice system can access an appropriate, integrated care pathway where and when this is needed. This applies particularly to mental health, substance use and specialist offender therapeutic pathways.
  5. It is important that NHS England works closely with HMPPS to ensure that trans individuals in the criminal justice system can make full use of offender treatment programmes that will support sentence planning and reduce the likelihood of reoffending.
  6. NHS England needs to take into account the report’s findings when creating service specifications for Gender Identity Clinics.
  7. NHS England and HMPPS should commission the trans social sector to provide practice support to trans people in the criminal justice system.
  8. The creation of a national trans health and justice network.
  9. Further research into the health and social care needs of transgender offenders and effective interventions that can support the rehabilitation of transgender offenders. 

 

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