Long before she got into trouble with the law, Cristina Nichole Iglesias felt that the body she was born in wasn't hers. By the 10th grade, court documents say, she was wearing girls' clothes and trying various hairstyles.
This week, the U.S. Bureau of Prisons is set to decide whether to recommend Iglesias for gender affirmation surgery after evaluating the case under order from a federal judge last month.
If approved, Iglesias could become the first inmate to receive such an operation while in federal custody.
“This is a landmark and monumental move forward, and something we hope will be followed up with treatment and care,” said Ed Yohnka, a spokesperson for ACLU of Illinois, which handled Iglesias’ case.
The decision is imminent because of a Dec. 27 ruling from U.S. District Judge Nancy Rosenstengel of Illinois’ Southern District that directed the Bureau of Prisons’ Transgender Executive Council to decide Iglesias’ case by Monday, the first time the bureau had ever been mandated to do so by judicial order.
Iglesias, 47, is an inmate at FMC Carswell, a federal prison medical facility for women in Fort Worth, Texas. She pleaded guilty in 2005 to sending an envelope to British officials that she falsely claimed contained anthrax and is scheduled to be released in December.
An estimated 1,200 transgender individuals are in the federal prison system, or about .07% of the overall inmate population of about 156,000.
In her ruling, Rosenstengel noted that Iglesias is not the first federal inmate to receive approval for surgery. The transgender council previously recommended another inmate for surgery in October, the first time it had ever done so – but the urgency assigned by the judge because of previous delays could make Iglesias the first to have the operation.
“The BOP system... has never provided a single surgery for a transgender person,” said Amy Whelan, a senior staff attorney for the National Center for Lesbian Rights. “It’s well overdue time that they start providing that necessary care.”
Iglesias' struggles began at a young age
The Bureau of Prisons’ transgender council is a group of senior-level administrators who guide agency decisions about transgender inmates, including their placement and care, bureau spokesperson Randilee Giamusso said. It includes two psychiatrists, a psychologist and a pharmacist, according to court records.
The documents say Iglesias entered the federal prison system in 1994, and it was from a federal prison that she sent the letter to British officials, listing the detention center as the return address.
"No threat was carried out in any way," wrote her public defender, Kathleen Williams, in asking for a more lenient sentence. She noted Iglesias' history of bipolar disorder and the crime's consistency with Iglesias' decade-long history of sending such letters.
"No anthrax was actually sent," Williams wrote. "This is not a typical terrorist act."
Iglesias ultimately received a 20-year sentence. Meanwhile, she continued to experience gender dysphoria but did not receive hormone therapy until 2015.
By 2016, the documents say, Iglesias had informed prison health officials that she wanted gender confirmation surgery and requested transfer to a women’s prison facility, both to fit her identity and because of harassment from male prisoners.
Iglesias, whose gender dysphoria was so extreme that she considered self-castration, was placed under suicide watch numerous times, according to the documents.
Gender dysphoria is a medical condition marked by mental distress brought on by an incongruity between a person’s gender identity and their sex assigned at birth, which can cause anxiety and depression if left untreated. Not all transgender people experience gender dysphoria, and for those who do, surgery isn’t always necessary.
In Iglesias’ case, Bureau of Prisons health professionals had by 2019 supported her eligibility for gender affirmation surgery, also referred to as gender confirmation surgery. It wasn’t until May that she was transferred from the federal penitentiary in Marion, Illinois, to FMC Carswell.
In her ruling, judge Rosenstengel faulted bureau officials for unnecessarily denying and delaying Iglesias’ treatment despite being “well-aware that inmates with gender dysphoria are at a higher risk of suffering from mental health issues and resorting to self-harm."
The judge added: "She is at risk for suicide, and her psychological condition will continue to deteriorate.”
Should the council recommend Iglesias for surgery, the judge ordered that Iglesias be immediately referred to the prisons bureau’s medical director, who will make the final determination.
The bureau then would have two days to submit a plan and timeline for Iglesias’ care and begin the search for a surgeon to perform the procedure.
If Iglesias’ request is denied by either the council or medical director, the judge ordered that the bureau file a notice with the court within seven days explaining the decision.
Giamusso, of the prisons bureau, said the BOP does not comment on any individual inmate's litigation or legal matters, medical information or conditions of confinement "for privacy, safety and security reasons."
However, she said the council does provide "a wide range of gender affirming accommodations based on comprehensive and individualized assessments. These accommodations can include gender affirming surgical referral when deemed appropriate."
Prisons 'have historically fallen behind' in providing care
In a statement, Iglesias said she was “excited” by the judge’s order, without which she would have continued “to fall through the cracks…. I am happy to have had the chance to tell my story and am hopeful that other transgender people will benefit from my case.”
While that day was an “important and emotional” one for Iglesias, Yohnka said, the fact that no federal inmate has previously received gender affirmation surgery shows the challenges faced by transgender prisoners. He hopes Iglesias’ case will help shape bureau guidelines for future cases as it moves forward.
“One hopes this would lead to a streamlined process where their first question would be about what care someone needs as opposed to creating barriers,” he said.
Whelan, who worked on a similar case at the state level, echoed that sentiment.
“Prisons have historically fallen behind in providing the care that the medical community knows is required,” she said.
Whelan represented Adree Edmo, who as an Idaho state prisoner successfully sued for the right to have state-funded sex reassignment surgery. The state’s appeal was rejected by the U.S. Supreme Court and Edmo received the surgery in July 2020.
Previously, a California inmate in 2017 became the nation’s first prisoner to have state-funded surgery as part of a settlement there.
The decisions, Whelan said, are part of a growing pattern “of courts understanding something that the medical and mental health community has understood for decades – that there is a clear course of treatment for people who experience gender dysphoria, and that withholding that care can be extremely harmful and discriminatory.”
Protocols for transgender care have been set by the World Professional Association for Transgender Health (WPATH) and endorsed by groups such as the American Medical Association, American Psychiatric Association, American Academy of Family Physicians and World Health Organization.
Those guidelines call for individuals to live in their identified gender role for at least one continuous year before proceeding with surgery, a procedure that should be supported by their primary care provider with referrals from two mental health professionals.
Yohnka, of the ACLU, said he hopes Iglesias’ situation can offer hope for other transgender inmates seeking gender affirming surgery “that a court is paying attention to their plight and that it’s possible they will actually get the care they have long sought for their own health. It really does create an atmosphere and an opportunity for folks moving forward.”
This article originally appeared on USA TODAY: Gender affirming surgery: Federal inmate could be nation's first