Gender, Place & Culture

A Journal of Feminist Geography

ISSN: 0966-369X (Print) 1360-0524 (Online) Journal homepage: https://www.tandfonline.com/loi/cgpc20

‘I just wanted them to see me’: Intersectional

stigma and the health consequences of
segregating Black, HIV+ transwomen in prison in
the US state of Georgia

Jennifer M. Kilty

To cite this article: Jennifer M. Kilty (2020): ‘I just wanted them to see me’: Intersectional stigma
and the health consequences of segregating Black, HIV+ transwomen in prison in the US state of
Georgia, Gender, Place & Culture, DOI: 10.1080/0966369X.2020.1781795

To link to this article: https://doi.org/10.1080/0966369X.2020.1781795

Published online: 23 Jun 2020.

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GENDER, PLACE & CULTURE
https://doi.org/10.1080/0966369X.2020.1781795

‘I just wanted them to see me’: Intersectional stigma

and the health consequences of segregating Black,
HIVþ transwomen in prison in the US state
of Georgia
Jennifer M. Kilty
Department of Criminology, University of Ottawa, Ottawa, Canada

ABSTRACT ARTICLE HISTORY

This paper mobilizes the findings generated from in depth, Received 2 October 2019
in person interviews conducted with ten Black, HIVþ trans- Accepted 10 May 2020
gender women who had previously served time in local
KEYWORDS
jails and prisons in the Atlanta region of the state of
Medication disruption; HIV;
Georgia, USA. The paper explores how intersectional stigma prison; segregation; stigma;
emerges in the carceral environment in relation to the transgender
women’s multiple identity locations and the ways that HIV
and transgender stigma in particular are linked to two
harmful correctional practices. First, participants revealed
that the ‘layering’ of these different forms of stigma
resulted in institutional coercion to suppress their gender
identity and to the inappropriate use of solitary confine-
ment, both of which led to increased mental and emotional
distress during their period of incarceration as well as after
they were released from jail or prison. Second, participants
were also frequently denied access to or had irregular
access to their HIV medication and hormone replacement
therapies (HRT), which can have significant mental and
physical side effects. In carceral environments, the manifest-
ation of intersectional stigma influences how individuals
are treated by staff, where they were housed and how their
institutional time is managed; in other words, it contributes
to mapping their carceral experience.

Introduction
There is a dearth of research on how transgender prisoners experience their
conditions of confinement (Sexton, Jenness, and Sumner 2010), their treat-
ment by other prisoners and correctional staff (Rosenberg and Oswin 2015),
their access to gender affirming health care (Larsen 2008), or their know-
€mdal et al. 2019,
ledge and practices pertaining to HIV/STI transmission (Bro
3; Clark, White Hughto, and Pachankis 2017). The term transgender refers to

CONTACT Jennifer M. Kilty jkilty@uottawa.ca Department of Criminology, University of Ottawa, 120

University Private, Ottawa, ON K1N 6N5, Canada.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 J. M. KILTY

both male-to-female and female-to-male transgender people; I denote male-

to-female transgender experiences by using the terms transgender women
or trans-women. This study contributes to filling these gaps by documenting
how intersectional stigma, which I conceptualize as a metaphoric prism,
shaped how participants experienced incarceration and their conditions of
confinement. By exploring the relations between HIV and transgender stig-
mas, this article adds a critical health focus to the trans and carceral geogra-
phies literature. Revealing how intersectional stigma underpins their
mistreatment by staff, participants identified that they felt coerced to sup-
press their gender identity, were isolated in solitary confinement, and experi-
enced disruptions and denial of access to HRT (hormone replacement
therapy) and at times, HIV medications.
Transgender prisoners are disproportionately represented amongst car-
ceral populations. Lambda Legal, a national LGBTQ þ organization in the
United States, estimates that nearly one in six transgender Americans and
one in two Black transgender Americans has experienced incarceration.
Brown and McDuffie (2009, 281) suggest that while the total population of
transgender prisoners in the US is unknown,
The point prevalence of incarcerated persons (excluding municipal jails) with GID
[an individual with gender identity disorder identifies with the opposite sex and
has persistent discomfort (dysphoria) with their sex or the gender role of that sex]
in any given state’s DOC [Dept. of Corrections] may be between 2 and 400, with
the largest states (e.g., California, New York, Florida, and Texas) having the greatest
number. A reasonable estimate is that there are between 500 and 750 inmates in
custody in state facilities and possibly another 50 to 100 in federal facilities.

Notably, transgender prisoners commonly experience difficulties accessing

transition related medical care, including hormone replacement therapy, gen-
der-reassignment surgery and associated counselling (Brown 2014; Brown
and McDuffie 2009; Kirkup 2018; Smith 2014; White Hughto et al. 2018;
Vitulli 2010). According to US legal scholars, some prisoners have had suc-
cess making eighth amendment applications arguing that the stress associ-
ated with the lack of access to this form of medical care for a marginalized
and vulnerable person is a form of cruel and unusual punishment
(Agbemenu 2015; Vitulli 2010; Smith 2012). While the eighth amendment
prohibits the federal government from imposing excessive bail, excessive
fines, or cruel and unusual punishments, given that the majority of successful
cases have involved individuals who have taken extreme measures to self-
remedy their situation by way of castration, genital mutilation and suicide
(Brown 2014; Kirkup 2018; Sexton, Jenness, and Sumner 2010; Smith 2014;
Vitulli 2010) – this legal argument is flawed and potentially dangerous.
Agbemenu (2015, 3) suggests that case law is setting a dangerous precedent
that may cause harm to transgender prisoners and may ‘create[] a difficult
 GENDER, PLACE & CULTURE 3

tension between securing access to treatment and advocating for the

acceptance of transgender individuals and their gender identity’.
As Vitulli (2010, 58, 61) argues, not only does ‘this standard and the way in
which courts wield it reinforce and renaturalize trans “prisoners” as objects of
legal, carceral, and medical regimes of power’, but the self-harming behaviours
exhibited by some transgender prisoners may be viewed as ‘self-conscious
strategies to obtain the treatment they need under the extremely violent and
repressive conditions of incarceration’. These insightful legal analyses problem-
atize using eighth amendment applications to secure better care for trans-
gender prisoners because they rely on the medicalization of gender dysphoria
as a framework, which pathologizes transgender identities as a psychiatric ill-
ness in the same way that homosexuality was historically medicalized as an
abnormal sexual perversion. In this way, these eighth amendment applications
may unintentionally contribute to the stigmatization of the transgender com-
munity, which reinforces ‘an oppressive gender binary’ wherein ‘stigma and
self-denial become the necessary foundation for open and honest gender
expression while incarcerated’ (Agbemenu 2015, 29-30; Vitulli 2010).
The US Supreme Court’s Eighth Amendment jurisprudence has also demar-
cated two important rights for prisoners that are specific to HIV transmission –
the right to be protected from harm and the right to be provided with
adequate medical care – yet there are no federal regulations mandating the pro-
vision of various harm reduction technologies (e.g., condoms, dental dams, lubri-
cation, bleach, sterile injection equipment) in prison (Larsen 2008, 28).
Approximately 1.5% of adult prisoners in the US are living with HIV, which is
three times the prevalence for the general population (Kemnitz et al. 2017), and
prisoners commonly report inconsistent access to HIV medications (Larsen 2008).
I begin this article with a brief review of the literature that examines how
transgendered people experience incarceration – especially in relation to the
use of isolation and access to medical care. After outlining the methodology, I
offer a critical analysis of the main themes presented in this article. The first
theme documents how participants experienced HIV and transgender related
stigma while in prison. The second and third themes examine how these forms
of stigma are related to problematic correctional practices; namely, carceral seg-
regation and irregular and even denial of access to HRT and HIV medications.

Transgender and HIV stigma and incarceration

While contemporary carceral spaces are organized and managed based upon
the normative male-female sex binary, which fails to consider the materiality
of gender performativity and expression (Agbemenu 2015; Smith 2014;
Sumner and Sexton 2016; Vitulli 2010), historically men and women were
housed in separate accommodations in the same facility (Kirkup 2018; Kunzel
4 J. M. KILTY

2008). Carceral spaces are highly gendered – at times, in harmful ways. For
example, transgender prisoners commonly experience secondary punishment
from correctional staff if they fail to adhere to heteronormative expressions
of sexuality and/or gender (Agbemenu 2015; Brown 2014; Jenness and
Fenstermaker 2014; Sumner and Sexton 2016; White Hughto et al. 2018) and
transgender women are especially at risk of potential physical and sexual vic-
timization by staff and other prisoners when housed in men’s institutions
(Grant et al. 2011; Sexton, Jenness, and Sumner 2010; White Hughto et al.
2018; Vitulli 2010).
Reflecting the transgender stigma that structures carceral policies and
practices, transgender women report experiencing institutional forms of gen-
der regulation, such as being forced to cut their nails and hair (Rosenberg
and Oswin 2015; Smith 2014), being prohibited from shaving and wearing
makeup, bras or feminine underwear (Rosenberg and Oswin 2015; Smith
2014), and being denied access to hormone replacement therapy (HRT),
which has been found to lead to depression and emotional instability
(McCauley et al. 2018; White Hughto et al. 2018). Failing to restrict one’s fem-
inine self-presentation also commonly results in disciplinary charges (Kirkup
2018; Rosenberg and Oswin 2015; Smith 2014).
These findings reflect the hypermasculine culture of the prison environ-
ment and the social hierarchies amongst both staff and prisoners regarding
appropriate gender performatives that increase the likelihood of negative
attitudes towards and even victimization of transgender individuals (Stohr
2015). This elevated risk of victimization is commonly used as a rationale by
correctional staff to discourage prisoners from expressing their transgender
identity in the name of safety, which has deleterious effects on their mental
health (Clark, White Hughto, and Pachankis 2017, 86; Stohr 2015; Vitulli
2010). Research also demonstrates that not only do transgender prisoners
have an elevated risk of experiencing physical and sexual violence while
incarcerated in comparison to cisgender prisoners (Brown 2014; McCauley
et al. 2018; Stohr 2015; Sumner and Sexton 2016), but that when combined
with the lack of consistent access to harm reduction technologies, this leads
to elevated risks for contracting a sexually transmitted infection – including
HIV (Grant et al. 2011; Larsen 2008; Sexton, Jenness, and Sumner 2010).
While the Prison Rape Elimination Act (PREA) of 2003 requires that staff
have appropriate training concerning transgender prisoners with respect to
communication methods, as well as on how to conduct a pat-down and
search in a professional, respectful, and the least intrusive manner possible –
including the prohibition of genital searches to determine biological sex
(Malkin and DeJong 2019; Stohr 2015), this kind of training has been shown
to be rare (Brown and McDuffie 2009; Clark, White Hughto, and Pachankis
2017; Sexton, Jenness, and Sumner 2010; White Hughto et al. 2018). Their
 GENDER, PLACE & CULTURE 5

general lack of knowledge or understanding of transgender health concerns

has resulted in inconsistent access to or denial of medications and medical
care (Brown and McDuffie 2009; Grant et al. 2011; White Hughto et al. 2018),
forms of discrimination that can lead to undue health concerns and compli-
cations (Clark, White Hughto, and Pachankis 2017; McCauley et al. 2018;
Stohr 2015). In a qualitative study investigating the perspective of correc-
tional healthcare providers regarding their care of transgender prisoners,
Clark, White Hughto, and Pachankis (2017) found that stigma detrimentally
affects health care on three levels: structural barriers to the provision of care
(i.e., limited training, restrictive health care policies, limited budget, and
oppressive culture regarding safety and security); interpersonal barriers to
the provision of care (i.e., custody staff biases); and individual barriers to the
provision of care (i.e., lack of cultural and clinical competencies).
Transgender prisoners are more likely to be living with HIV (Reisner,
Bailey, and Sevelius 2014; Sevelius and Jenness 2017) and HIV stigma has
been linked to lower motivation to seek health care, avoidance of HIV serv-
ices, and substance use (Kemnitz et al. 2017; Parker and Aggleton 2003;
Sexton, Jenness, and Sumner 2010). Individuals who are located at the inter-
section of multiple points of marginality based on their gender identity, race,
class, sexuality, and ability (among others) are more likely to experience
incarceration, violence, and difficulty accessing transition-related medical
care (Brown 2014; Brown and McDuffie 2009; Jenness and Fenstermaker
2014; Sexton, Jenness, and Sumner 2010; White Hughto et al. 2018; Vitulli
2010). One study found that only 16 out of the 26 US states surveyed had
explicit policies that would allow transgender individuals to continue HRT
once incarcerated and only four states had policies that would permit trans-
gender prisoners to initiate HRT while incarcerated (Brown and McDuffie
2009). A US survey of 27,715 transgender people found that 37 percent of
the 321 participants who had been incarcerated in the last year were prohib-
ited from continuing to take hormones while incarcerated (James
et al. 2016).
Reflecting the harmful impact of class bias in correctional transgender pol-
icy decision-making, the highly restrictive demands for HRT documentation
prior to entering the prison is especially challenging for those who are
unstably housed, who lack social support in the community, and/or who are
taking street hormones – which are not recognized by correctional policy
(McCauley et al. 2018; Sexton, Jenness, and Sumner 2010; White Hughto
et al. 2018, 75). Transgender prisoners have reported that not only do they
have inadequate access to HRT while incarcerated, but that correctional staff
regularly prioritized the provision of other medications (including both HIV
medications and psychotropic medications) over the provision of hormones,
which they felt indicated that the operating correctional view was that HRT
6 J. M. KILTY

lacks a significant health benefit (White Hughto et al. 2018). Transgender

prisoners have also indicated that some health care providers,
used the threat of gender-based violence by inmates and staff as a rationale for
withholding transgender women’s access to hormones … Correctional institutions
are tasked with ensuring the safety of inmates; thus, the femininity of transgender
women in male facilities poses challenges for the institution, challenges that
providers often play a role in managing (White Hughto et al. 2018, 76).

Given that incarcerated populations are disproportionately racialized, with

elevated numbers of Black, Hispanic and Indigenous peoples detained in
American prisons (Bronson and Carson 2019), it is important to consider how
race may intensify stigma and thus the distinct material experiences of racial-
ized transgender people housed inside carceral spaces (Sumner and Sexton
2016; Vitulli 2010). Rosenberg and Oswin (2015, 1272) examined the intersec-
tional manifestations (i.e. race, class, gender, sexuality) of the embodied
experiences of transgender prisoners. Adding HIV as an embodied identity
marker to their framework, this article examines how these social locations
coalesce to create layers of stigma that contribute to conditions of extra-
punitive marginality for incarcerated transwomen.

Methodology
This research was designed to provide a small American comparison to a
national research project in Canada that investigated the views of frontline
workers in AIDS Service Organizations (ASOs) on the criminalization of HIV
nondisclosure and the ways in which this legal approach to managing a
public health concern was affecting their service work. The comparative pro-
ject was situated in the geographic region of Atlanta, Georgia and funded by
a Fulbright Research Chair position for the 2016–2017 year. While the com-
parative aspect of the broader research project involved interviewing staff
who work in community-based HIV/AIDS care (using the same interview
guide designed for the Canadian study), the US based project also expanded
the goals of the initial Canadian study to include interviews with people liv-
ing with HIV (PLWH) so as to better understand how criminalization and
incarceration impacts their health experiences and access to care
and medication.
After receiving ethics approval from my home university’s REB, I relocated
to Atlanta, Georgia to begin the research in January 2017. I contacted the
Executive Directors (EDs) of ASOs located in and around the Atlanta region
and used snowball sampling to identify local community health centres from
which to recruit participants; the EDs forwarded an information sheet to
staff, who emailed the researcher directly to indicate their interest in partici-
pating and assisted in recruiting HIV positive service users. While I also
 GENDER, PLACE & CULTURE 7

conducted thirteen semi-structured interviews with ASO staff members for

the larger project, in order to prioritize the lived experiences of transgender
people, this paper mobilizes the data gleaned from the interviews conducted
with ten HIV positive ASO service users. Each of these ten participants had
experienced criminalization and had been incarcerated for at least one
month within the last five years. It was not a requirement for this group of
participants to have experienced criminalization and imprisonment for HIV
nondisclosure. After securing written informed consent, participants were
asked questions pertaining to: their personal experiences of criminalization
and imprisonment; the kinds of stigma they experienced; their gender iden-
tity and its impact on their carceral experience and access to medication
while incarcerated. Interviews were digitally recorded and transcribed verba-
tim and participants were given 35$USD for their participation in the one-
hour interview. Notably, these ten participants were all recruited from the
same community-based ASO and all self-identified as Black, HIV positive,
transgender women. The analysis revealed this intersectional identity loca-
tion to be a central factor shaping the participants’ experiences in relation to
the themes discussed in this paper.
The data were analyzed using a constant comparative approach to the-
matic analysis (Braun and Clarke 2006). First, I read the transcripts to better
understand the broader content of the data. Second, I generated codes to
describe the participants’ statements. Using an Excel file allowed me to track
saturation of codes (horizontal axis) across participants (vertical axis). Third, I
refined and combined the codes to identify the three themes discussed
herein: (a) intersectional stigma (which I further subdivide into HIV and trans-
gender stigma); (b) carceral isolation practices; and (c) the impact of incarcer-
ation on access to medications. Fourth, I reviewed the transcripts again to
ensure that the themes accurately reflected participants’ responses and
searched for discrepant cases, finding none. Fifth, I named and defined each
theme after establishing its nature and scope. Sixth, I selected quotes that
best reflected each point made in relation to each theme.

Intersectional stigma
Goffman (1963, 3) defined stigma is ‘an attribute that links a person to an
undesirable stereotype, leading other people to reduce the bearer from a
whole and usual person to a tainted, discounted one’. In this section I out-
line how participants experienced two forms of stigma – namely, that related
to their HIV positive serostatus and to being transgender – while they were
incarcerated.
8 J. M. KILTY

HIV stigma
Building on Goffman’s (1963) seminal work on stigma, Parker and Aggleton
(2003) conceptualized HIV related stigma as both a manifestation and a
driver of social inequality, arguing that it operates as a structural barrier that
leads to health disparities and negative health outcomes for PLWH. HIV
stigma operates across the personal, social, and structural levels and has
been found to negatively influence the health of incarcerated and formerly
incarcerated people. Notably, transgender women in the US are one of the
highest risk groups for HIV, with Black transgender women being dispropor-
tionately affected (Salazar et al. 2017). All ten participants expressed con-
cerns about the stigma they felt and experienced in relation to their HIV
positive serostatus. Speaking about her feelings when she was first diag-
nosed, Cora stated:
I was withdrawn, I didn’t want anybody around me, I didn’t want to talk to
anybody. I sat in a dark room every day in my apartment, for months, crying,
asking God to take this away, why did this happen to me? You go through all
kinds of crazy emotions. (Cora)

Elaine was similarly passionate when speaking about how HIV stigma affects
her daily life, including how friends and family relate to you due to the
unfounded fears they have about contracting the virus.
Yeah, they treated people like they were dirty. Like, child, please, my family look at
me like I go, I can eat, some people you can’t even go to your people’s house. You
got to eat out of a paper plate. I be like, bitch, please! I’d throw that shit on the
floor and walk away. Uh-huh, be like, this ain’t that, because you can’t contract
nothing just by off of a damn spoon or drinking out of a glass, or giving them a
kiss. You know? (Elaine)

Participants also described the ‘stickiness’ of stigmatic attributes (Goffman

1963) when expressing the problematic narrative connection people make
between race, sexuality and HIV, where one identity location is thought to
be inherently connected to the others.
When I was told I had HIV, back then people were so ignorant about it, they
thought, oh, because you’re gay you got it, or you Black, you got it. (Vera)

Vera’s point that we make connections between different identity markers,

especially those that reflect marginal positionalities, is particularly telling of
how stigma can operate at the intersection of multiple identity locations so
as to create multiple sources of oppression. In this way, stigmatic attributes
layer upon one another to reproduce different degrees of marginality.
While incarcerated, participants reported that their treatment by some cor-
rectional staff members was degrading, which they linked to their HIV
seropositivity.
 GENDER, PLACE & CULTURE 9

As far as, you know, the virus, we were treated like we were disgusting … They
[correctional guards] can see you coming up to the medical cart and they can see
who’s positive and who’s not. So, you know, it’s, that was kind of, that there made
me feel very uncomfortable. Because of the way they taunted me in jail, I can
imagine what they would do to me out in the street. (Helen)

While medical information is confidential, when kept as part of the person’s

electronic file various correctional authorities have access to it. Moreover, as
Helen points out, by dispensing medication in a public space anyone in the
vicinity may hear what type of medication you are taking and be able to
deduce what condition you may be suffering from. The next section exam-
ines how participants spoke about experiencing stigma related to their iden-
tities as transgender women.

Transgender stigma
Given that prison settings are segregated according to the normative male-
female sex binary, they are ‘ripe for the production and reification of trans-
gender stigma’ (White Hughto et al. 2018, 80). As Rosenberg and Oswin
(2015, 1278) contend:
the (dis)embodying effects of carceral masculine space are paradoxical, as trans
feminine individuals … experience hyperattention to their bodies. Because the
violence they experience is often attributed to their transness, their bodies are
reinscribed into the prison space as something that cannot be unnoticed or
unseen. Attempts to quell trans feminine embodiment pull invisibilized bodies back
into the prison walls, where they undergo the pull and push between seen and
unseen. (1278)

As trans-bodies experience ‘hyperattention’ in carceral spaces, the fact that

transgender women continue to express their gender identity in such a hos-
tile and oppressive environment is a testament to the pursuit of ‘a femininity
that achieves the real deal in order to manage the inevitable disrespect and
violence heaped upon the feminine’ (Jenness and Fenstermaker 2014, 27).
Given the heteronormative and hypermasculine nature of this environment,
‘trans bodies in prison become complex sites of negotiation, within which
circulate emotions, transitions, expressions, and (in)securities’ (Rosenberg and
Oswin 2015, 1278). One such insecurity emerges as a result of conflating
being transgender with other identity categories in ways that can lead to
deeply problematic assumptions about the individual and that may have
dangerous unintended consequences. As Sumner and Sexton (2016,
630) contend:
In occupying a position on the outskirts of mainstream inmate culture, transgender
prisoners joined “homosexual inmates”—with whom they were frequently conflated—
and other social undesirables, including many types of sex offenders (“pedophiles,”
“molesters,” and “rapists” among them), mentally ill prisoners, and snitches.
10 J. M. KILTY

Illustrating how trans-stigma permeates correctional practice, these types of

misperceptions can lead to victimization and isolation in carceral segrega-
tion. While the interview questions examined how participants experienced
stigma while incarcerated, they were also keen to discuss the stigmatic reac-
tions they faced in relation to being trans and HIV positive more broadly. In
fact, all ten participants described the common social reactions they endure
when people realize or suspect they are transgender, effectively illustrating
that transgender stigma permeates the daily lives of transgender people,
regardless of whether or not they are incarcerated.
I back away from the conversation at that point. The fear of what they may try to
do, and the fear of what I’m going to do if they try to do something, you know?
You’re ridiculed, you know, every day, all day, if you are not quite passable. (Cora)

You don’t need to tell nobody online … you need to be mindful. I’m always in an
open space, in the daytime, where I can see and meet with you and know how
you’re going to react. If you start looking the other way, rolling your eyes,
smacking your lips, that’s a bad vibe with me, so I don’t even go around
you. (Dana)

Both Cora’s and Dana’s statements describe the fear of potential victimiza-
tion that transwomen commonly experience, which is particularly telling of
the affective impact that trans-stigma can have on an individual’s daily life.
Even more pertinent for this paper, the following three quotes illustrate how
HIV and transgender stigmas are connected – or layered – where being
transgender leads to presumptions about HIV seropositivity.
I sit sometimes on buses and trains, and I hear people, and they say, oh, those
crazy, you know, boys that wanna be girls and all that kind of stuff, you know, it’s
crazy and they’re the reason that HIV is here, and it’s so wild and rampant and
everything and stuff. Maybe you should learn about HIV and transgender people
before you just make an irrational decision to hate someone. Because how do you
hate someone that you don’t even know? (Cora)
The reason why I find it difficult is because people are so judgmental. First thing
they’ll judge is that I’m trans. They already think that you have some kind of
sexually transmitted disease. And then the whole way of them thinking and doing
and reacting towards me, sometimes it changes. (Annie)
Yeah, so we have two stigmas. Being that we’re not supposed to be who we are
identity-wise and plus you have this disease, not disease, virus. That’s your life;
when you identify or you come out as a trans woman, this is who you are, HIV and
AIDS. (Dana)

The intersectional stigma that coalesces in relation to race, transgenderism

and HIV seropositivity can lead to both transphobia and a lack of knowledge
about transgendered people’s needs, which have in turn been linked to
negative interactions between patients or service users and care providers.
These negative interactions are aggravated in carceral settings and create ‘a
 GENDER, PLACE & CULTURE 11

sense of uneasiness in an already oppressive institutional setting’ (White

Hughto et al. 2018, 77). This was especially the case when participants were
housed in what are commonly referred to as ‘alternative dorms’ – what
Kunzel (2008) has referred to as ‘daddy tanks’ – carceral spaces dedicated to
segregated housing for LGBTQ þ prisoners under the guise of providing
them with safety and security.
When it comes to the alternative dorm in Fulton County, they don’t give a shit
about us in there, they really don’t. You’re liable to get more treatment being on a
life sentence than you would in the alternative dorm. You’d be better off trying to
mask yourself up if you’re, you know, if you’re a male, to get down with the
straight men, in order to get better treatment. Because they don’t give a shit. It
was degrading, it was disgusting, I wouldn’t recommend my worst enemy to go to
jail. It was horrible. My mental state wasn’t good. I had to go on suicide watch
maybe two or three times. (Helen)

The use of an alternative dorm for trans-prisoners is a common practice

(Kunzel 2008) and while correctional staff claim it is for their protection, it
showcases how non-normative gender expression continues to be marginal-
ized and suppressed in carceral spaces. Similarly, the regular act of being
addressed in mis-gendered ways by correctional staff, including health care
providers, ‘reinforces the gender binary by forcing her to embrace a male
gender identity as a form of conversion therapy’ (White Hughto et al. 2018,
77). Cora described another way that trans-prisoners are denigrated
in prison:
The guards were just cruel. As soon as our hair would grow out they would take us
down and strap us in a chair and put crazy haircuts on our heads or shave one
side off and leave the other side. It was cruel. I guess, what they were trying to do,
was to break us from actually being who we were and everything. Because they
didn’t want us to live. (Cora)

When asked if they had had negative experiences with different authority
figures due to being trans, all ten participants responded in the affirmative.
For example, Ivy stated:
Uh, yes I have. I’ve very much have, not only with police officers and guards. With
the ambulance people too, you know. They can be real shady, you know, just the
attitude or the smirks, the smart comments or the whispers – that aggravates me.
But if I’m going to the hospital, you shouldn’t have to … that’s the last thing that
you should be worried about. And that’s what made me like snap a couple of
times I’ve been to the hospital because it’s supposed to be more professional than
that. That’s the same thing with the police. (Ivy)

Ivy’s quote showcases how transgender stigma can lead to mistreatment by

correctional and medical authorities. As White Hughto et al. (2018, 78) con-
tend, transgender stigma contributes to the view that a trans identity ‘is
viewed as a problem or “risk” that correctional institutions must manage’.
12 J. M. KILTY

One mechanism that correctional authorities invoke in order to manage the

risks that transgender people and PLWH are seen to pose to the correctional
environment as well as the potential risks to their safety and security is the
use of segregation.

Carceral isolation practices

It is common for transgender prisoners to be held in solitary confinement.
Rosenberg and Oswin (2015, 1276) found that twenty-two of their twenty-
three participants reported that they had been isolated at some point during
their incarceration, ‘for time periods ranging from 14 days to indefinitely, and
often multiple times’ and many reported being ridiculed and even physically
and sexually assaulted by staff . Correctional administrators claim to isolate
transwomen in solitary confinement to protect them from harm (Smith 2012)
yet house them in men’s prisons to protect cisgender women from harm.
Smith (2014, 159) maintains that ‘to associate pre-operative transgender
women with male violence is to erase the identity and the uniqueness of
these people as individuals and instead define them by anatomy and all that
is associated with this anatomy’. PREA prohibits isolating prisoners on the
basis of gender identity or because they are at a high risk of sexual victim-
ization (Stohr 2015), unless there are no other alternatives available; when
used as a last resort, PREA also stipulates that the prisoner cannot be held in
segregation for more than 24 hours. Yet, in their review of state policies,
Malkin and DeJong (2019, 5) found that only ‘half of the states protected
against having LGBT-designated units or facilities’ and only ten states have
correctional policies that protect transgender prisoners against segregated
housing. Georgia was listed as having a case-by-case housing policy for
transgender prisoners as well as a policy prohibiting isolation in line with
PREA dictums.
As I have argued elsewhere (Kilty 2018), carceral isolation practices render
the segregated prisoner simultaneously disappeared yet hyper-visible – alone
but always visible to staff who watch them on CCTV cameras. Seven of the
ten participants spent time in solitary confinement while incarcerated; Nina
attributed her segregation to HIV stigma:
I know I was disrespected. They gave me my medication when they wanted to give
me my medication, because in that particular part, I was in H part in prison and
pretty much everybody there had to sit with the virus or other health issues.

Although HIV is now considered a chronic but manageable condition, Nina’s

statement illustrates how fear of HIV can lead us to ‘punish disease’
(Hoppe 2018).
Participants spoke more frequently to being isolated in response to being
transgender than to being HIV positive. Given how participants described
 GENDER, PLACE & CULTURE 13

their experiences of people making assumptions about the inherent connec-

tions between different identity locations – for example, where being trans
leads to the assumption that one is also HIV positive – I would argue that
HIV and transgender stigma are mutually reinforcing. It is worth quoting
Cora and Annie at length as they spoke about their time in solitary confine-
ment and how it impacted them.
At first, I was thrown in a cell and I was left there for days. And then they came
around and took me to another part of the facility and they ran all these tests and
once all the results came back they again put me in a single person cell and I was
there for maybe eight months before they brought me to where they stored
people who were HIV positive. It was really strict. We could not touch, or anything
like that. What they told me and my attorney was, the reasoning behind it was to
prepare me for going into the general population with people who were like me,
walk like me, talk like me, you know, and for protection from the other guys in
general population, learning and then maybe doing some bodily harm to me. But
for me, it was just crazy that I spent eight months alone. I saw an officer twice a
day and that was for feeding and nothing else. Just the bed and the toilet. I
couldn’t go to commissary or anything like that, to buy hygiene products or
anything. I showered once a week, if I’m not mistaken. And I got maybe two hours
of freedom from the solitary confinement where I went out on the yard and I could
walk around. The first eight months, yes. I was completely alone. (Cora)

Yes, to be isolated like that. I was being isolated because of me being trans; they
were saying they were concerned about my safety. But I was thinking that they
was more concerned of my, just being, well, you’re a trannie, whatever, you have
boobs, and you know what I’m saying, and guys wanna be looking at you in the
shower and we don’t want a problem. So, I just felt like I was being discriminated
against. (Annie)

Cora explains how transgender and HIV positive prisoners are often segre-
gated together in what Helen, above, referred to as the alternative dorm,
illustrating how these two identity locations are commonly conflated. I also
wish to problematize the notion that segregating transgender prisoners is
necessary for their safety. While there is certainly truth to that claim, we
must recognize that it also breathes life into dated rape myths that position
men, writ large, as incapable of controlling themselves sexually and that
blame women for their assaults because of the clothes that they were wear-
ing, or in this case, because of their very bodies. Education and training
about transgender issues for both correctional staff and prisoners is a neces-
sary first step in working toward desegregating transgender prisoners.
When I asked the participants about how being segregated affected them
mentally and emotionally, they expressed that it made it more difficult upon
their release from prison and that they found it hard to be around people,
including friends and family. Many described feeling anxious, depressed and
feeling extra-sensitive to light and sound.
14 J. M. KILTY

It scarred me because it gave me so much time to think about what I was going
through, just having the four walls you know, the darkness and everything, it just
kept repeating the same thing and I slipped into kind of a depression, where I’m
now still taking Trazadone for it, you know, just to keep me stable. And that is why
I still continue seeing my counselor too. And for a long time, even coming home, I
just didn’t want to be around people. You know, because I had been alone for so
long. (Elaine)

It drove me crazy. I was always crying. And I was just like begging for someone to
help me. I just wanted them to see me. That I wasn’t dangerous and that I needed
to be out of the hole. Yeah and I wanted to kill myself because it is like, oh my
God, I don’t want to be here already, and I’m isolated and all I see is a door and
walls, you know? I didn’t get much sleep. I woke up in the middle of night and I
just had to physically lay there, or I would get up and pace back and forth. (Ileana)
It was horrible, because you come out to take a shower once a week, once a day
when you do come out, you cannot make no phone call, couldn’t do nothing. I
was crying a lot.
It was like I shut down. Didn’t want to be bothered, didn’t want to be talked to.
Don’t say anything to me, get out of my face. Yeah, went into a nutshell. (Nina)

It is well documented that time spent in solitary confinement can lead to

serious detrimental effects on mental health and even brain atrophy (Kilty
2018; Haney 2003). The emotional toll of isolation that the participants
described is a concrete example of the harmful impact that intersectional
stigma can have on vulnerable people in this environment. The next section
outlines how intersectional stigma can also lead to harmful medical practices
– in this case – medications denial or disruption.

Medications denial and disruption

Erni (2013) contends that the all too frequent interruption and denial of hor-
mone replacement therapy medications to transgender prisoners is part and
parcel of the structural stigma and discrimination that this group experiences
and which exemplifies a form of state legitimation of transphobia and trans-
phobic carceral practices. Intermittent access to HRT medications can have
deleterious mental and physical health outcomes for transgender people
(Erni 2013; Grant et al. 2011; McCauley et al. 2018; Sevelius and Jenness
2017; Reisner, Bailey, and Sevelius 2014). When transgender individuals
experience a disruption in or denial of hormone therapies it can result in
‘hot flashes, dizziness, anxiety, suicidality, desire to engage in self-castration
and other mental health effects that can have dire physical consequences’
(Sevelius and Jenness 2017, 35-36).
Similarly, for people living with HIV, longitudinal research demonstrates that
intermittent anti-retroviral treatment (ART) causes a loss of CD4 cells over time
and is linked to viral load blips, which means periodic episodes of having a
 GENDER, PLACE & CULTURE 15

higher viral load (VL) – the number of copies of HIV per ml of blood (Pant Pai
et al. 2009). When this occurs, it illustrates a distinct loss in the beneficial
effects of ART compared to those individuals who are able to maintain a con-
tinuous ART regimen (Kemnitz et al. 2017; Larsen 2008; Pant Pai et al. 2009).
While intermittent ART is more beneficial than no ART, it is important to con-
sider the deleterious effects of intermittent therapy and the dangerous possi-
bility of developing treatment resistance (Pant Pai et al. 2009, 5).
When asked if they had consistent access to their HIV and HRT medica-
tions while incarcerated only two of the ten the participants responded in
the affirmative. The other eight participants reported either disruptions to
their medication regimens or outright denial of access to their medications.
The harmful physical side effects of experiencing disruptions to your HIV
medications adherence can be particularly severe, as several of the partici-
pants attested.
I suppose because it was too expensive they just would not opt into giving us our
meds. And like if we got a cold, or you know, everything like that and stuff, we
really didn’t get anything. You laid in your bed and you fought it off, no matter
how long it took, you know, with your body. But I got PCP pneumonia and it bore
three holes in the both sides of my lungs. So fluids was entering and I passed out
and that’s how I ended up in Grady and I stayed in Grady for seven and a half
months and that is where I learned I had zero T-cells, uhm, it was difficult for them
to treat me. (Cora)

Some participants, like Nina, suggested that there was a difference in terms
of access to their medications between their experiences in the local jail and
the prison. Both she and Helen also pointed out that when they did have
access to medications, they were often a different brand than they were tak-
ing in the community.
Not in jail, when I went to prison they [HRT medication] stopped. I had to start all
over, like I’ve been doing it two years now and everything’s coming along and I
was in there six months or three months, and I went back to a flat chest. When I
went to prison, the county said all of my medicine would come, but once we got
over to the prison, they took them. I didn’t get my heart medication, I didn’t get
my HIV medication like I was supposed to. They wanted me to do their medication.
But I’m not going to be a guinea pig for you. Cause I didn’t know what they were
giving me. (Nina)

Sometimes your medication gets messed up, you might not be taking the same
thing that you might be taking out on the street. You may be taking something
totally different. For myself, I take Truvada. I might not be getting Truvada, in jail. I
might be getting something totally different in jail. (Helen)

It is not uncommon for correctional authorities to change medications based

on what brands they have on their accepted prescription formularies, which
prisoners have identified as disruptive, stressful and as impeding their ability
to cope with the additional strain of criminalization and incarceration (Kilty
16 J. M. KILTY

2012). For example, Ivy spoke to the stress that having your medications
changed can have on the T cell counts of individuals living with HIV.
It just angered me. I mean, if you’re stressing about something when you’re in jail
and you can’t handle it, that just makes it worse. You’re worrying and that’s not
good when you’re HIV positive. Worrying can drop your T cells, yeah I’ve seen a lot
of girls go out like that, worrying. You can’t do all that. It’s your life. (Ivy)

In addition to the physical repercussions, participants like Ivy expressed that

they experienced additional stress and mental distress when their access to
HIV and/or HRT medications was disrupted or denied.

Conclusion
The voices of the participants in this study have much to teach us about the
spatialization of stigma. We may conceptualize the notion of intersectional
stigma as a kind of prism, which, in optics, is a transparent element with flat,
polished surfaces that refract light. Here, we may theorize each identity loca-
tion as a site through which stigma may be refracted. As these sites inter-
sect, the stigma that is refracted becomes layered – subsequently
aggravating the potentiality for forms of disadvantage and marginalization
to occur across different fields and to varying degrees. For example, it is
well-documented that gender-based discrimination is aggravated by both
race and class (Reisner, Bailey, and Sevelius 2014; Sexton, Jenness, and
Sumner 2010; Sumner and Sexton 2016; Vitulli 2010). In this way, Black,
transgender PLWH experience layers of stigma in relation to their various
social identity locations. In carceral environments, the manifestation of inter-
sectional stigma influences how this population was treated by staff, where
they were housed and how their institutional time was managed; in other
words, it contributed to mapping their carceral experience.
Findings from this research echo those of earlier studies and sadly demon-
strate the extent to which intersectional stigma leads to physical and mental
harm for incarcerated transgender individuals living with HIV. The carceral
environment, already a space prone to abuses of power, acts like a pressure
cooker that materializes physical and emotional forms of violence upon the
bodies and minds of transgender and HIV positive prisoners. As the partici-
pant narratives attest, emotional violence flows from isolation in solitary con-
finement and/or the use of alternative dorms for LGBTQ þ people and PLWH
as well as mistreatment by staff, who were found to taunt trans-prisoners
(e.g., using male rather than female pronouns) and to coerce them to sup-
press their gender identity. Physical violence occurred by way of isolation,
medication disruption and denial and by the methods staff used to force the
suppression of gender identity, including cutting some of the women’s hair
and nails without their consent. While used as an administrative mechanism
 GENDER, PLACE & CULTURE 17

to try to prevent violence and HIV transmission (Kunzel 2008; Rosenberg and
Oswin 2015; Smith 2012, 700), participants experienced carceral segregation
and interruptions in their access to HRT and/or HIV medications as forms
of punishment.
Despite the negative health and mental health consequences of restricting
transgender people’s access to HRT and HIV medications, restrictive policies
and practices continue to persist in US jails and prisons. Similar to earlier
findings, this research exemplifies how ‘restrictive policies and a culture of
transphobia guided the delivery of care and shaped the healthcare experien-
ces of transgender [and HIV positive] women while incarcerated’ (White
Hughto et al. 2018, 81). For example, participants in the present study like-
wise reported disruptions, delays, and even medications access denial (for
both HIV and HRT), negative attitudes from correctional staff and health care
providers, dismissive comments regarding the importance of maintaining
continuous access HRT, and the ‘prioritization of other medications deemed
to be more medically necessary than hormones (e.g. mood stabilizing medi-
cations, HIV medications)’ that have been reported by other researchers
(White Hughto et al. 2018, 81). While some health care providers claim to
deny HRT as a way to try to prevent gender-based violence, medication
delay and denial is ‘a form of symbolic violence (Valentine 2007), with dire
health implications’ (White Hughto et al. 2018, 81). This research contributes
to the trans and carceral geographies literature and adds a critical health
focus in order to examine the intersection of HIV and transgender stigmas.
While the theoretical implications of this work are important, I conclude with
a short description of the policy implications of this study in order to outline
practical suggestions that would improve the health, safety, and quality of
life for transgender and HIV positive prisoners.
In order to help curb transgender and HIV stigma and discrimination it is
essential to significantly improve correctional staff members and health care
providers knowledge about HIV and transgenderism. Mandatory transgender
and HIV 101 education classes and sensitivity training would help to build
cultural and clinical competence (Clark, White Hughto, and Pachankis 2017).
Sevelius and Jenness (2017, 37-38) outline a series of policy recommenda-
tions that correctional facilities should uniformly adopt in order to prioritize
and protect the health and safety of transgender prisoners, that this research
evidences support for, including: using the name and pronoun preferences
of the individual; determining housing assignments on a case-by-case basis
so as to assess preferences, safety needs, and histories of victimization; pro-
hibiting the use of involuntary segregation; ensuring private bathroom and
shower facility use; provision of undergarments and hygiene products that
correspond with the individual’s gender identity; prohibiting pat-down and
strip searches to determine biological sex; and access to HRT regardless of
18 J. M. KILTY

whether the individual was receiving treatment prior to incarceration. As

White Hughto et al. 2018, 82) contend,
Hormone therapy is a low-cost intervention (e.g. generic estrogen pills cost less
than $15 per month (Consumer Reports, 2008) and therefore unlikely to place a
large burden on correctional budgets … current policies that restrict hormone use
in the absence of proper documentation represent structural forms of transgender
stigma and must be changed.

These types of changes to policy and standard operating procedures can help
to improve the emotional and mental health of transgender and HIV positive
prisoners. Moreover, future research should strive to document the content of
correctional healthcare policies that involve HIV positive and transgender prison-
ers to identify progressive and discriminatory practices currently in operation in
prisons and jails across the country. Researchers should also prioritize conducting
qualitative interviews with staff to better understand how they enforce biased
and discriminatory practices. To conclude, I end this paper with a quote from
Dana, who communicated how remembering that we have a common shared
humanity should help counter transphobia, stigma and prejudice.
We are not demons. We are not Anti-Christ. We are human just like you, we just
happen to love who we love. And identify how we identify. That’s why we are
LGBTQ, we have different identities, we have different preferences. We have
diversity. We’re not the same people, and that’s what people don’t understand. We
are people too. We are human. I bleed just like you. I cry just like you. I smile just
like you. I do all of these things that say that I am human. And me personally, I
demand that I be treated as human. (Dana)

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This research was funded by a 2016-2017 Fulbright Research Chair at Kennesaw State
University, Georgia USA.

Notes on contributor
Jennifer M. Kilty is Associate Professor in the Department of Criminology, University of
Ottawa. Author of numerous articles and book chapters, her edited and authored books
include: Demarginalizing Voices: Commitment, Emotion and Action in Qualitative Research
(2014, UBC Press), Within the Confines: Women and the Law in Canada (2014, Women’s
Press), Containing Madness: Gender and ‘Psy’ in Institutional Contexts (2018, Palgrave), and
the Enigma of a Violent Woman: A Critical Examination of the Case of Karla Homolka
(2016, Routledge).
 GENDER, PLACE & CULTURE 19

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