Maddilyn Marcum is proud to say she was likely among the first transgender women incarcerated in Kentucky to receive hormone replacement therapy (HRT), health care that the 36-year-old says helps alleviate the gender dysphoria she experiences while incarcerated at Northpoint Training Center. 

But Marcum may soon be denied this critical, gender-affirming care. 

Republican lawmakers in Kentucky recently introduced two bills targeting incarcerated trans people. SB 2, introduced by Senate Majority Whip Mike Wilson, bans the use of hormone therapy and other forms of gender-affirming care in state prisons. The bill passed the Senate and now awaits a committee hearing in the House. 

HB 5, introduced by Rep. Kim Moser, requires all jails, prisons, and juvenile detention centers in Kentucky to house incarcerated people according to their sex assigned at birth. While SB 2 seeks to ban the use of hormone therapy completely, HB 5 has an exception that purports to allow trans people to continue treatment if they underwent hormone therapy upon admission to a correctional facility and if “physical harm would result from its discontinuation.” However, health care exceptions—like those carved out in abortion bans—are often designed to be unworkable. Ultimately, SB 2 would still require the eventual discontinuation of HRT.

Marcum told Prism that a recent article in a women’s health magazine taught her about the five Ps of mental performance—positive, present tense, personal, powerful, and pointed—and that this approach defines how she responds to the political landscape that shapes the health care she has access to.  

“This is all that is keeping me grounded right now,” she said. “Whenever I look at myself in the mirror, I do my best to be uplifted and empowered by remaining positive. I am somebody, and I matter.”

Politically motivated bills 

Like many of the anti-trans bills sweeping the nation, Kentucky’s bills attack a small and already vulnerable population. Trans people make up a tiny percentage of the incarcerated population. Of the nearly 13,000 people currently in Kentucky Department of Corrections (KYDOC) custody, 67—or 0.5% of the total incarcerated population—receive prescription hormone therapy for gender dysphoria, the Lexington Herald Leader reported. More broadly, there are currently fewer than 1,600 trans women and about 700 trans men in federal prisons nationwide, where more than 150,000 people are incarcerated. 

Kentucky’s bills also appear politically motivated, written to imply incarcerated trans people currently receive considerations and services they do not. SB 2, for example, bans the use of public funds for gender-affirming surgery. However, KYDOC and the state’s own government officials confirm that funds are not used in this manner. “I don’t want to parse words: no gender-affirming surgery has happened, did happen or will happen,” said Leah Boggs, general counsel for the Justice and Public Safety Cabinet, to the state’s Government Contract Review Committee during a meeting earlier this year. This was echoed by Morgan Hall, communications director for the Kentucky Justice & Public Safety Cabinet, who told Prism in a March 27 statement that “no taxpayer money has been spent on gender reassignment surgeries for inmates.”

Moser’s HB 5 also implies that trans people are incarcerated according to their gender identity. At Burgin’s Northpoint Training Center, Marcum is incarcerated alongside more than 1,200 men. The same is largely true for the 1,600 trans women in federal custody, where only two dozen are currently imprisoned in women’s facilities.

‘Cruel and unusual punishment’ 

Marcum had to fight for gender-affirming care since first entering the criminal legal system 11 years ago. She began HRT at the age of 20 and was swiftly denied gender-affirming care when she was first incarcerated at a county jail at the age of 25. Medical experts do not recommend an abrupt end to HRT, which causes hormone levels to dip dramatically. Marcum said her forced hormonal withdrawal had a “devastating” impact on her mental and physical health.

In 2015, when Marcum was sentenced to 40 years in KYDOC custody, she was first sent to Roederer Correctional Complex in La Grange, where her health continued to decline without treatment. 

“Whenever I tried to explain my HRT history and current hormone deficiency to medical staff, I was usually met with shrugs and cold indifference,” Marcum said. “Eventually, a medical hold was placed on my file, and I was transferred to Kentucky State Reformatory (KSR).” 

What Marcum didn’t know at the time was that KYDOC did not account for her medical record prior to her entering the state’s custody at Roederer Correctional Complex, and because the county jail where she was initially held halted her HRT, KYDOC was under no obligation to resume her care.

“It was like my entire five years of HRT didn’t count at all,” Marcum said.

At KSR, Marcum was subjected to a battery of medical tests and referred to a psychologist. After many months of confusion and frustration, a medical provider at KSR informed her of the state’s “freeze frame policy” when it came to HRT prior to incarceration. 

“Meaning, since I was on HRT when I entered KYDOC, my treatments should have continued,” she explained, growing emotional. “I was tired of feeling depressed and broken. Who wants to feel incomplete? The state’s decision was cruel and unusual punishment.”  

In a last-ditch effort to access the health care she required, Marcum utilized KYDOC’s internal grievance process to file a medical complaint against the state in June 2016. She told Prism she was initially met with the same response: Since she was not on HRT when she entered state custody, the state was not responsible for the treatment. Marcum appealed the decision several times before her complaint landed in front of KYDOC’s Health Services Division, which determined in August 2016 that her complaint had merit and she could resume HRT. 

“The elation I felt is difficult to put into words,” Marcum said. “I cried. I jumped for joy. I threw away all the loose razors I’d hidden away and tore up the suicide notes I’d written to my mother. For the first time since I was arrested, I felt like I could breathe again. I had hope.” 

While Hall did not respond to specific questions regarding Marcum’s alleged treatment in KYDOC custody, she told Prism the state of Kentucky currently “has a contract with an independent health care provider who makes medical decisions for all inmates, including prescriptions and treatment needed.”   

While Kentucky has developed a reputation for its anti-trans laws, Marcum said positive changes were made under the Biden administration. Though the effort was met with severe backlash from Republicans in the state, in 2018, KYDOC broadened administrative regulations to better accommodate the safety and health care concerns of incarcerated trans people. 

Marcum told Prism some changes, such as allowing trans people to purchase gender-affirming items from the commissary and express their gender identity, were small but necessary steps in the right direction.   

“The policies, of course, were not perfect,” Marcum said. 

These very policies came under fire on the first day of President Donald Trump’s second term. Hours after reentering the White House, Trump signed a flurry of executive orders aimed at revoking Biden-era policies. One EO, focused on “gender ideology,” seeks to end gender-affirming care in federal facilities and calls for transgender women to be housed with men in federal prisons. The order is facing multiple challenges in federal court. This includes a lawsuit filed by three trans women who successfully halted their transfer to men’s prisons where, they argued, they would face violence and sexual assault that would violate their right not to be subjected to cruel and unusual punishment as guaranteed by the Constitution. 

To comply with the administration’s anti-trans EO, the Bureau of Prisons last month released strict new guidelines for trans people in federal custody, requiring prison staff to misgender incarcerated trans people, use their dead names, and bar trans women from purchasing bras and other gender-affirming items at the commissary. Though it is likely a violation of the Prison Rape Elimination Act, the guidelines also allow male guards to give pat-down searches to trans women in custody.

The 2018 policy rolled out under the Biden administration is currently being followed by KYDOC, Hall said, because it was “determined by the Attorney General as effective.”

Marcum told Prism she wants to remain hopeful, but the anti-trans fervor sweeping state and federal governments makes her fearful she and other trans women will have to return to the “sickness and depression” that results from being denied gender-affirming care. 

Editorial Team:
Lara Witt, Lead Editor
Carolyn Copeland, Top Editor
Stephanie Harris, Copy Editor