Dr. Jennifer Aldrich and her student Eric Gramszlo share two passions: caring for members of the LGBTQ+ community and for people who are incarcerated. So when the prestigious AMA Journal of Ethics® asked Dr. Aldrich to co-author a research paper combining these topics, she was excited to share the news with Gramszlo, then in his third year at the Lewis Katz School of Medicine at Temple University.
“I said I’d love to work on it with her,” recalls the newly graduated Dr. Gramszlo, who received his dual MD/MA degree in urban bioethics last month.
Dr. Aldrich readily agreed. “It was really great to give a student an opportunity like this, especially a student like Eric who’s really fantastic,” said the professor of clinical medicine, who regularly lectures about incarceration and gender-affirming care.
The two joined with a third co-author, Jessica Kant, MSW, LICSW, MPH, a lecturer at the Boston University School of Social Work, and a licensed independent clinical social worker at the Center for Gender Surgery at Boston Children’s Hospital.
Researching and writing the paper was “a very collaborative experience,” says Dr. Aldrich. “Everyone worked really hard and put a lot into it.”
Citing Constitutional Support
Published in the journal’s June 2023 issue, “Gender-Affirming Care, Incarceration, and the Eighth Amendment” makes compelling medical, ethical, and legal arguments that people who are incarcerated should have access to gender-affirming care, including hormone therapy and surgery, if medically indicated. It argues that this standard of care should be the same for everyone – including those in jail or prison.
“It’s a pretty unique paper,” says Dr. Gramszlo, who also earned his bachelor’s degree at Temple. “We wrote about how the Eighth Amendment, which bars cruel and unusual punishment, can be used as a tool for people to get appropriate care.”
The article also calls for ending related harms, such as the use of solitary confinement for supposed “protection” of transgender people. It reports that prisoners are rarely housed in facilities that align with their gender identity, despite a federal law that protects this right.
“When you go to prison, you don’t get sentenced to die of a medical condition,” Dr. Aldrich explains. “Your sentence is about your crime. Losing your freedom is a punitive action. It shouldn’t be that you have to suffer enormously from some treatable illness. It’s the state’s duty to provide the standard of care to people who are incarcerated.”
What many people don’t realize is that transgender individuals who are denied gender-affirming care often feel tormented, says Dr. Aldrich, who treats such patients, including those who are incarcerated.
“Not every trans person wants surgery. But for some, it’s life-saving,” she explains.
“Access to gender-affirming care is associated with increased quality of life and decreased rates of self-harm,” the authors note. For example, such care lowers the odds of suicidality by 44% in transgender adults and by 73% in transgender youth, “compared to cohorts who do not receive gender-affirming care.”
Yet in Pennsylvania, for instance, Dr. Aldrich knows of only one incarcerated person who received gender-affirming surgery. And that was after the person “caused significant self-harm.”
Part of the problem, the authors explain, is that lay administrators make these decisions in the vast majority of carceral institutions. The paper argues that such facilities must shift such decisions to licensed medical professionals with appropriate expertise in gender-affirming care.
The issue affects a sizable group: experts estimate that “nearly 5,000 transgender people reside in U.S. state prisons [and] another 1,200 are incarcerated in the federal system,” the researchers state.
Advocating for Care
Drs. Aldrich and Gramszlo seek to educate and, ultimately, change prison policies.
“We hope it’s recognized that gender-affirming care is health care. Sometimes that includes surgical options for patients who are so tortured by their body that does not match their identity, that they resort to self-mutilation. You shouldn’t have to do that to get the attention of the deciders,” Dr. Aldrich says.
They acknowledge that society is often unsympathetic toward those convicted of crimes, as well as the LGBTQ+ community. Drs. Aldrich and Gramszlo encourage people to take a broader view.
“They have children, grandchildren, parents, siblings. They still matter,” notes Dr. Aldrich, who is board-certified in both internal medicine and infectious disease.
Moreover, most people who are imprisoned will eventually be released. “We should make sure they come home as healthy as possible,” Dr. Aldrich says.
This issue is particularly relevant to the Katz School of Medicine and Temple, she emphasizes.
“We pride ourselves on taking care of the community. Our community in North Philadelphia has a lot of risk factors [due to various social challenges] for being marginalized and forced into criminal acts. There’s so much that we can learn from the communities we serve. I think for students, that is especially true.”
Dr. Aldrich notes that Temple Health has a strong LGBTQ medical program, and Temple University Hospital is a designated LGBTQ Healthcare Equality Leader.
Benefits of Student Research
The Katz School offers a variety of opportunities for students to participate in research and collaborate with faculty. A research guide lays out the steps for getting involved. And students can present their work at the medical school’s research symposiums.
“This is so important,” Dr. Aldrich says. “It gives students a glimpse of what research is and how to work closely with faculty and learn the process of reading the literature, writing the drafts, and revising the drafts. Students learn the whole process of having an article submitted and approved, and how rigorous that is.
“Even if they don’t choose to do research, it helps them understand what goes into research and what goes into writing an article they might be reading.”
Dr. Gramszlo says he benefited from the project on multiple levels, including a deeper understanding of the issues.
“Working on this research paper gave me, even more, a sense of urgency and commitment to purposefully make gender-affirming care part of my practice,” notes Dr. Gramszlo, who recently started his psychiatry residency at Thomas Jefferson University Hospital.
Transgender people “are mistreated in so many ways,” he says. “Not just in carceral institutions but in medical institutions, housing, and social institutions,” to name a few.
The medical community can make a huge difference, Dr. Gramszlo believes.
“We’re the people providing gender-affirming care,” he explains. “We can say [these differences] exist and this is what care should look like for these people.”
“It’s really important for people to understand how necessary gender-affirming care is,” stresses Dr. Aldrich. “It’s not a luxury; it’s not cosmetic. We wouldn’t deny care for a cancer diagnosis. Because it’s so life-saving, I really feel it needs to be viewed from that same lens.”