When Kanautica Zayre-Brown was transferred to Anson Correctional Institution in 2019, she became the first incarcerated transgender person in North Carolina to move from a prison designated for one gender to one designated for another.

But that hasn’t solved all the problems of navigating a state prison system that seems ill-prepared for the realities of incarcerating transgender people. In an exclusive interview with Policy Watch, Zayre-Brown recently detailed her continuing struggles to be regarded as female.

That includes her fight to have a gender-affirming surgery, which she has been working toward since well before she entered prison. Though her doctors and specialists at the UNC Transgender Health Program  say it’s medically necessary, Zayre-Brown said the state won’t approve the procedure.

“Maybe because they haven’t dealt with this situation before, they’re still trying to learn to deal with it,” Zayre-Brown said. “But it’s been a really bad experience.”

The Department of Public Safety, which runs the prison system, would not comment on the specifics of Zayre-Brown’s case.

“North Carolina and federal law prohibit the release of information pertaining to an individual’s medical or confidential prison records,” said John Bull, communications officer with the department, in response to questions from Policy Watch.

“What we can tell you is that requests for transgender accommodations, which would include medical procedures, by policy are reviewed by a multi-disciplinary committee,” Bull said.

This committee includes 10 administrators, including the Health Services medical director, chief of psychiatry, behavioral health director, chief medical officer, and the Prison Rape Elimination Act director.

“Each individual’s situation is reviewed, and decisions made on a case-by-case basis,” Bull said. “Staff has been trained on transgender issues, including how to properly address a transgender offender.”

A total of 103 incarcerated people identify as transgender and five as intersex, according to the prison system’s intake screening and Transgender Accommodation Review Committee process. Prisoners have the right to deny being identified, which means those figures could be an undercount. Some people fear if they self-identify they’ll be abused by fellow incarcerated people and prison staff.

Jaclyn Maffetore, the ACLU staff attorney handling Zayre-Brown’s case, said it’s unclear how the state is making decisions about Zayre-Brown’s care.

“Unfortunately there hasn’t been the degree of transparency either to us or to Kanautica, a person who is deeply impacted by these decisions being made on her behalf, that there should be,” Maffetore said.

A long road

After she was arrested in 2017 on charges of insurance fraud and obtaining property by false pretenses, Zayre-Brown was held in a series of all-male facilities where she had to sleep in groups of men and use group showers and toilets with them. She faced harassment and threats and feared she would be raped. Guards and prison officials refused to acknowledge her as female. The state took a similar stance, initially.

Kanautica Zayre-Brown in 2019

Friends, family and LGBTQ advocates spent years fighting for her. The ACLU of North Carolina threatened a lawsuit. But finally, in 2019, Zayre-Brown made history in winning a transfer to a women’s facility.

“I thought it would be so much better,” Zayre-Brown said.

But over the last two years, she said, it has in many ways been worse. “The staff is not willing to adapt,” Zayre-Brown said of the prison where she’s now being held.

Now surrounded by other women, she has less fear of beatings or rape. Yet just as in the male prison, Zayre-Bown said the staff constantly misgender her, refusing to recognize her as a woman. They still use the name she was given at birth rather than the female name to which she legally changed it years ago. This has made her feel separate from the other women incarcerated at Anson, she said. The experience has exacerbated the gender dysphoria with which Zayre-Brown and many transgender people struggle.

The American Medical Association and American Psychiatric Association recognize gender dysphoria not as a mental illness but “a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify.”

More than 40 years of research into and treatment of transgender people experiencing dysphoria has led psychiatric and medical professionals to conclude the most effective course of treatment is gender transition — aligning one’s life socially and sometimes physically to better match their gender identity. Not all transgender people choose to medically transition, but for those for whom it is judged necessary, medical experts agree it can be life-saving.

Kanautica Zayre-Brown in 2019

Some transgender people elect not to have any surgical procedures related to their transition. Zayre-Brown was assigned male at birth and began transitioning to female in 2010. She has had previous gender affirmation surgery. She said she feels “90 percent” of the way to the fully realized transition toward which she was working before her arrest.

The state denied Zayre-Brown’s initial request for the surgery around the same time she was transferred to a women’s facility, Maffetore said. Shortly afterward, the prison adopted a new policy relating to providing gender-affirming care to people who are transgender, non-binary and intersex.

“Kanautica attempted to appeal that under the new policy,” Maffetore said. “She was told the denial took place under the old policy and was told to start all over again near the end of 2019. She did. Then COVID happened.”

Since then, progress toward approval for the surgery has been slow, Maffetore said. Zayre-Brown was told she would need to have a consult with a provider who specialized in gender-affirming care in order to determine whether or not the procedure she was seeking was necessary. Zayre-Brown finally had that consult at the UNC Transgender Health Program in July. “Our understanding is that multiple of her providers have determined at this point that gender-affirming surgery is the next step to treat her gender dysphoria,” Maffetore said.

But the state has taken no obvious steps toward allowing Zayre-Brown to have the procedure, even though, Maffetore said, “our position is that DPS has a constitutional obligation to provide that surgery,” Maffetore said. “When you choose to incarcerate somebody, you become responsible for their medical care and for any medical care that is deemed necessary. That applies to gender-affirming care, of course.”

ACLU staff attorney Jaclyn Maffetore represents Zayre-Brown

“Gender dysphoria is very serious,” Maffetore said. “Among other things, it’s responsible for the high suicide rate among trans folks.”

While the medical community is clear on that point, Maffetore said the prison system doesn’t seem to be.

One DPS doctor has said they believe the procedure is “elective” and not medically necessary, Maffetore said. Other DPS providers disagree. Specialists have been consulted and urged the procedure be approved. Now, four months after the consultation DPS said was necessary, Zayre-Brown and her legal representatives say they’re getting mixed messages.

“Some officials have told her she’s been outright denied. We’ve also been told DPS hasn’t made a decision yet. If DPS is not willing to remedy the situation themselves, we’re willing to do what is necessary to advocate for our client,” Maffetore said.

That includes a potential lawsuit, she said.

The situation needs to be resolved, Maffetore said. Not just for her client, but for the many other transgender people now being held in North Carolina prisons and those who will be in the future. They deserve to have a clear and transparent process where medical professionals and field specialists make these decisions in consultation with their patients, she said.

“We’re happy to have the spotlight on Kanautica, the struggles she has had and her story,” Maffetore said. “But this is much bigger than just one person.”

This article originally appeared on the website ncpolicywatch.org