Kristina Olvera wants to enjoy the simple pleasures of crossing her legs when she sits, applying eyeliner and pouting her lips.
Her landlord disapproves when she plays with her hair, grows out her nails or wears tight jeans.
That landlord, the Oregon Department of Corrections, recognizes her only as a man—Jose Antonio Olvera, 26, a heroin addict and career petty criminal who was sentenced to 28 months in prison after stealing nine pairs of jeans from Diesel in the Pearl District and $500 in merchandise from the downtown Sephora in 2012.
Olvera had been living as a woman and taking estrogen when the state sent her to the Columbia River Correctional Institution in Northeast Portland in January 2013.
There, Olvera says, prison officials have violated her constitutional rights against cruel and unusual punishment by denying her necessary medical and mental health care recommended for people who are transgender—that is, someone who identifies with, and usually wants to be, the opposite gender.
"I'm a human with rights and feelings that are being trampled on over and over by the Department of Corrections," Olvera wrote to prison officials in a tort claim last month.
Olvera's condition, gender dysphoria, isn't some made-up complaint concocted by a prisoner looking to make trouble. It's a widely established medical and psychiatric diagnosis, for which treatment includes hormones and allowing the subject to live as the opposite sex.
Olvera is not alone. Prison officials say they know of at least 10 such inmates in the state system.
Corrections department records obtained by WW show Oregon prison officials have for years been denying inmates with gender dysphoria medical and mental health treatment related to their diagnoses, even when treatment has been called for by physicians and other medical professionals.
The corrections department's actions run counter to federal court rulings in as many as eight states where judges have found that treatments sought by transgender prisoners are medically necessary.
In many cases, Oregon officials haven't just denied care in individual cases; for years, they have said they wouldn't treat gender dysphoria, or gender identity disorder, as the diagnosis has been called in the past.
In the best of circumstances, gender dysphoria is often misunderstood. For Oregon prison officials, who house nearly 15,000 inmates, dealing with men who feel they must live as women (and vice versa) makes their job all the more difficult.
"They're struggling to maintain order among all these inmates," says Dr. Megan Bird, a gynecologist with Legacy Health who treats transgender patients. "Do they put them in a men's prison and risk harm to them, or put them in a women's prison where they risk making other women uncomfortable?"
Corrections officials are struggling to manage an already challenging population. The corrections department says more than half of prisoners struggle with drug or alcohol addiction; one in five has a severe mental illness.
Bird and others say prisons are required by law to provide necessary medical and psychological care.
Under a recent settlement with one inmate, and the threat of a lawsuit from Olvera, Oregon corrections officials are considering a new approach. But the proposed policy, still a draft, shows little would change in the way medical officials treat transgender prisoners.
Corrections officials insist they are trying to bring about real change.
"It really is a culture shift within the Department of Corrections, having something in place that says, 'This is how we're going to work with transgender individuals,' and create more awareness throughout the organization," says corrections department spokeswoman Elizabeth Craig. "This is a complex issue."
It was 1952 when most Americans first learned of transsexuals (as transgender people were then called). That's when newspapers revealed the story of a Bronx-born man named George William Jorgensen who had traveled to Denmark, undergone surgery that turned him physically into a female, and returned calling herself Christine.
The international media attention that followed Christine Jorgensen's story created confusion about transsexuals that lingers today—are they just cross-dressing gays or people with mental illness?
Neither is the case. Gender dysphoria is a medical diagnosis that has been widely accepted for the past four decades.
"Scientists today can't explain why some people are born straight or gay, but we have enough evidence to be pretty confident that it's not something people can change or should be expected to try to change," says Harper Jean Tobin, director of policy at the National Center for Transgender Equality.
"Gender identity is the same way. All they have to do is read the science, read the law, read the standards of care, do the right thing."
Nearly 700,000 Americans today identify as transgender, according to a study by the Williams Institute at the UCLA School of Law.
In many respects, the past several years have witnessed extraordinary gains for transgender people. Legislation across the country that seeks to protect gays and lesbians often includes transgender people as a protected class.
Transgender people are also becoming more accepted and visible in the public eye. Acceptance has moved so far that the agricultural community of Silverton, 14 miles east of Salem, has a transgender man, Stu Rassmussen, as mayor.
But the diagnosis is still largely misunderstood, even by physicians and psychiatrists—and by many transgender people as well.
Anny May Stevens was born in 1962 as Edward Dean Stevens. Raised in Oklahoma and California, Stevens by age 8 was sneaking into her sisters' room to borrow their panties. "I'd ask him why he did it," Stevens' father, Carl, recalls. "He just said, 'Because it feels good.'"
Stevens, who later moved to Portland, struggled to live as a man. After several suicide attempts, Stevens found a therapist in 1993 who diagnosed her with gender identity disorder.
By then, physicians and psychiatrists were following widely accepted treatment guidelines first written in 1979 that included a mental health evaluation, hormones (for men, estrogen), and encouraging the patient to live as the opposite sex.
"It is medically necessary," says Dr. Jack Drescher, a member of the American Medical Association and author of the American Psychiatric Association position statement on access to care for transgender patients. "Many people who do not receive treatment are depressed, suicidal."
A physician prescribed estrogen for Stevens in 1994. "They made me feel whole, even though it wasn't complete," she says of the hormones. "I felt closer to what I needed to be." She went to court to have both her name and gender legally changed.
Stevens also had a serious drinking problem. In April 1997, she was staying at the Estate Hotel in Old Town when she invited a neighbor, a 35-year-old man, into her room. Stevens said he tried to sexually assault her, and she killed him—first stabbing him with a scissors, then striking him with a hatchet. She cut him more than 80 times.
"I am sorry but he asked for it," she wrote in a note she left by the body, according to news accounts at the time. "Anny May Stevens."
She pleaded guilty to manslaughter and received an 18-year sentence. Once in prison, Stevens found that corrections medical officials refused to continue the hormone treatments prescribed by her doctor.
Court records say the corrections department's medical director, Dr. Steven Shelton, wrote in Stevens' case file that the treatments she sought were "entirely elective."
Shelton, who is still the corrections department's medical director, told WW he would not discuss Stevens' case or the treatment of transgender prisoners in general.
Shelton's decision not to treat Stevens was at odds with rulings by federal courts, which by then had been telling states to follow a different path with regard to transgender prisoners.
In 1997, the 9th U.S. Circuit Court of Appeals (with jurisdiction over Oregon) ruled the state of California had to immediately resume providing estrogen to a transgender inmate who, like Stevens, had been taking the hormone before entering prison. Even earlier, in 1990, a federal judge in Michigan ordered that state's prison system to reinstate hormone treatment to a transgender inmate.
"Taking measures which actually reverse the effects of years of healing, medical treatment is measurably worse [than not providing treatment in the first place], making the cruel and unusual determination much easier," the Michigan judge ruled.
Stevens filed two handwritten lawsuits to challenge her lack of medical treatment by Oregon prison officials. A state judge in Malheur County tossed out her 2002 case without comment.
In a 2005 case, U.S. District Judge Janice Stewart acknowledged that Stevens' case paralleled those in other states in which prisons had shown a "deliberate indifference" to transgender inmates' "serious medical need." Deferring to the state judge's decision, however, Stewart dismissed Stevens' case.
Stevens is now in the Deer Ridge Correctional Institution in Madras and is scheduled to be released next year. Once out, she says, she will pursue gender reassignment surgery.
"I want to live my life as a woman," Stevens says. "I want to be whole."
One reason prison officials gave the court for refusing to refill Stevens' hormone prescription was that she posed a low risk of harming herself. Yet the department also refused to treat another inmate who repeatedly demonstrated she would kill or castrate herself without treatment.
Rebekah Brewis was 18 when she learned the confusion she had suffered all her life had a diagnosis.
Born Jorey Lee Brewis in Grants Pass in 1980, she had never felt like a man. In 1998, according to court records, an Oregon prison therapist diagnosed her with gender dysphoria. "I believed I was a woman," Brewis tells WW, "but I didn't know about transgender people."
In 2000, Brewis landed back in prison after breaking into an Ashland home. She pleaded guilty to robbery and received a 70-month sentence.
In prison, Brewis says she tried killing herself five or six times—first in 2002 at Eastern Oregon Correctional Institution by using a torn bed sheet as a noose. Soon afterward, she asked to be treated for her diagnosis, but the prison medical staff refused, Brewis said in court filings.
"You don't look like a girl," she says one prison counselor told her. "You look like a guy to me."
Shaving her legs was the one thing that made Brewis feel feminine. Shelton, the prison system's medical director, refused to allow it, court records say, because there was no medical need for the shaving. Officers disciplined Brewis when she did shave her legs. Nor could she pluck her eyebrows or shower alone. Guards taunted her. As Brewis recalls, once on her way to see a doctor, a guard yelled out, "Don't hang yourself on the way to medical!"
"I wasn't doing nothing wrong to nobody," Brewis tells WW. "You have to be so desperate if you want any help."
"If they have a diagnosis and they are not treated, that can lead to depression or suicide," says Jamison Green, a professor at the Center of Excellence for Transgender Health at the University of California, San Francisco. He said some patients who aren't treated—particularly inmates—will try to medicate themselves by cutting off their testicles.
"It happens in prisons because people are stuck and they have no hope," Green says. "They think no one will give them the treatment they need."
Brewis tells WW she thought if she no longer had testicles, the lack of testosterone would make her feel better. She also believed prison officials might move her to a women's prison—and that the act would prove to everyone she was not simply faking her diagnosis.
"I felt hopeless," Brewis says. "That's when I decided I had to castrate myself."
Court records say that on Dec. 30, 2004, Brewis sneaked photocopied pages of Gray's Anatomy, a standard medical textbook, out of the prison library and into her cell. With a pair of fingernail clippers she began cutting open her scrotum. But then she stopped.
"I got scared," she tells WW. "There was so much blood."
Guards found Brewis the next morning, one testicle protruding from her scrotum, according to court records. They rushed her to St. Anthony Hospital in Pendleton, stitched her up and placed her on suicide watch. Brewis says in court filings the attempt earned her a misconduct report for possession of a dangerous weapon and contraband.
She tried again several times to castrate herself, using razor blades or by cinching her scrotum with hair ties or twine. Despite this, corrections medical staff still refused to treat her diagnosis.
In 2005, Dr. Daryl Ruthven, the corrections department's chief psychiatrist, also diagnosed Brewis as transgender but wouldn't prescribe her hormones, court records say.
"Ruthven refused to recommend any treatment though conceded that female hormone therapy may alleviate the plaintiff's anxiety," according to court records later filed by Brewis. She also says Ruthven told her if she ever succeeded in cutting off her testicles, he'd have the hospital sew them back on.
When contacted by WW, Ruthven declined to comment.
After another suicide attempt in 2006—Brewis slit her arm 20 times with a razor blade—Portland lawyer Michelle Burrows heard about Brewis' case. She found local gender dysphoria expert B.J. Seymour. Medical records say Seymour recommended Brewis receive three months of counseling, get a prescription for estrogen, and be allowed to shave her body and change her name.
"These recommendations," Seymour wrote, "should help to alleviate the depression that has brought her to the point of attempting suicide and self-mutilation."
Court records say corrections department officials rejected the recommendation.
On Sept. 18, 2007, alone in her two-person cell, Brewis lay back on the plastic-covered mattress, a blanket covering her body, and her legs akimbo like a woman preparing for birth.
It was 5 am. She dug her fingernails into her scrotum, tearing slowly, breathing deeply. For five hours she labored, biting down on a prison-issue white towel, and stopping periodically to sop up blood with a roll of toilet paper.
"The image, the pain kept pushing me," she says of the urge that drove her. "It was like someone planning an escape from prison. That was my escape."
Once she had exposed her testicles, she tied off each epididymis with a rubber band and dental floss. After 27 hours, her testicles fell off. She smashed them just to make sure they couldn't be reattached.
A month after Brewis castrated herself, a corrections department physician, Dr. Jo Elliott-Blakeslee, recommended Brewis get estrogen treatments. The next year, another corrections department physician, Dr. Gregory Lytle, agreed.
Shelton, the department's medical director, put a stop to it.
"We do not treat transgender cases," Shelton told Lytle in 2008, according to a transcription Brewis made from Lytle's notes for a court filing. The prison system offered Brewis only testosterone as a hormone replacement.
Shelton declined to discuss Brewis' case. Elliott-Blakeslee and Lytle have since died.
Brewis refused the testosterone. But without hormones to balance her metabolism, immune system and behavior, she got hot flashes and night sweats. Her moods fluctuated, and her bones grew brittle.
"That person is at risk for all sorts of problems," says Randi Ettner, an Illinois-based clinical psychologist and member of the World Professional Association for Transgender Health. "Hormones regulate all the processes in our body. They are not optional. That person is really at risk."
Oregon's response to Brewis stands in contrast to a similar case in Idaho, where corrections officials also offered only testosterone to a transgender patient who had cut off his testicles with a razor blade. A federal judge in 2007 found the Idaho Department of Corrections' treatment violated the inmate's Eighth Amendment protection against cruel and unusual punishment.
Oregon officials instead responded in December 2009 by sending Brewis to the Oregon State Hospital in Salem, where she tried twice—unsuccessfully—to bring a lawsuit against corrections and mental health officials. She was released in April 2011.
"I was pretty angry, but you have to accept what you have to live with," Brewis says. "Today things are so much better. I am able to take care of myself and take the treatments I need."
The Idaho case is one of many court decisions in which states have been forced to treat transgender inmates under widely recognized standards of care.
A federal judge in Wisconsin in 2011 ordered the state's prison system to provide treatment to transgender inmates deemed necessary by medical experts. Federal judges in Massachusetts in 2011 and this year went further, saying the state must also provide "medically necessary" surgery.
Following a 2009 inmate lawsuit, the Federal Bureau of Prisons implemented a policy that allows transgender inmates in its system to receive treatment regardless of whether they were diagnosed before or after incarceration.
In 2013, the U.S. Department of Justice wrote guidelines for state prisons dealing with transgender inmates.
"Medical experts do not view transitional treatments for transgender people as dangerous or experimental," the guide reads, adding that the American Medical Association and the American Psychological Association "agree that these transition-related treatments are effective and medically necessary for individuals who have been appropriately evaluated."
Some institutions have implemented policies even without the threat of litigation, including those in Harris County, Texas, and Cook County, Ill., both in 2013.
Dr. Nneka S. Jones at the Cook County Sheriff's Office says inmates can meet with medical experts in transgender care. The jail provides underwear that fit a person's perceived gender and special shaving gels for inmates who want to get rid of their body hair.
"When you treat them with human dignity and respect, you can deter bad behavior," Jones says. "You'll spend more energy dealing with the day-to-day problems unless you make their stay more empathic, humane. It's definitely worth it."
Change may come to Oregon, in fact, because of Kristina Olvera. On paper, Olvera is hardly the kind of citizen one would expect to force the state's prison system to reform its ways.
Olvera says she started shooting heroin at 15. She stole video games from a disabled older brother to buy drugs. She wrote bad checks, broke into cars, stole anything she could pawn—from panties and perfume to dog food.
By the time she went to prison, court records show, she had been convicted of nearly 30 crimes, from theft and robbery to jaywalking and riding public transport without a fare.
She was born Jose Olvera in 1987 and grew up feeling as if she was more like a girl, enjoying sparkles and lip gloss and dressing in her mom's clothes. Olvera says she had been formally diagnosed as transgender and had lived as a woman before pleading guilty to theft in 2013.
Prison guards have chastised Olvera for acting too feminine, looking in the mirror and posing Vogue-style for photos. Disciplinary records say one guard called her "bitch" and "that thing" and refused to hand her mail, instead flinging it at her in front of other inmates. She says most inmates accept her, but some call her "tramp" or murmur, "It calls itself Kristina."
Olvera, medical records say, had been taking estrogen obtained illegally before entering prison last year. She has asked for a medical diagnosis and counseling while in prison, as well as hormones, but corrections officials have said no.
"I contacted Dr. Shelton, Medical Director, to verify the unwritten but broadly discussed policy," Richard O'Brien, a nurse at Columbia River Correctional Institution, wrote Jan. 30 in an internal department memo, "which has been that if the patient has been receiving treatment and hormones prior to their admission within ODOC, that we will continue/maintain them on the current doses, but that we do not initiate or advance them in their transition."
Olvera has since filed dozens of grievances and two tort claims with the department, the preliminary steps to filing a lawsuit against the corrections department. Unlike other inmates who have sued over transgender issues without legal representation, Olvera is preparing a case with her attorney, Michelle Burrows.
"Prison systems don't change unless they're told to," Burrows says. "You have to get a federal judge to say, 'If you incarcerate them, you have to treat them like human beings.'"
Corrections officials say they are writing a policy that will guide their staff on how to deal with transgender inmates (see below).
But corrections officials repeatedly declined to discuss the agency's past actions and decisions, turning down WW's requests to speak with medical and mental health staff, guards, administrators and director Colette Peters.
Corrections officials also declined to identify any medical staff members who had been trained to diagnose or treat gender dysphoria.
"We're doing what we're legally required to do," says Craig, the corrections department spokeswoman.
Gov. John Kitzhaber's office also didn't respond to WW's questions. State legislators who oversee the state's prison system said they are unfamiliar with the issue. "We have not had any discussions," says Sen. Floyd Prozanski (D-Eugene), chairman of the Senate Judiciary Committee.
Sen. Laurie Monnes Anderson (D-Gresham), who chairs the Committee on Health Care and Human Services, says her panel has never examined the issue. "There should be no problem with taking the agencies to task," she says. "There's no way they can violate the rights of an inmate."
"Oregon needs to adopt a policy," says Burrows. "And we're hoping Kristina can take that step and say, 'Here's what you need to do: develop policy for folks like me.'"
Olvera knows her lawsuit, which could be filed within the next two months, will drag on long after she's out of prison.
"They're not going to change things for me, but I can help inmates down the road, help them get adequate treatment," she says. "I never want anyone else to go through this.â
The Department of Corrections' new approach to transgender care won't change medical policies judges elsewhere have called unconstitutional.
The Oregon Department of Corrections is drafting its first formal policy on how to deal with transgender prisoners, after years of denying treatment to inmates with gender issues.
The agency is taking the action in response to tort claims by one inmate, Kristina Olvera, and a lawsuit brought last year by a post-operative inmate who was recently moved to the women's prison at Coffee Creek Correctional Facility.
The settlement with inmate Linda P. Thompson has forced corrections officials to spell out the steps they will take to identify and assess each inmate who might be transgender. For example, inmates might be allowed different underwear and to shower separately from other inmates.
"Everyone doesn't fit into a nice, neat box," says Heidi Steward, superintendent of Coffee Creek Correctional Facility and lead author of the new policy. "Years ago we said, 'If you were born a male, you're placed in a male institution. Figure out how to live.' We moved away from that model quite a while ago."
A review of the policy by WW, however, found that some of the steps are already required by federal law. But a closer look shows the proposed policy falls far short of the minimum standards of care adopted by many states, the Federal Bureau of Prisons and the World Health Organization.
The draft policy shows corrections officials will make few meaningful changes in past practices regarding medical treatment. Medical staff will continue hormones prescribed to inmates before they were jailed, but will not allow an inmate to start taking hormones if he or she hadn't been taking them before entering prison.
The Federal Bureau of Prisons, for example, changed its policy after an inmate challenged the practice in court. A resulting settlement required the U.S Department of Justice in 2012 to draft a new policy specifically allowing inmates without a prior diagnosis to receive recommended treatment.
"We may not provide them hormone therapy or make surgical procedures," Steward says. "But there are a lot of things we do deal with. If they started getting anxiety or depression, we would treat that."
A panel, the Nonconforming Gender Review Committee, would make recommendations about housing and treatment, but the policy would not require its nine members to obtain specialized training. Two of its members—including Dr. Steven Shelton, the corrections department's medical director—have denied inmates treatment in the past even when experts found that treatment was medically necessary.
WW asked Shelton and Dr. Daryl Ruthven, the corrections department's chief psychiatrist, if either had specialized training in the diagnosis or treatment of transgender patients. Both declined to comment. Corrections officials could not name any member of its committee who had training in the diagnosis or treatment of transgender patients.
When WW first sought a copy of the new policy last month, corrections department officials said they were working on a draft but claimed they had nothing written down. Officials later acknowledged a draft policy had been written but initially declined to release it, claiming it was protected by attorney-client privilege. When WW learned the policy had been shared outside the agency, corrections officials agreed to release the draft.
The agency has brought in Basic Rights Oregon—an advocacy group working to end discrimination based on sexual orientation and gender identity—to review its plan and train corrections staff.
Aubrey Harrison, deputy director of Basic Rights Oregon, says transgender people overall are more likely to be incarcerated, assaulted and denied medical care, as well as confront issues of housing and personal safety.
Harrison says her organization has been working with the corrections department to address problems with the treatment of inmates. "We've had really good conversations with them," she says. "What we're seeing is the DOC's willingness to address the problem." KATE WILLSON.