‘We Have to Fight’: Incarcerated Transgender Missourians Are Latest Target of Missouri Lawmakers

Jessica Hicklin fought for the right to transition in prison. | Courtesy photo

Jessica Hicklin may be best known as the trans woman who took the state of Missouri to court over access to gender-affirming care while incarcerated, with a successful ruling in 2018. Now five years later, as Missouri state legislators are sponsoring an array of bills targeting transgender health care, she describes this as a dark time for the trans community. But Hicklin is no stranger to fighting back — and finding joy on the other side of a long struggle: “My story was in a place and time when I should have had no hope…[but] here we are.”

That story begins long before Hicklin decided to file a federal lawsuit. Hicklin has known herself to be a woman since the age of 5, but while growing up in rural Kansas in the 1980s, she did not know what it meant to be transgender, or what a social or medical transition might entail. No such medical care would have been available to her. Instead, she sought what explanations she could and believed that her internal experiences were the result of schizophrenia. She coped with her dysphoria by using substances and in 1995, at the age of 16, committed a drug-related murder that led to a life sentence. She was incarcerated for 26 years in Potosi Correctional Center, a men’s maximum security Missouri prison, with about 800 other individuals.

During those 26 years, before such Supreme Court cases as Miller v. Alabama (2012) and Montgomery v. Louisiana (2016), which ruled against life sentences for people convicted of crimes as minors, Hicklin had no reason to believe that she would ever get to go home (or exist as her most authentic self).

Around the age of 21, she saw a magazine advertisement that featured a transgender woman and at long last had a glimpse of what might be possible. Hicklin began to conduct extensive research, including reading the World Professional Association for Transgender Health’s Standards of Care, a document that provides clinical guidance for health professionals to assist transgender and gender-nonconforming people with safe, effective care. Even so, Hicklin was understandably hesitant and afraid to pursue any of the options she was reading about while in prison. She knew that it was dangerous to be seen as a gay man, much less an out trans woman.

Hicklin has always been math-minded and made the grim calculation that, given what she thought to be the average life expectancy for trans folks, she could promise herself that she would transition by the time she was 36 and thereby try to at least avoid living most of her life in a “body that wasn’t mine.”

She now describes that logic as flawed but says that this line of thinking was her way of dealing with her reality at the time. She directed her energy towards litigation like Hicklin v. Schmitt, arguing for her release in light of the relevant Supreme Court rulings. She also dedicated herself to being a positive presence in her community by holding roles like victim empathy course teacher, GED teacher, prison paralegal, hospice worker and restorative justice committee leader.

Yet when her 36th birthday approached and her circumstances remained the same, Hicklin knew it was time to keep her promise to herself while still incarcerated, as impossible as it seemed.

“I tell people: I went to prison at 16 — concrete walls, steel cells, and everything that prison is. I faced violence when I first got there; I was sexually assaulted several times. I was told, ‘You will never leave this place.’ And yet that was not my prison. The prison of concrete walls has space in it to hope and grow and try to do things that have meaning for your life, but when your body is your prison, there is no hope.”

The first thing Hicklin did was file for a legal name change. She says, “That’s how I came out — they publish[ed] it in the newspaper.” Her news was met with some sincere curiosity from guards and administrators; Hicklin believes that the combined effect of her long-standing reputation in the facility — and a great deal of luck — meant that her experience was not as fraught with danger and mistreatment as is the norm. Guards asked her what was going on and if she was really “Jessica.” She told them, “Yes. That’s my name.”

Hicklin had already undertaken a decade of therapy and meaningful discussions with spiritual advisors, but her next step was to once again sit down with a mental health professional and truly address the fact of her womanhood anew.

The therapist referred Hicklin to a psychiatrist who in turn gave her the diagnosis of gender dysphoria, entering it into Hicklin’s medical records and referring her to an endocrinologist to begin gender-affirming hormone therapy, a.k.a GAHT. Hicklin recalls that this is when “shit hit the fan.” Department of Corrections officials adamantly resisted the recommendation for hormone therapy. She wound up with an addendum on her medical record saying that, recommended or not, GAHT was not in alignment with MODOC protocols.

MODOC had created a “freeze-frame” policy, meaning that incarcerated people could not access gender-affirming care if they had not already been receiving such care prior to incarceration. In-prison health care was provided by Corizon Health, a for-profit contractor that has faced hundreds of lawsuits and filed for bankruptcy in 2023. (MODOC has now contracted Centurion Health in Corizon’s place.)

Hicklin drafted a federal complaint and began communicating with lawyers and organizations that might be interested in her case. She was pleasantly surprised when Lambda Legal agreed to work with her and also felt deep gratitude to a small handful of DOC medical professionals who advocated on her behalf.

The legal battle lasted more than two years, a time that Hicklin describes as a fight for her life.

“I couldn’t wake up anymore like this. It’s so hard to explain to people who are not dysphoric that this is not a choice or a cosmetic thing; it really is a life and death issue,” she says. She was “not okay” during this period, and the attorneys she was working with made sure to check on her. Ultimately, the judge ruled that denying Hicklin GAHT and other transition-related needs constituted cruel and unusual punishment, in violation of the Eighth Amendment.

Despite this, Missouri lawmakers are trying to revoke that hard-won access to gender-affirming care in 2023 with HCS HB 419, which would apply to both youth and incarcerated adults. In a further deterrent to trans rights, the Missouri Senate already approved a bill this week that would ban gender-affirming health care for those under 18 — the bill still needs a second vote in the Senate and a vote in the House before becoming law.

The day that Hicklin won her lawsuit was one of the happiest of her life. But even better was the moment when she finally held a little green estrogen pill in her hand, which she considers a birthday. She took some time to “just sit there and look” at it.

That pill came from her first 30-day supply of testosterone blockers and estrogen, and 30 days was about how long it took for her to begin noticing the effects.

She was also allowed to fill out a form and purchase the same canteen items that any other incarcerated woman would be able to: makeup, correct undergarments, a hairdryer, etc.

She recalls the euphoria she felt the first time she put on lipstick and walked out of her cell: “It’s funny because there’s this argument that lipstick does not a woman make, and that’s very true; none of these things made me a woman — I am a woman — but being able to express who we are is an important part of being human … My happiness and my joy come out of me at every moment of my life now.” When we spoke in March of 2023, Hicklin also had dark red nails and lavender-tinted hair.

On the subject of her joy, Hicklin notes that not everyone might feel particularly invested in whether an incarcerated person gets to experience such emotions. One DOC employee even tried to refuse to give her the canteen curling iron.

“Some people might say: ‘We don’t really care if you’re happy — you’re in prison; you should suffer.” However, she believes firmly that her continued growth as a person was totally contingent on having access to transition-related care.

“I had confidence in my world that I didn’t have before — the confidence to be a good person. It’s like Maslow’s Hierarchy of Needs; if you don’t take the time to treat trans folks and their health care needs, you can never rehabilitate them. It should be common sense. If you have someone who carries a mental-health diagnosis, and you don’t treat it, you can’t expect them to all of the sudden change the rest of their lives. My life is very indicative of that. I was doing good things [in prison] — I was trying to — but after this point I’ve been able to hopefully contribute remarkable things to the world. You can’t expect people to come home and contribute to society if you’re not willing to give them access to medical care.”

Indeed, Hicklin urges the public to consider that, like herself, 95 percent of incarcerated individuals eventually return to their communities, and that even from a strictly utilitarian point of view, treating dysphoria is ultimately less costly for taxpayers than the consequences of untreated dysphoria. Carla Lantz — MSN, CNM, WHNP-BC, the Program Director of Gender-Affirming Hormone Therapy at Planned Parenthood of St. Louis Region and Southwest Missouri — says left untreated dysphoria can lead to chronic health problems, increased blood pressure, increased risk of diabetes and high rates of suicidality. Experiences of mental health concerns, addictions, irregular sleeping patterns, eating disorders, discrimination and violence can all also lead to even more serious health complications long-term. “This is health care like any other health care.”

The Missouri House of Representatives’ consideration of HCS HB 419 directly contravenes the lawsuit that Hicklin and Lambda Legal won. The paragraph that expands its scope to include both minors and incarcerated people of any age reads: “No public funds may be directly or indirectly used, granted, or distributed to any entity or organization that provides gender transition procedures to any individual under 18 years of age or to an individual in the custody of a prison or correctional facility.”

The bill was prefiled in December of 2022, and on March 9, 2023, the Standing Committee on General Laws voted “Do Pass with HCS.” The bill has several more steps before becoming law, including going to the senate and being signed by the governor. Legislators began the second half of the 2023 session at the State Capitol on March 20, 2023.

With steady determination in her voice, Hicklin asserts that there are “people who care and who are fighting and will continue to fight.”

One person active in this fight is Katy Erker-Lynch, the Executive Director of PROMO, a Missouri-based LGBTQ+ advocacy organization. They describe this current cluster of trans-rights-related bills as indicative of larger political trends. “When you look at the bills that include bans on adults’ access to gender-affirming care, it just makes it so clear that the goal of this legislation is to erase trans folks and queer folks from Missouri and to say that you do not have control over your body … especially when you’re in the custody of the Department of Corrections. [The message is that] ‘we can only control some adult bodies, and to the extent that we can, we’re going to cause harm to trans folks.’”

Erker-Lynch also remarks that these bills have an unusual number of sponsors, rather than the more typical co-sponsors, and chalks this up to Missouri legislators’ eagerness to show their bases that they personally got legislation of this nature passed. Nationally, public opinion about transgender rights is much more complex.

PROMO says that legislation like this even being on the table has a wide-reaching impact. Erker-Lynch describes that impact as “shame and exclusion and anxiety and stress.”

She explains, “In policy, the work we do in Jefferson City is within a white-dominant bureaucratic culture, but it matters that we fight these bills, because allowing this rhetoric — allowing these bills to be debated — gives permission to erase people. Black and Brown transfemmes face more violence and homicide than anyone else in the LGBTQ community. As we allow this discourse to continue, violence against the most vulnerable in the trans community escalates, and people are emboldened. We’re trying to change the narrative.”

Hicklin describes prison as a microcosm of society and has seen that very same ripple effect play out in real time. She says that, for the vast majority of trans people, their risk of abuse escalates when guards or other prison authority figures misgender and disrespect them. It sends a signal to other incarcerated people that the guards will not protect a transgender individual. Hicklin notes that this is also true for transmasculine people being held in women’s prisons and that she knows a trans man who was raped while incarcerated.

In Hicklin’s eyes, this legislation, which is being sponsored and debated by government officials who are not medical professionals, reflects the elaborate administrative barriers an incarcerated transgender person must navigate in order to even have a shot at receiving gender-affirming health care, even after her groundbreaking lawsuit. In addition to consultation with a therapist and psychiatrist, this process still requires final approval from a centralized MODOC committee. Hicklin asserts that only gender-related health care recommendations are second-guessed in that manner.

Despite the profound challenges, Hicklin is far from the only trans person to have resided in a state prison and sought such care. She is aware of 75-100 people in Missouri Department of Corrections custody who have come out as transgender, many feeling more able to speak up about their true selves as a result of Hicklin’s case. Yet the legal imperative to provide gender-affirming health care to incarcerated transgender people (even if it comes at the end of a circuitous road) does not mean that concerns have vanished.

Hicklin points out that not all trans folks need or even desire transitional care, or have a clinical diagnosis of gender dysphoria. But for those who do experience the anxiety and depression often associated with dysphoria, she says that the environment that the MODOC has set up in order to access gender-affirming care only adds to that distress.

“They have to out themselves in a generally hostile environment, generally not in a place that’s of their same gender (like me in a prison of 800 men), fighting for access to care and not getting it — that’s the typical experience.” Hicklin also describes bleak prospects for nonbinary and gender-nonconforming incarcerated people, who may be met with zero understanding and therefore find it difficult to even begin a dialogue with opposition.

Lantz emphasizes that acknowledging the emotional strain of dysphoria is not the same as classifying being transgender as a mental illness. “In health care, oftentimes we have to have some sort of diagnosis in order to provide services, [but] a diagnosis does not mean pathology or that there’s anything wrong with the patient.”

She also says that a patient’s humanity and autonomy are central to the WPATH Standards of Care. “Patients have the right to make decisions about their care. My job is to make sure that they’re safe, not to make those decisions for them.” In practice, informed consent includes thorough and ongoing discussion of expected benefits and potential risks, so that a patient can choose what feels right to them. When a patient does access gender-affirming health care for the first time, Lantz describes the outcome as a “beautiful and amazing” transformation. “They’re alive — feeling like themselves for the first time ever.”

With so much at stake, Hicklin urges non-justice-involved LGBTQ+ folks to recognize that incarcerated people are not in any way a separate group. She sees this as crucial solidarity: “[Incarcerated] folks came from our communities and will return to our communities. So what do you do for your best friend? Do that. People who are incarcerated are very isolated. We used to be able to communicate back and forth between prisons, but that’s not allowed anymore. Someone might be the only trans person in that prison. So be a pen-pal; find a way to let people know they’re not alone.” One national organization with a pen-pal program centered on incarcerated LGBTQ+ individuals is Black & Pink.

Hicklin was released in early 2022 following appeals in multiple courts and the Brown v. Precythe (2021) ruling, which mandated that Missouri’s parole board comply with prior Supreme Court decisions guaranteeing opportunities for release to people who were sentenced to life without parole as minors. She continues to be an advocate and now serves as Vice President of the Board of Directors for Metro Trans Umbrella Group.

In spite of current legislative events in Missouri, Hicklin believes with absolute certainty that trans people cannot be erased. “We’re beautiful people. There may be a period where we have to fight … but please don’t give up hope, and hold onto each other until we get there.”