The introduction of comments regarding the care of persons with gender identity disorder (GID) residing in prison settings began in 1998 with Version 5 of the Standards of Care (SOC), the first major revision of the SOC since 1985. Minor revisions to this brief section were made for Version 6 in 2001. Since 2001, there have been many legal and regulatory actions in countries where the SOC are widely used as the minimum standards to evaluate and treat persons with GID that have referenced this section in the SOC. The original paragraph addressing care for incarcerated persons has proven to be helpful by its existence, but limiting in its brevity and lack of scope. Version 7, likely to be a significant revision compared with the minor changes in Version 6, can be informed by the information that has come to light in the last 6 years, most notably through court actions that have used, or misused, the SOC. This invited article reviews the background of this section, rationale for revisions, suggested conceptual changes, and specific content for consideration for inclusion in Version 7 of the SOC.

The author reports on a case series of four inmates who engaged in attempted or completed surgical self-treatment of their gender dysphoria via autocastration, autopenectomy, or a combination in the absence of concomitant psychosis, intoxication, or other comorbidities that could reasonably account for this rare behavior. These behaviors occurred in the context of persistent denials of access to transgender health care in prison settings. The literature on genital self-harm is also reviewed. Incarcerated persons with severe GID may resort to life-threatening surgical self-treatments when persistently denied access to psychiatric evaluation and cross-sex hormonal treatment. In all cases of surgical self-treatment (SST; i.e., autocastration with the primary intent to reduce circulating testosterone levels) the intensity of gender dysphoria decreased compared to reported baseline levels, although symptoms of GID were still present. Of the four inmates, two were able to obtain access to cross-sex hormones after successful litigation at the time of this writing; another was not. One case remains active. This case series expands the limited literature on surgical self-treatment in the form of autocastration and autopenectomy with a focus on the potential influence of incarceration with denial of access to transgender health care.