Lyralisa Stevens, who was born male but lives as a female, is serving 50 years to life in a California prison for killing a San Bernardino County woman with a shotgun in a dispute over clothes.
Stevens is one of more than 300 inmates in the state prison system diagnosed with Gender Identity Disorder, a psychiatric condition addressed in free society with hormone replacement therapy and, in some cases, sex reassignment surgery.
Prison officials have provided female hormones for Stevens since her incarceration in 2003. But now she is asking the 1st District Court of Appeal in San Francisco to require the state to pay for a sex-change operation.
Stevens, 42, and her expert witnesses say that surgery is medically necessary, and that removal of her penis and testicles and transfer to a women's prison are the best way to protect her from rape and abuse by male inmates.
As prison officials have struggled to address chronic overcrowding, the constant threat of gang violence and a health system that federal judges have equated with "cruel and unusual" punishment, they have also gone to court multiple times to answer allegations that they failed to properly treat and protect transgender inmates.
Judges have sided with transgender prisoners — who according to a UC Irvine study are 13 times more likely to suffer sexual assault than other inmates — on some significant cases. In 2009, the California Supreme Court ruled that an inmate could sue guards for failing to protect her from repeated rapes and beatings by her cellmate. In 1999, an appeals court ordered prison officials to provide hormone therapy to inmates who were already taking them when they arrived. The treatments cost about $1,000 a year per prisoner.
A ruling in Stevens' favor would make California the first place in the country required to provide reassignment surgery for an inmate, according to lawyers for the receiver appointed to oversee California's troubled prison health system. They argue that the state should be required to provide only "minimally adequate care," not sex-change operations that cost $15,000 to $50,000.
Stevens, who has a slight build — 5-foot-6 and about 115 pounds — and entered prison with silicon injections in her breasts and hips to feminize her physique, said in a court filing that she feels like she's under threat of sexual assault in the men's facility and wants the surgery, in part, so she'll be sent to a women's institution.
"The male inmate is not expecting to see breasts … in the shower next to him," Stevens wrote. The situation can lead to violent disputes among the men and sparks attacks against transgender inmates, who may have less upper body strength because of the hormone therapy, Stevens said.
In a court filing supporting Stevens' petition, psychotherapist Lin Fraser said she has "grave concerns" for Stevens' safety because she "had been put alone in cells all night long with men who threatened and abused her."
California law requires prison administrators to assign the state's nearly 162,000 inmates to men's or women's institutions based on "gender," which officials determine solely by a prisoner's genitals. Richard Masbruch, who tried multiple times to castrate himself while in a Texas prison and eventually succeeded, is in the California Institution for Women inChino. Masbruch, who goes by the name Sherri, was transferred from Texas to serve 40 years for a 1991 rape in Fresno.
While confronting complaints and lawsuits by transgender inmates challenging their housing assignments during the mid-2000s, the California prison system commissioned a study by UC Irvine sociologists to help them understand the small, uniquely vulnerable population. The study found that 59% of transgender inmates said they had been raped or otherwise sexually assaulted behind bars, compared with 4.4% of the general prison population, lead researcher Valerie Jenness told the state Senate Public Safety Committee.
Despite those numbers, 59% of transgender inmates said they did not want to move to a women's institution.
"The advantages of being in a men's prison include the pursuit of sex and the possibility of securing a male partner," Jenness said. "Concern about safety is not a main factor in predicting [housing] preferences."
Stevens declined to join a group of transgender inmates interviewed by The Times recently at the prison system's main medical facility in Vacaville. But six others — of the 30 to 50 transgender inmates housed there at any given time — spoke candidly about their lives in prison.
Thomas Strawn, 52, who uses the name Lisa and is serving a life sentence after a third-strike conviction for burglary, said she is in a committed relationship with the man in the next cell and would not want to move.
"I stayed single for an entire year when I got here," Strawn said. "But now I got with somebody and I've been with him now two years."
Others, such as convicted killer David, or Bella, Birrell, 58, who said she had been raped in prison, would like to be transferred to a women's facility. "You don't have to worry about the constant harassment like you get from the men here," she said.
Only two of the six said they would be interested in a sex change operation if a court order compelled the state to pay the costs.
"I had made plans to try to get [the surgery] done before I committed the crime that I did," said Steve Alamillo, 39, who goes by Nikkas and is serving life for first-degree murder. "If the state can do that stuff, absolutely."
Willie Murphy, 47, who is also known as Mena and is serving life on a third-strike conviction for burglary, was among the majority, preferring to "keep what I got."
Surgery is where the California Department of Corrections and Rehabilitation draws the line.
"A prison is not required by law to give a prisoner medical care that is as good as he would receive if he were a free person, let alone an affluent free person," attorney Steven J. Bechtold, who represents the receiver, wrote in the state's response to Stevens' petition for the operation.
The prison system has lost on a similar point before. The state provides hormone therapy today because a federal court found in a 1999 case that failing to continue treatment for inmates who were on hormones before coming to prison amounted to cruel and unusual punishment.
"We regularly get questions about why we are treating these patients," said Dr. Joseph Bick, chief medical officer at Vacaville. "The bottom line is, not only is it appropriate, but it's mandated by federal courts."
Stevens, who has fathered three children, argues in her court case that the cocktail of estrogen and testosterone-blockers the state has provided since her incarceration in 2003 are no longer adequate to combat her emotional distress. Failing to provide surgery could increase her "risk of future self-harm," wrote Dr. Denise Taylor, a medical expert who filed a brief on Stevens' behalf.
Taylor also argued that leaving Stevens on estrogen therapy could lead to the reemergence of a benign tumor removed from her brain in 2005.
Bick, who filed a declaration with the court in January defending the state's position, said the previous tumor was not believed to be caused by estrogen therapy. He said Stevens' treatment in prison has been "adequate and successful."
Perhaps the biggest threat to Stevens' case is the state's budget crisis, in the view of several transgender inmates interviewed. They worried that a judge might be reluctant to rule in her favor with the state facing hard times.
"If I were out there, I wouldn't understand, especially if I was unemployed or trying to support a family," Birrell said.
"But if you could only go into our heads for a day or two to see what we go through internally," she said, "you would get a greater appreciation of how devastating it is to be a transgender individual locked up in a man's prison."