The federal prison system will stop providing gender-affirming medical or social transition care to almost any transgender people, under a new policy released by the Bureau of Prisons Thursday.

Gender identity, the policy states, is “disconnected from biological reality and sex” and “does not provide a meaningful basis for identification.” The move upends nine years of federal policy and will affect more than 1,000 people diagnosed with gender dysphoria in prisons across the country, who had longstanding access to basic gender-affirming care.

The new policy states that trans people will not have access to surgery, clothing or toiletry items that align with their gender identity. People behind bars on hormone medications will be forced to taper off them. Instead, the primary treatments will be therapy and psychiatric medications like antidepressants.

The policy, which was signed on Thursday and filed in federal court at a hearing in Washington, D.C., uses the phrase “sex trait modification surgery” to describe procedures that earlier iterations of the manual called “gender-affirming surgeries.” “The Bureau will not provide sex trait modification surgeries to address” gender dysphoria, it says.

The changes are in keeping with an executive order President Donald Trump signed last year, almost immediately after taking office, called “​​Defending women from gender ideology extremism and restoring biological truth to the federal government.” That order said the federal prison system “shall ensure that no Federal funds are expended for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex.”

As part of a lawsuit challenging Trump’s executive order, a federal judge had ordered the prison system to continue providing hormones and social accommodations. However, in court papers and interviews with The Marshall Project, transgender people have described their access to hormone treatments and social transition supports as inconsistent.

Attorneys representing transgender people in that suit said they will continue to press for their clients to receive the care they need. “It’s clear that this new policy is a ban on gender affirming healthcare,” said Shana Knizhnik, an attorney with the ACLU. “This is a policy that disregards the medical needs of our plaintiffs.”

The Bureau of Prisons did not immediately respond to a request for comment on the new policy.

For the last nine years — including during Trump’s first administration — the federal prison system operated under a policy that allowed transgender people to be offered hormones, surgery, and placement in prisons that matched a person’s gender identity — although the latter two rarely happened in practice. Alix McLearen authored earlier versions of the Bureau of Prisons’ transgender policy manuals as a senior official at the agency before her retirement in 2024. “Denying hormones to people in distress and withdrawing them from people who are stable undermines safe facility operations,” she said. “From a corrections management perspective, this is not just cruel, but reckless.”

The new policy is the latest move amid a culture war targeting transgender civil rights nationwide, with hundreds of anti-trans bills passed in state legislatures over the last several years. These efforts culminated last year with the Supreme Court upholding gender-affirming care bans for young people, which have passed in some 20 states. Jared Littman, an attorney for the government, cited that decision in Thursday’s hearing, arguing that the Supreme Court “made it pretty clear” that a ban with “any conceivable rational basis” must be allowed. Amid this push, prison systems in Georgia, Kentucky, Utah and Florida have banned access to gender-affirming care.

People incarcerated in Georgia are suing state officials over their policy, which is very similar to the new federal one. “If they implement that plan and it’s not enjoined, people will die,” said Chinyere Ezie, an attorney representing the plaintiffs in the Georgia suit, of the new federal prison policy. “People will die by suicide. People will die or be severely hurt from castration attempts. People who do not lose their lives will experience the very extreme physiological symptoms of hormone therapy withdrawal in addition to psychological symptoms, including depression, anxiety, and suicidal ideation.”

Stopping hormone therapy can lead to hot flashes, mood swings and insomnia, and may affect bone density, leaving people vulnerable to breaks and fractures. More than 600 people with gender dysphoria were getting gender-affirming hormones in federal prison, according to court documents filed last year.

C.C. Hunter, who is incarcerated in a men’s facility in Butner, North Carolina, was diagnosed with gender dysphoria and prescribed gender-affirming hormones by federal prison doctors and psychologists. If they were discontinued, “I would think and feel like the world was ended,” she said. “Like my life doesn’t really matter to these people.”

The changes come on the heels of a memo the Trump administration issued in December to auditors who inspect federal prisons, telling them to ignore provisions of a federal law called the Prison Rape Elimination Act that were designed to keep transgender people safe from sexual assault. Those provisions conflict with Trump’s executive order, the memo said. Transgender people are at greatly increased risk of sexual assault while they’re incarcerated compared to cisgender people.

The Prison Rape Elimination Act requires that officials deciding where to house transgender people give “serious consideration” to the “inmate’s own views with respect to his or her own safety.” Even under that policy, across both Democratic and Republican administrations, gender-affirming housing was rare, and surgery rarer still. By the end of the Biden administration, fewer than two dozen trans people were housed according to their gender identity. Two people had received gender-affirming surgery, only after their lawsuits led to a settlement or a judge’s order.

But hormones and social accommodations were readily available after medical and psychological evaluation. Special clothing and commissary items were also available, like bras for transgender women or chest binders for transgender men.

That began to change last year after Trump’s executive order led to a chaotic response in federal prisons, when transgender people had clothing and medications confiscated, only to be redistributed again, while wardens awaited guidance from Washington.

The new policy says no one newly diagnosed with gender dysphoria can have access to hormones, and anyone currently on hormones must taper off. Those who have already had surgery and those who have been on hormones “for an extended period of time and develop severe…withdrawal effects from tapering” may have their tapering plan “adjusted as necessary.” But the policy does not outline any scenario where a transgender person can stay on hormones indefinitely, as has long been the practice.

Courts have held that prisons issuing a blanket ban on any kind of medical care is a violation of the Constitution. In dozens of cases, judges have said prisons are required to provide gender-affirming hormones as needed. Denying the treatment, without an individualized assessment of each patient’s needs, can be cruel and unusual punishment, they found.

The new federal prison policy says that each person with gender dysphoria will get an “individualized treatment plan,” but there is a categorical ban on surgeries and new hormone prescriptions.

Experts caution that for many people, therapy alone is not adequate. Dan Karasic, a psychiatrist at the University of California, San Francisco, helped develop international standards for the treatment of transgender people and is an expert witness for prisoners in the ongoing lawsuit challenging the Bureau of Prisons’ implementation of Trump’s executive order. “For those people for whom hormones and surgery are indicated, psychotherapy is not a substitute. Psychotherapy does not make gender dysphoria go away. You are substituting an intervention that’s been demonstrated to be effective with one that has not,” Karasic said.

Some of the language in the new policy is nearly identical to a 2024 Florida policy that experts likened to “conversion therapy,” a discredited practice that claims to cure homosexuality. Under Florida’s policy, the state’s prisons eliminated access to women’s clothing and undergarments, stopped providing accommodations that allowed trans women to grow their hair long, and greatly restricted access to gender-affirming hormones.

“First, they made her cut her hair, then they took her bra away,” said LaTrisha Ramon, whose daughter Sauge Smith was incarcerated in Florida. Smith had well-developed breasts after years on hormones, and the prison uniform was a thin white t-shirt, which left her feeling exposed and unsafe. “Imagine walking around a men’s prison without a bra.”

Smith died by suicide in a Florida prison last year. Friends and family blame the prisons for suddenly stopping her gender-affirming care.

The Florida Department of Corrections has not responded to emails and a records request regarding Smith’s death. In an email to The Marshall Project, Smith’s partner, Ralph Miller, asked, “How many situations like Sauge is needed before it’s acknowledged that this is seriously not a game?”