Transgender identity and psychiatric care in Italian prisons: a thematic analysis of systemic gaps and institutional challenges

Background: Transgender and gender-diverse (TGD) individuals face high levels of stigma, discrimination, and psychological distress, which are amplified in carceral settings. Italian prisons have introduced specialized sections for TGD inmates; however, limited empirical evidence exists on their function and the psychiatric, social, and institutional challenges emerging within them. Methods: A case-informed qualitative design was applied to four TGD inmates housed in a specialized prison section in Northern Italy. Data were derived from routine psychiatric and endocrinological assessments, administrative documentation, informal and semi-structured interviews, and multidisciplinary team observations. A thematic cross-case synthesis was conducted to identify institutional determinants of distress and barriers to gender-affirming care. Results: Three themes emerged. (1) Context-dependent fluidity in gender identity recognition and categorization: institutional frameworks relied on static binary models, contributing to confusion and psychological strain. (2) Intra-group tensions within designated housing: discrepancies in transition pathways, administrative criteria, perceived authenticity, and the presence of sexual minority inmates generated conflict and social exclusion. (3) Gaps in gender-affirming and psychiatric care: logistical barriers, limited staff training, reliance on telemedicine, and inconsistent access to hormone therapy disrupted continuity of care and exacerbated distress. Discussion: These findings illustrate how rigid systems and ambiguous housing policies may reinforce minority stress and undermine psychiatric well-being. Protective units can inadvertently reproduce exclusion when gender identity and sexual orientation are conflated or when criteria for placement remain unclear. Correctional systems should adopt flexible gender-recognition procedures, implement trauma-informed practices, develop distinct housing policies, establish standardized pathways for gender-affirming care, and provide specialized staff training to ensure dignity, safety, and improved mental health outcomes for TGD inmates.