"The greatest loss is the dying I do inside a little bit every day," said Michelle Kosilek, an inmate who is serving a life sentence for murder.
Kosilek was Robert Kosilek when he was convicted in the killing of his wife. In 1993, while in prison, he legally changed his name to Michelle.
Since then, Kosilek has been fighting for the state Department of Correction to pay for sex change surgery, which can cost from $10,000 to $20,000. After two lawsuits and two trials, the decision now rests with a federal judge.
Kosilek's case has become fodder for radio talk shows, often provoking outrage among callers on topic of whether the state should pay for a convicted murderer's sex-change operation.
The case is also being closely watched by attorneys and advocates across the country who say Kosilek is an example of the poor treatment transgender inmates receive in prison.
Courts in several other states have ordered prison systems to allow transgender inmates to receive psychotherapy and, in some cases, hormone shots. But no inmate in the country has ever succeeded in getting a court to order a sex change operation, according to advocates.
"If people are not treated, they suffer tremendously," said Shannon Minter, a board member of the Transgender Law and Policy Institute. "It's just as cruel to withhold treatment for gender-identity disorder as it is to withhold treatment for any other medical issue."
In Massachusetts, four of the 12 inmates diagnosed with gender-identity disorder are receiving hormone shots, including Kosilek. Prison officials also allowed Kosilek to receive laser hair removal, female undergarments and some makeup.
Inmates in several other states have sued prison officials for sex change operations. Like Kosilek, they argued that gender-identity disorder is a serious illness that can lead to severe anxiety, depression, suicide attempts and self-castration. They argue that treatment for their condition is a "medical necessity" and denying it would violate the Eighth Amendment's prohibition against cruel and unusual punishment.
"It's the most absurd thing I've ever heard of," said Wisconsin state Rep. Mark Gundrum, who helped write a state law that bars the Department of Correction from using tax dollars for hormone therapy or sex-reassignment surgery.
He said the framers of the Constitution "were envisioning preventing people from being burned in oil or burned at the stake," not simply refusing to use taxpayer dollars for inmate sex changes or breast implants.
The law was introduced after Wisconsin inmate Scott Konitzer filed a lawsuit seeking a sex-change operation. The law took effect in January, but is being challenged by the American Civil Liberties Union and Lambda Legal.
In Colorado, inmate Christopher "Kitty" Grey, who is serving 16 years to life for molesting an 8-year-old girl, is suing the state to provide him with a gender specialist he hopes will determine that he needs a sex-change operation. The state Department of Corrections is already giving Grey female hormones.
"For all intents and purposes, I am a woman in a man's prison," Grey told the Denver Post in an interview earlier this year. "That's like putting a cat in a dog kennel," Grey said.
Colorado officials say that providing a sex-change operation for Grey or any of the other two dozen transgender inmates in the state's prisons would create security concerns.
Dr. James Michaud, chief of mental health for the Colorado prison system, said he does not believe sex-change operations are medically necessary.
"There are certainly people who are transgender who want surgery and who want to appear different, but I don't think that makes it medically necessary," he said.