BOP Program Statement 5260.01 § 4

a. Screening

Diagnostic screening and evaluation of GD can occur at any time throughout an inmate’s

incarceration. All diagnostic evaluations are documented in the electronic health record as a

Diagnostic and Care Level Formulation note. If primary care medical providers are diagnosing

GD, the diagnosis will be documented in the electronic health record as a Clinical Encounter

note.

If an inmate reports or presents a documented history of GD before incarceration, Psychology

staff will request the inmate to complete a BP-A0171 Record of Information Release form to

authorize the Bureau to obtain the inmate’s prior mental health records from community

providers who diagnosed or treated the inmate. Similarly, Health Services staff will request

completion of a BP-A0621, Authorization for Release of Medical Information form, to obtain

prior medical records relevant to the inmate’s care. Signed documents will be added to the

electronic health record. These signed documents will be added to the electronic health record

and Psychology staff will enter as a General Administrative Note. If the inmate refuses to sign

the records release form, this refusal will also be documented in the electronic health record as a

General Administrative Note.

As appropriate, a diagnosis of GD will be made by a mental health clinician or primary care

medical provider. The diagnosis will be added to the electronic health record. At a minimum, the

inmate will be classified and maintained as a Mental Health Care Level 2.

If referral to medical or psychiatric staff is needed, the mental health clinician will complete an

electronic referral to Health Services and document that request in the electronic health record as

part of a Clinical Contact or Consultation note.

5260.01 02/19/2026 PROPERTY OF US GOVERNMENT 4

b. Evaluation

A diagnosis of GD can encompass a diverse array of conditions, with widely differing

characteristics depending on the patient’s age of onset, mental health, intelligence, environment,

and motivation for identifying as the opposite sex. Like many DSM-V psychiatric conditions,

GD is complex and often accompanied by other psychiatric comorbidities.

All inmates diagnosed with GD will be individually evaluated. Anxiety, depressive, personality,

and posttraumatic stress disorders are mental health disorders that may coexist in those with GD.

Because any co-occurring medical or psychiatric disorders may complicate the treatment of GD,

a complete diagnostic and psychiatric/medical assessment of those with GD will be performed

by Psychology Services clinicians and Health Services, respectively. Documentation of this

evaluation will be entered into the electronic medical record.

Mental health clinicians or primary care medical providers will conduct a detailed clinical

interview, and consider the use of the following instruments (as applicable) to evaluate the

inmate:

 Clinical interview

 Beck Depression Inventory-II (BDI-II)

 Beck Anxiety Inventory (BAI)

 Wechsler Adult Intelligence Scale, 5th Edition

 Kaufman Brief Intelligence Test- 2nd Edition (KBIT-2)

 Montreal Cognitive Assessment (MoCA)

 Personality Assessment Inventory (PAI)

 Columbia Suicide Severity-Rating Scale Lifetime Recent (C-SSRS)

 Beck Scale for Suicidal Ideation (BSS)

 Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5)

 Utrecht Gender Dysphoria Scale- Gender Spectrum (UGDS-GS)

 If diagnosed with an autism spectrum disorder (ASD), the inmate may be additionally

assessed with the Adaptive Behavior Assessment System 3rd edition (ABAS-3)

The evaluation and testing results will be documented in the electronic health records as

Psychological Testing with results summarized in the Diagnostic Care Level Formulation note.

Primary care medical providers may document their diagnosis and evaluation of additional

medical concerns or treatment needs as a Clinical Encounter note.