The Prison-Like Public Hospital Systems Disproportionately Packed With Gay Men

At Coalinga State Hospital, located in a desolate, dusty part of California's Central Valley, 200 miles north of Los Angeles, 37-year-old Cory Hoch stands out. He's well liked by other patients, and his dry sense of humor and lively intelligence come across almost immediately. His feathered earring and neon-green sneakers infuse some color into the surroundings, while his khaki scrubs identify him as a patient.

Since the age of 19, Hoch has lived most of his life in some form of cage. He is one of the more than 5,000 people in a hospital system found in 20 states and at the federal level. They are trapped in a post-prison purgatory for those convicted of sex crimes, a system called "civil commitment." While we found that many people with sex offense convictions are released after their sentences are up, some, like Hoch, serve their time and then are held indefinitely in government-run hospitals, exchanging one form of prison for another.

Under civil commitment, Hoch is supposed to be treated (and held) only until he is considered no longer a "risk to the public," according to mental health experts contracted by the state. In reality, he may spend the rest of his life locked up. Perhaps more troubling is the overrepresentation of people like Hoch -- gay, bisexual, and queer men -- who are trapped in this system.

The world's gayest club?

The queerness of civil commitment isn't news to the people close to the issue. Resident newsletters, media reports of same-sex marriages occurring inside the facilities, estimated and self-reported accounts from people inside, and observations from advocates all point to a disproportionate number of queer men among those locked behind institutional walls.

The March 2010 issue of The Ally, Coalinga's newsletter produced by and for people in civil commitment, offers a vivid snapshot: "Men have recently taken to walking the halls arm-in-arm," noted an op-ed. "Lovers are out and about, walking around with their hands in each other's hip pockets, or just holding hands as they stroll." Another article references "conservative estimates" by social workers and psychologists pegging Coalinga's population as 55 to 65 percent gay or bisexual, and 1 percent transgender.

In 2012, the national newsletter for Citizens United for the Rehabilitation of Errants, a small national advocacy group for people in civil commitment, surveyed its readership on the "anecdotal trend we have observed that gay men are being disproportionately targeted for civil commitment." With 80 responses from 11 states, the survey wasn't scientific or representative, but it found that 11 percent self-identified as gay while another 23 percent stated that they were bisexual.

A 2013 article in the Star Tribune of Minneapolis, about the imminent marriage of two male couples at the Moose Lake Treatment Facility of the Minnesota Sex Offender Program, quoted one resident who estimated "30 to 35 percent" of residents were in relationships with each other. Enough residents identify as LGBT that in June 2017, Moose Lake held a Pride celebration.

At Larned State Hospital in Kansas, Mark (last name withheld to protect his privacy) estimates that 75 percent of the people at his facility identify as gay or bisexual. Tapatha Strickler, a therapist who worked at Larned between 2012 and 2014, agrees that "homosexuals are overrepresented" at the facility, which she compares to a supermax prison.

Michael Bass, until recently confined at the Central New York Psychiatric Center in central New York, said that "well over 50 percent" of CNYPC's population is out as gay or bisexual. "The library is almost like a gay club," he says -- one where there is no music, touching is forbidden, and everyone wears the same tan hospital uniform.

Anecdotal evidence from civilly committed men, institutional medical staff, and advocates for prison reform suggests an overwhelming bias: Nearly 40 percent are men who have sex with other men (MSM), whether or not they self-identify as gay, bi, or same-gender loving. Compare those numbers to a 2016 Gallup poll, which indicates that only 3.7 percent of American men replied yes when asked, "Do you personally identify as lesbian, gay, bisexual, or transgender?" making the vast numbers of gay and bisexual men in civil commitment even more disproportionate.

At the same time, pinning down the exact number of MSM in civil commitment is difficult. As in other spaces segregated by gender, convenience inevitably plays a role in sexual partnering (borrowing from pejorative prison lingo, some may be "gay for the stay"). And unlike general prison records, even basic information about this population is considered confidential under health privacy laws.

This makes it almost impossible to determine who is in civil commitment, what they are in for, what treatment they receive, and where bias against LGBT people may emerge in the system, effectively cloaking any discrimination and potential violation of rights.

We spent nearly a year speaking to dozens of medical professionals and people in civil commitment, attempting to confirm what we'd heard from activists and uncovered in the scant media reports on the topic. But backing up our suspicions with hard data about who winds up locked up proved elusive.

Even more perplexing is that there is no clear evidence these costly programs are even effective. No research exists to suggest the 20 states with civil commitment laws have lower rates of sexual violence or recidivism, compared to rates in the 30 states without such laws.

Commonly viewed as the worst of the worst, this population of inmates is invisible. So much so that even civil rights groups avoid them. It is true that many people in the category of "sex offender" have been convicted of significant harm to another person (often a minor), but the definition is alarmingly vague.

Courts can convict a variety of people as sex offenders, including sex workers, men soliciting consensual sex from other men, people who do not disclose their HIV status prior to sexual activity, and people who pee or go nude in public. Though it does not excuse the fact that in many cases the men in civil commitment have harmed minors, a large-scale survey in the journal Advances in Clinical Child Psychology looked at data from dozens of sex offender studies and found that 40 to 80 percent of juvenile sex offenders were victims themselves. But the troubling lack of data about the civilly committed means we may never know if men who have sex with other men are being disproportionately targeted for civil commitment.

The "pipe dream" of freedom

Eric S. Janus, the Mitchell Hamline School of Law professor who literally wrote the book on civil commitment -- Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State -- explains over the phone that he has long "had a hunch" MSM are overrepresented, but that no one collects such data.

Another reason for this lack of data collection is that civil commitment isn't a typical court process. Beforerelease from prison, evaluators (two forensic psychologists in most states) are tasked with identifying those they believe are likely to reoffend, based on controversial test data, which is key in the civil court decision that decides whether a person is committed.

Shan Jumper is clinical director at both the Illinois Department of Human Services Treatment and Detention Facility, a civil commitment facility in Rushville, Ill., and at Liberty Healthcare Corporation, a private medical contractor for U.S. prisons. In 2012, Jumper and two colleagues published a profile of the 377 men detained or committed under Illinois's sexually violent predator law between January 1998 and August 2008.

While having a male victim doesn't necessarily mean the person identifies as gay or bisexual, Jumper's study found that almost 40 percent of the civilly committed in Illinois have male victims. (The vast majority of people in civil commitment nationally are male; out of the nearly 1,000 patients in California, only one is female.) The researchers compared these findings with similar studies from Texas, Florida, Wisconsin, Washington, California, Arizona, and Minnesota. Across these states, at least 30 percent and as high as 47 percent of men in civil commitment had at least one male victim.

Some critics argue that outdated assessments and scientifically inaccurate testing could be to blame. The civilly committed, as well as mental health professionals, believe the specialists and the tests they use can be "profoundly homophobic," in the words of forensic psychologist and evaluator Karen Franklin.

Based in California, Franklin has worked as a civil commitment evaluator in her home state, plus in Iowa, in Washington, and at the federal level. Her belief -- which five other evaluators we spoke to shared -- is that there is widespread "implicit bias" and "subjectivity built into every single step of the process."

In 1998, the American Psychiatric Association came out firmly against civil commitment laws, finding them to be a "serious assault on the integrity of psychiatry."

Bias seems to be baked into the risk assessment phase. The Static-99R test, a 10-question checklist created in 1999 and revised (thus the "R") in 2012, is a widely used evaluation tool. Essentially consisting of calculations around the mathematical probabilities of recidivism, it is based on data about people convicted of sexual offenses: age, nature of conviction, marital status, and whether they reoffended or not. But professional associations, academics, and practitioners have grave reservations regarding its accuracy and effectiveness.

For instance, admitting to having a male victim nets the respondents more points, which reportedly increase their risk of reoffending. Another question asks: "Ever lived with a lover for at least two years?" An inmate is considered less risky if they have had a two-year live-in relationship prior to imprisonment. Living with a same-sex lover used to be and sometimes still is risky for many in the U.S.

In the Department of Justice's 2014 report Sex Offender Management Assessment and Planning Initiative, sex offender evaluator Dr. Phil Rich noted that the prevailing assessment tool for youth under 18 considers as risk factors particular circumstances that are far more prevalent among LGBT youth. Those more likely to score poorly on "stability of current living situation," for example, include LGBT youth who may be forced out of their homes and schools due to homophobia.

At age 7 and 9, Hoch was molested by two of his older siblings, giving him a worse score under "history of physical assault," which may have negatively affected his chances for release.

Another assessment tool that state courts have called ineffective, yet is still employed, is the penile plethysmograph. Developed in the 1950s, the PPG consists of a device attached to the penis to monitor its width as images are shown to an individual. Even a subtle change can be taken as arousal and thus affect a person's risk determination. Other responses, including turning away or failing to look at the image, can be considered cheating.

The informally named "peter meter" was deemed by a California court in 2006 to be an "Orwellian procedure." The court further stated, "There is a line at which the government must stop. Penile plethysmography testing crosses it." Yet it's still a part of the process that the state uses to justify indefinite confinement.

In the over two decades since California's civil commitment program started in 1996, out of a population of more than 1,000, only 272 were ultimately unconditionally released. While treatment varies, methods usually involve group therapy and a drug regimen. In many states, lie detector tests (considered unreliable and inadmissible as evidence in criminal courts) are mandated for anyone to move from one stage of treatment to another.

Hoch describes treatment as a "useless pipe dream," and he's not the only one. Approximately two-thirds of Coalinga's population refuses to participate in treatment, according to a 2009 report by the California Coalition on Sexual Offending, a group of doctors and law enforcement officials that advises California agencies on sexual abuse.

Other reasons offered for the low buy-in from inmates: a revolving door of therapists; that disclosures made in therapy may be used in arguments against the men's release; an environment that resembles a prison more than a hospital; the vague criteria for release; and the tiny number of people released -- even after being treated for years, or decades.

Courts have also raised concerns. In 2015, a U.S. District Court judge described Minnesota's program as "draconian" and unconstitutional after advocates highlighted that zero inmates had been released since it launched in 1994. Also in 2015, a British court barred the extradition of an individual charged with a sexual crime in the U.S. In the third case of its kind, the British court cited civil commitment as violating the European Convention on Human Rights. With little transparency and almost no public awareness about civil commitment, it's easy to understand why a resident at Kansas's civil commitment facility told us, "The only way to get out is with a tag on your toe."

No one watches the watchers

Jon Brandt is a Minnesota-based clinician who has assessed and worked with those convicted of sexual violence as well as their victims since the 1980s. He feels for the men who he believes pose no threat but exist in the limbo of an unjust system. A hundred years from now, Brandt says "we're going to look back at the turn of the century and realize how wrong -- how wrong -- we've had it."

At 17, Hoch, who had been adopted as a toddler by a conservative Christian family in Southern California, was sent to the Emily Griffith Home for Boys (now Griffith Centers for Children Chins Up Group Home), a Colorado residential facility for "troubled" youth who have been sexually abused and have abused others. He was later imprisoned, at 19, for molesting a 7-year-old boy. He served some of his three-year sentence in solitary confinement -- justified by authorities as being for Hoch's own protection due to his physical disabilities. (Hoch has hydrocephalus; excess spinal fluid puts pressure on his brain. Now legally blind as a complication from his condition, he uses a wheelchair, and lives with trauma from being raped by another inmate.) He served his time, but freedom never materialized.

Hoch now has "mixed emotions" about a lawsuit he filed against Coalinga's administrators for inadequate care, and a trial this summer, when he could be freed under California's compassionate release law for people with disabilities. But he isn't optimistic about his chances. Civil commitment is no one's cause celebre. Even civil rights groups and prominent LGBT organizations avoid it. For example, a spokesperson for the Human Rights Campaign, told us it "doesn't do work in this area." Our face-to-face meeting with Hoch was his first with an outsider -- not a doctor, nurse, or public defender -- in his 10 years at Coalinga.

Exit signs

Brandt reports that clinicians he speaks with at gatherings such as the Association for the Treatment of Sexual Abusers' annual conference insist that "20 to 80 percent" of people in civil commitment across the nation "shouldn't be there." The men inside wait on the rest of us to notice.

Other countries are developing proactive alternatives to civil commitment. Germany's "Kein Tater Werden" ("Don't Offend") program, founded in 2005, is revolutionary in inviting people who "like children in ways [they] shouldn't" to get free and nonstigmatizing treatment before the harm starts. A partner project was launched in Switzerland in 2009, but there is no U.S. equivalent.

Even if he is eventually released, Hoch knows that a conviction for molesting an underage boy will affect his chances on the outside -- for employment, housing, and relationships. A few things seem clear in the two-plus years we have known Hoch: A decade at Coalinga hasn't facilitated any rehabilitation -- he readily admits he now has more mental and physical health problems than when he entered the hospital. As a preventative measure, or as a deterrent, his seclusion is unproven. As our nation grapples with its massive incarcerated population (two million locked up and counting), Hoch's story illustrates a hidden, queer niche of the prison industrial complex where government resources feed a destructive system that isn't helping to end sexual abuse.

This article was reported in collaboration with The Investigative Fund at The Nation Institute.