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Beginning gender change in prison is a long shot 

Bradley Manning may want to live as a woman, but the young man sentenced to prison this week for leaking hundreds of thousands of secret government documents will face a difficult — if not impossible — task of beginning to switch his gender behind bars. Manning, 25, announced through his lawyer on TODAY Thursday that he intends to request hormone therapy while at Fort Leavenworth prison. "I a
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Bradley Manning may want to live as a woman, but the young man sentenced to prison this week for leaking hundreds of thousands of secret government documents will face a difficult — if not impossible — task of beginning to switch his gender behind bars.

Manning, 25, announced through his lawyer on TODAY Thursday that he intends to request hormone therapy while at Fort Leavenworth prison. 

"I am Chelsea Manning. I am female," the Army private wrote in a statement read on TODAY Thursday. 

Throughout Manning's court-martial for divulging government papers to the website WikiLeaks, the soldier’s gender confusion was a factor used by the defense.

The move raises a host of questions about Manning, about transgender inmates in the U.S. -- and about the treatment itself. Here are answers from experts and advocates familiar with sex-change issues.

Can Manning get hormone therapy in a U.S. military prison? 

Manning is being held at the military prison in Fort Leavenworth, Kan., where the now discharged soldier is expected to serve at least seven years and up to the full sentence of 35 years. 

“The Army does not provide hormone therapy or sex-reassignment surgery for gender identity disorder,” Kimberly Lewis, a spokeswoman for the prison, told NBC News. 

Manning's lawyer, David Coombs, told TODAY that he's "hoping" Fort Leavenworth "would do the right thing" and provide hormone therapy for Manning. "If Fort Leavenworth does not, then I'm going to do everything in my power to make sure they are forced to do so."

Coombs said that Manning hasn't discussed whether to pursue sex-reassignment surgery while in prison.

Why would he need such treatment?

Manning reportedly expressed ongoing distress over gender confusion and created an identity dubbed “Breanna” while deployed, and now identifies as a "she" named "Chelsea." She was diagnosed with gender dysphoria, the preferred term for gender identity disorder, or GID, according to Dr. David Moulton, the defense’s expert on forensic psychiatry. It’s a rare condition in which people feel that their physical gender does not match who they are on the inside.

In a statement read on TODAY, Manning wrote: "Given the way that I feel, and have felt since childhood, I want to begin hormone therapy as soon as possible. I hope that you will support me in this transition."

Have other prisoners received hormone therapy or sex-change surgery?

No inmates have received sex-reassignment surgery while in U.S. prisons, though dozens of lawsuits have forced changes at the state and federal level that have opened the door to such treatment, said Jennifer Levi, director of the Transgender Rights Project for the Gay & Lesbian Advocates and Defenders, or GLAD.

In the highest-profile case so far, a Boston judge told Massachusetts officials to grant the procedure last year to a transgender prisoner, Michelle Kosilek. Kosilek, formerly known as Robert, is facing a life sentence for the 1990 murder of wife Cheryl Kosilek. Kosilek's doctors have said that surgery is the only treatment that will fully address her gender identity disorder; she attempted castration and tried to commit suicide twice while held in an all-male prison. That court decision is pending on appeal. Kosilek has already received hormone therapy and laser hair removal.

In this undated photo provided by the U.S. Army, Pfc. Bradley Manning poses for a photo wearing a wig and lipstick. Manning emailed his military therapist the photo with a letter titled,U.S. Army via AP

Other inmates have received hormone therapy and other care for transgender issues. Under old rules, transgender inmates housed by the federal Bureau of Prisons were treated only for their existing conditions when they were admitted to prison. If they took hormones, for instance, that was maintained. But in 2010, after a lawsuit, the prison bureau changed its policy to allow treatment and care for problems diagnosed after incarceration. “Treatment options will not be precluded solely due to the level of services received, or lack of services, prior to incarceration,” the new policy states. That opens the door to new options, including surgery.

Very little is known about transgender inmates in military prisons, advocates say. Manning's request may even be unprecedented.

How often does this happen?

No one knows how many of the nearly 2.3 million prisoners in the U.S. are identified as transgender. A 2010 study by the California Department of Corrections identified more than 330 transgender inmates in a population of about 160,000, equal to about 0.2 percent. But the National Center for Transgender Equality estimates that the actual figure may be much higher. When that group surveyed transgender people in 2011, officials found that 16 percent of nearly 6,500 respondents reported that they’d been jailed at some time in their lives.

Why is this the prison's problem?

Doctors who treat transgender people and advocates who lobby on their behalf say that inmates are legally entitled to health care while incarcerated -- including services for gender identity issues.

“Treatment for people with severe gender dysphoria is medically necessary,” said Dr. Sherman Leis of the Philadelphia Center for Transgender Surgery, who performs sex-change operations three days a week.

Just as diabetics need insulin and people with heart problems need surgery, inmates with gender identity-related health problems require the most appropriate treatment, said Mara Keisling, executive director of the National Center for Transgender Equality.

“This is America; we do not deny prisoners health care,” Keisling said. “What happens if they break a leg while they’re in custody? What happens if they develop schizophrenia? It is illegal to withhold those treatments.”

What kind of ‘treatment’ are we talking about? 

For those in and out of prison, switching genders is a protracted, complicated process that involves years of psychiatric counseling, hormone therapy and -- sometimes, but not always -- surgery, experts say.

Male-to-female transgender people typically take the female hormone estrogen in sufficient doses to influence the development of breasts and other secondary sex characteristics. They must receive adequate regular doses for the rest of their lives to maintain their new gender. They often also undergo laser hair removal.

If surgery is indicated, it can involve a range of procedures including removal of the original sex organs and reconstruction of new genitals. Other surgeries can include removing or augmenting breasts and reshaping facial contours, Leis said. 

Coombs, Manning's lawyer, told TODAY that his client's final goal is not necessarily surgery. 

"No, I think the ultimate goal is to be comfortable in her skin and to be the person that she never had an opportunity to be," Coombs said.  

How much does it cost? And who pays?

Cost ranges widely from $12,000 to $30,000 or more for surgery with ongoing costs of up to $200 a month for hormone therapy and more for psychotherapy.

If a prisoner receives care while incarcerated, the taxpayers would foot the bill, advocates say.

Can this be a ploy for men to get into a women's prison?

GID is diagnosed by a doctor and the life-altering treatment must be prescribed. Besides, prisons usually go by birth gender when assigning inmates, so even after gender reassignment, a newly female prisoner could end up in a male population— or in isolation for her own protection.

Fort Leavenworth spokesman George Marcec told the Associated Press that Manning would need to petition for a transfer to a federal prison to receive hormone treatment. In addition, the prison staff can separate high-risk prisoners from the general population based on the level of security risk to the inmate and others, he added.

Officials with the United States Disciplinary Barracks said that they have procedures to ensure that Manning and any other transgender inmates are protected from abuse and assault while in custody. 

"The USDB has implemented risk assessment protocols and safety procedures to address high risk factors identified with the Prison Rape Elimination Act," the agency said in a statement.