The facility where the convicted Wikileaker will serve a 35-year sentence says it won't provide hormone therapy, but the legal precedent for transgender inmates is complicated

Patrick Semansky / AP Bradley Manning is escorted out of a courthouse in Fort Meade, Md., on July 30, 2013.

Bradley Manning’s revelation that she is transgender and wants to live as a woman known as Chelsea was met with an immediate roadblock from the military prison where she is set to serve 35 years for revealing government secrets. Fort Leavenworth Army Prison “does not provide hormone therapy or sex-reassignment surgery for gender identity disorder,” a spokeswoman said Thursday. But the law may see things differently.

Appearing on the Today show, Manning’s lawyer David Coombs said his client wants hormone therapy while in prison and he is prepared to “do everything in my power to make sure they are forced to… do the right thing.” Manning has not said whether she would pursue sex-reassignment surgery. Gender dysphoria, according to the American Psychiatric Association, applies to individuals “whose gender at birth is contrary to the one they identify with.” It is diagnosed by medical doctors and standard treatment often includes hormone therapy, which can reduce the risk of depression or even suicide.

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While the military appears unwilling to accommodate Manning’s wish, correctional facilities at the local state and federal level have developed a range of approaches for dealing with transgender inmates. Some municipalities, including Cook County in Illinois, Cumberland County in Maine, Washington, DC and Denver, Colorado, have specific policies tailored to the needs of transgender inmates that may include providing hormone therapy and specialized incarceration plans meant to protect transgender inmates, who face a greater risk of sexual assault behind bars.

In the courts, transgender inmates have won multiple legal challenges that have forced jails and prisons to provide hormone therapy. An inmate in a Massachusetts prison recently won a court decision requiring that the state pay for sex-reassignment surgery, although the state is appealing.

On the federal level, a Bureau of Prisons policy—issued in 2011 in response to a lawsuit—states that “current, accepted standards of care will be used as a reference” for developing medical treatment plans for inmates with gender identity disorder. And the Veterans Administration, which has a policy against providing sex-reassignment surgery, nonetheless provides hormone therapy for veterans diagnosed with gender dysphoria.

Military prisons, however, are a different matter. The 2003 Prison Rape Elimination Act led to Department of Justice regulations issued in 2012 requiring that non-military correctional facilities individually assess the needs of transgender prisoners, train personnel to respect gender identities and restrict the use of solitary confinement as a means of ensuring transgender prisoners are housed safely. Chris Daley, deputy executive director of Just Detention International, which works to stop sexual abuse of inmates, says a 2012 memorandum issued by President Obama means military prisons must develop similar policies.

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Daley is hopeful the military will take Manning’s gender identity into account when deciding how to house and treat him at Leavenworth. “The Army has been more proactive about reaching out to advocates and experts on this issue,” he says. “We don’t see any reason they wouldn’t adopt similar regulations for their facilities.”

Jennifer Levi, director of the Gay & Lesbian Advocates & Defenders Transgender Rights Project, says the Constitution’s 8th Amendment prohibiting cruel and unusual punishment applies to Manning regardless of whether he is in a military prison. “Ultimately, what controls the degree of medical care someone gets in a military prison is the Constitution,” she says.

Not providing hormone therapy to Manning could put him at risk for suicide, severe depression and self-mutilation, according to Randi Ettner, a clinical and forensic psychologist and chairwoman of a committee on incarcerated persons for the World Professional Association for Transgender Health. “Medically, it’s a very dangerous situation,” says Etttner, who helped Cook County Jail develop its transgender inmate policy cited by advocates as one of the best in the country.

Cook County’s policy includes asking transgender inmates where they would prefer to be housed, with male or female prisoners. (It’s unclear whether Leavenworth would consider grouping Manning with female prisons.) “Depending on where they are in their transition, people will make a decision that’s in alignment with where they are and would feel safest,” says Ettner.

Kevin Joyce, sheriff of Cumerland County, Me., which adopted rules for handling transgender inmates in 2009 that takes inmate preferences into account, says such policies are vital. “We need to be able to answer how we’re going to deal with transgender inmates in a respectable and responsible manner,” says Joyce.

Some jails and prisons place transgender inmates in isolation either out of bias of because they believe it is the safest place, says Ettner. While not uncommon, this can puts transgender inmates at further risk of developing mental health problems.

For now, Manning’s future treatment for his gender dysphoria remains in limbo. “The statement from Leavenworth is not the final word on this issue,” says Mara Keisling, executive director of the National Center for Transgender Equality. Hormone therapy “is legitimate medical care for a serious underlying medical condition. Trans-related health care isn’t anything but health care.”

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