When the transgender pioneer Christine Jorgensen returned home from sexual reassignment surgery in Denmark in 1955, the tabloids were unforgiving: "Bronx GI Becomes a Woman!" Today, some still cluck and tsk, but the world is more prepared to hear about people who feel they are trapped in the body of the wrong gender.
Bradley Manning is the latest gender dysphoric person, or person who believes his or her body is the wrong gender, to declare his desire to live as a woman. Manning chose the name Chelsea and says that he wants to begin hormone therapy as soon as possible.
For Manning, the difficulties of getting his medical needs met are considerably more severe as a military prisoner, who was sentenced to 35 years.
Sex reassignment surgery can cost $20,000 or more, and the ongoing cost of hormone therapy can be about $200 a month. Such treatment is not provided by the military, so covering the costs is one of the many challenges Manning will face.
According to NBC News, no inmates have received sex-reassignment surgery while in prison in the United States, although dozens of lawsuits at the state and federal level have paved the way for the procedure.
How Gender Changes Work
Dr. Sherman Leis, a surgeon with the Philadelphia Center for Transgender Surgery, suggests that a patient be on hormone therapy and presenting herself as a woman for a full year before male-to-female sex reassignment surgery. By dressing and living as a woman, the patient will begin to feel the realities of living life as the opposite gender.
But Dr. Anne Lawrence, a psychotherapist in Seattle who has studied and treated many gender dysphoric people, says that not all transgender people need to live a public life as the opposite gender. "The so-called real-life experience is distinct from hormone therapy," she says. "The two can be seen as potentially separable aspects of therapy. Some people who cannot transition to live full-time as women still find comfort in hormones."
And historically, long before there were medical interventions to aid transgender people, some Native Americans and people in non-Western cultures lived as members of the opposite gender without the benefit of hormones or surgery.
But before a biological male can even get on hormone therapy, his endocrinologist or other medical specialist in hormone therapy will probably want a letter from a mental health professional confirming a diagnosis of gender dysphoria.
Those prescriptions for a male wishing to become a woman would usually include both estrogens and testosterone-blocking agents, called antiandrogens. Testosterone is available in small amounts in women, but in men it is secreted in the testicles and is responsible for men's greater muscle and bone mass and the growth of body hair.
The sex-change candidate will start taking the predominantly female hormones estrogen (and possibly also progesterone) in doses four or five times higher than, say, women using it to control hot flashes. The combination of less testosterone and more estrogen and progesterone will result in softer skin, less body and facial hair, fewer erections, and some breast growth.
"There are some immediate effects, but it may take as long as 12 to 18 months for the full effects to develop," says Lawrence.
Women who experience gender dysphoria would instead begin taking testosterone, which would make the voice deepen, the breasts get smaller, upper body strength to increase, the clitoris to enlarge, and sex drive to increase.
The Final Step
Following hormone therapy, many people want to take the next step: genital reassignment surgery. For men like Manning, that means castration surgery, and the creation of female-appearing genitalia.
"Before we do gender reassignment surgery, we like to have two letters from mental health experts diagnosing gender identity disorder," says Leis.
While Manning will face enormous obstacles in completing the stated desire to become a woman, he just may have what might be called an advantage. He has nothing left to lose.
"If you're gender dysphoric living on the outside, you may lose family, friends, and your job if you undergo sex reassignment," says Lawrence.
Manning has lost much of that.