Army Pfc. Bradley Manning is escorted out of a courthouse in Fort Meade, Md., on July 2. / Jose Luis Magana, AP
Pfc. Bradley Manning's announcement Thursday that he intends to live the rest of his life as a woman comes at a time of tremendous change in medical and cultural attitudes toward transgendered people.
Manning, 25, was sentenced to 35 years in prison on Wednesday after having been found guilty of 20 charges ranging from espionage to theft for leaking more than 700,000 documents to the WikiLeaks website while working in Iraq in 2010. Manning has said that he intends to use the name Chelsea in the future and is taking hormonal therapy.
In March, the psychiatric profession's diagnostic manual eliminated the term "gender identity disorder" from its list of mental health disorders. That change reflects the profession's recognition that transgendered people, who do not identify with the sex with which they were born, are not mentally ill, says Jeffrey Parsons, a professor of psychology at Hunter College in New York.
The newest version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM-V, does include the term "gender dysphoria," or "the emotional stress somebody might experience because there is a discrepancy between their assigned gender, which they were born with, and the gender they feel they are."
A landmark court case may also affect how transgendered prison inmates are treated.
Last year, U.S. District Judge Mark Wolf ruled that the Massachusetts Department of Correction must provide sex-reassignment surgery for Michelle Kosilek, who was born male and is serving a life sentence for murder.
Hormones called anti-androgens can diminish male characteristics, such as body hair and male pattern baldness, and help redistribute body fat, leading to breast swelling, says Loren Schechter, chief of plastic surgery at Chicago Medical School, who performs gender-reassignment surgery, also known as gender-confirmation surgery. Feminizing hormones also promote female physical characteristics, such as softer skin and a more emotionally sensitive, less aggressive personality, says Randi Ettner, a clinical and forensic psychologist in Evanston, Ill., who has written three books on transgender issues. .
"Most transgender individuals have felt this way as long as they can remember," Schechter says. "They identify as a member of the opposite gender."
Hormones often allow transgendered people to have a "sense of well-being for the first time," Ettner says. "They may feel more comfortable in their own skin or say they feel like they are coming home," she says.
While some transgendered people are gay, others are straight and even married, Schechter says.
Many of his surgical patients were in the military, Schechter says. "They take on these hypermasculine roles to feel more manly," he says.
Kristin Beck, who was known as Chris when she was a Navy SEAL, released a book called Warrior Princess this year to describe her transformation.
Transgendered people are appearing more frequently in movies and TV, as well. Chaz Bono, who is the child of Cher and Sonny Bono and was named Chastity at birth, has appeared in the popular TV show Dancing With the Stars.
Some transgendered people take hormones to modify their appearance in preparation for surgery. Others have no interest in surgery, or seek out less extensive surgeries, says Schechter, a spokesman for the American Society of Plastic Surgeons.
For some, surgery is a means to official recognition, allowing them to change their gender on their driver's license, Schechter says.
Doctors have careful guidelines for evaluating people before performing gender-reassignment surgery, Schechter says.
Patients must present two letters from either a psychiatrist or psychologist with an M.D. or Ph.D. They must also undergo a psychological evaluation and be under the care of a regular doctor, who can prescribe hormones and provide other care.
Pre-surgical patients take hormones and are encouraged to take a "real life" test, by dressing and living as a different gender, Schechter says. Doctors recommend these procedures to avoid making a mistake with irreversible surgery.
Although gender-reassignment surgery has been performed since the 1950s, there are still only a handful of hospitals in the USA that offer it, Schechter says.
A growing number of insurance plans now cover gender-reassignment surgery, however, including the plans of the City University of New York and the University of Illinois. Medicare does not cover the surgery, although the American Civil Liberties Union is suing to change that, Schechter says.
Belgium, the Netherlands and a handful of other European countries also cover the surgery through their national health programs.
Costs are high.
A man who undergoes gender-reassignment surgery to appear female could expect to pay about $25,000 out of pocket, Schechter says. That includes the cost of removing the male genitalia and constructing a functional vagina. This procedure can be accomplished in a single procedure.
Creating male genitalia is a far more complicated procedure, involving multiple procedures, Schechter says.
Additional surgeries, such as breast implants for men, can cost more than $8,000, while facial plastic surgery can cost more than $10,000, according to the website of the Philadelphia Center for Transgender Surgery.
Women who want to live as men now sometimes undergo double mastectomies before leaving for college, so that they can identify as men in their new lives, Schechter says.
Schechter testified as an expert in the Massachusetts prison case, noting that the surgery would be appropriate for this patient.
The state of Massachusetts has appealed this ruling.
Society's attitude toward transgendered people has followed the same pattern as attitudes toward gays and lesbians, Parsons says. Psychiatrists stopped treating homosexuality as a mental disorder in the 1970s.
Today, guidelines for mental health recommend providing "affirming" messages to transgendered people, to help them be comfortable with who they are, Parsons says.
Policies about placement of transgendered inmates varies by state and county, Parsons says. Placing Manning in a male unit "would not be appropriate" and could expose her to violence.
On the other hand, women inmates may not feel comfortable around someone who is built as physically strong as a man, he says.
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