Hormone Therapy Is More Than Just a Physical Process

Bradley Manning’s request for hormone therapy will be rejected by Ft. Leavenworth—which could lead to serious mental-health problems, medical experts say. Brandy Zadrozny on the science of sex reassignment.


“I am Chelsea Manning. I am a female. Given the way I feel and have felt since childhood, I want to begin hormone therapy as soon as possible.”

And so, a day after receiving a 35-year sentence—the longest ever handed down for the leak of classified information—Bradley Manning announced his intention to transition to a female, in a statement read on NBC’s Today Show.

Chelsea Manning

U.S. Army Private First Class Bradley Manning, the U.S. soldier convicted of giving classified state documents to WikiLeaks, is pictured dressed as a woman in this 2010 photograph obtained on August 14, 2013. (Handout / Reuters)

Unfortunately, it’s unlikely that she will able to do so—the U.S. Disciplinary Barracks at Fort Leavenworth, the prison to while Manning has been unofficially assigned to, confirmed to The Daily Beast that it does not provide hormone treatment.

Such a denial, according to medical experts and LGBT advocates, could be seriously dangerous for the WikiLeaks informant’s mental health.

During the trial, two psychiatrists, Capt. Michael Worsley and Capt. David Moulton, testified that Manning suffered with gender dysphoria, a condition defined by stressful dissatisfaction with one’s gender at birth. According to the American Psychiatric Association, treatment for gender dysphoria includes counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. They also argued that the confusion and stress that came with her identity crisis, coupled with a hostile work environment, caused Manning’s mental health to quickly deteriorate, a sign that her commanders should have seen.

“I think [denying hormones] would be a very unfortunate and barbaric outcome in a situation like this,” said Dr. John Capozuca, a licensed psychologist and specialist in the transgendered community, who described medical transition as the standard treatment for gender dysphoria.

Manning hasn’t yet said she wants sex reassignment surgery; so far, she’s only interested in hormones, one of the first steps in the process of sexual reassignment.

Hormone replacement therapy is a common element for many males transitioning to females and has several effects—both physical and psychological, said Dr. Capozuca. Essentially, the hormones suppress an individual’s original sex characteristics, swapping them for more desired ones.

Manning would likely be prescribed some form of estrogen that would be taken orally, through injection, or by a skin patch.  Slowly, her skin and facial features would soften. Any belly fat might redistribute itself in a more “womanly” way around the hips, thighs, and buttocks. Body hair growth will slow, erections will become less frequent, and the testes will shrink. Finally, though it can take years, her breasts and (possibly) nipples will grow. 

These results are not permanent, though. Hormones must be taken for life or their feminizing effects will disappear.

Despite its dramatic effects, hormone therapy isn’t just about the physical; it can positively impact a transgendered patient’s emotional well-being, too.

While there are a range of experiences, Dr. Capozuca explained that many of the trans women he’s treated have reported “feeling more sensitive, more easily moved to tears.”

“Many trans women describe a feeling of comfort, of euphoria, and a feeling of being more confident with themselves,” he said.

A 2011 study in the Journal of Gay & Lesbian Mental Health showed that hormone therapy was also associated with lower levels of depression, anxiety and stress, and higher levels of social support and an improved quality of life.

Lauren McNamara, a transgendered woman and former online confidante of Manning, confirmed as much during her testimony at the WikiLeaks trial. "I don't think people understand what hormone replacement therapy does," she said. "This is something that's the best anti-depressant, anti-anxiety drug I have ever been on."

These testimonies have yet to impact army policy.

"All inmates are considered soldiers and are treated as such with access to mental health professionals, including a psychiatrist, psychologist, social workers and behavioral science noncommissioned officers with experience in addressing the needs of military personnel in pre- and post-trial confinement," Kimberly Lewis said in an email to Courthouse News. "The Army does not provide hormone therapy or sex-reassignment surgery for gender identity disorder."

This denial of treatment raises “serious constitutional concerns,” according to a statement issued by the American Civil Liberties Union.  “Without the necessary treatment, gender dysphoria can cause severe psychological distress, including anxiety and suicide. When the government holds individuals in its custody, it must provide them with medically necessary care. The official policy of the Federal Bureau of Prisons and most state agencies is to provide medically necessary care for the treatment of gender dysphoria, and courts have consistently found that denying such care to prisoners based on blanket exclusions violates the Eighth Amendment of the Constitution.”

The National Center for Transgender Equality (NCTE) says the army’s statement shouldn’t be taken as the final word.  “Ultimately, the army is not the decision maker on whether Chelsea gets basic health care,” said NCTE communications director, Vincent Villano. “The big picture is the eighth amendment which says that we can’t deny people in prison healthcare.”

And transition-related care, he said, is crucial to transgendered individuals.

Professional medical organizations from the World Professional Association for Transgender Health to the American Medical Association have called mental health care, hormone therapy and sex reassignment surgery effective and “medically necessary” treatments for gender dysphoria. Denial of this treatment, Villano said, amounts to cruel and unusual punishment.

The initial refusal might simply stem from the prison’s lack of experience dealing with Manning’s situation. None of Fort Leavenworth’s military inmates—452 last year—are transgendered, army spokesman Kimberly Lewis said.

Manning and his attorney are counting on a change in policy—whether it comes willingly or as a result of a legal challenge.

 “I’m hoping Fort Leavenworth will do the right thing and provide that [hormone therapy].” Manning’s attorney said on Today.

And if not, “then I’m going to do everything in my power to make sure that they are forced to do so.