Self-castration, suicide and waves of desperation are byproducts of the denial of sex hormones to inmates yearning to switch genders, advocates say.
But outside the walls, debate has been stirred on whether the prison system is the right place to help chemically escort a man to womanhood, or vice versa, and critics question if any taxpayer money should pay for the hormones used to help inmates undergo sex changes.
Thursday's revelation that convicted secret leaker Bradley Manning wants to live as a woman and begin hormone therapy ignited talk about what happens when prison doctors refuse hormones to inmates with gender identity disorder (GID): depression, death wishes, purposely amputated genitalia and, for those already en route to a new gender, the return or disappearance of certain male or female traits — from body hair to muscles to breasts.
The Army does not provide hormone therapy to such prisoners. At the very least, this significantly delays Manning's plan to physically morph into "Chelsea" -- as he's been sentenced to 35 years in Fort Leavenworth prison.
"You begin to feel like you might as well just die," said Miss Major, 70, who claims her estrogen prescription was withheld by the medical staff during a five-year stint at a New York prison for a prostitution conviction. Major had started taking the pills years before to look like the woman she always felt she was internally. Housed in isolation, and without the drugs, her breasts grew smaller, manly hair again coated her arms and legs, and her emotions ran wild.
"It's like a roller coaster ride without anything to hang on to. You have no control over what's happening to you. It's devastating. You don't know who you are anymore," added Major, who today lives in Oakland, Calif., and advocates for transgender people, including ex-inmates.
Already battling a deep disconnect with self-identity, then suddenly being removed from the medications meant to alter their genders, some inmates literally attack the issue in the bloodiest ways, lopping off their sex organs. About 30 such self-mutilations have been documented in U.S. prisons, said Dr. Lori Kohler, a staff physician for the California Department of Corrections and Rehabilitation and a national expert on medical management of transgender prisoners.
In California, Kohler has helped oversee hormone meds for about 400 inmates (out of a total population of 150,000). The vast majority of those 400 were born as males and want to become females, taking estrogen and growing female curves while housed in men's prisons.
"Withdrawing from estrogen can cause significant depression and a general mood disorder, much like what many women experience with menopause," Kohler said. "When they're off (hormones), people say they don't feel right, they feel terrible."
In one case Kohler followed, an inmate sliced off his penis and testicles while serving in a prison in another state; after being transferred to California, that inmate was placed in a women's correctional facility.
"They don't see it as self-mutilating. They feel like they're righting a wrong, correcting themselves," Kohler said. "This is a true issue for people, yet it's just so easily ignored and dismissed. Denying it is like saying: I don't believe in diabetes."
The drugs cost about $20 per month for female hormones (estrogen), and about $60 to $80 a month for male hormones (testosterone), she said. Such medical care in prison comes at the taxpayer's expense.
Prior to 2010, federal inmates who entered that system taking sex-change hormones were allowed to maintain those doses, but U.S. corrections officials denied the start of new hormone regimens for existing prisoners. A lawsuit filed by Boston-based attorney Jennifer Levi on behalf of an inmate caused the prison bureau to reverse that stand and treat gender identity disorder even after its diagnosed in prison.
Yet the administering of hormones to transgender inmates remains inconsistent across state prisons: Some do it, some don't, said Levi, director of the Transgender Rights Project at Gay & Lesbian Advocates & Defenders (GLAD).
"The reality is, the underlying medical condition of gender dysphoria is highly stigmatized and widely misunderstood. So people with no expertise, including prison staff, often reject the seriousness of the underlying medical condition just because of bias and discrimination," Levi said.
Transgender groups consider denying hormones in cases like Manning's "cruel and unusual punishment" and argue that hormone treatment for gender identity disorder is standard medicine and should be allowed in military prisons as in federal prisons. Manning's request may be the first time this has come up for a military prisoner.
But a large question remains among many critics outside the advocacy circuit: Should prisons be doling out sex-change drugs?
"It does cause all kinds of security issues for us," said Brian Dawe, executive director of American Correctional Officer, a group that works to promote the safety and working conditions of corrections workers. "There's also amount of cost to the taxpayers, which we care about because we're not only correctional officers, we're also taxpayers."
But correctional officers "don't make moral or sociological judgments on it," said Dawe, who worked as one in Massachusetts for 32 years. "That's up to the public."