When convicted intelligence leaker Bradley Manning asked Thursday for hormone treatment at a military prison so he can become Chelsea Manning, the response was immediate: No.
So would the former Army private have a better shot at becoming a woman if he were transferred to a civilian prison, a move his lawyer has suggested he might attempt?
Maybe. But he should get ready for a fight.
Recently, federal courts in some states, including Virginia, Maryland and Massachusetts, have authorized hormone treatment for inmates at government expense, ruling that it's part of an inmate's right to adequate medical care guaranteed by the 8th Amendment.
But no prisoner has undergone state-sponsored gender reassignment surgery, according to Dr. Ron Shansky, the former Illinois Department of Corrections medical director. He consults nationally on prison health-care issues, particularly concerning transgender inmates. He evaluated his first transgender inmate in 1989.
"These kind of requests are so rare -- few compared to the thousands in the system -- so corrections employees don't have a lot of experience or training," he said.
"And the prison system in this country has a history of being old-fashioned, puritanical," he said.
A correctional staffer is more likely to think that a male inmate acting like a woman is doing that out of defiance or acting out. "Only lately, I think, has there been some understanding that medical science says that this treatment is, in some cases, as critical as giving an inmate his heart medication or dialysis."
Robert wants to be Michelle
The only inmate close to getting a state-covered sex change is Michelle Kosilek.
She was Robert Kosilek, a laborer who was convicted of murdering his wife in 1990 and given a life sentence without parole.
Kosilek began asking for hormone therapy in 1992, arguing that he felt debilitating depression and wanted to kill himself. "She couldn't look in the mirror," said his lawyer, Joseph Sulman. "She felt trapped in her own body. She was not a man, despite having the genitals of a man."
Doctors diagnosed Kosilek with gender identity disorder, a condition listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, a book of classifications of mental disorders widely used by American mental health professionals. The newest edition, the DSM-5, now calls the condition gender dysphoria, but it's essentially the same symptoms: intense confusion and strain over one's gender.
Kosilek was eventually given estrogen and other drugs, Sulman said, but when she asked for surgery, many Massachusetts officials fiercely opposed funding the operation, which the Boston Globe has reported could cost $50,000.
In 2008, Republican state Sen. Scott Brown filed legislation to ban the use of taxpayer money to pay for the surgery.
"We have many big challenges facing us as a nation, but nowhere among those issues would I include providing sex change surgery to convicted murderers," Brown said, according to the Boston Globe. "I look forward to common sense prevailing and the ruling being overturned."
More than 20 state lawmakers sent a letter to the state's prisons chief saying they did not support providing Kosilek a state-funded operation.
The legislation failed.
In September 2012, two decades after Kosilek first requested treatment, U.S. District Judge Mark Wolf ruled that the state must pay for the surgery, citing the 8th Amendment.
Wolf made history. While other judges across the country had ordered corrections departments to provide drugs and psychotherapy to gender-confused inmates, he was the first to order that the state pay for surgery.
The government is in the process of appealing the ruling, and Michelle Kosilek remains, anatomically, a man.
"Michelle understands that to get this far is a very big deal. It's precedent-setting," Sulman said. "To go from not being able to look in the mirror to feeling trapped in her own body to knowing that there is chance to fully transition, I think her mental state has improved."
Michael wants to be De'lonta
A Virginia inmate is close to getting a similar ruling. In 2004, inmate Michael Stokes, serving 73 years for bank robbery, was able to reach a settlement with the state's corrections department that allowed her to receive hormones behind bars.
Stokes was going by Ophelia De'lonta and, with permission from correctional officials, styling herself like a woman, wearing makeup and tweezing her eyebrows. According to a court document (PDF), she was seeing a prison therapist about her incessant urges to rid herself of the genitalia she was born with. She kept telling prison officials that she felt overwhelmed.