How Does Gender Reassignment Surgery Work?

By Marc Lallanilla, Assistant Editor

Published: 08/22/2013 09:09 PM EDT on LiveScience

"I am Chelsea Manning. I am female." With these few words, Bradley Manning -- the U.S. Army private who rocked the world by releasing highly sensitive U.S. military secrets -- rocked the world once again.

Manning was sentenced Wednesday (Aug. 21) to 35 years in a military prison for leaking more than 700,000 documents to WikiLeaks ^[1] , including State Department cables and military video. Less than 24 hours after Manning's sentence was handed down, Manning's attorney David Coombs appeared on NBC's "Today"^[2] show to read a written statement.

"As I transition into this next phase of my life, I want everyone to know the real me," Manning wrote in the statement. "Given the way that I feel, and have felt since childhood, I want to begin hormone therapy as soon as possible. I hope that you will support me in this transition." (Manning also requested that "starting today, you refer to me by my new name and use the feminine pronoun.") [Top 10 Stigmatized Health Disorders ^[3] ]

Hormone therapy is only one step in the long and complex process of gender reassignment ^[4] . Not all people who seek gender reassignment, whether male-to-female or female-to-male, will go through the entire process, which can include genital reconstructive surgery.

Gender reassignment, sometimes called sex reassignment, can be performed for a number of reasons. People who are born with ambiguous genitalia ^[5] -- internal and/or external sex organs that display characteristics of both male and female sex organs -- are often assigned a gender shortly after birth that they later decide isn't right for them. These people may choose to have surgery that will give them the sex organs of their chosen gender.

Manning and gender identity disorder

Sex reassignment is also an option for people with a condition known as gender identity disorder ^[6] , or GID, which causes a person to develop a strong personal identification with the opposite sex. People with GID -- who may be heterosexual, bisexual or homosexual -- often have an interest in altering their genitals and may adopt the dress and mannerisms typically associated with the opposite sex, according to the National Institutes of Health. [5 Myths About Gay People Debunked ^[7] ]

Manning had been diagnosed with GID, and Manning's struggles with the condition have been an issue throughout the court-martial process. Shortly before Manning's arrest in 2010, Manning (who was openly gay for much of his adult life) sent an email to another soldier that included a photo of himself in a blonde wig and makeup; the email was titled, "My problem," according to ABC News ^[8] .

People with GID may also live with depression, anxiety and feelings of isolation. According to several accounts of Manning's life, Manning frequently complained of feeling desperate and isolated, due in part to the U.S. military's "Don't Ask, Don't Tell ^[9] " policy toward gays and lesbians.

The sexual transitioning process

Sex reassignment or "sexual transitioning" usually involves a team of experts, beginning with mental health professionals who conduct psychological evaluations, counseling sessions and screenings to determine if a diagnosis of GID is appropriate.

Hormone therapy ^[10] under the guidance of an endocrinologist is another essential component of sexual transitioning. Estrogen therapy will suppress male characteristics and encourage the development of female characteristics for male-to-female candidates such as Manning. Because estrogen therapy doesn't remove facial or body hair, electrolysis is usually required.

Hormone therapy may begin after, or be concurrent with, a period known as a "testing" or "real life," during which the individual lives openly according to his or her identity. This period may last from several months to two years or more. Because of the emotional and behavioral changes that occur during hormone therapy, it's critical that psychological counseling needs are addressed throughout this period and the whole sexual transitioning process.

If male-to-female genital reconstructive surgery is chosen, estrogen treatment temporarily stops a few weeks before surgery because hormone treatment can interfere with blood clotting. The operation can preserve genital sensation by using the head of the penis to create a clitoris, and the scrotum can be used to create labia (the testes are removed). After the operation, acrylic inserts known as dilators are used during healing to maintain the opening of the new vaginal canal. [7 Surprising Facts About the Penis ^[11] ]

The entire process for male-to-female reconstructive surgery may require two or more operations, plus regularly scheduled assessments and checkups over a period of years; hormone treatment continues for life. Some people may also choose to have breast implants, tracheal shaving to minimize the size of the Adam's apple, and other cosmetic procedures.

Will Manning get treatment?

The costs for hormone therapy, genital reconstructive surgery and other parts of the transitioning process are usually not covered by health insurance policies, and the out-of-pocket expenses can be very high.

"The Army does not provide hormone therapy or sex-reassignment surgery for gender identity disorder," Kimberly Lewis, a spokeswoman for the military prison in Fort Leavenworth, Kan., (where Manning is expected to serve at least part of her sentence) told NBC News ^[12] .

There are signs, however, that the federal prison system is changing to address the needs of inmates who are diagnosed with GID. A new policy, instituted in 2010, states that "treatment options will not be precluded solely due to the level of services received, or lack of services, prior to incarceration," NBC News reports.

Whether that means treatment for GID, including hormone treatment and genital reconstructive surgery, will now be allowed for federal prisoners remains to be seen. And Manning's request for treatment in the military prison system may be the first of its kind.

That hasn't stopped Manning's lawyer from pressing forth with a request that the military address all treatment options for Manning. "If Fort Leavenworth does not, then I'm going to do everything in my power to make sure they are forced to do so," Coombs said on the "Today" show.

Follow Marc Lallanilla on Twitter and Google+ . Follow us @livescience , Facebook & Google+ . Original article on LiveScience ^[18] .^[13] ^[14] ^[15] ^[16] ^[17]