This story is part of a series looking at transgender inmates in the U.S. and the challenges they face in confinement and upon release. The series focuses on topics such as being incarcerated in prisons that do not reflect the inmate's gender identity, the medical hurdles faced behind bars and rehousing after being released. The series includes dozens of interviews with inmates, experts and public officials.
Chelsea Manning has been described as many things in her life: Soldier. Hacker. Criminal. Whistleblower. Traitor.
The 35-year-old is perhaps best known for leaking hundreds of thousands of military and diplomatic records about the Iraq and Afghanistan wars to WikiLeaks in 2010. It's believed to be the largest unauthorized leak of classified material in U.S. history.
She spent seven years in prison for that leak.
And while incarcerated, she transitioned. Regardless of her high profile at the time, Manning faced many of the same struggles that other transgender prisoners in the U.S. deal with.
Manning told NPR that she and her attorneys dealt with a complex assortment of administrative parties, such as the Federal Bureau of Prisons, the U.S. Defense Department, a federal prison, a local jail and various courts. All of this opened her eyes to a system that is set up for prisoners of all stripes to fail, she said.
"How do you navigate these sometimes Byzantine administrative structures to get to understand who to go to and who to complain to?" Manning said. "The average person doesn't stand a chance. That's the frank truth."
Manning was housed with men at the Midwest Joint Regional Correctional Facility at Fort Leavenworth, Kansas. When she began transitioning, she requested gender-affirming care. She was refused.
That exacerbated Manning's diagnosed gender dysphoria and mental health problems while incarcerated, she and her attorneys maintained at the time. Despite knowing what would help alleviate these symptoms, Manning said, prison officials for her case did nothing. That's what many other prisoners, trans or not, deal with on a regular basis.
Prison officials "just don't care. They're there to protect the prison, and the workers, the employees — not the inmates. They're not there to advocate for an inmate," Manning said.
Studies have shown that incarcerated individuals are more likely than the general population to deal with chronic health problems. Access to proper treatment is unreliable. In Manning's case, she received gender-affirming care only after a lawsuit.
Manning's first lawsuit against the U.S. was filed in September 2014. Since then, not much has changed for trans inmates trying to get treated for gender dysphoria. Manning was even forced to advocate for access to proper care while incarcerated a second time in 2019 for a separate case.
A look back at Manning's legal fight
In July 2013, Manning was convicted and sentenced to 35 years in prison for her leak of government records.
A month later, she publicly announced she is trans, and she sought hormone therapy. She also requested permission to grow her hair out and to get access to items that would help her express her gender identity, such as cosmetics.
In Manning's case, because she was in the military, the Pentagon and not the Federal Bureau of Prisons was ultimately responsible for her care in custody.
Manning said she encountered outright hostility from the very top of the Defense Department. Then-Secretary of Defense Chuck Hagel would deadname Manning and referred to her using he/him pronouns, she wrote in her memoir, README.txt.
The Defense Department did not respond to NPR's request for comment.
The military's own doctors diagnosed Manning with gender dysphoria. And yet the American Civil Liberties Union said the military's response to Manning's request to treat this diagnosis was to say that it does "not provide hormone therapy or sex-reassignment surgery for gender identity disorder."
If an incarcerated person has a complaint over how they were treated, their first step is usually to file a grievance. There is generally an internal appeals process within each facility. That process must be exhausted before a person can pursue a lawsuit.
"These administrative methods slow things down. And they're used as an excuse before you can go to the courts," Manning said. "And they often weigh heavily in the direction of prisons and the carceral system."
Many of the incarcerated and formerly incarcerated individuals who spoke with NPR echoed Manning's remarks, saying this process was exhausting and confusing and often resulted in no changes.
Manning wrote of this fight in her memoir:
In December 2014, I successfully demanded access to cosmetics. The Pentagon ultimately made the decision about whether I'd be allowed to use lipstick, a surreal moment. And yet it still felt like a humiliating compromise, a stopgap measure that didn't address the fundamental, underlying issue.
In 2015, after a year of litigation, the U.S. government relented and allowed Manning to begin hormone therapy. According to the ACLU, this made Manning the first individual to get health care pertaining to gender transition while in military prison.
Manning told NPR she knew the federal government's opposition was futile because the precedents, regulations and doctors were on her side.
"The hang-up wasn't with the medical authorities. The hang-up wasn't the regulatory infrastructure. The hang-up was, they just didn't want to do it," she said.
Once word came down that Manning won her legal battle, she found that the men incarcerated alongside her were ecstatic that "one of their own" was successful in her fight against the system.
"Inmates were just thrilled to see an inmate asked for something, fought for it and won. Very rarely does that happen," she said.
After that, Manning said, she saw fellow inmates start requesting that the prison address their own medical needs that they were being denied care for.
"They started to fight for that. It was very encouraging for inmates, and it was very much a positive," she said.
Manning said her case was also a "watershed moment for the military."
But she's quick to note that she wasn't the first transgender person overall to fight for, and win, access to health care and some gender-affirming treatment in prison.
She points to the 1989 U.S. Supreme Court case of Dee Farmer, a trans woman who was imprisoned in a men's facility. That decision has been frequently used by prisoners challenging their treatment.
Hurt by the legal system — again
Manning's legal conflicts with the U.S. government and the military in 2014 wouldn't be the last time she would have to push officials to address her health care needs as a trans woman.
Two years after her 2017 release from prison, after President Barack Obama commuted her sentence, Manning was jailed again. This time it was over her refusal to testify before a federal grand jury in a case involving WikiLeaks and its founder, Julian Assange.
Manning said at the time of this case that she had just undergone gender-affirming surgery. While incarcerated at the William G. Truesdale Adult Detention Center in Alexandria, Va., for nearly a year, she says, her medical care was disrupted early on and subsequently affected post-surgical care.
"Despite the Department of Justice saying that there wouldn't be this issue, it became immediately an issue the second that we were in jail," she said.
Dr. Fan Liang, the medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health, said it's critical for any patient receiving gender-affirming surgeries to maintain good follow-up care.
"It's especially critical that they are in an environment in which they have adequate resources for post-operative follow-up care and a safe, supportive situation," Liang said.
The fight to get the Alexandria jail to address Manning's needs was one that also involved the Justice Department and the U.S. Marshals Service, under the custody of which she was remanded.
Her attorneys addressed their concerns to a judge during a hearing in May 2019, according to court documents. They said that the jail staff was ill-equipped to address the health needs of a trans woman and that Manning wasn't getting the right care fast enough.
"The source of the complications that Chelsea has experienced seem to have been at least in part due to the questionable hygiene of the jail and the lack of control that Chelsea herself has over her daily post-surgical regimen," Moira Meltzer-Cohen, the attorney representing Manning at that time, told the court.
Manning's lack of control over her post-surgical health care was something authorities were unwilling to change, Meltzer-Cohen said then.
The Alexandria Sheriff's Office, which is in charge of the facility where Manning was housed, told NPR that it is confident Manning "received the necessary and appropriate medical care" while in its custody.
The office said that all inmates' medical treatments and medications have to first be reviewed by the facility's health care team. Federal inmates, like Manning, may also require additional review by the U.S. Marshals Service, or a judge may order specific treatment for those individuals.
"The Alexandria Adult Detention Center's healthcare practices are consistent with and in compliance with national standards. Most recently, the National Commission on Correctional Health Care reaccredited our facility after finding it to be in 100% compliance with all applicable mandatory standards," the office said in a statement.
The U.S. Marshals Service did not respond to NPR's request for comment.
Manning said the delays she encountered while jailed in Alexandria until 2020 were eventually handled, but it left longer-term health impacts on her.
Manning said she does know that her treatment, including the lack thereof, as a trans woman is an example of how poorly jails and prisons are equipped to deal with the medical needs of all prisoners.
"Prisons just don't prioritize medical care in prison, period," she said.
She noted that she had strong legal representation, but it was still incredibly difficult for her and sometimes her lawyers to navigate confusing regulations and policies.
She asked, how can someone without formal education or the right support fight back?
Manning said her experience shows how "there needs to be a lot more robust protections for prisoners and prisoners' access to care in general, not just in terms of trans care. Because that will immediately benefit a larger group of people who are being harmed, while also benefiting trans people."
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