In a somewhat unusual turn of events, Private Bradley Manning claims that he identifies himself (or herself) as a woman named Chelsea Manning. He has also expressed the desire to undergo gender re-assignment, beginning with hormone therapy. Given that I hold to a rather broad conception of liberty, I believe that Manning has the right to change his gender and that this is morally acceptable. In fact, if physically being a man is problematic for him, then he certainly should take steps to make his physicality match his conception of his identity. His body, his choice.
One rather obvious obstacle that Manning faces is a lengthy prison term for his role in leaking secrets to WikiLeaks. Being in prison, he most likely will lack the funds needed to pay for hormone therapy. Even if he had the funds, there is also the matter of whether or not the Army would provide such services. As it stands, the Army apparently does not provide such services.
Manning’s attorney, David Coombs, has asserted that if the state fails to provide Manning with the therapy, then he will try to force it to do so. Interestingly, Manning’s case is not unique. In Virginia, a prison refused to allow a prisoner to undergo gender reassignment surgery. In Massachusetts, a federal judge ordered the state to pay for a convicted murder’s sex change operation. These matters obviously raise some philosophical concerns.
As noted above, I believe that an individual should be free to change his or her sex. I base this on the principle that what concerns only the person is a matter in which the individual should have complete authority. So, if Manning wishes to change his sex to match his claimed gender, he should be allowed to do so. This is something I see as a negative liberty—that is, no one has the right to prevent Manning from exercising his liberty in this matter. However, I do not see this a positive liberty—that is, no one else has an obligation to provide Manning with the means of exercising this freedom. As such, if Manning has the funds to pay for the process, then the Army should allow him to do so. The same would also apply to civilian prisoners.
One obvious concern is that prisons are sex-segregated. As such a person who has a sex change would complicate matters. Obviously, a person with a sex change should not be kept locked up with those of his or her previous sex. However, there might be legitimate concerns about locking up the person with members of his/her new sex in terms of safety. However, it seems likely that such matters could be addressed with minimal problems. As such, as long as the prisoner can pay for her own operation, then this should be allowed.
The next point of concern is the matter of whether or not the state should pay for hormone therapy and sex-change operations. On the face of it, the answer would seem to be an obvious “no.” However, it does seem worth considering the matter a bit further.
In general, prisoners tend to lack financial resources to pay for their own medical treatment. After all, a typical prisoner will not have a significant source of legal income nor adequate savings to cover major medical expenses. Since letting a prisoner suffer or die simply because she lacks the means to pay for treatment would be wrong (the state has responsibility for those it incarcerates), it certainly seems acceptable for the state to pay for legitimate medical care for prisoners. As such, if a prisoner needs an appendix removed, it seems right for the state to take care of this rather than let the prisoner die. However, if a prisoner is displayed with her breast size and wants implants, then this is hardly a legitimate medical need and hence the state would not be obligated to pay for such surgery—even if the person’s self-image involved large breasts and the person was very upset about not having said breasts. Thus, the general principle would be that the state should provide legitimate and necessary medical care but is not obligated to provide all medical services that prisoners might want.
Assuming that the above is acceptable, the remaining question is whether or not hormone therapy and sex-change surgery are medically necessary procedures (on par with removing an infected appendix) or if they are not (on par with breast implants).
On the face of it, a person who believes that his gender does not match his physical sex is not in a dangerous medical situation. Being a man or a woman is not, it would certainly seem, a life or health threatening situation. Using the example of Private Manning, he will not become ill or die if he remains a man. As such, the state would seem to have no obligation to foot the bill for sex-change operations any more than it is obligated to pay for breast implants or tummy tucks. After all, one’s body not matching one’s self-image is not a serious medical condition.
However, it can be argued that such a situation is a legitimate and serious medical condition. That is, the person’s mental health depends on a sex-change as much as a person’s physical health might depend on having an infected appendix removed. As such, the state should pay for such procedures.
The obvious counter is that if the state is obligated to ensure that prisoners are not suffering from factors that would negatively impact their mental health, then it would seem to follow that the prisoners should not be in prison. After all, prison is intended to be a place of punishment and that is supposed to cause mental duress.
Another obvious counter is that a person who believes their gender does not match her physical sex might be suffering some duress, but it seems odd to claim that this suffering creates a medically necessary situation. That is, that the person must have her sex changed in order to be in good enough health to serve her punishment sentence in prison.
I will freely admit that I do not know the extent of the suffering a person who believes that her sex does not match her gender might experience. If it is the case that this is a medically serious situation that creates a medical necessity on par with other conditions that the state treats, then the state should treat that condition. However, this does not seem to be the case. Thus, while a person has every right to change his sex, there seems to be no legitimate reason why the state should pay the bill for a prisoner to get a sex-change.