The Cost of Transgender Health Benefits
The Prevalence of SRS Among US Residents
Mary Ann Horton, Ph.D.
Transgender at Work
DRAFT of March 30, 2006
ABSTRACT
This paper measures the prevalence of Sex Reassignment Surgery (SRS) for US residents. It reports the
number of US residents undergoing SRS in the year 2001 using a survey of surgeons who offer SRS
procedures. This count is compared to the number of eligible US residents in the 2000 US Census to
estimate prevalence.
The number of US residents undergoing primary SRS in the year 2001 is about 1170 (740 Male to Female
or MTF and 430 Female to Male or FTM,) with the confidence range setting lower and upper bounds of
about 660 to 1420 MTF, and 290 to 1200 FTM. The prevalence of SRS per year among US residents is
about 1: 240,000(about 1:190,000 MTF and 330,000 FTM.) It follows that the overall prevalence of those
who will have or have had SRS in their lifetime is about 1:3,100 (1:2500 MTF and 1:4,200 FTM.) Since
not all those transsexuals diagnosed with Gender Identity Disorder (GID) have SRS, the prevalence of GID
can be estimated as 1:850 (1:500 MTF and 1:3350 FTM.)
Keywords
Transgender Prevalence. Sex Reassignment Surgery Prevalence
Submitted for publication to the International Journal of Transgenderism, http://www.symposion.com/ijt
Copyright © 2006 by Mary Ann Horton. All rights reserved. Redistribution by permission only.
Mary Ann Horton
Page 1
7/31/2017
The Cost of Transgender Health Benefits
1. Introduction
Many Health Care benefits policies contain an exclusion stating that any benefits related to sex
reassignment surgeryi are excluded from the coverage. Those opposing coverage cite high costs , which
are based on conservative prevalence estimates. Transgender activists counter that so few people go
through the process that the average cost per insured is very low.
How many people do go through this process each year? This study measures the annual number of
surgeries (run rate) on US residents, and calculates prevalence based on the US Census.
2. Previous Work
“The question is often asked: how many transsexuals are there?” This is not an easy question to answer,
because sex reassignment is usually quietly handled.
3.1 Prevalence of SRS
Prevalence is defined as “the number of people in a given population affected with a particular disease or
condition at a given time”. The prevalence of SRS is not well known. Many estimates have been made,
few based on experimental data. Estimates often focus on the prevalence of GID: “What fraction of the
population is transsexual?” or of SRS: “What fraction of the population has SRS at some point in their
lifetime?”
The DSM-IV (DSM, 1994) states, "Data from smaller countries in Europe with access to total population
statistics and referral suggest that roughly 1:30,000 adult males and 1:100,000 adult females seek sexreassignment surgery." Conway (Conway, 2002) stated that these figures were based on (Walinder, 1967)
in Sweden.
The Janus Study (Janus, 1993) found that 6% of males and 3% of females have personally cross-dressed.
The Janus question is asked in the context of variant sexual practices, and would appear to include the
entire scale of transgendered people, from post-operative transsexuals to those who have only dressed as
the opposite sex for Halloween.
Another study (van Kesteren, 1996) found the prevalence of transsexualism (GID) in the Netherlands to be
1:11,900 (MTF) and 1:30,400 (FTM.) This is based on the number of patients receiving treatment in the
country.
Richard Green (Green, 1999) gave the incidence of transsexualism at 1:30,000 FTM and 1:10,000 MTF.
Conway (Conway, 2001) estimated prevalence of MTF SRS in the US, by estimating the number of
surgeries each year and summing over the past several decades. She estimated that 1:2500 Americans born
male is currently a post-operative transsexual, and that at least 1 in 500 Americans born male has GID. She
estimates the incidence of transsexualism (the number of people to transition from male to female each
year) at 1:10,000 to 1:20,000, based on a 20 to 40 year career. Conway does "sanity checks" with other
methods of calculation. Based on an estimated annual surgical count of 1500 to 2000 and an annual male
birth rate of 2,000,000, she estimates lifetime prevalence of SRS at 1:1333 to 1:1000, that is, as many as
1:1000 people will have SRS sometime during their lives.
Others have made estimates of transsexual or transgender people in other cultures, based upon personal
experience. Conway (Conway, 2001) summarizes many of these estimates. These include:
 Number of Hijra in India: estimated at 1:375.
 Number of transsexuals "living as women" (without surgery) in Malaysia, estimated at 1:820.
 SRS in the U.K., estimated at 1:3750, and of transsexualism, 1:750.
 Katheoys in Thailand, estimated at 1:167.
Mary Ann Horton
Page 2
7/31/2017
The Cost of Transgender Health Benefits
3. Methodology
The goal of this study was to create a credible estimate of the prevalence of SRS. The surgical run rate was
measured by counting the total number of surgeries in one year and calculating the average cost per
surgery. Prevalence was calculated by comparing run rates with the US Census population of US residents.
Persons desiring irreversible surgical procedures who value the quality of the result will usually go to a
surgeon who has performed the procedure many times previously. It is known within the transgender
community that the vast majority of transsexuals seeking surgery go to one of a relatively short list of
surgeons for their final surgery. Most surgeons who routinely practice this type of surgery belong to Harry
Benjamin International Gender Dysphoria Association (HBIGDA.) In the fall of 2001, there were 43
individual surgeons and 12 clinics on the HBIGDA membership list. Of these, by reputation, the vast
majority of US transsexuals went to one of 15 surgeons. (Eight of these surgeons are in the US, and seven
of them are not.) This study refers to these 15 surgeons as major surgeons.ii
4.1 Survey
The author sent a survey in 2002 to all surgeons and clinics who were listed as members in HBIGDA. This
survey inquired about all surgeries performed by the specific surgeon in the calendar year 2001.
Respondents were assured that their individual answers would be kept confidential, and only aggregate data
would be released. Questions were designed to support calculation of the run rate (total number of
procedures performed annually), and the average cost per patient. The percentage of patients who are US
residents was requested. The data was adjusted to apply only to US residents, and compared to available
US census data. The percentage of the US population who undergo SRS each year (prevalence of SRS) was
then calculated.
SRS is a once-in-a-lifetime event for any given transsexual patient. Some patients, however, may undergo
multiple surgical procedures. It is important to count each patient exactly once, in order to accurately
estimate the run rate. To this end, the concept of a primary surgery is defined. This is a surgery that can
occur only once in any given patient, no matter how many follow-ups, corrections, reversals, or cosmetic
surgeries are done. In addition, the primary surgery must be a procedure that is required, that must be
performed for SRS to be considered complete.
For MTF patients, the primary surgery is defined to be the penectomy (removal of the penis.) This
procedure is generally accompanied by a vaginaplasty, but in case of complications, a second vaginaplasty
may be indicated. Only one penectomy is possible for any one patient
For FTM patients, the primary surgery is defined to be the bilateral mastectomy (top surgery.) The various
bottom surgeries (hysterectomy, metoidioplasty, phalloplasty) are not always indicated, but almost every
FTM patient will undergo a single top surgery.
Patient counting was based only on primary surgeries. Patient cost, however, was based on total cost of all
surgeries, including follow-ups to treat complications. Questions 2 and 5, below, requested total cost of all
surgeries.
The specific questions are shown in Appendix A. They may be summarized as follows:
1. How many MTF primary surgeries did you do in 2001?
2. What was the total cost of all the MTF surgeries?
3. What fraction of the MTF surgeries was done on US residents?
4. How many FTM primary surgeries did you do in 2001?
5. What was the total cost of all the FTM surgeries?
6. What fraction of the FTM surgeries was done on US residents?
Mary Ann Horton
Page 3
7/31/2017
The Cost of Transgender Health Benefits
Respondents were assured that their individual survey responses would be kept confidential. For this
reason, only summarized data is presented here.
After a two-month interval, follow-up letters were sent to the major surgeons who had not yet responded.
All major surgeons who had not responded were again contacted, until it was clear there would be no
further responses.
After tabulating the data, estimates for the major surgeons who did not respond were made, based on other
available information. For example, many surgeons' prices are well known or on their web sites. A former
patient who interacted with the staff for the 1-2 week period during their surgery estimated run rates. In
one case, missing data was discovered in a published book. Data was extrapolated to include other
surgeons.
Combining the surgical data with US Census data (Census, 2000,) it is possible to estimate the fraction of
the US population who had SRS in the year 2001.
4. Surgical Data
The data received from the surveys are summarized in this section. First, the raw data as received is
summarized. This raw data contained a few errors and omissions that were correctable. The second
section describes the reconstruction process and the data after reconstruction.
4.1 Raw Surgical Data
For reasons of confidentiality, specific surgeons are not listed in this paper. Rather, the aggregate totals
only are given here.
55 Surveys were sent out in 2002 to all surgeons and clinics listed in the HBIGDA membership directory.
Fifteen responses were received, 13 from major surgeons and 2 from others. Of the 13 responses received
from the 15 major surgeons, one survey was unusable, and 3 had correctable errors.
For surveys that were not directly usable, correspondence with the surgeons (or their office staff) permitted
the correction of some surveys. As a result, 12 of 15 major surgeons, or 80%, provided usable data for this
project. Two surveys were returned by surgeons who were not on the list of major surgeons. One of these
provided MTF data for the study; one provided both MTF and FTM data.
The 14 valid surveys (a 25% usable response rate) represented 866 MTF primary surgeries performed by
10 surgeons, and 336 primary FTM surgeries (top surgery) performed by 10 surgeons. 7 of the 14 surgeons
performed both MTF and FTM surgeries, 3 MTF only, and 4 FTM only. (Of the 12 major surgeons with
usable surveys, 3 do MTF, 3 do FTM, and 6 do both.)
Specialties of Surgeons
Number of Surveys
MTF FTM Both Total Response Rate
Returned by Major Surgeons
3
3
Sent to Major Surgeons
4
5
Returned by Other Surgeons
0
1
Sent to Other Surgeons
Returned (Total)
3
4
Sent (Total)
Table 1: Number of Surveys Sent and Returned
6
6
1
7
12
15
2
40
14
55
80%
25%
Partial data was also provided for FTM "bottom surgeries." One Ob/Gyn reported performing 3
hysterectomies and no mastectomies. (Most FTM transsexuals go to a regular Ob/Gyn for a hysterectomy,
not to a transgender specialist.) 6 surgeons are known to perform metoidioplasties, 3 providing data
Mary Ann Horton
Page 4
7/31/2017
The Cost of Transgender Health Benefits
totaling 21 surgeries, of which 20 were on US residents. 4 surgeons provided data about phalloplasties, and
5 others are believed to perform them. 49 phalloplasties were reported, of which 21 were on US residents.
For purposes of this study, only those who perform significant numbers of primary surgeries were counted
as major surgeons.
The surgeons estimated the percentage of their clients who were US residents. 624 of 866 MTF patients, or
72%, were US residents. 294 of 336 FTM patients, or 87%, were US residents.
4.2 Reconstructed Surgical Data
In informal discussions with transgendered US residents considering surgery, and of subject matter experts,
the same surgeons names come up repeatedly. It is therefore believed that the major surgeons account for
nearly all the surgeries performed on US residents. It is estimated that 95% of MTF patients who have SRS
go to a major MTF surgeon, and 75% of FTM patients who have top surgery go to a major FTM surgeon.
This difference is based on belief that it is more likely that an MTF will go to a major surgeon, because the
MTF procedure is highly specialized. While a specialized chest surgery is seen by many as important, it is
also more realistic for an FTM transsexual to get an ordinary mastectomy.
In some cases, surveys were returned but incorrect or incomplete. For major surgeons, the blanks were
filled in with estimates believed to be accurate. Methods used to correct or complete surveys include:
1. The surgeon or their office staff was asked to clarify the data.
2. A total cost was calculated by multiplying the cost of the procedure and the number of patients.
3. Published costs from the surgeon's web page were used.
4. Missing percentages of US Residents were filled in based on average percentage of other
surgeons.
5. Major surgeons who did not provide data were estimated based on their published price and the
estimates of volume by former patients.
6. Other surgeons who did not respond were considered part of the extrapolated percentage that are
not included in the measured data.
These methods made it possible to arrive at a total counted number of primary surgeries in 2001, and a
good estimate of the total costs for the primary surgery. Dividing by the extrapolation percentages (95%
and 75%) gives an estimate of the total volume and cost of primary surgeries. Multiplying by the
percentage of US residents gives a good estimate of the total number and costs of primary surgeries for US
residents. (See table 2.) Cost data and analysis is presented in (Horton, 2006.)
Table 2 summarizes the totals based on the survey and the reconstruction techniques above. Totals are
separated into Male-to-Female and Female-to-Male categories.
Surgical Data
MTF
Raw Number of Primary Surgeries counted
Estimated Additional Surgeries (reconstructed)
Reconstructed Number Primary Surgeries by major surgeons
Estimated Primary Surgeries by other surgeons
Extrapolated Total Primary Surgeries
Percent of counted surgeries on US residents
Primary Surgeries on US residents
FTM
Total
866
336
1202
79
39
118
945
375
1320
50
125
175
995
500
1495
74%
86%
77%
736
430
1166
Table 2: 2001 Surgical Frequencies
Mary Ann Horton
Page 5
7/31/2017
The Cost of Transgender Health Benefits
5. Prevalence Analysis
There has been much speculation about the prevalence of transsexualism. With the knowledge of the
annual run rate, and the assumption that the run rate is flat, the prevalence of primary surgery (SRS) can be
estimated.
5.1 Prevalence of Primary Surgery
If the US run rate is 1166 surgeries/year (MTF+FTM) and the population of adult US residents was 281
million in 2000, the frequency of SRS per year among adult US residents is about 1:241,000 (about
1:187,000 MTF and 1:333,000 FTM.) That is, about .0004% of the population has SRS each year.
A key question to ask is: “Of all the US residents currently alive, how many either have already had SRS,
or will have it during their lifetime?” The age distribution of those having SRS does not matter, as the
result will be the same for any distribution. Because we are asking about the fraction of those currently
alive, the key factor is life expectancy.
First, it is assumed the run rate will continue at the 2001 rate iii, and observe that a transsexual can have a
primary SRS surgery only once in a lifetime, at any adult age. It is also assumed that life expectancies, as
reported in the census based on sex, are accurate based on birth sex, and are not changed significantly by
SRS. Using the previous result that 1 in 187,000 people born male have SRS each year, this number can be
multiplied by the male life expectancy (74.3 years.) This gives about 1 in 2500 as the number of birth males
alive today who have had or will have SRS during some year in their lifetime.
Finally, using the estimate that 1 in 5 males with GID go on to have SRS, it follows that about 1 in 500
birth males alive today have transitioned or will transition. Using the estimate that 80% of FTM
transsexuals have primary surgery, the FTM and combined ratios can be calculated the same way, as shown
in Table 3. The prevalence of SRS, for both genders combined, can be calculated as 1:3134; that is, about
1 in 3,100 US residents alive today have had or will have SRS at some time during their adult lifetime. US
residential numbers are based on the 2000 US Census, eligibility is based on birth sex (e.g. those born male
are the population eligible for MTF surgery.) Numbers should only be considered significant to 2 digits.
MTF
FTM
Primary Surgeries on US residents
Number of US Residents
Total
736
430
1166
138,053,563
143,368,343
281,421,906
187,496
333,415
241,295
Ratio of US Residents having Surgery in 2001: 1 in …
Years of Eligibility
Prevalence: Ratio having SRS in lifetime: 1 in …
74
80
77
2,524
4,183
3,134
505
3,347
866
Prevalence: Ratio with GID in lifetime: 1 in …
Table 3: Prevalence of SRS among US residents.
In other words, in a company with 100,000 employees, 50,000 males and 50,000 females, about one
employee will have MTF surgery every 187,000/50,000 or 3 ¾ years, and one employee will have FTM
surgery every 333,000 / 50,000 or 6 2/3 years. The total work force in the company includes about 115
(100,000 / 866) people who have transitioned or who will transition. Of these, 32 (100,000 / 3134) people
have had or will have SRS during their adult lifetime. This leaves about 83 (115 – 32) who may be
transsexual but will not have SRS.
5.2 Frequency of FTM Bottom Surgery
Estimating the frequency of FTM bottom surgeries (hysterectomy, metoidioplasty, phalloplasty) is more
difficult. The primary surgery concept does not apply to bottom surgeries. The estimates made here are
based on interviews with a subject matter expert in the FTM community, and should be considered less
Mary Ann Horton
Page 6
7/31/2017
The Cost of Transgender Health Benefits
precise than measured data. Any qualified surgeon may do hysterectomies, so they are impractical to count
directly.
The subject matter expert estimated that 50% have a hysterectomy, 5% have a Metoidioplasty, and 6%
have a Phalloplasty. This results in an estimate of 250 hysterectomies, 25 metoidioplasties, and 30
phalloplasties during the calendar year 2001.
Based on an 80 year life expectancy of birth females, it follows that 1 in 6,660,000 birth females had a
Metoidioplasty in 2001, and 1 in 83,000 birth females have had or will have the procedure during their
lifetime. Similar results can be calculated for Hysterectomy-Oophorectomy and Phalloplasty, as shown in
Table 4 below.
Procedure
Frequency
HysterectomyOophorectomy
Metoidioplasty
Phalloplasty
Patients
50%
2001
Lifetime
Prevalence
Prevalence
250
1:666,000
1:8,300
5%
25
1:6,660,000
1:83,000
6%
30
1:5,550,000
1:69,000
Table 4: FTM Bottom Surgery Prevalence Estimates
5.3 Frequency of Nonsurgical Treatment
Estimates of costs of the nonsurgical treatments can be made based on well known costs of typical
treatments. Since not all transsexuals need every treatment, total volume can be estimated, based on
assumptions about treatment rates. If the fraction of transsexuals (those diagnosed with GID) who have
SRS is estimated, and the SRS run rate is known, the prevalence of GID can be calculated.
The assumption is made that not every transsexual has surgery. Rather some who have Gender Identity
Disorder will transition (living full time in the new gender role,) may or may not have therapy, may or may
not have Hormone Replacement Therapy (HRT,) and may or may not have surgery. Since those who do
not have GID should not have HRT or surgery, only the Transgender Health Benefit (THB) needs of the
population who have GID are considered. The fraction of those with GID is estimated that have therapy,
that have HRT, and that have surgery. With the numbers who have surgery and the fractions of those with
GID who have surgery, the number with GID can be calculated, and from that number the number who
have therapy and who have HRT can be calculated.
The fraction of transsexuals with GID that do have the surgery is estimated at 20% MTF and 80% FTM iv.
Then the number of transsexuals is extrapolated from the number of surgeries. For example, with 736
MTF surgeries each year, and if 20% of those with GID have surgery, there are 736 / 20%, or 3682, MTFs
diagnosed with GID each year. The next step is to estimate the rates of therapy and hormone usage among
those with GID. For example, it is assumed that 90% of MTFs with GID have therapy, it follows that 90%
of 3682, or 3313, MTFs have therapy. These percentage estimates are based on empirical observations by
subject matter experts, but not on scientifically collected data.
These calculations are summarized in Table 5. If the percentage estimates are accurate, there are about
4,219 people diagnosed with GID each year, and about 85% of them, or 3,582, will begin mental health
therapy each year. Similarly, 89%, or 3,743, will begin HRT each year, requiring both hormones and
doctor’s office visits to monitor their usage.
Nonsurgical Prevalence Estimates
MTF
FTM
Primary Surgeries on US residents
Total
736
430
1,166
Est. % with GID having Primary Surgery
20%
80%
28%
New GID diagnoses each year
3,682
538
4,219
Est. % with GID having Therapy
90%
50%
85%
Mary Ann Horton
Page 7
7/31/2017
The Cost of Transgender Health Benefits
Patients in year 1 of therapy
3,313
269
3,582
Est. % with GID having HRT
90%
80%
89%
Patients in year 1 of HRT
3,313
430
3,743
Est. % with GID having HRT
90%
80%
89%
Table 5: Nonsurgical Frequency Estimates
6. Limit Analysis
In arriving at the above best estimates, it was necessary to estimate values that were not directly measured.
To better understand the margin for error, each of these estimates was examined, to assess the practical
range of values. Boundaries were set for each estimate, beyond which the estimated value could not
reasonably reach. For example, major surgeons who did not respond to the survey could not have
performed fewer than zero primary surgeries, and could not reasonably have performed more such
surgeries than the busiest surgeons in their field.
Lower and upper bounds were set, referred to here as minimum cost and maximum cost. This permits lower
and upper bounds to be calculated for the resulting frequencies. All numbers should only be considered
significant only to 2 digits.
9.1 Limit Analysis of Surgical Prevalence
The relevant uncertainties about transgender prevalence rates are as follows:
1. No data is available for two major surgeons. Their run rates could have ranged from zero to a
number equal to the busiest surgeons in their specialty.
2. A good estimate of the count of primary surgeries performed by the 15 major surgeons has been
presented, but the amount of work done by other surgeons is unknown. This is dealt with by
estimating the percent of all primary surgeries performed by the major surgeons. The minimum
cost case is that all surgeries were performed by responding surgeons (e.g. 100%) A very
conservative upper bound can be established by supposing that as many MTF patients go to other
surgeons as major surgeons (e.g. 50%) and, similarly, that there are as many FTM patients having
mastectomies by other surgeons as by major surgeons (e.g. 50%.) These numbers are absurdly
high, but serve to set an upper limit for the worst case costs.
3. The percentages of extrapolated patients who are US residents could have ranged from 0% to
100% of all uncounted patients.
4. The fraction of transitioned transsexuals who eventually have primary surgery has been estimated
from 1 in 5 (20%) to 1 in 10 (10%.) A best estimate value of 20% with a range from 10% to 40%
has been chosen here.
5. The fraction of transitioned transsexuals who receive mental health therapy could have reasonably
ranged from 50% to 90%.
6. Since those with GID almost always seek hormones, in some dosage, the fraction of transitioned
transsexuals who receive hormones could have reasonably ranged from 80% to 90%.
Using the above lower/upper bound reasoning, primary surgery rates on US residents can be limited from
662 to 1418 MTF surgeries, and from 293 to 1199 FTM surgeries. This is illustrated in Table 6.
US Residents (millions)
Primary Surgeries on US
residents
Mary Ann Horton
Best Estimate
MTF
FTM
138
143
736
430
Total
281
Minimum Cost
MTF
FTM
138
143
1,166
Page 8
662
293
Total
281
959
Maximum Cost
MTF
FTM
138
143
1,418
1,199
Total
281
2,617
7/31/2017
The Cost of Transgender Health Benefits
Ratio of US Residents
having Surgery in 2001: 1
in …
Years of Eligibility
Prevalence: Ratio having
SRS in lifetime: 1 in …
Prevalence: Ratio with
GID in lifetime: 1 in …
187,496 333,415 241,295
208,698
489,245
293,607
97,392
119,529
107,539
74
2,524
80
4,183
77
3,134
74
2,809
80
6,139
77
3,813
47
2,072
47
2,543
47
2,288
505
3,347
866
1,124
2,455
1,525
207
509
297
Table 6: Limit Analysis of Surgical Counts
9.2 Limit Analysis of Nonsurgical Treatment Prevalence
Table 7 below uses the process of establishing boundaries around nonsurgical prevalence: therapy,
hormones, and doctor’s office visits in support of hormones. It is assumed that not every transsexual has
surgery, but rather some who are diagnosed with Gender Identity Disorder will transition to living full time
in the new gender role, may or may not have therapy, may or may not have HRT, and may or may not have
surgery. Estimates are then made of those with GID that have therapy, that have HRT, and that have
surgery.
By knowing the numbers who have surgery and the estimated fractions of those with GID who have
therapy, HRT, and surgery, the number with GID can be calculated, and from that number the numbers
who have therapy, and who have HRT can be calculated. Since all of these values are not known
quantities, but rather ranges, the range values can then be calculated. This is shown in Table 7.
If the number of MTF surgeries in a year is 736 (range 662 to 1418) and 20% of those with GID have SRS
(range 10% to 40%) the number with MTF GID can be calculated to be about 3682 (range 1654 to 14,175.)
If 90% of those with MTF GID have therapy (range 50% to 90%,) there are 3,313 (range 827 to 12,758)
MTF transsexuals entering therapy each year. Similar reasoning applies to HRT and to FTM and all
transsexuals. Doctor’s office visits are required for HRT so the HRT MD numbers will match HRT Rx.
Combined totals of MTF and FTM can be calculated by adding the two populations.
Best Estimate
Minimum Cost
Maximum Cost
MTF
736
FTM
430
Total
1,166
MTF
662
FTM
293
Total
959
MTF
1,418
FTM
1,199
Total
2,617
Est. % with GID having
Primary Surgery
20%
80%
28%
40%
40%
40%
10%
20%
13%
New GID diagnoses each
year
3682
538
4219
1654
733
2386
14175
5997
20172
Est. % with GID having
Therapy
90%
50%
85%
50%
50%
50%
90%
90%
90%
3,313
269
3,582
827
366
1,193
12,758
5,397
18,155
90%
80%
89%
90%
80%
87%
90%
90%
90%
3,313
430
3,743
1,488
586
2,074
12,758
5,397
18,155
Primary Surgeries on US
residents
Patients in year 1 of
therapy
Est. % with GID having
HRT
Patients in year 1 of HRT
Table 7: Fractions of Transsexuals who have SRS, Therapy, and HRT
11. Conclusion
Mary Ann Horton
Page 9
7/31/2017
The Cost of Transgender Health Benefits
This paper measures the frequency of SRS for US residents. It reports a survey of surgeons who do SRS
procedures, and estimates the number of US residents undergoing primary SRS in the year 2001 to be about
1170 (740 MTF and 430 FTM,) with the confidence range setting lower and upper bounds of about 660 to
1420 MTF, and 290 to 1200 FTM. The prevalence of SRS per year among US residents is about 1:
240,000(about 1:190,000 MTF and 330,000 FTM.) It follows that the overall prevalence of those who will
have or have had SRS in their lifetime is about 1:3,100 (1:2500 MTF and 1:4,200 FTM.) Since not all
those transsexuals diagnosed with GID have SRS, the prevalence of GID can be estimated as 1:850 (1:500
MTF and 1:3350 FTM.)
Appendix A:
(Questions sent to surgeons.)
Acknowledgements
(to be written.)
References
Census, (2000) US Census, US Residents by age, Number of Insured by age
http://www.censusscope.org/us/chart_age.html http://www.census.gov/hhes/hlthins/hlthin00/hi00ta.html.
www.census.gov.
Conway (2002) How Frequently Does Transsexualism Occur?
http://ai.eecs.umich.edu/people/conway/TS/TSprevalence.html
DSM (1994) Gender Identity Disorder, Pg 535, Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV.) American Psychiatric Association.
Green, Jamison (2004) personal correspondence.
Green, Richard (1999) Reflections on "Transsexualism and Sex Reassignment" 1969-1999: Presidential
Address, August 1999, Harry Benjamin International Gender Dysphoria Association.
Harry Benjamin International Gender Dysphoria Association (2001) Standards of Care, Version Six.
Horton, Mary Ann (2006) The Cost of Transgender Health Benefits, April 2006, Draft submitted for
publication to International Journal of Transgenderism.
Janus, Samuel S and Synthia L, (1993) The Janus Report on Sexual Behavior, (Reports that 6% of males an
3% of females have engaged in cross-dressing (e.g. 1 or more on Benjamin scale.)
van Kesteren, PJ, Gooren, LJ, Megans, JA (1996) An epidemiological and demographic study of
transsexuals in the Netherlands, 25(6) Archives of Sexual behavior 589.
Wålinder. Jan (1967) Transsexualism: A study of forty-three cases. Originally published by
Akademiförlaget-Gumperts, Göteborg
A typical policy reads “Transsexual Surgery. Expenses related or leading to surgery to change an
individual’s gender are not covered.”
i
Mary Ann Horton
Page 10
7/31/2017
The Cost of Transgender Health Benefits
ii
Of the eight surgeons located in the US, 1 does only MTF surgery, 4 do only FTM, and 3 do both.
Because the author's contacts and concept of "reputation" of a surgeon is US-centric, the results presented
here will not necessarily apply to other countries or cultures.
iii
This is based on an assumption that the primary barriers to SRS today are social, family, and medical. It
is also possible the rate will continue to rise, although this will require more surgeons to enter the field.
iv
Chest surgery is seen as more essential and more attainable by the FTM population, whereas MTF
transsexuals often cannot afford it, and live without the surgery.
Mary Ann Horton
Page 11
7/31/2017