The Incidence and Prevalence of SRS Among US Residents

The Incidence and Prevalence of SRS among US Residents
Mary Ann Horton, Ph.D. Transgender at Work

ABSTRACT
This paper measures the incidence of Sex Reassignment Surgery (SRS) for US residents. It reports the num er of US residents undergoing SRS in one calendar year (!""#) using a survey of surgeons $ho offered SRS procedures. This run rate is used to calculate incidence of SRS% and to estimate prevalence. &stimates of incidence and inherent prevalence of 'ender Identity (isorder ('I()% mental health therapy% hormone treatments% and )T* ottom surgeries are derived. The num er of US residents undergoing primary SRS in the year !""# (run rate) $as ##+" (+," *ale to )emale or *T) and ,-" )emale to *ale or )T*.) The incidence of SRS per year among US residents $as #. !,"%""" (#.#/"%""" *T) and --"%""" )T*% a ratio of #.+0.#.) It follo$s that the inherent prevalence of those $ho have had or $ill have SRS in their lifetime $as a out #.-%#"" (#.!0"" *T) and #.,%!"" )T*.) 1ot all have SRS. the inherent prevalence of diagnosed 'I( is estimated as #.!""" (#.#0"" *T) and #.!2"" )T*% a ratio of #./.#.) The inherent prevalence of transsexualism (including those $ho are not diagnosed) is estimated as #.#""" (#.+0" *T) and #.#,"" )T*.)

Keywords
Transsexual Prevalence. Sex Reassignment Surgery Prevalence

Presented at 3ut and &4ual 5or6place Summit 7onference% Septem er #!% !""2. Su mitted for pu lication 08#+8"2% v9.0% to the International :ournal of Transgenderism% This paper may e cited as. Horton, Mary Ann (2008) The Prevalence of SRS Among US Resi ents, !"t # $%"al &or'(lace S"mmit, Se(tem)er 2008, htt(*++,,,-tgen er-net+ta,+th)cost-html.(revalence 7opyright ; !""2 y *ary Ann <orton.

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The Incidence and Prevalence of SRS Among US Residents

1. Introd ction
This paper measures the annual incidence of Sex Reassignment Surgery (SRS) for US residents. It reports the num er of US residents undergoing SRS in one calendar year (!""#) using a survey of surgeons $ho offered SRS procedures to Americans. This incidence $as extrapolated to estimate prevalence. The companion paper (<orton% !""2) uilds on the incidence result to estimate the insurance cost to cover Transgender <ealth =enefits. 1.1 Previous Work The prevalence (>the num er of people in a given population affected $ith a particular disease or condition at a given time?) of SRS has not een conclusively esta lished. *any estimates have een made% fe$ ased on experimental data. These estimates focus on either the prevalence of transsexualism. >5hat fraction of the population has een diagnosed as transsexual@? or of SRS. >5hat fraction of the population has SRS at some point in their lifetime@? The (S*AIB ((S*% #//,) states% C(ata from smaller countries in &urope $ith access to total population statistics and referral suggest that roughly #.-"%""" adult males and #.#""%""" adult females see6 sexA reassignment surgery (5alinder% #/9+) found a prevalence of #.-+%""" *T) and #.#"-%""" )T* (ratio !.2.#) in S$eden% ased on a survey of therapists a out patients currently eing treated for 'I( over a ! year period. (Pauly% #/92) estimated a prevalence of transsexualism of #.#""%""" *T) and #.,""%""" )T* (ratio ,.#) in the US. (<oeniig% #/+,) found a prevalence of #.-,%""" *T) and #.#"2%""" )T* (ratio -.!.#) in the UD% ased on patients eing treated currently for 'I( over an ## year period. (Tsoi% #/22) found a prevalence of #./%""" *T) and #.!+%""" )T* in Singapore% ased on patients diagnosed $ith 'I( over a 0 year period. The :anus Study (:anus% #//-) found that 9E of males and -E of females have personally crossAdressed. The :anus 4uestion is as6ed in the context of variant sexual practices% and $ould appear to include the entire scale of transgendered people% from postAoperative transsexuals to those $ho have only dressed as the opposite sex for <allo$een. (5eitFe% #//-) found the prevalence of transsexualism in 'ermany to e #.-9%"""A#.,!%""" *T) and #./,%"""A#.#",%""" )T* (ratio !.-.# or !.!.#). This is ased on the num er of people re4uesting court orders for name changes or gender mar6er over a #" year period. (van Desteren% #//9) found the prevalence of transsexualism in the 1etherlands to e #.##%/"" *T) and #.-"%,"" )T* (ratio -.#.) This is ased on the num er of patients receiving <RT in the country over an #2 year period. Richard 'reen ('reen% #///) gave the incidence of transsexualism at #.#"%""" *T) and #.-"%""" )T*. 7on$ay (7on$ay% !""#) estimated prevalence of *T) SRS in the US% y estimating the num er of surgeries each year and summing over the past several decades. She estimated that # in !0"" Americans orn male is currently a postAoperative transsexual% and that at least # in 0"" Americans orn male has 'I(. She estimates the incidence of transsexualism (the num er of people to transition from male to female each year) at #.#"%""" to #.!"%"""% ased on a !" to ," year career. 7on$ay does Csanity chec6sC $ith other methods of calculation. =ased on an estimated annual surgical count of #0"" to !""" and an

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The Incidence and Prevalence of SRS Among US Residents annual male irth rate of !%"""%"""% she estimates intrinsic (later termed as inherent) prevalence of SRS at #.#--- to #.#"""% that is% as many as # in #""" people $ill have SRS sometime during their lives. ((e 7uypere% !""9) found the prevalence of transsexualism in =elgium at #.#!%/"" *T) and #.--%2"" )T*% ased on a survey of surgeons performing SRS. (3lyslager% !""+) calculates inherent prevalence from previous studies% introducing the concepts of Gatent Transsexualism (people $ho $ill e treated) and Inherent Transsexualism (including people $ho $ill never e treated.) &stimates of inherent transsexualism et$een #.#""" and #.!""" are reported. 3thers have made estimates of transsexual or transgender people in other cultures% ased upon personal experience. 7on$ay (7on$ay% !""#) summariFes many of these estimates. These include. • 1um er of <iHra (males living as $omen) in India. estimated at #.-+0. • 1um er of transsexuals Cliving as $omenC ($ithout surgery) in *alaysia% estimated at #.2!". • SRS in the U.D.% estimated at #.-+0"% and of transsexualism% #.+0". • Datheoys (males living as $omen) in Thailand% estimated at #.#9+.

!. "ethodology
The goal of this study $as to measure the incidence and create a realistic estimate of the inherent prevalence of SRS. The surgical r"n rate $as measured y counting the total num er of surgeries in one year% surveying the surgeons that most US residents go to% and the inci ence calculated y dividing the run rate into the total population from the US census. /nherent (revalence is then estimated y extrapolating one year of data over the average life expectancy. This contrasts $ith (revalence% $hich only counts people currently 6no$n to e in treatment. Inherent prevalence $ill also include people $ho have previously een treated% $ill e treated in the future% or have the condition ut $ill never receive treatment. Persons desiring irreversi le surgical procedures $ho value the 4uality of the result usually go to a surgeon $ho has performed the procedure many times previously. It is 6no$n $ithin the American transgender community that the vast maHority of transsexuals see6ing surgery go to one of a relatively short list of surgeons for their final surgery. =y reputation% the vast maHority of US transsexuals $ent to one of #0 surgeons. (&ight of these surgeons are in the US% and seven of them are not.) This study refers to these #0 surgeons as ma0or s"rgeons- It is elieved that the maHor surgeons account for nearly all the primary surgeries performed on US residents. 4.1 Survey The author sent a survey in !""! to all surgeons and clinics $ho $ere listed as mem ers in <=I'(A. This survey in4uired a out all surgeries performed y the specific surgeon in the calendar year !""#. Iuestions as6ed included the total num er of procedures performed annually% the total cost and average cost per patient% and the percentage of patients $ho are US residents. SRS is a onceAinAaAlifetime event for any given transsexual patient. Some patients% ho$ever% may undergo multiple surgical procedures. It is important to count each patient exactly once% in order to accurately measure the incidence. To this end% the concept of a (rimary surgery $as defined. This is a surgery that can occur only once in the lifetime of any given patient% no matter ho$ many follo$Aups% corrections% reversals% or cosmetic surgeries are done. In addition% the primary surgery must e a procedure that is re4uired% that generally must e performed for SRS to e considered complete. )or *T) patients% the primary surgery $as defined to e the penectomy (removal of the penis.) This procedure is generally accompanied y a vaginaplasty% ut in case of complications% a second vaginaplasty may e indicated. 3nly one penectomy is possi le for any one patient

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The Incidence and Prevalence of SRS Among US Residents )or )T* patients% the primary surgery $as defined to e the ilateral mastectomy (top surgery.) The various )ottom s"rgeries (hysterectomy% metoidioplasty% phalloplasty) are not al$ays indicated% ut most )T* patients $ill undergo a single top surgery. Patient counting $as ased only on primary surgeries. Patient cost% ho$ever% $as ased on total cost of all surgeries% including follo$Aups to treat complications. Iuestions ! and 0% elo$% re4uested total cost of all surgeries. The specific 4uestions may e summariFed as follo$s. #. <o$ many *T) primary surgeries did you do in !""#@ !. 5hat $as the total cost of all the *T) surgeries@ -. 5hat fraction of the *T) surgeries $as done on US residents@ ,. <o$ many )T* primary surgeries did you do in !""#@ 0. 5hat $as the total cost of all the )T* surgeries@ 9. 5hat fraction of the )T* surgeries $as done on US residents@ Respondents $ere assured that their individual survey responses $ould e 6ept confidential. )or this reason% only summariFed data is presented. After a t$oAmonth interval% follo$Aup letters $ere sent to the maHor surgeons $ho had not yet responded. All maHor surgeons $ho had not responded $ere again contacted% until it $as clear there $ould e no further responses. 4.2 Analysis The data $as analyFed% using the follo$ing approach. #. The run rate of primary surgeries per year $as esta lished. The ra$ counts in the surveys $ere reconstructed y correcting errors% in cooperation $ith surgeons and their staffs. *issing information $as extrapolated using other availa le information. )or example% many surgeonsJ prices are $ell 6no$n or on their $e sites. A former patient $ho interacted $ith the staff for the #A! $ee6 period during their surgery estimated run rates. In one case% missing data $as discovered in a pu lished oo6. (ata $as extrapolated to include other surgeons. )inally% the total patient count included nonAUS residentsK the US resident percentages from the surveys $ere used to reduce the total run rate to represent US residents. (See Ta le #.) !. The ottom surgery run rates (for )T* patients) $ere reconstructed y correcting errors $here possi le. *issing surgeons $ere extrapolated using mar6et share estimates from a su Hect matter expert ('reen% !""-.) )inally% the US resident percentages $ere used to estimate the US run rates. -. The annual primary surgery run rate $as divided into the US resident population from the !""" US 7ensus% yielding the annual incidencce of SRS. This incidence $as multiplied y the life expectancy from the census (separated y irth sex) yielding an estimate of the inherent prevalence of primary surgery (that is% the fraction of people alive today $ho have had or $ill have SRS or top surgery in their lifetime.) This inherent prevalence is divided y the fraction of transsexuals $ho have surgery (item , elo$) to estimate the inherent prevalence of transsexualism.. ,. Incidence of nonsurgical procedures $as calculated from percentage estimates. )or example% it $as estimated that 0"E of transsexuals $ith intense TS feelings are diagnosed $ith 'I(% and that 9"E of *T) transsexuals diagnosed $ith 'I( have primary surgery% therefore the inherent prevalence of *T) transsexualism is a out -.- times that of SRS. It $as estimated that /"E of *T) transsexuals diagnosed $ith 'I( underta6e <ormone Replacement Therapy (<RT%) so the incidence of ne$ <RT patients is /"E of the incidence of 'I(% or #0"E of SRS. )or analysis of the medical cost (in dollars per US resident) see the companion paper The 7ost of Transgender <ealth =enefits (<orton% !""2.)

#. S rgical $ata
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The Incidence and Prevalence of SRS Among US Residents The data received from the surveys are summariFed in this section. )irst% the ra$ data as received is summariFed. This ra$ data contained a fe$ errors and omissions that $ere correcta le. The second section descri es the reconstruction process and the data after reconstruction. 4.1 Primary Surgical Data )or reasons of confidentiality% specific surgeons are not listed in this paper. Rather% the aggregate totals only are given here. 00 Surveys $ere sent out in !""! to all surgeons and clinics listed in the <=I'(A mem ership directory. )ifteen responses $ere received% #- from maHor surgeons and ! from others. 3f the #- responses received from the #0 maHor surgeons% one survey $as unusa le% and - had correcta le errors. )or surveys that $ere not directly usa le% correspondence $ith the surgeons (or their office staff) permitted the correction of some surveys. As a result% #! of #0 maHor surgeons% or 2"E% provided usa le data for this proHect. T$o surveys $ere returned y surgeons $ho $ere not on the list of maHor surgeons. 3ne of these provided *T) data for the studyK one provided oth *T) and )T* data. The #, valid surveys (a !0E usa le response rate) represented 299 *T) primary surgeries performed y #" surgeons% and --9 primary )T* surgeries (top surgery) performed y #" surgeons. + of the #, surgeons performed oth *T) and )T* surgeries% - *T) only% and , )T* only. (3f the #! maHor surgeons $ith usa le surveys% - did *T)% - did )T*% and 9 did oth.) *issing data $as reconstructed and extrapolated% as descri ed a ove% to arrive at a total annual run rate of extrapolated total primary surgeries. (See Ta le #.) ,.! Bottom Surgery Data (ata $as also provided for )T* C ottom surgeries.C 3ne 3 8'yn reported performing - hysterectomies and no mastectomies. (*ost )T* transsexuals go to a regular 3 8'yn for a hysterectomy% not to a transgender specialist.) 9 surgeons $ere 6no$n to perform metoidioplasties% - of $hich provided data totaling !# surgeries% of $hich !" $ere on US residents. , surgeons provided data a out phalloplasties% and 0 others $ere elieved to perform them. ,/ phalloplasties $ere reported% of $hich !# $ere on US residents. )or purposes of this study% only those surgeons $ho perform significant num ers of (rimary s"rgeries $ere counted as maHor surgeons. ,.- Run Rate It is estimated that /0E of *T) patients $ho have SRS go to a maHor *T) surgeon% and +0E of )T* patients $ho have top surgery go to a maHor )T* surgeon. This difference is ased on elief that it is more li6ely that an *T) $ill go to a maHor surgeon% ecause the *T) procedure is highly specialiFed. 5hile a specialiFed chest surgery is seen y many as important% it is also more realistic for an )T* transsexual to get an ordinary mastectomy. *any of the maHor surgeons have practices outside the US% and their reported surgeries included oth US resident and nonresident patients. The surgeons estimated the percentage of their clients $ho $ere US residents. These percentages $ere com ined. 9!, of 299 *T) patients% or +!E% $ere US residents. !/, of --9 )T* patients% or 2+E% $ere US residents. These percentages $ere com ined $ith reconstructed data and used in the extrapolation process% to arrive at run rates for US residents. These methods made it possi le to arrive at a total counted num er of primary surgeries in !""#% and a good estimate of the total costs for the primary surgery. (See ta le #.) 7ost data and analysis is presented in (<orton% !""9.) Ta le # summariFes the totals ased on the survey and the reconstruction techni4ues a ove. Totals are separated into *aleAtoA)emale and )emaleAtoA*ale categories.

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Surgical Run Rates
Ra$ 1um er of Primary Surgeries counted &stimated Additional Surgeries (reconstructed) Reconstructed 1um er Primary Surgeries y maHor surgeons &stimated Primary Surgeries y other surgeons &xtrapolated Total Primary Surgeries Percent of counted surgeries on US residents Primary Surgeries on S resi!ents

MTF
299 +/ /,0 10 //0 +,E "#$

FTM
--9 -/ -+0 221 0"" 29E 4#%

Total
#!"! ##2 #-!" #+0 #,/0 ++E 11$$

Ta&le 1' 2%%1 Surgical Run Rates

%. Incidence and Prevalence Analysis
5ith the 6no$ledge of the annual run rate and incidence% and the assumption that the run rate is flat% the inherent prevalence of primary surgery (SRS) can e estimated. (.1 )nci!ence o* Primary Surgery If the US run rate is ##99 surgeries8year (*T)L)T*) and the population of adult US residents $as !2#%,!#%/"9 in !"""% the incidence of SRS (er year among adult US residents is a out #.!,#%""" (a out #.#2+%""" *T) and #.---%""" )T*.) That is% a out .""",E of the population has SRS each year. (.2 Prevalence o* Primary Surgery 'enerally% the term (revalence is understood to represent the fraction of the population at ris6 currently eing treated for a condition% and can e calculated y dividing the siFe of the group measured y service providers into a su set of the $ider population. These prevalence results are often 4uoted in other contexts% and are misinterpreted to represent the fraction of the entire population $ho is transsexual. (7on$ay% !""#) coins the term inherent (revalence to mean the fraction of the population that is transsexual% including those $ho havenMt yet sought treatment% postAops% and those $ho avoid formal treatment. Inherent prevalence can e calculated from the incidence and life expectancy. )igure # illustrates the distinction et$een measuring prevalence from actively treated individuals and inherent prevalence% and ho$ previous prevalence calculations fail to consider people $ho $ill e treated% people $ho have previously een treated% and people $ho $ill never e treated.

)igure #. Prevalence vs Inherent Prevalence. Previous studies have counted the >at ris6 population? to e those at least #0 years old. They have o served that most transsexuals see6 treatment et$een #0 and a out -0. 5hen using incidence to

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The Incidence and Prevalence of SRS Among US Residents calculate inherent prevalence% the age distri ution of those eing treated does not matter% as the result $ill e the same for any distri ution. =ecause $e are as6ing a out the fraction of those c"rrently alive% the 6ey factor is life expectancy. )irst% it is assumed the run rate $ill continue at the !""# rate% and o serve 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 ased on sex% are accurate ased on irth sex% and are not changed significantly y SRS. Using the previous incidence result that # in #2+%""" people orn male have SRS each year% this num er can e multiplied y the male life expectancy (+,.- years.) This gives a out # in !0"" as the num er of irth males alive today $ho have had or $ill have SRS during some year in their lifetime. (See Ta le !.) *any more people have 'I(% or transsexualism% than $ind up having primary surgery. )or example% of !"" males $ith intense TS feelings% #!" may see6 treatment% #"" may e diagnosed $ith 'I( and are counseled% /" may receive hormones% +" may transition% and only 9" may have SRS &ach of these criteria $ould result in different prevalence results. )or purposes of estimation% this study assumes the *T) ratios are as stated a ove% and also assumes that of !"" females $ith intense TS feelings% #!" see6 treatment% #"" are diagnosed $ith 'I( and are counseled% 2- receive hormones% 2- transition% and 9+ have primary surgery. These estimates are in line $ith previously pu lished results and current empirical o servations. The assumptions here are normaliFed at #"" 'I( diagnoses. The prevalence of intense TS feelings (transsexualism) may e t$ice as great as the prevalence of diagnosed 'I(. Using the estimate that 9"E of *T) transsexuals diagnosed $ith 'I( go on to have SRS% it follo$s that a out # in #0"" irth males alive today has een or $ill e diagnosed as transsexual% and that # in +0" may actually e transsexual ut not necessarily see6 treatment. It is estimated that 9+E of )T* transsexuals diagnosed $ith 'I( have primary surgery. The )T* and com ined ratios can e calculated the same $ay% as sho$n in Ta le !. The inherent prevalence of SRS% for oth genders com ined% can e calculated as #.-#-,K that is% a out # in -%#"" US residents alive today have had or $ill have SRS at some time during their adult lifetime. US residential num ers are ased on the !""" US 7ensus% eligi ility is ased on irth sex (e.g. those orn male are the population eligi le for *T) surgery.) 1um ers should only e considered significant to ! digits.
*T) Primary Surgeries on US residents 1um er of US Residents Incidence. Ratio of US Residents having Surgery in !""#. # in N Oears of &ligi ility Inherent Prevalence. Ratio having SRS in lifetime. # in N Inherent Prevalence. Ratio of diagnosed 'I(. # in N Inherent Prevalence. Ratio of transsexuals. # in N +-9 #-2%"0-%09#2+%,/9 +, !%0!, #%0#, +0+ )T* ,-" #,-%-92%-,---%,#0 2" ,%#2!%2"#%,"# Total ##99 !2#%,!#%/"9 !,#%!/0 ++ -%#-, #%/+, /2+

Ta&le 2' )n+erent Prevalence o* SRS an! Transse,ualism among S resi!ents. (.2 Fre-uency o* FTM Bottom Surgery &stimating the fre4uency of )T* ottom surgeries (hysterectomy% metoidioplasty% phalloplasty) is more difficult than primary surgery. The (rimary s"rgery concept does not apply to ottom surgeries. The estimates made here are ased on intervie$s $ith a su Hect matter expert in the )T* community ('reen% !""-%) and should e considered less precise than measured data. Any 4ualified surgeon may do hysterectomies% so they $ere impractical to count directly. It $as estimated that 0"E of transitioning )T* transsexuals have a hysterectomy% 0E have a *etoidioplasty% and 9E have a Phalloplasty. This results in an estimated run rate of !0" hysterectomies% !0 metoidioplasties% and -" phalloplasties during the calendar year !""#.

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=ased on an 2" year life expectancy of irth females% it follo$s that the incidence of *etoidioplasty $as # in 9%99"%""" irth females% and the inherent prevalence $as # in 2-%""". Similar results $ere calculated for <ysterectomyA3ophorectomy and Phalloplasty% as sho$n in Ta le - elo$. 1um ers are significant to ! digits.
Proce!ure <ysterectomyA3ophorectomy *etoidioplasty Phalloplasty Fre-uency 0"E 0E 9E Patients 2%%1 )nci!ence !#0 #.999%""" (."""#0E) !! #.9%99"%""" (.""""#0E) !9 #.0%00"%""" (.""""#2E) )n+erent Prevalence #.2%-"" (."#!E) #.2-%""" (.""#!E) #.9/%""" (.""#,E)

Ta&le #' FTM Bottom Surgery Prevalence .stimates (.# )nci!ence o* /onsurgical Treatment 1ot every transsexual has primary surgery. Rather some transsexuals $ill transition (living full time in the ne$ gender role%) may or may not have therapy% may or may not have <RT% and may or may not have surgery. A aseline $as set for the fraction of those $ith 'I( diagnoses $ho have surgery% allo$ing the run rate of 'I( diagnoses to e calculated. =y definition% #""E of those $ith 'I( diagnoses receive therapy. =ased on experience and the pu lished literature% estimates $ere made of the fraction of 'I( diagnoses $ho have <RT% and the fraction of people in the general population $ith strong transsexual feelings $ho see6 treatment and receive a 'I( diagnosis. )rom these estimated fractions% the incidence of 'I( can e calculated% and from that num er the incidences of therapy% of <RT% and of transsexualism in the general population can e calculated. There $ere +-9 *T) surgeries each year. If 9"E of transsexuals diagnosed $ith 'I( have surgery% the 'I( diagnosis run rate that year $as a out +-9 8 9"E% or #!!+% *T)s. Similarly% a out ,-" 8 9+E% % or 9,!% )T*s received 'I( diagnoses. These are also the approximate run rates of mental health therapy. The next step $as to estimate the rates of hormone usage among those $ho transition. )or example% $ith an estimate that /"E of *T) 'I( diagnoses% and 2-E of )T*s% receive hormones% the <RT run rates are #-9, *T) and ++- )T*. These calculations are summariFed in Ta le ,. /onsurgical Prevalence .stimates
Primary Surgeries on US residents &st. E of 'I( having Primary Surgery 1e$ 'I( diagnoses each year &st. E of 'I( having Therapy Patients in year # of therapy &st. E of 'I( having <RT Patients in year # of <RT Est. % of GID having HRT

MTF
+-9 60% #%!!+ 100% #%!!+ 90% #%#", 90%

FTM
,-" 67% 9,! 100% 9,! 83% 0-83%

Total
#%#99 63% #%29/ 100% #%29/ 88% #%9-+ 88%

Ta&le 4' /onsurgical Fre-uency Rates

&. "argin of 'rror (imit Analysis
In arriving at the a ove est estimates% it $as necessary to estimate values that $ere not directly measured. To etter understand the margin for error% each of these estimates $as examined% to assess the practical range of values. =oundaries $ere set for each estimate% eyond $hich the estimated value could not reasona ly reach. )or example% maHor surgeons $ho did not respond to the survey could not have performed fe$er than Fero primary surgeries% and could not reasona ly have performed more such surgeries than the usiest surgeons in their field. Go$er and upper ounds $ere set% referred to here as minim"m cost and ma3im"m cost. This permitted lo$er and upper ounds to e calculated for the resulting fre4uencies. The resulting ounds on prevalence are summariFed in Ta le 0.

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Best 'stimate "T) )T" Total
Prim ary Surgeries on US residents Incidence: Ratio of US Residents having Surgery in 2001 : 1in … Intrinsic Prevalence: Ratio having SRS in lifetim e: 1in … Intrinsic Prevalence: Ratio of GID: 1in …

"inim m Cost "T) )T" Total 662
208,698

"a*im m Cost "T) )T" Total 1,418
97,392

736
1 87,496

430
333,41 5

1,166
241 ,295

293
489,245

959
293,607

1,199 2,617
1 1 9,529 1 07,539

2,524 1,514

4,183 2,803

3,134 1,974

2,809 2,247

6,139 4,911

3,813 3,050

2,072 207

2,543 2,288 509 297

Ta&le (' 0imits o* Run Rate an! Prevalence

+. Com,arison to Previo s St dies
Previous studies have reported $idely varying values for the prevalence of transsexualism. *any authors have commented that they elieve they are underreporting prevalence% and methodologies have varied $idely. The prevalence values have een $idely cited% interpreted% and criticiFed in pu lic literature. <o$ever% some analysis yields insight into prevalence% and especially incidence% in the general population. (3lyslager% !""+) contains a related analysis of prevalence% ta6ing into account transsexuals $ho $ill some day e treated or $ill never e treated. *ost prior studies used a methodology of counting 6no$n transsexuals eing treated over some period of time% divided into the total census population (often of persons over age #0.) Such studies actually capture incidence% ecause they miss transsexuals $ho have completed treatment% $ho have not yet een treated% or $ho have found another $ay to address their transsexualism. It is sometimes possi le to calculate annual incidence% ased on the stated prevalence result and the length of the study period. )or example% (van Destern% #//-) found an *T) prevalence of #.##%/"" over an #2 year interval% e4uivalent to an annual incidence of #.!#,%""". Some studies measured prevalence of 'I( diagnosis% some measured <ormone Therapy (<RT%) and some measured primary surgery. &mpirical evidence sho$s that not all transsexuals $ith the 'I( diagnosis egin <RT% and an even smaller group completes surgery. 3ne $ould expect higher incidence for reports measuring 'I( than for <RT% and higher for <RT than for primary surgery (SRS%) and indeed that is the case. Ta le 9 sho$s these calculations for #! previous studies.

Ta&le $' )nci!ence o* 12 Stu!ies

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The Incidence and Prevalence of SRS Among US Residents )igures ! and - sho$ incidence for #! studies% grouped y 'I(% <RT% and SRS criteria% and associated trend lines. Trend lines generally sho$ an increase in incidence rates over time% pro a ly reflecting increased a$areness% acceptance% and availa ility of services. It seems that% for the most part% the incidence rates from the studies are reasona ly consistent $ithin the same criteria group.
"T) Incidence
500,000 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 1965 !
0 1965 ! 400,000 600,000 1,000,000 1,200,000

)T" Incidence

800,000

200,000

1970 HRT

1975 GID

1980

1985

1990

1995

2000

2005

2010

1970 HRT

1975 GID

1980

1985

1990

1995

2000

2005

2010

"in#a$ % !&

"in#a$ %HRT&

"in#a$ %GID&

"in#a$ % !&

"in#a$ %HRT&

"in#a$ %GID&

Figure 2' MTF Annual )nci!ence in 12 stu!ies

Figure #' FTM Annual )nci!ence in 12 stu!ies

(ifferences et$een reported prevalence rates can e partially explained y considering the criteria% the incidence% and the year of the study. The lo$est reported *T) prevalence% #.#""%""" (Pauly% #/92) and the highest% #.0"" (7on$ay% !""#) represent an incidence of #.#""%""" for diagnosed 'I( in #/92% and of #.!"%""" for inherent prevalence of 'I( (diagnosed or not%) $hich are -- years apart. =oth of these extremes are ased on estimatesK the measured *T) results fall into an even closer range. *ore recent studies report higher incidences% presuma ly reflecting greater acceptance of the process and more availa le treatments. )T* incidence rates vary more $idely% and do not trend as cleanly% ut even so% all results are $ithin an order of magnitude.

-. Concl sion
The num er of US residents undergoing primary SRS in the year !""# (run rate) $as ##+" (+," *ale to )emale or *T) and ,-" )emale to *ale or )T*.) The incidence of SRS per year among US residents $as #. !,"%""" (#.#/"%""" *T) and --"%""" )T*% a ratio of #.+0.#.) It follo$s that the inherent prevalence of those $ho have had or $ill have SRS in their lifetime $as a out #.-%#"" (#.!0"" *T) and #.,%!"" )T*.) 1ot all have SRS. the inherent prevalence of diagnosed 'I( is estimated as #.!""" (#.#0"" *T) and #.!2"" )T*% a ratio of #./.#.) The inherent prevalence of transsexualism (including those $ho are not diagnosed) is estimated as #.#""" (#.+0" *T) and #.#,"" )T*.) It is possi le to categoriFe many previous prevalence results y the event eing studied ('I( diagnosis% hormones% or surgery) and to calculate incidence of the event from stated prevalence results. 7omparing the derived incidence results% most results fall into a reasona ly consistent range% sho$ing that incidence rates of treatments have increased over several decades as understanding of transsexualism and availa ility of treatment has improved.

.. Ac/nowledgements
The author $ould li6e to than6 the surgeons $ho completed the initial survey% and :amison 'reen% &lio Bentresca% and *eral 7rane for their advice and su Hect matter expertise.

References

*ary Ann <orton

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The Incidence and Prevalence of SRS Among US Residents 7ensus% (!""") US 7ensus% US Residents y age% 1um er of Insured y age htt(*++,,,-cens"ssco(e-org+"s+chart4age-html htt(*++,,,-cens"s-gov+hhes+hlthins+hlthin00+hi00ta-html,,,-cens"s-gov7on$ay (!""!) <o$ )re4uently (oes Transsexualism 3ccur@ http://ai.eecs.umich.edu/people/conway/TS/TSprevalence.html (S* (#//,) 'ender Identity (isorder, Pg 151, 6iagnostic an Statistical Man"al of Mental 6isor ers, 7o"rth $ ition (6SM8/9-) American Psychiatric Association'reen% :amison (!"",) (ersonal corres(on ence'reen% Richard (#///) Reflections on CTranssexualism and Sex ReassignmentC #/9/A#///. Presi ential A ress, A"g"st 2:::, Harry ;en0amin /nternational <en er 6ys(horia Association<arry =enHamin International 'ender (ysphoria Association (!""#) Standards of 7are% Bersion Six. <orton% *ary Ann (!""2) 7ost of Transgender <ealth =enefits% !"t # $%"al &or'(lace S"mmit, Septem er !""2% htt(*++,,,-tgen er-net+ta,+th)cost-html.th)cost :anus% Samuel S and Synthia G% (#//-) The :anus Report on Sexual =ehavior, (Re(orts that => of males an 5> of females have engage in cross8 ressing (e-g- 2 or more on ;en0amin scale-) 3lyslager% )em6e and 7on$ay% Gynn% (!""+) 3n the 7alculation of the Prevalence of Transsexualism. &PATH 20th /nternational Sym(osi"mvan Desteren% P:% 'ooren% G:% *egans% :A (#//9) An epidemiological and demographic study of transsexuals in the 1etherlands% 21(=) Archives of Se3"al )ehavior 18:5Plinder. :an (#/9+) Transsexualism. A study of fortyAthree cases. !riginally (")lishe )y A'a emif?rlaget8<"m(erts, <?te)org

*ary Ann <orton

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