How Frequently Does Transsexualism
Occur?
by Lynn Conway
http://www.lynnconway.com/
Copyright
@ 2001-2002, Lynn Conway. All Rights Reserved.
Updated version of 12-17-02.
Original article
was posted on the web on January 30, 2001. See also:
Lynn
Conway exposes errors in estimates of the
prevalence of transsexualism (a brief overview) 11-07-05
Important note of 9-06-07:
We recently analyzed all the
early original papers on this topic and determined why their reported numbers were
so low. On applying rigorous methods for prevalence calculations,
the data in the old papers is shown as confirming the [Conway01] hypothesis
that transsexualism is far more common than suspected in the past. For more
about these developments, see:
Olyslager, F. and Conway, L., “On the Calculation of the Prevalence of
Transsexualism”,
presented at the WPATH 20th International Symposium, Chicago, Illinois,
September 6, 2007
See also
Reviewers' Notes and
Powerpoint Slides (NL)
for that paper.
Abstract
In this investigative report we calculate an approximate
value of the lower bound of the prevalence of male-to-female
(MtF) transsexualism in the United States, based on estimates
of the numbers of sex reassignment surgeries performed on U.S.
residents during the past four decades. We find that the prevalence
of SRS is at least on the order of 1:2500, and may be twice that
value. We thus find that the intrinsic prevalence of MtF transsexualism
must be on the order of ~1:500 and may be even larger than that.
We show that these results are consistent with studies of TS
prevalence emerging in recent studies in other countries. Our
results stand is sharp contrast to the value of prevalence (1:30,000)
so oft-quoted by "expert authorities" in the U.S. psychiatric
community to whom the media turns for such information. We ponder
why that community might persist in quoting values of prevalence
that are roughly two full orders-of-magnitude (a factor of ~100)
too small. Finally, we discuss the challenge that our much larger
and more realistic numbers present to the medical community,
public health community, social welfare community and government
bureaucracies.
Introduction
There are many reasons for wanting to know the approximate
prevalence of a developmental or medical condition. One important
reason is that the prevalence of a condition determines the attention
it receives by medical researchers, physicians, public health
officials, social welfare workers and government bureaucrats.
If a condition is presumed "extremely rare", then it
gets very little attention at all. If is it known to be not uncommon,
and if it has a very high impact on those affected (such as conditions
like multiple sclerosis or deafness), then it gets taken much
more seriously and more medical and social resources are applied
to its correction.
In this article, we'll show that it is fairly easy to calculate
approximate values of the prevalence of male-to-female (MtF)
transsexualism. We first estimate the number of postop women
in the U.S by accumulating the estimated numbers of sex reassignment
surgeries (SRS) performed on U.S. citizens and residents decade
by decade. We then divide that number by the number of adult
males in the country. The result is a rough lower bound on postop
prevalence, which we find to be about 1:2500. In other words,
at least one or more in every 2500 adult males in the U.S. has
had SRS and become a postop woman. The prevalence of untreated
intense MtF transsexualism must be many times that number, and
is perhaps on the order of 1:500.
When we compare this value with the one often quoted by "psychiatric
authorities" in the U.S. (1:30,000), we discover that those
authorities have persistently understated the prevalence of transsexualism
by almost two orders of magnitude. This is such a incredible
discrepancy that we must raise questions about why the psychiatric
establishment (which has largely seized control of information
provided about transsexualism to the media in the U.S.) has been
so persistent in promulgating vastly understated values of the
prevalence.
As we'll see, you do not need to be a scientist or psychiatrist
to perform these prevalence calculations or to understand them.
Any reputable journalist could come up with the same analysis.
Any informed reader can study and understand it.
Given the context of easily performed calculations from common-sense
data that conflicts greatly with "conventional expert opinions",
readers should think of this article as a piece of "investigative
journalism" rather than as a "scientific treatise".
Rather than merely refining already existing sound practice,
this article is intended to help "shift a paradigm"
of traditional thought, and help trigger a fresh start when looking
at these matters. Once off to that fresh start, we can then refine
our estimates by gathering more data and doing more calculations
while applying traditional scientific methods.
Those concerned with truth in these matters will sense that
we need to seize control of the discussion from "psychiatric
authorities" who write untruths in obscure "scientific
journals", and who then confront all criticism by showing
their "credentials" rather than showing their data
and their calculations. Having an "expert psychiatrist"
tell us that a "scientific report says it is so" isn't
good enough anymore. Instead, we need to see actual data and
calculations that make basic common sense. We can then judge
for ourselves if we believe the results.
By analogy, this is somewhat like surveying a piece of land.
Suppose an "expert survey" says a piece of land is
2 acres in size, and we walk around and pace-off the land's dimensions
and roughly estimate it to be 200 acres. Common sense tells us
all that something is really wrong with the "expert survey".
Sure, our rough estimate might be off a bit, and the land might
be 150 acres or 250 acres instead. But common sense tells us
it CANNOT be only 2 acres in size. We can then shift our concern
to speculating about how or why the "surveyors" missed
seeing the vast majority of the land they were supposed to survey!
Also, as we'll see, Lynn's estimates appear to be consistent
with estimates of prevalence of transsexualism emerging in other
countries around the world. Hopefully, by sharing and comparing
our methods, data, calculations and results across many countries,
we will gradually get an ever clearer picture of the number of
people intrinsically affected by transgender and transsexual
conditions. Improved estimates of prevalence can then be an important
factor in gaining improved levels of medical treatment, social
support, and public policy support for those affected by this
condition.
What is "prevalence"?
'Prevalence' is the number of cases of a condition present
in a given population at a given time. If there are 100 cases
of a medical condition in a city of 100,000, then the prevalence
there at that time is 1 in 1000 (usually denoted as "1:1000").
It's really important to have some clue as to how prevalent a
condition is, because that determines how much money is allocated
to public health studies, medical research and medical treatment
of that condition.
This is not to be confused with 'incidence', which is the
number of new cases of a condition appearing in given population
in a given year. Incidence and prevalence are related in complex
ways. For example, for short-term conditions such as broken bones,
many more people might have broken bones in a given year than
those that have them at any one time. So the prevalence of broken
bones at any one time would be smaller than the incidence of
broken bones in a given year. If the average time to heal was
four weeks, then the prevalence would only be 4/52 or ~ 1/13th
as large as the incidence of broken bones.
However, in conditions such as transsexualism, which are
usually self-diagnosed at a young age and last a lifetime, we
find that the prevalence at any given time is much larger than
the incidence (the number of NEWLY diagnosed cases in that year),
perhaps by a factor of 30 to 40. When calculating prevalence,
we consider the total accumulated number of current cases in
a population, rather than the number of NEW cases each year.
Current-day authorities' statements
about the prevalence of transsexualism:
Medical authority figures in the United States most often
quote a prevalence of 1 in 30,000 for MtF transsexualism and
1 in 100,000 for FtM transsexualism. You'll see these figures
over and over again, such as in recent news stories in the
Washington Post
[1]
and the New
York Times [2]. But don't these
figures seem odd to you? They portray transsexualism as being
incredibly rare. However, many people nowadays know a transsexual
or know of some in their school, company or small community.
Where do these "extreme rarity" figures keep coming
from?
These figures are from the American Psychiatric Association's
Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV)
[3]. The numbers are often sent to the
media by the two "elite psychiatric centers" that have
long promulgated and dominated thinking regarding "sexological
and psychiatric theories of transsexualism", namely the
Clarke Institute in Toronto, Canada and the Johns Hopkins School
of Medicine in Baltimore, MD. Here is the actual quote from the
DSM-IV-TR, August, 2000, p. 579:
"Prevalence:
There are no recent epidemiological studies to provide data on
prevalence of Gender Identity Disorder. Data from smaller countries
in Europe with access to total population statistics and referrals
suggest that roughly 1 per 30,000 adult males and 1 per 100,000
adult females seek sex-reassignment surgery."
These figures are from decades-old data in the years when
modern SRS had first became available. Some of the earliest published
reports of estimates of prevalence originate with Walinder in
Sweden in the 1960's. He calculated prevalences of 1:37,000 for
MtF and 1:100,000 for FtM transsexualism. Those numbers were
widely cited and disseminated among U.S. researchers at a conference
on Gender Dysphoria Syndrome at Stanford in February 1973, during
the early years of Stanford's gender program. Most later prevalence
calculations then tended to "confirm" Walinder's early
estimates, which were usually informally quoted as "1:30,000
and 1:100,000". Those were the prevalence numbers that I
heard from Dr. Benjamin in the late 60's, and those are the numbers
that we still see in the DSM today!
However, the number of people seeking and obtaining SRS has
increased dramatically since the 1960's, as more affected people
became aware of the possibility of treatment. More importantly,
these figures do NOT indicate the prevalence of UNTREATED intense
transsexualism. They only include those who bravely stepped forward
and asked for SRS at a time when discrimination was incredibly
intense. Common sense says there were many more who suffered
in silence than came forward openly. But how many?
Doing some detective work
to come up with better numbers:
Let's do some "numerical detective work". It's
not really all that difficult to do.
We'll simply estimate the actual numbers of postop transsexual
women in the U.S. and then divide by the number of adult males
(up to about age 60, since those older had little access to the
surgery in the past). In the process, we'll find that the psychiatric
"authorities" numbers are way, way too small - probably
by as much as two orders of magnitude.
Before 1960, only a tiny handful of SRS operations were done
on U. S. citizens. George Burou, M.
D. of Casablanca, Morocco, then began doing a large series
of operations in the 1960's using a vastly improved new "penile-inversion"
technique. Harry Benjamin, M.D., a U.S. physician who had done
pioneering research and clinical treatments of transsexualism,
began referring many U.S. transsexuals to Dr. Burou and to several
other surgeons who used Burou's new technique. (Lynn later learned
from Dr. Benjamin that in 1968 she had been among the first 600
to 700 transsexual women from the U.S. to have had SRS).
Harry Benjamin, M.D.
The great medical pioneer and compassionate
physician
[photo taken by Lynn Conway in
1973]
The U. S. numbers grew during the 1970's as gender-identity
programs at Johns Hopkins and Stanford University triggered an
easing of restrictions on SRS in U.S. hospitals, and several
U.S. surgeons began performing SRS. Even more patients went to
Burou and other experienced surgeons abroad in the 70's. Lynn
learned from Dr. Benjamin in mid-1973 that his records showed
that ~ 2500 SRS operations had been done on U. S. transsexual
women by that date.
The table below shows
Lynn Conway's rough estimate of SRS operations done by major
SRS surgeons both here and abroad on U. S. citizens in recent
decades, extrapolated to include those done by many secondary
surgeons (each performing smaller numbers per year). A range
of values is given, from conservative to most likely numbers.
Note that these numbers do not count other transsexual operations
also done by these surgeons (such as mammoplasty, labiaplasty
and SRS repairs). For more background on MtF sex reassignment
surgery, see Lynn's
SRS webpage [4].
At present about 800-1000 MtF SRS operations are now performed
in the U. S. each year, and that many or more are performed on
U.S. citizens abroad (for example in countries like Thailand,
where the quality of SRS is excellent and the cost is much lower).
Thus somewhere between 1500 and 2000 MtF SRS's are done per year
on U.S. citizens and residents. The top three U. S. surgeons
(Eugene Schrang, Toby Meltzer and Stanley Biber) together now
perform a total of 400 or so SRS operations each year. There
are a dozen or so other surgeons in the U.S. quietly doing smaller
numbers of SRS's each year. The pioneering surgeon Stanley Biber
has himself done over 4,500 SRS operations since he began doing
the surgeries in 1969; for many years Dr. Biber did two SRS's
per day, three days per week!
TABLE 1: Estimates
of MtF SRS operations among U. S. residents:
|
1960's |
1970's |
1980's |
1990's - 2002 |
|
1,000 |
6000-7000 |
9,000-12,000 |
14,000-20,000 |
Calculating a lower bound
on the
prevalence of MtF transsexualism:
Adding up the numbers of surgeries over these decades, we
find that there are roughly 30,000 to 40,000 post-op transsexual
women in the U. S. Of course some surgeries done by U.S. surgeons
are on foreigners (perhaps 15%?). And some who've undergone SRS
have passed away by now. However, the majority of post-op transsexuals
had SRS within the past 15 years, and a high percentage of them
are still living. TS's in the smaller group who underwent SRS
in the 60's to mid-80's were mostly young - in their twenties
and early thirties, and thus most of those women are also still
alive. Even accounting for mortalities, Lynn estimates that the
number of post-ops in the US is greater than 32,000.
To calculate a rough lower bound on prevalence of MtF sex
reassignment surgeries in the U.S., we simply divide the number
of postop women, which is about 32,000, by the number of U. S.
males between 18 - 60 (the age range from which most current
post-ops originated), which is about 80,000,000:
32,000/80,000,000 = 1/2500.
Anyway, we discover to our amazement that at least one out
of every 2500 persons who were originally male in the U. S. has
ALREADY undergone SRS to become female! This 1:2,500 estimate
is vastly higher than the 1:30,000 estimate so oft-quoted by
the medical community. The DSM-IV number is clearly way off,
and by at least a factor of 12! However, on closer examination
we will find the error is far worse than even that!
However, you must remember that the DSM-IV "estimate"
is for the prevalence of transsexualism, not the
prevalence of SRS. Recent newspaper articles always make
that interpretation, and refer to the 1:30,000 figure as a "the
number of transsexuals", not the number of postop women.
Lynn estimates at least 3 to 5 times as many people suffer
intense MtF transsexualism as those who have already undergone
SRS. The reasons are obvious: Many transsexual people are unaware
of the options and treatments for resolving the condition, and
suffer in silence thinking there is no hope. Many are terrified
to "come out" and seek help for fear of social stigmatization.
Many more are incapable of paying the high medical costs for
transition. Thus there must be on the order of 100,000 to 200,000
UNTREATED cases of intense transsexualism in the U.S.
Thus the number of treated and untreated cases must be ~
130,000 to 240,000. If the number were 160,000, which is nearer
the lower end of this range, then the prevalence of intense transsexualism
is ~ 160,000/80,000,000 = 1:500. This value is only a rough LOWER
BOUND on the prevalence, and the intrinsic value could easily
be much higher.
Doing a sanity check
on these numbers:
We can do a quick sanity check of these results by calculating
postop prevalence in a totally different way. Here we will calculating
is "incrementally". We can do this by dividing the
ongoing incidence of SRS each year by the incidence of male births
in the U.S. each year. Since there are now about 1500 to 2000
SRS's per year and about 2,000,000 male births each year in the
U.S, we find an incremental value for prevalence of between 1500/2,000,000
= 1:1333 and 2000/2,000,000 = 1:1000.
This result is actually more than twice that of the value
calculated above ( 1:2500), because the (annual) incidence of
SRS has risen over the past decades while the (annual) incidence
of male births has remained fairly stable. This value is therefore
somewhat closer to the intrinsic prevalence than earlier incremental
values decades ago, because of more widespread knowledge of and
access to treatments and a reduction in the stigmatization of
transsexual people in recent years. This incrementally-determined
value of recent SRS prevalence strongly supports a value of intrinsic
TS prevalence of 1:500, and suggests that it is perhaps as high
as 1:250.
Comparison of results with other
rough projections of the prevalence
of TG conditions:
Another form of sanity check can be done on these numbers.
We can determine if they are consistent with rough projections
of the prevalence of related gender conditions, and with expected
ratios of the prevalence of those conditions.
In the United States there are varying estimates of the prevalence
of crossdressing. Most conservative estimates are in the range
of 2% to 5% of all adult males engage in routine crossdressing
(1:50 to 1:20). These are people who crossdress part-time either
privately at home, or in private CD clubs, and who find great
satisfaction in this practice. In a majority of these cases there
is mainly a male fetishistic motivation for the crossdressing.
However, in a moderate fraction (1/3rd?) it mainly provides an
outlet for mild to moderate to strong transgender feelings.
Some fraction of the "transgender" crossdressers
moving through this community will go on to "transition",
and take on a full-time social role as women. Of these, some
will complete a "TG transition" (without SRS), obtain
new ID's, and live as women afterwards. A smaller group will
complete a "TS transition" by also having SRS. In the
United States those who complete a TS transition can in most
states take on full legal status as women (updating their birth
certificates, being able to marry men, adopt children, etc).
Long experience in the large crossdressers' clubs appears
to indicate that at least 1/10th to1/20th of all crossdressers
will eventually complete a full-time transition. Of those who
do transition, a smaller fraction, perhaps 1/3rd of them, go
on to a complete TS transition (including SRS). These numbers
are what you hear if you simply ask crossdressers who are long
experienced in these clubs. These rough numbers are also supported
by the rough ratios of TG's and postopTS's to CD's in the major
website listings of "transgender" people on sites such
as Susana
Marques TV/CD/TS/TG Directory [5],
URNotAlone [6]
and Fiona's Fantasyland
[7]. Many thousands of (CD + TG +TS)
girls are listed on those sites, and you can see the rough ratios
by directly scanning those listings. While there are clearly
many "self-labeling" problems in such sites, there
is no reason to suspect that the self-labeled ratios are skewed
very far from those actually encountered in the larger (non-"website")
population.
These numbers provide another way to project some estimate
expected prevalence of TS transitions, namely by starting at
the top and working down. For example, if there only 1:50 adult
males were CD's, and if only 1:20 of them transitioned, then
we'd expect 1:1000 (TG + TS) transitions. This would predict
a very conservative estimate of about 1:3000 for the prevalence
of smaller number of TS transitions, which is of the same order
of magnitude as we have calculated from the number of surgeries
being performed. And of course, this estimate would be much higher
if the prevalence of CD's and the fraction of CD's who transitioned
were higher than the lower (conservative) values given.
There is yet another way to look at this: Most transgender
activist groups in the U.S. estimate that about 1% to 2% of all
people have strong transgender feelings and need outlets for
expressing those feelings. Many of these people "act out"
either by part-time crossdressing (and become the "transgender
fraction" of crossdressers), or by adopting a full-time
"gender variant" (neither male nor female) persona.
Of these people, perhaps 1/3rd or so have more intense "transsexual"
feelings and really would prefer to be in the other gender if
they could find a way to do that. These numbers suggest some
"intrinsic" prevalence of the "inner experience"
of being "transgender" or "transsexual",
namely for the prevalence of "strong cross-gender feelings"
and for "intensely, desperately cross-gender longings"
on the order of 1:50 and 1:150 respectively.
However, only a small fraction of such people could accomplish
a TG or TS transition, even in the most accommodating of societies.
Nevertheless, even if only 1/3rd to 1/5th of those people could
transition, this would lead to a projected prevalence of TG transitions
at about 1/150 and of TS transitions at about 1:500. In other
words, those appear to be likely lower bounds on the "intrinsic"
prevalence of such transitions if we started with young people
right now and went forward into a time that is much more open
to and supportive of such transitions than the past decades.
By cross-comparing all the above data and calculations, and
exploiting the rough estimates of ratios of various conditions,
we can construct the following table of rough projections of
prevalences:
TABLE 2: Coordinated rough projections of prevalence
of CD/TG/TS conditions in the U.S.:
| Observed situations: |
Likely lower bounds on
"intrinsic" prevalence
|
Conservative lower bounds on current prevalence
|
| P/T intense CD'ers: |
1:20 |
1:50 |
| Those with strong TG feelings: |
1:50 |
1:200 |
| Those with intense TS feelings: |
1:150 |
1:500 |
| TG transitioners (w/o SRS): |
1:200 |
1:1000 |
| TS transitioners (w SRS): |
1:500 |
1:2500 |
Of course, all these are very rough numbers. They are still
subject to definitional and "labeling" problems. Nevertheless,
this table is suggestive of what the numbers might be and how
the numbers would likely cross-compare from category to category.
Note that the rough numbers we get "bottom-up" by counting
surgeries in order to calculate an improved lower bound on TS
transitioners in the U.S. (1:2500) are seen to be consistent
with rough "top-down" derivations from the estimates
of crossdresser groups and activist groups in the U.S. that there
are roughly 1% to 2% of people who are TG, and perhaps 2% to
5% of males who engage in frequent (private/club) crossdressing.
Thus this table "hangs together" in a common-sense
way, and is suggestive of where to focus further research to
refine these numbers.
The resulting matrix of projections of prevalences will vary
greatly from country to country and culture to culture, since
each culture differentially suppresses crossdressing vs transgender
expressions, and different labels and categories would need to
be included in different countries. In many countries there are
traditionalized "third sex" social options to which
many TG and TS people naturally migrate, whereas those same people
were they to live in the U.S. might instead choose to complete
a TG or TS transition here. Then too, the ratio of TS vs TG transitions
varies greatly from country to country. In many countries where
incomes are low and where social constraints are high, very few
transgender people can ever afford SRS. In such countries, TG
transition is usually the only available option. It would be
very useful if researchers could gradually build and cross-compare
the overall matrices of prevalences of transgender conditions
among more and more countries. Such culture-by-culture prevalences
matrices might help us better understand the underlying commonalities
of innate conditions that lead to varying transgender personas
as a function of one's culture of socialization.
Comparison of results with
data on TS
prevalence in other countries:
Let us now compare Lynn's estimates of TS prevalence in the
U.S. with that in other cultures where transsexuals have access
to some means for gender-transition. These comparisons are of
course greatly complicated by the great differences in terminology,
self-classification, gender-modification technology and cultural
patterns among different countries. Even so, we can make some
rough comparisons that help to further triangulate on the numbers.
For example, most rough estimates of the number of
Hijra
in India range around 1,000,000 in a country of about one
billion population. Since there are about 375 million males over
age 13 in India, the prevalence of Hijra there is roughly 1:375.
Recent communications between Hijra gurus and western transsexual
women suggest that a majority of those who undergo the primitive
Hijra "sex change" surgery are early-onset intense
transsexuals. Becoming Hijra involves a great loss of social
status, and so there must be many TS's in India who do not become
Hijra. Thus the value of 1:375 appears to be a reasonable lower
bound on the intrinsic level of intense transsexualism in India.
These numbers are further supported by a
recent
survey of transsexuals in Malaysia [8],
where there is a ghettoized "street tranny" culture
somewhat like that in the U. S. The Malaysian count yielded 50,000
"transsexuals living as women" (i.e., TG + TS transitioners)
in a population of 21.8 million. These women correspond to the
"TG transitioners" in the U.S. (those "shemales"
who socially transition but do not have SRS). The prevalence
of TG transitioners in Indonesia is thus 50,000 divided by about
8.2 million males over age 13, and is therefore about 1:170.
Some moderate fraction of this number (1/3rd? 1/5th?) are likely
to be intensely TS and would undergo SRS if they could find a
way to do that. In addition, there are undoubtedly many more
TG + TS people among the larger population who do not transition
due to the extreme social degradation that results. Therefore,
the value of 1:170 is likely to be of the same order of magnitude
of the prevalence of transsexuals in that society. (Note that
earlier
estimates [9] suggest that there
are at least 10,000 transsexual women in Malaysia, yielding a
prevalence of at least 10,000/8,200,000 ~ 1:820; this value also
falls within the same order of magnitude as Lynn's estimates).
In 2001,
Donna
Patricia Kelly [10] made an estimate
of the prevalence of transsexualism in the United Kingdom using
Lynn's methods as described in this report. Using a conservative
estimate of the number of postop women in the U.K., Donna calculated
the lower bound on the prevalence of postop women in the U.K.
at ~ 1:3750, and estimated the prevalence of MtF transsexualism
to be ~ 1:750. These values are also in the same general range
as Lynn's estimates.
The numbers are also in the same ballpark as those found
by Sam Winter of the Faculty of Education, University of Hong
Kong, Hong Kong, in his paper entitled
"Counting
kathoey" [11], in which
he reports counting approximately 6/1000 MtF (TG + TS) social
transitioners (i.e., 1:167) among large numbers of passersby
in various locations in Thailand. That paper is highly recommended
reading for its description of a novel method for estimating
(TG +TS) prevalence (counting katheoy among passersby using katheoys
as top-experts at "reading other katheoys" among passersby).
It seems likely that a modest fraction of this number (1/3rd?
1/5th?) are intensely TS and either have undergone or would undergo
full TS transition if they could. Thus the number supports a
lower bound on TS prevalence on the order of 1:500 to 1:800 or
so. [It would be valuable if further research could clarify the
fraction of TS/(TG+TS) among Katheoy, i.e., the fraction of Katheoy
who have had SRS, and whether that number is or is not constrained
by the costs of SRS in Thailand.]
All these studies begin to triangulate on a likely prevalence
of intense MtF transsexualism in the range of 1:500 or even larger.
This is almost one hundred times the number (1:30,000) published
by the APA in the DSM-IV-TR! Therefore, the DSM-IV prevalence
numbers must be too low by about two orders of magnitude.
The numbers also indicate a prevalence of transgender (TG)
transition (without SRS) in the range of more than 1:200 in many
countries.
Comparisons of TS prevalence with
the prevalence
of other medical conditions:
By comparison, consider the prevalence of other long-term
duration conditions that have profound impacts on people's lives.
The approximate prevalence of muscular dystrophy is 1:5000, multiple
sclerosis (MS) is 1:1000, cleft lip/palate is 1:1000, cerebral
palsy is 1:500, blindness is 1:350, deafness is 1:250, self-reported
epilepsy is 1:200, schizophrenia is about 1:100, and rheumatoid
arthritis is about 1:100. All of these conditions are high on
our society's radar screen and there is massive public empathy
for those who suffer from them. There are large research funds
available for studying and treating these conditions, and patients
have welcome access to any existing medical treatments that might
relieve such conditions.
Contrast those situations to intense transsexualism, which
has an equally profound impact upon a person's life. This socially
unpopular condition is totally off our society's radar screen,
access to effective treatment is out of reach for the vast majority
of sufferers, and the wider medical establishment and social
welfare community are totally unaware of the relatively high
prevalence (~1:500 to ~ 1:250 or more) and frequently tragic
impact of the condition when simultaneously stigmatized and left
untreated.
Sanity-checking the claim
that
the psychiatrists' numbers are
way off:
We can also sanity-check our claim that the psychiatrists'
estimates of the prevalence of transsexualism are way, way off.
This is easy to do by simply calculating some implications of
those numbers and observing that the implications are ridiculous.
For example, if only 1:30,000 males were intrinsically transsexual,
and if we expect at the very most that only 1/4 of them find
help and go through a complete transition including SRS, then
only 1:120,000 males would have SRS and become a postop woman.
Since there are 80,000,000 males between 18 and 60 in the U.S.,
this estimate of SRS prevalence says that there would be only
about 670 postop women in the U.S.! But of course we know that
there are probably two to three times that many males undergoing
SRS every year, so this is obviously a fantastically too-small
result.
Another way to look at it is this: If only 1:120,000 males
were at some time during their lives having SRS, and if the span
of ages for SRS was uniformly distributed between about 18 and
58 (a 40 year span), then only 1/40th of those males would be
having SRS in any given year. Thus we'd expect only 17 U.S. citizens
and residents to have SRS each year! Again, that's a ridiculously
low number, and is clearly off by about a factor of about 100.
Why do psychiatrists propagate
such erroneous values
for the prevalence of transsexualism?
As we've seen, the DSM-IV values for the prevalence of transsexualism
are wrong by about two orders of magnitude. Why would the psychiatric
community so grossly understate the TS prevalence numbers? And
if they aren't doing it deliberately, how could they be so ignorant
of their error? Let's speculate on what's going on here.
Part of the problem is just plain ignorance. The psychiatric
community only "reads its own publications". If the
only published report about the prevalence of transsexualism
in their journals is a totally outdated, flawed one from decades
ago, that's the paper they will quote! Anything else "is
not considered science" to them, and they won't pay any
attention to it.
The psychiatric community also generally ignores cross-cultural
or anthropological studies of human behavior that might better
illuminate conditions here in the U.S., and thus is not aware
of recent prevalence data emerging from other countries. The
community also seems out of touch with what goes on in the real
world of transsexual therapy and surgeries, or even simply what
goes on on the streets in our own society. Instead, they treat
whoever "comes through their door". They are thus subject
to all sorts of distortions in their perceptions of transsexual
people by seeing only the small biased samples of transsexual
people who unwittingly go see psychiatrists.
Perhaps most importantly, it is the strong self-interest
of psychiatrists to have their patients believe that transsexualism
is incredibly rare, for then takes years of expensive counseling
for the psychiatrist to be convinced that a patient is a "true
transsexual" who needs SRS. Psychiatrists can reinforce
a very "conservative, non-permissive" approach to treating
transsexualism IF they can continue to assure society that "true
transsexualism is incredibly rare", and that most people
who seek "sex changes" are mentally ill and in need
of "shrinking" by psychiatrists to cure them of their
"delusions".
The complete invisibility of the large numbers of post-op
TS women living in stealth also keeps the estimates low. After
all, the only transsexuals visible to most people in our society
(who don't see the big-city late-night street scene) are the
small TS minority groupings of (i) young and openly effeminate
boys and (ii) older transitioners and autogynephiles who are
having difficulty passing and coping during or after transition.
Those are also the only groups who tend to be seen by psychiatrists.
The street trannies living in big city ghettos are off everyone's
radar screen and never see psychiatrists. And the large numbers
of more advantaged young to middle-aged transsexuals who are
managing their own transitions would never think of going to
a psychiatrist to "help them with their mental illness problems".
Instead they almost all go to experienced, non-judgmental, practical-minded
gender counselors nowadays.
Most psychiatrists therefore never see any of the vastly
larger number of inconspicuous, successfully-transitioning transsexuals
here in the U.S. Most of these women quietly undertake social/hormonal
transitions with the help of practical (non-psychiatric, non-behaviorist)
counseling. They enter and complete their real life experience
(RLE), obtain SRS, and then assimilate as women back into society
in stealth mode, without ever interacting with traditional psychiatrists.
(For examples of such cases, see
Lynn's
TS Women's Successes webpage [12]
). Most psychiatrists don't even have a clue that these many
successful transitioners even exist!
Perhaps the explanation is at an even more mundane level.
It might be that almost no one in the psychiatric community thinks
quantitatively, in the manner of scientists and engineers, so
perhaps it's no surprise they didn't notice or grasp how far
off their numbers were! Echoing a question that Christine Burns
(then Vice President of Press for Change in the U.K.) asked upon
reading Lynn's numbers in 2001, we might ask "Can Psychiatrists
Count?"
Thus it took a research engineer (Lynn Conway, in January
2001) to visualize that there was a gross error in the oft-quoted
prevalence values, and then do these calculations showing that
the prevalence of postop transsexual women in the U.S. is at
least 1:2,500, implying that the prevalence of intense transsexualism
is at least 1:500, and maybe more.
Other pressures to "keep
the numbers small":
When this report went into circulation in 2001, the first
strong signals of resistance to Lynn's higher values of TS prevalence
came from a surprising source: From other transsexual women themselves.
The resistance was often extremely strong and irrational
in form. It usually took the form of outraged "denials"
and claims that "those numbers can't be right because the
experts have known for decades that it's 1:30,000". Many
argued about fine details in the calculations that might change
the result by small factors one way or the other, and then claimed
that therefore the "whole thing was totally wrong".
None of these folks seemed to grasp that the old numbers are
orders of magnitude in error, and that any small factors pale
beside such huge errors.
But why would transsexual women not want to believe these
new numbers? Why wouldn't they even try to check out the calculations
for themselves? There appear to be two main reasons why some
transsexual women are so highly invested in the old "1:30,000"
value of TS prevalence.
The first reason is simple: It is ever so much more special
to "be a transsexual" if it is "very, very rare".
In many web bios and coming-out sites we find many statements
such as "I am one in only 30,000 people who have this condition".
Lynn speculates that this concept of "great rarity"
endows some TS women with a sense of "specialness"
that helps counter the embarrassment and humiliation they feel
when coming out. Such women then strongly resist the idea that
being transsexual may not be particularly rare or special after
all.
The other reason for denying the reality of these new numbers
is a concern about medical care: In past efforts to get insurance
companies to pay for hormones and SRS, the 1:30,000 number has
always been used to calm fears about what it would cost to implement
those programs. By claiming that transsexualism is incredibly
rare, activists have projected that it would cost very little
to pay for all transitional medical care for TS people. Thus
the possibility that transsexualism is 100 times as common as
they previously thought came as a great shock to them.
However, their concern about the new numbers hurting the
case for medical insurance coverage is overblown: After all,
even if the prevalence is 1:500, then the INCIDENCE of transitions
in any given year is only 1/20th to 1/40th of that. Thus the
actual number of people who might transition each year in the
future is perhaps 1:10,000 to 1:20,000, which is still a VERY
small number. Thus the higher values of TS prevalence should
not hurt chances for gaining insurance coverage or government
medical program coverage for hormones and SRS. Concerns about
such programs should certainly not be a reason to deliberately
hide clear evidence that the prevalence of transsexualism is
much higher than thought years ago. In many ways the higher prevalence
should get medical authorities to take the situation of transsexual
people more seriously and be more concerned about their treatment
- since it isn't such a "totally rare" condition after
all.
Our numbers challenge the veracity
and credibility
of the psychiatric community and
the DSM-IV-TR:
Lynn's new, improved estimates of prevalence numbers, based
on simple obvious counts and arithmetic, are a direct CHALLENGE
of the U.S.psychiatric community's credibility, professionalism
and veracity in the entire area of transsexualism. Psychiatrists
might quibble with the details of Lynn's estimates, but they
can't escape the order of magnitude of their own error. That
community's error of two-orders-of-magnitude in their estimate
of the prevalence of transsexualism is truly egregious.
The obviousness of this error has heightened reactions in
the transgender community to the DSM-IV's proferring of incorrect
information about transsexualism. Lynn's numbers have widely
circulated in the trans community in the U.S. They are included,
for example, in the Gender
Identity of Colorado's webpage resource for the Reform of
Gender Disorders in the DSM-IV-TR, located at http://gidreform.org/
[13], as part of that site's well-reasoned
indictment of the psychiatric profession's mis-characterization
of transgenderism and transsexualism.
It's also somewhat amazing that the Harry
Benjamin International Gender Dysphoria Association (HBIGDA)
itself hasn't ever bothered to do a survey of the number of SRS
operations being performed. Even so, the recently released
Version 6 of the HBIGDA
Standards of Care [14] gives
a prevalence estimate as follow: "The earliest estimates
of prevalence for transsexualism in adults were 1 in 37,000 males
and 1 in 107,000 females. The most recent prevalence information
from the Netherlands for the transsexual end of the gender identity
disorder spectrum is 1 in 11,900 males and 1 in 30,400 females."
Thus we see HGIBDA quoting somewhat newer, but similarly
flawed "survey studies". Amazingly, HBIGDA carries
their results out to three significant digits, implying that
these are "very accurate results"! They also quote
these values not as new lower bounds on prevalence but as actual
values of prevalence, as did the psychiatrists.
HBIGDA thus continues to propagate the methodological errors
of the psychiatrists, quoting yet another "foreign survey
study" based on known SRS numbers which are obviously
a subset of the total SRS numbers. Any such study greatly underestimates
actual SRS numbers that include many women in stealth,
and even more vastly underestimates the much larger numbers of
pre-op intense transsexuals in that country.
These numbers also present a challenge
to the wider medical community,
public health community, social
welfare community,
and government bureaucracies:
The bottom line is that transsexualism is at least two orders
of magnitude more prevalent than previously recognized by the
U.S. psychiatric community. This result has important implications
for the diagnosis and treatment of transsexualism, and for the
construction of humane social policies regarding people having
this condition. It also helps to better put into perspective
the even larger prevalence of transgender conditions, and of
transgender (TG) social transitions.
For example, the presence of thousands of thrown-away and
run-away transgender and transsexual teenagers in the large inner-cities
in the U.S. has gone completely unrecognized and passed under
our society's "radar screen". Most people who encounter
TG and TS sex workers on our city streets simply assume that
they are "gay". However, there is very little overlap
between the TG/TS girls and the gay male community in most of
our cities, and thus the HIV prevention work aimed at gay men
has not reached into the TG/TS communities. This has led to a
heretofore unrecognized HIV epidemic and countless human tragedies
among these transgender street kids, as recently reported in
Salon.com
SCIENCE & HEALTH [15].
Out of ignorance of the realities of TG and TS conditions
and the prevalence of the condition, the medical establishment
in the U.S. has also persisted in often inhumane treatment of
TG/TS people who seek emergency medical help, even when they
do so for non-gender-related emergencies. In response to this
problem, the American Public Health Association has issued a
public health policy statement regarding "The Need for Acknowledging
Transgendered Individuals within Research and Clinical Practice,"
(APHA
Public Policy 9933) [16] beseeching
the medical community to treat TG and TS people, and treat them
more compassionately and professionally.
Fortunately, many enlightened cities and corporations in
the U.S. have noticed that transgender and transsexual people
are not uncommon, and have taken steps to protect their human
rights. A number of major cities in the U.S. (New York City,
Boston, Philadelphia, Dallas, etc.) have recently passed new
laws providing protections from discrimination for TG and TS
people. Some cities such as San Franscisco are also providing
shelters and support clinics to help young "street trannies"
with hormones, identification papers and employment counseling.
Many prominent corporations in the U.S., especially those in
high-technology, are now providing "Equal Opportunity"
employment protections for TG and TS people. In many of those
companies transsexual people can even transition "on-the-job"
without fear of loss of employment.
However, the bureaucracies in some states in the U.S.still
have poorly coordinated procedures for the updating of driver's
licenses, birth certificates and other ID's and personal records
of transitioners. In past decades when the transsexualism was
considered "extremely rare", some states did not bother
to formalize any procedures for changing the records of those
who change gender, and these situations were often handled one-at-a-time
in an ad-hoc and inconsistent manner. Hopefully the increased
visibility and activism of TG and TS people, along with a better
sense of the prevalence of these conditions, will lead those
states to update their bureaucratic procedures to properly accommodate
changes in gender.
Conclusions
In this report we found that the prevalence of SRS in the
U.S. is at least on the order of 1:2500, and may be as much as
twice that value. Therefore, the intrinsic prevalence of MtF
transsexualism here must be on the order of ~1:500 and may be
even larger than that. These results appear to be consistent
with studies of TS prevalence in recent studies in other countries.
These results stand is sharp contrast to the value of prevalence
(1:30,000) so oft-quoted by "expert authorities" in
the U.S. psychiatric community to whom the media turns for such
information. We explored reasons why that community might persist
in quoting values of prevalence that are roughly two orders-of-magnitude
too small. We speculate that this large error has been perpetuated
due to a combination of ignorance, financial self-interest, urges
to control the discussion, and an inability to think quantitatively
on the part of many psychiatrists. Or perhaps the old estimates
of the psychiatrists are like "urban legends", and
simply get automatically and thoughtlessly propagated over the
decades, without anyone ever questioning whether they even make
any sense. Whatever the reasons, it is clear that the psychiatrist's
estimates of TS prevalence are way, way off, and by a factor
of ~100.
The discovery of such a large error in the widely-quoted
estimates of TS prevalence presents many challenges to traditional
thinking in the medical community, public health community, social
welfare community, and government bureaucracies - and not only
about transsexualism but also about the even larger number of
transgender transitioners in our society. All these institutions
should take transsexualism and transgenderism much more seriously
than in the past, and should more thoughtfully and rigorously
consider the social welfare and human rights of the many transsexual
and transgender people among us.