By Joshua Arnold

The most mysterious feature of the 2023 SAFE Act Wars was that virtually every major hospital system — across 20+ states — lobbied vehemently against the bills. At nearly every public hearing, the speaking roster was saturated by three groups speaking in opposition: transgender activists, families with trans-identifying youth who hadn’t yet come to regret the procedures, and medical professionals, typically associated with a local hospital system.

Yet 2023 was a tipping-point year, in which the number of states with laws protecting minors from gender transition procedures increased from four to 22. This dramatic shift occurred because the dangerous, experimental nature of these surgeries became increasingly apparent. Otherwise progressive European countries such as the U.K., Norway, and Denmark pulled back on providing gender transition procedures to minors. Even state legislators, many of whom lack a medical background, were able to clearly grasp the lack of medical evidence and the potential for harm with these procedures, often articulating those reasons in the legislation they passed.

This raises the question, if the fundamental unsoundness of providing gender transition procedures to minors was evident to everyone from Norway to North Dakota, why couldn’t hospitals see it? A recent report from the American Principles Project suggests an explanation: hospitals and drug manufacturers were blinded by the Benjamins — billions of dollars’ worth.

The American Principles Project (APP) commissioned business consulting firm Grand View Research to conduct a market analysis measuring the volume of the gender-reassignment surgery industry. They recently estimated its value at a whopping $4.12 billion in 2022, with a compounded annual growth rate of 8.4% through 2030. The APP published those numbers this summer in an 88-page report.

Estimate Is Likely an Undercount

Due to various complications in data collection, nearly all estimates of the U.S. gender transition industry will be conservative (tending to undercount rather than overcount), the APP report stated, including the one they commissioned. American health care lacks the comprehensive, centralized data collection of socialized medicine, so researchers must compile data in other ways. For instance, a 2022 study by Komodo Health analyzed insurance claims and found 42,000 minors diagnosed with gender dysphoria in 2021, but this necessarily excluded all medical activity not covered by insurance.

Other studies have also struggled to find complete datasets. For example, studies that analyze gender transition procedures based on their medical code will necessarily fail to detect gender transition procedures labeled with a generic medical code. In a 2019 video, Dr. Shayne Taylor explained that this was a deliberate strategy. “For the patient who gets a big bill because their insurance doesn’t cover any transgender-related codes, I usually write ‘endocrine disorder not otherwise specified’ to allow me to order the labs that I want,” Taylor said.

Taylor was influential in convincing Vanderbilt University Medical Center to practice gender transition procedures because “these surgeries make a lot of money.” Based on figures from the Philadelphia Center for Transgender Surgery, “female-to-male chest reconstruction could bring in $40,000,” and “around $20,000 for a vaginoplasty,” Taylor cited. “That doesn’t include your post-op visits. That doesn’t include your anesthesia, your OR. So I would think this has to be a gross underestimate. I think that’s just, like, the surgeon’s piece of it.”

Leaked video of the profit rationale behind the gender transition program at Vanderbilt University Medical Center may have played a role in Tennessee enacting legislation to protect minors from gender transition procedures in March 2023.

Another reason to believe these numbers represent an undercount is that estimates of the number of trans-identifying people in America are significantly higher. The pro-LGBT Williams Institute estimated in June 2022 that 1.6 million Americans identify as transgender, including approximately 300,000 youth aged 13-17. While it’s possible that the Williams Institute has a political motive to inflate these numbers, it still yields a much larger estimate than studies that look at medical data.

Transgender activist Robbi Katherine Anthony “(who prefers going by RKA),” APP notes, multiplied the number of transgender-identifying Americans with the “average cost of transition,” estimated at $150,000, to speculate that the potential gender transition market could be valued in excess of $200 billion, “larger than the entire film industry.”

Even if these studies are significant undercounts, they do serve to show the trend. Every study shows a dramatic increase over time in people seeking treatment for gender dysphoria, especially among young people. One study reviewed for the APP report showed that “health system encounters for gender identity disorder rose from 13,855 in 2016 to 38,470 in 2020.”

Costly Procedures

Why such staggering costs? Gender transition surgeries are attempting to reshape — or more accurately, war against — a person’s natural biology. Advanced plastic surgery techniques can recreate the appearance if not the function of different organs. But, as Taylor suggested, the price tag for each individual procedure can be pricey. The APP includes a list of common procedures and their prices:

• Augmentation Mammoplasty, $6,000-12,000
• Voice Feminization Surgery, $5,000-9,000
• Reduction Thyrochondroplasty, $3,500-7,000
• Orchiectomy, $5,000-8,000
• Vaginoplasty, $10,000-40,000
• Chest Masculinization Surgery, $6,000-10,000
• Scrotoplasty, $4,000-6,000
• Hysterectomy, $9,500-22,500
• Phalloplasty, $20,000-150,000
• Mastectomy, $15,000-50,000
• Metoidioplasty, $20,000-30,000
• Facial Feminization Surgery, $20,000-50,000+
• Electrolysis, $50-200 (one-hour session)
• Laser Hair Removal, $200-1,000
• Vocal Training, $50-200 per hour

In general, these are surgeries to a person’s face, throat, chest, or genitalia that result in him or her looking more like the opposite sex. Readers who want more specificity can do their own research. It will not be family-friendly or conducive to good digestion. You have been warned.

These costs add up as trans-identifying individuals pursue multiple procedures. The APP estimated that the “total cost of fully transitioning” ranges from $87,300-410,600 for males and from $66,500-605,500 for females. This assumes five years of puberty blockers (at $3,000-$25,000 per year) and 60 years of cross-sex hormone use (from age 16 to age 76, the average life expectancy, with estrogen estimated at $240-2,400 per year and testosterone at $200-4,200 per year).

These cost estimates do not factor in related medical costs, such as hospital stays and anesthesia. Nor does it factor in the potential for secondary surgeries. “A study in the medical journal Plastic and Reconstructive Surgery found that up to a third of patients ‘undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty,’” cited the report. “A similar study in Aesthetic Plastic Surgery reported that revisions for transfeminine vaginoplasty are frequent. These are lifetime, repeat customers, and there are more of them all the time.”

Market Competitors

Whether the market is worth $4 billion annually or a somewhat larger amount, that’s a large pot to split between relatively few players.

According to the market analysis from Grand View Research, 11 hospital and surgery systems account for nearly half (48.7%) of the sex reassignment market revenue in 2022, with other medical systems comprising the rest. Seven of these are in California and New York (including Cedars Sinai, Mount Sinai, and Kaiser Permanente), and the other four are: Regents of the University of Michigan, Mayo Clinic, Cleveland Clinic, and The Johns Hopkins University.

(Keep in mind, however, that hospital and surgery centers operate in somewhat location-specific markets; coastal surgery centers are likely not competing for clients with, for instance, Sanford Health, the pro-transgender hospital giant of the upper Plains states.)

Grand View Research also attempted to construct a snapshot of the top drug companies providing gender transition hormones. However, this picture was far less complete; many puberty blockers and cross-sex hormones are prescribed off-label, making them harder to track, the APP explained.

The research only accounted for an estimated 14.6% of the market, totaling $234 million in 2022. The top five companies Grand View Research tracked were Pfizer, Inc. (4.6% estimated market share), AbbVie, Inc. (3.2%), End International plc (2.9%), Novartis AG (2.1%), and Lilly (1.8%).

Disaggregated data such as these contribute to the reliability of Grand View Research’s overall estimates. It shows their work, demonstrating that the overall estimates were not invented out of thin air, but represent the aggregate of more minute and concrete estimates, which are more likely to be accurate.

Lobbying Incentive

With such large potential profits on the line, it puts in perspective the efforts by hospital lobbyists seeking to defeat bills protecting minors from gender transition procedures.

If hospitals view gender-confused children as potential lifelong patients, then state laws protecting children from the depredations of gender transition procedures are a direct threat to their business model. Not only does it delay their ability to profit off these children for five years or so, but it also threatens their ability to recruit that child as a lifelong patient at all. Research cited by the Indiana State Medical Association in 2023 has shown that 60% to 95% of minors with gender dysphoria will eventually embrace their biological sex, if puberty is allowed to occur normally, whereas 95% of children who begin puberty blockers will proceed to cross-sex hormones and surgery.

These lobbying campaigns cannot be reduced to the simple question, what is the best practice medical care for children? The APP report notes, “There lurks beneath the surface of ‘best practices’ an incentive structure and a market, both real and potential.” That incentive structure and market are preventing medical systems from seeking the best interest of their gender-confused patients.

Joshua Arnold is a senior writer at The Washington Stand.