Blanchard, Steiner and Clemmensen, 1985
Gender Identity Clinic, Clarke Institute of Psychiatry, University of Toronto, Toronto, Ontario, Canada

The Gender Identity Clinic of the Clarke Institute was established in 1969 and, furthered since 1975 with means of the Ministry of Health of the Province of Ontario. Overall the author group has treated or at least certified most transsexuals in Canada. Steiner (1985, p. XI, p. 417) writes that she has seen, just during the previous 15 years, about 700 patients. Many researches about single aspects of transsexualism stem from this clinic, in which mostly the researched method used is presented clearly and extensively (overview in Steiner, 1985). As in this publication, the emphasis is on typologies, for example, the differentiation of heterosexual and homosexual transsexuals, not discussed more closely here.

• Sample
• Study Methods
• Evaluation Fields and Criteria
• Results
• Suicide Attempts
• Follow-up Studies Mentioned
• Authors' Conclusion
• Remarks

Study Methods
The authors participated in treatment and indication for surgery. Patients answered questionnaires that were given to them at the clinic or mailed to them.

Evaluation Fields and Criteria
Evaluated were partnerships, employment and income situations, as well as the subjective satisfaction with treatment results. The subjective satisfaction was sampled with two questions. The first question asked if the subject would want surgery again and it allowed for five different answers. In addition it was asked if subjects would rather live as a member of the present or former gender at the time of the follow-up study.

Results
The aspect of subjective satisfaction was not differentiated by gender. In the follow-up study, 93.7% were sure that they would undergo surgery for a second time. The other 6.3% considered this as possible. For the latter, surgery was statistically significant (p=.001) a shorter time (mean 81.2 months) ago, than for those who were sure (mean 49.4 months). Except for one female who had to endure a considerable professional demotion during gender reassignment and had answered the category "unsure," all others wanted to live in the new gender role.
Females: Three females lived from unemployment benefits, six from social welfare. This was correlated to a low education level and not with age or the time that had passed since surgery. The monthly income correlated with the time passed since surgery and it was on average higher for males than for females. Statistically age and education had no importance. Of the females pre-surgically classified as "heterosexual males" none lived post-surgically with a male, but every second one in a partnership that the authors classified as being lesbian. They deduced by this that the heterosexual orientation is permanent and is not influenced by gender reassignment. On the other side, 46.9% of the females classified pre-surgically as "homosexual males" lived post-surgically with males. Such partnerships correlate statistically to hair removal and breast implants.
Males: One male lived from unemployment benefits, none from social welfare. Of the males, 63.2% lived in a partnership with a female.

Suicide Attempts
One female, who had been hospitalized for drug abuse and suicide attempts pre-surgically finally committed suicide after being sick for a long time and after twice undergoing severe surgical procedures that were not connected to the sex reassignment.

Follow-up Studies Mentioned
Lothstein, 1982; Lundström, 1981; Pauly, 1981

Authors' Conclusion
The majority of patients said that retrospectively they most assuredly considered the decision for surgery as correct. The authors see, in the post-surgical satisfaction of patients, the confirmation for the positive and satisfactory termination of a many- year-long rehabilitation process. Because of a drop out rate of about 23% of the patients, they are reserved regarding the generalization of the results. Because of this and because surgical treatment of transsexuals was not founded on theory but had been practically established by a trial-and-error method, they consider further follow-up studies indispensable.
By evaluation of the authors there is far less proof for the success of conventional therapies (psychotherapy and psychiatric treatment) than for the success of hormones and surgical sex reassignment. "At present, however, there is more empirical evidence that clinical intervention in aid of gender reorientation is the best available treatment for carefully selected cases than there is evidence contradicting this" (p. 304).

Remarks
In the article another study is referred to that is concerned with the psychological characteristics of patients with gender identity problems. According to it, already the role change conduces to an emotional stabilization, reduction of depression and better capability for relations in a partnership; the surgical gender reassignment is not the only factor. The comparison of pre- and post-surgical data in this study is limited to the satisfaction that was compiled with simple questions. For the rest, the authors were mainly interested in the gender of the partner after a sex reassignment. For certainly objective data regarding income and working situation, there is no pre-surgical comparison data.