None of Blanchard’s work was intended to put obstacles in the way of transition. He wanted to understand the clinic’s patients, and help them decide what to do. Many were conflicted: concerned for their wives and children, and perhaps their careers. Moreover, autogynephilic desire seemed to compete with ordinary heterosexual desire, and could be temporarily eclipsed by a new partner. A man who had started fantasising about being a woman during adolescence might fall in love, conclude that those fantasies were a phase and marry—only for them to return years later. If the significance of persistent fantasies of having female genitalia was more widely known, fewer people would be made miserable by marriages entered in good faith that ended in misery when the husband transitioned.
In the 1980s and 1990s, when Blanchard was doing his research, the number of patients seen by gender clinics was tiny. The sole treatment pathway was physical transition: oestrogen and vaginoplasty for male patients; testosterone and mastectomy, and perhaps phalloplasty (a risky and complex operation in which flesh stripped from an arm or thigh is crafted into a neo-phallus), for female ones. Long delays were common. When patients were eventually seen, the personal crises that led to referral were past. And central to assessment was ensuring that they fully understood the goal of castration and bodily remodelling. They had to confront a tough question: was their desire to transition strong enough?
It made for strict gatekeeping. At the Clarke, four-fifths of patients abandoned the idea of transition before surgery. Some did not show up for the initial assessment. Others never returned, perhaps having concluded that living with gender dysphoria was preferable to proceeding. Even after that, referral for surgery depended on the “real-life test”: changing name, pronouns and clothing, and maintaining a cross-sex presentation for two years. A surprising number presented for follow-up appointments yearly, but never embarked on this trial. Clinicians could be confident that patients who stayed the course were unlikely to experience regret. And indeed, research at the Clarke—and other clinics with similar rules—found that hardly any did, and most were happier post-surgery.
The clinic would write to employers, asking for sympathy and flexibility during the real-life test regarding such questions as which workplace facilities patients would use. Post-surgery, the thinking went, they would use those intended for their adopted sex. Superficially, their bodies were now similar, and as for any risk of sexual violence from admitting males to female spaces, those males’ sexual organs had, after all, been removed.
