Jurassic Clarke

The Problematic History of Canada’s First Gender Clinic

By: Amelia Smith

Amelia Smith

Contributing Historian

Amelia Smith is a transgender historian and museum professional. A graduate of the Masters of Museum Studies program at the University of Toronto, her work seeks to bridge the gap between trans studies and museum studies. This resulted in her first exhibition, Transition Related Surgery: The Fight For Access, on the history of gender affirming surgeries in Ontario. She has previously worked as an exhibit designer for the Transgender Archives at the University of Victoria, and in January of 2021, she began her website notyouraveragecistory.com where she publishes a monthly blog post covering transgender museum studies, queer and transgender history, as well as other subjects that influences her practice. Her website is also home to the Annotated Bibliography of Transgender Museum Studies.

Photograph of Dianna Boileau, 1970. Image courtesy of the *ArQuives*.

On April 20, 1970, Dianna Boileau woke up from surgery at Toronto General Hospital and found herself in the history books. The Clarke Institute of Psychiatry (now part of the Centre for Addiction and Mental Health, or CAMH) had opened Canada’s first adult Gender Identity Clinic in Toronto the year before, and she had been selected to be its first official transgender patient. Boileau immediately knew what this meant, telling writer Felicity Cochrane in a 1971 interview for Chatelaine magazine that hers “was the first operation of its kind performed anywhere in Canada.”^[1] She had just had Canada’s first “sex change” operation. She would often describe the experience with the gender clinic fondly, such as in her 1972 biography, where she recalls a compassionate Dr. Betty Steiner, head of the Gender Identity Clinic, joyously embracing her just before she went in for surgery.^[2] In future interviews, she would describe the continuing relationship with the Clarke’s psychiatrist as a “crutch and a true friend” for her.^[3]

It is a nice story, but her experience is an outlier. While Boileau remembers the Clarke Institute somewhat fondly, for the trans participants that were not selected to be the inaugural patient it was a hostile place. Clinicians were often sexist and homophobic, basing their assessments upon subjective criteria. In fact, the Clarke, as the gender clinic came to be known, would not perform another surgery until the second half of 1972, a full two years after Boileau’s “landmark” operation.^[4] Many trans patients had felt that they were tricked into joining the Clarke’s program with the allure of surgery, only to be met by an institution that was interested only in studying transgender people, rather than helping them.^[5] This was the Clarke that everybody else saw: a combative gatekeeping institution whose practices cast a large shadow over the lives of transgender people in Ontario and beyond. This is that history.

Gender identity clinics started appearing in North America in the mid to late 1960s, with Canada’s first being at the Clarke. These institutions were frequently research centres, attached to prominent universities. The research goals were rarely for the benefit of the trans communities they saw, rather to understand the phenomenon of transsexuality. Thus, the clinicians sought to determine who was “legitimately” a trans person and therefore deserving of treatment. Diagnostic criteria were based in stereotypes; as Dallas Denny describes, “those who were not Marilyn Monroe burlesques of womanhood (or John Wayne parodies of manhood)” were rejected by the clinicians.^[6] It was entirely subjective, based upon the clinician’s individual tastes and whether they found the patient to be sufficiently attractive. In addition, clinicians frequently knew that their trans patients were lying to them, altering their appearance or their life story to better fit the clinician’s preconceptions. Rather than question why trans communities felt this was necessary, these clinics instead viewed their trans patients as liars who had to be uncovered.^[7] Gender identity clinics knew the power they wielded over their transgender population and were more than happy to benefit from it; if a patient was not willing to jump through all the hoops the clinic set for them, they would be denied service. The clinics more than happily played the role of gatekeeper.

The Clarke’s gender clinic was no different. Founded in 1969 in association with the University of Toronto, the Clarke was first and foremost interested in researching trans people. In October 1969, at the same time that Dianna Boileau was going through intensive tests to prove she was officially transgender for the clinic, a Clarke representative declared that they had not yet decided whether to advocate for surgery but were just looking to “learn more about the phenomenon.”^[8] In doing so, as one of their research goals suggested, they hoped to discover “indicators in early childhood [that would] determine whether the syndrome is reversible.”^[9] This outlook aligns with the Clarke’s youth gender clinic, which was shut down in 2015 because of its use of conversion therapy.^[10] That is a much larger story than can be told here. Beyond the stereotypes described in the previous paragraph, the Clarke’s expectations were strict; it would require a name change even if the patient had a gender-neutral name, forced married patients to get divorced even if their partner was supportive, and demanded multiple years of living as the patient’s assumed gender before even prescribing hormones, a practice that some trans people compared to aversion therapy.^[11]

Promoting the Clarke Institute of Psychiatry on College Street, August 1972, (from left to right); Dr. D. H. Frayn; Dr. Stanley Freeman; Dr. Abraham Miller; associate director John Borthwick, and director Dr. R. C. A. Hunter. Photo credit: Dick Darrell. Image courtesy of the *Toronto Star Archives* and the *Toronto Public Library*.

If the patient managed to jump through all these hoops, the healthcare that the Clarke provided was not much better. Medically transitioning through the Clarke meant insufficient information about the hormones that trans people were being prescribed, with some feeling that they had no other option than the Clarke.^[12] Surgery was the same. In the 1970s, the eponymous “sex change operation” actually had multiple steps, with the first being an orchiectomy, the removal of a trans woman’s testicles. However, in Canada, such operations were illegal.^[13] Nevertheless, Clarke clinicians required that trans women have an orchiectomy before continuing in the program, but they would not facilitate it. They would not tell patients who was performing the surgery, would not refer them, nor would they help them fund the necessary trip. It was entirely on a trans patient to get the surgery that the clinic deemed necessary. Their practices encouraged and profited off underground castrations.

These practices were all in the name of research, but the research that the Clarke produced was questionable at best. It was at the Clarke where sexologist Kurt Freund tested his penile plethysmograph machine. The device consisted of a series of wires and tubes that were attached to the patient’s penis while they were shown a series of sexually charged images in an attempt to research the patient’s arousal.^[14] Freund first developed the device in the 1950s in Czechoslovakia as part of the aversion therapy he conducted on his homosexual patients.^[15] At the Clarke, the plethysmograph was used on transgender patients as well as homosexuals and pedophiles, often to try to find an underlying origin.^[16] Many trans patients, including Boileau, found the entire process to be demeaning,^[17] while others found ways to cheat the machine and give the researchers the data that they wanted.^[18]

Freund’s research into trans people’s sexuality went on to inform one of Toronto’s greatest shames: Ray Blanchard and the theory of autogynephilia. Autogynephilia is the widely debunked idea that trans people are defined as two separate categories with distinct reasons for being trans: homosexual males (by which Blanchard means trans women who are attracted to men) and autogynephiles, claiming that trans women who are not attracted to men are aroused by the idea of being a woman.^[19] The reason for transitioning, according to Blanchard, was entirely dependent on the patient’s sexuality. Trans women either wanted to attract heterosexual men or had had something go wrong with their supposedly normal heterosexuality. Meanwhile, Blanchard simply refused to believe that trans men who loved men even existed.^[20] These criteria informed how trans people had to present themselves at the Clarke, because if they did not fit in, they would often be rejected. In recent years, transphobic activists have adopted Blanchard’s theories in order to claim that trans people are not “really trans” but are instead living out a sexual fetish. At its very heart, both then and now, autogynephilia has been used to deny trans people their personhood and to reject their experiences and, in doing so, their healthcare.

Despite the plethora of issues, the Clarke had maintained a privileged position within the trans healthcare system in Canada. For much of its history, the Clarke was the only clinic where Ontarians could get OHIP (the provincial health insurance plan) coverage for their surgeries. This meant that if a patient did not want to be put through Freund’s plethysmograph, did not fit into Blanchard’s theories about what made someone trans, did not change their name or get divorced, or if they wanted to seek out a second opinion on their hormone levels, they would be putting their access to surgery in jeopardy. A situation made all the worse by the fact that, across the country, surgery was often required for a trans person to change their legal gender.

The history of the Clarke is often presented as a story about the Ontario transgender communities, but this ignores a major element: other provinces sent their trans patients to the Clarke, as well, in order to access their provincial healthcare insurance. As recently as 2014, both Newfoundland and Saskatchewan required that patients be approved by the Clarke before they could have their surgeries covered by those provinces.^[21] Other provinces had previously had similar policies, with even Alberta directing trans people all the way to Toronto for assessments^[22] – an outrageous cost when the Clarke would approve only around six or seven surgeries every year, according to Viviane Namaste in 2000.^[23]

Into the new millennium, the Clarke had merged with three other sites to become CAMH, and the stranglehold that the clinic maintained over the Canadian trans population would slowly weaken. In 2012, Ontario became the first province in Canada to allow transgender citizens to change their legal gender without going through surgery, following a human rights complaint put forward by a trans Ontarian.^[24] Other provinces and territories would follow Ontario’s lead, and, over the next decade, the requirement for surgery would be eliminated across the country. Additionally, in 2016, Ontario relaxed its restrictions on surgery referrals, meaning that patients no longer had to be approved by CAMH. This change meant that more medical professionals could prescribe gender-affirming care than ever before.^[25] The gender clinic was no longer mandatory for Ontarians who sought provincial funding; it was just one of many options.

The legacy of the Clarke Institute’s Gender Identity Clinic is the total disregard for the transgender patients its clinicians saw. The Clarke was home to gatekeepers, and they were more than happy to wield this power against their patients. The institute’s clinicians were largely inexperienced with trans people and peddled crank theories while denying access to healthcare. They forced trans people to jump through hoop after hoop to be approved for surgeries that they were often not properly informed about. Subjective opinions on trans patients’ appearances determined whether they would move on to the next stage of their transition, often with little regard for the struggles they faced along the way. The theories that the clinicians spouted as a result of this power imbalance has fuelled anti-trans panics around the world, making trans lives more difficult everywhere. The Clarke was a cruel place, one that viewed patients as liars that needed to be fact-checked. With a global attack on transgender rights and healthcare, it is imperative that we remember the harms that clinics like the Clarke inflicted upon trans communities. If we don’t, we threaten to see these practice return.