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During the years when Blanchard conducted those studies, the complete cost of sex reassignment surgery was covered for Ontario residents by the Ontario Health Insurance Plan, provided that the Clarke clinic approved it. (No other clinic or individual was empowered to approve reimbursement for Ontario residents.) A patient did not even have to be a Canadian citizen, provided he or she was an Ontario resident. For the most part, the residents of other Canadian provinces seen by the Clarke team were covered by their own provincial health insurance plans, provided that they were assessed in Toronto at the Clarke clinic and approved for surgery there.

Thus, all or virtually all the subjects in Blanchard's studies were assessed in the context of a single-tier system of universal health coverage, that offered exactly the same services to rich and poor, educated and uneducated patients. It is possible, in theory, that his sample was slightly biased toward the less advantaged, because people with sufficient money to pay for surgery out of their own pockets could simply bypass the Clarke's approval and find their own surgeon to perform the operation. As a general rule, however, the rich are no more willing to part with their cash than the poor (often less so) and they are no more willing to pay for something that they can get for free. It is therefore likely that the subjects in Blanchard's studies were a fairly representative cross-section of Canadian society, or at least, the Canadian transsexual population. It is noteworthy that the median education of the subjects was Grade 12 (see 1989, "Concept of Autogynephilia," J Nerv Ment Dis).

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Northwestern University Department of Psychology