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Stephen Levine, M.D. & Candace Risen, L.I.S.W.

23230 Chagrin Blvd, Suite 350
Beachwood, Ohio 44122
Ph: (216) 831-2900
Fx: (216) 831-4306



A Discussion with Candace Risen - Co-Director

by Diane Frank

Some of the more prestigious medical facilities in the U.S. are the University Hospitals (UH) associated with Case Western Reserve University. It is thus no surprise that they developed services to support people with sexual, sexuality, and gender issues. Dr. Steven Levine founded the Center twenty five years ago under the name "Sexual Dysfunction Clinic" in the Department of Psychiatry at University Hospitals. In 1993 the Center separated from University Hospitals, and is presently called "The Center for Marital and Sexual Health."

The Center originally focused on the mechanical issues of sexual dysfunction. Over time it has broadened its mission to include a much wider spectrum, including alternative lifestyles, transgender issues, and treatment of sexual offenders.

As might be expected, the Center sees far more cases of crossdressing than more severe forms of gender dysphoria. Its staff provides counseling and support for couples as well as individuals. They feel that it is easier for couples to reach a positive accommodation with crossdressing because it is generally done part-time in the home or in related activities such as support groups, whereas transgendered people need to relate to the community as a whole, all the time.

While clinicians associated with the Center have special expertise and experience dealing with sexual/sexuality/gender issues their practice is not confined to these issues. This is important since (as will be discussed below) often these issues are associated with depression, anxiety and other difficulties, and it is these problems which can be treated within the managed care framework.

Candace Risen, co-director of the center and a psychiatric social worker, joined the Center when it was founded by Dr. Levine in the mid 1970's. Ms. Risen spoke to Cleveland Trans-Pride not long ago regarding access to the mental health care system for transgendered people. While her remarks in this instance focus on the needs of transgendered people, they are also of interest to crossdressers and spouses because of their content with regard to dealing with medical insurance issues and finding the right help.


Ms. Risen's talk covered four main topics:

•  The relationship of transgendered clients to counselors
•  The characteristics that a transgendered person should seek in their therapist
•   How to manage managed care and insurance issues
•  How to get the most out of the time spent in therapy

The relationship of transgendered clients to counselors

Ms. Risen candidly acknowledged that relationships between TG people and therapists can often become adversarial and tense. This is because the therapist can be perceived as a gatekeeper who controls access to something the transgendered person wants, be it hormones, surgery, and other issues requiring diagnosis and professional authorization. The therapist tries to serve as a facilitator in reaching those goals. The truth probably lies somewhere in between gatekeeper and facilitator.

The Center adheres to the Harry Benjamin standards for hormonal treatment and Sexual Reassignment Surgery (SRS). These standards have become more flexible over the years. For example, fulfilling the required real life test of living full time in the desired gender role can be difficult if not impossible without hormonal treatment.

Because the therapist is a gatekeeper under these conditions, a transgendered person seeking support can become resistant to the work of the therapist. This resistance can be counter productive for the patient in that its expression can lead to the therapist using labels such as "acting out," "border line" and assigning personality disorders from the Diagnostic and Statistical. Manual (DSM).


The characteristics that a transgendered person should seek in their therapist

In the face of this inherent conflict and Transgendered person needs to choose a counselor who is experienced. This cuts down on the feeling that they are paying to educate the psychiatrist, or are guinea pigs. Dr. Risen thought it would be good for there to be more Transgendered Counselor's and mourned the short life of Dr. Sheila Kirk's clinic.

Another important characteristic a therapist needs to have is toughness, both to withstand the sometimes resistive transgendered client behavior and not be intimidated. Most importantly, it takes a tough counselor to assure that the great losses (job, family, friends, and lifestyle) which can accompany changing ones life are faced and dealt with.


How to manage managed care and insurance issues

In dealing with managed care, you should be careful to keep your rights in mind. No one should be forced to settle for treatment by the nearest psychiatrist in the network of care providers. You should insist on association with someone with experience in sexual/sexuality/gender issues. You can demand to go out of the network and you MUST be persistent.

Clients should bear in mind the sex therapy (and other such quality of life issues) is usually specifically excluded from insurance policies. But gender issues are not sex therapy, and you must not allow an ignorant administrator to act on this erroneous belief. But in order for you to obtain coverage under your managed care program you must have a diagnosis other than gender issues. You may be depressed, confused or anxious as a result of your gender identity issues, or you may have an "adjustment" disorder.

Ms. Risen pointed out that from the psychiatric community's point of view just about everyone experiences one or more of these four conditions during their life and there is nothing unusual about it. You shouldn't let the possibility of accepting this kind of diagnosis (small stuff) get in the way of resolving you sexual/sexuality/gender problem (the big stuff). Don't let a diagnosis be an excuse to avoid seeking help.

As a last point on the topic, Ms. Risen advised that financial/management issues be handled in an upfront and open manner.


How to get the most out of the time spent in therapy

Ms. Risen again referred to the often adversarial relationship and pointed out that rigidity and inflexibility wastes time. In response to a question from a long term post operative attendee, Ms.. Risen asked that the community as a whole take note of this problem and have some awareness of it. It feels especially bad to know that some people are scared away from help they could get. The community should encourage people to give the Center a call to get basic information.


Questions

During the question and answer period, some other interesting issues came up. The Center encourages clients to stay in touch after SRS, but cannot force this. After SRS there is a high dropout rate. But the therapists are not wardens. Ms. Risen expressed the belief that it is not healthy to commit emotional suicide and totally deny ones past after SRS. It is much better to come to some kind of integration with the past. Not surprisingly, the easier time a person has a passing physically, the more likely they are to rewrite history.

With regards to SRS, most clients do not go to that level, but find some other accommodation.


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