Professional Psychology: Research and Practice 2011, Vol. 42, No.

2, 208 213

2011 American Psychological Association 0735-7028/11/$12.00 DOI: 10.1037/a0022522

Transgender and Gender Variant Populations With Mental Illness: Implications for Clinical Care
Lauren Mizock
Boston University

Michael Z. Fleming
Massachusetts Department of Mental Health, Boston, Massachusetts

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

There is a scarcity of literature on clinical care for transgender and gender variant populations with serious mental illness. At times, gender identity issues among individuals with serious mental illness have been labeled as delusions that should not be reinforced by providers. However, there are significant limitations to attributing gender variance among populations with mental illness solely to a psychotic process. The following case study research demonstrates the variation in gender identity issues among individuals with serious mental illness. These individuals may experience gender dysphoria exclusively in the context of acute psychosis or may have gender identity issues that are distinct from the mental illness. Denial of an individuals gender variant presentation by treatment staff may heighten distress, thus interfering with a collaborative treatment alliance while posing additional barriers to recovery from mental illness. Implications and applications for clinical training and further research will be presented in order to promote awareness and competent care of gender issues when co-occurring with mental illness. Keywords: transgender, mental illness, psychosis, gender variance, cultural competence

The journal of Professional Psychology: Research and Practice has highlighted the scarcity of literature on clinical care for transgender populations (Israel, Gorcheva, Walther, Sulzner, & Cohen, 2008; Russell & Horne, 2009)individuals whose birth sex does not match their interior sense of gender identity or outward gender expression. Even fewer articles have focused on populations with serious mental illness and transgender identities (Garrett, 2004). Several of the small, valuable articles that address transgender populations with mental illness (Hellman, Sudderth, & Avery, 2002; Lucksted, 2004) tend to group this population with lesbian, gay, and bisexual groups (together, LGBT). This grouping may conflate issues of gender identity with sexual orientation and miss overlooking a community with unique needs and concerns. Additionally, a common clinical approach to individuals presenting with mental illness and gender variance is to attribute the latter to the former and expect remission of gender identity issues with medication (Baltieri & DeAndrade, 2009; Roback et al., 1976b). This approach often leads to labeling transgender identity as a delusional belief that should avoid reinforcement or acknowledge-

ment by providers (Garrett, 2004; Latorre, Endman, & Gossmann, 1976; Meerloo, 1976; Paxton, Guentzel, & Trombacco, 2006; Roback, et. al, 1976a). However, there are significant limitations to attributing gender identity issues among populations with mental illness solely to a psychotic process. For example, although some gender identity shifts may coincide with a psychotic episode, there are individuals who have a mental illness that is distinct from their transgender identity (Garrett, 2004). Additional literature is needed to assist clinicians with evaluation of gender identity issues presented by individuals with psychotic symptoms in order to best direct appropriate clinical care (Hellman et al., 2002; Lucksted, 2004; Paxton et al., 2006). The need to broaden the knowledge base and competent mental health care for gender-variant individuals has been emphasized in the recently published report of the APA Task Force on Gender Identity and Gender Variance and in the resolution that was drafted from that report (American Psychological Association, 2009). The aim of this article is to delineate the range of gender identity variance among individuals with psychotic symptoms and suggest implications for clinical care.

LAUREN MIZOCK received her PhD in clinical psychology from Suffolk University. Dr. Mizock is currently a research fellow at the Center for Psychiatric Rehabilitation at Boston University as well as an outpatient therapist at Arbour Counseling Services. Her areas of research and practice include racial identity, transgender issues, and mental illness. MICHAEL Z. FLEMING earned his EdD from Boston University. Dr. Fleming is currently a Forensic Psychologist working for the Commonwealth of Massachusetts at The Dr. Solomon Carter Fuller Mental Health Center in Boston Massachusetts. His areas of research and practice include gender identity, media and psychology, and forensic psychology. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Lauren Mizock, Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Avenue, Boston, MA 02215. E-mail: lmizock@bu.edu 208

Diagnostic Considerations
Some researchers have proposed that it may be somewhat rare for gender identity variance and psychosis to co-occur (Baltieri & DeAndrade, 2009). However, the prevalence of this clinical presentation is hard to measure given the barriers to treatment that discourage help-seeking behaviors (Hellman et al., 2002). In addition, it has been a commonly held belief that gender identity confusion is characteristic of schizophrenia in particular (Latorre, Endman, & Gossmann, 1976). When coming across these cases, there is a need to rule out an underlying psychotic disorder that may constitute the gender identity questioning (Baltieri &

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DeAndrade, 2009). Depending on the severity of the psychotic symptoms of the individual, there may be some difficulty in distinguishing the underlying gender identity variance from episodic psychosis. The Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR; American Psychiatric Association, 2000) offers guidelines for differentiating transgender identity from delusion with the diagnosis Gender Identity Disorder (GID), which is typically used to identify transgender individuals. The DSM-IV-TR indicates that individuals with GID are not delusional because the individual feels like a member of the other gender and does not truly believe he or she is a member of another gender. Although this criterion can be helpful in distinguishing a transient delusional belief from transgender identity, the DSM diagnosis of GID is controversial in its tendency to pathologize transgender identity (Mizock & Lewis, 2008). However, others may find the existence of the disorder in the DSM to be helpful to garnering insurance reimbursement for sex reassignment procedures and other medical technologies used by some transgender individuals to change their external gender appearance (American Psychological Association, 2009). What are the clinical outcomes when individuals with gender identity variance present in inpatient facilities for treatment of psychosis? Frequently, these patients experience transphobia from staff and other patientssubtle or overt prejudice and discrimination due to negative attitudes towards transgender identity (Mizock & Lewis, 2008; Russell & Horne, 2009). Treatment staff may condone discrimination by other patients by ignoring the harassment and may view patients with gender identity variance as paranoid and delusional, basing mental wellness and recovery on increasing identification with their birth gender (Lucksted, 2004). Historically, clinicians have avoided a strong assessment of gender identity issues owing to misperceptions that they are delusional, self-destructive, displacing symptoms, or in denial (Meerloo, 1976; Roback et al., 1976a). Other previously held erroneous beliefs include the notion that transgender individuals are having difficulty accepting their homosexuality, leading to a schizophrenic change in sexuality (Socarides, 1969). Clinicians may become distracted by the novelty of gender identity issues, and other aspects of their presentation, such as mental illness or social identity (e.g., race, ethnicity, socioeconomic status, and disability), may be ignored (Lucksted, 2004). As seen in the LGBT literature, staff may commonly conflate sexual identity and gender identity, lacking awareness of the unique issues posed by gender variance, or mistakenly associate gender variance with homosexuality. However, it is important to note that gender identity and sexual orientation are intersecting constructs, with changes in gender identity often leading to changes in sexual orientation. Finally, staff may be unaware of the potential transphobic discrimination and violence that these clients may face upon discharge to another treatment facility as well (Lucksted, 2004; Mizock & Lewis, 2008).

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environments (Mizock & Lewis, 2008). The hypervigilance required of transgender individuals in transphobic environments adds a significant stressor that interferes with recovery (Lucksted, 2004). In cases of internalized transphobia, many individuals with serious mental illness may hope that their gender identity variance will disappear with treatment of their serious mental illness, allowing them to resume life without the double stigma and maltreatment (Garrett, 2004). Some clinicians may be interested in learning more about a clients transgender identity. However, these individuals may feel they have the burden to educate their providers, removing them from the patient role and taking attention away from their own treatment (Lucksted, 2004; Mizock & Lewis, 2008). Transgender populations face many health disparities that make increasing access to care especially important. Transgender populations are less likely to have health insurance coverage and may present with other demographic issues that combine to interfere with access to care (Hellman et al., 2002; Xavier, 2000). Increased suicide risks, self-harm, and trauma rates (Clements-Nolle, Marx, Guzman, & Katz, 2001; Kenagy, 2002; Mizock & Lewis, 2008; Xavier et al., 2004) add urgency to the need to create guidelines for competent transgender care. In addition to unique barriers faced by transgender individuals, populations with psychotic disorders face additional barriers to mental health that compound problems with resource access for transgender populations. Individuals with psychotic illness tend to rely on family members for practical and emotional support. Transgender populations with mental illness are more likely to face alienation by family members, therefore experiencing additional stress (Carroll & Gilroy, 2002; Lucksted, 2004). Societal bias can contribute to mental health and physical health problems for the populations as well as financial hardship (Paxton et al., 2006). The risk of loss of social and financial support is high both for transgender populations as well as those with serious mental illness (Garrett, 2004). Awareness of the barriers and stressors faced by individuals with psychotic disorders and gender issues is essential to providing clinical care and assessment that is uniquely tailored to this population.

Inpatient Treatment Setting

The following cases are taken from an inpatient service for populations with serious mental illness in an urban community mental health setting for involuntary admissions, some of which were for forensic purposes. The evaluation process determines that the individual will be committed to the hospital and, in the case of court referrals, involves a final disposition from the court. This treatment setting included groups on the milieu, individual therapy, psychological testing, substance abuse treatment, occupational therapy, medical care, and psychopharmacologic treatment. Patients in this facility typically present with a serious mental illness or are being evaluated for the presence of a serious mental illness. The role of psychologists in this system is to provide individual therapy and treatment, evaluate competency to stand trial and criminal responsibility in forensic cases, evaluate indicators of continued hospitalization, and assess risk factors associated with disposition and safety in the community. These cases underscore the variation in presentation among individuals in this treat-

Barriers to Treatment
Lack of clinical awareness of populations with gender identity issues and serious mental illness can pose significant barriers to treatment. Many transgender individuals with serious mental illness may avoid clinical intervention due to fear of transphobia in treatment environments and lack of interest in participating in such

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ment facility with gender identity issues in addition to a serious mental illness.

Clinical Case Examples Case 1

N. W. was a Latino American, 34-year-old, Catholic, femaleto-male transgender construction worker living in a rural area who was hospitalized following a suicide attempt in which he overdosed on his antidepressant medication while inebriated. During admission he presented with psychotic symptoms of depression including visual and auditory hallucinations and persecutory delusions. He asked to be called by a male name other than the female name on his legal documentation and wore masculine clothing when admitted to the unit. His medical records revealed a history of recurrent and severe major depression with psychotic symptoms as well as alcohol dependence. Initially, the treatment team questioned the presence of transgender identity or gender identity confusion related to psychotic depression. Further clinical interview and collateral informationgathering revealed that N. W. had passed as male in his community for many years and had been saving money for a phalloplasty procedure to continue sex reassignment surgery following his previous breast reduction surgery. N. W. was being prescribed antidepressants and testosterone by his primary care provider. He had not been in therapy for many years, given his negative experiences with therapists who were dismissive of his transgender identity. N. W. had moved to another part of the state to start over in the male gender where no one knew him. He met a devoutly Catholic woman who accepted him as a man and was planning to marry. They dated for several months prior to his disclosure of his birth sex, and his partner had accepted this history. N. W. had gone on a work trip with a former acquaintance who had known him when he was living as a woman. During that trip, N. W. was raped by his friend and became pregnant from the assault. He made a suicide attempt several months into the pregnancy given his fear and depressed mood at the thought of losing the life he had cultivated in his new community. The treatment team and staff psychologist assisted and supported N. W. in making a decision about the pregnancy congruent with his devout Catholic values. N. W. decided to carry the pregnancy to term in a Catholic hospital. The staff psychologist conducted outreach and planning with a local Catholic hospital that agreed to deliver the pregnancy that would allow N. W. to maintain his male identity aside from shaving his beard. N. W. decided to tell his community and workplace that he had been diagnosed with stomach tumor that would require surgery that had led him to become depressed and suicidal. His workplace allowed him to maintain an office job that was less physically taxing than the more arduous physical labor typical of his work. He went to the city for his procedure and informed his community that he had a teenage niece who was seeking him to adopt her child. There did not appear to be physical effects of the testosterone or overdose on the fetus. N. W. returned to the community with his child with the support of his wife. He followed up with the team 1 year after his admission and reported to be doing well with his new family. His

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symptoms of depressed mood, suicidality, impairment in functioning, and psychotic symptoms of depression had remitted. This case required significant outreach, planning, and therapy to improve self-efficacy and coping. The staff psychologist had met with the nuns at the Catholic hospital where N. W. was planning his pregnancy and had conducted an in-service to prepare the hospital for working with a transgender patient in a sensitive manner. Of note was the general support of N. W.s treatment team during his inpatient stay in his maintenance of his identity as a male on the unit. This support was seen as critical to his recovery process. It contrasted with the transphobic bias and discrimination typically reported by transgender populations in an inpatient facility (Garrett, 2004; Mizock & Lewis, 2008; Russell & Horne, 2009). One aspect of his presentation that appeared to contribute to his support as a male was his ability to pass as the other gender, something that is often more typical of transmen and less so of transwomen given the irreversible effects of testosterone on the body (Devor, 2004; Mizock & Lewis, 2008). This passing privilege may provide additional safety from the threat of transphobic discrimination among staff and patients.

Case 2
C. F. was a 21-year-old, Caucasian American, female-bodied college student who presented as male during psychotic episodes. She was referred to the inpatient facility in a state of manic psychosis and believed she was a reincarnation of a male Greek god. For that period of time, she was not only dressing in masculine ways but would speak frequently with other patients and staff on the unit about reincarnation as another form of transformation and her plan to commit suicide to achieve this state. C. F. had a history of generalized anxiety and panic disorder since the age of 15 with a previous hospitalization prior to her transition to college. She had been stable in the community until her therapist moved from her previous clinic and her insurance did not allow her to follow this therapist. In addition, she had been doing poorly in her classes and was experiencing extreme levels of stress while adjusting to college life. C. F. presented with a variety of gender issues on the unit that required accommodations. She would attempt to use the male bathroom on the unit and wore a bed sheet as a toga and a paper garland in her hair. The unit staff made adjustments with bathroom times where she could use the male bathroom when it was not in use by others and permit her to wear her choice in attire. These accommodations succeeded in increasing collaboration with the treatment team in order to engage in medication and groups on the milieu. The team attempted to focus on medication and therapeutic treatment of delusional symptoms of mania and avoided reacting in an extreme manner to the patients gender presentation. With this approach in addition to comprehensive treatment through medication, therapy, psychoeducation, and family support, her positive symptoms reduced, and she returned to college within a few months of her admission with no further report of gender identity issues. This case exemplifies the possibility for gender identity issues to co-occur solely in the presence of acute psychosis and to diminish with treatment. In addition, this case underlines the importance of avoiding exotification of the patients gender identity presentation in order to focus on treatment of symptoms that interfere with

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functioning. The co-occurrence of gender issues and psychotic episodes suggests the need for treatment team staff to be sensitive to potential gender identity issues that may occur solely in the context of a psychotic episode. At the same time, treatment staff must maintain awareness of the wide range of gender identity issues that may arise in conjunction with serious mental illness.

Case 3
A. G. was a 42-year-old male-bodied veteran of the war in Afghanistan who came to the inpatient unit to be evaluated for criminal responsibility. His attorney strongly believed that his client was experiencing dissociative symptoms at the time of his alleged offense as a result of posttraumatic stress disorder (PTSD). He was arrested dressed in womens clothing and alleged to be soliciting sex from men. Once in court and on the inpatient unit he expressed embarrassment for his behavior and admitted that he had been engaging in high-risk activities since his discharge from the military. Specifically, he had been dressing as a woman and engaging in unprotected sexual activity in gay meet-up areas, coupled by periods of dissociation, depersonalization, and derealization typical of his symptoms of PTSD. In addition, he was carrying out a nightly ritual of intermittently driving into oncoming traffic for 10-15 min before being able to go home and go to sleep. He had no prior legal history. His high-risk behavior had begun since his return from the war, and he had been troubled by flashbacks. These centered on one particular moment when, in his capacity as a medic, he was administering to sick patients. The usual pattern of outgoing mortar was suddenly interrupted by the concussive blasts of incoming shells. He remembered seeing soldiers lifted into the air and floating around him. He believed he was having a psychotic break. As he struggled to regain awareness, he realized that the bodies that he saw floating in the air were fellow soldiers being blown up. When he awoke he was in a medical bed where he recovered until he was discharged home. A. G. was isolative on the unit and overwhelmed by actively psychotic patients on the unit in addition to his shame around his cross-dressing behavior. During his 20-day forensic section he was able to connect to clinical staff and do some brief work exploring his intersecting issues with gender and sexuality. He was able to slowly consider how his risky behaviors had come to be fused with gender identity exploration. His experience of trauma also appeared to be impacting feelings of identity disintegration. Given the stigma associated with homosexuality and cross-dressing, he had begun to pursue these activities in high-risk contexts in order to heighten a sense of arousal and threat typical of individuals with PTSD and sexually compulsive behaviors (Carnes, 2001). Clinical staff worked with him on a disposition he would be able to follow through on. He wanted to avoid the Veterans Administration (VA), fearing that he would face more stigma there about his gender and sexual identity issues. He was linked to a private therapist with a reduced fee, and he returned to his coursework at a local nursing school as he worked toward his degree as a registered nurse. This case highlights the potential impact of trauma in bringing about a sense of identity disintegration and seeking out high-risk behaviors that resemble re-experiencing and arousal symptoms of

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PTSD (Mizock & Lewis, 2008; Mueser, Rosenberg, Goodman, & Trumbetta, 2002). In reaction to the stigma of LGB identity, individuals may engage in sexually compulsive behaviors after attempts to avoid this aspect of their sexuality, further heightening the anxiety and compulsive nature of these behaviors (Carnes, 2001). This case also brings to light the fear of biased treatment in VA settings, where the culture of traditional masculinity prevails (Brooks, 1998), requiring additional sensitivity training at VAs. Disproportionate rates of veterans with transgender identity have been found (Mizock, Shipherd, Maguen, & Green, 2011). These disproportionate rates may result from a last-ditch effort among male-to-female transpersons to reassert traditional masculinity by entering the military (Brown, 1988). In addition, female-to-male transpersons may be drawn to the military, where it is both normative and required to present in a more traditionally masculine manner (Brown & Rounsley, 1998). Preventive mental health efforts toward veterans with gender identity issues can be helpful to avoiding legal involvement and untreated co-occurrences of PTSD.

Case 4
E. C. was a 60-year-old, homeless birth female who presented as male and asked to be called by George Johnson, III. He identified as a retired biochemist with two doctoral degrees in the sciences. He had been brought to the emergency room after informing staff at a local homeless shelter that he had plans to kill himself. During the first few weeks of his hospitalization he appeared agitated and isolative, refusing to take part in blood tests to monitor his antipsychotic medication due to fear that the government was attempting to poison him. He dressed in masculine clothing and spoke with a deep voice during community meetings where he identified himself with the aforementioned name. Social work staff were unable to locate his identity via the social security number he had supplied, and the shelter he frequented was also unable to verify his legal identity. He informed medical staff during an exam that he did not have male genitals because he had been butchered by the government. E. C. appeared identifiably female-bodied, and the majority of the inpatient staff referred to him by a female alias that was given to him by the shelter. E. C. developed a close alliance with the staff psychologist to whom he spoke to about the humiliation he suffered in responding to this female name. He had allowed himself to be called by the female name for fear of extending his hospitalization by appearing noncompliant. He became less agitated over time with the administration of antipsychotics and was regarded as having model behavior on the unit. The staff psychologist conducted numerous consultations with the treatment team in regard to reflecting the name and gender pronoun by which E. C. wished to be called. Many staff feared they were reinforcing a delusion about gender that was part of his psychotic process. The clinical team maintained this belief over the course of E. C.s hospitalization, which was exemplified in problems with his discharge plan. E. C. had been shown a womens homeless shelter by treatment staff, which infuriated him. In addition to his discomfort with being placed in a womens residence, he insisted that he had a condominium in an expensive neighborhood nearby. He was eventually discharged to the street, per his request, with a referral to a local clubhouse program.

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Therapy served as an important space where E. C. valued a sense of safety and confirmation of his gender identity presentation. This was especially true given the treatment teams resistance to acknowledging transgender identity in this case. E. C.s symptoms of psychosis stabilized with medication and comprehensive treatment on the unit. It was important to note that he sustained his gender identity presentation over the course of his hospitalization. This presentation was combined with a likely delusional persona as a biochemist with numerous professional degrees. Although there was an element of grandiosity in the persona E. C. had likely created for himself, it became clear throughout several months of therapy that E. C. had a longstanding history of gender identity issues and may have created this persona as a way to overcompensate for shame he may have felt in being identified as female. E. C.s distant interpersonal style was suggestive of schizotypal personality traits that may have been served by the scientist persona he presented. This case demonstrates the complexity of the intersection of serious mental illness and gender identity issues. The need for a person-centered approach to care with this population is also highlighted here. It is important to reflect the presenting gender identity of the individual regardless of associated delusions in order to validate the individual and show respect. Standard practice in working with individuals with serious mental illness is to avoid engaging in struggles around delusions (Kingdon, Turkington, & John, 1994). Given the developing and shifting nature of gender identity development, supporting the individual in the gender identity that is currently presented or is being explored is essential to avoid contributing to stress and stigma that interfere with recovery from acute symptoms of mental illness (Garrett, 2004; Paxton et al., 2006).

Discussion
These case studies illustrate the variations in gender identity issues that individuals with symptoms of psychosis may present. An individual with gender identity issues may experience gender variance solely in the context of acute psychosis or may have a transgender identity that is distinct from the mental illness. Assessment can be difficult when the individual is in an acute state of crisis and may require extended evaluation in order to clarify the nature of the gender variance. It is crucial to reflect and validate the gender identity issues of any individual, including those with serious mental illness. This approach avoids further stigma that might interfere with recovery and enhances a collaborative working alliance. Denial of the presenting gender identity of the patient by treatment staff may only add stress to the disposition, interfering with a treatment alliance, and pose additional barriers to treatment. Therefore, clinical training and further study are needed to promote a culturally competent approach towards gender issues when co-occurring with serious mental illness. The Report of the APA Task Force on Gender Identity and Gender Variance has emphasized the need for clinicians to provide culturally competent transgender care (American Psychological Association, 2009). Cultural competency refers to a complex skill set, knowledge base, and sensitivity to unique considerations of a particular cultural identity (Arredondo & Toporek, 2004). Cultural competency in transgender care may include awareness of the history, politics, and terminology specific to transgender popula-

tions. Detailed information on transgender-affirmative mental health care is described in other resources (i.e., Bockting, Knudson, & Goldberg, 2007; Carroll & Gilroy, 2002; Carroll, Gilroy, & Ryan, 2002; Chen-Hayes, 2001). This literature is generally applicable to issues of gender identity and gender variance that co-occur with mental illness. One important recommendation is to reflect the preferred gender identity and gender pronouns used by the individual seeking care. In addition, case management, outreach, and referrals to agencies specializing in transgender care may facilitate resource access (Carroll, Gilroy, & Ryan, 2002). Supervision and consultation on clinical work with transgender and gender variant individuals with serious mental illness can support culturally affirmative care (Mizock & Lewis, 2008). Finally, the resolution that was drafted from the aforementioned APA report mandated improved training of psychologists as well as exposure to educational materials on gender variance and transgender identity in order to facilitate culturally competent interventions (American Psychological Association, 2009). In addition, there is a need for further research on transgender issues and serious mental illness given the difficulty of accessing this population. Barriers to research include participants fear of being pathologized and difficulty with operationalizing gender identity issues based on variation in self-identification (Lucksted, 2004). There is silence around transgender identity in addition to lesbian, gay, and bisexual identity in the mental health system due to a history of mistreatment and vulnerability as well as a lack of knowledge and skill of providers (Lucksted, 2004). Moreover, there has often been a focus in the literature on sex reassignment surgery (Baltieri & DeAndrade, 2009; Roback et al., 1976b), which is not always relevant among individuals with gender variance. More research is needed to investigate barriers to treatment and treatment alliances that enhance outcomes in populations with serious mental illness and transgender identity. There is a need for research examining differences in male-to-female and female-tomale transpersons specifically, as well as investigation of issues for individuals who do not fit within these categories, such as gender questioning and gender queer populations (Israel et al., 2008). Although the present case study research offers exploration of cases in depth when it is difficult to gather a larger number of cases, there are clear limitations to case study research in the ability to draw rigorous, data-driven conclusions (Gravetter, & Forzano, 2009; Hellman et al., 2002). Mixed-method and qualitative methodologies may better assess prevalence and investigate complex issues of identity and treatment among populations whose voices have often remained silenced (Bobo & Fox, 2003; Cox, 2004). There is a significant need for training when working with transgender individuals when mental illness and gender identity issues intersect (Israel et al., 2008). It is important not to exotify individuals with gender identity issues and become distracted from other core goals of improving functioning and making decisions about disposition that are central to recovery. At the same time, it is essential to maintain cultural sensitivity to the gender identity issues among this population. Clinicians must work with individuals with serious mental illness and gender identity concerns to develop an understanding of how the two clinical aspects might interact. Treatment coordination may be required on the part of the therapist to educate other providers in a clients network (Garrett,

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2004). It is also important to note that therapists who are knowledgeable about LGB issues may not be familiar with transgender issues and require specific training on transgender identity (Israel et al., 2008). Given the double stigma faced by transgender populations with serious mental illness, sensitivity and awareness among clinicians are vital to reducing discriminatory treatment and promoting recovery.

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Received September 1, 2010 Revision received October 14, 2010 Accepted December 1, 2010