June 10, 2009

BOARD MEMBERS PRESENT: James L. McGhee, Chair; James Shaye Keys, Secretary; M. Lara Siazon Arguelles; Mary Ann Jones, PhD; LaVaughn Kellum King; Susan McIntyre; Tom Purvis; and Errol Wishom.

BOARD MEMBERS ON LEAVE: Jagruti Shukla, MD, MPH, Vice- Chair; Officer Kelly Dunn, Lisa Williams; Njoroge Tho-Biaz, MA; and Virginia Wright.

OTHERS PRESENT: Robert Cabaj, MD., Director of Community Behavior Health Services (CBHS); Helynna Brooke (MHB Executive Director); Loy M. Proffitt (MHB Administrator); Noah King, Public Interest; Bob Bennett, CEO, Family Service Agency Of San Francisco (FSA); Rachel Loewy, PhD, University of California at SF (UCSF) Department of Psychiatry; Karey Fenderson, MHA-SF; Jessica Brandt, MHA-SF; Melissa Syropiatko, MHA-SF; Natalie Ortega, Program Coordinator, Lavender Youth Recreation & Information Center (LYRIC); Katherine Belcsak, Special Projects Involving Research, Action and Learning (SPIRAL) Intern; Marisa Hedgpeth, SPIRAL Intern; Florence Fee, JD., No Health without Mental Health (NHMH); Claudia Haas, Family of Consumers.

Ms. Brooke called the roll. No quorum was established for this meeting, so no votes were taken on any action items.

Mr. McGhee: Sarah Accomazzo, MHB Intern, will not be giving a presentation about the Gender Appropriate Behavioral Health Services Workgroup. Ms. Brooke will provide handouts and give a brief description. Ms. Accomazzo will give a full report in July.

1.1 Discussion regarding Community Behavioral Health Services Department Report, a report on the activities and operations of Community Behavioral Health Services, including budget, planning, policy, and programs and services.

Mr. McGhee: Dr. Bob Cabaj, the Director of Community Behavioral Health Services (CBHS) will give the Director s report and then follow that with the Mental Health Services Act Updates.

Dr. Cabaj: We started integration of substance abuse and mental health services five years ago. On Friday June 5, 2009, Dr. Christine Cline of Zialogic conducted a consultation visit. Zialogic has worked with CBHS to assist us with our integration process. The next phase of integration is primary care.

Mayor Gavin Newsom is asking for $4 million cut for this year and $8 million cut for next year in the mega RFP, instead of $7 million and $14 million. For the overall budget, one of the issues was the union vote. After the first voting of a No , the SEIU Union did agree to a wage concession. This means some more money will be available.

The Innovation component of the Mental Health Service Act (MHSA) is moving ahead as if it will still be available, although, there is a small risk of the California State budget taking the money.

MHSA is currently our only source of new funding. We are moving forward with the Prevention and Early Intervention (PEI) MHSA plan and the Request for Proposals will be posted shortly. Ms. Marlo Simmons who has a Masters in Public Health is the new PEI coordinator for CBHS.

Mr. Keys: My first comment is that Ms. Marlo Simmons as the new Prevention and Early Intervention coordinator has a great resume, but I do not see her mentioning anything about PEI for seniors. Secondly, can you elaborate on the 5% of Proposition 63 money being allocated to the Innovation component?

Dr. Cabaj: Although Ms. Simmons spent most of her career working with children and adolescents, I believe she may have transferable skills for PEI for older adults. Innovation is 5% of Community Services and Supports (CSS) and PEI money. The 5% allocation stipulates that all interested parties must apply for the money just like any other programs that are seeking funding support from MHSA.

Dr. Cabaj: In San Francisco, people at risk can be anyone but tend to be in a lower social economic strata and cultures experiencing discrimination. Prevention focus will extend to environmental as well as personal. For example, what impact will there be if we can close liquor stores in certain areas?

Dr. Jones: In March 2009, Dr. Nadine Burke did the Impact of Trauma And Stress on Physical Health presentation. She showed that early childhood traumas have long-term effects on children and many of them often develop chronic diseases in their adult lives. African Americans have many more chronic illnesses than the general population.

The biggest unknown is the State budget. There are talks about eliminating outpatient managed care for mental and behavioral health services. The State is looking at possibly having only inpatient care. There is a big effort to fight Governor Arnold Schwarzenegger for clarification.

There are talks about not raising taxes, but various fees are ways to get around that. This is tantamount to stealth tax. Or another way to manipulate the funding to counties is using different delay tactics such as not releasing necessary funding to some counties in a timely manner.

Mr. Keys: Many people really do not understand the budget process. Has CBHS collected data to find out how budget cuts would affect emergency care and housing services?

Dr. Cabaj: We do not oversee those expenditures. Technically, no services are eliminated. 1582 people are affected by the Indigent cut. Since we have no real hard data showing impact, we need to count on the outcomes for the statistics.

Mr. Keys: What types of mental health services generally get squeezed out by the budget cuts?

Dr. Cabaj: Mayor Gavin Newsom imposes the cuts to our budget. Usually, during tough economic times, substance abuse gets the first cut.

Dr. Cabaj: Yes, there will be some redirection of MHSA for programs or services eliminated. For example, AB2034, the Homeless Outreach program could use MHSA money.

Mr. Keys: With regard to budget cuts, has there been effort to show the work that CBHS has done with MHSA funding?

Dr. Cabaj: We got a resolution about the good work that CBHS has done with MHSA.

Mr. Keys: Has there been any efforts by CBHS with the MHSA funding to create new services given the budget cuts?

Dr. Cabaj: We always explore feasible options to ensure our core services in mental health are available and expand when possible.

Ms. Haas: Ms. Claudia Haas is with Family of Consumers and inquired about the availability for the public of research on the prevention and early intervention of schizophrenia, how the MHSA advisory committee operates and how staff get cultural competency training.

Dr. Cabaj: The advisory meeting is open to the public. Cultural competency training is more technical and is designed for contractors.

Dr. Chris Cline of Zialogic conducted a consultation visit with CBHS on Friday, June 5, 2009. During this visit, Dr. Cline met with the Integration Quality Improvement Committee, the Integration Advisory Committee; the Integration Implementation Workgroup and CBHS Program Managers; and the CBHS Core Executive Team. She also introduced, revised, and edited versions of the COMPASS and CODECAT tools, as well as an additional instrument, the COCAP- (Co-Occurring Capability for Substance Abuse and Mental Health Provider Agencies- a tool for recognizing progress in systems and agencies.) The revised tools will be available for use during the next fiscal year.

Marlo Simmons, MPH is the new MHSA Prevention and Early Intervention (PEI) Coordinator for CBHS. Marlo was born and raised in San Francisco. For the last ten years, her career has focused on managing programs and supporting advocacy efforts promoting the health of children and adolescents. Before coming to CBHS, Marlo served for three years as the Adolescent Health Coordinator for the DPH Maternal, Child and Adolescent Health (MCAH) Section. In addition to supporting health programs for adolescents, Marlo was the lead staff for Mayor Newsom s Transition Youth Task Force. Prior to working for DPH, Marlo managed the California Adolescent Health Collaborative s Mental Health Policy Program. Her responsibilities on that project included: Monitoring mental health policy in California; writing the California Adolescent Mental Health Policy News, a web-based newsletter; participating in the Campaign for Proposition 63 and developing resources for providers working with out-of-home youth - those in foster care, the juvenile justice system, and homeless youth. Marlo s experience also includes working in a school-based health center and developing clinical tools and trainings to educate providers about California Confidentiality and Minor Consent Laws. We welcome her and her considerable talents to the MHSA team and to our CBHS family.

The Community Housing Partnership (CHP) has been awarded approval for its funding application for the Parcel G project, at 365 Fulton Street. The total cost of development is projected to be $38,028,751.00, covering the cost of 120 studio apartments with kitchenette and bathrooms, exclusively reserved for extremely low income, formerly chronically homeless individuals. MHSA will provide the funding of $1,200,000 for 12 units to be dedicated for MHSA clients. Clients referred to this housing site will be supported by MHSA full service partnership providers. The site is scheduled to open in 2011.

Four neighborhood meetings held in April on the Innovation component of the MHSA were met with enthusiastic and inspired ideas on how best to serve the mental health community from a diverse and dedicated group consisting of consumers, providers, administrators, and family members. A follow-up meeting on June 3, 2009, dealt with arranging all the submissions in clusters, based on their similarities. These ideas will next go before the MHSA Advisory Committee in June, for their review and consideration as part of the component plan.

COMMUNITY SERVICES AND SUPPORTS UNDUPLICATED CLIENT COUNTS FOR THE THIRD QUARTER

The table below shows the unduplicated client counts for the third quarter of this fiscal year reported to the Department of Mental Health. These counts have already exceeded the projected numbers we anticipated to serve for the entire year. Kudos to all the MHSA funded agencies for all their hard work and dedication.

The Mental Health Services Act Advisory Committee meets bi-monthly from 3-5 pm, alternating between advisory meetings and community forums. The MHSA Advisory Committee will take on a very active role in defining the projects to be funded through the Innovation Component. As a result of our campaign to recruit continued membership to this Committee, the next scheduled meeting will be comprised of established as well as newly recruited members. The next scheduled meetings are:

Goals and Objectives for Cultural Competency Report-
Wednesday, July 15^th and Wednesday, August 5^th9:00 am - 12:00 pm in the San Francisco Library, 100 Larkin Street

The Goals & Objectives for Cultural Competency Reports training will provide a step-by-step instruction and demonstration on establishing measurable cultural & linguistic competence goals and objectives for positive health outcomes. These goals and objectives will provide the essential elements of implementing and developing culturally and linguistically competent services that are sensitive and responsive to the needs of local community, and addresses issues of ethnicity/racial minority, age, gender, sexual orientation, and religious/spiritual beliefs. As well, the goals and objective will provide a plan on how programs will involve clients and families appropriately in all aspects of service delivery system, including but not limited to: planning, policy development, services delivery, and evaluation. The training is recommended for DPH program managers and contractors who develop or review DPH required Cultural and Linguistic Competency Reports.

To register for this training, please contact Norman Aleman, CBHS Training Coordinator

Past issues of the CBHS Monthly Director s Report are available at:http://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSdirRpts.asp

To receive this Monthly Report via e-mail, please e-mail richelle-lynn.mojica@sfdph.org

Mr. McGhee: There are no specific Mental Health Service Act updates this evening other than the items already mentioned by Dr. Cabaj.

PREVENTION AND RECOVERY IN EARLY PSYCHOSIS PROJECT-- A COLLABORATION OF FAMILY SERVICE AGENCY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO AND THE MENTAL HEALTH ASSOCIATION OF SAN FRANCISCO (MHASF); BELINDA LYONS, EXECUTIVE DIRECTOR, MHASF; BOB BENNETT, CEO, FAMILY SERVICE AGENCY OF SAN FRANCISCO; RACHEL LOEWY, PHD, UCSF DEPARTMENT OF PSYCHIATRY.

GENDER APPROPRIATE BEHAVIORAL HEALTH SERVICES, SARAH ACCOMAZZO, MHB SPECIAL PROJECTS COORDINATOR

PRESENTATION I: Prevention and Recovery in Early Psychosis Project (PREP)-- a collaboration of Family Service Agency, University of California, San Francisco and the Mental Health Association of San Francisco (MHASF); Belinda Lyons, Executive Director MHASF; Bob Bennett, CEO, Family Service Agency of San Francisco; Rachel Loewy, PhD, UCSF Department of Psychiatry.

Ms. Syropiatko: I would like to introduce tonight a presentation called Prevention and Recovery in Early Psychosis Project (PREP). Thank you for allowing us to come and share our program with you. PREP intends to transform the standards of care in schizophrenia treatment. This program is a collaborative creation of UCSF, Family Services Agency and Mental Health Association of San Francisco. We value the time you have taken to fit us into your schedule and hear about this innovative program. And, thank you for your support. We look forward to working collaboratively with you on the Mental Health Board, CBHS, Department of Public Health (DPH) and local providers as we develop and implement this exciting program. I would like to introduce you to Bob Bennett, President and CEO of FSA-SF, so he can share the PREP Vision.

Mr. Bennett: I am with Family Services Agency of San Francisco (FSA-SF). There is a lot of schizophrenia in my family. Given that schizophrenia can be a genetic predisposition and having first-hand experience of seeking prevention and recovery in early psychosis treatment for a niece, I understand the frustration people go through in getting help for early diagnosis for psychosis.

The goal of current standard treatment is symptom management. In the American population, 1% will develop schizophrenia, 1% will be diagnosed with bi-polar disorder and 3% will have some kind of psychosis. In San Francisco, 6500 individuals have schizophrenia, 78% of schizophrenics do not even receive a minimally adequate medication regimen, according to the PORT project, and most of them die at least twenty years earlier through suicide, being a victim of violence, or side effects of medications.

Psychotic people sometimes will stop taking medications altogether to see if they are okay. Then, they end up being 5150 d again, and the cycle of over-medication, getting released and stopping medication will happen again.

Many people have perceived psychoses -- which affects not only the life of the individual, but also family, friends, and the larger community -- as an incurable diseases, as an analogy, just as they did for early treatments for AIDS. But, now we have nucleoside/nucleoside reverse-transcriptase inhibitors (NRTI s) as medications to prevent full-blown AIDS. Professionals all over the US are showing new ways to symptom management and cognitive therapy. With our Can Do attitude, we hope to do more for people afflicted with psychoses because the reality is that remission, rehabilitation, recovery and respect are possible goals.

Ms. Loewy: I m from UCSF and a clinical psychologist with 14 years of research in early psychosis prevention. People can look normal for most of their childhood. Then, as they get older, they develop self-awareness and start to question their realities. They wonder why they hear whispers but others do not, or why they see things that may or may not be there. About a third of them develop full psychosis within two-and-half years.

Dr. Jones: Is there any difference between the ages of early psychosis between girls and boys?

Ms. Loewy: Girls tend to develop psychosis later in their twenties or even thirties, probably because of the hormonal effects of estrogen, although we are seeing and increase in the development of earlier psychosis in females. Boys tend to develop psychosis in their late teens.

Ms. Loewy: Researchers have shown menopause may induce late age psychosis sometimes because of hormonal changes.

Ms. Loewy: Now I am going to turn over to Ms. Syropiatko who will talk about Outreach.

Ms. Syropiatko: As part of outreach efforts, FSA will have speakers who have been through the PREP program.

Ms. Syropiatko: We have literature in several languages, like Spanish and Chinese. We are working on ways to make mental health access work. We have gone to schools to do outreach to Latino communities.

Ms. Loewy: Yes, we have recognized many different types and there are twelve different diseases that are part of schizophrenia.

Mr. Keys: The Mental Health Board is interested in the integration of primary care with mental health. Are doctors and clinicians in primary care being educated to recognize schizophrenia and psychosis?

Ms. Lowery: We try to put out research to clinicians so they can recognize signs of schizophrenia.

Mr. Bennett: Psychiatrists and doctors are often reluctant to diagnose schizophrenia. Would it be good to have the process where primary care refers to mental health staff for clinical interventions? About a third of the people who have a schizophrenic episode will go through it. Bad or disrespectful care often leads to a downward spiral. The point of early intervention is to better the outcomes later because of the Strength-Based Care management. Too often, doctors just add medications on top of medications. We are looking at lowering the doses of medications.

Ms. Syropiatko: In cognitive behavior therapy (CBT), we foster coping skills and support network development.

Mr. Purvis: What happens to people who do not get treatment when they start showing signs in their 40 s and now they are in their 70 s? Is that because they have aged-out?

Ms. Loewy: It all depends. I advocate the early approach because younger people are more receptive and responsive. We prefer the early treatment because they have not been mistreated or stigmatized by society.

Dr. Jones: Do you distinguish the difference between case management and care management?

Mr. Bennett: We do not like the term case management because the word case is pejorative. An illness does not define a person. We focus on treating the person as a whole. Not only in collaboration with UCSF, and MHB, but FSA is researching a systematic, strength-based approach to working with clients. Since July 2008, we have served over 66 clients to date, focusing on people who have had their first psychotic break within the last five years. The referral number is 415-476-7278.

Member of the Public: A member of the public wondered why it is so difficult to diagnose schizophrenia.

1. Remission: To stably remit schizophrenia in most sufferers through a combination of early detection, rigorous diagnosis, and an array of science based treatments.

2. Rehabilitation: To restore cognitive, social, and vocational functioning to normal levels

3. Recovery: To return individuals with schizophrenia to a normal, productive life

4. Respect: To approach treatment as a collaboration with clients to help them achieve their life goals

· Schizophrenia is an illness that affects not only the life of the individual, but also family, friends, and the larger community.

· About 1% of the population is diagnosed with schizophrenia. This translates into 6,500 individuals in San Francisco, 60 million worldwide.

· Individuals with schizophrenia die, on average, 25 years early, through suicide, misadventure, and the side effects of medication.

· The average person suffers from full-blown schizophrenia for almost three years before they are correctly diagnosed.

· The PORT project found that 78% of schizophrenics do not even receive a minimally adequate medication regimen.

· Most people with schizophrenia will alternate through repeated cycles of overmedication, treatment refusal, decompensation, involuntary hospitalization.

· Standard treatment aims at symptom management, not remission, rehabilitation, and recovery.

· A focus on remission, rehabilitation, and recovery using cutting edge approaches

· Unique window of opportunity for prevention of psychosis and/or poor functional outcomes

· Presentations and materials given to clinicians, community groups and clients

· UCSF conducted 10 week Early Psychosis training & 12 week CBT training for FSA clinicians

· Early psychosis was incorporated as a funded priority in the County s MHSA PEI Plan

· Funding obtained from Margoes Foundation, GAP Founders Award, private donors for start-up phase (July 2008- present)

· Early Psychosis Consultation Clinic has seen over 40 clients since July 1, 2008 for evaluation, treatment recommendations and feedback to clients/ families

· Any insurance or county of residence (generous sliding scale available for non-SF Medi-Cal

PRESENTATION II: Gender Appropriate Behavioral Health Services, Sarah Accomazzo, MHB Special Projects Manager

Mr. McGhee: Ms. Brooke will pass out information about this group and provide a brief overview. Ms. Accomazzo will give a more detailed presentation in July. I know Ms. Brooke will also mention it, but I encourage all of you to go the Women and Girl s Reception and Networking Event tomorrow evening from 4:00 pm to 6:30 pm at the San Francisco Women s Building. Assemblywoman Fiona Ma will be speaking and there will be a free raffle for lunch with Assemblywoman Ma. The MHB is a co-sponsor of this event with the California Women s Mental Health Policy Council.

4.2. a PROPOSED RESOLUTION: Be it resolved that the minutes of the Mental Health Board meeting of May 13, 2009 be approved as submitted.

4.2 b PROPOSED RESOLUTION: Be it resolved that the Mental Health Board Endorses the Guiding Principles of Budget Reduction Strategies Created by the San Francisco Human Services Network. (Attachment A).

4.2 c PROPOSED RESOLUTION: Be it resolved that the Mental Health Board will contribute $125.00 to the National Alliance on Mental Illness Walk.

Ms. Brooke: We are on target for Program Reviews. Although we are required to do five reviews, it looks like we will have about seven to eight reviews.

June 11 is the Women, Girls, and Behavioral Health: Where Do We Go From Here?" Reception and Networking event. The Guest Speakers are Assemblywoman Fiona Ma and Deputy Chief of Staff Catherine Dodd.

Mr. McGhee: I am glad that so many board members will be attending the CALMHB conference next weekend. Loy Proffitt will be going to the conference as well so that he can learn more about the mental health board. And because so many people need a ride and the hotel is a ways from the train station, Loy will be renting a van and driving to San Jose, leaving Friday at 11:30 am and returning at the end of the conference, leaving San Jose at 4:30 pm Saturday. Staff will be contacting you to arrange a place to meet.

5.3 Report by Members of the Board on Their Activities on Behalf of the Board.

Ms. King: The Southeast Group Meeting is making great progress. The NAMI walk was successful. Our team the Families Against Stigma Team (FAST), raised $1,300 for NAMI.

Mr. McGhee: I want to congratulate you and Ms. Brooke for coordinating meetings in the Southeast sector.

Mr. Purvis: The National NAMI conference will be in San Francisco this year in July. I will follow up with the board on this later.

5.4 New business - Suggestions for future agenda items to be referred to the Executive Committee.

Ms. Natalie Ortega, Ms. Katherine Belcsak and Ms. Marisa Hedgpeth submitted their comments.

We are a group of LGBTQQ youth from LYRIC (Lavender Youth Recreation & Information Center) in the SPIRAL internship. This is the second round of SPIRAL. The first took place last July and was partially funded by CBHS. SPIRAL seeks to empower queer youth by allowing them to use theater as an educational tool to share out their experiences with mental health and substance use services with the hopes of institutionalizing change. It is our recommendation that San Francisco raise the standard of cultural competency in behavioral health services for transitional aged queer youth, who are people between the ages of 16-24. We have come to this recommendation through our own day-to-day experiences and would like to share them with you.

Hi, I'm Kate. I'm 18 years old and I have struggled with severe depression and cutting. I'm here to express concern about the impersonal manner in which mental health care providers deal with youth.

When I was 15 years old, I started going to Dialectical Behavior Therapy, or DBT, a group therapy program for teenagers, most of whom were girls. We were there to learn skills to stop our various self-destructive behaviors. It was the first time I had ever been surrounded by girls who were openly dealing with problems that I could relate to. But the therapist refused to let us stray from the confines of our quote unquote "DBT Bible," a textbook of sorts that laid out our therapy lesson plans. This formulaic way of approaching therapy often got in the way of my healing; it was as if we were talking about my math homework as opposed to my desire to end my life. When my peers and I would start to share our stories with one another, our therapist would cut us off, insisting that we "get back on track." Her condescending attitude made it difficult for the group to trust her and this created an unproductive group-dynamic that yielded no therapeutic benefit.

As I have experienced the health care system, it is often implied that personal discussion of mental health issues should be left to an individual and her therapist. In a world where self-harm, eating disorders, and drug abuse continue to be taboo topics of discussion, it would have been really helpful for me to be able to talk openly about my struggles with my peers. Many providers operate under the assumption that we teens don't know what's good for us and that we need to be protected from each other's influence.

I assert that teenagers in a supportive environment can provide help for one-another, often in a more judgment free way than their therapists can. We need to be given that chance, the chance to say what works for us and what doesn't. Mental health care providers should not be trying to make patients fit their therapeutic formula; rather they should be tailoring their therapy to fit their patients. I believe that youth who have experienced mental health issues should be included in the process of hiring mental health-care providers. The youth are the ones being treated, so we should have a say in who is qualified to treat us. They should be trained in terms of the communities they are serving and this would then raise the standard of cultural competency.

In San Francisco there are a total of about 5 organizations that supply queer youth with mental health services. These are New Leaf, Dimensions, Larkin Street youth center, CUAV (Community United Against Violence) and LYRIC. Not only are these organizations infrequently advertised but they are mainly located in the Castro or Downtown. Queer youth are everywhere there for support should be accessible everywhere they are. 20-40% of the youth who are homeless are queer. Not only is the experience of being homeless stressful but while also being in a 'hostile' environment. My suggestion would be to not cut funds but actually increase funding for queer friendly organizations. And open up new clinics and organizations in all districts not just the Castro.

The standard of cultural competency in behavioral health services needs to be raised because of my experiences. I remember being eleven years old and storming up and down the stairs in my parents house yelling, I want a Kelly! Kelly was my friend s therapist. I don t think I truly understood what the word therapist meant at the time, but I knew that my friend met with Kelly once a week to talk to about what she was feeling. My parents stood firm in their belief that I did not need to see a Kelly because I was not crazy.

Despite their wishes, I saw my first therapist when I was 18 after my brother was admitted to a drug rehabilitation center. My therapist was pregnant and after one session I was referred to someone else. After I graduated college I worked for an organization that supported folks through traumatic moments in their lives. I used my health insurance and started with my second therapist. She looked like me, was only a few years older than me and I remember how these things contributed a lack of feeling of judgment.

Shortly after I moved again and started with my third therapist. During our first session, our intake session, she used my tears and vulnerability to what I recall feeling as if I had been raped. I walked out after that session and was reluctant to give therapy another chance. However, I couldn t give up on my feelings and myself. After all, I had been the only one to give them a chance and I couldn t let myself down and so I met my fourth therapist. She was kind and nonjudgmental. She did not demand changes in my behavior, but met me where I was, which at the time was starting to come out. She could see a tear forming in the back of my eye and knew just how to keep the conversation going without forcibly extracting that tear. I especially appreciated this in her work. I moved again and started with my fifth therapist. The week before I was scheduled to have breast reduction surgery I went to see her to discuss my fears of dying while under anesthesia and she met that with the statement Look down at your waist. You look like you have gained 15 pounds. Why don t you try and lose some weight instead of having surgery? I walked out of that session and in my heart of hearts wasn t sure if I could do this again.

Last year I started with my fifth therapist, who I am still seeing. She is a feminist therapist who works with and understands social justice and anti-oppression frameworks and practices a harm reduction approach. With her I can discuss my internalization of intersecting forms of oppression such as racism, homophobia and sexism (or Genderism as I refer to it, since for me gender is a socially constructed term).

I have been coordinating SPIRAL at LYRIC this past year with an incredible staff; two inspiring teams of interns and a community that is relentless in demanding change. This fall I am beginning a Masters in Social Work program at the University of Washington in Seattle. I hope to use my degree to further this work. My course of study will concentrate in social policy as I believe this is where my voice is most important. It has taken years for me to recognize the strength of my voice and I ensure you it will take more than an eternity to unlearn that. I am a queer, Colombian, Chilean, feminist, genderqueer activist, philosopher and I am taking up room.

In order to change this, my suggestion would be to use people like me in the community, who would suggest removing transgender identity disorder from the DSM-IV, to get this valuable input in order for therapy to be impactful. We are all here today supporting each other because this support is what we rely on to succeed. If we received this support through our behavioral health services, this would greatly benefit our lives and the lives of other queer youth using mental health and substance abuse services in San Francisco. Thank you for hearing us today.

Ms. Haas: She mentioned that in the recent news talking about the suicide of the Naked Man whom was incarcerated in the San Francisco County jail. She wondered what protocols are used to treat inmates who have mental illnesses while in police custody.