The Right to Die With Dignity

The Right to Die With Dignity

Jennifer Maria Padron, M.Ed, CPS, PhDc Public Health & Amanda Barnabe

We are US Peers and we are Peers in everything that Peerness implies from State (Georgia, Maryland, Texas) certification. Acting in a healer saint wrap around service advocate activist give back to the community type of social supportive role, Peer supports and professional adherence accounting for personal-responsibility rings true. As well, we hold fast (in sum) to all federal Certified Peer Specialist SAMSHA related principles and codes.

We work pro bono or on average for >$12/hr as a Certified Peer Specialist in both public and private behavioral health systems of care for US Mental Health (MH), Substance Use (SUD) and now are in support of any individual experiencing criminal justice intersected challenges and where behind locked doors robbed of hope, we have insured that the Forensic Peer Recovery Specialist Endorsement and Certification is your brand new best friend in the State of Maryland.

We are unapologetic queers, submersed in this revolution of peer developed and implemented advancements battling a dark history of psychiatric practices.

We are practiced as a Certified Peer Specialist in the frontier, in rural and urban environments of the US.

We are trained, practiced and tried first responders and we are respected in 24/7/364 mobile crisis intervention (MH/SUD) and/or emergency response in rural and metropolitan environments where the demographics are broadly suicide or homicide or sometimes both.

We are the other and we know it.

We’re the damned.

We are the nonconforming square pegs, metropolitan, gender queer, gender fluid, gender non-conforming non-Judeo Christian, women of color with a disabling previous diagnosis of serious persistent mental illness.

We live lives in recovery as tortured psychiatric survivors who have survived to now.

We are more than our diagnosis.

We are more than our sexual identity.

We don’t buy-in to mental health or mental illness or the disease model or the medical model.

We get it and expect more.

If you can, then do. If you can’t, step aside for us to get ‘er done.

In the Winter of 2012 I (Padron, 2012) was impressed with five completions.

The State of Texas Department of State Health Services and Mental Health America of Texas Suicide Prevention point of contacts dealing with suicide education and prevention contacted me to ask me if I knew the details on the 5 completions from suicide of peers. I was aghast. Yes, I knew them. I know them. Their thinking was that they had a cluster on their hands. I hung up. I deleted their emails. I did not return their calls. I did not accept their calls.

Death and dying from our own hands is not a new feature to this (dis)ease. There is one death by suicide in the US every 12.3 minutes and every 30 seconds globally.

We are of the opinion today that should a person desire to die, then that is their right. At the moment there is anything sembling a Plan, there is nothing you or I can say to another person truly to “save” that life. It is one’s right inasmuch and as stigmatizing that suicide and mental illness is punitive, deadly even, it is in our experience that quite simply what works is to simply sit and listen with the individual in distress, in turmoil and emotional, physical, spiritual pain.

Inasmuch as the impulse derides or appears to lack any commonsensical logical thinking at the moment or eclipse of completing – saying simply, I love you or I would miss you terribly helps both people at the crux of a suicidal intervention back to center. Mixed episodes for those diagnosed with Bipolar 1 disorders tend to be at greatest risk.

Now, we ask you why then when, why, how and where does our dying and planning one’s death, and/or even by talking about it between ourselves, with others (e.g., lover, friend, family, providers) is this act formally considered a new feature and the not so (un)symptomatic of the clinically depressed, the bipolar disorders, the schizophrenia spectrum disorders, or anxiety/panic and/or the personality disorders?

The 25 year, on average, mortality rates of individuals living with a serious persistent mental illness number in the hundreds of thousands today (NASMHPD, 2007). It is my community’s genocide.

Why shouldn’t we count pharmaceutical and population’s genocide to psychiatric diagnosis and assuming my logic is correct then, why is Suicidal Completion numbers so shocking to you?

Many friends and colleagues are lost to dying from physically based illnesses such as cancer, heart attacks, congestive heart failure, stroke, car accidents, drownings and the like and more from suicidal completion. What is the difference between my dying from 30 years of consuming psychotropic prescriptions killing me slowly, like rat poison, with its’ long term effects causing pre-diabetic ailments, exhaustion, mind numbing grips of lack of passionate living, obesity, high blood pressure, cognitive impairment, or taking my life as juxtaposed with dying from a socially acceptable debilitating disease?

For selfish reasons alone, as a Certified Peer Specialist (Georgia, Maryland, Texas) we are rather directed by SAMHSA and national Core Competencies to provide Hope via all fashionable ventures in the name of Recovery. My story will not save anyone. My Hope and Story certainly cannot and will not save another person from completing. We’ve tried. We’ve lost too many. That we’re still walking, breathing, bitching and pissed off says it all. We are invincible. With at least ten (10) combined failed attempts, we conclude that we are unkillable. We are immortal.

We are Spiritually led to the opinion that the right to die a good death in dignity is an inherent privilege and may very well be perhaps the only thing which we retain control over, truly. There is one death by suicide in the US every 12.3 minutes and every 30 seconds globally. Individuals are killing ourselves off, completing, because living a life with a diagnosed serious persistent mental illness equates to being held in shackles by the current US antiquated, creaking, leaking mental health system built from a history of asylum, of involuntary commitment, of psychoactive medication dosing, chemical restraints and the dichotomy of failed medical healthcare professionals and vulnerable mental health consumers.

We are privy to terrible drownings and more divergent choices of suicidal completion (e.g., hanging, guns, auto, motorcycle, biking, cliff/bridge jumping, belts, poison, od’s, auto erotic asphyxiation). The US Community Public Mental Health system is in the business of Death and we are Agents of it, then.

We see no difference between dying from a terminal Stage IV invasive physical disease or the fact that 45 combined years of consuming psychotropic prescriptions is killing our bodies like mercury poisoning, with presumptive and eventual long term effects causing diabetic related ailments, exhaustion, mind numbing grips of lack of passionate living, obesity, disjointed involuntary movements, high blood pressure, cognitive impairment.

The right to die a good death in dignity is an inherent privilege and may very well be perhaps the only thing which we retain control over, truly.

Rate of Queer suicide attempts (%) (Trevor Foundation and Williams Institute 2016)

  • According to surveys, 4.6 percent of the overall U.S. population has self-reported a suicide attempt, with that number climbing to between 10 and 20 percent for lesbian, gay or bisexual respondents. By comparison, 41 percent of trans or gender non-conforming people surveyed have attempted suicide.
  • The most recent, comprehensive data on suicide attempts was gathered by The Williams Institute, in collaboration with the American Foundation for Suicide Prevention. Its report, Suicide Attempts Among Transgender and Gender Non-Conforming Adults, analyzed responses from 6,456 self-identified transgender and gender non-conforming adults (18+) who took part in the U.S. National Transgender Discrimination Survey.
  • Beyond the overall number of suicide attempts, the rates are consistently high from respondents ages 18 to 65, when they begin to recede. Trans men are the most impacted, with 46 percent reporting an attempt in their lifetime. Trans women are close behind at 42 percent, and female-assigned cross-dressers report rates of 44 percent.
  • Rates of transgender and gender non-confirming suicide attempts by age (%) (Source 2016).
  • Rates of transgender and gender non-confirming suicide attempts by gender identity (%) (Source 2016).
  • Race and ethnicity also play a role. More than half of all American Indian, Alaska Natives and mixed-race/ethnicity respondents have attempted to take their own lives, and the figures aren’t much better for the black (45 percent) and Latino (44 percent) trans communities. Even those with the lowest rates—Asian or Pacific Islander and white respondents—are still almost nine times higher than the national average.

Queer adolescents are more likely to be involuntarily committed to a long term mental health facility where they are subjected to being forcibly medicated with powerful psychotropic drugs, and archaic treatments such as aversion therapy, sensory deprivation, rotational therapy, ECT, restraint isolation and other inhumane practices. Homosexuality was removed from the DSM in 1973 but we are still persecuted, tortured and psychically damaged in our community’s youth.

SAMHSA’s efforts and initiative to increase the numbers of “saved” lives from suicide is telling. People are killing themselves out of presumably apparent poverty, experienced trauma, loss, grief, hate crimes, living shelterlessly, living disenfranchised and marginalized, from battling in combat and seeing it full front and center or from being out and out and exhaustively beaten to a pulp by our mental health system.

In SAMHSA’s and the Alliance for Suicide Prevention (2012) paper and study, “National Strategy for Suicide Prevention: How You Can Play a Role in Preventing Suicide,” they comprehensively detail the following facts:

  • Suicide is the 10th leading cause of death in the United States, claiming more than twice as many lives each year as homicides. i
  • On average, more than 33,000 Americans died each year between 2001 and 2009 as a result of suicide—more than 1 person every 12.5 minutes. ii
  • More than 8 million adults reported having serious suicidal thoughts in the past year, 2.5 million people reported making a suicide plan in the past year, and 1.1 million reported a suicide attempt in the past year. iii
  • Nearly 16 percent of students in grades 9 to 12 report having seriously considered suicide, and
  • 8 percent report having attempted suicide once or more in the past 12 months. iv

Although suicide can affect anyone, the following populations are known to have an increased risk for “suicidal” behaviors:

  • Individuals with mental and/or substance use disorders;
  • Individuals bereaved by suicide;
  • Individuals in justice and child welfare settings;
  • Individuals who engage in non-suicidal self-injury;
  • Individuals who have attempted suicide;
  • Individuals with medical conditions;
  • Individuals who are lesbian, gay, bisexual, or transgender (LGBT);
  • American Indians/Alaska Natives;
  • Members of the Armed Forces and veterans;
  • Males in midlife; and
  • Older

Further, in SAMSHA’s Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018. (HHS Publication No. (PEP) 14-LEADCHANGE2. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.) they speak to creating, “… a framework and process for identifying, developing, and implementing strategies to yield specific outcomes and ultimately influence system change” (p. 6). SAMHSA’s Strategic Initiative (SI #3, pp. 19-22) describes Disparities fall-out:

“Trauma, violence, and involvement with the criminal justice system disproportionately affect individuals, families, and communities of color, including indigenous and native populations. Racial, ethnic, sexual, and gender minority individuals experience trauma not just as individuals, but often also in the context of historical, intergenerational, or community trauma, which further compounds the effects of specific traumatic events. Mass trauma, such as natural disasters, often leave these communities underserved, unserved, or cut off from recovery resources. These communities are overrepresented in the justice system, are provided less opportunities for diversion from the system, and often move deeper into a system that itself is traumatizing and not geared toward recovery for people with mental or substance use disorders. For some people in these communities, the justice system becomes the de facto behavioral health system.”

For hundreds upon thousands of individuals living within the spiritual and emotional day to day anguish compounds and builds traumatizing distress. For individuals living with dual diagnosis and/or co-occurring physical health issues, how does recovery and hope really save us from the very “medicinal” prescriptive medications which are killing us slowly, bit by bit, day after day? They will not and they won’t help. We have accepted that we are dying a fast death biochemically due to extraneous debilitating side effects from 45 years of combined clinically invasive medication with concurrent treatment adherence at the hands of psychiatric staff nationwide. Our vital body organs are damaged, disease inflicted. We show premature damaged sugared blood coursing our veins blurring vision. Increasing terrible physical pain, aching and tenderness with effected cognition and comprehensibility is affected. We are already dying and we welcome relief.

Our argument rests in the very simple understanding that there is no difference between physical or psychiatric illness. That the body inherently breaks down and dies is tantamount to one’s humanity towards longevity of eternal life of one’s mind, heart and spirit. The daily poisoning of one’s body daily with antipsychotics, antidepressants, mood stabilizers from big pharma (e.g., Eli Lilly, Astrazeneca, Bristol Myers Squibb) weighs heavily on increasing opportunity for physical structural breaking down due to consistent poisonous or negligible medication dosing.

Symptoms to many of these very prescriptive psychiatric solutions is increased suicidal ideation which may or may not lead to death of the body. Given the presumptive mutual agreement between provider and acknowledging non-revocability to remaining truly self-informed, then contractually, we retain a right to die a physical death. We choose not to accept that which is de facto from a failed behavioral health and public community mental health system within the United States, or being jailed physically, and to be scapegoated publically and personally.

To die in dignity means that you must acknowledge and accept a daily walk with Death.  “Die Wise: A Manifesto for Soul and Spirit” Author Stephen Jenkinson, a Death Doula, a man busy in the death industry speaks to one’s right to die wisely. No judgment. There is just honoring the individual’s right to choose how to, when to and where.

  • Centers for Disease Control and Prevention. Fatal Injury Data, 2009. Web-based Injury Statistics Query and Reporting System. Available at Accessed January 12,
  • Centers for Disease Control and Prevention. Fatal Injury Data, 2009. Web-based Injury Statistics Query and Reporting System. Available at Accessed January 12,
  • Substance Abuse and Mental Health Services Administration. Utilization of mental health services by adults with suicidal thoughts and behavior. (National Survey on Drug Use and The NSDUH Report.) Rockville, MD: Author; 2011.
  • Centers for Disease Control and Youth risk behavior surveillance—United States, 2011. MMWR. 2012;61(4) 1-162




The Horror, The Horror

Written by Amanda Barnabe and Jen M. Padron

old empty room by barnabe
Old Room, Photo Credit: Amanda Barnabe, 2015

The first line of treatment in US psychiatric care is the prescription of psychotropic medications to an effected individual exhibiting mental diversity symptomology entailing behavioral and/or physical medically descriptive treatment.

The symptoms and prescribed diagnosis, according to the Diagnostic Statistical Manual’s (DSM-5, 2016) symptomology of “Serious Mental Illness” (SMI) includes anxiety or panic disorder(s), behavioral and mood disorder(s) with the more complex or complicated issues being major depression and the bipolar or schizophrenia spectrum disorders.  The result then, is a dire public health crisis. Suicide completion numbers worldwide today tragically occur every 40 seconds[1] and injury accounts for 30-40% of excess mortality, where 60% of premature deaths in persons with a diagnosis of schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases[2]. Compared with adults without diagnosed mental illness issues, people with SMIhave higher rates of chronic disease, heart disease, seizure conditions, hypertension, diabetes, and obesity.

Physical health problems are a major issue among individuals living with a psychiatric label.  Nearly half (45%) of all individuals living with any mental disorder have two or more debilitating physical disorders further lowering their quality of life and leading to a significantly high rate of comorbid physical issues[3].

Physical co-morbidities is the leading reason why people with SMI are dying 25 years earlier than the general population[4]. There is a higher frequency of multiple general medical conditions that more than double the rate of premature deaths from these conditions[5].

Loss of life expectancies in the United States for depression, bipolar, and schizophrenia has lowered total life expectancy by 12 – 25 years as compared to individuals not in the community public mental health system[6].  According to the Substance Abuse and Mental Health Services Administration[7] and NASMHPD[8] individuals living with a diagnosed SMI, limited to receipt of current public mental health care are dying on average 25 years nationwide earlier than those receiving private care for mental illness. Forty-six (46) years ago, in 1967, 1:3 American adults filled a prescription for a “psychoactive” medication, with total sales of this family of drugs reaching $692 million[9].

In the US, psychotropics are broadly prescribed, the least regulated, and fall in the fastest, biggest-selling class of drugs nationally. In 2010, $16.1 billion was spent on antipsychotics in the US, to treat depression, bipolar and schizophrenia.  $11.6 billion was spent on antidepressants, while $7.2 billion for the treatment for ADHD, according to IMS Health, which tracks prescription drug sales (Wall Street Journal, 2011). MH treatment spending between 2009 and 2020 estimates showed a percent contribution of each provider type to the eagerly anticipated $91 billion increase in the treatment for the SMI nationwide. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) refers to SMI as “mental disorders” (i.e., codes in sections 290 through 319)[10].

A medically, clinically necessary diagnosis substantiating the use of psychotropic medication dosing is geared to control and manage exhibited DSM-5 symptomology popularized and normalized by the American Psychiatric Association, the American Medical Association, National Association of Social Work and the American Psychological Association. The US SMHA expenditures for mental health treatment alone was $38,098.64 in the millions (2013) which included jails, prisons, MH/SUD facilities, but not did not include children’s services nationwide[11]. 35.5% percent of all US Social Security Disability Insurance (SSDI) beneficiaries live with such a diagnosis[12]. The SSA 2012 numbers of 10,088,739 SSDI beneficiaries nearly doubled from 5,044,388 since 1995.

Kaiser Health Foundation of State Effected SMHA:

Using IMS data for 2012 as a starting point, baseline expenditures representing $/spent for SMI prescribed and purchased psychotropics are predicted using the formula (described earlier):

Δ expenditures = Δ P * Δ Q

where Δ means growth represented by 1 plus the percent change (example: 5.1 percent growth = 1.051), P represents price of services, and Q represents quantity of services. Spending was projected at the molecular level for those products expected to lose patent protection or at the therapeutic class level for all classes where the generic share was higher than 70 percent.

“For quantity of prescriptions, growth in the number of prescriptions for each therapeutic class was projected using the “target growth” technique described in the baseline projections section above. This method uses average growth over 2009–2012 and, in one case, over the longer time period of 2002–2012 to establish the growth rate at the end of the period. An assumption that the growth in volume will change gradually from 2012 to 2020 to hit that target growth rate was used.  In addition, patent expiration dates were used to determine points in time when branded medicines lost market exclusivity and would lose volume. The assumption was also made that most consumers would switch from a branded to the generic version, with 70 percent of the switching occurring in the first year after patent expiration and 95 percent in the second year after patent expiration,” (HHS Publication No. SMA-14-4883, 2014).

Source:  Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014[13].

Social stigma for diagnosis and living with an SMI increases triggers and stressors to an already vulnerable, disenfranchised, marginalized and impoverished population of citizens living with perceived mental illness and physical comorbidity. LGBQT individuals are 2 or more times more likely than heterosexual individuals to have a mental health condition. 11% of trans individuals reported being denied care by mental health clinics due to bias or discrimination. Lesbian, gay, bisexual, gender queer, trans and questioning youth are 2 to 3 times more likely to attempt suicide than heterosexual youth.

Critical Issues Faced by Multicultural Communities[14]:

  • Culturally insensitive health care system
  • Higher levels of stigma
  • Language barriers
  • Lower rates of health insurance
  • Less access to treatment
  • Less likely to receive treatment
  • Poorer quality of care
  • Racism, bias, homophobia or discrimination in treatment settings

Trending study on the association of ill health and SMI includes analysis of physical wellness measures and Quality of Life (QoL).  QoL has emerged to be an “influential outcome measure in people with psychosis”[15] related most significantly to schizophrenia and major depression.  There is a significant relationship between physical health, overall subjective health levels and QoL in pervadive research between illness-related factors with chronic mental health disorders, substance abuse/addiction disorders and comorbidities.  Psychiatric and comorbidities ill-health symptoms diminish QoL[16]. Preventable physical health conditions rise out of the lack of exercise due to the high rate of tobacco smoking, poor nutrition and prescribed psychotropic medication side effects, giving way to cardiovascular disease, raised sugar levels (Type 2 diabetes), hypertension, and liver disease[17].

The physical health of individuals living with a psychiatric and/or substance abuse disorder and comorbidity is currently inordinately neglected in treatment which requires an Integrated care solution. Co-locating behavioral and physical primary care providers to deliver a balanced, whole regimen in assessment, treatment plan and a consistent continuum of care[18] in a public/private health care environment.  Drake, et al., (1998) support an Integrated behavioral health and substance abuse treatment in an assertive community treatment (ACT) approach for patients living with a psychiatric and substance abuse/addiction dual disorder based upon clinical and epidemiological data indicating that the rate of the SMI population with comorbidity are significantly higher than in the general population[19]. Reducing the severity of needs for individuals living with an SMI and substance abuse/addiction disorder benefits ensures a higher experienced personal QoL for recipients of public community health services[20]. Predictors of higher QoL stem from lowered needs, having one’s personal and social supports in place, having a higher personal feeling of worth, less substance abuse/addiction disorders and having housing in place increases self-worth and predicts a favorable long-term outcome in schizophrenia with better daily and social functioning[21].

The absence and lowered levels of personal needs, having a sense of daily hope, lessened social exclusion, greater safety to self and a measureable, identified personal benefit to living are directly involved with greater personal QoL[22]showing value in ensuring a higher QoL in this disenfranchised population.  It has been argued that “… fostering hope and positive self-concept should be central components of recovery-oriented services and interventions…”[23] and is strongly linked to individuals experiencing increased QoL. An effective early intervention method to improving the physical health of adults with SMI to achieve higher overall QoL’s and meaningful Physical Health Quality of Life (PHQoL) is to develop and implement effective, culturally attune and sustainable lifestyle interventions[24].

In the scientific literature, there have been several reviews of randomized controlled trials (RCTs) on Peer providers (Certified Peer Specialist, Forensic Peer Recovery Specialist, Recovery Coach and Community Health Worker) for mental health services. Controlled studies substituting people with lived experience for providers of direct or adjunctive mental health services generally find the same impact on service user outcomes as other mental health providers, with improved treatment outcomes in some instances with no additional risk of harm to service users[25]. There is also theoretical literature which addresses the challenges and benefits of hiring consumer providers in mental health agencies[26] and a long history of activist writings on the importance of leadership, community-building, and mutual support among people with lived experience of the mental health system[27].

As of February 2016, 43 States, two Territories (Guam and Puerto Rico), the District of Columbia and the Veterans Administration system have established programs to train and certify Peer specialists is in process of developing and/or implementing a program. Appalachia Consulting[28] contracted proprietary CPS curricula is used in 23 states. Recovery Resources[29] free CPS curricula is used broadly by the Department of Veterans Affairs and a limited number of states. Recovery Innovations / Recovery Opportunities (Ashcraft, 2015) contracted and proprietary CPS curricula is also broadly purchased and contractually provided.

Given the groundswell of perspectives that endorse the growing prominence and importance of Peer support in mental health and human services, it is essential that we document evidence to examine the impact the peer support workforce has on access to care, cost of services, participant outcomes, and system and provider outcomes[30]. Included in this must be rigorous research on the particular approaches and philosophies of peer support workers that make them an addition rather than a substitute for clinical and social care disciplines[31].

The real horror is that Western “medicines” were “supposed to make one feel better” and is juxtaposed with the overwhelming intention that psychotropics are chemical restraints designed to alleviate psychiatric symptomology. It is in the authors’ opinion that mental illness and the disease model rarely takes into consideration cultural bias, white privilege, trauma, re-traumatization or hate ofthe other. For the mentally ill, psychotropic medications hold the illusion of controlling (mal)behavior in that the individual is molded to meet public acceptance levels of socially accepted cultural mores, inherently white, male, patriarchal, heterosexual Judeo-Christian based and is hierarchical.

The caveat then, is that psychotropics are often not prescribed to improve apatient’s QoL alone, but rather, to shape neat predictable cookie cutter shapes of people with shared life experience or to fit antiquated sociocultural stereotype and meet appropriate biased social expectation and roles of compliance.



[1] World Health Organization (2016). Retrieved April 11, 2016

[2] National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council Report, 2006

[3] Harvard Mental Health Letter, (2003); NASMHPD, (2006); Parks, Svendsen, Singer, Foti, (2006).

[4] Fricks, (2012); Mental Health America, (2010); National Alliance on Mental Illness, (2011).

[5] Kelly, Boggs, and Conley, 2007; Mauer, 2006; Parks et al., 2006; Sokal et al., 2004; Saha, Chant, and McGrath, 2007; Laursen et al., 2013).

[6] Robert WhitakerAnatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, 2010.

[7] National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council Report, 2006.

[8] Ibid.

[9] Robert WhitakerAnatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, 2010.

[10] Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

[11] National Association of State Mental Health Program Directors Research Institute, Inc. (NRI), (2013)

[12] Annual Statistical Report on the Social Security Disability Insurance Program

[13] SAMHSA, 1996 (Coffey et al., 2000; Levit et al., 2013; Levit, Kassed, Coffey, Mark, McKusick, et al., 2008; Levit, Kassed, Coffey, Mark, Stranges, et al., 2008; Mark et al., 2000; Mark et al., 2007; Mark and Coffey, 2004; Mark, Coffey, McKusick, et al., 2005; Mark, Coffey, Vandivort-Warren, et al., 2005; Mark, Levit, Vandivort-Warren, Buck, and Coffey, 2011; Mark, McKusick, King, Harwood, and Genuardi, 1998; McKusick et al., 1998; SAMHSA, 2010; SAMHSA, 2013).

[14] National Alliance on Mental Illness (NAMI) (2016). Cited statistics provided by the National Institute of Mental Health., the Substance Abuse and Mental Health Services Administration, New Evidence Regarding Racial and Ethnic Disparities in Mental Health and Injustice at every Turn: A Report of the National Transgender Discrimination Survey.

[15] Theodore, K., et al., 2012, p. 545

[16] Parks et al., (2006).

[17] Must, Spadano, Coakley, Field, Colditz, & Dietz, (1999).

[18] Robson & Keen, (2012).

[19] Cuffel, (1996).

[20] Fleury, M., et al, (2013).

[21] Karow, A., et al., (2014).

[22] Fleury, M., et al, (2013).

[23] Hodgekins & Fowler, 2010; Theodore, et al., (2012), p. 549.

[24] Fricks, L., (2014).

[25] Pitt, V., Lowe, D., Hill, S., Prictor, M., Hetrick, S. E., Ryan, R., & Berends, L., 2013; Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E., (2014).

[26] Davidson et al., (2006); NASMHPD, (2014).

[27] Chamberlin, (1978); Morrison, (2013).

[28] Fricks & Powell, (2015).

[29] Harrington, S., (2015)

[30] Hardin & Padron, (2014).

[31] Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E., (2014).