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In their earliest years, the gay or transgendered person at first has no word to name something that feels different about their experience in the world. They eventually discover that not only is a word waiting out there in the real world to describe who they are, but who they are has a particular meaning for those around them. They discover that they must contend with a whole history of meaning attached to this new entity, their sexual identity.

Many sexual minority individuals are likely to recall that the name associated with their burgeoning sexual identity was negatively valued by others. And they quickly learn that any behavior expressive of what they genuinely feel inside is not the norm for almost all others around them.

In this way, sexual and gender orientation takes on cultural meaning. The gay or transgendered individual typically comes to believe that they do not fit in to many of the social groups that constitute the society around them. They may keep this part of themselves a secret, or renounce who they are in order to try to fit in. But the emotional toll of denial, deceit, shame, and lack of fulfillment can become intolerable.

Most, therefore, embark on a journey to find others like themselves. They discover alternative cultural groups where they can openly share their attitudes and values, give positive meaning to their sexuality, and create and nurture a space where their behavior as a gay or transgendered person is the norm. Many will eventually make an effort to come out and share who they really are with people from the culture of their upbringing.

For those sexual minority individuals who also suffer from a major mental illness, the process of finding and maintaining a cultural space that reflects their inner sexual identity becomes significantly more complicated. Many will enter hospitals, clinics, day programs, residencies, and rehabilitation programs that are a throwback to the culture of their upbringing. They find themselves once again in a cultural environment geared to opposite sex relationships and traditional gender roles, with all the old associations of negative values and attitudes potentially nearby.

For those from the mainstream that have difficulty understanding the mental toll this can take, imagine that you are the only heterosexual person in a gay family. Your peers are all gay, your doctor and therapist are gay, as are all the people in your therapy group and in the residence where you live. Many of your acquaintances are supportive of who you are, but some assume you are gay because everyone else is, and some make disparaging remarks about 'straight' people. While you feel accepted in some ways, you also feel uneasy, awkward and alone in others. You're not sure your gay therapist can understand who you are, and you are tired of explaining who you are. You know your 'roots' are not here, and you want to connect with others like yourself.

You've tried to connect with other heterosexuals, but they give you the cold shoulder when it becomes apparent you have a mental illness, or you are reluctant to get too intimate with anyone, fearing they will be scared away if they learn you have a psychiatric disorder. You doubt your own ability to fit in and socialize as a heterosexual with mental illness.

A relatively novel development in psychiatry for mental health organizations and clinicians is now a growing interest in cultural competence regarding mental health services for lesbian, gay, bisexual, and transgender (LGBT) individuals. When the American Psychiatric Association removed homosexuality from its categories of mental disorders in the early 1970's, therapies that were affirming of gender and sexual orientation differences were just barely developing. Variations in sexual and gender orientation were considered forms of psychiatric illness for many years. Even today, those convinced they are in the body of the wrong sex (transgendered individuals such as transsexuals) can still be classified under Gender Identity Disorder. As data accumulated over the years, and perspectives and values shifted, it was increasingly recognized that some of these human differences should not be defined as diagnoses. It has taken virtually three decades for these personal traits to be understood within a cultural context rather than according to their former perception as pathological entities, and to grasp the critical role of cultural factors in mental health treatment.

The growing trend in psychiatry to make mental health programs more culturally competent means that both mental health care providers and institutions that provide mental health services specifically strive to work more effectively with people from diverse cultural backgrounds. This is easier said than done. Although there are guideposts to help mental health professionals get there, there is no specific cutoff point or examination that can make it official. With effort, cultural competence grows over time as knowledge, experience, fluency and wisdom accrue. Furthermore, a rapport with those from different cultural groups can develop in various ways. It is rare for LGBT people with major mental illness to find a cultural space they can call their own. It is a singular moment when the deep, personal experience of being sexually different, while contending with the impact of mental illness, finds validation through a group of similar people in the real, outside world.

In New York City, there are now two public programs that provide this cultural space on a regular basis: the Zappalorti Society, a support group that was started by a consumer of psychiatric services, which meets at the Lesbian and Gay Community Services Center (208 W. 13 St., NY, NY 10011; telephone 212-620-7310), and the Rainbow Heights Club, developed at South Beach Psychiatric Center in its efforts to provide more culturally appropriate mental health services to the LGBT community. The Club provides everything from cooking to meditation to computer classes (25 Flatbush Avenue, 4th Floor, Brooklyn, NY 11217; telephone 718-852-2584). Culturally specific programs like these can provide the opportunity for LGBT individuals with major mental illness to feel safe, comfortable, and connected in ways they never thought possible.