Trans and Schizophrenic: When Diagnosis Impacts Transition

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) recognizes both gender identity disorder and schizophrenia as mental illnesses that can and do coexist. So I was surprised to find that, when my doctor would not prescribe me hormones without a letter from my psychiatrist stating that my gender identity issues weren’t a product of my schizophrenia, the psychiatrist said he would never write such a letter.

“You can’t prove a negative,” he said. “I’m not saying you’re not transgendered, but I can never be sure that this transgendered thing is legitimate.”

So there it was. Although I could pass pretty well without the hormones, one day I would develop male-pattern baldness and other secondary sex characteristics of the wrong gender. I was doomed to become irreversibly masculine.

My parents and I were stunned. In modern times, most people wouldn’t think it was mentally healthy for a person to conceal her gender identity and live as the wrong gender for the rest of her life. How, then, could it be not only right, but necessary for someone who had already suffered a psychotic break to live that way? Even worse, my mother asked him if he understood what an emotional blow it was for me to hear that I could never have hormones for the rest of my life. Basically he shrugged and said “that’s protocol.” Before my mother could recover from her shock at his response he went on to say that because my medicine was so effective for me, he would only need to see me once every three months. I was forced to consider the possibility that he just didn’t give a damn about my happiness.

If he had read my medical records he would have known that my first psychotic break was exacerbated by my fear that I would never be recognized as a woman. In my senior year of high school I had come out to my parents and friends as trans. I began seeing a therapist and after six months I got her to sign off on my getting hormones. At the time, my therapist’s approval was all I needed, and so I initiated hormone replacement therapy. All this time I had been taking anti-psychotics for past mental health issues that included toileting in a bucket, fear of robots from the future, and running around in my underwear in the middle of winter. But I hadn’t actually been diagnosed with schizophrenia yet, so no one stood in my way of getting hormones.

That would change as my symptoms progressed. Despite loyally sticking to my medication regimen, I fell ill again. I was afraid that Israel would invade the U.S. and so I thought I had to get the president’s attention. Jill Biden taught at the school I was attending, and when I saw her secret service detail I began to scan them closely with my eyes to see if they had any devices to communicate to the president with.

“Who is she?” one of them whispered to another.

“I think she’s a student.”

I became fearful, so I left. Next week when I came back for class, a couple of secret service agents pulled me aside and interviewed me.

“Why did you run from them? Did you know they were secret service agents?” they asked.

I became fearful so I started banging my head against the wall to control my thoughts, but they then decided to take me to the hospital because I was hurting myself. “We need to take you for a psychological evaluation because we think you’re a danger to yourself.”

I turned and tried to run, so they wrestled me into handcuffs and brought me to the emergency room. At the emergency room I tried to run away and so they tied me to the bed. Blinded by rage I screamed, “You can’t stop me from killing the president!”

“How would you kill the president?” one agent asked.

“If you donate to his campaign you’re entered into a raffle. The prize is a seat at a dinner with him. I’m going to win and choke him at the dinner.”

I was committed to a psychiatric unit, and when I was discharged three weeks later the secret service pressed charges and I was arrested. They dropped the charges after I’d spent nine months in jail because they decided I was too mentally ill to understand the charge or the court proceedings. I was transferred back to the same psychiatric unit and two months later I went home.

But I was haunted by memories of my time as a female in a male jail. While in jail, I ran into several problems because I looked like a woman. I had inmates chasing me around the corridors, offering me food for sex, and one inmate even sexually assaulted me. The worst part was that they wouldn’t give me my hormones in jail. So when I got out I immediately went back to the doctor who had prescribed them to me. She wouldn’t do this without a letter from my psychiatrist because I had been diagnosed as schizophrenic.

“I know you were on hormones before, but I just need some extra assurance,” she said.

When I was actively psychotic I never mentioned my desire to transition. It’s only when I’m healthy that I pursue hormone replacement therapy and laser hair removal. When I was at my worst, I couldn’t even think about my gender identity. I was too preoccupied by my fears. I was afraid harmless things, like street signs or trees, were trying to kill me. I became concerned only for my survival. I couldn’t even think about my gender identity.

My parents have noticed the trend that I only talk about transitioning when I’m healthy, and they support me in my transition. But even with my parents on my side my psychiatrist refuses to write me the letter I need. No matter how long I’m mentally stable, no matter how long I live full time as a woman, he will never approve me for hormone replacement therapy. This is why my parents and I were so stunned at my psychiatrist refusal to even discuss the matter. It doesn’t mean I can’t transition. What it does is create an additional financial barrier. This doctor was not the first to refuse to write me a letter for hormones. Every doctor that I’ve seen within my health insurance has refused. So I have to see a private psychiatrist for several months to get his or her approval. The only way around this is to take black market hormones, which I don’t want to do.

With my parents’ encouragement, I hope to share my story to help other people in my position. No one should have to live as the wrong gender for his or her entire life because they have a mental illness.

About the author: Sam Ashkenas is a twenty-year-old former college student. She came out as trans at the age of seventeen. At the age of eighteen she was diagnosed with schizophrenia. She initiated hormone replacement therapy, but was taken off the hormones after being arrested. Now she is out of jail and working to get back on hormones.

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Sam Ashkenas

Sam has written 1 article for us.


  1. Thank you for this article! It was a difficult read. I hope you win your battle and will be able to get back on hormone therapy. Much love!

  2. I don’t know if you’re anywhere near Miami but I’m a psychiatrist and would not have a problem writing such a letter. So if you are able to or would like to come see me please let me know how to reach you in the comments.

  3. Sam, this story is tragic. You should never have been jailed when clearly what you needed was treatment. I’m so sorry you’ve had these problems. :(

  4. One hopes the author is able to avail herself of international resources in such times.

  5. It’s something like a fifth of people in jail have mental illness. I should find the real statistics on that, but regardless it is really terrible to be in that situation. I hope you are able to find a more understanding psychiatrist that realizes that trans shouldn’t even be a psych diagnosis … I would love to hear an update on your story as things hopefully get better for you.

    • Over 64% of local jail inmates, over 56% of state inmates, and over 45% of federal prisoners. The statistics are higher in men’s jails and prisons. It says a lot about the state of mental health care in this country, specifically prevention/early intervention.

    • And you can thank Ronald Reagan’s ass for THAT.

      (Seriously though this is fucking monstrous and I cope with wanting to cry through humor. What has been done to this woman is so cartoonishly evil, and it’s sick that we’re all dangerously vulnerable to similar treatment.)

      • Well, actually, most of the issues with mental health care and the prison system involve foster care. In some states a whopping eighty percent of inmates have spent time in care. Almost every single one of them has been diagnosed with something or other, usually ODD. Their problems weren’t dealt with, they were over-medicated, and they didn’t get adequate help. They don’t belong in psych wards, either. What they needed was therapy to work through their trauma and support systems in place to stop the trauma from continuing, not to have a label smacked onto their forehead, drugged up, and being bounced around from home to home. That’s why I mentioned early intervention/prevention. Support systems in place for at-risk children and families, and for traumatized children. It’s what I want to do with my life, as a psychiatrist. I was in foster care. Most of the kids I was in care with didn’t deserve their diagnoses. I was diagnosed with RAD, ODD, ASD, PTSD, and a host of other things at varying points. I am function best off of meds.
        I think schizophrenia is a different beast. Same for bipolar that’s not really dealt with (my mother has it and doesn’t deal with it; it ultimately landed me in foster care). Jails may or may not be the best place (although, if you threaten to kill the president in front of the Secret Service, I can understand why jail happened) for the mentally ill, but honestly, psych wards aren’t either. Jails do more to rehabilitate their inmates than psych wards do, from what I’ve seen in my own family. There’s a program in the UK that puts former convicts diagnosed with schizophrenia with families in a sort of group home situation. Great things are happening with that. I don’t know. I wish their was a magic wand to make it all better but there’s not. We’ve made great strides since the Eunice Kennedy Shriver era, though, so hopefully we’ll continue along that trajectory.
        I do hope you can get hormones. Are they concerned hormones may affect your mental health? My mom’s hormone levels have to be checked because they can make all of her issues worse.

  6. I can’t imagine how hard this must be, Sam. Thanks for sharing your story. I hope you can get back on hormones and stay healthy. Wishing you the best.

  7. Thank you for sharing your story. It’s so important that people with mental illness speak openly about it, and it was a privilege to read about your experiences. I hope the medical system improves such that you won’t have barriers to hormone access in the future.

  8. I’m so sorry to hear (like Marika) that you were put in jail for being sick. I HOPE HOPE HOPE you find helpful/compassionate doctors who want to make you actually FEEL BETTER instead of following “protocol.” What horrible rules to live within–when you live so amazing outside of them! Thank you THANK YOU for sharing this. It’s an awwwessssssome way to start awareness. Your heath is and SHOULD be so important to your community and physicians.

  9. I’m so sorry; my heart goes out to you. I hope you’re able to find a psychiatrist who is able separate your gender identity from you mental illness. Your writing on the subject is very eloquent.

  10. Thank you so much for sharing your story with us, Sam. My heart is with you in your journey to transition and in bringing awareness to the trials those with mental illness are made to endure. <3

  11. I’m so sorry you have had and continue to endure this. I get it at a lesser level, but still one uncomfortably close – I delayed treatment for suicidal depression for nearly a year for that reason (I was already on HRT and feared that seeking treatment would mean both that I was taken off of HRT but forever denied access to my surgery letters, which I was actively seeking at that time and receiving excuses from my therapist to justify months of delays in writing it.)

  12. I’m not going to lie; going to jail has always been one of my biggest fears, especially since I’m trans. You had to go through that hell and now you can’t get the treatment you desperately needed in the first place. I can only hope that things will look up for you in the future.

  13. My ex-had this exact issue. She was denied hormones at every official channel, and had her supply when she got committed. It’s awful because it exacerbates her dysphoria, which hurts her overall mental health.

    Honestly, get hormones international. The only difference between mail order and pharmacy is the doctor’s note. And doctors will still treat you and check your levels. You can do it while going to a private psychiatrist for official validation, but there’s no reason to delay treatment of a medical condition.

    • This. You’re the only person who has to live your life. Crush everything that stands in your way. Walk into the doctor’s office, slam your hand down on the table, and say, “This is happening. Help me do it safely or have it on your conscience.”

  14. I live in the northern Virginia area. My therapist (the one who initially wrote me the letter for hormones) has directed me to a local psychiatrist whom she has worked with before, but seeing a psychiatrist outside my insurance is financial prohibitive. I didn’t know that you could still have your hormone levels checked if you were getting the hormones internationally. Who should I go to to get them checked and where should I buy them from? When I was on hormones they were prescribed by Whitman Walker clinic in Washington D.C. They also did the blood work to take my hormone levels.

    Thanks everyone for reading and posting your comments!

    • I have a friend, Scout, who runs the Fenway Institute/Fenway Health in Boston. Have you considered contacting them? They might be able to help.

    • If you go to a doctor, and tell them your doing heroin, they’ll still test you for health complications. They just won’t write you a prescription for Vicodin.

      It’s an awful analogy, but that’s how a lot of doctors think. While prescriptions make them liable to malpractice suits, there’s no harm (to them) in testing you for health complications related to HRT.

      The downside is that you have to do most of the legwork when it comes to medical care: what to test for, treatment options for various complication, what’s insured, etc. It’s not overwhelming, and there’s ample resources online. But you have to take the lead.

      As for where buying: look for an online pharmacy. It’s a two week delivery because it comes from overseas. There used to be plenty pharmacies Stateside, but they were shut down because you could also buy Vicodin from them (there’s that connection again). It’s also a crime in the US and Canada to write any prescription without having at least one face to face consultation.

      Mind, it’s not a crime to buy hormones. They’re marked as Unregulated. If you ordered Vicodin, Customs would cease it at the border and turn your name over to the DEA. It’s a quirk in policy that had nothing to do with trans* folk, but hurt us because trans* folk weren’t even considered when making it.

      • Also, I want to note that online pharmacies are comparable in price to prescription medications, so you wouldn’t have to worry about a financial burden.

  15. Thank you so much for writing this. I was recently diagnosed with bipolar and I am grateful you are brining light to the treatment of mentally ill people.

    Good luck and all the love to you. No one should have to endure the hardships you have suffered. I am so impressed by your strength and will to continue. Much love and positive energy your way.

  16. I’m horrified that all that has happened to you, Sam :( My brother and aunt both have schizophrenia and that’s hard enough to deal with on its own. I hope you find a more understanding psychiatrist soon, and thanks for sharing your story x

  17. Craziness. Like IUD’s and hysterectomies, hormone therapy should be a choice made by the PATIENT, not some “professional” who thinks they know best. Also, you should have never been in jail for having a psychotic break. Prisons are the new mental institutions in this broke-a$$ country.

  18. I’ve recently had experiences surrounding the intersection of mental health and being trans*. I had a manic episode in response to antidepressants I was taking, and was given a query diagnosis of bipolar. My psychiatrist refused to prescribe me hormones because he didn’t feel he was qualified to deal with the topic. He sent me to another psychiatrist who said I couldn’t start until I could prove that my mood was “stable”. Which basically means not being depressed. A large part of my depression is directly related to not being on hormones. I know people who lied about their mental health status in order to get hormones, and are therefore not getting treatment that they need for their other condition. I know people who had to wait a years before they could prove they were over their PTSD. Sometimes I feel like it isn’t fair that I’m too mentally ill to receive treatment for my “mental illness”. I feel trapped in a system that can’t help me. I think it’s because people feel the need to pathologize transness, because we somehow turned out ‘wrong’ and they have to find a reason why. And that sucks.

    • Yo, you got issues. And I’m sure a “lopitoffofme” is the answer… sarcasm btw. Do us a favor like the other 50 percent and kill yourself

  19. Hey Sam,

    I self-identify as the reclaimed titles of Mad and Queer, and have a shitload of pride in both. Madness is fucking badass.

    Sanism: a form of discrimination and oppression against someone because of a mental trait or condition they have, or are judged to have.

    That being said, your psychiatrist is a fucking ass. It makes me so angry that this barrier exists.

  20. i am so sad for you- i feel so deeply for you, and the thing is i can never fully understand. as a woman, assigned female at birth, identifying as a woman, and appearing as a woman- i will never never feel the incongruity that you do.
    no one should have to live with (untreated) mental illness- or without resources to feel like the realest person they can.
    i don’t know you, but i love you so much and i’m sending all my good thoughts, fairies and mind glitters to you. i’m drunk and crying and i want you so much to be happy. ok? fuck everyone, ok? if feelings could fix problems, we would all hold hands and try and fix them for you.
    i hate your psychiatrist.

    • Call your doctor’s office and say, “I want blood work done for the hormones I’m taking. When’s the next appointment,” I imagine.

  21. I am also a psychiatrist and this story makes me very very sad. I don’t know where you live or if it is at all feasible for you to move to a more accepting environment for your transition, or even travel somewhere for a psychiatric consult to get a recommendation.

    I heard Dr. Deutsch speak at a conference this weekend and I know people at the Center for Excellence for Transgender Health have extensive experience with this sort of issue. Maybe you can contact them and see if they have any suggestions or referrals for you?

    I am sorry you are going through this. It pains me to read your story and I truly hope you find the support you need and deserve.

  22. I hope everything works out for you. No one should have to fight so hard to become the person they need to be.

  23. This makes me so sad to read – you’ve been through hell, and I can’t imagine how brave you’ve had to be to come through these experiences so far. I wish I could say they’re over. Don’t let anyone (even psychiatrists – especially psychiatrists) tell you that your illness defines you, that you have no hope of recovery, that you are “less than” for having experienced these unusual and frightening states. As a trans woman and as someone who has experienced a highly stigmatizing mental illness, I’m sure you know that the world is against you twice over. The fact that you are still standing, trying, and even writing about your experiences is wonderful and important. I’m in awe.
    If you live near Philadelphia, I’ve heard that the Mazzoni Center ( offers really wonderful care for trans* folks that circumvents many of the usual gatekeeping issues. I hope that you find a psychiatrist who isn’t such a complete piece of shit soon.

  24. How do I know what dosage of the hormones to take if I’m not getting them from a doctor?

    • I don’t have experience with this, but maybe try the dosage you were taking before? You want to be as close to what a doctor would prescribe for you.

      I really hope Whitman Walker would still do the hormone checks/recommendations even if they won’t or can’t prescribe hormones for you.

  25. Also, I’ve been having chest pains and dizziness and haven’t figured out why yet. I don’t know if hormones would complicate that, but I’m also afraid that if I’m on hormones my doctors will blame my health problems on them.

    • i would like to hope that they wouldn’t, but given my experience with doctors, think that’s a pretty realistic fear. one potential way around that might be to be sure you bring up these other health concerns before you go on hormones, so that you have a documented pre-hormones history you can point to if it’s brought up.

      (also: great post, and best of luck!)

    • One possibility to keep in mind is that the chest pains and dizziness could be physical symptoms of anxiety (especially if the chest pains feel more like tension/tightness rather than pain, and the dizziness is not so strong that it causes you to fall down or faint). I would not encourage you to write them off as such right away – if they are really giving you trouble, get them checked out by a physician by all means. But I’ve worked with many people with physical symptoms of anxiety who go for years not knowing that their symptoms are simply due to anxiety, so I just wanted to pass it along as one thing to keep in mind.

      • There is a strong possibility that it’s anxiety. I’ve had both and I have struggled with anxiety, and the chest pains have gotten better with medication.

        Also, re: dizziness, my blood pressure used to just be low and I would sometimes have my vision black out when I stood up. Doesn’t happen as much because now I run about 110/70 instead of 90/60. It could be something like that.

        If you’re concerned about it, get it checked out and documented though.

  26. I’m sorry that you’re having chest pains on top of everything else. It’s bullshit that you can’t see a doctor who will actually CARE for ALL of you — your physical and emotional health and your gender identity. It makes me sick that you have to silence parts of yourself because the docs are so ignorant.

    I’m a social worker and I work mostly with adolescents. I printed your article out for my office because we’re all trying to understand better the intersection of mental health and trans* issues. Thank you for writing it.

  27. Sam– I’m so sorry to hear of your struggles and grateful you have shared them with us.

    Several people have already commented on the correlation between the lack of mental health supports and imprisonment. (In many states, the Department of Corrections is a larger provider of mental healthcare than public health centers).

    I just wanted to mention a related resource, the National PREA Resource Center (PREA = Prison Rape Elimination Act).

    Though passed in 2003, it took almost 10 years before the rules for standards for prison rape elimination were passed, last August.

    Far too often trans* women and other gender non-conforming people are the prime targets for rape in jail. It’s terrifying to think of the number of trans* people who end up imprisoned because of lack of mental healthcare who are then forced to suffer even more by being sexually assaulted.

    I hope we as a community can all do more to prevent these tragedies– talking about them is the first step.

  28. hello all, I have been reading Autostradde on and off for years and I have to say that I am very impressed by all the trans* content in it lately.

    Is Autostraddle changing its direction? Am I the only one wondering about this?

    • Not an editor or anything, but I am fairly sure that what’s going on is that they put out a call for submissions from trans* women after recognizing that there is a major hole in their regular staff from trans* contributors leaving.

      And these are those awesome submissions! seems like they got a lot of them, which is great.

  29. Hey Sam, I hope this isn’t out of line, but I’m worried about the ordering meds over the internet thing. In some people hormonal changes can trigger psychosis. This isn’t just a trans thing, it happens with cis people whose hormonal mix changes for whatever reason.

    I’m absolutely not saying “don’t take hormones,” just that when you go on hormones you might need to adjust your psych meds too, to stay healthy. In a better world, you’d have a good endocrinologist and psychiatrist working with you and each other to find the right doses. In this world… I really hope you can find a supportive psych.

  30. This is honestly one of the reasons I am so afraid to seek treatment for whatever is going on with my head. I want to have top surgery, and I’m afraid they’ll take me off testosterone if they think I’m mentally ill. It’s some flavor of psychosis, so I know it could happen. I hope you someday can return to hormones, and that the health care system catches up to us.

  31. I’m getting hormones internationally now. Thanks for the advice everyone! My health insurance is finally sending me to an expert therapist and hopefully I’ll get a prescription for hrt soon.

  32. Sam, I am also a transgender person with schizophrenia. I was diagnosed at 16, a year after I came out as a transman and following two years of repeated hospital stays. I am now 18 and am seeking hormone treatment, but the first doctor I saw denied me treatment because of my schizophrenia. I am “too complicated” to be legitimately transgender, nevermind that my gender dysphoria has long outdated my psychotic symptoms. I was just writing because I was saddened to see that you were denied treatment. When I came upon your article, I was looking into insurance coverage for top surgery in my state. I thought that it would have a happy ending- that you finally found a doctor willing to treat you or write a referral letter, but it makes me angry for you and for me, and for every other mentally ill trans person, particularly those with schizophrenia. I hope that in the time since this article was written that you have been able to start hormones and get any other trans related treatment that you need.

    • I have been out for five years and been approved for hrt by two therapists yet still can’t get a prescription.

  33. Sam, I read the comments and I am so glad you are getting hormones now. I’m a young trans man with schizophrenia who has yet to go on hormones, but is trying, and this article really scared me, but at least there was some semblance of a happy ending, even if the medical field remains intensely bigoted against both trans and mentally ill people. I was able to get a referral from a doctor for an endocrinologist even though she knew I was schizophrenic, so maybe I’m actually getting lucky. Yet to get the stuff yet though so who knows how things will turn out for me. I wish you the greatest of luck in your future. Thank you so much for sharing your story.

  34. I too am for all purposes Schizophrenic. I too am transgender. It was very interesting because both symptoms hit me at the same time. I firmly believe there is a connection. Look up targeted individuals on google and then relate the technical reasons for this about what happened to your son. I too went through this at the same years 2009 – present.

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