Trans and Schizophrenic: When Diagnosis Impacts Transition

click here for more trans*scribe

click here for more trans*scribe

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.

Special Note: Autostraddle’s “First Person” personal essays do not necessarily reflect the ideals of Autostraddle or its editors, nor do any First Person writers intend to speak on behalf of anyone other than themselves. First Person writers are simply speaking honestly from their own hearts.

Sam has written 1 article for us.


  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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?

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

Contribute to the conversation...

Yay! You've decided to leave a comment. That's fantastic. Please keep in mind that comments are moderated by the guidelines laid out in our comment policy. Let's have a personal and meaningful conversation and thanks for stopping by!