Nearly seven months ago, I made the decision to start testosterone as a part of my gender transition.

I remember feeling so overjoyed that this part of my journey was beginning. The torment of being in a body that caused me so much distress, and being misgendered left and right adding salt to my wounds, made HRT not just a desire of mine but a real necessity.

If you’d asked me where I’d be by now, my self of seven months ago would talk about how high my dose would be, all the changes that would be happening, my desired date for top surgery (would it be September? December?), and how I’d be so much closer to the body I needed to have – closer than I’d ever been.

But none of that is true. In fact, I’m almost exactly where I started.

I’m still here because my testosterone dosage is only half of a typical starting dose – extraordinarily low and nearly ineffective, because there’s not a single doctor willing to increase it.

I’m still here because I was denied the recommendation needed to move forward with top surgery.

I’m transgender and I’m trying to transition. But the door keeps getting slammed in my face again, and again, and again.

There’s not a lot of conversation happening around the specific challenges that transgender people with mental illness are facing. I first wrote about this when I discussed my experiences in a psychiatric hospital, where I was almost denied my hormones altogether.

As someone with bipolar and a whole assortment of other diagnoses, I continually come up against obstacles in my transition that I would not otherwise face if I were neurotypical. 

I’ve been told before to stop taking hormones. I still remain on a dosage that barely alters my body – because there are concerns about how the hormonal changes will affect my sanity, despite having no evidence that it will and knowing we could lower the dosage if it did.

Most recently, I was told that I couldn’t move forward with top surgery because I was in a mild depressive episode, and that we would have to wait a few months to revisit the possibility of surgery. Seeing as the waiting period for surgery can be anywhere from six months to 2 years, it’s unclear to me why we couldn’t address my depression while I was on the waiting list for surgery.

Transition can already feel like it takes centuries just to get an inch closer to where we need to be.

So imagine, then, that you are a transgender person with mental illness, who not only has to deal with the typical challenges of gender transition, but you must also navigate the exhausting barriers that therapists, psychiatrists, and doctors place in front of you.

Imagine having no idea when you’ll be permitted to access the care that you desperately need – that you’ll remain imprisoned in a dysphoria-induced hell until you pull it together and become acceptably sane for your doctors.

It’s true that transgender people with mental illness have needs that are unique and important, due to the biochemical nature of both medical transition and mental illness. And it’s true that making life-altering changes during times of turmoil can sometimes do more harm than good.

But it’s also true that countless mentally ill transgender people have been denied hormones or surgery to their own detriment, causing real and even lasting damage.

It’s true that the woeful lack of research around mentally ill transgender people means that many medical professionals simply don’t know how to support this vulnerable population.

And it’s absolutely true that being unable to transition can worsen a transgender person’s mental health – and clinicians who do not take this into account, treating medical transition as optional rather than urgent and necessary, are contributing to the very mental health crisis they wish to avoid.

As I sit here with the inability to go further in my medical transition – stuck in a desperate situation that continues to eat me alive every day – it is obvious to me that mentally ill transgender people are being failed at every level.

If our only “solution” is to not transition, we need new and better solutions.

Assuming my bipolar stabilizes further, there will most likely be a time – I don’t know, hopefully this year? – when I can move forward, after more than half a year of being held back.

And while I’m hopeful that I’ll be able to resume my transition, I remain paranoid and fearful that it can be taken away from me at any time.

If this is what it looks like to be a mentally ill transgender person in the San Francisco Bay Area, I’m terrified to know what it looks like elsewhere in the country, where care is even less accessible and trans-competent clinicians are few and far between.

We deserve better than this. If a medical intervention is what a person needs to be well, why would we ever treat it like it’s optional? How are our gender transitions any different?




  1. How it looks elsewhere? Well, you’re denied transition if you are not “binary enough” anyway (which psychiatrist and sexuologist will (won’t) confirm, forced “gender neutral” name “in between” (the doctors’ words, not mine), at least two years of “appropriate gender presentation” (how does that look like? I don’t know.), no new name and birth certificate unless you are sterilized (incl. hysterectomy) and have top surgery / or sterilized and have bottom surgery, if you are woman. Oh, you’re not binary MTF or FTM? You don’t exist.
    And yes, people with mental diagnoses (def. schizophrenia and bipolar – fellow bipolar and borderline speaking here) are routinely refused hormones and dealt with in an incredibly discriminating and belittling manner, just like we are kids who cannot simply be trans and definitely cannot make any decisions.
    Sorry for ranting. Also, I’m speaking from relatively tolerant and “civilized” European Union country, if anyone wonders.

    – Jaden

    p.s. can you make it an option to comment without one of those 3 accounts? It’s quite limiting 😦

    Liked by 1 person

    1. Thanks so much for sharing this. I have heard variations on this SO MANY TIMES that I wonder how any of us who are non-normative in some way (I hate even phrasing it that way) ever get to move forward with our lives.

      I can’t really remove the restriction on needing an account, because when I do, trolls often flood the comments and it becomes unsafe for folks. :/ I can check again and see if there’s a happy medium, maybe a way to make it a little less limiting. But LQTU is on Facebook which is where a lot of people comment ( if that’s easier for you!


  2. Sam, I’m so sorry. I wish I knew what to say, I wish this wasn’t a reality for you, or for any of us. I hope your voice helps to make the changes that are so desperately need. Thank you so much for sharing your struggles, and I wish you the best sunshine. Take gentle care of yourself ^.^

    Liked by 1 person

    1. Sort of – I keep being told that they need to stop my period but no one is doing anything. It’s usually not advisable to have a period while taking testosterone, but apparently not inadvisable enough to actually help me stop it. I don’t know if that has to do with me being mentally ill or me just falling through the cracks again. -_-

      Liked by 1 person

      1. Ask for trenantone (I am not sure if this is right spelling…). But I’ve also problems with mental health and my doctor told me to think of testosterone again. And he also said when I am ready to take T, I should not stop taking trenantone. Ask your doctors about it.

        Liked by 1 person

      2. I’m not on testosterone (and have no plans to start, at least now) but what I do is taking birth control pill (which I don’t really need otherwise – the irony, right?) without the monthly breaks, I usually make one break every 3 months (and regret it immediately, as I don’t really deal well mentally with periods) but that’s more to save money, you can definitely go at least 5-6 months without break, depending on the brand and your personal hormonal balance. It’s not a perfect solution, but the only one available to me, until I persuade a doctor here / save up to travel elsewhere so I can get hysterectomy.

        And also, I just don’t talk to my gyn about either my mental issues or my identity, I just keep the doctors separate and try to get what I can. (which is sad, but the only way for trans folks with mental health issues /non-binary trans folks here, really, as most people learn the hard way.)

        Liked by 1 person

  3. I am an autistic and disabled trans woman. Despite the understated difficulties that come with even seeking help, I have been denied *all* kind of transitioning altogether. Some psychologists have said permanently “as I cannot be trans”. Social services simply ignored my requests and turned me down, or wanted me to dance around expensive psychologists following ridiculous criteria for years that I can’t afford, both monetary-wise and sanity-wise.
    No hormones, no social help (name, ID etc), nothing.

    When I started to pursue transition six years ago I went from a miserable experience to at my best health at first, hopeful for a bright future. I found myself leaving home frequently and able to take lots of classes, being happier about doing a lot of things and much more capable.
    But, as treatment was denied and I was shoved on more obstratizing bureoucratic loopholes and eventually stopped by gatekeeping, everything worsened and worsened. I quit absolutely wonderful things I enjoyed because I could not bear being denied transition. Unable to deal with the horrifying dysphoria at its most damaging and with every attempt for progress being stopped throrough the years… I eventually became bedbound, locked myself, and as the last opportunity I had closed its doors I simply tried suicide.

    This takes place everywhere. It needs to change.


    1. This. Is. TOTAL. BULLSHIT. My email inbox is already flooded with horror stories. So many neurodiverse people are being denied their bodily autonomy and their transitions. It’s an outrage and I don’t understand why access, particularly for neurodiverse folks, isn’t talked about more apart from the conversations we’re having on blogs and in forums.


  4. When he admonition, “Do no harm,” leads to decisions (always framed as for your own good) harmful, then another, more courageous path is needed. Sam, your transition battle is but one example, though a particularly acute one. People with mental illness are daily counseled not to try to do too much. “We don’t think you could handle school or work, so sit and stay disabled, and forget the life you thought once you might have.” Could it be that the resources are spread too thin to provide needed support? Lack of understand is likely – yes, more research is badly needed. I know, from reading you that they are missing the point that your transition is important to your mental health. Not trans myself, I can only try to listen and imagine what it must be to walk about in the world with a mismatched soul and body. I hope you soon find a way out of the labyrinth of misunderstanding.

    Liked by 1 person

  5. Great post, sad content. I mean, it makes me sad, that GP´s would prescribe all kinds of heavy-duty medications for mental health (rather than even considering natural and less drastic options), but they won´t consider an attempt at increasing the dose. Plenty of mental health medication that is prescribed in the matter of seconds have severe side effects (sometimes even increase in suicidal thoughts) and this is never given much thought.. It´s kafkaesque.

    I´m not entirely sure what it´s like here in the Netherlands. I am currently transitioning, but the model of transition is different than U.S: we go through mandatory talks with a psychiatrist and a psychiatric evaluation before we´re allowed to have hormones (or not). I expect my therapist to be pretty open minded but I guess I´ll just have to wait and find out.

    Also an afterthought on the term “mentally ill”. I´m not offended, so don´t worry about that. I just want to think about the term. Sometimes it sounds to me like 100% of the mind is ill because it´s such a general term. It leaves no room for the idea that there might be parts of your (and my) brain that are healthy.



    1. Thanks for sharing all of this! One thing about mentally ill is that we also call ourselves “sick” or “ill” when we are generally speaking about our wellness, even though we aren’t implying that every single facet of our bodies and minds are sick. I think it’s an issue with language overall and not specifically with the phrase “mentally ill” – though I can certainly say that there have been times where not a single fraction of my brain was well, which is valid, too. Lots to think about here!

      Liked by 1 person

  6. Reblogged this on androgendernaut and commented:
    Sam Dylan Finch writes about the difficulties of individuals who want to transition yet also suffer from mental health issues. To me, this seems like a reinforcement of the already existing tendency to treat transgender individuals in a rather patronizing way, assuming that they need protection from themselves.

    Naturally this consideration is in place. But seeing that NOT transitioning can further complicate mental health problems and depression, it seems that even the transgender person with mental health problems should have a right to try a higher dose of hormones with the possibility of going back on a lower dose.

    How much sense does it make, that psychiatrists would prescribe medications with severe side effects for mental health in a matter of seconds, but would not consider giving transgender individuals a chance to feel more like themselves?


  7. Being in a slightly comparable, but much less dire situation, I feel for you, Sam.
    I hope you know that many wish you a physical transition exactly according to your wishes.

    You say “there’s not a single doctor willing to increase it”:
    Have you tried finding a clinic that provides HRT on an “informed consent” basis?

    The PDF linked on lists no less than five clinics in San Francisco. has some different ones. There may be better lists. Now I’m not sure if that means they actually do work with informed consent (i.e. no ifs and buts), but I think it’s at least worth a try.

    I think you’re very much in your right to try a higher dose of testosterone. If it turns out to have a nasty interaction with your current condition, then you could always decide to dial back. You are the one to decide if the pretty obvious benefits are worth the risks involved, especially a possible increased for suicide. A quick search on FtM HRT and suicide turned up this:

    I have had definitive suicidal thoughts, but never made any concrete plans. Still, personally, I would reason that if I’d die because of HRT (with suicide the only obvious mechanism), that would just be my fate. I suppose I’d compare it to the risk of dying while traveling, whether it is by foot, bike, or car. I consider a lot of travel (except for vacations) to be non-optional. If I die because of it, so be it.

    Apparently, there are also surgeons who do top surgery on an informed consent basis. See for example . Per , it appears that at least some require you to go off certain medication, which may be a problem for you. Did the person denying you top surgery provide a rationale for why your depressive episode would be a problem? I wasn’t able to find anything on that quickly. I’d say your brain is at a safe distance from your chest. But then, I’m no doctor. 🙂

    You can read more about informed consent as it pertains to transgender healthcare at .


  8. Im an MTF’ Why would shizoprenia BE deemed as a right to even be more Descriminated, ARE People DUmb enough TO blame the person transitioning for their own mental problems ???’ DO they even Realize’ Some of those physological problems’ are on going because the person REquires A Huge Change in their life to recover themselves, That means, Gender recovery, New life, Anything to make them Feel good about themselves to get through the toughest disorders they Grew up’ due to the life that was forced on them

    Please remove this discrimination’ We cant afford people descriminating trans anymore’ when its already tough for us.

    Liked by 1 person

  9. I struggle with this as a cisgender therapist and social justice warrior. It’s why I opened a private practice, in addition to working at a very large university… So I could be more liberal with my policies for letter writing. WPATH Standards of Care determines international transgender health policies and they require mental health issues be “reasonably well-managed” for HRT and top surgery. It is open for interpretation and most agencies will err on the side of caution to avoid potential litigation (with no evidence this would put their practice at risk). I try to work with psychiatrists, support groups, and with therapy to establish enough stability to move forward with the treatment of choice. I’m new to the independent counseling field, but I already know of at least one center here in Florida who provide gender-related letters and HRT to those who’ve been turned away elsewhere. Search for therapists using the Informed Consent Model. Maybe you’ll find a diamond in the rough who’s able to work with you to meet criteria AND they have an HRT provider willing to stretch their comfort zone with the right team. My heart is with you and everyone who gets shafted because of their neurodiversity or mental health issues… Or size… Or addiction… Or financial ability… Or fear of familial rejection… ❤

    Liked by 1 person

  10. I think it’s really weird that this happened at all in San Francisco. I live in conservative Central Florida, and my mental health has been very, very, much less than perfect, and I still got on T in a sinch. It might just be because I have a very good therapist, who helps me more than anyone to access treatment.


    1. The clinicians you have make such a tremendous difference in access to care. 😦 Once I had better clinicians, it was such a different story! I’m so grateful that you have a really good therapist — I wish everyone did!


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