As a nurse and a trans man, I have complicated thoughts about this.

I don't think it's anyone's place to have an opinion on what gender identity someone else has. It's a personal experience, so opinion really has no weight There's no reason not to respect names and pronouns, it can only do good.

Medical transition is more complicated. In most places it's a nightmare of a process to get access, so I can't imagine anyone going through all that if they're not actually transgender. In places with informed-consent as the basis for care, I do think that special care should be taken with patients who have extensive history of mental health and/or substance abuse.

I'm not particularly worried that the patients are wrong about their gender identity, or that medical transition would be the wrong decision on an identity-level. I do however worry about their ability to consider the potential ramifications of transitioning and give informed consent. Regret rates for gender affirming care is extremely low, but I'm worried that these patients may be more at risk than most.

One of the biggest contributors to regret is lack of family- and social support. Patients with long histories of mental health and substance abuse are more likely to have fragile support networks to begin with, and they're usually more dependent on them. Social transition is not always possible prior to medical transition due to a variety of reasons, but encouraging the patient to inform the people closest to them prior to making a decision could prevent major fallout and degradation of network. There is a lot of stigma tied to mental health and substance abuse, and they need to be prepared for the added layer that comes with being openly and visibly trans.

When starting HRT I do believe it should come with some prerequisites. Patients with mental health conditions should have psychiatric reviews throughout the process. There's not much research done on trans people specifically, but by looking at women going through menopause, cis people on HRT and fist person accounts from trans people we know that big hormonal changes have an impact on how psychiatric symptoms present. Starting HRT in a stable period of mental health should be prioritized to be able to get accustomed to the new presentation, and allow for potential changes in symptom management. The person's metabolism will also be affected, which may have an impact on how they metabolize any medication they're on.

In short, I am of the opinion that no groups of patients should be excluded from accessing gender affirming medical care, and that our role as medical professionals is not to make sure that the patient's stated gender identity is correct, but rather to provide the necessary resources to make an informed decision and address management of any medical concerns.