In Quest of An Authentic Identity – An Exploratory Study of Mental Health Assessment of Gender Incongruence in Urban India

In Quest of An Authentic Identity – An Exploratory Study of Mental Health Assessment of Gender Incongruence in Urban India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article In Quest of An Authentic Identity – An Exploratory Study of Mental Health Assessment of Gender Incongruence in Urban India Ketki Ranade, Mohan Raju Shankarappa, Neeraj Kumar, Aryan Somaiya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5613392/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Apr, 2025 Read the published version in BMC Psychiatry → Version 1 posted 10 You are reading this latest preprint version Abstract Last decade in India has seen increasing visibility and dialogue on trans health including gender affirmation interventions. This has been enabled by growing mobilisation and assertion from trans communities and a range of legal and policy changes supporting trans inclusion. In this paper, we focus on mental health assessment of gender dysphoria/ incongruence that is the first and an essential step for a transgender person in the Indian context to be able to access medical and surgical gender affirmation interventions. We discuss findings of a mixed-method, exploratory study conducted with 165 mental health professionals in three cities of India. In this paper we primarily present qualitative data on mental health professionals’ understanding of gender incongruence, their practice of assessment, rationale for the same and ways in which they end up gatekeeping access to medical and surgical gender affirmative interventions. Concepts such as biological determinism of gender, trans normativity, pathologisation of trans and gender diversity, mental stability and capacity are used to critically discuss findings. Gender Dysphoria Gender Incongruence GID Certificate Mental Health Assessment Trans and Gender Diverse (TGD) persons Background The last decade has seen a range of legal and policy changes pertaining to the lives of transgender persons in India; starting from recognition of transgender persons as equal citizens by the Supreme Court of India (NALSA v/s Union of India, 2014), decriminalisation of LGBT persons (Navtej Singh Johar v/s Union of India, 2018) and passing of a law - Transgender Persons (Protection of Rights) Act, 2019 by the Indian Parliament. These legal changes have provided impetus to several policy actions and welfare measures promoting rights of transgender persons. On the backdrop of this legal-policy environment, transgender health, particularly gender affirmative interventions have received significant attention. Several healthcare professional bodies and NGOs have proposed guidelines and manuals on gender affirmation care for trans persons[1] . Systematic and scoping reviews of literature on LGBT health in India has indicated heightened mental health burden, stigma and stressors among transgender persons and barriers to care such as experiences of discrimination in healthcare settings (Chakrapani et al. 2023; Pandya & Redcay, 2020; Saraff et al. 2022; Wandrekar & Nigudkar, 2020). Other studies on trans health have highlighted use of conversion treatments that seek to cure transgender persons’ gender identity (APTN, 2021) and gate keeping by Mental Health Professionals (MHPs) while providing referrals for gender affirmative interventions (Chakrapani et al. 2024; Raghuram, 2024). A study conducted among 452 medical students and practicing doctors in Kerala (a southern state in India) indicated low levels of awareness on transgender health including gender affirmative interventions and moderate levels of transphobia particularly among male doctors (Fenn et al., 2023). While several of these studies have focussed on health and mental health care needs, healthcare experiences of transgender persons and awareness among medical professionals about trans health, none of these specifically focus on the process of mental health assessment that is currently mandatory for Trans and Gender Diverse (TGD) persons to access gender affirmative interventions in India nor do they focus on the mental health professional (MHP) and their attitude and practice. Hence, the current study with its focus on mental health professionals’ (MHPs) knowledge, attitudes and practice with their TGD clients is significant. Our study examined how MHPs conceptualize gender incongruence and gender diversity, as well as their approach to working with TGD clients. In this paper we specifically focus on the assessment process followed by MHPs for diagnosing gender dysphoria/ incongruence (GD/GI) and providing referral for medical and surgical gender affirmation. According to the World Professional Association of Transgender Health (WPATH) Standards of Care – 8 (SOC-8), a formal diagnosis of GD/GI is not essential for TGD persons to access medical or surgical gender affirmation interventions nor is it a requirement that the assessment for gender incongruence be carried out by an MHP. However, in practice, in India, a MHP evaluation and certification of GI/ GD always precedes medical or surgical gender affirmative interventions. Recently, the Ministry of Health and Family Welfare, Government of India (2024) issued, ‘Standard Operating Procedure (SOP) for Medical Treatment of Transgender Persons’ that require a certificate of GI from one psychiatrist for hormonal interventions and by one psychiatrist and one clinical psychologist/ psychiatrist for surgical interventions. This document has been criticised for having been developed without any consultative process with TGD communities or experts working on TGD health and also as it contradicts Section 15 of the Transgender Persons (Protection of Rights) Act, 2019 that recommends use of WPATH guidelines to develop a Manual on TGD Health for India[2] . Methodology This is a multi-site research, employing a mixed-method, exploratory design. As literature on MHPs’ knowledge, competence, attitudes and practice with their TGD clients in the Indian context is near-absent, this is a formative, exploratory research study. The study was conducted in three metropolitan cities of India – Mumbai, Delhi and Bangalore. The selection of these three metropolitan cities was driven by availability and willingness of experienced researchers. The principal investigator and three co-investigators, themselves belonging to gender and sexually diverse groups, brought valuable lived experiences and insights to the study. Historically, research on queer-trans issues has been done by ‘outside-expert’. In our study we turned the gaze on to experts who treat TGD individuals. The investigators were supported by three research associates, one in each city, to ensure robust data collection and contextual understanding across the metropolitan sites. A non-probability, purposive sampling was used in the present study. A total of 165 MHPs currently practicing in the cities of Mumbai, Bangalore and Delhi were interviewed, using a researcher - administered quantitative interview schedule. 45 of these practitioners also responded to a qualitative in-depth interview. In this paper we present predominantly qualitative data. The three inclusion criteria for the study were - i) a postgraduate degree/ diploma in either Psychiatry, Psychology, Counselling, or Medical and Psychiatric Social Work and/ or an MPhil in Clinical Psychology or Psychiatric Social Work; ii) a minimum practice duration of one year; and iii), the MHP should have seen a minimum of three TGD clients in the course of their practice. In addition to the inclusion criteria, we tried to ensure diversity of sampling by approaching MHPs practicing in different settings, including public and private hospitals, clinics, Non-governmental/ civil society organisations (NGOs/ CSOs), home-based, online practice, and so on. Practitioners who had seen a relatively higher number of TGD clients, and/ or were actively working on TGD issues within their professional associations or in collaboration with NGOs/ CSOs were approached for participating in the qualitative in-depth interview. Ethics clearance for this study was obtained through the Institutional Review Board of the Tata Institute of Social Sciences, Mumbai.[3] A content validation of the tools used in the study was done through experts in TGD mental health, in research methodology, and lived experience experts. A total of six mental health and research experts, along with five community members who self-identified as TGD and had experience of accessing mental health care responded to the relevance, adequacy, feasibility, clarity and organisation of the tools. Tool revision was done in accordance with this expert feedback. All participant data was coded to anonymize participant details, ensuring confidentiality throughout the study. Table 1 Profile of the Research Participants Total number of participants (N = 165) n % City Mumbai 54 32.7 Bangalore 67 40.6 Delhi 44 26.7 Educational Background* [highest degree received] MD/ DPM Psychiatry 49 29.7 MA/ MSc Psychology 61 37.0 MPhil Clinical Psychology 27 16.4 MPhil Psychiatric Social Work 9 5.5 MA in Social Work (MSW) 6 3.6 PG Diploma Counselling/ Counselling Courses 13 7.9 Gender Identity Cis Woman 105 63.6 Cis Man 51 30.9 Transgender/ NB/ Genderqueer 8 4.8 Agender 1 0.6 Age Range 20–30 49 29.7 31–40 48 29.1 41–50 36 21.8 51–60 20 12.1 Above 60 12 7.3 Mean Age: 39.63 years Duration of Practice 1–3 Years 21 12.7 3.1–5 Years 24 14.5 5.1–10 Years 42 25.5 10.1–20 Years 41 24.8 20.1–30 Years 23 13.9 Above 30 Years 14 8.5 Mean Duration of Practice: 12.9 years Practice Settings of Participants** Public Hospital (Teaching & Non-Teaching) 39 23.6 Private Hospital (Teaching & Non-Teaching) 27 16.3 Home-Based 65 39.4 Clinic-Based 54 32.7 Online 41 24.8 NGO 10 6.06 Number of TGD Clients seen in past 1 year Up to 10 Clients 113 68.5 11–30 Clients 36 21.8 More Than 50 Clients 10 6.06 * MD/ DPM, MA/MSc refer to postgraduate degrees in psychiatry and psychology/ social work respectively; MPhil is a 2-year long hospital based clinically focused advanced course undertaken after a postgraduate degree in psychology or social work. ** Total is greater than N = 165 as there are multiple responses across categories As seen in Table 1 , of the 165 participants, 54 were from Mumbai, 44 from Delhi, and 67 from Bangalore. For the qualitative interviews, of these 165 participants, 15 participants were recruited in each of the study sites, making for a total of 45 qualitative interviews. The participants’ ages ranged from 24 to 76 years, with the mean age for the study sample being 39 years. The range for years of practice experience was a minimum of 1 year to a maximum of 45 years, with the mean practice experience for the sample being 12.9 years. There were a total of 105 cis women, 51 cis men, 8 participants who self-identified as transgender/ non-binary/ genderqueer and 1 participant who self-identified as agender. In terms of educational background, there were 49 psychiatrists, 61 psychologists, 27 clinical psychologists, 9 psychiatric social workers, 6 social workers and 13 working as counsellors. Most participants (n = 113) had seen up to 10 TGD clients over the past one year, while a few (n = 36) had seen between 11 to 30 TGD clients, and fewer still (n = 10) had seen more than 50 TGD clients in last one year. Data was collected between June 2022 to March 2023. Main Findings a) The GID Certificate Of the 165 study participants, 78 practitioners i.e., 47% of the participants reported being approached by TGD clients for assessment and to get referral letters for gender transition services[4]. While majority of the study participants used the terms gender dysphoria and gender identity disorder interchangeably, majority of them referred to the letter of support for medical or surgical transition as ‘certificate of GID’ . Use of the language of certification by the MHPs suggests that they perceive their role to be that of experts who apply their scientific knowledge to decide who qualifies for the GID certificate and subsequently to access gender affirmative interventions. Chakrapani et al. (2024) in their study with transmasculine persons report use of the phrases ‘approval process for transition related care’ and ‘passing the assessment’ by their transmasculine study participants to refer to the mental health assessment they underwent before accessing gender transition services. Use of these phrases suggest that the trans persons view the mental health assessment as a test, an examination that they must pass to access medical or surgical transition. In this paper we reflect on MHPs perceptions and attitudes not just towards normative and diverse genders and their self-perceived role in assessment of the same but also their views about mental illness, capacity and competence, soundness of judgement or lack thereof. b) Looking for the ‘Authentic’ Trans Person MHPs quest for the real/ authentic transgender person led them to several areas of inquiry that lay outside the conventional psychiatric assessment aimed at diagnosing presence or absence of mental illness and the question of whether gender dysphoria is independent of or secondary to/ a symptom of an underlying mental disorder. MHPs in this study sought to ascertain level of certainty that the TGD client felt about their gender and plans for transition, their motivation for the same; they sought to ascertain the anatomical sex of their TGD clients, their intelligence quotient, stability of their personality, their knowledge of ‘cross-dressing’ and ability to pass in their self-identified gender and several such factors before providing ‘the certificate’. Literature on transgender gender identities within the psy disciplines is replete with pathological and medicalized ideas such as primary and secondary transsexualism or true and false transgender referring to gender non-conformity that is innate v/s that which is acquired (Roean, 2011). Another such dichotomy is that of desisters and persisters i.e. those gender non-conforming children who desist from gender non-conformity as they mature v/s those who persist in their gender non-conformity even after puberty (Roean, 2011). Then there is the description of sexual motivation behind gender diverse expressions, for instance, Autogynephilia, a term coined by Ray Blanchard in the late 1980s to refer to a type of heterosexual man, who, typically around puberty, begins to experience cross-gender arousal in response to imagining himself as a woman. This cross-gender arousal according to Blanchard was a form of paraphilia that eventually became the primary factor driving these individuals to transition physically, to female. Another type of transsexual that Blanchard described was the “homosexual transsexual”, who was feminine from a very early age and was, as an adult, attracted exclusively to men. Transsexual women belonging to this latter group were thought to be a type of feminine gay man who ultimately transitions to female in order to attract heterosexual men. Blanchard viewed all transsexual women as being sexually motivated in seeking gender transition and in so doing essentially invalidated the trans experience through sexualisation of trans women (Serano, 2016). These classifications of trans persons within psy literature implies that experts in trans healthcare need to be equipped with adequate competence and investigative tools to identify the authentic ‘transgender’. In addition to pathologizing classificatory frameworks, developmental-psychological discourses too offer a limited subject position to trans persons. Development psychology literature conceptualises gender (as with all human development) along a pre-determined, linear course that follows specific stages or milestones. In doing so it offers a restrictive pathway of development for transgender persons that follows a script such as early and persistent signs of gender dysphoria displayed through discomfort and disgust with one’s anatomy, struggle with gendered clothing, grooming, toys, play of one’s assigned gender and later sexual attraction to gender considered opposite to one’s birth assigned sex-gender. Thus, development psychology offers a guiding map along which a transgender identity that is innately present is expected to unveil (Rosqvist et al., 2014). Mental health professionals when encountered with the narrative of a TGD person in the clinic and taking on an expert position certifying the authenticity of their transness tap into these classificatory, pathologizing and restrictive frames available within the psy disciplines to decide on whether to provide the certificate. Among our study participants, we find both these impulses, one a pathological lens to view TGD persons and another a culturally rooted, normative lens of gender as binary, fixed, naturalized and biologized. In keeping with this view of gender, MHPs expect their trans clients to neatly fit into gender roles and expression of their gender of identification and thereby create newer standards of trans normativity to which their TGD clients must adhere in order to qualify for access to transition services. Dewey et al. (2017) observe that in order to access medical and surgical interventions trans people have to subject themselves to a complex mental health assessment and diagnostic process in which fitting into a culturally, medically and subsequently legally defined gender norm qualifies them to be the authentic trans person. The following narratives of MHPs describing their assessment process for GD/ GI illustrate this point. Table 2 MHP narratives of Assessment Process for giving a Gender/ GID Certificate Ascertain Stability, Certainty and Normative Gender Presentation “We're really clear that if there is even a slightest doubt, if you're not absolutely certain, then I will send to somebody else for another opinion. Because I'm not going to certify something unless I'm clear and convinced that the guy knows what he's doing.” (62 year old cis man, Psychiatrist, Mumbai) “When you come to the hospital I should see a woman. In fact we tell them to cross dress because if the male is there and he wants to become a woman, you start staying like a woman and come to the hospital like a female we should see a female not male”. (60 year old cis man, Psychiatrist, Mumbai) “So many patients come to us without cross dressing. So then we asked them ki please aap minimum six months ke liye toh cross-dressing karke hi ayiye fir hi hum aage ka procedure karenge... [please cross dress for a minimum of six months and only after that we can consider further procedure] Secondly, we guide them about the cross dressing. Thoda barabar se kar sakte hai [they can do it properly] like for male to female, to use proper padded bras, female to male then use proper binders and all which they are not aware and that is creating a lot of problem. They say nehi hum toh kabhi loose shirt pehen ke gaye [they say we manage by wearing a lose shirt] then see that is problem no, so then we have to explain to them. So, you properly cross dress many of the male to female will not have long hair. So then we had to explain that aapko thora baal lambe rakhne zaroori hai [you have to grow your hair long] so that that acceptance comes like a female… that kind of thing. And dressing has to be a bit changed”. (35 year old cis man, Psychiatrist, Mumbai) Ascertain motivation for gender transition “I have read so many reports, maybe in Kerala or Tamil Nadu [two states in Southern India], two women working together have developed liking to each other. And then they became so very close. People started telling them that you're so close, as though you are a couple you know… then one of the girl said why don't you change your gender and then we'll get married... So assess whether they are doing it for themselves or are they doing it for others? How convinced they are about it, and why are they convinced. They need not convince me but I must be convinced that he is sure of himself. Because then later, he should not regret it… gender is something which is you know, very obvious to people, so you can't keep changing it again”. (55 year old cis woman, Psychiatric Social Worker, Delhi) “One case, very strange actually, someone said it's very easy to earn money if you get a sex change because you can trade sex for money… so you know this was a young male who was not working you know and I have seen this patient for a long time like two to three years and gender was never an issue and never came up but then three to four psychiatrists called me and told that he had gone to them for GID certification. So I am not sure what was the motivation behind requesting sex change”. [44 year old cis woman, Psychiatrist, Bangalore] Ascertain Natal Sex – physical/ genital examination “When you get the certificate you have to take signature of the patient or take his thumb impression, check their genitals, some feel uncomfortable, we don't give them a certificate”. (47 year old cis man, Psychiatrist, Delhi) “The doctor will ask them okay, are you comfortable with male doctor or female doctor?, so if it’s a male and he wants to get converted to female and he says I'm comfortable with male doctor so male doctor will examine and he will examine the genitals and write it down that I have examined he has normal, masculine characteristics. In female to male, the female would write… female examined, note down if she has breasts, and she has normal female genitals... See, one of you come to me and you say I'm a female. You look like a male? But you say no, no, I'm a female. So, I accept what you are saying, but I have to write on the paper and on what basis I have accepted you as a female. So from outside you look like a male, but if you are saying female, if you give permission I examine and I say I have examined the patient and actually she's a female” (60 year old cis man, Psychiatrist, Mumbai) Ascertain familial approval and consent “A young woman (trans man based on context of the interview), a 19-year-old – may or may not be an adult coz family members are still guardians for a young woman in India. So, I would ask for a parental letter of consent before giving a certificate”. (44 year old cis man, Psychiatrist, Mumbai) "...if somebody is 18 (years old), he or she does not need the consent of the family, but somebody is married, so they cannot undergo gender change without either getting a divorce, or their partner has to give an affidavit in the court with their agreement. And you have to sign a paper saying they're okay with that, that the person is going to change.” (47 year old cis man, Psychiatrist, Delhi) As can be seen in the narratives above, MHPs in this study engaged in what Meadow (2010) referred to as ‘projects of excavation’ (p. 823) in their search for the authentic trans person, who could qualify for gender transition. These narratives suggest that MHPs, based on their cultural as well as medical understanding of sex-gender as biologically determined, interchangeable or rather one flowing from the other wanted to check/ confirm the genital sex of their TGD clients through performing a physical examination. Similarly, MHPs with their normative understanding of gender as binary expected their TGD clients to fit perfectly and even pass in their gender of identification. Some expected their TGD clients to have lived in their gender of identification before issuing the gender certificate, a condition (real life experience) that is no longer required to be met as per global standards of trans care (Coleman et al., 2022). Some MHPs held culturally rooted patriarchal beliefs about natal families’ control over what are seen as their ‘female born children’ as being more significant than the young TGD person’s autonomy and right to self-determination. Similarly, the culturally rooted idea of marriage as a sacrosanct institution that needs to be held in higher regard than individual wishes or aspirations of a TGD spouse is reflected in the narrative where the MHP asks the TGD client to get spousal letter of consent or divorce before providing a ‘certificate of GID/ GD’ when in fact marital status of a person has no bearing on the gender identity of the individual. The idea of assessing correct motivation for seeking gender transition too undermines the TGD person’s self-knowledge and autonomy over their body. These narratives suggest that MHPs go well beyond the scope of gender assessment and seek to purportedly mitigate and in effect regulate what they perceive to be social consequences of gender transition of their TGD client; in doing so MHPs often end up gatekeeping access to medical and surgical transition. c) Use of Psychometric Tests in GID Certification Majority of the study participants used standardized psychological tests in addition to a clinical interview before deciding on whether to give a ‘certificate of GID’ to their TGD clients. It’s important here to note that established global standards for assessment of GD/ GI do not require use of psychometric tests. Moreover, the tests used by our study participants were not measures of GD/GI. Participants reported using projective tests (n = 32), personality tests (n = 24), intelligence and other cognitive tests (n = 12), screening tools for psychopathology (n = 8), a sex role inventory (n = 1) and a blood test (n = 1) as part of assessment before recommending their TGD clients for transition-related services. Table 3 Types of Psychometric Tests Used in Assessment for Gender/ GID Certificate Type of Psychometric Test Frequency Projective Tests 32 Rorschach Test 26 Thematic Apperception Test 5 Sentence Completion Test 1 Personality Tests 24 Millon Clinical Multiaxial Inventory (MCMI) 12 Minnesota Multiphasic Personality Inventory (MMPI) 10 16 PF 2 IQ Tests 12 Binet Kamat Test of Intelligence (BKT) 3 Wechsler Adult Intelligence Scale (WAIS) 2 Wechsler Adult Performance Intelligence Scale (WAPIS) 1 Standard or Raven’s Progressive Matrices (SPM/RPM) 3 Raven’s Coloured Progressive Matrices (CPM) 1 IQ Test Not Named 2 Screening Tests for Mental Illnesses 8 Beck Depression Inventory 3 Beck Anxiety Inventory 2 Yale Brown Obsessive Compulsive Scale (Y-BOCS) 1 Hamilton Depression Rating Scale (HAM-D) 1 General Health Questionnaire (GHQ) 1 Sex Role Inventory 1 Total Nos. of Tests 77 Table 4 Duration of Assessment No. of sessions for GD/ GI Assessment No. of study participants 3 or 6 sessions 16 No Response 2 Total 78 Practitioners reported variously on the duration of assessment for providing a certificate. Of the 78 who provided such letters, 36 reported needing under 3 sessions, 24 reported 4–6 sessions and 16 reported more than 6 sessions in order to provide referral letters for hormonal and or surgical interventions. Two practitioners did not provide a number. The fees charged by practitioners ranged from INR 500 to 2500 per session implying a high cost for mental health assessment. The rationale for use of psychometric tests varied among the participants. The most obvious was to rule out the possibility of gender dysphoria being symptom of/ secondary to an underlying mental illness or to screen for co-morbid mental health conditions and to ascertain that these did not diminish capacity of the person to comprehend their diagnosis of GD/ GI and the treatment options on offer. However, the study participants also stated that psychometric tests were their way of ensuring that the TGD person was indeed a good fit for the irreversible medical and surgical transition that would follow and that they would not later regret their decision to transition. Yet others stated that in the absence of state-notified clinical protocols for mental health assessment to determine “fitness” for gender affirmation therapy, standardised psychological test reports would appear more unbiased and reliable and provide the MHP medico-legal protection in the event of a legal scrutiny – a likelihood that increased several folds in the face of hostile and unsympathetic families of their TGD patients. Thus, the MHPs anxiety about possible regret on part of the TGD person or a probable legal action against them from family members of the TGD person seemed to guide the extreme caution in assessment and leading to gatekeeping of access to gender affirmative interventions. Table 5 Rationale for using Psychometric Tests Ascertain Capacity and Intelligence “Is it really his or her gender? Or is it something that the person is saying under a particular delusion that I have become a transgender, it has happened, it happens to a lot of people. Someone who in the state of active psychosis thinks that they have become a eunuch, or they are changing they are metamorphosizing themselves, their body's changing into that of a eunuch, it's a very common theme. Not unheard of… So, that is one entity that we are careful about. So immediately certification is not done there, the treatment has to be done first, and maybe later, the call can be taken”. (31 year old cis man, Psychiatrist, Mumbai) “First of all, you want to check out and see whether the guy is, if he’s got normal intelligence, that's very important. So he should have cognition, and he should have an understanding of what he's doing. So if you have somebody who's intellectually, not up to the level, then we certainly would not certify because we would believe that he doesn't know the consequences of this behavior. Then you do personality tests. See these tests are not mandatory, I prefer to do them. Because I'd like to be very clear.” (62 year old cis man, Psychiatrist, Mumbai) Looking for gender dysphoria/ incongruence in psychometric tests “Once clinically we are convinced that yes he is having GID then we refer him to psychological testing. So, Rorschach, MMPI is done. If required sentence completion test is done. There are some confusional states and I am not able to see the GID in Rorschach, MMPI… usually it is seen in MMPI but if not then in such dicey situations we have to undergo the sentence completion test also to see what kind of words she uses in sentence completion, what is the preference and use of pronouns and all…” (35 year old cis man, Psychiatrist, Mumbai) Medico-legal Concerns & Institutional Barriers “To be honest, many times I have felt like I am just doing the whole set of tests because I am supposed to do it, because the protocol of the place that I am working at says so and because it is a package [of GD assessment]. Like I said earlier, I genuinely don't think that any projective or personality tests are required.” (34 year old cis woman, Clinical Psychologist, Bangalore) “The problem is about the legalities around it. One is always unsure whether one is dealing in the right way from a legal perspective. For example, if we are following mainly WPATH suggestions, the IPATH (Indian Professional Association of Trans Health) one that has come out doesn't seem to be very different. So, one is essentially following some professional advice whose legal position in the country is not very clear. One hopes that this is something that the court will accept but one doesn't really know what happens. One feels a little anxious because it is quite possible that sooner or later a family member may put up a case if they are not satisfied. The risk is there and that’s why we are a little anxious about the legalities. Because the treatment process is not well-established right now. All of us are doing it at an individual level”. (57 year old cis man, Psychiatrist, Delhi) As seen in Tables above ( 2 , 3 , 4 & 5 ), TGD clients needed to jump through several hoops of normativity before they could be considered eligible for gender transition services. They needed to aspire to be the perfect man or woman with the correct amount of masculinity or femininity and exude appropriate form of mental stability and cognitive capacity while also exhibiting persistent distress and dysphoria with their birth assigned sex-gender. Being a fully functional adult in terms of adequate personal, social and occupational functioning, desiring gender transition, having gathered relevant information about gender affirmation therapies and voluntarily seeking the same was not enough for MHPs to consider making a referral for medical or surgical interventions. Given the long history of pathologization of trans identities as mental illness and continued presence of gender dysphoria as a diagnostic category in the DSM V, TGD clients’ mental competence will remain suspect and in need of investigation and proof when in contrast cis gender clients can seek the same set of medical or surgical interventions for medical or cosmetic purposes by merely giving informed consent and without having to undergo a psychological evaluation. Dewey et al. (2023) point to the irony in the process of assessment, “The process requires trans people to delicately balance appearing stable enough to make competent decisions yet unstable enough to ‘be at the precipice’ of losing everything which seemingly translates to one’s seriousness and realness of gender identity” (p. 20). With gender incongruence no longer classified as a mental or behavioral disorder in the ICD-11 (WHO, 2022), whether MHPs would be able to trust self-report by TGD persons and grant them the epistemic authority over their own experience of their gender (Ashley, 2019) and whether attitudinal as well as medico-legal and institutional barriers will be cast away needs to be seen. The recent SOP for medical treatment of Transgender persons issued by the Ministry of Health and Family Welfare (MoHFW, 2024) crushes the hope for the possibility of a self-determined, informed consent model for treatment of gender incongruence in the near future. This SOP endorses an expert/ MHP - driven assessment process, continues the use of language of certification and strengthens the binary, transnormative ideal by prescribing a linear process of gender transition starting with a psychiatric certificate of GI followed by hormonal treatment for a minimum of one year and then two certificates from psychiatrists and one from an endocrinologist before accessing surgical intervention. Thus currently, a non-binary trans person or any TGD person not seeking to follow all the linear steps of transition mentioned in the protocol are excluded from gender affirmative interventions by design. We wish to highlight two more issues pertaining to psychometric testing with TGD clients. First, norms for interpreting test results for all of the above tests are developed on cis gender persons and communities and results or scores of TGD persons are interpreted in light of these norms which poses a problem. A study by Karia et al. (2019) conducted in a public hospital in Mumbai city showed that patients with GID falsely scored high on Paranoia, Schizophrenia and Psychopathic deviate measures on MMPI. Authors state that these high scores were not corroborated on clinical examination with no evidence of psychosis and the higher paranoia was in fact reality based and was linked to experiences of ridicule, stigma and a sense of mistrust and cautiousness while engaging with medical professionals. The following quote of a psychiatrist in our study explains this finding well. A psychiatrist commented that the elevations seen in psychopathology scales like the MMPI[5] and MCMI[6] could be looked at as trans-specific coping strategies in the context of prevailing stigma and discrimination. I have stopped looking for anything in the MCMI profile because, you know, I read up not too long ago that even [with] the psycho-diagnostic tests like MCMI or MMPI, the results are very different pre-transition and post-transition and that was quite surprising, because these are not really state- dependent tests. They are supposed to be consistent over a period of time. A lot of parameters that come elevated and may [seem] pathological in the reports are actually ways of coping with the scenario of gender incongruence. The paranoia, for example – we usually see paranoid scales a little bit high. We see the depressive or dysthymic scales a little bit high. And these are very obviously results of the way a person is coping with their environment. [38 year old cis man, Psychiatrist, Mumbai] It is important to note that despite these research findings (of Karia et. al. 2019) having been published in the official publication of the Indian Psychiatric Society, MHPs in the three cities where we collected data in the year 2023 continued to use personality tests and other psychometric assessments as part of their GD/ GI assessments. In the absence of clinical rationale and presence of contrary evidence, continuing to waste TGD client’s resources of time and money is a serious case of harmful practice, especially given the evidence that costs of gender affirmation interventions are a major stressor and a barrier to care for TGD persons in India (Chakrapani et al. 2024; Srinivasan & Chandrasekaran, 2020). Interestingly a few practitioners pointed out that if someone from the Hijra community[7] comes to their clinic for getting the certificate they are more likely to refer them directly to the surgical department and not subject them to the extensive scrutiny that trans identified clients undergo. One way to understand this is that most hijra persons have left their natal families and are living within the hijra kinship-community system (locally known as gharana system ) and therefore are socially and culturally recognised as such. They are already marked as living outside normative familial-social structures. Thus, when a socio-cultural test has been passed the need to subject them to stringent psy tests and proof can be bypassed. Moreover, a hijra person seeking gender transition is unlikely to be seen as seeking to re-enter normative gendered social systems of marriage-family and hence the necessity to regulate this figure is not as high. One or two people who have come for surgeries have been Hijras, who see themselves as Hijra, so they have come for surgeries. Then we sent them to surgery directly. They had already gone through a certain portion so we directly sent them. (57 year old cis man, Psychiatrist, Delhi) …majority of them ran away from their homes and started staying with this community. And after that actually they're living life with them, but the only part what is remaining is that they still have male genitals. So we send them to the plastic surgery department. We do make a paper of gender identity disorder for them as well. (60 year old cis man, Psychiatrist, Mumbai) Raghuram (2024) argues that there is a historical familiarity with the Hijra figure as a third gender in the Indian context and it is this cultural intelligibility that shapes a different norm for the third gender among healthcare providers as well as policy and law makers in India. He explains that the project of reinforcing gender binormativity among TGD persons by medical professionals as well as by TGD persons themselves who aspire to fit into the gender binary system co-exists in the Indian context with a gender trinormativity ascribed to indigenous identities such as Hijra, Kinnar and so on. d) Nature of Relationship between TGD Clients and MHPs The current model of mental health assessment to provide a gender certificate sets up the client-provider relationship to be of an examiner-examinee wherein the examiner has to evaluate, scrutinize, investigate, monitor and the examinee has to submit, confirm, provide correct, rehearsed and possibly fake responses to pass the exam. Several of our study participants lamented that often their relationship with their TGD clients was a transactional or instrumental one and not a meaningful, genuine, therapeutic one. This is reflected in some of the responses below: “They see the role of a psychiatrist as limited to the certification process. Because certification process is there, they may look into us or they may contact us, if the certification role is not there, they will not approach us”. (30 year old cis man, Psychiatrist, Bangalore) I see that a lot of them think of this as a formality. And genuine help is not welcomed by most people that I've seen so far. They in fact are angry or upset when we inform them of not having the fitness to undergo surgery, whether it is because of depressive symptoms, anxious personality, or if it is because of a lot of confusion, no clear orientation presented on whatever testing we've done. None of that is taken in the spirit of actual help, but it is rather looked at as a roadblock as a frustration… they don't welcome this as help, you know, so this is looked at more as something to tick off. And when it's not really being ticked off the list, it results in anger rather than self-care and taking the advice seriously, or even taking medical help… (29 year old cis woman, Clinical Psychologist, Bangalore) …majority of the time, they will not say that they have other psychiatric disorder, because then that will come in the way of their certification. so they say ‘ki haan humein thora chinta hai’ (yes, I am a bit worried) but that is a normal about whether he will be accepted or not accepted (60 year old cis man, Psychiatrist, Mumbai) MHPs in this study discussed their frustration at being unable to meaningfully support their TGD clients or treat psychiatric morbidities that they may be suffering from due to a trust deficit from the client’s side. Chakrapani et al. (2024) reported the other side of the story from the perspective of trans masculine persons whom they studied. Their study participants reported that they experienced the psychiatrist or psychologist as being “in charge” of their access to transition-related care and were intimidated by the amount of power that psychiatrists had over their access to transition care. In response, transmasculine community members were cautious about revealing any doubts or mental health challenges they were facing, as they worried that the doctor might refuse to provide a letter. Thus, in the absence of genuine trust and safety, conditions essential for formation of a therapeutic alliance, genuine mental health concerns of TGD persons may remain invisible to the MHP despite multiple assessment sessions and use of psychometric tests. To quote one of the participants in the study by Chakrapani et al., 2024 - “My friends told me that whatever the doctor asks, speak positively: if you feel disturbed or, negative, or uncomfortable, the doctor will cancel your GID [diagnosis/certificate] …” (p. 14). Conclusion Trans communities in India are increasingly mobilising to assert their rights and as the Indian state and judiciary seeks to accommodate them as citizens, protocols in law and medicine are being formulated to regulate these non-cis gender bodies. These protocols of gender affirmative technologies seek to craft trans normativity through reproduction of cis-binary-gender norms (Achuthan, 2021). As seen in this paper, MHPs deploy psy language and technologies to justify their gender assessment methods when in reality they are gatekeeping and reproducing socio-cultural cis-binary gender norms. Shuster (2021) in their book ‘Trans Medicine – the emergence and practice of treating gender’, states that medical authority is consolidated by evidence, expertise and experience. However, when evidence and expertise is sparse as is the case with the emerging area of trans medicine in India, uncertainty is higher. Healthcare providers in such situations, as can be seen among the current study participants leverage scientific language and tools of assessment such as psychometric tests to bolster medical authority and in doing so ‘shift their own uncertainty onto an expectation that trans people should demonstrate infallible certainty about gender affirming interventions’ (Shuster, 2021, p.18). At such a juncture, collaborative knowledge building by developing meaningful partnerships between MHPs and TGD communities whose lived experience can guide practice is the need of the hour. Trans scholarship and activism globally has been making demands for depathologising trans care by removal of diagnosis of gender dysphoria from the DSM, calling for increased transparency in medical decision-making and by replacing a psychiatric-driven assessment process with a collaborative decision-making and informed consent model of treatment (Schwend, 2020). In this context, Indian TGD communities and activists along with LGBTQ identified MHPs, doctors and allies need to join forces to advocate for depathologisation, developing training programs for MHPs on gender diversity and TGD-specific mental health needs and work towards self-determined, informed consent models of trans care. We hope that the findings from our preliminary research can be used in support of more comprehensive training and supervision for MHPs on TGD concerns. Given that our study focused on major metropolitan areas, conducting a nationwide study would significantly enhance our understanding of mental health assessments for TGD communities by trained mental health professionals. This broader scope would help identify regional disparities and provide an overview of the current practices and needs across different areas. Abbreviations TGD - Trans and Gender Diverse MHP – Mental Health Professional WPATH – World Professional Association of Transgender Health GD – Gender Dysphoria GID – Gender Identity Disorder GI – Gender Incongruence DSM – Diagnostic and Statistical Manual of Mental Disorders ICD – International Classification of Diseases Declarations Ethics approval and consent to participate The ethics clearance for this study was obtained through the Institutional Review Board of the Tata Institute of Social Sciences on 2 nd May 2022; Serial No. of IRB meeting: 2021-22, 35. The committee reviewed the research and ethics protocol for the study. Consent for publication and Consent to Participate All participants were provided a participant information sheet about the study and signed informed consent forms before participation. All data has been anonymised to protect participant privacy. Clinical trial number: not applicable Availability of data and materials Data collected for this exploratory study is not part of any national repositories. The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests Authors declare that they have no competing interests Funding The study was funded as a grant by the American Jewish World Service. Funder had no role in the preparation of the manuscript or conceptualisation of the study. Authors' contributions KR (corresponding author) prepared the manuscript. All authors reviewed the manuscript. MRS, NJ suggested edits that were finalised by KR. KR, MRS, NJ, AS participated in conceptualisation, data collection, coding and analysis. Acknowledgements Authors wish to acknowledge three research assistants – Prarthana Pai, Indranarayan Roychowdhuri and Arzoo Singh who collected data, participated in data entry, transcription and coding. References Achuthan, A. (2021). Gender-affirmative technologies and the contemporary making of gender in India. Economy and Society , 50 (3), 423-447. APTN, (2021). Conversion Therapy Practices Against Transgender Persons in India, Available at https://www.aidsdatahub.org/sites/default/files/resource/conversion-therapy-2020-india-country-snapshot.pdf Last accessed on 1/12/24 Ashley, F. (2019). Gatekeeping hormone replacement therapy for transgender patients is dehumanising. Journal of medical ethics , 45 (7), 480-482. ATHI & Jamia Hamdard, (2021). Indian Standards of Care for Persons with Gender Incongruence and People with Differences in Sexual Development/Orientation, Delhi: Wisdom Publications, Available at https://www.athionline.com/_files/ugd/5cceb3_a9f97e6326d64fdda153df499d97c2f0.pdf Last accessed on 1/12/24. Chakrapani, V., Newman, P. A., Shunmugam, M., Rawat, S., Mohan, B. R., Baruah, D., & Tepjan, S. (2023). A scoping review of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people’s health in India. PLOS Global Public Health , 3 (4), e0001362. Chakrapani, V., Santos, H., Battala, M., Gupta, S., Sharma, S., Batavia, A., Siddiqui, S.J., Courts, K.A. & Scheim, A. I. (2024). Access to transition-related health care among transmasculine people in India: A mixed-methods investigation. PLOS global public health , 4 (10), e0003506. Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L., Deutsch, M. B., ... & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8 (SOC – 8). International journal of transgender health , 23 (sup1), S1-S259. Dewey, J. M., & Gesbeck, M. M. (2017). (Dys) functional diagnosing: Mental health diagnosis, medicalization, and the making of transgender patients. Humanity & Society , 41 (1), 37-72. Dewey, J. M., Oppenheim, E. R., & Watson, D. P. (2023). (Dis) Empowering Trans People: Depathologization Through Treatment Guidelines and Provider Decision-Making. Humanity & Society , 47 (3), 342-364. Fenn, J., Lalwani, C., Sukumar, S., Ullatil, V., Natarajan, G., & George, S. (2023). Awareness and attitude of medical personnel in Kerala, India to transgender persons. Asian Journal of Social Science , 51 (1), 11-17. Government of India, (2019). The Transgender Persons (Protection of Rights) Act, Ministry of Law and Justice, Available at https://prsindia.org/files/bills_acts/bills_parliament/2019/The%20Transgender%20Persons%20 (Protection%20of%20Rights)%20Act,%202019.pdf Last accessed on 1/12/24 Karia, S., Alure, A., Dave, T., Shah, N., & De Sousa, A. (2019). Paranoia in patients with gender dysphoria: A clinical exploration. Indian Journal of Psychiatry , 61 (5), 529-531. Majumder, A., Chatterjee, S., Maji, D., Roychaudhuri, S., Ghosh, S., Selvan, C., ... & Sanyal, D. (2020). IDEA group consensus statement on medical management of adult gender incongruent individuals seeking gender reaffirmation as female. Indian Journal of Endocrinology and Metabolism , 24 (2), 128. Meadow, T. (2010). “A rose is a rose” on producing legal gender classifications. Gender & society , 24 (6), 814-837. Ministry of Health and Family Welfare, Government of India (August, 2024). ‘Standard Operating Procedure (SOP) for Medical Treatment of Transgender Persons’ , Nirman Bhawan: New Delhi. Available at http://www.dghs.gov.in/content/uploaddata/sop%20transgender.pdf Last accessed on 7/12/24 National legal services authority vs. Union of India and others, (2014, April). Civil Original Jurisdiction, Writ Petition (CIVIL) No.400 of 2012, With Writ Petition (CIVIL) No. 604 of 2013, Supreme Court of India, Available at https://main.sci.gov.in/jonew/judis/41411.pdf Last accessed on 1/12/24 Navtej Singh Johar & ORS vs. Union of India (2018). WRIT PETITION (CRIMINAL) NO. 76 OF 2016, Supreme Court of India, Available at https://digiscr.sci.gov.in/view_judgment?id=MTkzOQ Last accessed on 1/12/24 Pai, N.M., Naik, S.S., Kumar C.N.,, Bada Math, S. (Eds.), (2021). Manual on Mental Healthcare of Transgendered persons in India. NIMHANS Publication No: 205; ISBN: 978-93-91300-07-4 Pandya, A. K., & Redcay, A. (2021). Access to health services: Barriers faced by the transgender population in India. Journal of Gay & Lesbian Mental Health , 25 (2), 132-154. Pemde, H. K., Bansal, U., Bhattacharya, P., Sharma, R. N., Kumar, S., Bhatia, P., ... & Garg, J. C. (2023). Adolescent Health Academy Statement on the Care of Transgender Children, Adolescents, and Youth. Indian Pediatrics , S097475591600534-S097475591600534. Raghuram, H. (2024). Power, policy, and transgender identities: A case study of gatekeeping by mental health professionals in accessing gender affirming surgeries in India. Indian Journal of Medical Ethics , 9 (2), 101-108. Roen K (2011) The discursive and clinical production of trans youth: Gender variant youth who seek puberty suppression. Psychology and Sexuality 2(1): 58–68. Rosqvist, H. B., Nordlund, L., & Kaiser, N. (2014). Developing an authentic sex: Deconstructing developmental–psychological discourses of transgenderism in a clinical setting. Feminism & Psychology , 24 (1), 20-36. Saraff, S., Singh, T., Kaur, H., & Biswal, R. (2022). Stigma and health of Indian LGBT population: A systematic review. Stigma and Health, 7 (2), 178–195. https://doi.org/10.1037/sah0000361 Schwend, S. A. (2020). Trans health care from a depathologization and human rights perspective. Public Health Reviews , 41 (1), 3. Serano, J. (2016). Outspoken: A decade of transgender activism & trans feminism. Switch Hitter Press Shuster, S. M. (2021). Trans medicine: The emergence and practice of treating gender . New York University Press. Srinivasan, S. P., & Chandrasekaran, S. (2020). Care of transgender individuals in India: A clinical perspective. Indian Journal of Social Psychiatry , 36 (4), 284-288. Wandrekar, J. R., & Nigudkar, A. S. (2020). What do we know about LGBTQIA+ mental health in India? A review of research from 2009 to 2019. Journal of Psychosexual health , 2 (1), 26-36. World Health Organisation (WHO), (2022). ICD – 11 Classification of Mental and Behavioural Disorders, Geneva: WHO Footnotes Some examples of these guidelines and manuals include - Indian Standards of Care for Persons with Gender Incongruence and People with Differences in Sexual Development/Orientation (ATHI, 2021); Adolescent Health Academy Statement on the Care of Transgender Children, Adolescents, and Youth (Pemde et al. 2023); IDEA group consensus statement on medical management of adult gender incongruent individuals seeking gender reaffirmation as female (Majumder et al. 2020); Manual on Mental Healthcare of Transgendered persons in India (Pai et al. 2021). It is important to note that this document has no bearing on the data collected in this study as the SOP was published only in August, 2024 and data for this study was collected between June 2022 to March 2023. The presence of this SOP gives further legitimacy to the practice of necessity of a MHP certification of GD/GI before accessing gender transition. IRB clearance was obtained on 2nd May 2022; Serial No. of IRB meeting: 2021-22, 35 There is no clarity in India on the educational qualifications of MHPs who can provide referrals/ letter of support for TGD clients seeking gender transition services. In practice these are usually provided by psychiatrists or clinical psychologists. Total number of psychiatrists and clinical psychologists in the sample in this study is 76 MMPI (Minnesota Multiphasic Personality Inventory) is a standardised psychometric test in adult psychopathology. MMPI-2, the widest used form of this test, published in 2008, has 567 true/ false questions. MCMI (Millon Clinical Multiaxial Inventory) is a self-report psychometric tool to assess personality traits and psychopathology. MCMI-IV, the most recent edition, was published in 2015 and has 195 true/ false items. “ Hijra ”is a historically rooted socio-cultural identity/way of being in South-Asia, and refers to persons who are assigned the male sex-gender at birth; whose gender expression and identity may be feminine/woman; and who may identify as “third gender”, outside the binary of man and woman. Hijras traditionally live in a kinship system with other hijra persons. There has been extensive Indian and international scholarship on the presence of the hijra figure within mythological Hindu texts and in pre-colonial as well as colonial and contemporary times. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Apr, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 20 Jan, 2025 Reviews received at journal 16 Jan, 2025 Reviews received at journal 07 Jan, 2025 Reviewers agreed at journal 06 Jan, 2025 Reviewers agreed at journal 03 Jan, 2025 Reviewers agreed at journal 31 Dec, 2024 Reviewers invited by journal 30 Dec, 2024 Editor assigned by journal 18 Dec, 2024 Submission checks completed at journal 18 Dec, 2024 First submitted to journal 10 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5613392","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":392353679,"identity":"67fd1aee-ee2b-4309-81f3-cd9d93fb2cf9","order_by":0,"name":"Ketki Ranade","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIie3QLQvCQBjA8WcczHJgvTFwX+FkMBWVfZVHDkxrKyYRDJaB1eCHOKNtsmC0DgRRBiaDSQYWpxO1eBgN9093x/24FwCd7g9jAASwHHM43+flqoqQNzFm+Ct5xgnF19nfsybThO9h5zQqySLr5k3fGZHVliqITROCCGF9GfVDN0DWk7Ep2ipSY4LECGjIOPDsgiAH6tlK4mQP4svNqXFtIisuVr0oic3I/WLYk2ngFX/HjFFMTSWxIuFy5ChkegytqF+8JTHd1lxB2HqVWfkAu3IjFue8M/SdyfiQnhSkjH9OyLddOp1Op/u5G3UwRAS3d7AaAAAAAElFTkSuQmCC","orcid":"","institution":"Tata Institute of Social Sciences","correspondingAuthor":true,"prefix":"","firstName":"Ketki","middleName":"","lastName":"Ranade","suffix":""},{"id":392353680,"identity":"45784373-25e4-4c79-8425-ff03d64ab0a8","order_by":1,"name":"Mohan Raju Shankarappa","email":"","orcid":"","institution":"Mylife Psychologists","correspondingAuthor":false,"prefix":"","firstName":"Mohan","middleName":"Raju","lastName":"Shankarappa","suffix":""},{"id":392353681,"identity":"dfdfc06f-3866-437d-a473-8d7f7a29dc04","order_by":2,"name":"Neeraj Kumar","email":"","orcid":"","institution":"The Unsound Project","correspondingAuthor":false,"prefix":"","firstName":"Neeraj","middleName":"","lastName":"Kumar","suffix":""},{"id":392353682,"identity":"a0f2f854-345d-4849-a2c9-94411a5bfd03","order_by":3,"name":"Aryan Somaiya","email":"","orcid":"","institution":"Guftagu Counselling and Psychotherapy Services","correspondingAuthor":false,"prefix":"","firstName":"Aryan","middleName":"","lastName":"Somaiya","suffix":""}],"badges":[],"createdAt":"2024-12-10 05:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5613392/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5613392/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-025-06740-4","type":"published","date":"2025-04-16T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81050874,"identity":"e6d35f31-7561-45bb-8cd4-739285ed4cc6","added_by":"auto","created_at":"2025-04-21 16:06:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2022834,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5613392/v1/fcaeef1f-a5f6-4da0-a6c1-6afa7730ba75.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"In Quest of An Authentic Identity – An Exploratory Study of Mental Health Assessment of Gender Incongruence in Urban India","fulltext":[{"header":"Background","content":"\u003cp\u003eThe last decade has seen a range of legal and policy changes pertaining to the lives of transgender persons in India; starting from recognition of transgender persons as equal citizens by the Supreme Court of India (NALSA v/s Union of India, 2014), decriminalisation of LGBT persons (Navtej Singh Johar v/s Union of India, 2018) and passing of a law - Transgender Persons (Protection of Rights) Act, 2019 by the Indian Parliament. These legal changes have provided impetus to several policy actions and welfare measures promoting rights of transgender persons. On the backdrop of this legal-policy environment, transgender health, particularly gender affirmative interventions have received significant attention. Several healthcare professional bodies and NGOs have proposed guidelines and manuals on gender affirmation care for trans persons[1]\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eSystematic and scoping reviews of literature on LGBT health in India has indicated heightened mental health burden, stigma and stressors among transgender persons and barriers to care such as experiences of discrimination in healthcare settings (Chakrapani et al. 2023; Pandya \u0026amp; Redcay, 2020; Saraff et al. 2022; Wandrekar \u0026amp; Nigudkar, 2020). Other studies on trans health have highlighted use of conversion treatments that seek to cure transgender persons\u0026rsquo; gender identity (APTN, 2021) and gate keeping by Mental Health Professionals (MHPs) while providing referrals for gender affirmative interventions (Chakrapani et al. 2024; Raghuram, 2024). A study conducted among 452 medical students and practicing doctors in Kerala (a southern state in India) indicated low levels of awareness on transgender health including gender affirmative interventions and moderate levels of transphobia particularly among male doctors (Fenn et al., 2023).\u003c/p\u003e \u003cp\u003eWhile several of these studies have focussed on health and mental health care needs, healthcare experiences of transgender persons and awareness among medical professionals about trans health, none of these specifically focus on the process of mental health assessment that is currently mandatory for Trans and Gender Diverse (TGD) persons to access gender affirmative interventions in India nor do they focus on the mental health professional (MHP) and their attitude and practice. Hence, the current study with its focus on mental health professionals\u0026rsquo; (MHPs) knowledge, attitudes and practice with their TGD clients is significant. Our study examined how MHPs conceptualize gender incongruence and gender diversity, as well as their approach to working with TGD clients. In this paper we specifically focus on the assessment process followed by MHPs for diagnosing gender dysphoria/ incongruence (GD/GI) and providing referral for medical and surgical gender affirmation.\u003c/p\u003e \u003cp\u003eAccording to the World Professional Association of Transgender Health (WPATH) Standards of Care \u0026ndash; 8 (SOC-8), a formal diagnosis of GD/GI is not essential for TGD persons to access medical or surgical gender affirmation interventions nor is it a requirement that the assessment for gender incongruence be carried out by an MHP. However, in practice, in India, a MHP evaluation and certification of GI/ GD always precedes medical or surgical gender affirmative interventions. Recently, the Ministry of Health and Family Welfare, Government of India (2024) issued, \u0026lsquo;Standard Operating Procedure (SOP) for Medical Treatment of Transgender Persons\u0026rsquo; that require a certificate of GI from one psychiatrist for hormonal interventions and by one psychiatrist and one clinical psychologist/ psychiatrist for surgical interventions. This document has been criticised for having been developed without any consultative process with TGD communities or experts working on TGD health and also as it contradicts Section 15 of the Transgender Persons (Protection of Rights) Act, 2019 that recommends use of WPATH guidelines to develop a Manual on TGD Health for India[2]\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis is a multi-site research, employing a mixed-method, exploratory design. As literature on MHPs\u0026rsquo; knowledge, competence, attitudes and practice with their TGD clients in the Indian context is near-absent, this is a formative, exploratory research study. The study was conducted in three metropolitan cities of India \u0026ndash; Mumbai, Delhi and Bangalore. The selection of these three metropolitan cities was driven by availability and willingness of experienced researchers. The principal investigator and three co-investigators, themselves belonging to gender and sexually diverse groups, brought valuable lived experiences and insights to the study. Historically, research on queer-trans issues has been done by \u0026lsquo;outside-expert\u0026rsquo;. In our study we turned the gaze on to experts who treat TGD individuals. The investigators were supported by three research associates, one in each city, to ensure robust data collection and contextual understanding across the metropolitan sites. A non-probability, purposive sampling was used in the present study. A total of 165 MHPs currently practicing in the cities of Mumbai, Bangalore and Delhi were interviewed, using a researcher - administered quantitative interview schedule. 45 of these practitioners also responded to a qualitative in-depth interview. In this paper we present predominantly qualitative data.\u003c/p\u003e\n\u003cp\u003eThe three inclusion criteria for the study were - i) a postgraduate degree/ diploma in either Psychiatry, Psychology, Counselling, or Medical and Psychiatric Social Work and/ or an MPhil in Clinical Psychology or Psychiatric Social Work; ii) a minimum practice duration of one year; and iii), the MHP should have seen a minimum of three TGD clients in the course of their practice. In addition to the inclusion criteria, we tried to ensure diversity of sampling by approaching MHPs practicing in different settings, including public and private hospitals, clinics, Non-governmental/ civil society organisations (NGOs/ CSOs), home-based, online practice, and so on. Practitioners who had seen a relatively higher number of TGD clients, and/ or were actively working on TGD issues within their professional associations or in collaboration with NGOs/ CSOs were approached for participating in the qualitative in-depth interview.\u003c/p\u003e\n\u003cp\u003eEthics clearance for this study was obtained through the Institutional Review Board of the Tata Institute of Social Sciences, Mumbai.[3] A content validation of the tools used in the study was done through experts in TGD mental health, in research methodology, and lived experience experts. A total of six mental health and research experts, along with five community members who self-identified as TGD and had experience of accessing mental health care responded to the relevance, adequacy, feasibility, clarity and organisation of the tools. Tool revision was done in accordance with this expert feedback. All participant data was coded to anonymize participant details, ensuring confidentiality throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eProfile of the Research Participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal number of participants (N\u0026thinsp;=\u0026thinsp;165)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCity\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMumbai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBangalore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelhi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Background* [highest degree received]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMD/ DPM Psychiatry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMA/ MSc Psychology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMPhil Clinical Psychology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMPhil Psychiatric Social Work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMA in Social Work (MSW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePG Diploma Counselling/ Counselling Courses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender Identity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCis Woman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCis Man\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransgender/ NB/ Genderqueer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAgender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age: 39.63 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.1\u0026ndash;5 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u0026ndash;10 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.1\u0026ndash;20 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.1\u0026ndash;30 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove 30 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Duration of Practice: 12.9 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice Settings of Participants**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic Hospital (Teaching \u0026amp; Non-Teaching)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate Hospital (Teaching \u0026amp; Non-Teaching)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome-Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic-Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNGO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of TGD Clients seen in past 1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUp to 10 Clients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u0026ndash;30 Clients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore Than 50 Clients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eMD/ DPM, MA/MSc refer to postgraduate degrees in psychiatry and psychology/ social work respectively; MPhil is a 2-year long hospital based clinically focused advanced course undertaken after a postgraduate degree in psychology or social work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003eTotal is greater than N\u0026thinsp;=\u0026thinsp;165 as there are multiple responses across categories\u003c/p\u003e\n\u003cp\u003eAs seen in Table \u003cspan\u003e1\u003c/span\u003e, of the 165 participants, 54 were from Mumbai, 44 from Delhi, and 67 from Bangalore. For the qualitative interviews, of these 165 participants, 15 participants were recruited in each of the study sites, making for a total of 45 qualitative interviews. The participants\u0026rsquo; ages ranged from 24 to 76 years, with the mean age for the study sample being 39 years. The range for years of practice experience was a minimum of 1 year to a maximum of 45 years, with the mean practice experience for the sample being 12.9 years. There were a total of 105 cis women, 51 cis men, 8 participants who self-identified as transgender/ non-binary/ genderqueer and 1 participant who self-identified as agender. In terms of educational background, there were 49 psychiatrists, 61 psychologists, 27 clinical psychologists, 9 psychiatric social workers, 6 social workers and 13 working as counsellors. Most participants (n\u0026thinsp;=\u0026thinsp;113) had seen up to 10 TGD clients over the past one year, while a few (n\u0026thinsp;=\u0026thinsp;36) had seen between 11 to 30 TGD clients, and fewer still (n\u0026thinsp;=\u0026thinsp;10) had seen more than 50 TGD clients in last one year. Data was collected between June 2022 to March 2023.\u003c/p\u003e"},{"header":"Main Findings","content":"\u003ch2\u003ea) The GID Certificate\u003c/h2\u003e\n\u003cp\u003eOf the 165 study participants, 78 practitioners i.e., 47% of the participants reported being approached by TGD clients for assessment and to get referral letters for gender transition services[4]. While majority of the study participants used the terms gender dysphoria and gender identity disorder interchangeably, majority of them referred to the letter of support for medical or surgical transition as \u003cem\u003e\u0026lsquo;certificate of GID\u0026rsquo;\u003c/em\u003e. Use of the language of \u003cem\u003ecertification\u003c/em\u003e by the MHPs suggests that they perceive their role to be that of experts who apply their scientific knowledge to decide who qualifies for the GID certificate and subsequently to access gender affirmative interventions. Chakrapani et al. (2024) in their study with transmasculine persons report use of the phrases \u003cem\u003e\u0026lsquo;approval process for transition related care\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;passing the assessment\u0026rsquo;\u003c/em\u003e by their transmasculine study participants to refer to the mental health assessment they underwent before accessing gender transition services. Use of these phrases suggest that the trans persons view the mental health assessment as a test, an examination that they must pass to access medical or surgical transition.\u003c/p\u003e\n\u003cp\u003eIn this paper we reflect on MHPs perceptions and attitudes not just towards normative and diverse genders and their self-perceived role in assessment of the same but also their views about mental illness, capacity and competence, soundness of judgement or lack thereof.\u003c/p\u003e\n\u003ch3\u003eb) Looking for the \u0026lsquo;Authentic\u0026rsquo; Trans Person\u003c/h3\u003e\n\u003cp\u003eMHPs quest for the real/ authentic transgender person led them to several areas of inquiry that lay outside the conventional psychiatric assessment aimed at diagnosing presence or absence of mental illness and the question of whether gender dysphoria is independent of or secondary to/ a symptom of an underlying mental disorder. MHPs in this study sought to ascertain level of certainty that the TGD client felt about their gender and plans for transition, their motivation for the same; they sought to ascertain the anatomical sex of their TGD clients, their intelligence quotient, stability of their personality, their knowledge of \u0026lsquo;cross-dressing\u0026rsquo; and ability to pass in their self-identified gender and several such factors before providing \u0026lsquo;the certificate\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eLiterature on transgender gender identities within the psy disciplines is replete with pathological and medicalized ideas such as primary and secondary transsexualism or true and false transgender referring to gender non-conformity that is innate v/s that which is acquired (Roean, 2011). Another such dichotomy is that of desisters and persisters i.e. those gender non-conforming children who desist from gender non-conformity as they mature v/s those who persist in their gender non-conformity even after puberty (Roean, 2011). Then there is the description of sexual motivation behind gender diverse expressions, for instance, Autogynephilia, a term coined by Ray Blanchard in the late 1980s to refer to a type of heterosexual man, who, typically around puberty, begins to experience cross-gender arousal in response to imagining himself as a woman. This cross-gender arousal according to Blanchard was a form of paraphilia that eventually became the primary factor driving these individuals to transition physically, to female. Another type of transsexual that Blanchard described was the \u0026ldquo;homosexual transsexual\u0026rdquo;, who was feminine from a very early age and was, as an adult, attracted exclusively to men. Transsexual women belonging to this latter group were thought to be a type of feminine gay man who ultimately transitions to female in order to attract heterosexual men. Blanchard viewed all transsexual women as being sexually motivated in seeking gender transition and in so doing essentially invalidated the trans experience through sexualisation of trans women (Serano, 2016). These classifications of trans persons within psy literature implies that experts in trans healthcare need to be equipped with adequate competence and investigative tools to identify the authentic \u0026lsquo;transgender\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eIn addition to pathologizing classificatory frameworks, developmental-psychological discourses too offer a limited subject position to trans persons. Development psychology literature conceptualises gender (as with all human development) along a pre-determined, linear course that follows specific stages or milestones. In doing so it offers a restrictive pathway of development for transgender persons that follows a script such as early and persistent signs of gender dysphoria displayed through discomfort and disgust with one\u0026rsquo;s anatomy, struggle with gendered clothing, grooming, toys, play of one\u0026rsquo;s assigned gender and later sexual attraction to gender considered opposite to one\u0026rsquo;s birth assigned sex-gender. Thus, development psychology offers a guiding map along which a transgender identity that is innately present is expected to unveil (Rosqvist et al., 2014).\u003c/p\u003e\n\u003cp\u003eMental health professionals when encountered with the narrative of a TGD person in the clinic and taking on an expert position certifying the authenticity of their transness tap into these classificatory, pathologizing and restrictive frames available within the psy disciplines to decide on whether to provide the certificate. Among our study participants, we find both these impulses, one a pathological lens to view TGD persons and another a culturally rooted, normative lens of gender as binary, fixed, naturalized and biologized. In keeping with this view of gender, MHPs expect their trans clients to neatly fit into gender roles and expression of their gender of identification and thereby create newer standards of trans normativity to which their TGD clients must adhere in order to qualify for access to transition services. Dewey et al. (2017) observe that in order to access medical and surgical interventions trans people have to subject themselves to a complex mental health assessment and diagnostic process in which fitting into a culturally, medically and subsequently legally defined gender norm qualifies them to be the authentic trans person. The following narratives of MHPs describing their assessment process for GD/ GI illustrate this point.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMHP narratives of Assessment Process for giving a Gender/ GID Certificate\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAscertain Stability, Certainty and Normative Gender Presentation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026apos;re really clear that if there is even a slightest doubt, if you\u0026apos;re not absolutely certain, then I will send to somebody else for another opinion. Because I\u0026apos;m not going to certify something unless I\u0026apos;m clear and convinced that the guy knows what he\u0026apos;s doing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(62 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When you come to the hospital I should see a woman. In fact we tell them to cross dress because if the male is there and he wants to become a woman, you start staying like a woman and come to the hospital like a female we should see a female not male\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(60 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So many patients come to us without cross dressing. So then we asked them ki please aap minimum six months ke liye toh cross-dressing karke hi ayiye fir hi hum aage ka procedure karenge...\u003c/em\u003e [please cross dress for a minimum of six months and only after that we can consider further procedure] Secondly, we guide them about the cross dressing. Thoda barabar se kar sakte hai [they can do it properly] \u003cem\u003elike for male to female, to use proper padded bras, female to male then use proper binders and all which they are not aware and that is creating a lot of problem. They say nehi hum toh kabhi loose shirt pehen ke gaye\u003c/em\u003e [they say we manage by wearing a lose shirt] \u003cem\u003ethen see that is problem no, so then we have to explain to them. So, you properly cross dress many of the male to female will not have long hair. So then we had to explain that aapko thora baal lambe rakhne zaroori hai\u003c/em\u003e [you have to grow your hair long] \u003cem\u003eso that that acceptance comes like a female\u0026hellip; that kind of thing. And dressing has to be a bit changed\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(35 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAscertain motivation for gender transition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I have read so many reports, maybe in Kerala or Tamil Nadu\u003c/em\u003e [two states in Southern India], \u003cem\u003etwo women working together have developed liking to each other. And then they became so very close. People started telling them that you\u0026apos;re so close, as though you are a couple you know\u0026hellip; then one of the girl said why don\u0026apos;t you change your gender and then we\u0026apos;ll get married... So\u003c/em\u003e assess whether they are doing it for themselves or are they doing it for others? How convinced they are about it, and why are they convinced. They need not convince me but I must be convinced that he is sure of himself. Because then later, he should not regret it\u0026hellip; gender is something which is you know, very obvious to people, so you can\u0026apos;t keep changing it again\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e(55 year old cis woman, Psychiatric Social Worker, Delhi)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;One case, very strange actually, someone said it\u0026apos;s very easy to earn money if you get a sex change because you can trade sex for money\u0026hellip; so you know this was a young male who was not working you know and I have seen this patient for a long time like two to three years and gender was never an issue and never came up but then three to four psychiatrists called me and told that he had gone to them for GID certification. So I am not sure what was the motivation behind requesting sex change\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e[44 year old cis woman, Psychiatrist, Bangalore]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAscertain Natal Sex \u0026ndash; physical/ genital examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When you get the certificate you have to take signature of the patient or take his thumb impression, check their genitals, some feel uncomfortable, we don\u0026apos;t give them a certificate\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(47 year old cis man, Psychiatrist, Delhi)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor will ask them okay, are you comfortable with male doctor or female doctor?, so if it\u0026rsquo;s a male and he wants to get converted to female and he says I\u0026apos;m comfortable with male doctor so male doctor will examine and he will examine the genitals and write it down that I have examined he has normal, masculine characteristics. In female to male, the female would write\u0026hellip; female examined, note down if she has breasts, and she has normal female genitals... See, one of you come to me and you say I\u0026apos;m a female. You look like a male? But you say no, no, I\u0026apos;m a female. So, I accept what you are saying, but I have to write on the paper and on what basis I have accepted you as a female. So from outside you look like a male, but if you are saying female, if you give permission I examine and I say I have examined the patient and actually she\u0026apos;s a female\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(60 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAscertain familial approval and consent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;A young woman\u003c/em\u003e (trans man based on context of the interview), \u003cem\u003ea 19-year-old \u0026ndash; may or may not be an adult coz family members are still guardians for a young woman in India. So, I would ask for a parental letter of consent before giving a certificate\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(44 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;...if somebody is 18\u003c/em\u003e (years old), \u003cem\u003ehe or she does not need the consent of the family, but somebody is married, so they cannot undergo gender change without either getting a\u0026nbsp;divorce, or their partner has to give an affidavit in the court with their agreement. And you have to sign a paper saying they\u0026apos;re okay with that, that the person is going to change.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(47 year old cis man, Psychiatrist, Delhi)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAs can be seen in the narratives above, MHPs in this study engaged in what Meadow (2010) referred to as \u0026lsquo;projects of excavation\u0026rsquo; (p. 823) in their search for the authentic trans person, who could qualify for gender transition. These narratives suggest that MHPs, based on their cultural as well as medical understanding of sex-gender as biologically determined, interchangeable or rather one flowing from the other wanted to check/ confirm the genital sex of their TGD clients through performing a physical examination. Similarly, MHPs with their normative understanding of gender as binary expected their TGD clients to fit perfectly and even pass in their gender of identification. Some expected their TGD clients to have lived in their gender of identification before issuing the gender certificate, a condition (real life experience) that is no longer required to be met as per global standards of trans care (Coleman et al., 2022). Some MHPs held culturally rooted patriarchal beliefs about natal families\u0026rsquo; control over what are seen as their \u0026lsquo;female born children\u0026rsquo; as being more significant than the young TGD person\u0026rsquo;s autonomy and right to self-determination. Similarly, the culturally rooted idea of marriage as a sacrosanct institution that needs to be held in higher regard than individual wishes or aspirations of a TGD spouse is reflected in the narrative where the MHP asks the TGD client to get spousal letter of consent or divorce before providing a \u0026lsquo;certificate of GID/ GD\u0026rsquo; when in fact marital status of a person has no bearing on the gender identity of the individual. The idea of assessing correct motivation for seeking gender transition too undermines the TGD person\u0026rsquo;s self-knowledge and autonomy over their body. These narratives suggest that MHPs go well beyond the scope of gender assessment and seek to purportedly mitigate and in effect regulate what they perceive to be social consequences of gender transition of their TGD client; in doing so MHPs often end up gatekeeping access to medical and surgical transition.\u003c/p\u003e\n\u003ch3\u003ec) Use of Psychometric Tests in GID Certification\u003c/h3\u003e\n\u003cp\u003eMajority of the study participants used standardized psychological tests in addition to a clinical interview before deciding on whether to give a \u0026lsquo;certificate of GID\u0026rsquo; to their TGD clients. It\u0026rsquo;s important here to note that established global standards for assessment of GD/ GI do not require use of psychometric tests. Moreover, the tests used by our study participants were not measures of GD/GI. Participants reported using projective tests (n\u0026thinsp;=\u0026thinsp;32), personality tests (n\u0026thinsp;=\u0026thinsp;24), intelligence and other cognitive tests (n\u0026thinsp;=\u0026thinsp;12), screening tools for psychopathology (n\u0026thinsp;=\u0026thinsp;8), a sex role inventory (n\u0026thinsp;=\u0026thinsp;1) and a blood test (n\u0026thinsp;=\u0026thinsp;1) as part of assessment before recommending their TGD clients for transition-related services.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTypes of Psychometric Tests Used in Assessment for Gender/ GID Certificate\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of Psychometric Test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProjective Tests\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRorschach Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThematic Apperception Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSentence Completion Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonality Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMillon Clinical Multiaxial Inventory (MCMI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinnesota Multiphasic Personality Inventory (MMPI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 PF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQ Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBinet Kamat Test of Intelligence (BKT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWechsler Adult Intelligence Scale (WAIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWechsler Adult Performance Intelligence Scale (WAPIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStandard or Raven\u0026rsquo;s Progressive Matrices (SPM/RPM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRaven\u0026rsquo;s Coloured Progressive Matrices (CPM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQ Test Not Named\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eScreening Tests for Mental Illnesses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeck Depression Inventory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeck Anxiety Inventory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYale Brown Obsessive Compulsive Scale (Y-BOCS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHamilton Depression Rating Scale (HAM-D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneral Health Questionnaire (GHQ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex Role Inventory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Nos. of Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e77\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDuration of Assessment\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of sessions for GD/ GI Assessment\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of study participants\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 or \u0026lt;\u0026thinsp;3 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 to 6 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;6 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePractitioners reported variously on the duration of assessment for providing a certificate. Of the 78 who provided such letters, 36 reported needing under 3 sessions, 24 reported 4\u0026ndash;6 sessions and 16 reported more than 6 sessions in order to provide referral letters for hormonal and or surgical interventions. Two practitioners did not provide a number. The fees charged by practitioners ranged from INR 500 to 2500 per session implying a high cost for mental health assessment.\u003c/p\u003e\n\u003cp\u003eThe rationale for use of psychometric tests varied among the participants. The most obvious was to rule out the possibility of gender dysphoria being symptom of/ secondary to an underlying mental illness or to screen for co-morbid mental health conditions and to ascertain that these did not diminish capacity of the person to comprehend their diagnosis of GD/ GI and the treatment options on offer. However, the study participants also stated that psychometric tests were their way of ensuring that the TGD person was indeed a good fit for the irreversible medical and surgical transition that would follow and that they would not later regret their decision to transition. Yet others stated that in the absence of state-notified clinical protocols for mental health assessment to determine \u0026ldquo;fitness\u0026rdquo; for gender affirmation therapy, standardised psychological test reports would appear more unbiased and reliable and provide the MHP medico-legal protection in the event of a legal scrutiny \u0026ndash; a likelihood that increased several folds in the face of hostile and unsympathetic families of their TGD patients. Thus, the MHPs anxiety about possible regret on part of the TGD person or a probable legal action against them from family members of the TGD person seemed to guide the extreme caution in assessment and leading to gatekeeping of access to gender affirmative interventions.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRationale for using Psychometric Tests\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAscertain Capacity and Intelligence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Is it really his or her gender? Or is it something that the person is saying under a particular delusion that I have become a transgender, it has happened, it happens to a lot of people. Someone who in the state of active psychosis thinks that they have become a eunuch, or they are changing they are metamorphosizing themselves, their body\u0026apos;s changing into that of a eunuch, it\u0026apos;s a very common theme. Not unheard of\u0026hellip; So, that is one entity that we are careful about. So immediately certification is not done there, the treatment has to be done first, and maybe later, the call can be taken\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(31 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;First of all, you want to check out and see whether the guy is, if he\u0026rsquo;s got normal intelligence, that\u0026apos;s very important. So he should have cognition, and he should have an understanding of what he\u0026apos;s doing. So if you have somebody who\u0026apos;s intellectually, not up to the level, then we certainly would not certify because we would believe that he doesn\u0026apos;t know the consequences of this behavior. Then you do personality tests. See these tests are not mandatory, I prefer to do them. Because I\u0026apos;d like to be very clear.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(62 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLooking for gender dysphoria/ incongruence in psychometric tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Once clinically we are convinced that yes he is having GID then we refer him to psychological testing. So, Rorschach, MMPI is done. If required sentence completion test is done. There are some confusional states and I am not able to see the GID in Rorschach, MMPI\u0026hellip; usually it is seen in MMPI but if not then in such dicey situations we have to undergo the sentence completion test also to see what kind of words she uses in sentence completion, what is the preference and use of pronouns and all\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(35 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedico-legal Concerns \u0026amp; Institutional Barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;To be honest, many times I have felt like I am just doing the whole set of tests because I am supposed to do it, because the protocol of the place that I am working at says so and because it is a package\u003c/em\u003e [of GD assessment]. \u003cem\u003eLike I said earlier, I genuinely don\u0026apos;t think that any projective or personality tests are required.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(34 year old cis woman, Clinical Psychologist, Bangalore)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The problem is about the legalities around it. One is always unsure whether one is dealing in the right way from a legal perspective. For example, if we are following mainly WPATH suggestions, the IPATH\u003c/em\u003e (Indian Professional Association of Trans Health) \u003cem\u003eone that has come out doesn\u0026apos;t seem to be very different. So, one is essentially following some professional advice whose legal position in the country is not very clear. One hopes that this is something that the court will accept but one doesn\u0026apos;t really know what happens. One feels a little anxious because it is quite possible that sooner or later a family member may put up a case if they are not satisfied. The risk is there and that\u0026rsquo;s why we are a little anxious about the legalities. Because the treatment process is not well-established right now. All of us are doing it at an individual level\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(57 year old cis man, Psychiatrist, Delhi)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAs seen in Tables above (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e \u0026amp; \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e), TGD clients needed to jump through several hoops of normativity before they could be considered eligible for gender transition services. They needed to aspire to be the perfect man or woman with the correct amount of masculinity or femininity and exude appropriate form of mental stability and cognitive capacity while also exhibiting persistent distress and dysphoria with their birth assigned sex-gender. Being a fully functional adult in terms of adequate personal, social and occupational functioning, desiring gender transition, having gathered relevant information about gender affirmation therapies and voluntarily seeking the same was not enough for MHPs to consider making a referral for medical or surgical interventions. Given the long history of pathologization of trans identities as mental illness and continued presence of gender dysphoria as a diagnostic category in the DSM V, TGD clients\u0026rsquo; mental competence will remain suspect and in need of investigation and proof when in contrast cis gender clients can seek the same set of medical or surgical interventions for medical or cosmetic purposes by merely giving informed consent and without having to undergo a psychological evaluation. Dewey et al. (2023) point to the irony in the process of assessment, \u0026ldquo;The process requires trans people to delicately balance appearing stable enough to make competent decisions yet unstable enough to \u0026lsquo;be at the precipice\u0026rsquo; of losing everything which seemingly translates to one\u0026rsquo;s seriousness and realness of gender identity\u0026rdquo; (p. 20). With gender incongruence no longer classified as a mental or behavioral disorder in the ICD-11 (WHO, 2022), whether MHPs would be able to trust self-report by TGD persons and grant them the epistemic authority over their own experience of their gender (Ashley, 2019) and whether attitudinal as well as medico-legal and institutional barriers will be cast away needs to be seen. The recent SOP for medical treatment of Transgender persons issued by the Ministry of Health and Family Welfare (MoHFW, 2024) crushes the hope for the possibility of a self-determined, informed consent model for treatment of gender incongruence in the near future. This SOP endorses an expert/ MHP - driven assessment process, continues the use of language of certification and strengthens the binary, transnormative ideal by prescribing a linear process of gender transition starting with a psychiatric certificate of GI followed by hormonal treatment for a minimum of one year and then two certificates from psychiatrists and one from an endocrinologist before accessing surgical intervention. Thus currently, a non-binary trans person or any TGD person not seeking to follow all the linear steps of transition mentioned in the protocol are excluded from gender affirmative interventions by design.\u003c/p\u003e\n\u003cp\u003eWe wish to highlight two more issues pertaining to psychometric testing with TGD clients. First, norms for interpreting test results for all of the above tests are developed on cis gender persons and communities and results or scores of TGD persons are interpreted in light of these norms which poses a problem. A study by Karia et al. (2019) conducted in a public hospital in Mumbai city showed that patients with GID falsely scored high on Paranoia, Schizophrenia and Psychopathic deviate measures on MMPI. Authors state that these high scores were not corroborated on clinical examination with no evidence of psychosis and the higher paranoia was in fact reality based and was linked to experiences of ridicule, stigma and a sense of mistrust and cautiousness while engaging with medical professionals. The following quote of a psychiatrist in our study explains this finding well.\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003eA psychiatrist commented that the elevations seen in psychopathology scales like the MMPI[5] and MCMI[6] could be looked at as trans-specific coping strategies in the context of prevailing stigma and discrimination.\u003c/p\u003e\n \u003cp\u003eI have stopped looking for anything in the MCMI profile because, you know, I read up not too long ago that even [with] the psycho-diagnostic tests like MCMI or MMPI, the results are very different pre-transition and post-transition and that was quite surprising, because these are not really state- dependent tests. They are supposed to be consistent over a period of time. A lot of parameters that come elevated and may [seem] pathological in the reports are actually ways of coping with the scenario of gender incongruence. The paranoia, for example \u0026ndash; we usually see paranoid scales a little bit high. We see the depressive or dysthymic scales a little bit high. And these are very obviously results of the way a person is coping with their environment.\u003c/p\u003e\n \u003cp\u003e[38 year old cis man, Psychiatrist, Mumbai]\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIt is important to note that despite these research findings (of Karia et. al. 2019) having been published in the official publication of the Indian Psychiatric Society, MHPs in the three cities where we collected data in the year 2023 continued to use personality tests and other psychometric assessments as part of their GD/ GI assessments. In the absence of clinical rationale and presence of contrary evidence, continuing to waste TGD client\u0026rsquo;s resources of time and money is a serious case of harmful practice, especially given the evidence that costs of gender affirmation interventions are a major stressor and a barrier to care for TGD persons in India (Chakrapani et al. 2024; Srinivasan \u0026amp; Chandrasekaran, 2020).\u003c/p\u003e\n\u003cp\u003eInterestingly a few practitioners pointed out that if someone from the Hijra community[7] comes to their clinic for getting the certificate they are more likely to refer them directly to the surgical department and not subject them to the extensive scrutiny that trans identified clients undergo. One way to understand this is that most hijra persons have left their natal families and are living within the hijra kinship-community system (locally known as \u003cem\u003egharana system\u003c/em\u003e) and therefore are socially and culturally recognised as such. They are already marked as living outside normative familial-social structures. Thus, when a socio-cultural test has been passed the need to subject them to stringent psy tests and proof can be bypassed. Moreover, a hijra person seeking gender transition is unlikely to be seen as seeking to re-enter normative gendered social systems of marriage-family and hence the necessity to regulate this figure is not as high.\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003eOne or two people who have come for surgeries have been Hijras, who see themselves as Hijra, so they have come for surgeries. Then we sent them to surgery directly. They had already gone through a certain portion so we directly sent them.\u003c/p\u003e\n \u003cp\u003e(57 year old cis man, Psychiatrist, Delhi)\u003c/p\u003e\n \u003cp\u003e\u0026hellip;majority of them ran away from their homes and started staying with this community. And after that actually they\u0026apos;re living life with them, but the only part what is remaining is that they still have male genitals. So we send them to the plastic surgery department. We do make a paper of gender identity disorder for them as well.\u003c/p\u003e\n \u003cp\u003e(60 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eRaghuram (2024) argues that there is a historical familiarity with the Hijra figure as a third gender in the Indian context and it is this cultural intelligibility that shapes a different norm for the third gender among healthcare providers as well as policy and law makers in India. He explains that the project of reinforcing gender binormativity among TGD persons by medical professionals as well as by TGD persons themselves who aspire to fit into the gender binary system co-exists in the Indian context with a gender trinormativity ascribed to indigenous identities such as Hijra, Kinnar and so on.\u003c/p\u003e\n\u003ch3\u003ed) Nature of Relationship between TGD Clients and MHPs\u003c/h3\u003e\n\u003cp\u003eThe current model of mental health assessment to provide a gender certificate sets up the client-provider relationship to be of an examiner-examinee wherein the examiner has to evaluate, scrutinize, investigate, monitor and the examinee has to submit, confirm, provide correct, rehearsed and possibly fake responses to pass the exam. Several of our study participants lamented that often their relationship with their TGD clients was a transactional or instrumental one and not a meaningful, genuine, therapeutic one. This is reflected in some of the responses below:\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They see the role of a psychiatrist as limited to the certification process. Because certification process is there, they may look into us or they may contact us, if the certification role is not there, they will not approach us\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(30 year old cis man, Psychiatrist, Bangalore)\u003c/p\u003e\n \u003cp\u003eI see that a lot of them think of this as a formality. And genuine help is not welcomed by most people that I\u0026apos;ve seen so far. They in fact are angry or upset when we inform them of not having the fitness to undergo surgery, whether it is because of depressive symptoms, anxious personality, or if it is because of a lot of confusion, no clear orientation presented on whatever testing we\u0026apos;ve done. None of that is taken in the spirit of actual help, but it is rather looked at as a roadblock as a frustration\u0026hellip; they don\u0026apos;t welcome this as help, you know, so this is looked at more as something to tick off. And when it\u0026apos;s not really being ticked off the list, it results in anger rather than self-care and taking the advice seriously, or even taking medical help\u0026hellip;\u003c/p\u003e\n \u003cp\u003e(29 year old cis woman, Clinical Psychologist, Bangalore)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026hellip;majority of the time, they will not say that they have other psychiatric disorder, because then that will come in the way of their certification. so they say \u0026lsquo;ki haan humein thora chinta hai\u0026rsquo;\u003c/em\u003e (yes, I am a bit worried) \u003cem\u003ebut that is a normal about whether he will be accepted or not accepted\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(60 year old cis man, Psychiatrist, Mumbai)\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMHPs in this study discussed their frustration at being unable to meaningfully support their TGD clients or treat psychiatric morbidities that they may be suffering from due to a trust deficit from the client\u0026rsquo;s side. Chakrapani et al. (2024) reported the other side of the story from the perspective of trans masculine persons whom they studied. Their study participants reported that they experienced the psychiatrist or psychologist as being \u003cem\u003e\u0026ldquo;in charge\u0026rdquo;\u003c/em\u003e of their access to transition-related care and were intimidated by the amount of power that psychiatrists had over their access to transition care. In response, transmasculine community members were cautious about revealing any doubts or mental health challenges they were facing, as they worried that the doctor might refuse to provide a letter. Thus, in the absence of genuine trust and safety, conditions essential for formation of a therapeutic alliance, genuine mental health concerns of TGD persons may remain invisible to the MHP despite multiple assessment sessions and use of psychometric tests. To quote one of the participants in the study by Chakrapani et al., 2024 - \u003cem\u003e\u0026ldquo;My friends told me that whatever the doctor asks, speak positively: if you feel disturbed or, negative, or uncomfortable, the doctor will cancel your GID [diagnosis/certificate] \u0026hellip;\u0026rdquo;\u003c/em\u003e (p. 14).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTrans communities in India are increasingly mobilising to assert their rights and as the Indian state and judiciary seeks to accommodate them as citizens, protocols in law and medicine are being formulated to regulate these non-cis gender bodies. These protocols of gender affirmative technologies seek to craft trans normativity through reproduction of cis-binary-gender norms (Achuthan, 2021). As seen in this paper, MHPs deploy psy language and technologies to justify their gender assessment methods when in reality they are gatekeeping and reproducing socio-cultural cis-binary gender norms. Shuster (2021) in their book \u0026lsquo;Trans Medicine \u0026ndash; the emergence and practice of treating gender\u0026rsquo;, states that medical authority is consolidated by evidence, expertise and experience. However, when evidence and expertise is sparse as is the case with the emerging area of trans medicine in India, uncertainty is higher. Healthcare providers in such situations, as can be seen among the current study participants leverage scientific language and tools of assessment such as psychometric tests to bolster medical authority and in doing so \u0026lsquo;shift their own uncertainty onto an expectation that trans people should demonstrate infallible certainty about gender affirming interventions\u0026rsquo; (Shuster, 2021, p.18). At such a juncture, collaborative knowledge building by developing meaningful partnerships between MHPs and TGD communities whose lived experience can guide practice is the need of the hour. Trans scholarship and activism globally has been making demands for depathologising trans care by removal of diagnosis of gender dysphoria from the DSM, calling for increased transparency in medical decision-making and by replacing a psychiatric-driven assessment process with a collaborative decision-making and informed consent model of treatment (Schwend, 2020). In this context, Indian TGD communities and activists along with LGBTQ identified MHPs, doctors and allies need to join forces to advocate for depathologisation, developing training programs for MHPs on gender diversity and TGD-specific mental health needs and work towards self-determined, informed consent models of trans care. We hope that the findings from our preliminary research can be used in support of more comprehensive training and supervision for MHPs on TGD concerns. Given that our study focused on major metropolitan areas, conducting a nationwide study would significantly enhance our understanding of mental health assessments for TGD communities by trained mental health professionals. This broader scope would help identify regional disparities and provide an overview of the current practices and needs across different areas.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTGD - Trans and Gender Diverse\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMHP \u0026ndash; Mental Health Professional\u003c/p\u003e\n\u003cp\u003eWPATH \u0026ndash; World Professional Association of Transgender Health\u003c/p\u003e\n\u003cp\u003eGD \u0026ndash; Gender Dysphoria\u003c/p\u003e\n\u003cp\u003eGID \u0026ndash; Gender Identity Disorder\u003c/p\u003e\n\u003cp\u003eGI \u0026ndash; Gender Incongruence\u003c/p\u003e\n\u003cp\u003eDSM \u0026ndash; Diagnostic and Statistical Manual of Mental Disorders\u003c/p\u003e\n\u003cp\u003eICD \u0026ndash; International Classification of Diseases\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eEthics approval and consent to participate\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe ethics clearance for this study was obtained through the Institutional Review Board of the Tata Institute of Social Sciences on 2\u003csup\u003end\u003c/sup\u003e May 2022; Serial No. of IRB meeting: 2021-22, 35. The committee reviewed the research and ethics protocol for the study.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eConsent for publication and Consent to Participate\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll participants were provided a participant information sheet about the study and signed informed consent forms before participation. All data has been anonymised to protect participant privacy.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eClinical trial number: not applicable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eAvailability of data and materials\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eData collected for this exploratory study is not part of any national repositories. The datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eCompeting interests\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAuthors declare that they have no competing interests\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFunding\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe study was funded as a grant by the American Jewish World Service. Funder had no role in the preparation of the manuscript or conceptualisation of the study.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAuthors\u0026apos; contributions\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eKR (corresponding author) prepared the manuscript. All authors reviewed the manuscript. MRS, NJ suggested edits that were finalised by KR.\u003c/p\u003e\n\u003cp\u003eKR, MRS, NJ, AS participated in conceptualisation, data collection, coding and analysis.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAcknowledgements\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAuthors wish to acknowledge three research assistants \u0026ndash; Prarthana Pai, Indranarayan Roychowdhuri and Arzoo Singh who collected data, participated in data entry, transcription and coding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAchuthan, A. (2021). Gender-affirmative technologies and the contemporary making of gender in India. \u003cem\u003eEconomy and Society\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(3), 423-447.\u003c/li\u003e\n\u003cli\u003eAPTN, (2021). 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IDEA group consensus statement on medical management of adult gender incongruent individuals seeking gender reaffirmation as female. \u003cem\u003eIndian Journal of Endocrinology and Metabolism\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(2), 128.\u003c/li\u003e\n\u003cli\u003eMeadow, T. (2010). \u0026ldquo;A rose is a rose\u0026rdquo; on producing legal gender classifications. \u003cem\u003eGender \u0026amp; society\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(6), 814-837.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Family Welfare, Government of India (August, 2024). \u003cem\u003e\u0026lsquo;Standard Operating Procedure (SOP) for Medical Treatment of Transgender Persons\u0026rsquo;\u003c/em\u003e, Nirman Bhawan: New Delhi. Available at http://www.dghs.gov.in/content/uploaddata/sop%20transgender.pdf Last accessed on 7/12/24\u003c/li\u003e\n\u003cli\u003eNational legal services authority vs. Union of India and others, (2014, April). Civil Original Jurisdiction, Writ Petition (CIVIL) No.400 of 2012, With Writ Petition (CIVIL) No. 604 of 2013, Supreme Court of India, Available at https://main.sci.gov.in/jonew/judis/41411.pdf Last accessed on 1/12/24\u003c/li\u003e\n\u003cli\u003eNavtej Singh Johar \u0026amp; ORS vs. Union of India (2018). WRIT PETITION (CRIMINAL) NO. 76 OF 2016, Supreme Court of India, Available at https://digiscr.sci.gov.in/view_judgment?id=MTkzOQ Last accessed on 1/12/24\u003c/li\u003e\n\u003cli\u003ePai, N.M., Naik, S.S., Kumar C.N.,, Bada Math, S. (Eds.), (2021). Manual on Mental Healthcare of Transgendered persons in India. NIMHANS Publication No: 205; ISBN: 978-93-91300-07-4\u003c/li\u003e\n\u003cli\u003ePandya, A. K., \u0026amp; Redcay, A. (2021). Access to health services: Barriers faced by the transgender population in India. \u003cem\u003eJournal of Gay \u0026amp; Lesbian Mental Health\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(2), 132-154.\u003c/li\u003e\n\u003cli\u003ePemde, H. K., Bansal, U., Bhattacharya, P., Sharma, R. N., Kumar, S., Bhatia, P., ... \u0026amp; Garg, J. C. (2023). Adolescent Health Academy Statement on the Care of Transgender Children, Adolescents, and Youth. \u003cem\u003eIndian Pediatrics\u003c/em\u003e, S097475591600534-S097475591600534.\u003c/li\u003e\n\u003cli\u003eRaghuram, H. (2024). Power, policy, and transgender identities: A case study of gatekeeping by mental health professionals in accessing gender affirming surgeries in India. \u003cem\u003eIndian Journal of Medical Ethics\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(2), 101-108.\u003c/li\u003e\n\u003cli\u003eRoen K (2011) The discursive and clinical production of trans youth: Gender variant youth who seek puberty suppression. Psychology and Sexuality 2(1): 58\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eRosqvist, H. B., Nordlund, L., \u0026amp; Kaiser, N. (2014). Developing an authentic sex: Deconstructing developmental\u0026ndash;psychological discourses of transgenderism in a clinical setting. \u003cem\u003eFeminism \u0026amp; Psychology\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1), 20-36.\u003c/li\u003e\n\u003cli\u003eSaraff, S., Singh, T., Kaur, H., \u0026amp; Biswal, R. (2022). Stigma and health of Indian LGBT population: A systematic review. \u003cem\u003eStigma and Health, 7\u003c/em\u003e(2), 178\u0026ndash;195. https://doi.org/10.1037/sah0000361\u003c/li\u003e\n\u003cli\u003eSchwend, S. A. (2020). Trans health care from a depathologization and human rights perspective. \u003cem\u003ePublic Health Reviews\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(1), 3.\u003c/li\u003e\n\u003cli\u003eSerano, J. (2016). Outspoken: A decade of transgender activism \u0026amp; trans feminism. Switch Hitter Press\u003c/li\u003e\n\u003cli\u003eShuster, S. M. (2021). \u003cem\u003eTrans medicine: The emergence and practice of treating gender\u003c/em\u003e. New York University Press.\u003c/li\u003e\n\u003cli\u003eSrinivasan, S. P., \u0026amp; Chandrasekaran, S. (2020). Care of transgender individuals in India: A clinical perspective. \u003cem\u003eIndian Journal of Social Psychiatry\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(4), 284-288.\u003c/li\u003e\n\u003cli\u003eWandrekar, J. R., \u0026amp; Nigudkar, A. S. (2020). What do we know about LGBTQIA+ mental health in India? A review of research from 2009 to 2019. \u003cem\u003eJournal of Psychosexual health\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(1), 26-36.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation (WHO), (2022). ICD \u0026ndash; 11 Classification of Mental and Behavioural Disorders, Geneva: WHO\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Some examples of these guidelines and manuals include - Indian Standards of Care for Persons with Gender Incongruence and People with Differences in Sexual Development/Orientation (ATHI, 2021); Adolescent Health Academy Statement on the Care of Transgender Children, Adolescents, and Youth (Pemde et al. 2023); IDEA group consensus statement on medical management of adult gender incongruent individuals seeking gender reaffirmation as female (Majumder et al. 2020); Manual on Mental Healthcare of Transgendered persons in India (Pai et al. 2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e It is important to note that this document has no bearing on the data collected in this study as the SOP was published only in August, 2024 and data for this study was collected between June 2022 to March 2023. The presence of this SOP gives further legitimacy to the practice of necessity of a MHP certification of GD/GI before accessing gender transition.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e IRB clearance was obtained on 2nd May 2022; Serial No. of IRB meeting: 2021-22, 35\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e There is no clarity in India on the educational qualifications of MHPs who can provide referrals/ letter of support for TGD clients seeking gender transition services. In practice these are usually provided by psychiatrists or clinical psychologists. Total number of psychiatrists and clinical psychologists in the sample in this study is 76\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e MMPI (Minnesota Multiphasic Personality Inventory) is a standardised psychometric test in adult psychopathology. MMPI-2, the widest used form of this test, published in 2008, has 567 true/ false questions.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e MCMI (Millon Clinical Multiaxial Inventory) is a self-report psychometric tool to assess personality traits and psychopathology. MCMI-IV, the most recent edition, was published in 2015 and has 195 true/ false items.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e \u0026ldquo;\u003cem\u003eHijra\u003c/em\u003e\u0026rdquo;is a historically rooted socio-cultural identity/way of being in South-Asia, and refers to persons who are assigned the male sex-gender at birth; whose gender expression and identity may be feminine/woman; and who may identify as \u0026ldquo;third gender\u0026rdquo;, outside the binary of man and woman. Hijras traditionally live in a kinship system with other hijra persons. There has been extensive Indian and international scholarship on the presence of the hijra figure within mythological Hindu texts and in pre-colonial as well as colonial and contemporary times.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gender Dysphoria, Gender Incongruence, GID Certificate, Mental Health Assessment, Trans and Gender Diverse (TGD) persons","lastPublishedDoi":"10.21203/rs.3.rs-5613392/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5613392/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLast decade in India has seen increasing visibility and dialogue on trans health including gender affirmation interventions. This has been enabled by growing mobilisation and assertion from trans communities and a range of legal and policy changes supporting trans inclusion. In this paper, we focus on mental health assessment of gender dysphoria/ incongruence that is the first and an essential step for a transgender person in the Indian context to be able to access medical and surgical gender affirmation interventions. We discuss findings of a mixed-method, exploratory study conducted with 165 mental health professionals in three cities of India. In this paper we primarily present qualitative data on mental health professionals\u0026rsquo; understanding of gender incongruence, their practice of assessment, rationale for the same and ways in which they end up gatekeeping access to medical and surgical gender affirmative interventions. Concepts such as biological determinism of gender, trans normativity, pathologisation of trans and gender diversity, mental stability and capacity are used to critically discuss findings.\u003c/p\u003e","manuscriptTitle":"In Quest of An Authentic Identity – An Exploratory Study of Mental Health Assessment of Gender Incongruence in Urban India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-20 17:17:44","doi":"10.21203/rs.3.rs-5613392/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-20T14:06:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-16T06:22:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-07T08:44:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5224732990401512708898818551772153888","date":"2025-01-06T15:03:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51128696390455889685305266154698064083","date":"2025-01-03T20:40:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313020757324265669380278886158269456974","date":"2024-12-31T06:57:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-30T05:03:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-18T15:09:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-18T15:06:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-12-10T05:42:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"308a09fe-4589-4f4b-b69b-51b744882bd4","owner":[],"postedDate":"December 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:01:44+00:00","versionOfRecord":{"articleIdentity":"rs-5613392","link":"https://doi.org/10.1186/s12888-025-06740-4","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-04-16 15:57:48","publishedOnDateReadable":"April 16th, 2025"},"versionCreatedAt":"2024-12-20 17:17:44","video":"","vorDoi":"10.1186/s12888-025-06740-4","vorDoiUrl":"https://doi.org/10.1186/s12888-025-06740-4","workflowStages":[]},"version":"v1","identity":"rs-5613392","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5613392","identity":"rs-5613392","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}