“Some people with schizophrenia or other mental disorders identify with another gender. This is why it is important for transgender people to get a psychiatric evaluation before they undergo gender reassignment surgeries. And since these surgeries are irreversible, this evaluation is very important.”
This psychiatrist’s opinion about the imperative of psychiatric clearance for transgender people to undergo gender affirmative surgical procedures captures a major tension in the field of transgender rights, the tension between the right to self-determined gender identity and the mediating role of psychiatric authority. At the core of this imperative is the presumption that possessing a non-normative gender identity carries an inherent “risk” of psychopathology and as a result, transgender people are compelled to prove their mental soundness to access gender affirmative treatments, particularly surgeries. Facilitating this mediating path of psychiatric clearance is the use of psychometric assessments that inform clinical judgment.
Psychiatric Interrogation and Transgender Care
The quest to obtain psychiatric clearance often proves arduous for transgender people especially in a country like India with limited mental health services, uncertain licensure systems, and a general lack of awareness about gender diversity and transgender rights among mental health professionals (Duffy and Kelly, 2018; Manickam, 2015, Tosh, 2016).
Another major concern is that the onus is placed on transgender people to prove that they are not mentally ill, which is ethically dubious (Ashley 2019). A further concern that arises is the adequacy of generic psychometric assessments to capture the lived realities of transgender people and the deterministic way in which these assessments are administered such that they foreclose any scope of nuanced clinical judgments.
There is also the question about whether someone with a genuine mental illness should be deprived of access to gender affirmative treatments and how it can be ascertained whether or not there is a correlation between their mental health and their gender identity.
Instead of this overreliance on psychiatric authority and the arbitrary usage of psychometric assessments, informed consent appears to be a more comprehensive strategy to ensure that individuals undergoing gender affirmative surgical procedures are adequately informed about the nature and implications of these procedures while ensuring that their personal integrity and choices are preserved without subjecting them to unfounded psychiatric interrogation.
Conversations with two trans men in Mumbai who had undergone gender affirmative surgeries reveal the bureaucratic procedures – predominantly psychiatric assessments – they had to go through to obtain psychiatric clearance, which required them to accept the labels of “gender identity disorder” and “gender dysphoria” even though they did not show any symptoms of mental illness.
Drawing on global transgender activism discourses that critique the arbitrariness of psychiatric gatekeeping of transgender people’s access to gender affirmative procedures, this article similarly questions the necessity, ethics, and accuracy of these assessments. A conversation with a psychiatrist in Mumbai who was identified as being supportive of transgender people’s rights is also included this study to present insights about what psychometric assessments can offer transgender people and how these assessments can be positioned in a holistic clinical judgment. The article concludes with a call for the greater use of informed consent in transgender healthcare as an alternative to psychiatric gatekeeping, with mental health professionals playing a supportive and enabling role rather than a deterministic one.
A Short History of Psychopathologization: Psy-Disciplines’ Gatekeeping of Transgender Rights
The codification of gender and sexual diversity as mental disorders in the World Health Organization’s (WHO) International Classification of Diseases (ICD) and the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) is testimony to the key role that the Psy-disciplines of psychiatry, psychology, psychiatric social work and others have played in psychopathologizing gender and sexual diversity. Pathologization can be defined as “the psycho-medical, legal, and cultural practice of identifying a feature, an individual, or a population as intrinsically disordered” (CastroPeraza et al, 2019:2). It could also be defined as “the conceptualization of bodily characteristics, habits, practices, living forms, gestures, people, and groups of people as mentally disordered, ill, abnormal, or malformed” (Schwend, 2020:2). When the focus of pathologization is on psychological characteristics then this is called psychopathologization.
By classifying diverse gender identities outside of the cisgender norm as mental disorders, the Psy-disciplines have contributed to the social stigma and curtailment of human rights of gender minorities.
Laurence Kirmayer considers a psychiatric diagnosis to be ‘a map and charter of a social world’ (2005:193). A psychiatric diagnosis is not merely a common reference point for mental health professionals but is culturally and socially embedded (ibid:192). For patients, a diagnosis entails a reconstruction of their identity, enabling them to identify as “legitimately distressed or disabled” while also making them vulnerable to stigma (ibid).
The restrictive implications of gender diversity being classified as mental disorders has led to activists demanding the declassification of gender diversity from standardized diagnostic classifications, as well as to mental health professionals re-evaluating the rationale for this classification. A brief overview of the classification history of gender diversity in the ICD and the DSM reveals some of the ways in which the Psy-disciplines have attempted to grapple with tensions between transgender rights and psychiatric rationality.
The category “transsexualism” was introduced into the DSM-III in 1980 with the two categories “Gender Identity Disorder (GID)/Child Transsexualism” and “Gender Identity Disorder/Adolescent and Adult, Non-Transsexual Type” and “Gender Identity Disorder/Not Otherwise Specified”. In the DSM-IV, these classifications were changed to “Gender Identity Disorder in Children”, “Gender Identity Disorder in Adolescents or Adults”, and “Gender Identity Disorder Not Otherwise Specified”. In the DSM-V in 2013, the category “Gender dysphoria” was introduced to describe only the distress associated with gender diversity and not gender diverse identities per se.
“Transvestitism” was introduced into the ICD-8 in 1965, changed to “transvestism” in 1975 and then to “Gender identity disorders” in the ICD-10 in 1990. 1 “Cisgender” refers to an individual who identifies with the gender identity that was assigned to them at birth. The ICD-11, which was enforced from 2022, has replaced GID with gender incongruence (GI) in a new chapter on conditions relating to sexual health. Gender incongruence in the ICD-11 is defined as follows: “Gender incongruence is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group” (WHO 2020).
The Complications of Classifications:
This retaining of gender incongruence as a sexual health condition has been regarded as a compromise between declassifying it as a mental disorder and retaining it as a medical category to enable transgender and other gender diverse people to access necessary healthcare and health insurance where they are eligible for the same (eg: Drescher et al, 2012; Inch, 2016; Rodriguez et al, 2018). But the retention of gender incongruence arguably perpetuates the medicalization of gender diversity and carries the risk of perpetuating Psy-gatekeeping in tacit ways (Castro-Peraza et al, 2020; Inch, 2016; Rodriguez et al, 2018).
Critics further contend that the concept of gender incongruence is still premised on binary conceptions of sex and gender (male/female, masculine/feminine) with a caveat that claims to prevent the pathologization of gender diverse identities per se. Hence, gender diversity remains classified as a health condition within the latest editions of the DSM and the ICD despite several evolutionary stages to its classification history. Although the ICD currently classifies it as a sexual health concern, this arguably creates scope for Psy-gatekeeping since sexuality is a complex subject with various bio-psycho-social dimensions.
The historical association between gender diversity and mental disorders perpetuates to this day and it has resulted in surgeons, who perform gender affirmative procedures, mandating psychiatric clearance for transgender people to access these forms of healthcare.
This requirement is generally applied in an arbitrary manner to all transgender people irrespective of whether they present any signs of mental distress or not and places their right to access gender affirmative treatments on the Psy-professional’s judgment.
This judgment is further guided predominantly by psychometric assessments that are not specifically designed for the purpose of guiding transgender people navigate gender affirmative treatments. The World Professional Association for Transgender Health’s (WPATH) international guidelines on transgender health issues includes gender affirmative procedures and strongly recommends, but does not mandate, mental health professionals to play an important role in mediating transgender people’s access to gender affirmative treatments. The guidelines consider psychometric assessments to be an important resource in this process, which some healthcare professionals and transgender rights activists have challenged since this seems to be a validation of arbitrary Psy gatekeeping (Cavanaugh et al 2016).
Although this predicament of transgender people is well documented, there is very little documented evidence about the lived journeys of transgender persons navigating the psychiatric system to obtain the clearance necessary to obtain gender affirmative treatments, especially in India. This brief study is aimed to address this gap through an analysis of transgender persons’ own experiences with Psy gatekeeping as well as a psychiatrist’s perspective on the need for psychometric assessments for this purpose.
Methodology: Interviews About Lived Experience
Two transgender persons who belonged to a support group in Mumbai of which the author is a part were interviewed with the study. Both these persons identified as trans men and had undergone mastectomies and hysterectomies. One of the men, SP, was contacted through reference sampling by an acquaintance of the author while the second man, Ajay, was selected purposely based on an informal conversation he had with the author at a social event. The men were requested to share their experience with accessing psychiatric clearance in order to get gender affirmative surgeries. Detailed notes of their experiences were taken, typed out, and then shared with them for their feedback. This final transcript with their feedback was considered for analysis.
For the psychiatrists, recommendations were taken from members of the support group about psychiatrists who they considered to be affirmative of gender and sexual minorities. A literature review of scholarship published by psychiatrists in Mumbai was also conducted and the authors were approached for interviews. Four psychiatrists consented to interviews although only one of them had worked with transgender patients while all the others had only worked with sexual minorities.
The psychiatrists were all asked whether they felt psychometric assessments were needed for transgender patients to access gender affirmative treatments and the one psychiatrist who had experience with providing transgender people with the necessary certification was urged to share more details to substantiate his responses. He was also asked questions about his opinion about the right of people with mental illness to access gender affirmative treatments.
Findings and Discussion
SP’s Experience: Proving the Absence of a Mental Disorder
SP is a trans man in his twenties who lives in Mumbai, India. At the time of the interview in 2018, he was working in his family’s pharmacy. SP reported that his family had ambiguous feelings about his gender identity growing up. At first, they were unhappy with his identity but eventually accepted him for who he was albeit with occasional apprehensions.
SP also shared how he had strong friendships ever since he was in school and that his friends stood up for him whenever he was faced with threats of bullying or intrusive questions. SP said that he did not experience any kind of trauma or distress about his gender identity ever in his life. It was only when he reached puberty that he found the experience of menstruation extremely stressful and uncomfortable.
A few years prior to the interview, SP had undergone mastectomy at a private plastic surgery clinic. He did not require any kind of psychiatric clearance to undergo this procedure. However, SP had to encounter a vast amount of red tape to secure psychiatric clearance when he opted for a hysterectomy. He approached a psychiatrist at a well-known government hospital in Mumbai who asked him to get a Minnesota Multiphasic Personality Inventory (MMPI) and the Rorschach inkblot tests done through a psychologist. The MMPI is a clinical tool that is used to assess the presence of psychopathological conditions.
SP approached a psychologist in a private setting for the tests. He had not informed his family about his plans for the day as he was concerned about how they would feel about his plans to get a hysterectomy. As a result, his family members kept calling to enquire about his whereabouts.
This was very stressful for SP and he could not concentrate on the test. Furthermore, he found the questions on the test difficult to understand since he was not very comfortable with English. All these factors contributed to SP receiving a diagnosis of a “high level of depression”, which made him ineligible for surgery.
SP was extremely disappointed but he did not give up. He approached the psychiatrist in the government hospital, explained the situation to him and asked him for his advice. The psychiatrist assured him that he believed in SP’s gender identity and validated his desire for the surgery. He asked him to approach a psychologist again to get the MMPI done again. But SP could not afford to spend any more on these assessments, so he asked the psychiatrist if he could just undergo these tests at the government hospital. SP’s friend had earlier told him that the government hospital provided high quality medical care either at very low or no costs but that he would have to be willing to spend a long time to get the procedures done. This reassured SP to entrust the hospital with his psychiatric assessment even if it meant spending more time.
The psychiatrist agreed to let SP take the tests in the government hospital. He administered the MMPI-II to him and asked him to remain calm and take his time with the test. He also had another doctor stay in the room with SP and translate the questions from English to Hindi as per SP’s need. This time, SP’s score on the test sufficed to make him eligible for surgery. The psychiatrist briefly discussed with SP the implications of the surgery and its irreversibility.
He was given a certificate which diagnosed him with “Gender Identity Disorder”, which sufficed to declare SP eligible for surgery.
Ajay’s Experience: Identity vs Dysphoria.
Ajay is a trans man in his twenties. He was working as a Human Resource Manager in a company in Mumbai at the time of the interview in 2018 and later shifted to Bangalore for a job as a Diversity and Inclusion Manager.
Like SP, Ajay mentioned that he did not face any adversity in his childhood related to his gender identity either from his family or his peers and he did not have any major challenges accepting himself.
However, he was unaware about what “transgender” meant or the possibility that he might be transgender. Instead, he was only aware of homosexuality and identified as lesbian during childhood. His beliefs about his identity gradually began to evolve during his undergraduate and graduate studies in psychology. Ajay said that although the curriculum did not explicitly discuss gender and sexual diversity, he began to better understand these subjects through his formal education and supplemented it with his own reading. Eventually, Ajay realized that he identified as transgender and wished to undergo gender affirmative treatments. Like SP, he required psychiatric clearance to undergo a hysterectomy.
Ajay got this procedure done in a private hospital in the state of Gujarat and had his psychiatric evaluation done in the same hospital. He was administered the Rorschach ink blot test and the Thematic Appreciation Test (TAT) to assess his mental health prior to surgery, The Thematic Appreciation Test (TAT) is a clinical tool that provides insights into a person’s personality and emotional states by asking them to frame a story based on a series of ambiguous images that are shown to them. The test was developed by psychologists Henry A. Murray and Christina D. Morgan at Harvard University in the 1930s (Cherry 2025c). Based on the results of the test, Ajay was declared mentally fit for surgery.
Ajay observed that most hospitals were not aware about the DSM-V and the category of “gender dysphoria” and were hence issuing certificates of “gender identity disorder”. He believed that the hospital where he had undergone the surgery was better informed about the latest terminology pertaining to transgender rights.
What Causes Distress? The Dubious Rationale for Psychiatric Assessments.
Neither SP nor Ajay reported having experienced any discomfort with their gender identity or experiencing any kind of mental distress. Under these circumstances, the rationale for a psychiatric assessment appears questionable and rather arbitrary. SP’s situation was a little more complex than Ajay’s since his family members were ambiguous in accepting him and he could not be open with them about his desire to undergo gender affirmative surgery. This ambiguity along with his difficulties with English played a key role in his diagnosis of depression that made him ineligible for surgery. Clearly, this diagnosis was not representative of SP’s psychological state but was a product of his circumstances at the time, as both SP and the psychiatrist concurred.
His trysts with the psychometric assessments also reveal the cultural and linguistic inappropriateness of these assessments, which questions their universality.
Ajay’s observation about the distinction between gender identity disorder and gender dysphoria is also significant for a few reasons. Firstly, rather than ignorance, it is likely that the government hospital in Mumbai followed the ICD-11 classification as opposed to the DSM-V classification, which is justified since the ICD is more commonly used in India. Secondly, Ajay perhaps prefers the term “gender dysphoria” as the DSM-V is more recent than the ICD-11 and because the category of gender dysphoria purports to medicalize only the distress associated with one’s gender identity and not the identity itself, which seems validating of one’s right to self-determine their gender identity.
But Ajay himself reported no distress associated with his gender identity, making the attribution of any mental disorder to him unethical.
It is also problematic that both men were administered generic psychiatric assessments as there does not appear to be any kind of specialized assessment to suit their specific situation.
Another important ethical dilemma that psychiatric gatekeeping poses is that many transgender people might experience varying degrees of mental distress owing to stigma and misconceptions related to their gender identity. This distress might not have any correlation with their gender identity at all but if psychometric assessments reveal this distress, it might be arbitrarily linked to their gender identity deeming them ineligible for gender affirmative treatments. This is deeply unethical.
A more nuanced situation is a person who might have schizophrenia or another major mental illness and identify as transgender but their gender identity has no correlation with their mental illness. Under current diagnostic regimes, such a person cannot seek gender affirmative procedures and there does not seem to be any clear way to establish whether or not their gender identity has any connection with schizophrenia. The current arbitrary regime of psychiatric gatekeeping precludes possible answers to these crucial and sensitive questions.
A Psychiatrist’s Take
As a part of this study, four psychiatrists from Mumbai were interviewed about their perspectives on transgender people’s requirement for psychiatric clearance in order to become eligible for gender affirmative procedures. All of them believed in the need for psychometric assessments to rule out the possibility of mental disorders such as schizophrenia, borderline personality disorder, bipolar disorder and paranoias. But only one of the psychiatrists had experience working with transgender people and with providing them the certification they required to undergo gender affirmative treatments. These were his perspectives about the need for these assessments:
“I think these psychometric assessments are needed because they help to give us a history of the person and form a clinical judgment. We want to rule out psychological disorders. We check to see if their insight and judgment are preserved and write a report…A good plastic surgeon would always want to get a psychiatrist’s opinion and work in conjunction with the psychiatrist. They want a certificate that says that the person is of sound mind and that their capacity and judgment are preserved. Nowadays, there are some plastic surgeons with questionable ethics who go ahead even without a psychiatrist’s opinion but you need a system of checks and balances. It is up to the psychiatrist to word the report and to include a clinical history of the patient.”
When asked what he thought about the right of people with mental health issues to access gender affirmative treatments, the psychiatrist said:
“We don’t decide that; that is up to the surgeon to decide whether they would want to perform the surgeries or not. We just submit our report about the person’s insight and judgment and mental capacities. People with psychiatric illnesses often have impaired judgment and cannot fully understand what the implications of the surgery are. They also imagine things. Even when people are abused, they sometimes cannot accept their bodies and want to change them to something else. I would not advise anyone with a psychological disorder to undergo a major surgery in a hurry because adjustment after the surgery is extremely tricky. There are also hormones involved, which can aggravate psychological problems. I would advise them to have top surgery [mastectomy or breast augmentation depending on the person] and then wait for a long time before considering bottom surgery [hysterectomy, vaginoplasty, phalloplasty depending on the person]. There is a cost factor to these surgeries that needs to be considered and also legal issues. People might come after you [the psychiatrist] or the surgeon. People with psychological problems who are undergoing treatment or medication of some kind and who have good insight can reasonably opt for surgery but they need to exercise caution.”
This psychiatrist’s response appears comprehensive and nuanced in terms of his regard for the rights of transgender people as well as individuals with diagnoses of psychological challenges. He does not eliminate the possibility of people with mental health issues accessing gender affirmative procedures but calls for a careful, stage-wise approach. He further foregrounds the importance of counselling by “specialized psychiatrists or psychologists” who are trained and sensitized in transgender health issues and who are familiar with the WPATH guidelines as well as with updates to the guidelines.
His observation about some plastic surgeons resorting to unethical practices by not seeking psychiatric collaboration also suggests that the elimination of Psy-gatekeeping does not automatically validate transgender people’s right to self-determine their gender identity and could just be a questionable business strategy. But when read in conjunction with SP’s and Ajay’s experiences with Psy gatekeeping, several ethical questions persist.
Psy-Gatekeeping: Unanswered Questions and Complications
While the psychiatrist considered psychometric assessments to be only a part of overall psychological assessment, they appeared to constitute the whole psychiatric profiling of the two men. Counselling was briefly mentioned by SP and perhaps Ajay underwent the same, too, but the counselling was not a significant part of the mental health evaluation these men received. Moreover, the psychiatric assessments also seem to have a curtailing impact on psychiatric authority, as was evident in SP’s case. Although the psychiatrist was convinced of the veracity of SP’s identity, he was compelled to find a way to mould SP’s performance on the MMPI to get a desired result and was not confident about issuing a letter validating SP as being psychologically fit for the surgery given the diagnosis of depression resulting from the MMPI.
This is reflective of what the psychiatrist claimed about the psychiatric assessment being a legal safeguard of the medical professionals and, as Ajay’s and SP’s cases reveal, it appears to serve this purpose more than it does to benefit the patients or to help them make more informed decisions.
The psychiatrist’s narrative raises other important questions about the need for mental health professionals to be a part of the system of gender affirmative treatments at all. Ashley (2019) observes that owing to the corporal focus of gender affirmative treatments, Psy-gatekeeping is completely absurd unless there is sufficient grounds to justify the same. This argument appears to be valid based on SP’s and Ajay’s experience. However, given that some surgeons might seek to bypass psy authority merely for personal gain and the enabling role that aware and sensitized psy professionals can potentially play, it might be a good idea for psy professionals to be a part of transgender persons’ healthcare teams and leverage the process of informed consent.
Solving the Puzzle: Informed consent and Individual Rights
A more comprehensive approach to psychometric assessments is the informed consent model. The model can be conceptualized as followed:
[Informed consent] requires that clinicians or someone administering treatment…effectively communicate anticipated benefits and potential risks of a treatment, as well as the reasonable alternatives to that treatment. It relies on the patient’s capacity for understanding and weighing these options. Integral to the practice of informed consent is the principle of respect for patient autonomy—that is, respect for a person’s right of self-determination—and the belief that clinicians will work to facilitate patients’ decisions about the course of their own lives and care (Shah et al 2024).
In transgender healthcare, the informed consent model involves detailed discussions between clinicians and patients to ensure that patients are fully informed about the procedures that they are about to undergo and the implications of the same. Mental health professionals need not necessarily be a part of this discussion but they could be involved strategically depending on the situation and could potentially benefit the person. As the psychiatrist interviewed for this study said, “Plastic surgeons do not receive any education in psychiatry. They have about three or four lectures in psychiatry but that is not enough to give them a good picture of what a person might be going through psychologically.”
This suggests that including a mental health professional could benefit some transgender clients who explicitly ask for their inclusion or who have documented evidence of experiencing mental distress. Even in these situations, psychometric assessments should not be the primary tool to guide clinical judgment; the mental health professional should use counselling and dialogue to solicit informed consent with Psy-assessments being used only when absolutely necessary and not in a deterministic manner.
This comprehensive model aims to leverage patient autonomy and gives clinicians the opportunity to gain holistic insights into the patient’s motivations and choices. Informed consent is based on the principle of mutual trust rather than the presumption of pathology and carries the promise of better healthcare decisions and better satisfaction with the outcomes. There are certainly limitations to the informed consent approach such as the patient presenting a fictitious “ideal” narrative to the clinician to get approval for surgery (Cavanaugh et al 2016) but given the holistic nature of this model and the limitations of psychometric assessments, the former appears to be worth considering seriously and its efficacy explored and documented.
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Suchaita Tenneti
Suchaita is an independent researcher and development sector professional working in the areas of youth inclusion, disability, and gender and sexuality. She holds a PhD in Sociology from the Jawaharlal Nehru University, New Delhi.