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Trans Affirmative
Mental Health Care
Guidelines:
Results of a Mixed- Method
Inquiry in Three Cities of India
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Research Associates
Indranarayan Roychowdhuri, MPhil in Psychiatric Social Work, Mumbai
Prarthana Pai, MPhil in Applied Psychology (Clinical & Counselling Practice), Bangalore
Arzoo Singh (part-time), MA Psychology, Delhi
Study Support
American Jewish World Service [AJWS]
2023
Trans Affirmative
Mental Health Care Guidelines:
results of a mixed-method
inquiry in three cities of India
Research Team
Principal Investigator
KP/ Ketki Ranade, PhD
Center for Health and Mental Health, School of Social Work,
TISS, Mumbai
Co-Investigators
Neeraj Kumar
Mental Health Practitioner
& Interdisciplinary
Feminist Researcher
Founder, The Unsound Project
Delhi
Mohan Raju S
Clinical Psychologist
Formerly with M S Ramaiah
Medical College and Hospitals,
Bangalore
Aryan Somaiya
Psychotherapist
Co-founder, Guftagu
Counselling &
Psychotherapy Services
Mumbai
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Copy Editor: Smriti Nevatia
Design - Cover and Layout: Neelima P Aryan
About the Publication
This publication is solely for non-commercial purposes and is intended to be used for teaching, training
and research. It may be freely downloaded and used for teaching, training and research purposes, with
due acknowledgements to the authors and institutions. For reproducing, reprinting, translating parts
or the whole of this document, permissions need to be sought from the corresponding author of this
publication.
Corresponding Author Details
KP/ Ketki Ranade
Faculty, Center for Health and Mental Health
School of Social Work
Tata Institute of Social Sciences
V.N. Purav Marg, Mumbai-400088
Email: ketki.ranade@tiss.edu
Suggested Citation:
Ranade, K., Kumar, N., Raju, M.S., Somaiya, A., Pai, P., Roychowdhuri, I., Singh, A. (2023). Trans Armative
Mental Health Care Guidelines: results of a mixed-method inquiry in three cities of India, TISS, Mumbai
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ENDORSEMENTS
The report on Trans Armative Mental Health Care is a much-needed step forward in a much-
neglected domain. The research that led to this report is ne tuned to assess existing attitudes to
transgender persons, including candid interviews with healthcare personnel of varying seniority.
Guidelines have been suggested to improve the mental health care of trans folk, and these come
not a day too early.
Dr Ajit V Bhide, Psychiatrist & Psychotherapist & Past President,
Indian Psychiatric Society (IPS)
This is a well-researched rst of its kind document that contributes evidence based guidelines for
Trans armative mental health services and in doing so, lls a major gap in the medical education
institution. The guidelines address the concerns not just of the transgender community but also
their families, intimate relations, support groups and medical professionals, thereby advocating
a holistic approach to mental health care that goes beyond diagnoses and treatment of disorders.
This is a much-needed good practice reminder in the eld of mental health today and always.
Dr Ranjita Biswas, Psychiatrist, Therapist, Member of Sappho for Equality, Kolkata & Co-author of the
report, A Good Practice Guide to Gender-Armative Care (2017)
An excellent resource that bridges the gap between laws, guidelines and our experiences and
challenges in the therapy room. The evocative narratives encourage us to reect on structural
inequalities and barriers, to question therapist neutrality and build ethical, arming and
contextually relevant mental health care services. A landmark report with the potential to transform
training and practice processes across the country.
Poornima Bhola, Professor of Clinical Psychology, National Institute of Mental Health and Neuro Sciences
(NIMHANS) & lead author of Reective Practice and Professional Development in Psychotherapy (2022)
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I congratulate Ketki Ranade/KP and their team for the very relevant and insightful Trans Armative
Health Care Guidelines which has stemmed from a well conducted study. The report they have
presented is a MUST READ for all mental health professionals. The 12 guidelines recommended in
this report are very helpful. As a Psychiatric Social Work (PSW) Professional working with families
and training mental health professionals in family therapy, the guideline on Working with Families
of Origin of TGD clients has made me realise that the training in family therapy that we impart is
not trans armative and there is an urgent need to rectify this.
Dr Sobhana H, Associate Professor, Department of Psychiatric Social Work, LGBRIMH, Tezpur and
President, Association of Psychiatric Social Work Professionals (APSWP)
This report is timely and relevant, especially given the near absence of knowledge or capacity building
in curriculum and training in the mental health disciplines about trans clients. Based on a research
study on perceptions and practices of mental health practitioners, it provides a documentation of
existing armative practices adopted by practitioners, and serves as a set of concrete and useful
guidelines to adopt with trans clients. The key feature of the report is that it blends ably macro-
level understanding of societal/systemic issues aecting transgender individuals, and micro-level
psychosocial skills for alleviation of distress and promotion of their empowerment and agency.
Hopefully, the report will stimulate those in the eld to go beyond the ‘mandate’ of a mental health
practitioner to work as allies and advocates in countering trans-prejudice and enabling trans-
inclusive environments.
U. Vindhya, Former Professor of Psychology, Tata Institute of Social Sciences, Hyderabad campus & author
of Feminist Psychologies in India in the Oxford Research Encyclopaedia of Psychology (2020)
The document validates the experiences of transgender and gender-diverse individuals, outlining
guidelines for care providers to reduce disparities in mental health care delivery. Although limited
to metropolitan cities, it sets the stage for developing a model for providing gender-armative
care by mental health providers in India. Kudos to the entire research team for their excellent work.
Air Cmde (Dr) Sanjay Sharma (Retd), Managing Director, Association of Transgender Health India (ATHI) &
Board Member, World Professional Association of Transgender Health (WPATH)
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BACKGROUND
The last decade has seen increased visibility for the rights of transgender persons in public, legal
and policy discourse in India. The Supreme Court judgement that provided recognition to transgender
persons as equal citizens (Supreme Court of India, 2014) and the passing of the Transgender Persons
(Protection of Rights) Act by the Indian Parliament (GOI, 2019) have been major milestones that have
driven the formulation of national and state-level policy and welfare programmes for transgender
persons in the country, especially in the areas of education, livelihood and shelter.1 In the context of health,
the Transgender Persons (Protection of Rights) Act, 2019, Section 15 (healthcare facilities) promises a
range of services and action by the government. These include making healthcare facilities – including
gender-armative therapies – accessible to transgender persons; providing for a comprehensive
insurance scheme that covers gender-armative therapies; developing a health manual related to ‘sex
reassignment surgery’ in accordance with international protocols; and reviewing medical curricula and
research for enhancing the competencies of healthcare providers to address trans-specic health issues.
While the progress on implementation of the Act, especially in the area of healthcare, is arguably slow
and uneven across states, the presence of the law has most denitively drawn attention to the hitherto
neglected area of trans health and mental health.
Few High Court judgements in the country have addressed trans health; for instance, a Madras High
Court judgement directed the National Medical Commission to address the issue of dignied inclusion
of LGBTQ+ persons in medical curricula (S Sushma v/s Commissioner of Police, Chennai, 2021). The
same judgement declared as illegal the use of conversion treatments aimed at curing sexual orientation
and gender identity. In another judgement, the Kerala High Court directed the state to take stringent
action against forced conversion treatments and to form an expert committee and guidelines to deal
with the issue of conversion treatments (Queerala v/s State of Kerala, 2021).
Research on the health and mental health care needs of transgender and gender diverse (TGD)2 persons
has also brought to the fore experiences of violations within mental health service contexts and other
barriers to healthcare access. In the last decade, several studies have documented a higher incidence of
mental illnesses such as depression, suicidality, substance use disorders (Hebbar et al., 2017; Virupaksha
et al., 2016; Sartaj et al., 2021) among transgender persons. Research has also demonstrated a link
between experiences of victimisation and stigma, and poor health outcomes in the form of alcohol use,
depression and risk for HIV among transgender women (Chakrapani et al., 2017). A report based on a
qualitative study in West Bengal documented practices of conversion/ curative treatments carried out
on young transgender persons. These treatments were provided by formal health and mental health
care providers as well as quacks, and religious or spiritual leaders (APTN, 2021). A scoping review
(Pandya et al., 2020) on barriers to accessing health services among transgender persons in India states
that apart from the experience of discrimination at healthcare facilities, the lack of treatment protocols
forms one such barrier. Other scoping reviews on LGBTQ+ health in India highlight the role of stigma,
discrimination, violence, victimisation and non-availability of gender-armative medical care in
government hospitals, as well as poor physical, psychological and sexual health among LGBTQ+ persons
(Chakrapani et al. 2023; Sara et al. 2022). Finally, as suggested by research on TGD mental health,
TGD persons are more likely to use mental health services for three main reasons: one, they may have a
higher incidence of mental health problems due to minority stress; two, those TGD persons who want to
1 There has also been an extensive critique of this law from within trans communities in India, leading to a legal
challenge to some provisions of the Act by trans activists, before the Supreme Court of India.
2 Transgender and Gender Diverse Persons is a term used by the American Psychological Association in guidance
documents on mental health practice with transgender clients (Hope et al. 2022).
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access medical and surgical transition services need the assistance of MHPs to access these; and three,
TGD persons may be brought to MHPs for conversion/ curative treatments. It is against this backdrop
that research on competence (knowledge, attitude, practice) among MHPs in India to deal with TGD
issues becomes signicant.
What do we know about Mental Health Practice with Transgender and
Gender Diverse (TGD) clients in India?
There have been several initiatives by organisations and medical teaching institutions in India to
articulate guidelines/ frameworks for trans-armative healthcare. One of the earliest of these was in
2017 by Sappho for Equality, an organisation working on the rights of lesbian and bisexual women and
trans persons in West Bengal, which brought out a guide, A Good Practice Guide to Gender-Armative
Care. This was based on consultations with health and mental health care providers working with
TGD clients in and around Kolkata (Sappho for Equality, 2017). Similarly, in 2021, the Association for
Transgender Health in India (ATHI,) developed the Indian Standards of Care for Persons with Gender
Incongruence and People with Dierences in Sexual Development/ Orientation, along the lines of the
‘Standards of Care for the Health of Transgender and Gender Diverse People’ by the World Professional
Association of Transgender Health (Coleman et al., 2012). There have been other initiatives, such as the
‘Idea Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals
Seeking Gender Rearmation as Female’ by a group of endocrinologists (Majumder et al., 2020), and the
‘Adolescent Health Academy Statement on the Care of Transgender Children, Adolescents, and Youth’
(Pemde et al., 2023). The National Institute of Mental Health and Neurosciences (NIMHANS) published a
‘Manual on Mental Healthcare of Transgendered persons in India’ (Pai et al., 2021). The TransCare MedEd
initiative, a collaboration of public health experts and institutions, brought out the ‘Competencies on
Trans-Armative Medical Provision Booklet’ (TransCare MedEd, 2022).
It is encouraging to see this range of initiatives on trans healthcare occurring over a short span of ve to
six years. While it is beyond the scope of this document to review these multiple initiatives that has each
sought to provide some guidance to clinicians working in the area of trans health and mental health care,
we wish to highlight two aspects related to the mental health sections of these guidelines/ statements.
The rst is that there seems to be, across these documents, a lack of dialogue and of incremental
learning on trans mental health issues and care. As a result, some perceive the role of mental health
professionals (MHPs) as limited to assessment and care in the context of gender transition; others take
a broader developmental perspective on the roles of child and adolescent mental health professionals as
well as of parents, schools, mental health organisations in working with TGD youth in light of emerging
trans/ gender diverse identities. Our second comment is in the context of the methodologies used to
arrive at the consensus statements/ guidelines. The framing of most of these documents is based on
consultations with a few domain experts/ practitioners or professional taskforces that have reviewed
existing literature and, in a few instances, consultation with TGD communities. While reviewing existing
Indian and international literature and drawing on the rich experience of experts in the eld are valuable
strategies, we suggest that empirical research documenting actual practice with TGD clients would be
of much value, and is currently missing in the emerging discourse on trans-armative mental health
care in India.
The current study is one of the initial attempts to document MHP knowledge, attitudes and practice
with TGD clients as well as MHP training and supervision needs in the area of TGD mental health.
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ABOUT THE RESEARCH STUDY
This is a multi-site research study employing a mixed-method approach and an exploratory,
concurrent triangulation design. It is a mixed-method study because it employs both quantitative and
qualitative methods. As literature in the Indian context on mental health practice with Transgender
and Gender Diverse (TGD) clients from the practitioner’s perspective is sparse, this is a formative,
exploratory research study on practitioners’ knowledge, competence, attitudes and practice with
their TGD clients. Finally, it uses a concurrent triangulation design (Creswell et al., 2003), as we have
collected quantitative and qualitative data simultaneously and analysed them together for the purposes
of comparing, contrasting, corroborating and cross-validating ndings. A total of 165 mental health
practitioners (MHPs) currently practicing in the cities of Mumbai, Bangalore and Delhi were interviewed,
using a quantitative interview schedule. 45 of these practitioners also responded to a qualitative in-
depth interview. The three inclusion criteria for the study were: a) 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; b), a minimum practice duration of one year; and c), the
MHP should have seen a minimum of three TGD clients in the course of their practice. 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, 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 ve community members who self-identied 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.
We recruited our study participants using purposive sampling: in addition to the inclusion criteria
mentioned above, we tried to ensure diversity of sampling by approaching MHPs working in dierent
settings, including public and private hospitals (teaching and non-teaching), clinics, NGO/ CBOs, home-
based, online practice, and so on.
As can be seen in the infographics, 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-
identied as transgender/ non-binary/ genderqueer and 1 participant who self-identied as agender. In
terms of educational background, there were 49 psychiatrists, 61 with a postgraduate degree (MA) in
Psychology, 27 with an MPhil in Clinical Psychology, 9 with an MPhil in Psychiatric Social Work, 6 with
an MA in Social Work and 13 with a PG Diploma in Counselling.
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 the
same time period. In terms of the age range of the TGD clients, 15 participants reported having seen
clients who were 12 years of age or younger for gender identity-/ dysphoria-related concerns, while 90
participants had seen clients between 13 to 18 years for gender identity- and dysphoria-related issues.
13 participants reported having seen TGD clients who were 60 years old or more.
3 IRB clearance was obtained on 2nd May 2022; Serial No. of IRB meeting: 2021-22, 35
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Delhi
26.7%
(n=44)
Mumbai
32.7%
(n=54)
Bangalore
40.6%
(n=67)
City
Educational Background [highest degree received]
MD/ DPM Psychiatry
MA/ MSc Psychology
MPhil Clinical Psychology
MPhil Psychiatric Social Work
MA in Social Work (MSW)
PG Diploma Counselling/ Counselling Courses
29.7% (n=49)
37.0% (n=61)
16.4% (n=27)
5.5% (n=09)
3.6% (n=06)
7.9% (n=13)
Gender Identity
Cis Woman
63.6%
Cis Man
30.9%
Agender
0.6%
Transgender/NB/
Genderqueer
4.8%
PROFILE OF THE RESEARCH PARTICIPANTS
Total number of participants (N=165)
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Mean Age: 39.63 years
Age Range
20-30
29.7% 29.1%
21.8%
12.1%
7.3%
31-40 41-50 51-60 Above 60
Mean Duration of Practice: 12.9 years
Duration of Practice (in Years)
1-3
12.7% 14.5% 25.5% 24.8% 8.5%13.9%
3.1 - 5 5.1 - 10 10.1 - 20 Above 3020.1 - 30
* Total is greater than N=165 as there are multiple responses across categories
** Teaching & Non-Teaching
Practice Settings of Participants*
Public Hospital** Private Hospital** Home-Based
Clinic-Based Online NGO
23.6% (n=39) 16.3% (n=27) 39.4% (n=65)
32.7% (n=54) 24.8% (n=41) 6.06% (n=10)
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Number of TGD Clients seen in past 1 year
Number of Practitioners seeing TGD Minors & Seniors
Up to 10 Clients
68.5%
(n=113)
More Than 50 Clients
6.06%
(n=10)
11-30 Clients
21.8%
(n=36)
12 years of age
or younger
15
60 years of
age or older
13
12 - 18 years
90
Common Presenting Problems Among TGD Clients %
Gender Dysphoria & Discomfort with Gender 18.2
Diculties With Family Acceptance & Self-Acceptance 17.5
Sexuality, Intimate Relationship Issues, Marriage Pressure 14.3
Co-Morbid Mental Illnesses (including Substance-Use-Related Issues,
Personality Disorders)
12.4
Needing Referral Letter for Medical/ Surgical Interventions &
Information about Gender Armation Surgery
10.1
Suicidal Ideation or Self-Harm 9
Bullying & Violence 8.4
Workplace-Related Issues 4.6
Other 5.3
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ABOUT THE TRANS-AFFIRMATIVE MENTAL HEALTH
CARE GUIDELINES
This document presents twelve good practice guidelines for mental health practice with TGD
persons in India. The guidelines have been developed based on the research study under discussion.
Using descriptive statistics and thematic analysis, we have attempted to arrive at an understanding
of practitioners’ knowledge of, attitudes towards and practice with their TGD clients, as well as their
conceptualisations of the mental health problems faced by their TGD clients. The twelve guidelines
presented below are thus grounded in empirical research data on MHP practice with TGD clients.
Literature on guidelines, standards of practice, protocols of mental health interventions with TGD clients,
globally and in the Indian context, has been used as background material to enhance the understanding
of the data collected. We have particularly drawn on the ‘Guidelines for Psychological Practice with
Transgender and Gender Nonconforming People’ by the American Psychological Association (2015) and
‘Community-Derived Practice Adaptations for Psychological Services with Transgender and Gender
Diverse Adults’ (Hope et al., 2022).
Guideline 1. Trans-Affirmative Conceptualisation of Mental Distress/ Illness in
TGD Clients
MHPs equip themselves with knowledge of trans-specific stressors and their
impact on the self, identity, relationships and overall life of the TGD person,
and use this understanding in assessment and conceptualisation of distress
and mental illness in their TGD clients.
Many of the study participants opined that while the symptoms and syndromes with which TGD clients
presented remained the same as with any other cisgender client/ patient, the genesis and explanations
for these symptoms/ distress in TGD clients were more often than not related to the challenges faced
by them due to their non-normative gender identities and expression. Some of the terms highlighted
by participants while dwelling upon the explanations for TGD client distress included trauma/ complex
trauma, adverse childhood experiences, psychosocial/ environmental factors. Some used terms such as
structural problems and systemic and social justice lens to conceptualise TGD mental health concerns.
Other terms used included exogenous or reactive (rather than endogenous). Our data suggests that
participants conceptualised TGD distress from a macro/ structural lens wherein cis-binary-gender
structuring of social systems and of everyday life had an adverse impact on TGD persons’ mental
health. Additionally, relational and interpersonal strain due to trans-related prejudice or ignorance in
the immediate environment of the TGD person – within families, educational institutions and peer
groups – added to their distress. Finally, the impact of structural and interpersonal adversity aected
TGD persons at an intrapsychic level.
The minority stress model developed by Meyer (2007) and adapted by Hendricks and Testa (2012) for
clinical work with transgender and gender non-conforming clients (TGNC) is a useful framework for a
trans-armative conceptualisation of mental distress and illness. Hendricks and Testa (2012) explain
three processes through which TGNC persons are subjected to minority stress. The rst is a hostile and
stressful social environment or external, objective and veriable events that create stress for TGNC
persons, for instance, being misgendered, forced to wear a school uniform based on the gender assigned
at birth, being subjected to ridicule or jokes. The second is the anticipation and expectation of the
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external stressors that cause the need for vigilance and having to hide one’s identity, and the nal one is
the internalisation by the TGNC person of negative social attitudes and prejudice. Clinicians seeking to
provide trans-armative care would do well to incorporate the minority stress framework that views
distress experienced by TGD persons in the context of trans-negativity at the societal and interpersonal
level, and its impact on the self of the TGD person. In the Indian context, Ranade et al. (2022, pp. 142-
145) use the minority stress lens to discuss the psychic impact of growing up as a minority in one’s own
family that can foundationally aect the parent-child attachment and attunement, and may continue to
aect the trans person even in adulthood.
The following quotes from the study participants discuss dierential stressors at the intrapsychic and
interpersonal level experienced by TGD persons, and the ways in which these aect them.
‘For trans kids, their every minute is torture if the parents know about it and
refuse to ask and fail to accept. It starts with being bullied or beaten up but
not understood, not being heard, forced to, you know, associate with a certain
group of people – so if it’s a boy who asserts as a trans woman, then push
more towards boys – “Ladkon ke saath jaakay khelo” (“Go play with the boys”).
So, every minute is dicult for them… Surprisingly the bullying also happens at
the hands of the teachers, the second layer of adults that you look up to… So, a
lot of bullying happens from the adults around them, the ones that ordinarily
people would consider as safe zones for children.’
42-year-old woman, Counsellor, Bangalore
‘I think it’s quite dierent in terms of the content, like content of the
cognitions… like what the transgender client is worrying about, or feeling
hopeful, hopeless about, or is feeling worthless about is a lot to do with
that gender and adapting to it and to the people around them. So, if we’re
talking about syndrome, and the symptoms, that syndrome is the same but
from a cognition lens, it’s dierent.’
29-year-old woman, Clinical Psychologist, Bangalore
‘I think the kinds of stresses they face are very dierent, the anxieties that they
have would be very dierent, it would be like, “Will I have a peer group which
will accept me? Will they allow me to be the person I want to be?” . . . it was all
a reaction to the whole situation that they were going through, which is natural.
I think it was more reactive . . . though it was a mental health issue, but it was
not pathological in that sense.’
68-year-old woman, Clinical Psychologist, Bangalore
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‘For a regular client it may be like standard trauma but for a trans client,
it may be childhood trauma plus being disappointed in one’s body, so the
reason would be dierent. There is also vigilance, right? They have to be
vigilant about the way their body occupies space. So, you know, having to
think about, like, in your binary spaces, how to dress and be able to pass, or
suppose there is a function or something in which you have to dress with
the gender assigned at birth, then navigating that, anticipating the distress,
nding ways to minimise that time, that you spend in [that] clothing, I think
all of that leads to extra stress. Umm, a lot of fatigue and mental work that
you end up doing.’
29-year-old woman, Psychologist, Mumbai
‘I’m working with twins, so a set of two clients – and it is so dierent between
the two. And it has always been seen as [a] temperament thing by the family.
They both are 16. But when I speak to this young person who’s exploring their
gender and has come out as trans to the parents, they say, “I can’t even think
about asking for the kinds of opportunities that my brother does. So, I would
really like, for example, to learn Bharatnatyam, but I ended up telling my dad
that “Can I learn contemporary pop dance?” I see this very often ingrained in
trans clients. This sort of sense of not being even able to think of a free life with
entitlement. It’s like, – “how will I ever seek something that in my own internal
framework I don’t believe can exist for me?”’
49-year-old woman, Psychiatrist, Delhi
Participants also discussed the role of macro factors such as housing or workplace issues as a source of
trans-related stress among their TGD clients.
‘A client who, you know, nally started hormone, HRT (hormone
replacement therapy) and all of that. We talked about it for such a long
time and it was like this dream that they will start and they can nally
transition. But then when they were about to start, this fear about, how safe
would it be, you know because they live in a rented house, also at [their]
workplace, what would transitioning publicly mean? So, this client was
struggling with the fear of being thrown out of their rented house. Their
plan was to start transitioning and give themselves three to four months
in the current house, while they would still dress as the gender that they
were assigned, to be able to pass and then once the eect of the transition
started, then they will try and pass as the gender that they want to
transition to. So this was a trans woman. So basically, she was planning that
after three, four months she can dress more like a woman and then look
for [a] house as a woman. So that kind of calculation, right? Like that kind
of planning just to ensure your safety. I mean, it’s just so terrible, you don’t
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get to experience like pure unadulterated joy at nally taking the step to
transition because you have to deal with all these other things. Even if this
was something that they were so excited about, something that they talked
about [for] a long time now. It’s still a struggle – same thing with the oce,
as they are transitioning . . . ’
31-year-old woman, Psychologist, Delhi
Guideline 2. Trans-Affirmative Conceptualisation of Intimate Relationship
Concerns of TGD Clients
MHPs use a systemic lens informed by an understanding of trans-specic
relationship stressors aecting the relational lives of TGD couples, such as lack of
acceptance, poor social support, legal barriers, forced cis-heterosexual marriages.
Participants discussed relationship stressors involving TGD persons in light of trans-specic experiences.
For instance, acceptance and understanding of trans identities by intimate partners, ways in which
gender transitioning (social, medical, surgical, legal transitioning) aected their relationships, the
impact of dysphoria on sexual relationships, dealing with the social pressure of forced cis-heterosexual
marriage on TGD persons or their partners – especially so for cisgender partners of TGD persons.
Participants also discussed the absence of social support for TGD individuals and the burden that this
can put on their intimate relationships in the absence of validating and accepting families, friendship
circles or colleagues. An absence of social recognition and validation of the relationships of TGD persons
was recognised by many participants as a structural barrier to TGD mental health and relationship
quality. Thus, participants sought to conceptualise the relationship concerns of TGD persons not from
the normative frame of cisgender, heterosexual married couples but from a trans-specic lens of social,
cultural, interpersonal, legal challenges that impact possibilities/ viability, quality and resilience in the
intimate relationships of TGD persons.
Hudak and Giammattei (2014) alert us to the impact of heteronormative culture in the theory, research
and practice of couple and family therapy, indicating the need for a paradigmatic shift in order
to understand and respond to non-normative couple relationships. In the Indian context, there is a
serious dearth of research on the relationship concerns and therapeutic needs of TGD persons and
their partners. The following examples of couple work done by study participants assumes a greater
signicance in this context.
‘They had come as a couple. They were in a long-distance relationship. Also,
they had a signicant age gap between the two of them. And they were having
a lot of diculties in their relationship because one person was out and the
other wasn’t. Also, there was a lot of dysphoria that they would experience
when they would try and be sexually intimate because it was triggering to one
of the individuals in the relationship.’
32-year-old woman, Clinical Psychologist, Delhi
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‘I nd a lot of insecurity in terms of relationships in the transgender
population, especially among transmen, more than transwomen. Usually,
they [do] not have a network also; transwomen like Hijras, they live in a
network, they have community support. Transmen often live in isolation
and not much of social support. They rely on one partner for all their
emotional needs and all kinds of support and a lot of insecurities with
respect to this relationship especially when there is disconnect from family,
friends or even colleagues.’
34-year-old woman, Psychiatrist, Bangalore
‘The girlfriend initially thought it’s a curiosity, not a diagnosis, and this is
how he wants to be in a relationship. When they are having sex, he wants to
wear feminine clothes and she thought it’s his preference, but then when
he disclosed to her that “I am a trans woman and I want to come out as
a woman”, she took a back step and then the relationship was dissolved.
Later on, when they came out as a trans woman and HRT was started, and
then family came into the picture and family supported [the person]. They
disclosed to the workplace also… Later this girlfriend again came back.
And now since she’s come back, there is this readjustment issue. What is
the relationship now? What do we stand for? Because when they broke
up, she thought of him as her boyfriend and now she’s come back. So, this
relationship – does it stand as a committed relationship or not? All these
[are] issues we are dealing with now.’
38-year-old woman, Psychiatrist, Mumbai
‘Lot of issues in relationships, and not to say attachment issues, those are
because of parenting and past experiences with partners, but for a trans client
or a non-binary client, they’re more worried about whether or not this person is
going to accept my trans identity?’
26-year-old non-binary person, Counsellor, Mumbai
‘There is a sense of accepting some of these complaints as part and parcel of
the process, like relationship troubles… It’s very dierent because somebody
who doesn’t belong to that community is not going to tell you they’re upset
about their husband marrying another woman but they’re okay with it or they
understand. But a transgender individual is able to say, “I understand that he
has to marry someone who is born as woman.”’
29-year-old woman, Clinical Psychologist, Bangalore
18
‘A major stressor for one of my trans clients was that his partner was
forcibly married o to a man.’
34-year-old woman, Clinical Psychologist, Bangalore
Guideline 3. Customisation of existing Mental Health Services
to Respond to TGD Concerns
MHPs move from a ”neutral” stance of claiming that their services are non-
judgemental and respond to “all” clients in the same way, to recognising the
specicities of TGD experiences and altering their practice to respond armatively
to these experiences.
A trans-armative approach involves making changes to one’s existing practice – such as through the
use of trans-aware and inclusive language, recognising and countering the negative impact of trans-
prejudice, supporting and validating the identities, strengths and experiences of trans individuals –
are increasingly recognised as the gold standard in trans care (Austin et al., 2018). Adaptations made
to standard mental health practice to respond to trans-specic concerns and contexts have yielded
positive results (Lucassen et al., 2020; Straus et al., 2019; Austin et al., 2018).
MHPs participating in this study also recognised the inuence of institutional barriers faced by TGD
persons in accessing mental healthcare, for instance, the need to produce identity documents that often
carry clients’ deadnames4 in order to register at the hospital/ clinic, or the diculties of providing a
photo identity proof, or the challenges involved in using gender-specic restrooms in hospital settings.
Practitioners discussed multiple changes they made to their practice to better respond to their TGD
clients. They discussed micro practices with their TGD clients that would be dierent from those used
for their other clients. This included making an extra eort to make TGD clients feel safe and heard,
in the context of knowing that the client may have had previous experiences of therapeutic spaces
that were lacking in TGD-specic competence or understanding and empathy. Practitioners reported
foregoing the standard practice of insisting on an informant accompanying an adult TGD client before
recommending the latter for medical and surgical transitioning services. Some practitioners mentioned
including non-family members in the care plans for crisis situations. They spoke about being self-
reexive about their evolving understanding and practice with TGD clients. Some talked of adapting
their therapeutic model to better address TGD concerns, and others talked about ways in which their
therapeutic model allowed for accommodating TGD-specic issues.
‘With my trans client I will be, like, in words reect back what they said,
because I want them to kind of register that I understood what they’re saying.
So, I’m a little more verbal, than just being like, “Yeah, that sounds bad”.
4 A deadname refers to the name given to the person in childhood, to which the person does not relate as it does
not reect their gender or their sense of self and identity.
19
So that changes, wherein you’re doing a lot more paraphrasing and a lot more
reecting in the initial sessions because there is also a sense that you are also
being tested…’
32-year-old woman, Clinical Psychologist, Delhi
‘I think I have a very expressive face and when faced with a person who
has gone through some experience because of their marginalised social
identity, there’s always this look, it almost feels like sympathy, this weird
look… I want to look at them as a person, before anything else. You don’t
want to be too apologetic. You don’t want to be too sympathetic; you don’t
want to be too anything. It also means that you don’t have to glamorise
that concern that much in the session or link it at every point. And I think in
the beginning, I had these questions that would it be insensitive to not talk
about it or talk too much about it… Eventually, I felt like, if your intention is
sort of clear, I think the person in front of you will eventually understand
that you don’t mean any harm, and that sort of made me feel that okay,
even if I’m not doing something correct, you know, I can always ask, like, I
can always cross check and ask…’
25-year-old woman, Psychologist, Mumbai
‘I am a trauma therapist and I do transgenerational work. Of course, I have
to adapt it to unconventional situations. That’s essentially what we did with
this couple that involved a trans person. They both worked with their own
genogram and what they understood of relationships. Genograms of not
just their biological families, but also what they identied as like, you know,
really signicant queer relationships that they had witnessed, and were
subconsciously emulating, because we’re all emulating something, whatever,
you know, that may be in our mind.’
32-year-old woman, Clinical Psychologist, Delhi
‘I’m aligned to a particular way of working, which is called narrative
practices. One of the things that we really hold on to is this idea that people
have preferred ways of being, but also that the sense of self is supported
by voices, that our sense of self is socially constructed. So, we’re always
looking for those voices that might support, particularly when people are
claiming a subjugated identity. So, I’m always alert in the conversations
for who I can rope in. We may use therapeutic letter-writing or witnessing
practices . . . ’
44-year-old woman, Psychologist, Mumbai
20
‘The concerns need to be addressed in more of an atypical way and keeping
in mind [the] cultural context of a community. Some of them have come to
accept that they cannot remain a part of the natal family in the same way, but
are still able to maintain some connections, maintain that distance, and yet
being in touch, which is quite a confusing relationship and they struggle to
rebuild a relationship. And, to be frank, many of them tell me that they have
been able to do it.’
29-year-old woman, Clinical Psychologist, Bangalore,
in the context of clients from the Hijra community
Participants discussed making changes to intake sheets, consent forms, the physical setting of the
practice/ clinic to make it inclusive, arming and welcoming for TGD clients. Some of them spoke about
the importance of using inclusive language and updating one’s knowledge of the terminologies, labels,
pronouns that TGD clients use.
‘So I was not in a private set-up previously but while setting up my own
practice after six years of working, I was making the whole intake sheet,
consent form and everything. I was very sensitive about having all the
genders mentioned and asking people for their preferred name on these
forms.’
28-year-old woman, Psychologist, Bombay
‘Some kind of tailoring, modication is denitely necessary… So the way the
therapist will talk to you, you know, using the same principles, but maybe
dierent examples, maybe using, um, terminologies or just asking you[r]
pronouns… awareness about asking pronouns has really been there among
most of us at the hospital.’
31-year-old man, Psychiatrist, Mumbai
‘They felt that they could come to the clinic and talk about what they
wanted. And some of them would dress up dierently when they came to
the clinic because they felt it was a safe place. Or we had toilets, so they
would sometimes come and just before the appointment would actually
dress up and enter my room with that and feel good about it, and then
after the appointment maybe dress down again and go.’
49-year-old woman, Psychiatrist, Delhi
21
A common dilemma that practitioners spoke about was that of conceptualising TGD concerns from a
structural, eco-systems, social justice and psychosocial framework, while intervening not at the macro but
micro, individual level – addressing feelings, aect, thought, behaviours and working towards reducing
distress and enabling healing. A macro socio-political perspective is signicant in understanding
the context of suering among all marginalised identities. Moreover, this perspective enables de-
pathologisation by not locating social suering within an individual, decient psyche. However, at times
a macro systemic analysis of the roles played by cisgenderism, heteronormativity and caste-patriarchy
in the exclusion and marginality of TGD persons can create a sense of helplessness among clients as well
as practitioners. Hence, working with a macro understanding while employing micro skills that enable
clients to understand the source of their distress, that promote client empowerment and agency, that
work with their strengths and enable healing, is vital. Some of our participants reected on the ways in
which they engage with this dilemma in their clinical work.
‘I don’t want to get caught up completely in a sympathy cycle. I don’t want
to end up passing on a message that it’s not your fault at all, that the world
is wrong, because that is painful too. To be honest, there has to be a certain
ownership of emotional health, there has to be a certain, you know, sense
of empowerment that the client also has to feel, but not at the cost of them
doubting themselves. So, it’s that sweet spot of when do you introduce this
conversation and say, hey, you know, here’s where there are things beyond our
control, that is actively messing up with your life. And for now, let’s focus on
what we can do with this reality.’
33-year-old woman, Psychologist, Bangalore]
‘I nd acceptance and commitment therapy (ACT) very useful to try to
bring that internal locus of control in this way, that you’re the boss. You get
to decide, you get to choose, you are the one deciding; people can direct
things at you but there is a psychological lter between people and you.
You get to screen those which are relevant to you and make sense to you.
So, I kind of use a lot of ACT techniques with this population. So one of the
very big concepts of ACT is that you need to live a life that deeply matters
to you… From DBT (Dialectical Behaviour Therapy) I borrow a lot of self-
validation approaches. I also borrow a lot from self-compassion research.
I think the way you can validate yourself, things you can say to yourself to
deal with it. I don’t stick to CBT (Cognitive Behaviour Therapy) at all these
days or any form of behavioural intervention because I feel the issues that
are present are more at a hurt and pain level and having to deal with this,
especially in post-disclosure issues. I think making sense of their lives is
something CBT cannot help [with]. The idea of CBT that you have a faulty
cognition, one cannot go with that when they are already feeling labelled.’
33-year-old woman, Clinical Psychologist, Delhi
22
‘They sometimes feel that the world is very black. So there I have to help to
make a subtle shift between denitely validating their experience but also
giving them an alternate perspective to see where this is coming from, and
help them take a solution-focused approach.’
34-year-old woman, Clinical Psychologist, Bangalore
‘I talk a lot more about ecosystems when I’m working with trans clients. So,
I guess, in [the] sense of social justice, but that seems really broad a term
to use . . . there is a lot of, like, need to contextualise their experience to
what’s happening outside because a lot of times, all of it gets internalised.’
32-year-old woman, Clinical Psychologist, Delhi
Guideline 4. Mental Health Services Specific to TGD Clients
Apart from customising their existing services, MHPs provide additional services
such as support groups and crisis intervention for their TGD clients, and liaise with
local LGBT organisations
The previous guideline referred to adaptations in existing mental health services to respond to TGD
client concerns. This guideline refers to psychosocial services that may need to be added to the usual
repertoire of mental health services in order to respond armatively to TGD clients. These include
crisis intervention services, particularly in the context of violence and discrimination, liaising with
organisations working on LGBTQ issues that provide shelter, legal aid, police intervention, and so
on. 93 of the study participants stated that they provided some form of crisis intervention support to
their TGD clients. Running a support group for TGD clients and their families was another example of
trans-specic psychosocial interventions that participants discussed. A few participants saw their role
as extending beyond psychological interventions for their TGD clients to aspects such as connecting
clients to community resources – such as job portals, support groups, blogs and other online resources,
NGOs, TGD-armative healthcare and transition services, TGD-armative ction and non-ction
literature. 58 of the study participants spoke of referring a client to a local NGO or CBO working on
TGD persons’ rights. Connecting clients to support groups and NGOs was as much about vconnecting
them to resources as it was about reducing isolation and enabling clients to nd anchors and role
models within their communities. Overall, this guideline refers to MHPs’ attunement to the unique life
challenges of their TGD clients, and their eorts to creatively and innovatively respond to these.
‘I remember one client who was harassed by the police in their city and she
was from Tamil Nadu… I tried, you know, some practical help kind of things like
[taking] the help of the Commissioner, sending an email and speaking to the
Commissioner myself for this client.’
44-year-old woman, Psychiatrist, Bangalore]
23
‘So, one of the sought-after requirements for trans binary or trans and
gender non-conforming clients is {a} peer group support. There, I sort
of intervene and currently I run my own sort of community group on
Telegram.’
42-year-old woman, Counsellor, Bangalore
‘I sort of connect people, you know, to resources... sometimes I also share or
look for job opportunities for them. I send peoples’ CVs to those who might
have a vacancy or something.’
31-year-old woman, Psychologist, Delhi
‘I have on my list about seven, eight people who’ve always said that, you
know, we’ve had this journey and if you get a young person who you think
would like to speak to somebody who’s been already a little bit ahead in
that journey . . . So, they’ve said blanket consent from our side, you can just,
you know, we trust you well, so I often connect them to each other. And
there’s also a few parents who have been really instrumental, who said
that [they would] be willing to speak to parents and all of that. So, there’s a
good set of community, I use it with my discretion. But I think that’s also [an]
important part of the work that not too many people talk about.’
49-year-old woman, Psychiatrist, Delhi
‘If the person expresses loneliness, says, “I don’t nd my type of people,
whom to go to, who to talk to, I don’t know where to ask these questions
regarding transitioning and all that” – no matter how understanding, let’s say,
there’s a women’s group on WhatsApp, which is good at heart and fantastic
and everything. Even then, I cannot just put the client, a trans woman, on
that group. It’s not the same as in a trans group where they will know when
someone says that the hormones are playing havoc with me… The biggest
need I have felt across almost all my trans cases is the[ir] need to socialise and
associate with people of their own kind, like not just for [socialising], but for
other things as well. You want to ask questions like “What are the TG-friendly
bars around?” So it doesn’t have to be roney dhoney vale sawaal (questions
related to distress), not always, yaar, it can be for enjoyment also, like “Which
dating app do you use?”’
42-year-old woman, Counsellor, Bangalore
24
‘I am in touch with NGOs, which work on trans issues, so I provide the
contact of those NGOs to them. So it depends, some people, they ask me
to help them connect with NGOs. So those people I will connect.’
50-year-old woman, Psychiatric Social Worker, Bangalore
Guideline 5. Increasing Accessibility of Mental Health Services to TGD Clients
MHPs recognise challenges faced by TGD clients in accessing trans-armative
mental health services and hence make an eort to visibilise their work through
various media and nd strategies to make their services aordable to TGD clients.
MHPs interviewed for this study were aware of the challenges involved in accessing trans-armative
mental health services, especially in the context of harmful practices such as conversion treatments
being prevalent even in the country’s metros, and in the absence of public awareness about the issues
faced by TGD persons. While a majority of the participants (n=131; 79.4%) stated that they were seeing
an increase in the number of TGD clients in their practice, they were aware of their clients’ challenges
in accessing trans-armative care and believed that making their own services more accessible, and
reaching out to the TGD communities, was important. Participants identied their sources of referral
for TGD clients as word-of-mouth, i.e., being known as an MHP who works on TGD issues (27.2%); ex-
patients/ clients (18.9%); psychiatrists/ other doctors (23.9%); social media (17.4%); and NGOs working on
transgender rights (11.9%).
Participants discussed social media as an eective tool for putting out information about their services
as well as their views on trans issues. Having their name and contact details placed on e-lists developed
by LGBTQ+ organisations as well as crowd-/ client-sourced lists of MHPs in dierent parts of the
country was another strategy to make their services visible and thereby accessible to TGD clients. Some
practitioners also spoke of creating short YouTube videos for raising awareness on LGBTQ+ issues.
‘lnstagram and LinkedIn are two amazing platforms where I’m posting
regularly. Seeing my work, they connect and DM and then we take it forward.’
42-year-old woman, Counsellor, Bangalore
‘I’m also listed on some of those e-lists of, you know, gender-armative
counsellors. So that’s where my clients get my reference, and also on my
social media – I’ve written it very clearly that I’m queer-armative, and I
work with queer clients. So yeah, that’s where people usually get to know
about me.’
28-year-old woman, Psychologist, Mumbai
25
‘So I have a Google form and also a website and I have my prole on some
of the pages related to queer mental health and I’m based in [...] location
in Mumbai. So a lot of times people might search things like, you know,
“psychologist near me” or something, and my name pops up . . . ’
25-year-old woman, Psychologist, Mumbai
‘So they have come through posts that I’ve put out on my social media
account in association with an organisation, Health Professionals for Queer
Indians. So I put out a video, and it reached to some people. So, they came
to me with their parents, as they had just come out to their parents and
needed some support with that.’
31-year-old man, Psychiatrist, Mumbai
A major barrier to accessing mental health services is the nancial barrier. Young TGD clients who are
still students, nancially dependent on their parents, and often not “out”5 to their families, nd it dicult
to gather the resources to pay for MHP services. Also, for TGD clients from lower socio-economic strata,
being able to aord health, mental health and, in this context, transition services is a major challenge.
Many of our study participants, especially those in private practice, talked about having a sliding scale,
providing concessions, and even raising funds for some of their TGD clients. One of the organisations
had a “pay as you can” policy, wherein the TGD client paid whatever they could aord in a particular
week for their therapy session.
‘Financially, also, you know, it’s a sliding scale for them. It may not be for other
people but yes, there is a sliding scale for them. And I have also arranged
nances, you know, not in terms of anything else, but at least for medication
and stu. I have tried whatever [works].’
54-year-old man, Psychiatrist, Delhi
‘The nancial implications of continuing therapy is also a consideration. So,
we used to have a sliding scale for our clients, and sometimes we would
raise money for them, and then we would give them discounts. Doing free
sessions is not sustainable after a period of time but we do what we can.
Sometimes at our own discretion, I would see a young person, who was
the last session for the day and would not get billed. We had a pact even
with the hospital at that point of time where we would not even register
them because once registered it is out of my hands. It’s like that in bigger
hospitals…’
49-year-old woman, Psychiatrist, Delhi
5 Not being “out” here refers to the TGD person not having disclosed their gender identity to their family members.
26
Guideline 6. Working with Families of Origin of TGD Clients
MHPs work with families of TGD persons by providing trans-armative information
as well as emotional support and seeking to increase attunement between the
TGD client and their family.
Several participants reected upon working with the families of TGD persons. One of the ways in which
families responded to their TGD children was by seeking MHP appointments to cure what they read as
gender deviance or disorder, hoping for their child to become better adjusted to their assigned sex at birth
(this is addressed in the next guideline – on MHP responses to conversion treatment requests). However,
families also responded to their child’s gender expression and identity with confusion, tentativeness,
questions, worry, self-blame, guilt, and so on. Study participants discussed the role of MHPs in
educating family members on TGD issues, addressing their questions and providing information as well
as engaging with the aective and moral dimensions of parental reactions to their child’s transgender
identity. These often took form of questions like ‘Isn’t this unnatural?’ or ‘ Is it my fault that my child
is trans?’ MHPs therefore have an important role to play not just in providing scientic information
about TGD identities from mental health literature, including the depathologisation of trans identities,
but also in unpacking the normative and moral questions about the naturalness and normalness of
gender and the role of families and parents in shaping the child’s gender. Shifting the conversation
from normal/ abnormal or natural/ unnatural to socially constructed norms around gender, and helping
families examine their own understanding of gender norms, constitutes an important step towards
helping them build empathy for their TGD child. Coolhart and Shipman (2017) suggest that normalising
and arming transgender identities as natural variations of humanity and working towards increasing
attunement between family members and their TGD child’s gender expression are signicant steps in
enhancing familial acceptance.
The practitioners interviewed for this study used dierent routes to educate families and build empathy
and understanding on trans issues. These included using a medical model of TGD identity or gender
dysphoria as illness that can be treated through gender-armative therapies and thus avoiding any
blaming of the TGD client or of their parents and families. Although an illness model contradicts
the depathologisation position on TGD identities and is contrary to the present usage of gender
incongruence in ICD-11, this was viewed by some practitioners as a rst step in facilitating acceptance
within families. It is important to note that family therapy approaches that seek to “manage” or
accommodate non-normative sexualities or gender variance by enabling families to “cope” have been
critiqued for their continuing pathologisation of LGBT identities. Hudak and Giammattei (2014, p.9) call
for a transformation in family therapy that embraces diversity as the norm and ‘upholds the value and
beauty of non-heterosexual and gender variant family members not in spite of their identity but because
of it’. Ranade et al. (2022, p. 153) state in the context of working with queer clients’ families of origin
‘...being queer is not a tragedy, an accident, a catastrophe facing the family – it is about making space
in the psyche and within the family for diversity and dierence, which can be challenging, causing pain
and, maybe, stretching the boundaries of the family system, but is also an opportunity for growth for all,
as individual human beings and as a family.’
Another way in which participants responded to families was by helping them to work through the
emotional loss of the child (son/ daughter) they thought they had and to adjust to the new reality of their
child’s life and future. Some participants used a more sociological approach to educate families on how
gender norms are socially constructed and how, therefore, the gender given at birth need not be thought
27
of as an unchangeable and immutable truth that has to be guarded at all costs, with a person having to
t into one of the two genders or forcing themselves to get along with their assigned gender.
‘They want to know whether it is an illness. Why is it that this has happened? is
it a genetic condition? is it something that we did wrong? Some people would
try to blame their peers, that friends were like that. So they want to understand
why it happened… They have not usually talked about it as an illness. They
think of it as a choice. Not that the person is ill but if he [does not want] to, he
may not transition. So why does the person want to change?’
57-year-old man, Psychiatrist, Delhi
‘Families have a very negative attitude not only towards the person, but
the people who are probably understanding them as well. They’re like,
“Oh, you are telling this as a doctor, then how do you think he is or she is
going to respond? You should be able to tell them that this does not exist,
or something like this is not there.” So, their requests are entirely dierent.
So, a lot of time is kind of spent on psychoeducation, making them
understand.’
32-year-old woman, Psychiatrist, Bangalore
‘For a caregiver of the client or relative of the client, if they’re being brought
to a doctor or a psychologist, they will think that this alternative sexuality or
something, this identifying as a dierent gender is a mental condition. So,
it is our responsibility to gently let them know that it’s not a disease entity.
Probably some years back, 30 years back or 40 years back, it used to be, but
as research and everything advanced, you know, they have realised that this is
not a disease entity. It’s just a dierent form of normal. So that is probably our
responsibility as mental health professionals to counsel and psychoeducate
relatives about.’
31-year-old man, Psychiatrist, Mumbai
‘I’ve had several sessions with parents trying to understand their loss. They
had certain expectations from the child and there is a loss. It’s like losing
my child, I don’t know how or where she will be. So that kind of reaction.
So, it is some support that is needed in these families. They have not sort
of disowned them or, you know, ostracised them, but at the same time,
complete acceptance has also not been there.’
68-year-old woman, Clinical Psychologist, Bangalore
28
‘We used to do this really interesting thing, where we would have family
sessions, for anybody who’s just come out to their parents or wanting to come
out to their parents, both trans clients as well as other queer identities, and we
answered questions about – What is gender? What is natural and unnatural
about it? What are the risks of any sort of conversion-treatment-like activities
on the mental health of the person? How can you actually support? And it was
a somewhat, we never wrote it down, but it kind of owed as a module-like
thing, almost. And then if they had questions, they would come back the next
time. It was like a two-session thing that we were doing.’
32-year-old woman, Clinical Psychologist, Delhi
Guideline 7. Dealing with Conversion Therapy Requests
MHPs seek to educate families about the ill eects of conversion treatments on
the TGD individual, and also about the position of MHPs in India and internationally
on the inecacy and unethicality of these practices.
112 of the 165 practitioners, i.e., nearly 68% study participants said they had been approached by families
with a request for conversion treatment for their TGD child/ family member. 57 (34.5%) practitioners said
that TGD clients had themselves requested conversion treatment. 109 (66%) practitioners stated that
they had heard of MHPs in their cities who practiced conversion treatments to help clients live in their
birth-assigned sex. Despite socio-legal changes in India over the past few years, including the Madras
High Court declaring the use of conversion treatments illegal (Sushma v/s Commissioner of Police,
2021), the demand for conversion treatment persists. The practice of such treatments, purportedly to
cure transgender gender identities, seems to persist as well, as indicated by the data quoted above, and
as reported by a few other Indian studies (APTN, 2021; Chatterjee & Mukherjee, 2021). In this context,
responding to familial requests for conversion treatments is a challenging task. Many practitioners
lamented how, despite their best eorts to educate the family about TGD issues and the ill eects of
conversion treatments, and providing support to the families to move towards acceptance, many of
these families and TGD clients were lost to follow-up. Practitioners discussed various responses –
outright and immediate refusal to provide conversion treatment services; engaging with the family,
68% 112/
165
MHPs were approached by
families seeking conversion
treatment for their TGD child
57/
165
MHPs were approached by TGD
persons themselves for
conversion treatment
66% 109/
165
MHPs had heard of MHPs in their city
practicing conversion treatments
29
building rapport and trying to educate them; using their expert authority to impress upon the family
the ill eects of these treatments and their lack of ecacy. One of the practitioners actively encouraged
a family to seek a second opinion from any other MHP on the ecacy and ethics of using these treatment
options. Unfortunately, this practitioner could not be certain that other MHPs would necessarily have
an armative view of TGD identities. Thus, despite strong activism from LGBT communities, MHP
associations condemning conversion treatment practices, and a court order declaring these treatments
to be illegal, MHPs have an uphill task ahead of them to help parents and families see their TGD child
for who they are and support and cherish them in the face of a cis-binary-gender world. Despite top-
down changes – such as legal change or MHP associations making public statements – the absence
of wider social as well as professional education, and a lack of consensus on transgender identities
being non-pathological, makes the task of responding to conversion treatment requests a dicult one.
Nevertheless, the MHPs participating in this study sought to respond to such requests in dierent ways,
none of which legitimised the use of, or the claims of cure made about, conversion treatments.
‘A child psychologist discussed a case where, after a few sessions with
the trans-identifying young person, she started working with the family to
get them to engage with their child’s gender journey, but the father was
unwilling and angry and wanted the psychologist to get the child to ‘stop
zall this’. The child psychologist then suggested that they seek a second
opinion in order to be surer. She said, ‘One part of my job with them was
to help them consult with dierent people. They were in Bangalore, not
in Delhi. So, I was giving them other people’s numbers and information,
[asking that they] please speak to more people. Maybe see another
psychiatrist – don’t need to see another psychologist [but] someone else,
somewhere else. So I told them to go to NIMHANS and just do a random
search and consult with someone else.’
33-year-old woman, Psychologist, Delhi
‘The client came from a very interior part of rural Maharashtra. The mother as
well as the brother did not really open up to the concept that a girl, a born girl
could have a male gender. So, they wanted her to start acting like a girl, you
know, grow out her hair. She had cut o her hair and she had started dressing
as a boy like she wanted to. And they really wanted that to happen during
the hospital stay. They were not really open. We tried a lot, but it’s the social
conditioning over so many years that was dicult to penetrate. And we could
not keep her beyond a point, because the moment the family realised that we
were not doing much to change her, but we were actually psychoeducating
them, they started requesting discharge… we really don’t know how much of
our eorts got through to them.’
31-year-old man, Psychiatrist, Mumbai
‘I’m very happy that right now, conversion therapy is kind of termed as
illegal and people practicing it are to be punished by law. They should not
30
be promisingsuch things to families, because they will then keep running
around with the hope that there will be someone who can change this
person’s mind from A to B and it will not help them understand that this
is a real condition or this is denitely something that a person is going
through, instead [it] gives them an understanding that this person might be
acting, or this is not a real problem. I think people should not promote or
encourage conversion therapy at all.’
32-year-old woman, Psychiatrist, Bangalore
Participants also discussed other forms of conversion/ correction eorts apart from bringing the TGD
person to MHPs for the purpose, and these included a range of micro-aggressions and gender policing
practiced by parents, siblings, teachers, peers, and so on. They underlined that these forms of social
correction/ conversion treatment also had deleterious eects on the TGD person.
Guideline 8. Role of MHPs in Gender Transition Services
MHPs play a vital role not just in assessment of gender dysphoria/ incongruence
and providing letters of support/ referral letters for gender transition services, but
at every step of the gender transition/ armation process.
78 of the 165 MHPs i.e., 47% of the participants reported being approached for assessment and referral
letters for gender transitioning services. The assessment methods used by MHPs varied – in a few
instances, it included reliance solely on a detailed clinical history and in-depth clinical interview
of the client, and sometimes of an informant as well. However, a majority of the study participants
used standardised psychological tests. They reported using projective tests (n=32), personality testing
(n=24), cognitive and neuropsychological testing (n=12), screening tools for psychopathology (n=8), a
sex role inventory (n=1) and a blood test (n=1) before recommending their TGD clients for transition-
related services. Practitioners reported variously on the duration of assessment for providing a referral
letter. 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 hormones or
surgery. Two practitioners did not provide a number. There was no consensus among practitioners
about the rationale for using psychological assessments. The absence of clear clinical protocols about
mental health assessment to determine “tness” for gender armation therapy or to screen for co-
morbid mental health conditions meant that many MHPs sought to use standardised psychological
tests in the belief that such test results would appear more unbiased and reliable if there were to be
medico-legal scrutiny at any point. A clinical psychologist mentioned using psychological tests as part
of an institutional requirement, more than as a clinical necessity. A psychiatrist commented that the
elevations seen in psychopathology scales like the MMPI6 and MCMI7 could be looked at as trans-specic
coping strategies in the context of prevailing stigma and discrimination. It is worth noting that no
6 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.
7 MCMI (Millon Clinical Multiaxial Inventory) is a self-report psychometric tool to assess personality traits and psy-
chopathology. MCMI-IV, the most recent edition, was published in 2015 and has 195 true/ false items.
47% 78/165
approached for assessment and referral
letters for gender transitioning services
Under 3
sessions
4-6 sessions More than
6 sessions
Did not
provide
number
36 24 16 2
Duration of Assessment for Providing a Referral Letter
31
be promisingsuch things to families, because they will then keep running
around with the hope that there will be someone who can change this
person’s mind from A to B and it will not help them understand that this
is a real condition or this is denitely something that a person is going
through, instead [it] gives them an understanding that this person might be
acting, or this is not a real problem. I think people should not promote or
encourage conversion therapy at all.’
32-year-old woman, Psychiatrist, Bangalore
Participants also discussed other forms of conversion/ correction eorts apart from bringing the TGD
person to MHPs for the purpose, and these included a range of micro-aggressions and gender policing
practiced by parents, siblings, teachers, peers, and so on. They underlined that these forms of social
correction/ conversion treatment also had deleterious eects on the TGD person.
Guideline 8. Role of MHPs in Gender Transition Services
MHPs play a vital role not just in assessment of gender dysphoria/ incongruence
and providing letters of support/ referral letters for gender transition services, but
at every step of the gender transition/ armation process.
78 of the 165 MHPs i.e., 47% of the participants reported being approached for assessment and referral
letters for gender transitioning services. The assessment methods used by MHPs varied – in a few
instances, it included reliance solely on a detailed clinical history and in-depth clinical interview
of the client, and sometimes of an informant as well. However, a majority of the study participants
used standardised psychological tests. They reported using projective tests (n=32), personality testing
(n=24), cognitive and neuropsychological testing (n=12), screening tools for psychopathology (n=8), a
sex role inventory (n=1) and a blood test (n=1) before recommending their TGD clients for transition-
related services. Practitioners reported variously on the duration of assessment for providing a referral
letter. 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 hormones or
surgery. Two practitioners did not provide a number. There was no consensus among practitioners
about the rationale for using psychological assessments. The absence of clear clinical protocols about
mental health assessment to determine “tness” for gender armation therapy or to screen for co-
morbid mental health conditions meant that many MHPs sought to use standardised psychological
tests in the belief that such test results would appear more unbiased and reliable if there were to be
medico-legal scrutiny at any point. A clinical psychologist mentioned using psychological tests as part
of an institutional requirement, more than as a clinical necessity. A psychiatrist commented that the
elevations seen in psychopathology scales like the MMPI6 and MCMI7 could be looked at as trans-specic
coping strategies in the context of prevailing stigma and discrimination. It is worth noting that no
6 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.
7 MCMI (Millon Clinical Multiaxial Inventory) is a self-report psychometric tool to assess personality traits and psy-
chopathology. MCMI-IV, the most recent edition, was published in 2015 and has 195 true/ false items.
47% 78/165
approached for assessment and referral
letters for gender transitioning services
Under 3
sessions
4-6 sessions More than
6 sessions
Did not
provide
number
36 24 16 2
Duration of Assessment for Providing a Referral Letter
available national or international guidelines for gender transition services recommend psychological
testing as part of standard assessment.
Some participants in this study did question the utility of psychological tests being done in the absence
of any clear rationale, and at a cost to the client in terms of both time and money. We have included this
critical questioning of the uneven practice of psychological testing before giving a letter of support/
referral letter to TGD clients as a good practice, demonstrating as it does a client-centred and rational
approach by some MHPs.
‘I have stopped looking for anything in the MCMI prole 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 dierent 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
Assessment Methods used by MHPs
Projective Tests
Personality Testing
Cognitive and Neuropsychological Testing
Screening Tools for Psychopathology
Sex Role Inventory
Blood Test
32
24
12
8
1
1
32
obviously results of the way a person is coping with their environment.’
38-year-old man, Psychiatrist, Mumbai
‘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. Like I said earlier, I
genuinely don’t think that any projective or personality tests are required.’
34-year-old woman, Clinical Psychologist, Bangalore
‘A good case-history-taking with empathy is important. What was [their]
identity like when there was some confusion, some conict? When did they
consolidate it? When did they become clear about it? Then how did they
handle the society and family? Then the process of coming out right now,
how long is it? Relationship issues now, the sexual orientation or sexual
identity, their living arrangement, then I would ask about their work prole,
how they will deal with this identity at workplace or at residence? Okay, and
how comfortable are they? If they have not told anyone then what may be
the reasons? What are the challenges? How they plan to handle these things,
right? For surgery, what are the complications or consequences they’re aware
of? And how they’re going to handle it. And are they mentally prepared for this
permanent transformation? With surgical, do they understand it is irreversible?
If it was hormonal, then are they aware about what will be the actual physical
eects and side eects? What is their future plan after hormonal therapy? So
these are some of the questions that I would ask in my clinical interview and
ask them sensitively…’
34-year-old woman, Psychiatrist, Bangalore
All major guidelines recommend a continuum of care while working with the TGD population. Participating
MHPs also discussed the importance of following up post-hormones and surgery to provide continued
psychological support. They emphasised their pro-transition position while helping their clients set
realistic goals. They recommended including assessment of nancial, social and emotional status in the
comprehensive clinical assessment. Assisting TGD individuals with severe psychiatric disorders like
psychoses posed a challenge. Many practitioners commented that the psychiatric condition itself need
not come in the way of seeking transition services; however, they wanted to ensure that the psychotic
symptoms were not related to or causing gender identity issues. A small number of practitioners
adopted a wait-and-watch approach while working with TGD clients with severe psychiatric illnesses.
‘Helping the person understand what exactly is going on – right from giving
the right information to helping them see transition as a treatment. Actually,
we should be pro-transition, because we are pro-treatment. Helping
33
them understand and build realistic expectations for medical transition,
even for social transition. It’s not as smooth for everyone and it’s not as
catastrophic also, as people think a lot of times… Addressing all the anxieties,
misconceptions, helping them understand their family members’ emotional
journey, and build [a] better support system. You know, a lot of times when
parents are, for example, going through a phase of denial or anger, which is
part of the journey towards acceptance, sometimes the patients may get angry
about it, may dissociate from them. And that can lead to more diculties. So,
helping them build [a] good social support system, helping them with the right
referrals. Even making decision[s] for surgery, for HRT, whatever it is, I think a
psychiatrist should be part of that whole decision-making process to help the
person understand what is to be expected. What will be the result of delaying
a certain thing, what will be the result of, you know, going too rushed into
something… also post-transition, providing them with all kinds of mental health
support that’s needed. A lot of times being on hormones can lead to some
mental health issues. So, to keep a check on that, recognise that early on and
intervene.’
38-year-old man, Psychiatrist, Mumbai
‘It’s complex how the hormone treatment will interfere with the psychotic
illness and things like that but in principle I feel they should not be
discriminated [against] just because they have mental illness, as long as
the psychopathology is not about the gender itself.’
44-year-old woman, Psychiatrist, Bangalore
‘Not everything on the internet is true nor is everything available on the
internet, [it’s] a scam. That’s when the role of an MHP comes in to sift the grain
from the cha. Counselling can become directive in such cases where it is
more knowledge- and information-based. MHPs also need more knowledge,
for instance, not in many other cases would the MHP need to have so much
knowledge on legal rights or schemes for livelihood or whether in a particular
state the government hospitals provide concessionary reassignment surgery.’
42-year-old woman, Counsellor, Bangalore
‘We have come to the consensus that a medical journey, be it for mental
health concerns, is not a deal-breaker for going ahead with transition. The
whole mental health disturbance might be precipitated by the dysphoria in
itself. If there is readiness, in terms of emotional stability and the resources
to be able to help themselves in terms of crisis, risk assessment, and
generally those are the things that we do, look for red ags because we’d
34
like them to have the emotional capacity to be able to go towards the next
changes, right?’
33-year-old woman, Psychologist, Delhi
One participant, a psychiatrist, discussed her experience with some of her university-educated and
articulate clients, who questioned the authority of MHPs to certify anyone’s gender. Some of these
clients brought copies of court judgements to her that were related to the right to self-determine one’s
gender. In response, she invited these clients to write joint letter/s of support to be used for practical
purposes such as seeking medical transition, change of name on documents, in educational institutions,
and so on. She says,
‘So, I will do two letters, one, you and I will write and if you nd a progressive
surgeon, use this letter, if not, you still want to get the surgery done, you
can then use the other [the conventional format of a certicate for gender
dysphoria]. So, we just make do with whatever there is. But in all of this,
keeping the meaningfulness of that letter very clear. Some of it is needed for
the logistical purposes of where we are at today. And I’m not taking away your
dignity.’
49-year-old woman, Psychiatrist, Delhi
Guideline 9. Working with TGD Minors
The Indian Standards of Care for Gender Incongruent Children and Adolescents
(ATHI, 2021) suggest that health professionals working with minors should employ
the mnemonic LEARN [L – look, listen, learn from the child about their gender
identity; E – educate self, parents and society; A – advocate for the rights of the
child at home and in the educational institution; R – resources for parents, children
and society; N – being non-judgemental].
Research suggests that gender identity development can occur as early as between the ages of 1.5 and
3 years (Ehrensaft, 2016) and that variability in sex-typed behaviour exists from a young age, wherein
masculine girls and feminine boys can be recognised, as much as feminine girls and masculine boys.
Research also suggests that the degree of sex-typed behaviour observed in a person as a toddler
predicts the degree of sex-typed behaviour they will show in adolescence (Golombok et al., 2012),
indicating that degrees of sex-typed behaviour may be consistent over time. Researchers and clinicians
dier in their position on the extent to which childhood gender non-conformity persists into adult
transgender identities, and consequentially have divergent views on the management of childhood
gender incongruence. Newhook (2018) suggests that the polarising desisters v/s persisters debate on
childhood gender incongruence (about the extent to which childhood gender non-conformity persists
into adulthood) has led to an excessive focus on futurity (the adult future of childhood gender non-
conformity) and stability of trans identities over time, at the cost of being sidetracked, in the present
moment, from the needs of young people with gender non-conformity.
35
Despite divergent views about the continuity of childhood gender non-conformity into adult TGD
identities, there seems to be consensus on the harm caused by reparative treatments that seek to t
gender diverse children into their birth-assigned gender or natal sex, and on the importance of social
and familial support to gender diverse children in navigating their gender journeys (Keo-Meier &
Ehrensaft, 2018). Ehrensaft (2016) uses the concept of a gender web, a four-dimensional structure that is
each child’s personal creation, spinning together the three major threads of nature, nurture, and culture,
interfacing with each other and with the fourth dimension of time, that allow the child to construct a
gender self. The gender armation model developed by Keo-Meier and Ehrensaft (2018, p. 13) denes
gender health as ‘the opportunity for a child to live in the gender that feels most real and/ or comfortable
for the child and the ability for children to express gender without experiencing restriction, criticism, or
ostracism. In the model, the role of the mental health professional is that of a facilitator in helping a
child discover and live in their authentic gender with adequate social supports.’
In the present study, 105 of the 165 participants reported seeing TGD minors in the course of their
practice. 15 participants reported having seen clients who were 12 years old or younger referred for
issues around their gender identity and expression, while 90 reported seeing clients who were between
13 and 18 years old. A minority of the study participants engaged therapeutically with their TGD clients
and their families. The most common response among participants was an advice of “wait and watch”
until the TGD person was an adult. However, some of the participants described their therapeutic work
with TGD minors. A child psychologist talked about her work with a trans masculine 9-year-old, who
was referred to her for behavioural issues and impulsivity. She discusses ways in which she centres
a trans-armative perspective while integrating a developmental lens using stabilisation along with
bodily and emotional regulation to work on impulsivity.
‘What was worrying the family and bothering the school was [an] early
sexualisation of relationships and very early exploration of body with other
people in the school. There were a lot of gender themes that we had to
navigate… we realise this young person is doing things to get a response
from others, because they want a response, which is going to eventually
help them, say, and present as a man and boy, and like a male person, that
they’re desperately trying to show everybody around them. And it was
coming from a space of gender presentation, but it looked very dierent,
105 of the 165 MHPs reported seeing
TGD minors in the course of their practice
13 - 18
years old
12 years old
or younger
15 90
63.6%
36
right? So, say, drink alcohol, like dad does in a party, for example, then he
would, like, hide alcohol from his father’s cupboard and drink when no
one’s watching. And they were, like, as young as nine, and that would be
potentially risky . . . Yes, he is seeking attention, but he’s seeking attention
also towards his gender presentation. Because for him, that’s what he
understands of the social context of being a man that when you express
your sexuality, or your choices or your intentions, that’s what’s making me
a man… looking at my older brother, or looking at my father or my cousins,
or TV or whatever they’re watching. That’s where they’re learning the social
representation of it and he has to explore it to be able to nd out what ts
him…There was high impulsivity and lack of overall body regulation, we
knew that some of it is coming from the restlessness in the body also. And
once the overall regulation will get better, they would be able to assess
whether they need to navigate every space by being this thunderbolt…’
33-year-old woman, Psychologist, Delhi
Another psychologist discussed working with a TGD minor to deal with the bullying, related to their
gender expression, that they were facing in school.
‘He would come with his mother and mother had, to some extent, accepted,
or she thought of it as a possibility. So the concerns that this boy had were
that he was being bullied at school because he was a bit eeminate and that
made it worse for him and he was not able to assert himself in school. And so,
we did a lot of work on that and I helped him with it… Being internet-savvy, he
had read up a lot on gender armation and he wanted to start o on hormone
therapy early. He must have been in [the] 10th standard, I think. He wanted to
start hormone therapy, while his mother was feeling that we should wait a little
bit till he is an adult and then start the process. So, there was this negotiation
going on, and I, I would kind of try to facilitate whatever was possible between
them. He would ask me these questions, whether I’m making the right decision
and, you know, then we would go through, asking him to do, all the pros and
cons and the usual decision-making approach, so I helped him with that.’
68-year-old woman, Clinical Psychologist, Bangalore
A child psychiatrist who has worked with TGD minors talked about the role of changes in international
guidelines such as the Standards of Care by the WPATH, particularly on the administration of puberty
blockers to adolescents, and the evolving conversations among clinicians in India including recent online
conferences on trans health that have helped mutual learning and education among MHPs as well as
other medical professionals involved in trans health and mental health care. Some MHPs discussed
oering treatment for mental illnesses to their TGD clients while educating families not to confuse
mental illness and its symptoms with gender dysphoria or incongruence.
‘So initially, when we had a 13-year-old or a 12-year-old saying, “I’d like to go
37
for changes right now”, we didn’t have any guidelines. So, we used to say, “Wait
till 18.” I think in the last about one-and-a-half to two years, I’ve started saying,
“Okay, wait, something can be done even now.” And for the 7- or 8-year-olds,
I’m already preparing the parents that things can be done. Because they are
pre-pubertal. So I think that’s a result of the SOC 7 of WPATH, which changed
certain things completely.’
49-year-old woman, Psychiatrist, Delhi
‘With younger clients, reversible changes such as social transition can
be supported and even puberty blockers are okay, especially with good
parental and peer support.’
38-year-old man, Psychiatrist, Mumbai
‘So the 17-year-old had come predominantly because he had bipolar disorder
and the parents were not keen on them getting any treatment at all, because
they felt that the medications that were given in the past for the treatment
were responsible for the gender or a transgender feeling that this person
had developed this year, and that this was not there at all for the last 15 years.
They developed a psychiatric condition, started on treatment, and following
that this person has been reporting clearly that he has become a “he” from a
“she”. And [the] parents were completely against psychiatric medications. And
the kid was having signicant diculty in studying or, you know, completing
the course; she was, he was in 12th then. He had great diculty with getting
it done. And the parents were not for medication. So, a lot went into how this
is not responsible primarily for change in gender. That this is a completely
dierent issue from what transgender is, and so on.’
32-year-old woman, Psychiatrist, Bangalore
Guideline 10. MHPs as Allies and Advocates
MHPs recognise that their role goes beyond helping their TGD clients cope with
the eects of trans-prejudice, towards helping build awareness on TGD rights,
creating trans-inclusive environments and combating trans-prejudice as allies
and advocates for TGD persons.
MHPs recognise the myriad ways in which trans-related stigma, discrimination and violence aect the
mental health, well-being and quality of life of their TGD clients. These experiences of TGD persons as
gender minorities often start within natal families and continue in educational institutions, workplaces,
public spaces, among peer groups, as well as within intimate relationships (APA, 2015). Trans-armative
MHPs recognise their role in working with TGD clients not only to help them cope with the eects of
38
trans-prejudice and build resilience, but also to create trans-inclusive environments and combat trans-
prejudice. The Supreme Court of India, in its judgement decriminalising homosexuality, emphasised
the role of MHPs and counsellors in creating awareness on LGBT issues within families, educational
and employment spaces, and thereby helping to foster self-acceptance by LGBT persons and to create
a discrimination-free society for all (Kapoor & Pathare, 2019). Pertinently, a group of MHPs had in fact
played an ally and advocate role for the LGBT community by ling a petition in the Supreme Court in
support of decriminalisation of homosexuality (Ranade et al., 2022).
MHPs participating in this study, too, recognised the many challenges faced by their TGD clients
and sought to go beyond the clinical/ therapeutic space in supporting them. The study participants
acknowledged their dual privilege as cis-gender persons and as experts, and used this privilege to
speak up for the cause of transgender rights to the larger public as well as within their professional
circles. MHPs discussed the need to go beyond clinical competence to work with TGD clients and equip
themselves with information such as legal rights, governmental schemes and other resources for TGD
persons.
‘In a lot of other cases, you don’t need to have so much of legal knowledge,
but here you also need to make them aware of their legal rights… if you
have knowledge of the law of the land of the particular state you’re
operating in, if you know of any schemes that are available for transgender
[persons] propagated by the government . . .’
42-year-old woman, Counsellor, Bangalore
‘When the Transgender Act came in, I read it. It’s a very small Act, to be very
honest, it’s barely some 30 pages. And it’s just about eight sections. It’s a great
read. I just read through all of it. I then converted the Act into a PPT. And then I
presented it at multiple forums to help spread awareness about the legalities.’
42-year-old woman, Counsellor, Bangalore
‘I remember once, just a quick personal sharing here, consulting a
gynaecologist for my own health and trying to have a conversation about
how many clients does she see that are gender non-conforming? And
seeing if she’s actually open to it or not? No, I’m not doing it with any
specic intention in that moment. But I know it’s coming from a little bit of
a space of advocacy and awareness-building conversation that why not,
if I can, you know, at least identify two or three new such people. I just
have more safe spaces to oer to my clients as well. (A) little bit of that
active networking can denitely help and go a long way, while we’re still
struggling to nd a community of helpers who are armative.’
33-year-old woman, Psychologist, Bangalore
39
Another participant shared how she took the initiative of printing T-shirts with slogans such as
‘Trans men exist’ and ‘Trans lives matter’ in liaison with some of her co-workers for a group of health
professionals in her running group. This was her way of spreading awareness within the community of
medical professionals.
‘I just said, why don’t we make a T-shirt? just to raise awareness. Everyone
is wearing something just to create some awareness, so instead of wearing
the event T-shirt why don’t we wear this T-shirt –and we distributed it in the
running group of the hospital, and many times when we run, we wear that
and we run, some people do ask us… many people don’t know so they ask us,
”What is this?” and “Why are you wearing this?” and all that, and we tell them,
so it’s like [an] awareness campaign.’
44-year-old woman, Psychiatrist, Bangalore
A participant narrated how he, along with some colleagues, reported videos by an MHP advertising
conversion therapy. In this case, being an ally/ advocate was synonymous with standing up for what is
right and being ethical in one’s practice so as not to promote malecence.
‘I will not name [anyone] but I’ve seen psychiatrists, senior psychiatrists
from Maharashtra, not psychiatrists, just one person actually, who would
really advertise about conversion treatment in his clinic. And that had
caused a great disturbance among some of the health professionals who
were working for queer people. So we had reported his videos, and shortly
after that the IPS (Indian Psychiatric Society) gave out this statement
against conversion therapy, like within a week or something. That could
be connected to our reporting or could be a coincidence, we don’t really
know.’
31-year-old man, Psychiatrist, Mumbai
Guideline 11. Practitioner Self Awareness and Reflexivity
MHPs reect on their own personal gender-sexuality journeys, associated beliefs
and values as well as professional engagement with non-normative genders and
sexualities and changes in these trajectories over time. Most signicantly, MHPs
recognise that their personal and professional beliefs impact their engagement
with their clients.
Literature on reective practice alerts us to the fact that ‘who we are inuences what we see (and do not
see) and how we see it’ (Bhola et al., 2022, p. 2). Knowing oneself, one’s values and beliefs and actively using
self-awareness to work with clients and in one’s own journey of change and growth is thus a vital aspect
of being an MHP (Bennett-Levy, 2019). We present here the complex layers of personal and professional
experiences with TGD persons upon which participants of this study reected. These reections also
40
had a dimension of historical time. Historical time here refers to external time/ calendar years, and
changes occurring over time in the ways in which TGD lives have been represented within diagnostic
and classication systems, curriculum and textbooks of psychiatry and psychology; as also to subjective
time, i.e., the age, experience, values/ beliefs of the MHP, and changes in these aspects over time.
With respect to personal experiences, most MHPs spoke of being socialised in normative ways and
hence believing in the naturalised cis-binary-gender system, while encountering the gendered “other”
mainly in the form of the Hijra gure engaged in begging at trac signals or seen singing and dancing
at weddings. Some recalled the emotion of fear associated with this gure, due to otherness/ distance,
stigmatising social beliefs about the Hijra community being child kidnapers, or the power of cultural
beliefs around the curses of the Hijras. Some participants reected on having had a trans masculine
person at their all-girls school or a trans feminine classmate in their undergraduate medical college.
One of the participants talked about having a trans student in the postgraduate psychiatry programme
that they taught and supervised at; another talked about a trans person in the family and the exclusion
and ostracism that this person faced from the family.
‘So the rst client was my student. And one day, she told me that she has
this feeling that actually she’s not a, uh, means, biologically, she’s a girl but
she feels from her mind in her brain, she feels that she’s a boy. And she’s
very, very uncomfortable with her body. And she would like to consider sex
change operation… And nally, she underwent sex change operation, hormonal
therapy and now she has become he, and he’s doing excellent work and he got
married also now, and he’s staying with his wife and he’s living a very fruitful
and very creative life. So that gave us the feedback that there are people and
after [an] operation, you can really provide them a very good life and they’re
very happy after the operation.’
60-year-old man, Psychiatrist, Mumbai
‘My rst interaction goes back a very long time. This was in my childhood.
My mother’s cousin is a trans woman. Today she’s out and proud, but
back in the day I remember I was not allowed to talk to him. I am not
misgendering him but back then he was my mother’s male cousin,
who would grow his hair out and paint his nails and have eeminate
mannerisms. Whenever we would go to their place, his mother would try
and shut him o in a room saying, “Don’t come out when there are guests.”
I was not allowed to interact with that person. I was asked to stay away.
I was told that even if you see him on the road, just ignore, don’t talk to
him. So those were my rst memories of someone that I knew upfront,
you know, without knowing that the person is trans… Only when I grew
up, I understood – and I have been guilty of a lot of discrimination myself,
because whenever I used to see him, I used to ignore him. I used to look
the other way. When I began to realise what I had done, when I began to
realise who she was, and why she was the way she was [back] in the day,
it was to no fault of hers. It was no fault of hers that I was discriminating
against her, and my entire family had pitted me against meeting or
41
interacting with her. For many years, I lived with a lot of guilt. A lot of my
work towards queer sensitisation also stemmed from there…’
42-year-old woman, Counsellor, Bangalore
‘I think my contact with the transgender community was only seeing people
from the Hijra community in trains, buses, trac signals, and I earlier thought
of them as scary people. But that was the only image that was there. I had
absolutely no idea about gender, sexuality, about trans, who trans people are
until my Master’s.’
28-year-old woman, Psychologist, Mumbai
As participants reected on their personal journeys of shifting from their normative gender socialisation
that involved ignorance about TGD issues or even trans-prejudice, they identied the role of engagement,
social contact with TGD persons, and information on TGD issues as factors that enhanced their cognitive
and, eventually, empathic awareness. 111 of the 165 study participants (67.2%) said that they had a TGD
person in their social circle of colleagues, friends or family. 101 (61.2%) stated that they had attended an
LGBT-themed lm festival, social event, or pride march. Thus, as suggested by literature on stereotype
and prejudice reduction (Dixon et al., 2016), exposure to counter-stereotypic information and intergroup
contact have signicant roles to play in the process of “de-biasing” and enhancing empathy.
On the professional front, participants reected on their initial contact with TGD clients and the
tentativeness, confusion and, at times, the sense of helplessness they felt in the absence of any guidelines,
protocol or training on TGD mental healthcare. Participants also reected, however, on self-motivated
and self-initiated eorts to learn about TGD mental health, and acknowledged the importance of being
mindful of the experiential distance between a cisgender therapist and a TGD client.
‘I think that the rst time I interacted with a trans client, I did validate what
the client was going through. But apart from that, I was not really able to
67.2% said that they had a
TGD person in their social
circle of colleagues, friends
or family
61.2% stated that they had
attended an LGBT-themed
film festival, social event, or
pride march
42
do a lot. I was just able to contain the client. I think I did not have the skill
and ability to maybe delve deeper as to how this journey has been, what
do they feel right now about themselves, about being trans, about living
with a family, about living within a normative family, having children, and
all of that. So, I was not able to delve deeper for the fear that even if I were
to retrieve this information, I don’t know what to do with it, because I don’t
think I’m skilled enough to be able to address that…’
28-year-old woman, Psychologist, Mumbai
‘I distinctly remember my rst one. This [was] 1999 or 2000. I was working at
that point of time in one of the government hospitals in Delhi in the psychiatry
department, and this was a young person who said that they were a man and
the assigned gender at birth was female and they had basically reached the
government hospital next door to try and get surgery done and the surgeon
had referred them to the psychiatry department saying that unless you get
some sort of consent from them, nothing can be done. So that’s how they
landed up with us, and I clearly told them that I had never seen this before. I
went to my seniors and they said, “Well, this is rare but here is the paragraph
in the book that tells you about it.” So, I read up that one paragraph and then
over a period of the next few weeks this young person, trans man – now I
know the vocabulary, [at] that time I didn’t. So, I ended up speaking to them for
about three and a half to four hours. Eventually, they got admitted along with
their father on the male side, that was their only condition that I will not get
admitted on the female side. And I spent quite a few hours with them over the
next few days, every evening.’
49-year-old woman, Psychiatrist, Delhi
‘The rst interaction was pretty awkward… when I began working, there
were times when I used to be a little, you know, taken aback by just the
appearance, because I was just 24-25, you know, I was young back then
when I started practicing and I used to feel uncomfortable asking some
questions in the very beginning. So, in the very beginning I was awkward, I
was confused, I didn’t know and I was a little ashamed of the fact that I’m
not very well-versed with gender identity and things.’
34-year-old woman, Psychologist, Mumbai
‘The dierence between then and now, I will say, is that it was very, very
clinical. The rst time I saw this patient, who was trans, it was all about the
symptoms and all about relieving the symptoms. The other aspects of it, which
also should be ideally part of the treatment, like using the right pronouns,
43
using the chosen name, not the given name, you know, helping out with
social adjustment, helping out with the legal adjustment, that was completely
outside of our perspective then. So, I think that would be a major dierence,
of course, and another thing was, we stuck very starkly to the standard of
care guidelines back then, six months of HRT or more, or having that real life
experience rst, even before starting the medical transition, insisting upon that,
and you know, having six months of that, with all the social diculties that the
person had to go through. That was how we approached it rst, but over the
years I learned that you have to be way more helpful to the patient than just
relieving the clinical symptoms.’
38-year-old man, Psychiatrist, Mumbai
‘So I’ve always wanted to go read up and understand the community
better. Learning that there is a distance [from] which we are operating.
And, you know, maybe we cannot co mpletely close that gap. So, learning
to function in that gap, being mindful that, you know, our worlds might
be dierent. And I have to change some parts of my perspective [when]
I’m meeting someone from the community. So, the looking lens is more
reective.’
29-year-old woman, Clinical Psychologist, Bangalore
‘Firstly, what I learned in the process is that I wouldn’t be able to help unless
I deconstructed my own beliefs about my own gender and my own sexuality.
So, what it means to be a woman, what it also means to express myself as a
woman, what it means to identify as a woman, so I had to look back, reect on
all of that. And I felt that unless I genuinely felt this from within, I wouldn’t be
able to help people.’
28-year-old woman, Psychologist, Mumbai
Participants reected on their own gender-sexuality and on other marginal locations, in the process
of understanding the challenges faced by their TGD clients. Two of the participants who were Muslim
women, one a queer woman and another a heterosexual, single woman who had broken several norms
expected of cisgender, heterosexual Muslim women, spoke about their struggles and the resultant
empathy for lives that are lived outside of social norms. Another queer psychiatrist spoke of being out and
how that meant that she would lose clients when they found out about her sexuality, and also of gaining
clients from the queer-trans community who would choose to come to her with the expectation that she
would understand them better. Some of the queer-trans MHPs spoke about using self-disclosure as a
therapeutic tool, especially with younger clients suering from internalised queer- and trans-prejudice,
and also in order to serve as role models.
44
‘So they were calling me “ma’am” and I was like, I am not “ma’am”, I identify
as non-binary and they were like, “Oh! it’s so nice to meet an older NB
person. I didn’t know people like this existed.”’
28-year-old non-binary person, Psychologist, Delhi
‘Personal identity? Bringing your personal in, into the therapy, I feel, for queer
people there is also that absence of the positive norm, positive dening of
their identity and experiences. As a teacher, I had denitely seen that when
you are a teacher and you are “out”, it lends some dignity to the student. They
drew some strength from that. That was helpful. This is how I negotiated in my
therapeutic practice too. I don’t shy [away] from giving that example.’
42-year-old woman, Psychologist, Delhi
Guideline 12. Training, capacity building and supervision to develop
competence for working with TGD Clients
MHPs recognise the need for specialised training on TGD mental health including
but not limited to assessments of gender incongruence and providing letters of
support for gender armation therapies. They are motivated to build their own
capacities and to seek supervision for providing TGD-competent and armative
mental health care.
The American Psychological Association (APA) Task Force on Gender Identity and Gender Variance
(TFGIGV) survey of 2009 had found that less than 30% of psychologists and graduate student participants
reported familiarity with issues that Transgender and Gender Non-Conforming (TGNC) people
experience. The National Transgender Discrimination Survey (Grant et al., 2011) reported that 50% of
TGNC respondents had to educate their health care providers about TGNC care, 28% postponed seeking
medical care due to anti-trans bias, and 19% were refused care due to discrimination. Stryker et al. (2022)
conducted a survey to study training experiences of clinicians for TGNC care with 281 counsellors, social
workers, psychologists, psychiatrists – and found that only 20% of their participants had been exposed
to relevant content on TGNC care during their graduate training, and that the most common sources of
training opportunities were professional conferences (76.4%) and mentorship (41.2%).
In India, as recently as June 2021, a High Court order (S Sushma v/s Commissioner of Police, Chennai) led
the National Medical Commission (NMC) to take note of the derogatory content regarding LGBT lives
in undergraduate medical curricula and textbooks (Agarwal & Thiyam, 2022). The NMC later set up a
committee to suggest changes to the psychiatry curriculum for a well-informed inclusion of LGBTQ
issues. Such reviews of the curricula of other streams of mental health education, such as psychology,
counselling and social work, have not taken place. It is not surprising, then, that in our present study
104 of the 165 participants (63%) stated that TGD issues were either not covered at all or only partly
covered during their formal education as mental health professionals. This percentage is, however,
likely to be much higher, as LGBTQ+ inclusion in the formal training of MHPs is still quite sparse in
India. 129 (78.2%) participants said that they felt the need for training on TGD mental health, while
45
114(69.1%) said that they had attended some workshop, seminar or training (online or oine) on LGBT+
mental health. Most of these trainings ranged in duration from a few hours to a few days; most were
not specically focused on TGD mental health but addressed TGD issues alongside those of cisgender
gay, lesbian and bisexual clients. 98 of the MHPs (59.4%) said that they had heard of some guidelines or
protocols on TGD mental health care, although only 89 were able to name any such guideline. A majority
of these 89 (n=52) mentioned the WPATH guidelines, while a few had heard of protocols by NIMHANS,
Indian Standards of Care (ATHI, 2021) and Queer Armative Counselling Practice (Ranade et al., 2022).
137 participants (83.03%) said that they had heard about the Transgender Persons (Protection of Rights)
Act and 79 (47.9%) said that they knew what this Act said about the role of health care providers in TGD
health. Thus, although the formal training of MHPs in India may not equip them with the necessary
knowledge and competence to work with their TGD clients, increased public discourse about trans-
specic legislations and rights along with motivation among MHPs to build their own capacities and
seek supervision are, admittedly, important steps towards building competency for trans-armative
mental healthcare.
Several of the MHPs reported reaching out to seniors and peers who had experience of working with
TGD clients, for supervision and resources on TGD mental health. Some had had the opportunity to
work outside the country in specialised gender clinics; others mentioned having attended trainings
abroad on gender-sexuality where they learnt more about TGD mental health. Many spoke of the value
of learning from the lived experiences of TGD communities. Mental health educators, too, have been
taking the initiative to conduct additional training sessions on queer- and trans-armative counselling.
104 of the 165 participants stated
that TGD issues were either not
covered at all or only partly
covered during their formal
education as mental health
professionals
63%
129 said that they felt the need for training on TGD mental health
114 said that they had attended some workshop, seminar or
training (online or offline) on LGBT+ mental health.
78.2%
69.1%
Only 89 were able to name any
such guideline.
59.4% 98 of the MHPs said that
they had heard of some
guidelines or protocols on
TGD mental health care
46
The role of MHP associations in developing practice guidelines and protocols on TGD health and in
providing ongoing training programmes for continued medical education (CME) was highlighted by
some participants.
‘When it comes to hands-on training, we don’t get that or, like, we are not as
well-equipped to deal with trans clients. All the knowledge accumulated
with respect to the practice, you know, actual practice was from M (a
colleague who had been working with TGD clients at the hospital for
almost a decade). M helped me out. He gave me resources, and this is after
I became a clinical psychologist, you know, so this kind of training should
have probably been there during my MPhil itself, which I felt was lacking,
and I think that was a huge obstacle.’
29-year-old woman, Clinical Psychologist, Bangalore
‘I went through this training, a certicate course in Amsterdam. There I got to
meet people who had sex reassignment surgery and how they felt about it,
and they spoke openly about their lives. So there also I got it, you know, [a]
better understanding of the whole thing. Initially, the understanding was very
theoretical, very [little], I would say. But as I got exposure, I think it denitely
improved, and I was more sensitive to all the issues that they could be going
through.’
68-year-old woman, Clinical Psychologist, Bangalore
‘In my formal education there was no exposure, although my teachers
were queer-armative. After I nished my training, two of my teachers
took the initiative to teach us about queer-armative counselling practice
during the COVID period. These were online sessions and they started from
the very basics like who is L, G, B, T etc. That was my rst exposure. They
educated us about the queer community. We were so involved that the
duration of the classes kept on extending, and one session became almost
three sessions . . . My current supervisor in the organisation is from the
initial batches of the Queer Armative Counselling Practice (QACP) course.
She is very good and very supportive. I also have friends around me who
have done both, the online sessions conducted by my teachers and later
the QACP course. This enables us to consult each other when we are stuck.’
25-year-old woman, Psychologist, Mumbai
47
‘The societies that we have, like the Indian Psychiatric Society (IPS) or the
national level societies of endocrinologists, or the plastic surgeons, they
can formulate their guidelines. There has been useful material published by
NIMHANS, which is one of the apex institutes for psychiatry. It has a detailed
step-by-step, things that should be done. So, the same thing converted into a
small and simple, say, owchart, which could be circulated by the IPS among
the psychiatrists, or something like that, would help.’
31-year-old man, Psychiatrist, Mumbai
‘We denitely have a lot of CMEs regarding LGBT issues because the Indian
Psychiatric Society has a subcommittee on LGBTQ issues that keeps on
taking such training or CMEs and conference[s] regarding this.’
35-year-old man, Psychiatrist, Mumbai
48
CONCLUDING REMARKS AND WAYS FORWARD
Trans Armative Mental Health Care Guidelines has been an eort to document good practices
employed by psychologists, psychiatrists, social workers and counsellors in their varied practice settings
of hospitals, clinics, NGOs, online consulting spaces. The signicance of this document is two-fold: it’s a
rst-of-its-kind attempt to document mental health practice with TGD clients in India; and second and
most importantly, it highlights the self-motivation of MHPs who, in the absence of formal training on
TGD mental healthcare, strive to provide the best care they can to their TGD clients. It is our hope that
this document presenting the practice wisdom of our study participants will make the path easier for all
MHPs who struggle to provide comprehensive care to their TGD clients.
It is important to note that the ndings of this study are not generalisable to all MHPs and their
knowledge or practice with TGD clients in India, primarily because we selected our study participants
purposively to include those MHPs who were known in each of the study sites to be working with TGD
clients.
In conclusion, we would like to highlight some areas of therapeutic practice with TGD clients and their
families that are missing in this document and in research on TGD mental health in India, in the hope
that these research gaps may be lled in the future.
a. There is a need for using a life course perspective to understand TGD mental health concerns – as
each developmental period from childhood, adolescence, youth to being older adults would aect
the kinds of concerns that TGD clients would present with, in counselling. Moreover, the normative
developmental tasks associated with each developmental stage in life-span studies would be
complicated for TGD persons due to trans-specic stressors.
b. The impact of transitioning on family relationships has not been articulated much in this document,
as we have primarily focused here on the immediate responses of the family and on the need for
their psychoeducation and dealing with their requests for conversion treatments.
c. This document does highlight a few relationship and couple concerns among TGD persons;
however, the families of choice that TGD persons make, particularly in the absence of support from
their families of origin, and which may be constituted in varying ways and may include persons
not related by blood or marriage – these non-normative family structures have not been included
in this document. Similarly, we have not engaged here with TGD person/s as parents, and their
support needs in raising children.
d. Finally, although there is consensus on not using conversion treatments with TGD clients among
MHP associations in India, there is an urgent need to develop some guidance document on ways of
responding to these requests by TGD clients and their families that would help to build awareness,
normalise variations in gender identities and expressions, deal with internalised trans-prejudice,
and provide support to these individuals and families to move towards acceptance.
49
NOTE ON TERMINOLOGIES USED IN THE
DOCUMENT
Literature on transgender health and mental health uses a number of terms to refer to persons whose
self-dened gender identity or expression does not match the sex-gender assigned to them at birth.
Some of the identity terms that have been used in literature to refer to transgender persons are also
used in this document:
* Transgender Person – A person whose gender identity does not match with the gender and sex they
were assigned at birth
* TGD – Transgender and Gender Diverse
* TGNC –Transgender and Gender Non-Conforming
* Trans person – A transgender person
A few other terms used in this document:
• Cisgender Person – A person whose gender identity conforms with the gender and sex that they
were assigned at birth
• Gender incongruence – A marked and persistent incongruence between the gender felt or experienced
by a person, and the gender associated by society with the sex they were assigned at birth
• Gender Dysphoria – The psychological distress that results from an incompatibility between a
person’s self-perceived gender identity, and the gender associated with them by society based on the
sex they were assigned at birth
• Gender Identity – How an individual denes their own gender, which depends on a person’s deeply
felt internal experience of gender. It need not correspond with the sex assigned to the person at
birth, and to the expectations that society has from this assigned sex or its associated gender.
“Gender Identity” is self-determined – that is, only the individual concerned can declare what their
gender identity is. There is no medical or psychological test to determine a person’s gender identity
• Gender Transition Service – Includes services that help an individual arm their gender identity,
including social (clothes, hair, grooming, in ways that are perceived to be closer to the self-identied
gender); medical (hormones, laser); surgical; and legal (changing name and gender on identity
documents and certicates)
• Queer – An umbrella term used to refer to diverse sex characteristics, genders and sexualities that
are not cisgender and/or heterosexual
• Passing –refers to a transgender person being correctly perceived to be of the gender they are,
or identify with, and not being perceived as a transgender person or as a person with the gender
identity assigned to them at birth.
• Ally – Someone who, while not identifying as queer themselves, is supportive of the rights of
LGBTQIA+ persons and communities, and may also use their privilege/ position in society to promote
LGBTQIA+ rights.
50
Note on misgendering in quotes from participants
We have sought to retain verbatim the quotes from study participants, which has meant at times that
if the participant misgendered a client or a patient or used statements like ‘he became she’, this has not
been corrected by the authors. In a few instances, the practitioner self-corrected in the course of the
interview, and that has been retained as well.
51
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