Persistent and intense distress about assigned gender or insistence that individual belongs to a different gender Marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics

1. GENDER IDENTITY
DISORDER
Total slides –77
1
Gender Dysphoria / Gender Incongruence
Presenter
Dr Rachit Sharma
Junior Resident (Psychiatry)
Armed Forces Medical College,
Pune
Moderator
Dr Harpreet Singh
Sr Adv (Psychiatry) & HoD
Dept of Psychiatry
Command Hospital (SC), Pune

2. Outline
• Introduction
• Important terms
• Mythology and History
• Comparative Nosology
• Epidemiology
• Acquisition of gender
identity
• Differential diagnosis
• Treatment
• Course and Prognosis
• Role of psychiatrist
• Indian scenario
• Armed Forces
perspective
• Take home points
2

3. Important terminology
3

4. Important terminology
• SEX
– Status of biological variables that can be
described as either male typical or female typical
in normatively developed individual
• GENDER
– Attributes of people, which are associated with
biological sex
– Refers to social categories of Males (boys, Men)
and females (girls, women)
4
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

5. Important terminology
• GENDER IDENTITY (EXPERIENCED GENDER)
– One’s persistent inner sense of belonging to either
male or female gender category
• GENDER ROLE (EXPRESSED GENDER)
– Outward expression of inner sense of gender identity
– Those things that a person say or does to disclose
himself or herself as having the status of a boy or
man, girl or women
5
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

6. Important terminology
• TRANSGENDER
– Indl whose gender identity (or gender expression) and
natal gender are discordant or not conforming to
social norms
• The Transgender Persons Bill 2016 defines
Transgender as
“Neither wholly female nor wholly male; a
combination of female or male; neither female nor
male”, and “whose sense of gender does not match
with the gender assigned to the person at the time of
birth”
6
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

7. Important terminology
• TRANSSEXUAL
– Indl who has , or plans to employ hormonal or
surgical means to modify the body so as it
conforms to one’s experienced gender
– MTF or transwomen
– FTM or transman
• GENDER REASSIGNMENT SURGERY/ GENDER
CONFIRMATION SURGERY
7
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

8. Important terminology
• HOMOSEXUAL/ HETEROSEXUAL/BISEXUAL
(ANDROPHILIC/GYNAEPHILIC/ANALOPHILIC)
• GENDER DYSPHORIA
– Unhappiness or a sense of inappropriateness with
one’s natal sex or the gender role associated with
that sex
• FETISHISTIC TRANSVESTITISM
• DUAL ROLE TRANSVESTITISM
8
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

9. Mythology & History
9

10. Mythology
• INDIAN MYTHOLOGY
– DWAPAR YUG –
• SHIKANDINI – SHIKANDI legend
• ARJUNA- Cross gender and cross dressing as
VIRHANALLA
• ARAVAN – MOHINI
10
Somasundaram O. Transgenderism: Facts and fictions. Indian Journal of Psychiatry 2009 Jan-Mar; 51(1)

11. Mythology
• GREEK MYTHOLOGY
– TIRESIAS, a man whose body was changed into
female body by Goddess Hera
11
Somasundaram O. Transgenderism: Facts and fictions. Indian Journal of Psychiatry 2009 Jan-Mar; 51(1)

12. History
• 19TH & 20TH CENTURY
KARL ULRICH (1825 – 1895)
– Urnings – Men born with a female
spirit trapped inside their body
RICHARD VON KRAFFT-EBING (1840-1902)
• PSYCHOPATHIA SEXUALIS
• METAMORPHOSIS SEXUALIS PARANOIA
12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

13. History
MAGNUS HIRSCHFELD (1868 – 1935)
• Established Scientific humanitarian society
• Differentiated between desires of
Homosexuality to have partner of same
sex) and transsexualism
(to live as other sex)
13
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

14. History
• 20TH CENTURY
– George Jorgensen Christine Jorgensen
– Dr Christian Hamburger performed this surgery
and published his report in JAMA
– Awareness about the concept of gender identity
14
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

15. History
JOHN MONEY (1921 – 2006)
• Research on children born with DSD
• Gender identity is acquired
• Parental attitude and Family rearing practices
HARRY BENJAMIN (1885-1986)
• Coined the term transsexual
• Transsexualism – Biological in nature
• HBIGDA  WPATH
15
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

16. History
– ROBERT STOLLER (1924-1991)
• Introduced and described the concept of gender identity
• Emphasized the role of childhood family dynamics in
gender identity
• Influenced by Separation – Individualization theory of
Margret Mahler
– RICHARD GREEN (1936 - )
• Studied cross gender behaviour in prepubescent children
• The “Sissy Boy Syndrome” and the Development of
Homosexuality
16
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

17. Comparative Nosology
17

18. Comparative Nosology
18
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

19. Comparative Nosology
19
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

20. Comparative Nosology
20

21. Comparative Nosology
21
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

22. Comparative Nosology
22
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.

23. Comparative Nosology
23
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.

24. Comparative Nosology
24

25. Comparative Nosology
25
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.

26. Diagnostic criteria
26

27. ICD-10
27

28. Transsexualism (F 64.0 )
A. Desire to live and be accepted as a member of the
opposite sex, usually accompanied by the wish to
make one's body as congruent as possible with
one's preferred sex through surgery and hormonal
treatment
B. Presence of the transsexual identity for at least two
years persistently.
C. Not a symptom of another mental disorder, such as
schizophrenia, or associated with chromosome
abnormality
28

29. Dual-role transvestism (F 64.1)
A. Wearing clothes of the opposite sex in order to
experience temporarily membership of the opposite
sex
B. Absence of any sexual motivation for the cross-
dressing
C. Absence of any desire to change permanently into
the opposite sex
29

30. Gender identity disorder of childhood
(F 64.2)
A. Persistent and intense distress about assigned gender or
insistence that indl belongs to different gender
B. Persistent marked aversion to assigned gender’s clothing
and insistence on wearing clothing and accessories of other
gender, intense desire to participate in the games and
pastimes of other gender
C. Persistent repudiation of anatomic structures of his/her
gender
D. Has not yet reached puberty
E. The disorder must have been present for at least six months
30

31. DSM -V
31

32. Gender Dysphoria in Children
1. A strong desire or an insistence that one is the other gender
2. A strong preference for cross-dressing
3. A strong preference for cross-gender roles in make-believe
play or fantasy play
4. A strong preference for the toys, games, or activities
stereotypically used or engaged in by the other gender
5. A strong preference for playmates of the other gender
6. A strong rejection of gender typical toys, games, and
activities
7. A strong dislike of one's sexual anatomy
8. A strong desire for the primary and/or secondary sex
characteristics that match one's experienced gender.
32

33. Gender Dysphoria in
adolescents and adults
1. A marked incongruence between one's experienced/ expressed
gender and primary and/or secondary sex characteristics (or in
young adolescents, the anticipated secondary sex
characteristics)
2. A strong desire to be rid of one's primary and/or secondary sex
characteristics because of a marked incongruence with one's
experienced/expressed gender (or in young adolescents, a
desire to prevent the development of the anticipated secondary
sex characteristics)
3. A strong desire for the primary and/or secondary sex
characteristics of the other gender
4. A strong desire to be or to be treated as other gender
5. A strong conviction that one has the typical feelings and
reactions of the other gender 33

34. ICD -11
34

35. Gender incongruence of childhood
1. A strong desire to be a different gender or insistence that he
or she is a gender different from one’s assigned gender
2. A strong dislike for his or her sexual anatomy or anticipated
secondary sex characteristics and/or a strong desire for the
primary and/or anticipated secondary sex characteristics
that match the experienced gender
3. A strong preference for the toys, games, plays or activities
stereotypically used or engaged in by the other gender
35

36. Gender incongruence of
adolescence and adulthood
1. A strong dislike or discomfort with one’s primary
and/or secondary sex characteristics (in adolescents,
anticipated secondary sex characteristics)
2. A strong desire to be rid of some of all of one’s
primary and/or secondary sex characteristics (in
adolescents, anticipated secondary sex
characteristics)
3. A strong desire to have the primary or secondary sex
characteristics of the experienced gender
4. A desire to be treated (to live and be accepted) as a
person of the experienced gender
36

37. Epidemiology
37

38. Epidemiology
• Prevalence (In specialized gender clinics)
– Natal adult males – 0.005 – 0.014 %
– Natal adult females – 0.002 – 0.003 %
• Age wise sex differences in rates of referrals to
speciality clinics (natal male to natal female)
– Children– 2:1 to 4.5:1
– Adolescents – 1:1
– Adults – 1:1 to 6:1
38
Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolescent
health, medicine and therapeutics. 2018;9:31.
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

39. Gender Identity acquisition
39

40. Milestones
AGE MILESTONES
9 months Able to associate male and female faces with male
and female voices
15 to 24
months
Able to associate gender labels such as lady or man
with male and female voices
Can label adults as male or female
30 months Can label peer and self appropriately by gender
3 years Awareness about their genitals
6-7 years Gender constancy and Gender stability
40
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

41. Role of Biological factors
Models for potential role of biological and
psychosocial factors for development of gender
identity
1. Model of Direct biological effect
2. Model of Indirect biological effect
3. Model of Permissive biological effects
41
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

42. Model of
Permissive biological effects
Biological factors
Neural machinery
Restricted period
Gender identity
Formative
experiences
42

43. Role of Psychosocial factors
1. Verbal labelling and nonverbal gender-cuing
of children by parents and others in their
social environment
2. Shaping of gendered behaviour by
– Positive and negative reinforcement
– Explicit statements of gender-role expectations
3. Parent–child attachment
43
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

44. Differential diagnosis
44

45. DD: GD in childhood
1. Non conformity to gender role/ Simple
atypical gender behaviour
2. Epiphenomena of coexisting disorders,
including psychotic disorders
3. Perceived social advantage of being that
gender
4. To escape a perceived disadvantage of the
assigned gender (e.g. sexual trauma)
45
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.

46. DD: GD in Adolescents and Adults
1. Fetishistic transvestism (F65.1) (Transvestic
disorder )
2. Body dysmorphic disorder
3. Schizophrenia and other psychotic disorders
46
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.

47. Treatment
47

48. STAGED TRANSITION
Fully reversible steps 1. Presenting as the desired
gender
2. Pubertal suspension
Partially reversible procedures Administration of gonadal
hormones to bring about the
desired secondary sex
characteristics
Irreversible procedures Bottom surgeries -
Gonadectomy, Vaginoplasty in
natal males
Top surgeries –
Mastectomy and surgical
construction of male-typical
chest
48
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

49. Treatment: Prepubertal children
• Only psychotherapeutic approaches are used
1. First approach – Inducing desistence
• Working with the child and caregivers to lessen
gender dysphoria
• To decrease cross-gender behaviours and
identification
2. Dutch approach – Wait and watch
3. To educate and guide them through the process
of transitioning
49
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

50. Treatment: Adolescents
1. Rule out any psychopathlogy
– Recent psychological trauma
– Psychotic or other disorders
2. Pubertal suspension
3. Gender reassignment surgery
– After ample time of living in the desired gender
role
– After 1 year of hormonal treatment
– Legal age of majority to consent
50
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer

51. Treatment: Adults
• Gender reassignment surgery
– Gender reassignment surgery (TOP/BOTTOM)
• For MTF - Breast augmentation and surgical
construction of a vulva, clitoris, and vagina
• For FTM - Bilateral mastectomy, surgical construction of
penis and scrotum
– Additional surgical procedures
• For MTF - Voice training, vocal cord modification, and
Botox injections
• For FTM - Procedures to feminize facial appearance
51
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An
Overview and Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-A3.

52. Treatment
• Counselling regarding practical legal matters
– To maintain the option of being a parent of one’s
biological child – Sperm banking
– How to change a gender descriptor on a birth
certificate, a driver’s license, or a passport
– How to be responsive to the concerns of
family, school, job and place of worship
– Increased libido with androgen use, Safe sexual
practices
52
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An
Overview and Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-A3.

53. Course and Prognosis
53

54. Course and Prognosis
• Onset – Between 2 – 4 yrs
• Gender incongruence among prepubescent
children - Feelings are unstable and are likely to
change
• Gender incongruence extending beyond puberty -
Leads to its persistence into adulthood
• Rates of persistence (childhood to adolescence)
– Natal males – 2.2 - 30 %
– Natal females – 12 - 50 %
54
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.

55. Course and Prognosis
• Non-persistence of gender dysphoria
(childhood to adolescence)
– Natal males – 63 -100 % - androphilic
– Natal Females – 32 -50 % - gynaephilic
55
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.

56. Role of Psychiatrist
56

57. Role of Psychiatrist
1. Assess and diagnose gender concerns and to
ensure that they are addressed
2. Assess and diagnose any coexisting
psychopathology and see that it is addressed
3. Assess eligibility for hormonal and/or surgical
treatments, or refer to professionals capable
of making such assessments
57

58. Role of Psychiatrist
4. Assess capacity to give informed consent for
hormonal and surgical treatments
5. To make them aware of the full range of
treatment options and their physical,
psychological, and social implications,
including risks, benefits, and impact on
sexual functioning and reproductive
potential
58

59. Role of Psychiatrist
6. Ensure adequate psychological and social
preparation for transition treatments
7. Refer patients for hormonal or surgical
treatments, collaborating with providers as
needed
8. Ensure continuity of mental healthcare as
indicated throughout transition and beyond
59

60. Indian Scenario
60

61. Transgender community
• The Transgender Persons Bill 2016 defines
Transgender as
• “Neither wholly female nor wholly male; a combination
of female or male; neither female nor male”, and “whose
sense of gender does not match with the gender assigned
to the person at the time of birth”
• Hijras , Aravanis, Kothis, Jogtas/Jogappas , Shiv-
Shakthis , Khwaja saras
61
A Right to Exist: Eunuchs and the State in Nineteenth-Century India Laurence W. Preston Modern Asian Studies, Vol.21,No.2 (1987), pp.371-387)
Singh Y, Aher A, Shaikh S, Mehta S, Robertson J, Chakrapani V. Gender transition services for Hijras and other male-to-
female transgender people in India: availability and barriers to access and use. International Journal of Transgenderism.
2014 Jan 2;15(1):1-5.

62. NALSA v/s UoI
• The Hon’ble Supreme Court directed Centre and
State Governments to grant
– Legal recognition of gender identity whether it be
male, female or third-gender
– The SC said they will be given educational and
employment reservations as OBCs
– If a person surgically changes his/her sex, then he or
she is entitled to her changed sex and can not be
discriminated
62
National Legal Services Authority v. Union of India 15 april 2014

63. Sec 377 of IPC
• 06 September 2018 - Navtej Singh Johar &
Ors. v. Union of India & Ors
• Judgement by Hon’ble Supreme court
• “Only constitutional morality and not social
morality can be allowed to permeate rule of law.
Sexual orientation is one of the many natural
phenomena, any discrimination on basis of sexual
orientation amounts to violation of fundamental
rights”
63
Navtej Singh Johar vs. UOI; Akkai Padmashali vs. UOI; Keshav Suri vs. UOI; Arif Jafar vs. UOI; Ashok Row Kavi
vs. UOI; Anwesh Pokkuluri vs. UOI

64. Armed Forces Perspective
64

65. • The sailor underwent the gender
reassignment in 2017 as she felt that she was
"a woman trapped in a man's body"
65

66. • "sad and worrying that a 'man' the Indian Navy
deemed fit for the job of being a sailor has suddenly
been declared unfit because of an organ change,“
• Sabi, who was diagnosed with Gender Identity
Disorder, said that she had tried to seek help from the
naval doctors, but they had turned her away, consulted
civil doctors in Visakhapatnam
• She also alleged that she was "mentally harassed and
kept in a psychiatric ward for six months. They tried
to prove me mentally unfit but they failed"
66

67. Armed forces : Current position
67

68. Army Act 1950
68

69. Navy Act 1957
69

70. Air Force Act 1950
70

71. Amendment Bill 2018
71

72. Proposed amendments
72

73. International scenario :
LGBT in Armed forces
73

74. Countries allowing LGBT
in Armed forces
74

75. Timeline : Right for LGBT to serve
75

76. Take home points
• There can be incongruity between assigned
gender and experienced gender
• This incongruity is no longer considered as a
disorder, with picture becoming more clear
with recent judgements
• Greater responsibility lies with mental health
professionals to help these indl in treatment,
social awareness and their integration into the
society
76

77. References
1. Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of
Psychiatry 10th ed. 2017 Wolters Kluwer
2. Berlin FS. A conceptual overview and commentary on gender
dysphoria. Journal of the American Academy of Psychiatry and the
Law Online. 2016 Jun 1;44(2):246-52.
3. Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB,
Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S, Briken
P. Disorders related to sexuality and gender identity in the ICD‐11:
revising the ICD‐10 classification based on current scientific
evidence, best clinical practices, and human rights considerations.
World Psychiatry. 2016 Oct;15(3):205-21.
4. Lee PA, Houk CP. Evaluation and management of children and
adolescents with gender identification and transgender disorders.
Current opinion in pediatrics. 2013 Aug 1;25(4):521-7.
77

78. References
5. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders (DSM-5®). American Psychiatric Pub; 2013 May
22.
6. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender
dysphoria in adolescence: current perspectives. Adolescent health,
medicine and therapeutics. 2018;9:31.
7. Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg
HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and
Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-
A3.
8. Singh Y, Aher A, Shaikh S, Mehta S, Robertson J, Chakrapani V.
Gender transition services for Hijras and other male-to-female
transgender people in India: availability and barriers to access and
use. International Journal of Transgenderism. 2014 Jan 2;15(1):1-5.
78

79. References
9. F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/
gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12.
10. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender
dysphoria in adolescence: current perspectives. Adolescent health,
medicine and therapeutics. 2018;9:31.
11. Section 377 IPC Navtej Singh Johar vs. UOI; Akkai Padmashali vs.
UOI; Keshav Suri vs. UOI; Arif Jafar vs. UOI; Ashok Row Kavi vs. UOI;
Anwesh Pokkuluri vs. UOI
12. NALSA vs UoI 2014
13. Somasundaram O. Transgenderism: Facts and fictions. Indian
Journal of Psychiatry 2009 Jan-Mar; 51(1)
14. WHO. The ICD -10 Classification of Mental and Behavioural
Disorders;1992
79

80. Literature and Cinema
80

81. THANK YOU 81