Indian psychiatrist at the crossroads of transgender care: Gatekeeper, advocate, or redundant authority?

ICD-11 marks a conceptual shift by recognizing gender incongruence as not a mental disorder while retaining it within the classification under sexual health to facilitate healthcare access, coding, and insurance reimbursement. Thus, its continued inclusion is primarily an administrative necessity rather than a reflection of psychopathology. Although psychiatrists have increasingly viewed their role as facilitating care rather than policing identity, mandatory psychiatric documentation has often been experienced by transgender individuals as gatekeeping. The 2026 amendments to the Transgender Persons (Protection of Rights) Act further complicate this landscape by replacing self-declared gender identity with certification through designated medical boards for legal recognition. This perspective examines the historical, clinical, ethical, and legal dimensions of psychiatric involvement in transgender care within the Indian context. It argues that while psychiatry has an essential role in assessing decision-making capacity, identifying co-occurring mental disorders, managing psychosocial distress, and promoting safe hormone use, it should not function as an authority that validates or invalidates an individual's gender identity. Recent legislative changes risk reinforcing defensive psychiatric practices and reinstating institutional gatekeeping, potentially delaying access to care and increasing reliance on unsupervised gender-affirming interventions. Drawing parallels with the consultative role of psychiatrists in organ transplantation, we propose a collaborative, multidisciplinary model in which psychiatrists serve as facilitators, advocates, and providers of mental healthcare rather than custodians of identity. Strengthening residency training, developing clear national guidelines, and harmonizing legal and healthcare frameworks are critical to achieving this transition.