This Photo by Unknown Author is licensed under CC BY-SA

SECTION 377 IPC: CLINICAL

UTILITY AND RECENT ADVANCES

 MODERATOR:- Dr. P.R.Avinash PRESENTED BY:-Dr. Rohit Gondwal

 Assistant Professor Resident 3st year
 Dept of Psychiatry Dept Of Psychiatry

This Photo by Unknown Author is licensed under CC BY

Introduction

History

Theories

Changes in ICD and DSM

Mental health problems

Section 377

Psychiatrist challenges

Future directions

Summary

This Photo by Unknown Author is licensed under CC BY

FACTS

First secular
law criminalizing
"the abominable vice of
buggery" and making it
punishable by hanging
Karl Heinrich Ulrichs (1825-1895)
first activist for homosexual civil rights
German lawyer  • "Urnings" who had a female soul in a male
Karl Heinrich Ulrichs body
 (1825-1895) was perhaps • He hypothesized that there were
the first activist for competing male and female "germs" that
homosexual civil rights determined male and female anatomy
and psyche

11 century

Karl Maria Kertbeny (1824-

1882) coined the term
"homosexual" in 1869 
 Sodom and Gomorrah: the Jean Martin Charcot 
story in Genesis 19 in Bible • 1882 as "inversion of the
Saint Peter Damien KarlWestphal "contrary genital sense”
 Masturbation sexual sensation" and "sexual perversions" 
Napoleonic Penal Code claimed it was
 Fornication • sexual inversion was a
• debauchery or corruption" of congenital
 Bestiality neuropsychiatric degenerative
minors of either sex
 Oral or anal sex condition like hysteria and
• "offenses against public
epilepsy
decency
• the Code never. criminalized
homosexuality https://www.aglp.org/gap/1_history/
  Sigmund Freud 
 Everyone is born with bisexual tendencies,
PSYCHOANA expressions of homosexuality could be a
normal phase of heterosexual development.
LYTIC   “Homosexuality is assuredly no advantage,
THEORIZING but it is nothing to be ashamed of, no vice, no
degradation; it cannot be classified as an
illness; we consider it to be a variation of the
sexual function, produced by a certain arrest
of sexual development”

Jack Drescher , 2015

Homosexuality in DSM and ICD
Edition Year Parent category Diagnosis Rationale
DSM-I 1952 Personality disorders Homosexuality Individual is ‘ ill primarily in terms of
Sociopathic personality society and of conformity with the
disturbance prevailing cultural milieu ’
DSM-II 1968 Personality disorders Sexual Homosexuality Deeply ingrained maladaptive patterns of
deviation behaviour
DSM-II sixth 1973 Personality disorders Sexual Sexual orientation individuals whose sexual interests are
printing deviation disturbance directed primarily toward people of the
same sex and who are either disturbed by,
in conflict with, or wish to change their
sexual orientation

1980 SOD was replaced

by 
ego-dystonic homos
exuality
 

Jack Drescher ,et al,2015

 Edition Year Parent category Diagnosis Rationale

DSM-III 1980 Psychosexual disorders Other Ego-dystonic desire to acquire or increase heterosexual arousal, so
psychosexual disorders homosexuality that heterosexual relationships can be initiated or
maintained, and a sustained pattern of overt
homosexual arousal that the individual explicitly
states has been unwanted and a persistent source of
distress
DSM-III-R 1987 Psychosexual disorders Sexual disorder not ‘ persistent and marked distress about one ’ s sexual
otherwise specified orientation
DSM-IV 1994 Sexual and gender identity Sexual disorder not persistent and marked distress about one ’ s sexual
disorders otherwise specified orientation
DSM-IV-TR 2000 Sexual and gender identity Sexual disorder not persistent and marked distress about one’s sexual
disorders otherwise specified orientation
DSM-5 2013 None None n/a

Jack Drescher ,et al,2015

Edition Year Parent category Diagnosis Miscellaneous
ICD-6 1948 Categories specifically related to Homosexuality
sexual functioning or sexual
disorders Pathologic personality
Sexual deviance
ICD-7 1955 Categories specifically related to Homosexuality
sexual functioning or sexual
disorders Pathologic personality
Sexual deviance
ICD-8 1965 Categories specifically related to Homosexuality Diagnosis includes ‘ lesbianism ’and ‘ sodomy ’
sexual functioning or sexual
disorders Sexual deviance
ICD-9 1975 Categories specifically related to Homosexuality ‘ The limits and features of normal sexual
sexual functioning or sexual inclination and behaviour have not been stated
disorders Sexual deviations and absolutely in different societies and cultures but
disorders are broadly such as serve approved social and
biological purposes. ’ Code to be used ‘ whether
or not it is considered a mental disorder. ’

Jack Drescher ,et al,2015

 Edition Year Parent category Diagnosis Miscellaneous
ICD-10 1990 Psychological and Sexual
behavioural disorders maturation
associated with disorder
sexual development Ego-dystonic
and orientation sexual
orientation

ICD-11 2017 None none

(proposed)

Jack Drescher ,et al,2015

 Theories of Homosexuality

Theories of Pathology Theories of Immaturity Theories of Normal Variation

“developmental arrest,” adult The contemporary cultural

“Normal,” heterosexual
homosexuality is equated with belief that people are “born
development
stunted growth gay” is a normal

Events can occur pre- or postnatally

(i.e., intrauterine hormonal exposure, excessive
mothering, inadequate or hostile fathering, sexual
abuse, etc.). 
Jack Drescher , 2015
  Several models have been proposed to conceptualize
homosexual orientation.
 e Kinsey Scale
 a two-dimensional map of erotic orientation
 asexual (low heterosexual and low homosexual)
CONCEPTUALI  heterosexual (high homosexual and low homosexual)

ZATIONS OF  Homosexual(low heterosexual and high homosexual)

 bisexual (high heterosexual and high homosexual)

HOMOSEXUAL  Stage Model

IDENTITY  Minton & McDonald, 1984; and Troiden, 1989) follow a

sequence of four general stages that can be described as
 (1) Awareness or Sensitization,
 (2) Internalization or Acceptance,
 (3) Disclosing,
 (4) Synthesis or Integration.

Janna L. Horowitz 2002

  Phase 1: Awareness, in which the individual is aware of a difference
from the heterosexual norm, and in which an awareness of a community

MCCARN 
of lesbian/gay people may arise.
Phase 2: Exploration, in which the woman seeks to define her position
in relation to the reference group along the dimensions of attitudes and

AND 
membership.
Phase 3: Deepening/commitment, which is marked by a commitment to
make a personal relationship to the reference group and the possible

FASSINGER consequences of doing so, in addition to a deepening awareness of the

value and the oppression of the lesbian/gay community.
 Phase 4: Internalization/synthesis, the “final developmental phase”,

(1996) which entails the woman identifying herself as a member of the

minority group, internalizing this identity, and synthesizing it into her
overall self-concept. The synthesis is reflected in feelings of fulfillment,
security, and the ability to maintain the self-concept across contexts.

Janna L. Horowitz 2002

 MENTAL
HEALTH
PROBLEMS
FACED BY
LGBTIQ PEOPLE
David J. Lick et al 2013
 LGB victimization leads to
 Major depressive disorder
 Generalised anxiety disorder
 Substance use
 High risk of suicide
 poor overall health status to heightened incidence of
specific diseases
 Specific issues
 verbal harassment related to their sexual orientation
 physical assault and property damage

David J. Lick et al 2013

 Proximal
• Victimization
• Conflict with once's
Distal identity
• Marriage • Anxiety about future
• Inequality • Negative feeling with
one’s sexual orientation

David J. Lick et al 2013

ARTICLE 377
 A writ petition is preferred by NAZ Foundation , a non government organization in year 2009
as a public interest litigation to challenge the constitutional validity of section 377 of the IPC,
which criminally penalizes what is described as “UNNATURAL OFFENCE”

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
  First record of sodomy as a crime at Common

HISTORY Law in England were chronicled in the Fleta,

1290, and later in the Britton, 1300.

OF
 Sodomites should be burnt Alive
 Later penalize by hanging according to
BUGGERY ACT of 1533

LEGISLAT
 Oral- genital sexual acts removed from the
definition of buggery in 1817.
 1861, the death penalty for buggery was

ION
abolished in England and Wales

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
 Lord Macaulay and introduced in 1861 in British India.
 Section 377 IPC is contained in Chapter XVI of the IPC titled “Of Offences Affecting the
Human Body”.
 Within this Chapter Section 377 IPC
 sub-chapter titled “Of Unnatural Offences” and reads as follows:

 377. Unnatural Offences - Whoever voluntarily has carnal intercourse against the order of
nature with any man, woman or animal, shall be punished with imprisonment for life, or with
imprisonment of either description for a term which may extend to ten years, and shall also be
liable to fine.
 Explanation - Penetration is sufficient to constitute the carnal intercourse necessary to the
offence described in this section."
Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
CHALLENGES
 Section 377 IPC serves as the weapon for
 Police Abuse;
 Detaining And Questioning,
 Extortion,
 Harassment,
 Forced Sex,
 Payment Of Hush Money;
 Perpetuates Negative And Discriminatory Beliefs Towards Same-sex Relations And Sexuality
Minorities;
 which consequently drive the activities of gay men and MSM, as well as sexuality minorities
underground thereby crippling HIV/AIDS prevention efforts

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
 Section 377 IPC is the only law that punishes child sexual abuse and fills a lacuna
 it violated certain Constitutional human rights, namely, those to life and liberty, equality before
the law, and rights protecting individuals from discrimination

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
SECTION 377 IPC AS AN INFRINGEMENT OF THE
RIGHTS TO DIGNITY AND PRIVACY

Dignity according to Article 21

 claim concerning private, consensual, sexual relations are also afforded protection within the ambit
of the said fundamental right to life and liberty.

 Section 377 IPC denies a person's dignity and criminalises his or her core identity solely on
account of his or her sexuality and thus violates Article 21 of the Constitution.


Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
WHETHER SECTION 377
IPC VIOLATES
CONSTITUTIONAL
GUARANTEE OF EQUALITY
UNDER ARTICLE 14 OF
THE CONSTITUTION

Naz-Foundation-v.-Government-of-NCT-
of-Delhi-and-Others-The-High-Court-of-
Delhi-at-New-Delhi-India-2
 Section 377 violates:
 (i) Article 14 which guarantees equal protection of laws and protection from arbitrariness
 (ii) Article 15 which prohibits discrimination based on sex
 (iii) Article 19
 (1) (e) which guarantees the freedom of expression and
 (iv) Article 21 which guarantees the right to life, right to dignity, the right to privacy and the right to
health . In summary, the Court arrived at this conclusion based on the following principles:
 Identity is an integral part of one’s right to life and right to dignity. Sexual orientation is an inherent
aspect of one’s identity.

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
 The right to sexual orientation and the right to express the same are inherent components of a
person’s right to live with dignity.
 The right to make choices about one’s personal life, and to express the same, is an expression
of one’s decisional autonomy and the right to privacy.
 Discrimination based on stereotypes about gender roles amounts to discrimination based on
one’s sex.
 The right to health is an integral part of the right to life.
 While examining the constitutionality of Section 377, the Court

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
YOGYAKARTA PRINCIPLES
 On 26th March, 2007, a group of human rights experts launched
 the Yogyakarta Principles on the Application of Human Rights Law in Relation to Sexual Orientation
and Gender Identity (Yogyakarta Principles).
 experts came from 25 countries representative of all geographical regions.
 They included one former UN High Commissioner for Human Rights,
 13 current or former UN Human Rights Special Mechanism Office Holders or Treaty Body Members,
 two serving Judges on domestic courts
 a number of academics and activists

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
 THE YOGYAKARTA  “Sexual Orientation” is understood to refer to
PRINCIPLES DEFINE each person’s capacity for profound
THE EXPRESSION emotional, affectional and sexual attraction to,
“SEXUAL and intimate and sexual relations with,
ORIENTATION” AND individuals of a different gender or the same
“GENDER IDENTITY”
AS FOLLOWS:
gender or more than one gender;”

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
 “Gender Identity” is understood to refer to each person’s
deeply felt internal and individual experience of gender,
which may or may not correspond with the sex assigned
at birth, including the personal sense of the body (which
may involve, if freely chosen, modification of bodily
appearance or function by medical, surgical or other
means) and other expressions of gender, including dress,
speech and mannerisms.”

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
   Human beings of all sexual orientation and gender

THE identities are entitled to the full enjoyment of all

human rights;

PRINCIPLES  All persons are entitled to enjoy the right to privacy,

regardless of sexual orientation or gender identity;

RECOGNISE:
 Every citizen has a right to take part in the conduct of
public affairs including the right to stand for elected
office, to participate in the formulation of policies
affecting their welfare, and to have equal access to all
levels of public service and employment in public
functions, without discrimination on the basis of
sexual orientation or gender identity.

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
 The provisions of Section 377 IPC will continue to govern
non-consensual penile-non-vaginal sex and penile-
nonvaginal sex involving minors.
 By ‘adult’ we mean everyone who is 18 years of age and
above.
 In summary, the Court arrived at this conclusion based on
the following principles:
CHANGES
 Identity is an integral part of one’s right to life and right
to dignity. Sexual orientation is an inherent aspect of
one’s identity.

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
  Depression - Much more common in this group due to the
fact that they are unable to speak their hearts out with
MENTAL someone. This constant stress often precipitates
depression.

HEALTH  Anxiety - The constant worry about being discovered as

different. Many say that they battle the thought of coming

ISSUES IN out to their loved ones on a daily basis.

 Adjustment issues - Sometimes the acceptance is not

THE LGBT found when they expected it. It could be at the workplace,
relatives, or elsewhere.

COMMUNI  Body image related issues- Many transgenders fight this

urge for years together. Few even spend the major part of
their life as the sex to which they don’t feel a sense of
TY belonging to.
 Fear of abandonment issues

 Relationship issues

Naz-Foundation-v.-Government-of-NCT-of-Delhi-and-Others-
The-High-Court-of-Delhi-at-New-Delhi-India-2
AS A
PSYCHIATRI
ST WHAT
SHOULD WE
DO?
 It is a term that is often used by
 lesbian,
 Gay
 Bisexual
 transgender (LGBT) individuals disclosing their sexual orientation

COMING
and/or gender identity to others
  It. Is a long and ongoing process
 wherein an individual first comes out to oneself
 then later to others around him/her.
 Coming out to oneself is recognizing OUT
 one's own sexual identity
 labelling it, following which the individual may want to tell
others about these feelings
 Coming out to family members may be particularly difficult.
 Family relations and bonding play an important role in the
individual's decision to come out to them.
 Weak family relations significantly detract an individual from
coming out to family members including parents..

Gurvinder Kalra 2012

Gurvinder Kalra 2012
QUESTION IN COMING OUT
Gurvinder Kalra 2012
 LGBTIQ clients to help them become comfortable with
who they are, rather than provide a cure for something
which is not a disease or illness.
 :With new patients, create an accepting and affirming
environment by not assuming sexual orientation or
gender identity.
BEST  Ask, “Do you have sex with men, women or both?”
 “How do you identify yourself?”
PRACTICES  We should be sensitive to patients in transition,
 ask both how they’d like to be addressed as well as use the
appropriate pronoun.
 Assess level of openness and self-acceptance;

Robert Paul Cabaj, M.D.APA

 Be aware that there is NO basis for so-called “conversion or reparative” therapy which
are unscientific attempts to change sexual orientation through shame-based efforts that
result in depression, anxiety, and increased suicidality.
 All major health groups condemn such attempts. Refer to the APA’s position statement
on therapies focused on attempts to change sexual orientation for more information.
 Be aware that families can be helped to accept their gay or lesbian children and that in
turn leads to greatly reduced suicidality and anxiety in such youth given the risk of
suicide, be comfortable to ask about risk and resilience factors.

Robert Paul Cabaj, M.D.APA

SEVEN GUIDING PRINCIPLES:
 Gender and sexuality exist in continuums with infinite possibilities.
 The gender and sexuality continuums are separate, yet interrelated realms.
 The gender continuum breaks down into separate, but not mutually exclusive masculine and
feminine continuums.
 Sexuality is composed of three distinct realms: orientation and attraction, behavior, and
identity. These three realms are interrelated but not always aligned.
 Gender may develop based upon biologic sex, but this is not always the case (i.e.,
transgendered, intersex, androgynous individuals).

Robert Paul Cabaj, M.D.APA

 There are biological, psychological, social, and cultural influences
at play in gender and sexual developmental trajectories. Social
factors, such as family and peer relationships, robustly shape
behavior during preschool and school age years.
 Each individual is unique and composed of multiple identities that
exist within and interact with other sociocultural realms, such as
socioeconomic status, geographic region, race and ethnicity,
religious and spiritual affiliation, gender and sexuality among
others.

Robert Paul Cabaj, M.D.APA

THE MULTIDIMENSIONALITY
OF SEXUAL IDENTITY
 Desires, Behaviors, and Identity
 . Considering the variation of human sexual experience and the fact that we probably cannot
ever have enough categories to represent our diversity, three questions arise:
 (1) do we do away with all categories;
 (2) do we modify the categories;
 (3) do we reconfigure the way we look at sexual identity?

Janna L. Horowitz 2002

 RECENT
ADVANCE  Related to same- sex marriage

S AND  Adoption

 Surrogacy

FUTURE  Inheritance issues with law

DIRECTIO
N
Data from younger samples and
longitudinal designs

FUTURE
Novel approaches for Family Based Research
DIRECTION
characterizing Research on Romantic
Relationships IN
mechanism that drive Research simultaneously

disparities
examining multiple
levels of analysis RESEARCH
AREA
Methodological Innovation Needed
in Sampling SM Adolescents

Brian Mustanski,2016,
 FUTURE  Why do we need intervention research specific to SM
youth?
DIRECTION  cultural, contextual, and developmental factors that need
to be addressed in interventions

S IN  Attempting to intervene on sexual orientation

 “reparative therapy”—approaches that claim to be able to

INTERVENT change an individual’s sexual orientation.

 Currently, every major professional mental health

ION organization has issued position statements that such

practices are not only ineffective but also harmful

RESEARCH
 . More recently, several states have passed laws
prohibiting such practices, but little has been written about
the long term effects of exposure or how to support SM
youth in recovering from such experiences.

Brian Mustanski,2016,
Intervening to improve SM health Intervention research may benefit from
utilizing a framework

prevention
health promotion in the context of the life-course,
accumulation of events at each stage of life that
shapes and influence later
prevention,
treatment,
adverse health outcomes,
it stresses the importance of scaffolding youth
before, or during, periods of vulnerability to avert
adverse health outcomes

Brian Mustanski,2016,
CHALLENGES TO RESEARCH ON THE HEALTH
AND DEVELOPMENT OF SM YOUTH

 Regulatory obstacles
 unwilling to approach their parents for permission, and those willing differ vastly on a range of
outcomes
 Lack of consistent recognition of SM populations as a minority or disparity population

Brian Mustanski,2016,
FUTURE ISSUES
 Significant gaps remain in knowledge of clinically proven models for reducing mental health
problems and promoting mental health in LGBT youth.
 Serious gaps remain in knowledge regarding mental health for transgender youth.
 Strong evidence indicates that bisexual youth have higher rates of compromised mental health,
and more research and theory are needed to understand these patterns.
 Intersectional approaches are needed to better understand the interplay of sexual orientation
and gender identity with race and ethnicity, social class, gender, and culture.
SUMMARY