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Emergent meanings of gender dysphoria in medical consultations between transgender people and psychiatrists in Pakistan attempt to answer the question- who is genuinely transgender? The use of biomedical models to investigate the ‘realness’ of trans experience has orchestrated complexities of care as psychiatric evidence of gender dysphoria becomes the gateway to citizenship. Psychiatrists become accessories of state bureaucracy as assessors of legitimate citizenship claims in relation to the Transgender Persons (Protection of Rights) Act 2018. I follow the developing meanings of gender dysphoria as it becomes socially imbricated with Sunni Muslim medical ethics regarding the ‘natural’ body. Even as gender variant citizens discover their selves as political participants, their bodies need to correspond with biopsychological truths of citizenship in an infrastructure of suspicion. How does the sociality of the medical encounter make space for proving or denying gender dysphoria as a genuine psychic state? This paper looks at the varied ways in which doctor-patient interactions become a place of evidence production to satisfy state legislative demands of citizen psychology. Using an interdisciplinary approach that draws on legal literature and medical anthropology, I explore diagnostic practices and expectations of gender dysphoria to explicate the meaning of transgender health within psychiatric care.