“Do not transition”: Psychiatrists discuss why Russia's ban on gender change might lead to surge in suicides

Straight pride in the State Duma

The new draft law is very brief; essentially, it is the addition of a new article to the “Law on the Protection of Citizens' Health.” It states: “Medical workers are prohibited from carrying out medical interventions aimed at gender transition of an individual, including the development of primary and/or secondary sexual characteristics of another gender.” However, it is attributed to nearly 300 deputies as its authors. Therefore, the session on June 14 went smoothly: parliamentarians did not hold back with their cannibalistic remarks, made jokes about suicide, and referred to transgender individuals as “abracadabras.”

The urgent need for the prohibition on “gender transition” was explained by Deputy Speaker of the State Duma, Pyotr Tolstoy, from the United Russia faction:

“Boys who are defending our country today with weapons in their hands should return to a different country, not the one that existed before the start of the special military operation. According to the Ministry of Internal Affairs, from 2016 to 2022, 3,000 people underwent gender reassignment. In fact, this can be done today based on simple medical certificates, of which no official records are kept. These certificates are issued by nearly all private clinics in Russia. Unfortunately, the Ministry of Health is unaware of the number of such surgeries being performed. The cost of the procedure does not exceed 30,000 rubles ($360).”

The response to the deputy came from Health Minister Mikhail Murashko, who attempted to navigate between “patriotism” and professionalism:

“The Ministry of Health supports the inadmissibility of gender change based solely on the patient's desire. Therefore, the tightening and strengthening of decision-making factors regarding surgical or hormonal treatments should undoubtedly be based on high-level expert councils, and accordingly, federal institutions should be involved in this process.”

Then the discussion on the topic was revived by Biysultan Khamzaev, also a deputy from United Russia:

“I have a question that probably concerns many. What about those three thousand people who have already changed their documents today? They are sort of both women and not women, so that they don't come to the registry office with abracadabra later. It's a practical question. What do we do with them? Do we somehow determine their status because they were once not women or not men, for example? What are we going to do with them?”

The deputies laughed and applauded. Pyotr Tolstoy explained that the law would not be retroactive but he advised Hamzaev specifically to “exercise caution.” Vyacheslav Volodin, the speaker of the State Duma, summarized the discussion as follows:

“The law is a rare occurrence, with almost all deputies of the State Duma supporting its initiation. We all have our differences here, representing different parties and principles... However, as we move towards the second reading, we hope that the Ministry of Health refrains from inventing any amendments, using the pretext of concern for the people. If they truly care, they can demonstrate it by prohibiting all forms of such depravity.”

Psychiatrist exposes deputies' incompetence

Upon the request of The Insider, psychiatrist O., who specializes in working with transgender individuals, exposed the incompetence of the deputies.

“Regarding the claim that 'changing one's gender can be easily accomplished through simple medical certificates, of which no official records are kept; these certificates are issued by nearly all private clinics in Russia; the cost of the procedure does not exceed 30,000 rubles.' First, obtaining a certificate that authorizes a gender change in official documents is an extremely difficult task. While the procedure itself may seem straightforward, the overall process is intricate and time-consuming. The notion that acquiring such a certificate is a simple matter is purely a fabrication by those deputies who make such statements. Furthermore, these documents possess a certain level of security as they are produced by specialized printing presses. They are not mere ordinary forms that can be printed using a regular printer. Each certificate is assigned a unique number and is subject to meticulous record keeping.

And, of course, it is untrue that these certificates are issued by all private clinics in Russia. Only a very small number of clinics engage in this practice, and they can be counted on one hand. As for the claim that 'the cost of the procedure does not exceed 30,000 rubles,' the deputy is likely suggesting that, supposedly, for this amount, a person is guaranteed to receive the certificate. This is also not true. Refusals do happen, and there are reasons for them, especially if the person does not have a diagnosis of “transsexuality.” By the way, in state-funded organizations, this certificate is provided free of charge, and the examination is conducted at no cost. Therefore, this entire paragraph is a fabrication, as none of it corresponds to reality.

Moving on. 'The Ministry of Health supports the inadmissibility of gender change based solely on the patient's desires...' Overall, a very interesting discussion arises. So, the Ministry of Health supports the “inadmissibility of gender change based on the patient's desire.” But in Russia, there is no possibility to change gender solely based on one's desire. In some countries, it is indeed being debated that people may have a legal right to change their gender documents based on personal choice. However, in our country, such changes are not made at will but require medical justifications. The discussion here is essentially meaningless. Unfortunately, it creates an illusion that any individual can simply come and 'change their gender' based on their own volition. This is not the case.

And as for the need to 'tighten' regulations and everything 'should be based solely on high-level expert councils...' It is unclear what is being referred to here because the current system, which is in place, is primarily okay with doctors and yields results for patients. What purpose does it serve to 'tighten regulations and gather consultations'? What is the purpose of 'tightening regulations and convening expert councils'? It appears to only lead to prolonged decision-making, with little to no benefit.

The Ministry of Health claims that there will be suicides. And indeed, there will be. If this law is adopted in the form in which it was voted for, it will only result in an increase in suicides among transgender persons. Yet, the deputies argue that it is all about depravity and immoral thoughts that need to be banned. This demonstrates their willingness to sacrifice these lives in order to fulfill their political ambitions and gain political points.”

What is “transsexualism”?

In the International Classification of Diseases, “transsexualism” is assigned the code F64.0 and is classified as a “gender identity” disorder: a persistent desire for the physical characteristics and social roles that connote the opposite biological sex.” This phenomenon is not new and was known even during the Soviet Union era. The treatment for this condition is also well-established: it involves hormonal therapy and a legal gender change to enable individuals to live in their preferred gender. The decision to undergo body surgeries or not is a personal choice made at a later stage. However, it's important to note that the biological sex remains the same, as chromosomes cannot be altered. Therefore, it is inaccurate to refer to it as a “change of sex.” Instead, the term “gender transition” is more appropriate.

“Is it possible to forgo the transition?” asks Moscow psychiatrist K. “Certainly, it is not life-threatening, but it significantly impacts a person's quality of life. Living in a body that doesn't align with one's identity can be highly distressing, leading people to self-harm or even contemplate suicide while attempting a self-guided gender transition (there are numerous documented cases of such experiences). Considering that medical procedures, such as hormonal therapy, can reduce health risks and improve the overall quality of life (which is often the case for transgender individuals), their relevance and benefits are undeniable.”

Transgender individuals who have started hormonal therapy and live under their preferred name say that “everything feels as if it falls into place, everything is in its proper position.” Those who haven't started the therapy do not wish to discuss their lives at all.

“It's easier for me to kill myself now”

Andrey is a young transgender man who works in a non-governmental organization (NGO) in a major city as an “peer consultant,” helping other individuals like himself solve the issues they face.

“I communicate with transgender people from our city in a chat where I serve as an administrator. There are about 60 people in this chat, all of them over 18 years old. Some are 19-20 years old, while others are over 40. People in various age groups who do not have the opportunity to undergo a gender transition often express suicidal thoughts and contemplate the possibility. Even if they don't intend to commit suicide, they doubt that they will live for long. It was like this before, but now it's even worse. 18-year-olds see no hope. They worry that they will have to live their whole lives without transitioning, and they don't want that kind of life. They don't believe they can endure it, so they don't even want to try. They see two options: either live a life they don't want or attempt a transition now when it becomes illegal and face severe punishment. And then people see a third option – suicide; they even consider somewhat rational. It sounds alarming and greatly concerns me as a social worker.”

Adults in their thirties or older don't have it any easier. In the chat, there's a 28-year-old woman who identifies as transgender. She hasn't been able to start her transition simply because she lacks the means to do so. She can't even afford to travel to the city where the necessary assessments are conducted. Her life was already hard, but now she says, 'I see no purpose in continuing to live in despair, knowing that the best years of my life were spent in the wrong role. I won't be able to transition successfully on my own and appear as a woman. I will always be perceived as a man. If I try to feminize my appearance, I'll simply look grotesque, and someone will most likely kill me. So, it's easier for me to kill myself now...' It's disheartening that I frequently find myself having conversations and working with individuals in such a desperate state.

Transgender people face numerous problems, including loneliness, isolation, violence, familial rejection, insecurities regarding their appearance and voice, and regrets about wasted time. And the situation has worsened. What exacerbates the issue is that society used to turn a blind eye, but now it has aggressively turned against them. Nowadays, there is a sensationalized interest in exploiting their experiences for media attention. This heightened scrutiny of transgender lives leaves people feeling horrified. Reading comments in various online platforms advocating for treatments like electroshock therapy or even violence towards people like me, it's only the defiance against such a world that gives me a reason to keep going.”

“The process of undergoing the commission may drag on for years”

“If this law is passed, it will directly prohibit doctors from providing medical assistance,” says psychiatrist O., who regularly participates in commissions that assess individuals diagnosed with “transsexualism.” “It will force them to violate their oath as Russian doctors to 'act in the best interest of the patient.' I believe this should concern doctors of all specialties as it sets a dangerous precedent.”

Until recently, the process for a transgender person to navigate through official channels was challenging yet straightforward and well thought out. The initial requirement was that the person had to be 18 years old. Then the provisions of Order No. 850n, “On the Approval of the Form and Procedure for Issuing a Document on Gender Change by a Medical Organization,” came into effect. The essence of this order is that if a psychiatrist, whether in private practice or a state medical institution, diagnoses a person with F64.0 “transsexualism,” they are referred to a commission within one month for psychiatric examination to confirm the diagnosis. It is during this process that the person can obtain a certificate (087/u) that allows them to change their documents and undergo physical surgeries.

According to the psychiatrist, the difficulty lies in the fact that, firstly, the order is not detailed enough, for example, there is no specified duration of observation. Furthermore, the specialist believes that the majority of psychiatrists are unfamiliar with the concept of gender identity and have limited experience working with gender incongruence. Consequently, there are few commissions established for this purpose. However, for those specialists who are knowledgeable in this area, the order simplifies the entire procedure significantly.

The commission is essentially a psychiatric examination of an individual, and it can be conducted by any clinic that meets two conditions: having a psychiatry license and certified sexologist and clinical psychologist on staff. However, there are no specific guidelines, and the institutions conducting the commission operate based on their own plans and ideas about how it should be done.

“The speed of the procedure can vary,” the doctor says. “In some cases, a person seeks assistance and undergoes the commission within two weeks or a month. However, in other institutions, the process may drag on for years due to changes in leadership, doctor turnover, or the doctors' lack of knowledge and reluctance to assume responsibility. It is important to note that I have never encountered a situation where a person is immediately placed on the commission without undergoing a preliminary examination. Even individuals with a confirmed diagnosis are first referred to a psychiatrist, followed by a psychologist and a sexologist. Only when these specialists have no doubts will the person be directed to the commission, which comprises a psychiatrist, sexologist, and clinical psychologist, under the guidance of the chief physician. All four specialists convene in the same office and engage in a conversation with the individual...”

However, there is a possibility that the certificate may not be granted. For instance, if a patient is mistakenly diagnosed, where the initial psychiatrist observed symptoms that the commission did not find. Another factor is the presence of an acute mental disorder, which serves as a contraindication. On the other hand, if everything is in order, the individual is issued a certificate known as 087/u, enabling them to change their gender marker in official documents. The process itself can take several months, followed by an additional period of up to six months for the actual document changes.

“We are unaware of the subsequent journey of these individuals as they typically vanish from the specialists' purview,” the doctor explains. “Has there been an increase in people seeking the certificate? Yes, but not because there is a surge in transgender persons. It primarily stems from the fear of not being able to secure the certificate within the given timeframe. Some individuals have contemplated it for a long time, while others have been preparing for it. However, now they have ceased postponing their decision due to the genuine risk of the entire process being revoked. The certificate is crucial for them since the only form of treatment for such individuals is the ability to live in the gender that feels authentically true to them. It does not necessitate medications or specialized medical interventions; it simply grants them the freedom to live as they truly are and as they genuinely feel.”

“Everyone is worried, and the mood is gloomy”

The number of transgender individuals in Russia remains unknown even to the NGOs that offer them assistance. They belong to one of the most secretive groups. However, globally, their population is estimated to reach up to 25 million. It is evident that at present, in Russia, hundreds, if not thousands, of people are facing a situation where they are directly informed that they will not receive any support.

Karina, a 24-year-old, traveled from Siberia to Moscow in order to obtain the certificate. Initially, she was requested to write an essay about her life journey leading up to the present day. Subsequently, she had to engage in lengthy consultations and interviews with medical professionals.

“Going through the commission was a long process, and it cost money,” says Karina. “It's not as simple as walking in and asking for a certificate. No, it's more involved. But it was doable. I have the certificate now, but I was planning to change my documents closer to autumn. I'm currently finishing my studies and obtaining my diploma. After that, I wanted to change all my documents at once. As for surgeries, I wasn't planning to undergo any. Vaginoplasty is complex, challenging, time-consuming, and not everyone is ready for it. The cost can amount to 600,000 ($7,400), and considering our difficulties in finding employment it's an unaffordable sum. Now, that issue is no longer relevant. However, if they prohibit hormonal therapy as well, it will be even worse. Hormones play a significant role in calming a person, and they are more crucial than surgeries.

We were already struggling. Around 80 percent of us have attempted suicide. And when you open up to your family, and they don't support you from all sides, it becomes even worse. Hormonal therapy and changing documents were the only way to live in harmony with oneself.”

Nikolay says that he “managed to get through” but only with the help of a medical certificate.

“Less than a year ago, I obtained a medical certificate and changed my documents. I started hormonal therapy. It was indeed a long journey: from the very first thought to the acceptance by society and family. And the money! Even saving enough money for a trip to another city for the medical commission, even that was difficult. All these officials are detached from reality if they believe that an average Russian can wake up one morning, decide to change their gender, and pay 30,000 rubles for a certificate. The medical commission process was very lengthy and complex. And now all I need to do is to register and deregister with the military enlistment office. Surgeries? Well, they were already unaffordable before, the cost is approaching that of a mortgage. And as for hormonal therapy... If they also ban it... I can't even think about it right now.

It is unfortunate for those who may no longer have the opportunity. Many people had plans to save money and undergo the process calmly during their vacations. However, now those who had planned things for the summer and fall are trying to act immediately. Everyone is worried, and the mood is gloomy. I have a friend who intended to undergo the medical assessment in the future, once he had stable employment and housing. However, I am now deeply concerned about his well-being. The issue of suicide is already close to us, and if I hadn't come across information at the age of 14 that I was not alone, I would likely have been in a grave by now...”

“Plans? The plan now is to turn on stealth mode, hide and run away,” says Karina. She intends to search for work in any other country where doctors are not prohibited from helping patients.

Comment from a lawyer: the ban on abortions is on the horizon

Vladimir Komov, senior partner of the Human Rights Initiative “LGBT+ Case,” says, “The concern is that due to the new ideology, the state has the authority to deny individuals adequate treatment at its own discretion. Although the diagnosis is still recognized by the government, they no longer have any intention to provide the treatment as required by both international standards and our own. It is worth noting that many international standards were influenced by the Soviet school of psychiatry. As early as 1991, the USSR Ministry of Health approved an instruction indicating that changing documents and gender markers in passports is a mandatory step in assisting transgender individuals. The concept of “changing gender in documents” has been recognized in Russian law since 1926. Moreover, any competent psychiatrist will affirm that it is impossible to improve the life of an individual diagnosed with F 64.0 without hormonal therapy and socialization in their preferred gender.

And then this draft law comes into play. It's understandable why the Ministry of Health is now cautious and afraid to oppose the government. Firstly, it's scary. After the adoption of the “Law on LGBT Propaganda” in December 2022, Roskomnadzor explicitly prohibits doctors, among others, from speaking positively about gender transition. I believe we will witness attempts in judicial practice to hold doctors accountable for fulfilling their oath and helping people. The fines imposed on officials in such cases are draconian.

Secondly, it is widely understood that this represents a consistent policy pursued by the authorities. Alongside the law prohibiting “LGBT propaganda,” a government resolution was issued in December, which imposes restrictions on people diagnosed with F 64.0, preventing them from engaging in specific professional activities. The long list of prohibited fields includes transportation, healthcare, and education. Surprisingly, even positions such as a dean's secretary fall within the scope of these restrictions. It is important to note that many transgender people have found acceptance and opportunities in higher education, where their contributions to scientific endeavors are respected, regardless of their gender as stated in their passports.

What does this imply for society? It signifies that the state not only seeks to curtail the rights and freedoms of its citizens and penalize dissenters but also assumes the authority to determine who should receive medical treatment and who should not. Essentially, this grants the state the power to exert control over the bodies of individuals. Consequently, if we continue along this path of legal thinking, considering that laws tend to operate with inertia, it is conceivable that further measures may be introduced, such as labeling feminist and LGBT movements as extremist, prohibiting abortions, and implementing a system of punitive medicine.”