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Obscurantism as a diagnosis: Russia's homophobia leads to rejection of new disease classification

Russian authorities recently admitted that 20% of soldiers returning from the war in Ukraine suffer from post-traumatic stress disorder. In line with the tradition of punitive psychiatry, these people risk being misdiagnosed with “schizophrenia” instead of receiving proper treatment. The situation could have improved had the Russian Ministry of Health followed through with plans to adopt the International Classification of Diseases (ICD) as its standard for making diagnoses. However, the update was vetoed for a very specific political reason: to avoid acknowledging that homosexuality is not a disease. This decision will negatively impact not only LGBTQ people in Russia, but also those with autism spectrum disorders and other mental health conditions. Implementing the latest version of the ICD could have prompted doctors and administrators to familiarize themselves with new treatment protocols and encouraged medical faculties to update their educational programs. Instead, the Russian government’s purported defense of “traditional values” took precedence over the health of its citizens.

Content
  • Focus on human rights: how the new disease classification differs from the old one

  • Schizophrenia Instead of PTSD: the legacy of Soviet punitive psychiatry

  • The unnamed diseases

  • One step forward, two steps back

RU

Focus on human rights: how the new disease classification differs from the old one

The International Classification of Diseases (ICD) is a highly specialized tool used for diagnosing medical problems in a standardized way. The World Health Organization (WHO), which maintains the project under the aegis of the United Nations, periodically reviews its classifications, removing outdated diagnoses and introducing new ones. Some diseases are merged, others separated, and some reclassified into different medical categories. After a new version of the ICD is approved by the WHO — usually once every couple of decades — national healthcare systems gradually implement it.

The most recent version, ICD-11, was approved in 2019. At the end of 2021, the Russian Ministry of Health approved the transition to the updated addition, and 200 million rubles from the federal budget were allocated to pay for the switch. However, upon closer inspection, it was found that ICD-11 changes the criteria for recognizing certain aspects of human sexuality as diseases, a move the Russian authorities deemed unacceptable.

The decision to adopt ICD-11 initially faced criticism from the Soviet-nostalgic Zavtra newspaper, followed by the Russian Orthodox Church. By early February 2024, the State Duma had joined in, and on February 6, 2024, the Ministry of Health announced the cancellation of the reform “due to the large number of appeals from citizens, public organizations, as well as senators and deputies, regarding potential contradictions with traditional moral and spiritual values, which are protected by law.”

One of the main proponents behind these numerous appeals, Deputy Speaker of the State Duma and United Russia member Pyotr Tolstoy, explained to Vedomosti on February 5 that “we need to reject the implementation of those ICD norms that address issues of gender identity and the LGBT topic.”

The State Duma decided it was necessary to “reject the implementation of those ICD norms that address issues of gender identity and the LGBT topic”

The main differences between the new and old disease classifications impact two significant areas of healthcare: mental disorders and sexual disorders. Several changes relate to autism, stress disorders, and attention deficit hyperactivity disorder (ADHD). In addition, ICD-11 introduces the diagnosis of “gaming disorder” for the first time.

Again though, Tolstoy’s concerns were not about Russian youth spending too much time playing “Call of Duty.” Instead, sections of the new classification concerning homosexuality, gender identity, and sexual preferences have drawn the attention of those in Russia advocating for “spiritual and moral values.” In ICD-11, entries related to transgender issues are moved from the category of mental disorders to sexual disorders. These are now classified as “gender incongruence,” a condition related to sexual health rather than mental illness.

According to the new classification, having sexual fantasies alone is not enough to warrant a diagnosis — and the stigma that comes with it. To diagnose “pedophilia” under the new standards, a case must involve not just attraction, but attempts to act on it.

ICD-11 no longer considers behaviors as mental disorders if they do not harm oneself or others. For instance, BDSM practices are not classified as evidence of a disorder so long as they are consensual and conducted voluntarily.

ICD-11 no longer considers behaviors as mental disorders if they do not harm oneself or others

According to Regina (name changed upon her request), a sexologist who assists LGBTQ people in Russia, the new classification shifts its focus towards the protection of human rights:

“ICD-11 eliminates any references to sexual orientation that lack clinical significance or relevance to public health. These were still present in the previous version.”

This new approach has stirred strong reactions among Russian psychiatrists working for state-run institutions. For instance, in a recent interview with Medvestnik, Olga Bukhanovskaya, a member of the Russian Society of Psychiatrists, argued against adopting ICD-11, stating that its “proposed interpretation for conditions such as transsexualism, zoophilia, transvestism, and other disorders of sexual preference is unacceptable from the standpoint of traditional Russian psychiatry.”

Schizophrenia Instead of PTSD: the legacy of Soviet punitive psychiatry

The persistence of “classical Russian psychiatry” is precisely why Anna (name changed), a psychiatrist who worked until recently at Moscow’s Serbsky National Medical Research Center for Psychiatry and Narcology, argues the urgent need for a transition to ICD-11:

“In Russia, two psychiatric schools coexist: the traditional one, rooted in Soviet practices and authoritative opinions, and the newer one, oriented towards evidence-based medicine and contemporary research. The shift towards evidence-based medicine has been particularly slow in psychiatry due to its intricate nature.”

An example illustrating the harm of traditional Soviet psychiatry is found in the diagnosis of ADHD in adults. While other countries treat it, Russia does not recognize this diagnosis. Psychiatrists from the traditional school often believe that as individuals mature, ADHD evolves into various personality disorders, Anna explains: “These patients may receive diagnoses of schizophrenia or bipolar disorder.” According to Anna, psychiatrists practicing evidence-based medicine sometimes classify such cases as pediatric to comply with regulations: “They prescribe medications intended for children, effectively treating these conditions covertly.”

In Russia, no-one is diagnosed with ADHD

Another example pertains to the diagnosis of “schizophrenia.” In Russia, individuals returning from combat zones may mistakenly receive this diagnosis. According to Yuri Zarubin, a psychologist who emigrated from Russia after the onset of full-scale war: “For instance, a person might have been captured and subjected to prolonged beatings, or experienced repeated sexual violence. Complicated post-traumatic stress disorder (PTSD) affects self-esteem, leading people to withhold their experiences from doctors who may not inquire further into the underlying causes. This condition can also manifest with suicidal thoughts, substance abuse, and psychotic episodes.”

The adoption of the updated international guidelines could help. “In ICD-11, 'complicated PTSD' is a new classification,” Zarubin says, whereas ICD-10 used “enduring personality change after catastrophic experience.” The shift focuses not on personality change but on diagnosing the disorder itself, suggesting a different treatment approach. Unlike typical PTSD, complicated PTSD lacks a clear single traumatic event as its cause.

Currently, there is a high likelihood that a person in Russia who notices symptoms of PTSD may simply avoid seeking medical help due to fears of receiving a psychiatric diagnosis. Whether it's labeled as “schizophrenia,” “bipolar disorder,” or some other mental disorder, such diagnoses cut off a person’s access to employment in state institutions — including the police, a common career path for veterans.

A person who notices PTSD symptoms may simply avoid seeking medical help due to fears of receiving a psychiatric diagnosis

According to Zarubin, awareness among doctors about the diagnosis of “complicated PTSD” in medical classifications could lead to a different approach towards such patients. This understanding would help professionals recognize that people contemplating suicide, exhibiting aggression (which is a normal response in stress disorders), or using alcohol or drugs may not necessarily have schizophrenia. Instead, they could be experiencing complicated PTSD, for which specific protocols such as EMDR (Eye Movement Desensitization and Reprocessing), prolonged exposure therapy, and cognitive-behavioral therapy can be effective.

Meanwhile, traditional Russian psychiatrists are concerned that the adoption of ICD-11 could lead some patients who ought to be diagnosed with schizophrenia to be deprived of proper treatment. For example, Olga Bukhanovskaya from the Russian Society of Psychiatrists explained in an interview that Russia has a “comprehensive classification of mental illnesses,” including “several variations of schizophrenia.” She argued that ICD-11 undermines Russian “national achievements in assessing severe illnesses,” suggesting that some people may go undiagnosed and consequently miss out on quality psychiatric care.

Bukhanovskaya mentions the diagnosis of “slow-progressing schizophrenia,” a longstanding tool of Soviet punitive psychiatry, as an achievement of Russian medicine. This diagnosis continues to be used in Russia today for similar purposes as it was during the Soviet era. It was precisely this type of schizophrenia that shaman Alexander Gabyshev was diagnosed with to justify his involuntary treatment. In 2021, the Memorial human rights center classified Gabyshev as a political prisoner.

The unnamed diseases

The process of transitioning to new standards is slow. In most countries, ICD-11 officially came into effect only on January 1, 2022. The previous version of the classification was developed in 1989, but the first country to adopt it — Thailand — did so only in 1994. Russia followed in 1999, and the U.S. in 2015. Some countries still use ICD-9.

Nevertheless, the introduction of new terminology and changes in wording alone can sometimes significantly improve many lives. A notable illustration involves autism spectrum disorder (ASD). Previously, individuals with ASD were diagnosed with different conditions, such as “Asperger's syndrome” and “Kanner syndrome.” In ICD-11, the emphasis is on the spectrum itself, categorizing individuals based on their functional abilities, speech development, and intellectual progress. However, in current Russian practices, diagnosing autism in adults is exceedingly rare.

“Many adults with autism are treated with neuroleptics,” explains psychiatrist Anna. “Only those who are incapacitated and disabled receive an autism diagnosis upon reaching adulthood. Disability is only acknowledged in the most severe cases. Meanwhile, individuals with autism spectrum disorders have distinct needs that are acknowledged in other countries. For instance, one of my Russian patients has now confirmed his autism diagnosis in the Netherlands. He will benefit from support and accommodations during exams, such as taking them in a distraction-free environment.”

In traditional Russian psychiatry, not only is ADHD not considered a diagnosis for adults, but also several medications commonly used in the West are viewed as dangerous narcotics. Primary treatments for ADHD such as Ritalin and bupropion are prohibited in Russia.

Anna explains that, “We often have to initiate treatment using second-line medications like atomoxetine. Psychiatrists from the Soviet era argue that in the West, ADHD is diagnosed, and children are heavily medicated. However, in Western countries, the emphasis is on enhancing quality of life, whereas in Russia, some doctors believe a disorder should be tolerated unless it's life-threatening. The banning of substances like Ritalin exemplifies this quality-of-life issue.”

Research indicates that untreated ADHD is associated with an increased risk of suicide. Adopting the ICD-11 would facilitate addressing this issue, and would also help with gathering contemporary data and pursuing approval for internationally recognized medications in Russia.

Another new diagnosis in the international classification is “prolonged grief disorder.” This diagnosis prompts healthcare providers to recognize that not every instance of emotional distress demands treatment for depression; rather, some grief experiences are part of normal life. “Grief is always triggered by an external event, such as a house fire or the loss of a loved one,” explains psychologist Yuri Zarubin, emphasizing the distinction. “But in Russia, it's common for someone who has experienced a house fire and sustained burns to end up in the hospital seeing a psychiatrist who starts alleviating their distress with antidepressants. This approach may unintentionally hinder the natural grieving process and potentially increase the risk of developing PTSD after discontinuing the medication.” However, Zarubin notes that when someone continues mourning for three years instead of the culturally expected six months, it indicates that something is hindering the grieving process.

Of course, the “disease” that led to Russia’s ICD-11 controversy in the first place involved the updated classification’s approach to sexual minorities. While Russia continues its path of discrimination against the LGBTQ community, adopting ICD-11 could potentially help reduce stigma in society. For example, the new standards relocate transgender issues from the psychiatric section to the sexological one, diminishing psychiatrists' absolute authority over patients. As sexologist Regina explained: “Currently, psychiatrists may hospitalize transgender persons for a month to exclude psychotic reactions or schizophrenia, whereas these people often require more essential help from endocrinologists.”

Also shifted from the psychiatric section is “acute stress reaction,” which is now placed under a distinct chapter titled “Factors influencing health status.” Yuri Zarubin illustrates such a condition from his practice during the early stages of full-scale war:

“He was a person who had relocated from Ukraine to Poland. He couldn't think in either Ukrainian or Polish and harbored self-disdain for thinking in Russian. Therapy proved instrumental in resolving his identity conflict. A traditional-minded doctor, aware of suicide risks, might have opted to prescribe mood-altering medications, but such an approach wouldn't address the underlying internal conflict. This unresolved conflict could have resurfaced even more strongly after the cessation of medication, potentially leading to the development of chemical dependence. Faced with time constraints, doctors often prioritize prescribing medications without fully considering the social factors that prompted the patient to seek treatment.”

One step forward, two steps back

Embracing the latest version of the ICD could potentially motivate healthcare professionals and administrators to explore new treatment approaches and protocols, while medical schools could revise their educational programs. As a result, the primary impact would be to “raise lower standards of care,” according to Yuri Zarubin. He suggests that the professional community is “likely to reassess standards, revising training programs for psychiatrists, psychologists, neurologists, and clinical psychologists, acknowledging that many current approaches may not be effective.”

In psychology and psychiatry, approaches quickly become outdated. For instance, the Moscow Institute of Psychoanalysis currently teaches the outdated American debriefing technique (processing events with emotional detachment), which research reveals not only fails to aid during stress but may increase the risk of PTSD. Conversely, some educational institutions teach NLP (Neuro-Linguistic Programming), which lacks scientific recognition.

The consequences of untreated conditions or outdated methods are now evident on the streets of Russian cities. Veterans and people residing near conflict zones in Russia may count only on basic psychological and psychiatric assistance. But the impact may soon be felt much farther from the front lines, as soldiers who fought in Ukraine return home without proper rehabilitation, only to continue perpetuating violence back in their communities.

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