A brief historical background will help to understand the context in which psychiatric oppression of transgender people operates in Russia. Since the 1960s, psychiatry was used systematically as a weapon against dissidents in the Soviet Union. The infamous diagnosis ‘sluggish schizophrenia’ was used to detain in mental hospitals, opponents of the government, and other people, whose behaviour was considered to be against social norms. There, they were subjected to compulsory treatment.

There is no evidence that transgender people in the USSR were intentionally subjected to the political abuse of psychiatry – for the simple reason they were invisible. However, when they appeared in front of the psychiatrist, either of their own volition or thanks to those who considered their behavior deviant, they were faced with the same cruel system, which goal was not the person's welfare but the continuation of social norms and official ideology. According to an interview with a trans woman, which appeared in the press in 1961, when she first tried to get help from the doctors, she was ‘beaten and medicated into a vegetative state’; and received the diagnosis ‘Paranoid schizophrenia’. Due to the preoccupation of Soviet psychiatry with ‘schizophrenia’, it seems that this diagnosis was often given to transgender people (however, direct evidence for that period is difficult to find).

This historical context is to some degree similar to the situation in post-Soviet Russia. Although on a smaller scale, punitive psychiatry is being revived in present-day Russia, the latest case is that of Mikhail Kosenko, a protester at the Bolotnaya Square protests in 2012, who was diagnosed with 'paranoid schizophrenia' and forced to receive psychiatric treatment. The attitude towards transgender people in Russian psychiatry continues to follow the Soviet model in some forms.

Although on a smaller scale, punitive psychiatry is reviving in present-day Russia.

Legal framework

Many transgender people in Russia need to change their names and legal gender in order not to be discriminated against. But this procedure, known as legal gender recognition (LGR), is not clearly defined in Russian legislation. Federal law N143 ‘On the acts of civil status’ briefly mentions the possibility of LGR in article 70: ‘Making amendments or changes to the statement of the act of civil status is made by the civil registry, where ... a document of the established form about the change of sex issued by a medical organisation is submitted’. However, no exact ‘document of the established form’ exists, and that gives the registries and the courts room to arbitrarily judge which medical interventions a person must accomplish in order to be eligible for LGR.

In most cases, two documents are required for a change of status: psychiatric diagnosis F64.0 ‘Transsexualism’ and/or sex reassignment surgery. Even if the diagnosis is not explicitly required, doctors will not perform surgery without it, with few exceptions. That all but makes psychiatric assessment a requirement for transgender individuals who wish to change their legal status.

Procedure

Unlike, for example, in Ukraine, no centralised body for issuing a diagnosis of ‘Transsexualism’ (F64.0) exists in Russia What is more, undergoing psychiatric assessment in a place different from that where one lives is possible. It is also possible to get the diagnosis from a different psychiatric commission, if the first attempt fails. This gives transgender people in Russia a great degree of flexibility in choosing between different psychiatrists. However, this flexibility is limited by the low number of non-transphobic doctors who have an understanding of trans issues. Until recently, there was only one such psychiatrist in the whole country — Dmitry Isaev, who works in St Petersburg. Another clinic, which positions itself as trans friendly — Department of Reconstructive Surgery, Andrology and Sexopathology (RSAS) — opened in Moscow in 2013. Given the long distances, not many trans people from Siberia and the Far East of the country can afford to travel to St Petersburg or Moscow, and rent a lodging during their stay. Moreover, they may be required to visit a psychiatrist several times before they receive the diagnosis. These circumstances limit their choice to local facilities where doctors tend to be ignorant of trans issues, extremely transphobic and rude.

No centralised body for issuing a diagnosis of ‘Transsexualism’ (F64.0) exists in Russia (unlike, for example, in Ukraine).

The treatment of transgender patients in Russia was previously described in the Decree of the Ministry of Health N311: ‘Models of diagnostics and treatment of mental and behaviour illnesses’, enacted in 1999. As we will see, this decree caused some negative changes to psychiatric practice. In 2012, the decree was repealed, and in 2013 in its place the ‘Standard of primary medical care in the case of sexual identity disorders’ was introduced (the exact reason for this change is not known, but it definitely is not connected to pressure from human rights activists). The new document requires examinations by a psychotherapist, psychiatrist, sexologist, endocrinologist and medical psychologist for individuals who wish to obtain the diagnosis ‘Transsexualism’. It is too early to judge whether these amendments will result in any change in psychiatric practice. The new Standard is very short and mentions only the specialists that a trans person must visit, and the average number of appointments with each of them. It also mentions the drugs that can be used for hormone-replacement therapy. But only four drugs are in the list, which might shut off access to other drugs in future. And, unlike Decree N311, it does not explain the criteria and recommended treatment, meaning that the old Decree might still be in use as an unofficial guide for psychiatrists.

Psychiatric interview

Obtaining the diagnosis of ‘Transsexualism’ usually requires several appointments with a psychiatrist. Additional inspections by a sexologist, psychologist, gynaecologist, as well as hormones and karyotype tests are usually required. If the psychiatrist considers the applicant appropriate, a commission of several medical practitioners is appointed.

The experiences of trans people during the interviews with psychiatrists and the commission vary significantly, from quite positive or neutral reviews, as far as St Petersburg and Moscow are concerned, to horrible situations in many other places. No matter where they are interviewed, trans people are constantly addressed in the wrong gender by their passport name. Asking about the applicant's personal and sexual life is another widespread practice. Here is a fragment of conversation between Alexandr Bukhanovsky, a psychiatrist in the Phoenix psychiatric clinic, in Rostov-on-Don, and a trans man:

- Do you have natural sexual intercourse?
- What do you mean by natural?
- As a woman or anally?
- Anally?
- Do you take off your clothes when in an intimate relationship?

Asking about the applicant's personal and sexual life is another widespread practice.

A trans woman who tried to get the diagnosis of ‘Transsexualism’ in the Moscow Research Institute of Psychiatry reports that 90% of questions were about ‘sex, masturbation, anal stimulation, nocturnal emission [and] fantasies’. After that, she was told that she is not a ‘typical’ transsexual but a homosexual with obsessions.

Sex-related questions can be accompanied by general rudeness towards the patient, as follows from the questions a trans woman was asked by Mikhail Beil'kin, a sexologist from Chelyabinsk:

- So why the fuck do you need a vagina? What the hell brought you here?
- When was the last time you fucked your wife?
- Why the shit do you want a vagina, if you don't like boys?

This conversation brings us to the question of the interconnection between gender identity and sexual orientation. Although a few progressive psychiatrists accept that a trans person can have any orientation, most still insist that one must be heterosexual in their gender of choice to be ‘enough trans’. The above-mentioned Decree N311 listed ‘homosexual orientation’ (according to sex, assigned at birth) as one of the symptoms of ‘Transsexualism’.

It is common for psychiatrists to make offensive comments about the applicant's appearance; this usually goes together with an attempt to dissuade someone from changing gender. This was actually one of the steps of ‘psychotherapy’ aimed at a ‘reconciliation with the innate sex', according to Decree N311. A friend of mine was told during the commission in RSAS, Moscow, ‘You will never become a real woman, and no normal man will want to have an affair with you’, and ‘You will never look thoroughly like a woman’. Bukhanovsky's comment about a trans man was that ‘Outwardly, I would not say that you are a man’.

In most cases, appearance in accordance with gender stereotypes seems to play an important role in receiving the diagnosis of ‘Transsexualism’, although this depends on the psychiatrist. For example, a trans woman in Krasnoyarsk, was shouted at by doctor Andrej Sumarokov for wearing ‘female’ clothes. When trying to dissuade ‘trans; people, psychiatrists use not only cissexist and heterosexist arguments, but patriarchal ones as well: ‘You are choosing the wrong way for fulfilling your destined function, you have everything physiological and biological ... you could become pregnant...’ (Bukhanovsky, to a trans man).

Psychiatric torture

Inspection by a psychiatrist is not enough in many cases, and transgender people are required to stay in a psychiatric institution for around 30 days. Feedbacks on this experience vary from ‘better than expected’ to what may be defined as psychiatric torture. In less common cases, transgender people are hospitalised against their will upon demand by a parent. This may happen to minors under 15 years-old, who can be hospitalised, with the consent of their parents, according to the Law ‘On Psychiatric Care’. Due to high levels of corruption in the Russian health system, transgender individuals older than 15 can also be hospitalised against their will: ‘For a bribe, I was locked in the psikhushka [Russia word for mental hospital], and fed with Zyprexa [antipsychotic drug], and told that I had schizophrenic delusions as a result of birth trauma’.

Transgender people are required to stay in a psychiatric institution for around 30 days.

Whether voluntarily hospitalised or not, transgender individuals are placed in the facilities with other patients according to their legal gender, one that is different from the one they identify with. This can lead to hostility and violence from other patients. A trans woman describes having been raped three times, with no effort by the personnel to stop it: 'My parents recommended putting me in hospital, and cure my head of nonsense. Of course, I tried asking for a diagnosis of transsexualism, but no one listened to me; and I was put in a "tigers" cage, that is a cell for seriously ill and violent patients. I arrived in female clothes and I was immediately manhandled there, even raped three time by some bastards, but the staff didn't care!’ This woman received the diagnosis of ‘Schizotypal personality disorder’, and had to pass a psychiatric assessment again in a different city to get the required diagnosis of ‘Transsexualism’.

Psychiatric torture is widespread in Russian mental hospitals. Before hospitalisation, transgender individuals are made to sign an agreement on using drug treatment — even though their goal is to receive a diagnosis, not to be treated. In Krasnoyarsk, one person described what this treatment might be like: ‘I was in a madhouse for 30 days. I was injected with neuroleptics, without antidotes. I was subject to pressurising psychopathy, and 24 hours a day they watched to see whether I will cope with it or go mad’. This person reports that no one told her what she was being treated for, and which drugs were used. But, after a month, she received the diagnosis of ‘Transsexualism’. What is perhaps more astonishing is that such mistreatment is not only the result of incompetent doctors but is officially described in Decree N311 as a method of pharmacotherapy ‘in cases of psychogenic diseases, with employment of tranquilizers, antidepressants, anxiolytics, nootropics, sedatives’.

Furthermore, taking hormones may be prohibited in some hospitals. This measure not only violates an individual’s human rights, but also is harmful for the health of transgender individuals who had started taking hormones before hospitalisation, because irregular variation of hormone levels is not recommended.

Reform

The situation described above obviously needs to be changed. Actions aimed at educating Russian psychiatrists about trans issues on the national level may be one option. This, however, is hardly possible in the current political situation, and the complete unwillingness of most psychiatrists to listen to trans activists' arguments (whom they perceive as patients, not equal participants in the dialogue). And even if this were to happen, it will not remove the system of ‘gatekeeping’ (controlling access to gender recognition), but will only make it a little less oppressive.

Standfirst image: Depiction of the effects of schizophrenia. Image by Velekvez via Shutterstock (c)