Social and medical practices of gender transition in Russia

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BACKGROUND

The concepts associated with gender identity and approaches to the classification of gender identity disorders are undergoing significant changes, reflecting a shift in emphasis on the psychosocial aspects of the problem [1]. So far, there has been no definitive way to assess the actual proportion of transgender people in the Russian population because most studies have been conducted in Western countries [2–4]. Existing data indicate a high proportion of transgender people in several countries, although many transgender people are not involved in surveys, which also includes those who never seek help. Additionally, epidemiological studies use different approaches to understand gender identity disorders [5].

A recent meta-analysis of studies conducted across countries showed that the prevalence of transsexualism (the definition by the International Classification of Diseases, 10th Revision [ICD-10]) ranges from 2.6 to 6.8 per 100,000 people [6]. An analytical review of data from 17 countries concluded that a realistic estimate of the proportion of transgender and gender nonconforming people in the general population is 0.1%–2%, depending on inclusion criteria and geographic location [7]. At the same time, in countries with a history of population studies of transgender people, an increase in the proportion of adults who identify as transgender has been revealed [3].

No epidemiological studies have been conducted on the proportion of transgender people in Russia [8]. Although the number of studies focusing on investigating and solving medical issues related to gender transition has been growing around the world, such works are rare in Russia [9–12]. In a recent large-scale international study on the mental health of the population during the COVID-19 pandemic, 2.66% of respondents from Russia indicated their gender as nonbinary [13]. Despite the recorded increase in demand for transgender healthcare services in recent years [10, 14, 15], there is little information on the clinical and social characteristics of transgender people living in Russia.

This study aimed to analyze the social and medical aspects of the practice of gender transition in Russia in order to develop (improve) approaches to providing medical (psychiatric) care to this population group.

MATERIALS AND METHODS

International experience suggests that online research is a potentially effective option for capturing and exploring gender diversity [4, 16]. This is attributed, among other reasons, to the fact that Internet research aimed at transgender people ensures anonymity and confidentiality [17]. Hence, an anonymous online survey was chosen for the study [9].

The inclusion criteria were age over 18 (inclusive) and residence in Russia, indicating that the gender experience of the respondents differs from the sex marker determined at birth. The study included the completion of a structured questionnaire developed by the researchers. Subjective perception of housing conditions and financial situation was assessed using the Likert scale, with scores ranging from 1 to 10. The data were password protected and confidential, and the identity of the respondents could not be known. Participation in the online survey was anonymous and voluntary. The study protocol was approved by the ethics committee of St. Petersburg State University.

The final sample included questionnaires by 588 respondents (mean age 24.01 ± 6.70). At the time of the study, the respondents lived in all the federal districts of the Russian Federation, namely Central (n = 236; 40.1% of the sample), North-West (n = 172; 29.2%), Southern (n = 27; 4.6%), North Caucasian (n = 5; 0.9%), Volga (n = 58; 9.9%), Ural (n = 30; 5.1%), Siberian (n = 44; 7.5%), and the Far East (n = 16; 2.7%). Moscow (n = 174; 29.6% of the sample) and St. Petersburg (n = 151; 25.7%) were the most commonly places of residence of the respondents.

Statistical processing of the results obtained was performed using parametric and nonparametric methods. The critical level of significance was p = 0.05. To describe categorical variables, absolute values and fractions of the whole n (%) were used. Variables with a continuous distribution were described as the arithmetic mean and standard deviation (mean ± SD), and discrete variables and ordered data were described as the median and 1–3 quartiles (Md [Q₁; Q₃]). Pearson’s χ² test was used to compare the qualitative data. To compare continuous and scale data in the case of three or more groups, the Kruskal–Wallis test with χ² distribution was used. Correction for multiple hypothesis testing was performed using the Benjamini–Hochberg procedure. Statistical processing of the material was performed using the programming language R v4.1.0.

RESULTS

The majority of respondents indicated transmasculine direction of the gender transition (69.9%; n = 409), while transfeminine and “other” directions were indicated by 23.1% (n = 136) and 7.3% (n = 43) of the research participants, respectively. Respondents who indicated the “other” direction of transition specified their gender as non-binary (n = 16), (trans) androgynous (n = 6), agender (n = 4), gender fluid (n = 1), and other without specification (n = 16). The sample was divided into comparison groups based on the direction of the gender transition, namely transgender men (mean age 22.83 ± 5.89), transgender women (mean age 27.93 ± 7.96), and other transgender people (mean age 22.77 ± 4.78).

The social characteristics of the respondents are presented in Table 1. Notably, working respondents in all the groups more often worked in specialties for which they received no training. The proportion of socially maladjusted respondents was relatively high and included those who did not receive education and were unemployed at the time of the study (n = 91; 15.5% of the entire sample; average age 24.45 ± 7.2 years). A high frequency of migration of respondents was established; more than half of the respondents indicated that they had changed their place of residence.

 

Table 1. Social characteristics of respondents

Social characteristics	Transgender men (n = 409)	Transgender women (n = 136)	Other transgender people (n = 43)	χ2(df); p
	n (%)	n (%)	n (%)
Education				χ2(8) = 4.82, p = 0.776
Partially completed	14 (3.4)	5 (3.75)	3 (7.0)
Secondary	82 (20.0)	22 (16.2)	9 (20.9)
Vocational secondary	61 (14.9)	23 (16.9)	4 (9.3)
Incomplete higher	149 (36.4)	49 (36.0)	13 (30.2)
Higher	102 (24.9)	37 (27.2)	14 (32.6)
Employment status *				—
Continued education	198 (48.4)	28 (20.6)	19 (44.2)
Work on specialty	74 (18.1)	34 (25.0)	8 (18.6)
Work in the specialty one has not trained in	162 (39.6)	56 (41.2)	12 (27.9)
Non-student and unemployed	57 (13.9)	25 (18.4)	9 (20.9)
Change in place of residence in the past	214 (52.3)	79 (58.1)	26 (60.5)	χ2(2) = 2.1; p = 0.486
Housing conditions; Md [Q1; Q3]	7.0 [5.0; 8.0]	7.0 [5.0; 9.0]	6.0 [5.0; 8.0]	χ2(2) = 1.554; p = 0.460
Financial situation; Md [Q1; Q3]	5.0 [3.0; 6.0]	5.0 [3.0; 7.0]	5.0 [3.0; 7.0]	χ2(2) = 0.786; p = 0.675

Note. *Multiple answers were possible.

 

The assessment of satisfaction with housing conditions and the financial situation of the respondents showed relatively low results without statistical differences between the comparison groups. In contrast, the respondents rated their financial situation lower than the housing conditions.

Table 2 shows the characteristics of the gender transition of the respondents. Most respondents first confronted with the fact that their gender identity did not correspond to their sex at birth and/or did not fit into the social framework during childhood or adolescence, with a peak at 11–14 years (39.8% of the entire sample). Transgender women were more likely than other transgender people to indicate that they had started gender transition and initiated medical body alterations associated with gender transition (hormone therapy and/or surgery). At the same time, the age of onset of the gender transition of respondents in the vast majority of cases was after attaining majority, with a peak at 18–25 years (32.0% of the entire sample). More than half of the respondents had medical body changes associated with a gender transition initiated by themselves (59.4% had medical body changes associated with gender transition).

 

Table 2. Medical and social characteristics of the gender transition of respondents

Medical and social characteristics	Transgender men (n = 409)	Transgender women (n = 136)	Other transgender people (n = 43)	χ2(df); p
	n (%)	n (%)	n (%)
1	2	3	4	5
Age at which the respondents first thought that their gender identity did not correspond to their sex at birth and/or did not fit into the social framework				χ2(12) = 51.231; p < 0.001
Under the age of 5 years old	58 (14.2)	16 (11.8)	1 (2.3)
5–10 years old	71 (17.4)	28 (20.6)	4 (9.3)
11–14 years old	184 (45.0)	37 (27.2)	13 (30.2)
15–17 years old	55 (13.4)	23 (16.9)	11 (25.6)
18–25 years old	23 (5.6)	16 (11.8)	10 (23.3)
After the age of 25 years old	2 (0.5)	5 (3.7)	0 (0)
No answer	16 (3.9)	11 (8.1)	4 (9.3)
Age of onset of gender transition				χ2(10) = 84.721; p < 0.001
Under the age of 18 years old	42 (10.3)	14 (10.3)	2 (4.7)
18–25 years old	120 (29.3)	59 (43.4)	9 (20.9)
26–30 years old	26 (6.4)	14 (10.3)	0 (0)
31–40 years old	5 (1.2)	19 (14.0)	1 (2.3)
After the age of 40 years old	2 (0.5)	2 (1.5)	0 (0)
Transition not started	214 (52.3)	28 (20.6)	31 (72.1)
Social transition*				—
I introduce myself with my chosen name	292 (71.4)	73 (53.7)	28 (65.1)
I use the grammatical gender that corresponds to my gender identity	293 (71.6)	68 (50.0)	28 (65.1)
I try to look like my gender identity	326 (79.7)	83 (61.0)	23 (53.5)
There are medical body alterations associated with gender transition (hormone therapy and/or surgery)	145 (35.5)	88 (64.7)	6 (14.0)	χ2(2) = 49.905; p < 0.001
If the respondents have medical body changes associated with gender transition, they were initiated**				χ2(6) = 41.568; p < 0.001
After examination by a psychiatrist and/or endocrinologist	16 (11.0)	7 (8.0)	2 (33.3)
After passing a psychiatric commission and receiving a certificate for legal document replacement	61 (42.1)	7 (8.0)	0 (0)
On their own	65 (44.8)	73 (82.9)	4 (66.7)
No answer	3 (7.3)	1 (1.1)	0 (0)
Transsexualism was officially diagnosed (F64.0)	128 (31.3)	47 (34.6)	3 (7.0)	χ2(2) = 12.442; p = 0.002
Changed the gender marker (letter in the column “sex”) in the documents	84 (20.5)	27 (19.9)	1 (2.3)	χ2(2) = 8.444; p = 0.015
Currently, constant intake of hormones	125 (30.6)	83 (61.0)	2 (4.7)	χ2(2) = 63.697; p < 0.001
Currently, constant supervision of an endocrinologist (on issues related to gender transition)	61 (14.9)	25 (18.4)	0 (0)	χ2(2) = 8.931; p = 0.012
Gender transition included surgeries				χ2(8) = 321.898; p < 0.001
Yes, all planned surgeries have been completed	17 (4.2)	0 (0)	0 (0)
Yes, the surgeries were partially completed, and I plan to undergo more	34 (8.3)	16 (11.8)	0 (0)
No, but I plan to	299 (73.1)	87 (64.0)	16 (37.2)
No, and I do not plan to	29 (7.1)	14 (10.2)	21 (48.8)
No answer	30 (7.3)	19 (14.0)	6 (14.0)
Satisfaction with the current body status				χ2(4) = 15.784; p =0.003
Satisfied	22 (5.4)	12 (8.8)	7 (16.3)
Partially satisfied	139 (34.0)	62 (45.6)	14 (32.6)
Not satisfied	248 (60.6)	62 (45.6)	22 (51.2)

Note. *Multiple answers were possible. **The indicator was calculated from the number of respondents with medical body changes associated with a gender transition.

 

Transgender people from the “other” group reported an officially established diagnosis of “transsexualism” (F64.0) less often, did not change their gender marker (the letter in the “sex” column) in the documents, and took hormones significantly less often than the other groups. Despite hormone therapy, at the time of the study, 41.0% of the respondents who took hormones (14.6% of the entire sample) were under the supervision of an endocrinologist (on issues related to being transgender). In general, satisfaction with the bodily status in the study sample could be characterized as low. Approximately half the respondents were dissatisfied with their body status.

DISCUSSION

In our study, the social and medical aspects of the gender transition in people living in Russia were described for the first time with a sufficiently large sample size. Notably, a large proportion of transgender men took part in the study, which is consistent with data from international studies [14]. In particular, UK government statistics for 2005–2014 indicate an increase in requests for gender recognition certificates, predominantly from transgender men [18].

The study involved primarily young people living in the Central or Northwestern Federal District of Russia. This may be because this age group is more active on the Internet and in social networks where the study was conducted and because two of the largest and, unofficially, most “tolerant” cities in Russia, Moscow and St. Petersburg, are located in these districts.

There is a strong perception that lesbian, gay, bisexual, transgender, and queer (LGBTQ) people from the regions move to larger cities as part of their transition to adulthood, or for their safety, health (including mental health), and psychological well-being, which is primarily based on the assumption of greater well-being and security for this transgender people in these cities with large LGBTQ communities [19]. However, a recent study in Australia showed that the desire to migrate to cities to live a full-fledged gender or sexually diverse life has decreased among young people of the last generation [19]. In our study, a high frequency of migration was established.

An explanation for the aging phenomenon of respondents may be that the world is registering the “rejuvenation” of those seeking medical assistance related to transgender health. Thus, the first nationwide observational study of patients diagnosed with transsexualism who underwent gender confirmation surgery in Denmark showed that patients had begun to seek gender confirmation surgery at a younger age [20]. The median age of transgender people under the supervision of an endocrinology clinic and primary care facility in Australia was 27 years, with a range of 16–72 years [14].

Our study showed that transgender people living in Russia are characterized by noticeable difficulties in social adaptation, manifested in a high unemployment rate (15.5%), which is several times higher than the official unemployment rate (4.6%) in Russia at the time of the study [21]. Further, respondents rated their financial situation relatively low. The results of our study are consistent with data indicating a high unemployment rate (up to 21%) among transgender people, despite a high level of education [14].

High rates of unemployment among transgender people (33%–35%) have been reported in the United States of America and in Spain [22, 23]. In an earlier study conducted in Moscow, 46.4% of transgender people surveyed reported problems they faced in official organizations. 35% indicated the difficulty of obtaining medical services and work, and almost two-thirds of the respondents (65%) required social adaptation services and psychological support; however, only 42% knew about the ongoing activities. Most of these events in the form of lectures, training, and psychological consultations in Russia are conducted by initiative groups of LGBT and T-communities (89.3%), while most of the rest (23%) are conducted by commercial organizations; there is practically no state support (1.6%) [24].

The research results demonstrate that a successful transition in the workplace, even with a permanent job, is a complex process requiring social and managerial support, environmental adaptation, and legal advice [25]. It is not uncommon for employers and coworkers to be unaware of the changes required for transgender employees. There is evidence of the absence of an unequivocal attitude of society toward transgender people in Russia. In particular, a survey of cisgender Moscow residents showed that only a third of those surveyed (32%), who had no experience of communicating with representatives of the LGBT community, expressed their readiness to communicate with transgender people; 37% of the respondents admitted the possibility of communicating with them after they came out. The rest said they would not communicate with transgender people [24]. Further, the low level of general social support, social inclusion, and support from society for transgender people is associated with a history of suicide attempts [2].

Most of those interviewed in this study first thought their gender identity did not correspond to their sex at birth and/or did not fit into social norms during childhood or adolescence. These data are consistent with the classical Russian concepts [26] and the latest international studies [27]. In another Russian study, it was revealed that one’s awareness of being transgender occurred mainly at the age of 5 to 22 years, distributed evenly in three periods of growing up; namely, up to 7 years (25.4%), from 8 to 14 years (37%), and adolescence up to 22 years (25%) [24].

Transgender women indicated more often than other transgender people that they had begun the transition process and initiated medical body alterations associated with gender transition (hormone therapy and/or surgery). According to some data, non-binary people resort much more rarely to gender-affirming medical interventions and legal gender reassignment than transgender men and transgender women [28], which was confirmed in our sample.

The differences in the frequency of gender confirmation surgery reflect global trends. In particular, genital surgery is no longer necessary for transgender men to feel “male enough” [20]. The results of a study conducted in the USA show that the desire to undergo surgical procedures for gender confirmation is unique for each person and should never be assumed a priori for transgender or non-binary patients [29]. Not everyone who identifies as transgender desires medical intervention; several patients undergo social transition and change gender expression without medical intervention [30].

The results of a retrospective cohort study of 20 years of gender reassignment surgery performed at a Brazilian university center show that the mean age at surgery was 32.2 years (range 18–61 years), and the average duration of hormone therapy before surgery was 12 years (range 1–39 years) [31]. In a Russian study of 46 transgender men aged 20 to 35, 11% of the subjects in the group reported complete gender reassignment surgery and 15% of respondents reported partial surgery [12]. A survey of transgender men who underwent the entire complex of gender reassignment surgeries showed that implementing complex surgical interventions may significantly improve the quality of life and the psycho-emotional status of patients [32].

The fact that more than half of the respondents in our study who began the gender transition and had medical body changes initiated it on their own, that is, without examination by a psychiatrist and/or endocrinologist or passing a psychiatric commission and obtaining a 087u certificate, is particularly concerning. At present, in Russia, a transgender person can turn to an endocrinologist for prescribing hormonal therapy or to a surgeon for surgical intervention only after the diagnosis of transsexualism is confirmed by a psychiatrist, according to ICD-10. Moreover, the procedure for issuing form 087/u, “Certificate of gender reassignment,” to submit to the civil registry office for making corrections or changes to the civil status record is regulated by the order of the Ministry of Health of the Russian Federation dated October 23, 2017, No. 850n. At the same time, endocrinologists are advised to make sure that the patient’s desire to change gender is justified before starting hormone therapy, explain all the positive and negative consequences of therapy, and discuss options for maintaining fertility [33].

A significant disproportion between the indicator of hormone therapy intake and the frequency of observation by an endocrinologist (on issues related to transgenderism) was revealed; that is, more than half of the respondents took hormonal drugs without supervision of an endocrinologist. Gender-affirmative therapy involves the same potential risks as hormone replacement therapy in cisgender patients [33]. This necessitates regular clinical monitoring of physical changes and potential adverse effects in response to treatment, as well as laboratory monitoring of the level of sex steroid hormones every 3 months during the first year of therapy, and then one or two times a year [34].

The number of people who reported that they were officially diagnosed with transsexualism (F64.0) and had already changed their gender marker in their documents was lower than the number of people who indicated that they already had medical changes in the body associated with gender transition. The study showed a large proportion of people who already had medical changes in their bodies. However, they did not change the gender marker in their documents, with the largest difference in this indicator being transgender women; this, undoubtedly, can negatively affect the social adaptation of the respondents.

The results of the present study must be considered in light of their limitations.

The main limitation of the study is its anonymity and remoteness. When planning the study, the authors relied on the criteria for the diagnostic category “gender incongruence” (HA6) of the International Classification of Diseases, 11th revision, and on the standpoint of the World Professional Association for Transgender Health. The structured questionnaire questions in the study were composed in such a way as to confirm that the respondents had a noticeable incongruence between their perceived gender and the sex assigned at birth. However, it is essential to consider that some respondents never consulted psychiatrists to confirm their gender incongruence and obtain an official conclusion to begin medical changes in the body associated with gender transition.

Further, the invitation to the study was distributed through the Internet resources of the trans-initiative group, and the risk that a person who did not identify them self as transgender may click on the link was assessed as minimal.

The study cannot be considered population-based and representative. Although our data confirm the high frequency of respondents’ migration, the reasons for the change in the place of residence require further evaluation.

CONCLUSIONS

1. The data obtained in our study elucidated the social and medical aspects of the practice of gender transition in Russia. Our study found that there were noticeable difficulties in achieving social adaptation for transgender people living in Russia. The results indicate the widespread self-initiation of gender transition and the practice of taking hormones without the supervision of an endocrinologist, which may lead to complications and clinically significant medical consequences and is of great concern. Whether this is due to unavailability of medical care, transphobia, (self-) stigmatization, or some other reason requires further study.
2. Gender transition is a complex process; successful implementation requires a multidisciplinary team of qualified professionals competent in dealing with gender dysphoria and gender incongruence [33]. The management of transgender people ideally involves a multidisciplinary team of a general practitioner, psychologist, psychiatrist, endocrinologist, sexologist, gynecologist, urologist, surgeon, and trained nursing staff [30].
3. Gender identity problems should be diagnosed by psychiatrists. Given the psychological vulnerability of many transgender people [9], psychiatric and psycho-psychotherapeutic care should be available throughout the transition and after its completion [33]. Trained peer support workers can alleviate psychological distress by facilitating access to support services and providing counseling on the non-medical aspects of gender transition [30].
4. The data obtained determine the relevance of developing a system of specialized medical care for transgender people with mandatory destigmatizing psychotherapeutic and psychiatric care. The study results highlight the need for further study of the socio-psychological well-being and mental health of transgender people, and the availability of medical (psychiatric) care for transgender people living in Russia.

ДОПОЛНИТЕЛЬНО

Финансирование. Исследование не имело спонсорской поддержки.

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов по представленной статье.

Вклад авторов. Чумаков Е.М. и Ашенбреннер Ю.В. — проведение исследования, сбор и анализ результатов; Чумаков Е.М. — подготовка первой версии манускрипта; все авторы участвовали в редактировании манускрипта и подготовке финальной версии статьи; Лиманкин О.В. — руководитель работы.

Funding. The author received no specific funding for this work.

Conflict of interest. The authors declare no conflicts of interests.

Contribution of the authors. E.M. Chumakov and Y.V. Aschenbrenner — conducting the study, collecting and analyzing the results; E.M. Chumakov — preparing the first version of the manuscript; all authors participated in editing the manuscript and preparing the final version of the article; O.V. Limankin — study supervisor.

About the authors

Egor M. Chumakov

St.-Petersburg Psychiatric Hospital No. 1 named after P.P. Kaschenko; Saint-Petersburg State University

Author for correspondence.
Email: chumakovegor@gmail.com
ORCID iD: 0000-0002-0429-8460
SPIN-code: 2877-2154

Cand. Sci. (Med.), Assistant Professor

Russian Federation, 190121, St. Petersburg, Kanonerskaya str., 12; 199034, St. Petersburg, Universitetskaya nab., 7–9

Nataliia N. Petrova

Saint-Petersburg State University

Email: petrova_nn@mail.ru
ORCID iD: 0000-0003-4096-6208
SPIN-code: 3341-2372

Dr. Sci. (Med.), Prof.

Russian Federation, 199034, St. Petersburg, Universitetskaya nab., 7–9

Yulia V. Ashenbrenner

St.-Petersburg Psychiatric Hospital No. 1 named after P.P. Kaschenko

Email: ashenbrenner22@gmail.com
ORCID iD: 0000-0003-0032-1704
SPIN-code: 1092-0688

Psychiatrist

Russian Federation, 190121, St. Petersburg, Kanonerskaya str., 12

Larisa A. Azarova

St.-Petersburg Psychiatric Hospital No. 1 named after P.P. Kaschenko

Email: azarova812@me.com
ORCID iD: 0000-0002-1144-2782

Deputy chief physician

Russian Federation, 190121, St. Petersburg, Kanonerskaya str., 12

Oleg V. Limankin

St.-Petersburg Psychiatric Hospital No. 1 named after P.P. Kaschenko; North-Western State Medical University named after I.I. Mechnikov; St.-Petersburg Institute of Postgraduate Improvement of Physicians-experts of the Ministry of Labour and Social Protection

Email: limankin@mail.ru
ORCID iD: 0000-0001-6318-7536
SPIN-code: 5228-1344

Dr. Sci. (Med.), Prof.

Russian Federation, 190121, St. Petersburg, Kanonerskaya str., 12; 191015, St. Petersburg, Kirochnaya str., 41; 194044, St. Petersburg, Bolshoy Sampsonievskiy pr., 11/12

References

Supplementary files