How Estonian Bureaucracy Obstructs Gender Transition
Estonia prides itself on being a digital state built on efficiency and equal access. Yet for many trans people, E-Estonia is a forest of bureaucracy and expert panels, as Sascha Lumi learned when beginning her legal and medical transition.
I thought I was above the whole concept of medical transition. I’d seen plenty of trans people online who had managed without the ordeal of hormones, potential operations, and fighting doctors and laws. It all seemed like a shortcut to social isolation and trauma, and I didn’t feel I needed it.
“Estonia doesn’t want you to transition,” I told myself. By “Estonia” I probably meant my line of work, which, like many here, is very conservative and averse to anything that might be perceived as drama. There was also the concern that I might be “too old to make a good trans woman,” and that I would never be attractive, or at least not according to my own conception of what an “attractive woman” was.
Appearance, Confidence and Self-Perception
What, I think, changed my viewpoint was a conversation with a long-time trans friend, who pointed out her own experience with medical transition. I began to think, in terms I felt and still feel are healthy, that I had already transitioned in the eyes of my closest friends, but that I wouldn’t feel like my true, authentic self until I had allowed hormones to change me physically and mentally, and state recognition to change me legally.
Maybe, I felt, hormones could push me into a place where I felt affirmed as a woman almost without question. I enquired about the waiting times for Estonia’s gender commission, known officially as the Ministry of Social Affairs Expert Committee.
Photo: Lena Balk, Unsplash
Reform on Paper
Estonia, as has been covered by Feministeerium before, uses a määrus or decree to cover gender transition in the law. This was amended at the end of August as part of amendments to the Health Care Organisation Act. The new määrus or (loosely) addendum amends one of the major points of contention trans people had – the previous roughly two-year waiting period between first and second commission meetings required before documentation could be changed. Now, the first meeting can lead to the granting of hormone replacement therapy (HRT) through an Estonian prescription, and the approval to make a change in the population register. The need for the Minister to approve transitions is now also no longer on the statute books. As I was to find, this can make a significant difference in how quickly one is seen, though certain criteria are considered by the Commission.
However, according to a 2026 report by the Estonian Human Rights Centre and written by Aili Kala, “gender-affirming healthcare is no longer dependent on ministerial approval, and the commission is now expected to have an advisory role. However, it appears that the changes have not been implemented in practice. The Estonian LGBT Association has received clear information from the medical commission and trans people that the provisions of the regulation currently remain mostly formalities, without actually protecting the interests of trans people. Such practice violates the fundamental right to self-determination and the protection of health.”
That aforementioned commission is a committee of health professionals, working in an arrangement that began in the nineties, albeit the original Commission disbanded by its own initiative in 2021, with a new Commission not sitting until 2022, creating a backlog of cases which led to widely negative perceptions of the process among the trans community. A major factor that has changed with the new määrus is that appeals of Commission decisions are now permitted. The waiting list to be seen, which had been reported as being as long as three to five years for both of the two hearings formerly needed, seems now to be shortening, and there is evidence of increased numbers of Commission sessions.
Choosing Telemedicine
Nonetheless, it’s important to remember that my medical transition journey began in the pre-September world, when it seemed like my Commission sitting would be years away. As I swallowed hard, convinced I would be too old to really enjoy it by the time I could legally transition, Discord proved unexpectedly helpful, with trans friends sending me DMs advising me of the private options if I were to begin hormones before seeing the commission. This article is not meant to act as any kind of advisory to people also going through transition – you should weigh up the options for yourself, depending on your own circumstances. I don’t have unlimited resources, but I decided I could at least take action myself.
The idea of going the DIY route was a non-starter for me; I am a rules-based person, and I do not like the idea of medication being sent by post. I also had been warned that a dim view of DIY HRT was taken by the Commission. There were, as I understood it at the time, two legal and semi-affordable options for getting hold of estrogen in Estonia without commission approval: GenderGP and Imago. Based on reviews of GenderGP and Imago on Reddit and Discord, and some news stories about GenderGP that put me off, I went with Imago. I had to take part in an introductory video call with one of their representatives, send results from a blood test and a starting fee in, and take part in a 45-minute call with one of their doctors, who would be the person in charge of signing off my prescriptions.
Photo: Matheus Ferrero, Unsplash
Good People Within the System
I have to also give credit to my family doctor in Estonia: while much of this article describes an opaque and bureaucratic state system, almost every system has good people working somewhere within it. Filled with pent-up tension about coming out to yet another person in authority, I started speaking to my doctor almost robotically, before realising that she empathised with me and wanted to help. I shouldn’t have worried: while firm at times, my doctor has always responded thoughtfully to my questions, and although I was supposed to pay for my blood test at a private lab, she let me take it at the family medical centre. A similar positive story comes from the representative at Pelgulinna Women’s Clinic Fertility Centre, who was willing to patiently answer all of my sometimes dumb questions about sperm-freezing, then expedite my visit, after I had been hit with hidden charges by one of the leading private clinics.
What this tells me is that, although healthcare should be blind in terms of how it treats different people, a lot of what you get out of the system depends on the unconscious bias of whether individuals feel they want to go the extra mile for you. That so much of trans access to healthcare is centred around how nice you are perceived as being to people is frustrating, but it also may be by design rather than accident. Systems built around patient or customer compliance and nicety are less likely to be subject to scrutiny or rebellion.
The E-State’s Blind Spot
The flip-side of an e-state like Estonia, where the government makes what it views as essential interactions achievable in seconds, is that what that same government considers a non-essential part of its interaction with the public sometimes lags behind. Estonia has decided in the määrus to move from the outdated ICD-10 medical designations, such as ‘Transsexualism’, describing being trans as a mental-health disorder, to ICD-11, using the more neutral term ‘Gender Incongruence’. However, this update has not happened across the board as of yet, although anyone diagnosed with ‘Transsexualism’ can appreciate how demeaning and misleading the term is.
Another example of this government intransigence is the laissez-faire attitude towards pharmacies. Within the European Union, wet-ink signed paper prescriptions with the doctor’s full details and the specific medicine required must be fulfilled by any EU pharmacy that carries the medicine in question. In fact, according to the EU’s website, wet ink is not even a requirement, and yet Imago still makes sure its paper prescriptions contain one, as insurance.
Photo: Diego Delso, Wikimedia Commons
Therefore, imagine my surprise when, preemptively checking that Apotheka in Viru Keskus could take the prescription, I was told by their pharmacy manager that the parent company was going to court to be permitted by the government not to have to fulfil Imago prescriptions (something nobody has been able to confirm)1. After some queries to their head office by the Estonian Trans Association, their spokesperson replied that it was Apotheka’s policy to allow their pharmacies the choice to decide whether or not to fulfil a prescription. Pharmacists stare dubiously at the paper prescription (Estonia is not signed up to the Clynxx digital prescription system used by Imago and UK pharmacies), making the customer feel like they’re at a Cold-War border post with migration papers.
Anti-androgens (testosterone blockers), typically prescribed by telemedicine providers due to the difficulty of effectively transitioning on Estradiol alone, are not sold in Estonia on the basis of Imago prescriptions. Helsinki felt like an option for a while, but the Finnish government have leapt upon a very particular reading of EU law, ruling as I understand that Spanish doctors such as those who write many of Imago’s prescriptions, must be tied to Spanish clinics, rather than the Malta-based firm. It feels like an attempt to tighten the net on the only way for many people in Estonia to get HRT without going onto the DIY market.
The Illusion of Choice
This freedom of choice might seem by some to clash with EU law, and highlights that for trans people not yet confirmed by Commission, the postcode lottery of finding a sympathetic pharmacy which is willing to carry out its legal responsibilities is yet another emotional load for the individual to carry. Were the law enforced consistently, gender-affirming healthcare would be available to the people who need it, rather than being viewed as a gift to be given to those who are nice and say the right things to the right people.
Eventually I got hold of my Estradiol in Estonia, and (with more difficulty) my Androcur. The latter was described to me as “the last in Estonia,” and that may have been accurate; Bayer have decided to stop marketing it to the Baltic countries, meaning the Estonian state is now making one-time orders of generic cyproterone for trans patients on the state system. Imago prescriptions should be served, though, as we have seen, it depends on the benevolence of individual pharmacists, and their reading of EU law.
I saw changes. My moods softened, I felt less explosive in my anger and more calculating. My body hair grew slower, while my head hair grew thicker. My voice remains stubbornly deep, but truly HRT is all I could have hoped it would be. I was ready for the long haul, budgeting for Imago prescriptions, when the Commission offered me an afternoon slot, late in the year.
Facing the Commission
To say I prepared rigorously for the Commission would be an understatement. I used ChatGPT as debate preparation, asking it to pump potential questions my way, then rate my responses. I spent the morning before the hearing with my nonbinary friend, as we talked through the potential scenarios.
The Commission itself had a fearsome reputation, and on our way into the offices, my friend and I were met by a member of staff, who sternly told us to wait and that I should fill out some questionnaires. Left alone with my own thoughts, I started to ruminate. I had been told that the surprisingly quick date for a hearing, having applied in the summer, was due to a number of factors, including my age. As was explained to me later, if I had been 18, it might have been different. However it appears the Commission is making serious attempts to get through the backlog of applicants, so potentially it is not only older trans people who get seen within a few months.
Photo: Product School, Unsplash
Four people interviewed me, and it felt like a much fairer interview than I had prepared for. I was told beforehand to avoid defensiveness or obvious overreaction to any questions that may be hurtful, but what actually happened was that the line of questioning was, in the main, empathetic to my situation, understanding that I may live alone, but I have a strong support network, and a supportive family. I was asked about my childhood, about when I began to feel feelings related to being trans, and when I came out to my friends.
More controversially, I was asked about Imago, with members expressing concern about their credentials (seemingly without having got in direct contact with them), and one doctor’s alleged Mexican medical licence. I responded that the clinic had been nothing but responsible in the way it had worked with me, that it was providing me with mental-health services along with its prescriptions and medical check-ups, and that the doctor I was seeing was, as far as I had been aware, Spanish (though I questioned silently how much of a difference a non-European doctor’s licence should make).
The only other question that felt surprising was over weight changes – I was asked if I stress-ate, and was asked what my lowest weight I could recall had been. I felt, nonetheless, that some of the negative perception of the Commission from the community around me was based on a reality that had either passed, or that it depended greatly on the composition of the hearing; there were no questions about sexual fantasies, or speeches about contagion, for example, two points on which I had been warned.
Foto: Scott Graham, Unsplash
This is not to say that controversial or borderline offensive questions are never asked by Commission members – I cannot judge, because I can only discuss the hearing I attended. However the people I sat centrally in front of – feeling exposed, with no table on which to balance my glass of water – were courteous to me, and seemed to comprehend how unusual and anxiety-inducing the hearing feels to those answering questions.
Following the September changes, there is no official letter from the Ministry of Social Affairs announcing Commission approval – no “Estonia thinks you’re really trans!” moment. Instead there is a low-key entry on Terviseportaal, laying out in detail the feedback of the Commission chair. In that feedback, it was suggested that my answers were lacking in expression, and seemed at times a little mechanical; this may have suggested my preparation was a little too rigorous to appear spontaneous, although it was hard to maintain a balance between passionate and pragmatic while nerves were jangling, and this didn’t seem to have negatively affected their assessment of my responses. Otherwise, the feedback was exactly as I remembered the meeting proceeding. This note is followed by a digitally signed form confirming that a name and gender change can be made in the Population Register when wished.
No to transmedicalism
Beginning medical transition and going through the Commission process has certainly changed me. I mentioned earlier that a system based around how professionals feel about those they are serving – a system based at least partly on impressions, breeds compliance among clients, seeing this as a way to get ahead.
The change in my attitude towards the Commission doesn’t change my perception that the system is fundamentally unfair to trans people, and that people should not have to perform proof of identity to a panel of professionals in order to receive healthcare and the right to change their gender legally. This fits in with the politics of ‘passing’. The idea of a Commission visitor being nonbinary is, according to anecdote, often not taken as seriously as it ought.
On another point, I understand the arguments about a duty of care to young people, but equally I do not think access to life-improving healthcare should be age-restricted if the individual applying is a consenting adult. In Estonia, but also in Europe as a whole, we need to review and update how our medical systems regard trans people. The move from ICD-10 to ICD-11, when it is eventually rolled-out, will help, but ultimately attitudes need to move with the numbers and letters.
Photo: Julia Zyablova, Unsplash
I took part in a great deal more micro-analysis of myself during and immediately after the Commission process. This may have been looking in the mirror, asking if I was changing enough, or too much, or listening back to my voice and asking myself if I “sounded too male”. The thing I most wanted to make sure of was that it did not turn me into a transmedicalist. Anyone who feels they are trans can be trans – they do not need a panel to tell them that. Equally, HRT does not equal transition, any more than operations do. The processes the state requires trans people to go through run the risk of creating people who build up a conception that transness is something bought or developed externally, when it is not.
If there were any advice for others going through the Commission application process it would be not to compare oneself to anyone else, not to obsess about ‘passing’, and to be true to the path they wish their transition to take, however much state protocols might create what seems to be a preferred pipeline. Coming out as trans is about realising one’s authentic self. Follow the law, be aware of your legal rights, be politically aware, but do not allow any form of groupthink to define you. The next chapter of my life starts now – my wish is that yours can begin soon too.
- Comment from Liis Prii, Head of the Supervision Department at the Ravimiamet (State Agency of Medicines):
“Ravimiamet has not restricted or prohibited the dispensing of medicines on the basis of prescriptions issued by the GenderGP and Imago clinics.
We have received questions from pharmacists regarding the dispensing of medicines on the basis of European Union prescriptions, and we plan to send an information letter to all pharmacists in the near future explaining the rules for dispensing medicines based on EU prescriptions, so that pharmacists have consistent guidance on this matter.
Estonian pharmacies may dispense prescription medicines on the basis of prescriptions issued in EU member states, Norway, Iceland and Switzerland, provided that: the prescription contains all the required information; the prescription is valid (an EU prescription cannot be valid for more than 60 days after it has been issued); the prescription bears an original signature (that is, not a printout or copy); the prescription is clear and legible for the pharmacist; the prescribed medicine is available in the pharmacy; there is no suspicion that the prescription may be forged; and in the case of a minor patient, the pharmacist must ensure that the guardian consents to the dispensing of the medicine.
We ask that people contact Ravimiamet in specific cases where a pharmacy refuses to dispense a medicine on the basis of an EU prescription, so that we can investigate the reason for the refusal, determine whether it complies with medicines regulation, and, if necessary, clarify the principles of dispensing medicines to the pharmacist.”
