A non-transparent system and assessment specialists, i.e. how the Estonian state treats transgender people

Transgender people in Estonia are aware of what awaits those who turn to psychiatrist and sexologist Dr Imre Rammul, head of the medical assessment committee for gender reassignment. The questions have remained the same for years, the same applies to prerequisites and even ignorant jokes.

Joosep* is a transgender man in his thirties who works as a video technician. During his first visit, Rammul told him that he has also specialised as an andrologist, but there are fewer and fewer “normal” men turning to him for help. That there is more and more talk about paedophiles, zoophiles and transsexuals in the media and he does not understand the need for all of this. This meeting was the most unpleasant for Joosep. “I wasn’t told these things by a troll on social media; it was a person I turned to for help and support,” he describes.

There are other cases where people who ask for help from experienced specialists encounter confusing behaviour. Rammul denies having behaved in an inappropriate manner.

People who need the service of gender recognition have been afraid that Rammul will not let them or other applicants in the future pass the selection process. This is the reason why the system and its participants have not been openly criticised before. Those who have talked to me also feel that no one is interested in changing the procedure for gender recognition despite complaints.

The Estonian state recognises a person as a man or woman by means of the first number of their personal identification code and entries in registries and on documents, such as ID cards and passports. The procedure for gender recognition encompasses activities which are undertaken when gender data, such as a person’s personal identification code and name, need to be changed because their gender identity does not correspond to them. In addition, legal gender recognition enables access to medical services, such as hormone replacement therapy which helps adjust a person’s appearance on the basis of their self-perceived gender.

In Estonia, the gender recognition process has been regulated by one legal act since 1999: regulation ‘Common Requirements for Medical Operations for Gender Reassignment’. It describes two stages. First, a person who wishes to change their legal gender must get permission from the medical assessment committee established by the Ministry of Social Affairs. Second, their documents can be changed to correspond to their gender when two years have passed from obtaining permission.

The medical assessment committee is an institution established with a directive of the Minister of Social Affairs. Everyone who needs the state to change their gender marker and issue the corresponding documents must turn to them. Psychiatrist and sexologist Dr Imre Rammul has been in charge of the committee since its establishment 21 years ago and its four members have also remained the same. The state has not carried out any supervision of the committee. The committee is not currently operating; it was dissolved at its own initiative. Since the beginning of this year, people who need their gender recognised have had nowhere to turn to.

In this article, seven people talk about their experiences in the hope that the procedure will be changed for future applicants. The descriptions concern the interviewees’ experiences with the gender recognition system from 2003-2020.

Inappropriate values and irrelevant questions

Terje had an appointment with the committee in 2003. It was an important milestone for her, but the doctors enquired whether she had erotic dreams. Terje replied that she did not and that she was asexual. “They laughed so much that their bellies were shaking and claimed that women cannot be asexual, only frigid,” Terje, who has studied economics, recalls her experience with the committee.

Viktoria Shperova, who works as a cashier, and Sara Arumetsa, a Master’s student of philosophy, say that they were asked questions which do not concern their gender identity, such as: What kind of role do you assume when having sex? Who do you sleep with? Who do you prefer? What do you find arousing? Emma, a software developer, adds that she had not had any relationship at the time of her appointment with the commission and that she found the questions intrusive and repetitive.

I call Imre Rammul to enquire about the process. The former lecturer and doctor with experience in running a psychiatry clinic resolutely explains that these irrelevant, intimate questions are necessary to find out the applicants’ motivation for appealing to the committee. “Their motivation may have nothing to do with changing their gender; for instance, avoidance of military service or something entirely different,” he says. He fails to answer whether anyone has attempted to carry through their wish to avoid enlistment. “The question is why do we even need this committee,” he says.

The active psychiatrist and sexologist denies any kind of unfriendliness or ambiguous jokes made towards people in a vulnerable state and says that conversations have always remained constructive.

Illustration by blu3milla

What is going on in the committee?

Those who apply for gender recognition basically have five to ten minutes to convince the committee that they are who they are and wish to live like this. The committee has power over that person’s future life when making a decision. The people I have talked to say that it is not clear what the committee’s decisions are guided by – at times, it seems that they are based on stereotypes and myths.

“He repeatedly asked me when I would finally start wearing a suit and cut off my long hair.”

“He commented on my appearance, made a compliment and compared my looks with those of other applicants. He said, ‘here are some middle-aged blokes with a shoe size of 45 who look like sailors and will never make beautiful women’.”

According to Rammul, questions regarding clothing or sexual reactions and the emotions associated therewith are entirely appropriate. He adds that he does not actually know what kind of emotions these questions gave rise to among the applicants.

The doctor, who has been described as a person with a fine sense of humour in the comments on the Tervisetrend portal, denies having laughed at his patients. He also remarks that other medical workers may not have relevant training or experience in order to be able to work with transgender people – he claims that his own patients provided such feedback. “I’ve been told about strange incidents by those who have turned to all kinds of people,” Rammul says. He considers it completely impossible that he himself has made inappropriate jokes.

An extensive study published in 2020, which concerns the access of transgender people living in the European Union to the legal gender recognition procedure, states that access to gender recognition and hormone replacement therapy is often granted only to those who express their gendered nature in a traditional manner, i.e. as a man or woman who is as manly or feminine as possible.

There are two valid legal genders in Estonia: man and woman. According to the interviewees, it is better not to even mention any kind of self-awareness other than this binary separation between man and woman, i.e. a non-binary gender identity, in front of the expert committee because it may disrupt and extend the process of gender recognition.

Former applicants say that you cannot make any inquiries to the committee or discuss your options: you either get the green light or you’re turned away. “It is normal for questions or doubts to arise when making such a big decision, especially if there’s little information,” says Rodion, an art student, speculating about their attitude. In response to this, Rammul commented that he can follow existing rules and that we should wait for the new International Classification of Diseases (ICD). This might give us more freedom in deciding on various identities.

Problems not only caused by communication with the committee, but the entire procedure

The committee’s work, described as superficial by the interviewees, is one thing, but the entire procedure for legal gender recognition is another.

According to the Estonian procedure, transgender people have the right to obtain documents that correspond to their identity when two years have passed from the adoption of the medical assessment committee’s decision and the beginning of hormone replacement therapy. Their appearance starts to change in the desired direction in the early stages of therapy, within a couple of months, but they cannot change their documents right away. As such, people are forced to live and prove their identity using a document that does not reflect their appearance or gender expression.

For someone who has started hormone replacement therapy, these two years are disconcerting, marked by troubles and an unsolicited obligation to explain their gender and appearance to strangers. For example, a pharmacist may refuse to sell a prescription drug because they think that the customer presented a false document, a person cannot perform their professional duties because the guard of a site expected someone of the opposite gender or they cannot buy a discounted ticket on a train or open an account at a bank. There are many similar cases and they occur repeatedly.

On every trip, border guards gave Marcus a body check, examined his document and asked him whether he was a boy or a girl in front of a crowd of people. “The period of gender transition has been a traumatic process. I’ve tried to forget it,” says Marcus, who works as a consultant.

The system is non-transparent and little information is available

The people who talked to me described the system as difficult to understand and poorly accessible. There is no public information concerning the medical assessment committee, making it difficult to make an appointment with them. The information has been available on the homepage of the Estonian LGBT Association in recent years, but not on the channels of the Ministry of Social Affairs or medical family counselling centres, i.e. the institutions that are the contact point for those in Estonia who need to get their gender recognised. “The entire process seems to have been shot from the hip,” says Sara.

It is difficult to get an appointment with the committee because they don’t answer their e-mails. Instead, you have to repeatedly call Dr Rammul directly and insist on it. Registration leaves no traces. If you are too insistent, you will be subjected to verbal abuse (Rammul also denies this). You are notified of the meeting shortly in advance and if the time is not suitable for you, it will be postponed to the distant future again. The committee usually meets twice a year.

“This entire committee issue is so secretive and non-transparent; it smacks of doomsday. If you haven’t gone through it yourself, you don’t know what to expect,” says Marcus.

Completely diagnosis-focused and controversial

Emma’s medical history includes transsexuality and gender identity disorders. “In my everyday life, I don’t feel like I have a diagnosis, but at my GP’s office, I’m a person with a diagnosis.”

The regulation requires the assessment committee to diagnose a transgender person with a medical mental disorder (gender dysphoria or transsexualism), but without other mental disorders. The regulation does not take into consideration the fact that due to the widespread hostility towards transgender people in society, it is highly likely that they have had long-term depression. “You never know whether mentioning depression may pose an obstacle for you at the committee,” says Sara.

In addition, such diagnoses are in conflict with the World Health Organization’s 2019 decision ending the categorisation of trans-related conditions as mental and behavioural disorders. The pathologising practice lays the foundation for hostile beliefs, discrimination as well as mental and physical violence against transgender people, since it regards transgender issues as negative and requiring treatment, not as a state – as human experience and self-determination.

Language use and the content of the procedure are outdated

According to the regulation, the Minister of Social Affairs (after the separation of the ministry’s activities, the Minister of Health and Labour) signs a directive allowing hormone therapy on the basis of the committee’s decision. The minister who gives permission does not meet the person who starts hormone therapy and only gives permission via their signature on the document.

In the minister’s directive, a transgender man is called a ‘socially adapted female transsexual’. “I’m applying to have my gender marker changed to that of a man, but reading the document, I see that I’m a transsexual and… a woman. Is that some kind of a certificate for a drag queen?” Rodion says, puzzled by the state’s use of language.

The applicable legislation is contradictory, leaving it unclear whether hormone therapy is required by law. Although access to medical procedures is vitally important for most transgender people because it helps them align their appearance with their inner self, not everyone needs this or can undergo it for health reasons. In the case of the Estonian practice, hormone therapy is unavoidable because you cannot change your gender on your documents without it.

Transgender Europe, a Pan-European organisation advocating the rights of trans people, Amnesty International and the Estonian LGBT Association criticise systems that impose obligatory medical procedures in connection with legal gender recognition and recommend the separation of the two. The current medicalised approach undermines people’s right to physical integrity and free self-determination.

People who need support are forced to educate specialists

Looking for a service or advice, almost all of the interviewees have had the experience where they have to instruct medical workers, psychologists or officials.

“My GP felt completely awkward when I asked her for a referral to a geneticist. She said that I should think about the wellbeing of my parents and not upset them with my being transgender. She implied in every possible way that I’m doing something that is disapproved of when I’m actually making the only possible decision that’s right for my mental health,” says Joosep.

Rodion described his visit to an endocrinologist to enquire about gender transitioning. “He didn’t know anything and for the rest of the half an hour that I spent there, we googled what had to be done together. He printed out the 1999 regulation on transsexuality and I had to take action on my own on the basis of it,” says Rodion.

As issues concerning trans people or gender in general have not been addressed in the curricula of doctors or other professionals dealing with people outside the social sciences, the training of specialists who come into contact with transgender people is a matter of chance. This means that people seeking support have to carry the burden of constantly educating specialists.

Problems are structural and start with legislation

The faults described by the interviewees – the outdated regulation and procedure for gender recognition, the communication problems of a leading specialist and adherence to stereotypes – reflect and reproduce the attitudes experienced by transgender people in society.

It would help to alleviate the situation if the state separated medical and legal procedures in connection with gender recognition. Changing your gender marker should not be dependent on hormone replacement therapy and people should be able to decide what they need more on their own.

Instead of the committee, humane advice concerning mental health and the person’s own decision, which they submit to a relevant authority, would suffice. We could follow the example of Denmark, Belgium or Portugal where this procedure is already in place. The same arrangement is also recommended in the joint report of the Estonian Equal Treatment Network.

The state could offer several options for gender recognition because a variety of experiences and needs exist. The top-down imposition of the same diagnosis and treatment on everyone is not in accordance with the principle of free self-determination.

The people I interviewed for this story said in conclusion that they need one thing: for society and institutions to recognise them and their identity in the same manner as those whose sex determined at birth matches their gender identity. However, constant questions, doubts and comments in the medical system as well as in everyday life give the impression that people have to be ready to justify their existence and fight for it at all times. This paves the road to traumas, depression and detachment from society.

All transgender people definitely need to be treated in a manner that respects human dignity.

This article was written on the basis of the experience of seven people. Thank you Sara, Rodion, Joosep, Viktoria, Marcus, Emma and Terje.

This article was originally published in Estonian in July 2021.

* References to the interviewees include their full name, forename or pseudonym according to their wishes.

Heli Paluste, Head of the Health Care Unit of the Ministry of Social Affairs

We are aware that the judicial area regulating gender recognition and the composition of the medical assessment committee (MAC) operating on the basis thereof have remained unchanged for a long time. We also understand the emotions of those who are personally affected.

Therefore, changes to the MAC’s composition and the regulation along with the new Public Health Act package are on the agenda.

When approving the composition of the new MAC with the minister’s directive, we wish to adopt the modern approach, and the new committee will have wider representation both with regard to the number of members and their professions, encompassing clinical psychologists in addition to medical professionals, among others. Our goal is to give the committee a more guiding and supporting role in the future.

With regard to the rules of procedure, it will be possible to hold committee meetings in Tallinn and Tartu (at West Tallinn Central Hospital or Tartu University Hospital, respectively).

The updated rules of procedure also include the MAC’s annual reports to the ministry, which was indeed missing in the old directive.

The minister will likely sign the MAC directive in the coming weeks and the committee will be able to start working before autumn.

We will finalise a new implementing regulation that uses the renewed terminology of the field and updates and simplifies the bureaucratic process in autumn when the procedures for the adoption of a new Public Health Act are taken over by the parliament. We have discussed the draft of the implementing act, which accompanies the explanatory memorandum to the bill, with the parties, but it will definitely be specified. The renewed MAC will certainly be able to contribute on the basis of its first experiences.