Diagnosis as denunciation: Kremlin meddling in doctor-patient confidentiality has a long history

RU

Soviet doctors against abortion in the 1930s–1940s

In the USSR, doctors worked closely with the authorities starting from the Stalin era. In 1936, the Soviet government, aiming to boost birth rates, passed a law completely banning abortion, which predictably led to a rise in underground procedures. Women who suffered complications from failed illegal abortions sought medical help, leaving doctors to decide whether to report these “criminals” to the NKVD. At times, doctors were even more zealous about informing on patients than prosecutors expected.

Strangely enough, the authorities showed little interest in investigating abortion cases. In 1943, at the height of the Great Patriotic War, a female employee of the People's Commissariat of Health at a departmental meeting harshly criticized the prosecution service for its “weak efforts”:

“I fully confirm that the prosecution authorities have weakened their work in the fight against abortions… In 1940, there was a special prosecutor assigned specifically to abortion cases. We used to go out into the field together with prosecutors, inspecting the work of judicial and investigative bodies as well as healthcare institutions… Now all of this has become a thing of the past.

I can cite numerous examples of cases the prosecution simply ignores. Out of 242 cases in Moscow, the outcomes of 187 remain completely unknown. Moreover, the prosecution does not even consider it necessary to respond to our institutions’ inquiries about the fate of the cases we submitted.”

Responding to the criticism, a prosecution official present at the meeting, Comrade Levi, attempted to explain why prosecutors were not initiating a “sufficient” number of cases against abortion:

“The fact is, not every out-of-hospital abortion is a criminal act. You can’t prosecute a woman simply because she had an abortion! You’d be the first to scream in protest if we clogged the courts with such cases! We require doctors to submit cases to the prosecution only when there are clear grounds for pressing charges. Do they do this? No, they don’t. Why? I must say that the main and fundamental reason is that, in the minds of the population — including judicial and investigative workers themselves — abortion is not considered a crime. I even had a case where a prosecutor came to me asking if I could perform an abortion for his wife.”

Collaboration between doctors and Soviet authorities on abortion cases came to an end in 1955 when Nikita Khrushchev’s government lifted the ban.

Venereal diseases in the 1960s: doctors join forces with the state yet again

In the early 1960s, the Soviet Union experienced an outbreak of venereal diseases that spread across multiple republics. Doctors attempted to contain the situation but lacked sufficient resources. As a result, they turned to the police and state security organizations for assistance.

In Kyiv, the doctors' decision to cooperate with law enforcement was made in December 1960 at a city committee meeting attended by the local prosecutor and the head of the police department. Archival documents indicate that within a year, the police and prosecutors had “brought to justice 23 patients leading an immoral lifestyle.” In 1962, authorities forcibly subjected “42 patients and 10 sources of infection” to treatment. A total of 144 people suspected of “immoral behavior” and “operating brothels” were expelled from the city.

Kyiv’s doctors and police did not stop there. In 1964, dermatology and venereology clinics began submitting to the police monthly lists of those who were “unemployed, led a promiscuous sex life, and posed a constant source of infection.” A total of 235 “undesirables” were identified, more than 30 of whom were convicted and expelled from Kyiv.

Doctors and law enforcement collaborated in the fight against venereal diseases in other places as well. In the Odesa region, venereologists and police officers conducted joint raids on known gathering places of sex workers. Medical officials emphasized the “benefits” of such operations:

“It is important to note the usefulness of raids conducted by the police in cooperation with dermatology and venereology clinics. These raids are carefully planned in advance, with locations frequented by women of loose morals and homosexuals being identified and studied… As a result of multiple raids, police detained and subjected 834 women of immoral behavior to medical examinations, of whom 576 — 70% of those examined — were found to have venereal diseases.”

A report from the Kaliningrad Regional Ministry of Health stated that “in 24 out of 34 cases, syphilis infection occurred through homosexual contacts.” In response, the region established a special commission consisting of prosecutors and local venereology clinic doctors. The commission compiled lists of homosexual people for “periodic monitoring”:

“Between 1962 and 1963, up to 40 homosexuals, including those with syphilis, were convicted under Article 121 of the Criminal Code for sodomy. Later, an even larger group of pederasts was identified, and their names were handed over to the criminal investigation department of the OKVD [Regional Dermatological and Venereal Disease Clinic] for periodic monitoring, both clinical and serological. Among them were doctors, paramedics, school principals, sailors, and actors.”

Doctors, police, and homosexuality in the 1970s

The Soviet medical and law enforcement systems worked especially closely in the fight against “sodomy.” In 1970, an employee of the Moscow Bureau of Forensic Medicine, Ivan Blyumin, wrote an entire dissertation on how to identify signs of sexual intercourse between men based on their genitalia. The police eagerly supplied him with “criminals,” and Blyumin eagerly examined them. However, he ultimately failed to provide the Ministry of Internal Affairs with concrete guidelines for detecting “sodomy,” limiting himself to general recommendations.

Meanwhile, the police were in desperate need of clear instructions on how to catch homosexuals. The Soviet regime was moving away from Stalinist practices of issuing guilty verdicts without substantial evidence, and the role of so-called “socialist legality” was growing. Convictions required solid proof. However, authors of investigative manuals on “sexual crimes” openly admitted that gathering proof in such cases was nearly impossible:

“For consensual sodomy, both parties bear criminal responsibility, meaning they strive to conceal their crime and typically provide no testimony that could aid in its investigation. Witnesses to such crimes are extremely rare. As a result, investigations of these offenses must primarily rely on indirect evidence.”

Despite the obstacles, the number of criminal cases for “sodomy” in the USSR surged dramatically starting from the late 1960s. It is known that in 1979, the Ministry of Internal Affairs instructed psychiatrists to “develop methods for identifying individuals with various forms of homosexuality.” However, it is possible that guidelines with more “advanced” tactics for catching homosexuals — beyond mere surveillance and infiltration of their gathering places — had emerged even earlier.

Not all psychiatrists worked with the police. Some doctors in the USSR treated homosexual patients without informing the authorities. One such physician was Jan Goland, a psychiatrist from Gorky.

Goland was not just a psychiatrist, but also a specialist in sexology. Moreover, he focused on psychotherapy for homosexuality. Unlike other Soviet doctors, who attempted to “treat” homosexuality with neuroleptics, Goland believed that psychotherapy alone was sufficient to help patients “acquire” heterosexuality.

Throughout the 1960s and 1970s, homosexual men from across the Soviet Union traveled to Gorky to undergo Goland’s treatment. He never forced hospitalization on his patients and was highly selective in choosing candidates for therapy. Each patient was asked the same question: “If tomorrow the USSR announces that homosexuality (Goland used the term “homosexualism”) is no longer a crime, would you still want to continue treatment?” If the person answered no, Goland refused to treat them.

Goland believed this approach reduced the likelihood of “relapses” among his patients and could help avoid trouble with the police. After all, law enforcement might have had questions about him too — who were these men in his office, and what were these sexology books on his desk? Goland feared that such materials could be classified as pornography.

Goland did everything possible to maintain the confidentiality of his patients. He asked them not to provide any personal information and to use fictitious names that he invented for them. Officially, he treated homosexual patients for “neurosis,” which provided an additional layer of protection. However, despite his concern for patient confidentiality, undergoing “treatment” with Goland still caused serious psychological suffering. One of his patients described his experience in a diary:

“Last night was terrible. I went to bed early, exhausted from my latest failed attempts at autogenic training, and woke up in the middle of the night from an intense homosexual dream…then I couldn't fall asleep for a long time. Thoughts of Orenburg kept running through my head — I remembered at least five people with whom I had once had a sexual relationship. I tried in vain to push these thoughts away and sleep. I must say, everything in my head is completely tangled. It seems there is a life-or-death struggle between my homosexual and heterosexual tendencies, but for now, the former is winning.”

It wasn't just well-known doctors like Goland who showed at least some modicum of understanding toward patients with this “delicate” diagnosis. One young man recalled how, in a moment of desperation, he “confessed” to a dermatologist-venereologist, who, to his surprise, did not report him to the police but instead offered advice on how to “cure” himself:

“There was a doctor at the dermatological and venereal disease center to whom I, in a moment of unusual despair, opened up. He told me that in the Netherlands, there was some kind of chemotherapy drug — he called it Uradil or something like that. I believe in medical science, and despite what people sometimes say about doctors, I think that if a doctor takes on a patient, their experience and medications will make anyone healthy.

…I was intrigued by a short article in Science and Technology, which mentioned that in the Federal Republic of Germany, if I remember correctly, they treated 100 sexual addicts — which I also consider myself to be. They treated them with drugs, chemically shutting down their sexual function while simultaneously trying to retrain them. I believe the success rate of such treatment was 90%.”

However, such cases were exceptions to the general practice of doctors cooperating with the state. After all, sexology was a branch of psychiatry, and in the 1960s and 1970s, psychiatrists actively assisted the authorities in suppressing dissidents and other ideological opponents.

Soviet citizens who actively opposed the regime were given unfounded diagnoses such as “sluggish schizophrenia” before being subjected to forced hospitalization. Moreover, some psychiatrists working at the infamous Serbsky Institute held various ranks within the state security agencies.

For example, Professor Daniil Lunts was both a psychiatrist and a KGB colonel. One of his “patients,” Pyotr Grigorenko, a former Soviet general who later became a dissident, recalled his forced treatment as follows:

“I saw with my own eyes how Professor Lunts came to work in a KGB colonel's uniform. However, he always entered the ward wearing a white coat. I also saw other doctors from this institute in KGB uniforms.”

Medical confidentiality during the HIV epidemic in the USSR in the late 1980s

In the early 1980s, the global press began reporting on a new and unknown disease that would later be called HIV/AIDS. Initially, the Soviet leadership was not particularly concerned, believing the illness threatened only sex workers, homosexuals, and drug addicts — but not “normal people.”

In reality, the HIV/AIDS epidemic in the USSR emerged in an entirely unexpected place: children’s hospitals, where doctors, unaware of the risks, spread the infection through unsterilized medical equipment. Fear of contracting AIDS turned into a nationwide paranoia, affecting even the medical community. Many doctors failed to maintain the confidentiality of their already frightened and demoralized patients. At that time, the disclosure of such a sensitive diagnosis could turn a person's life into a nightmare.

Some doctors, likely out of a sense of “professional duty,” shared their patients' diagnoses with the police — especially if the patients belonged to the so-called “risk group.” A 33-year-old sex worker named Irina told a Nedelya newspaper correspondent how doctors immediately informed local law enforcement about her HIV diagnosis, and how it affected her life:

“The head of the district clinic — that witch — first of all notified the police about my illness. The local officer, in turn, went around to all my neighbors and warned them. Of course, I was fired — I used to work as a cook. Now I’m as popular in town as a movie star. Everyone knows my name. At first, I was too scared to leave the house. I hid. My son is being bullied at school by his classmates… The teachers demand that he bring medical certificates every month. How many tests can a child take — he’s perfectly healthy!

My loved ones suffer too. For example, my sister-in-law recently went to a gynecologist, and the doctor bluntly asked her, ‘Are you related to [name]?’ And then refused to examine her. I don’t even want to talk about the doctors. They act like cowards, like traitors. Once, I went to a general practitioner, and she was too scared to even check my blood pressure or listen to my heart — just waiting for me to leave as soon as possible. Or when I had a toothache — whichever dentist I told that I had AIDS, they all kicked me out. I suffered for two weeks, and then I just kept quiet about it. What else was I supposed to do? I won’t confess again. I’ve had enough.”

Alexander, a 35-year-old drug user, recalled that his hospitalization for HIV came with a full escort:

“I’m from a village. They took me to the hospital with a whole convoy — the local officer, the collective farm chairman, and workers from the sanitary-epidemiological service. Five people in total! They must have thought I’d run away. On the way, they interrogated me: where, with whom, and how?”

Homosexual men undergoing symptomatic treatment for HIV also braced themselves for the likelihood that their doctors would not keep their diagnoses secret. Maxim, a 30-year-old gay man preparing to be discharged from a Moscow hospital specializing in HIV treatment, openly admitted his fears:

“I’m getting discharged in a few days, and I can already imagine what awaits me. I’ve heard enough stories from others in my ward. The doctors at the district clinic will definitely make sure to inform my workplace, my parents — all the details about my illness. I feel bad for my parents — it’ll be a shock for them. Basically, life will be hell.

I’ve made up my mind: I’m going to demand that my doctor sign a paper promising confidentiality, and I’ll warn him: if he blabs, I’ll kill him! I have nothing to lose, I’m doomed.”

By the late 1980s, the perestroika-era press had begun to widely address the various flaws in Soviet life. One such issue was the violation of medical confidentiality. A correspondent for the Sovetskaya Rossiya newspaper noted that breaches of patient confidentiality by doctors were a pervasive phenomenon in the USSR:

“Medical confidentiality is one of the most fundamental ethical principles — one could say, the cornerstone of the medical profession. Yet how frequently it is violated. And not even for personal gain, but simply out of habit, casually… Of course, it was standard practice not to record certain diagnoses on sick leave forms, especially if the illness was of a sensitive nature. But not writing it down is merely a way of avoiding written evidence that you, as a doctor, disclosed a medical secret. Actually keeping that secret is something else entirely. The importance of this ethical rule must be understood so profoundly that no doctor would make a distinction between what can be discussed — because it's a ‘trivial’ illness — and what must remain secret — because it's ‘serious.’”

In the context of the established Soviet practice of cooperation between the healthcare system and the regime, Putin’s amendments granting law enforcement agencies access to data on “dangerous” patients hardly seem like an innovation. There are unlikely to be significant obstacles in the exchange of information between doctors and security agencies. In modern Russia, where the persecution of LGBT people is a key component of state ideology — alongside calls for high birth rates and abortion bans — such cooperation seems likely to succeed.

That said, it would be inaccurate to claim that the sharing of patient data between doctors and law enforcement will be universal. It won’t be. Just as in the Soviet healthcare system, many ethical professionals in Russia will remain steadfast in their commitment to medical confidentiality. Ultimately, a patient’s privacy will depend on the integrity of each individual doctor and their level of support for the current policies of the Russian regime.