A sweeping Russian draft law to ban legally or medically changing gender was approved by the lower house of parliament on Friday in its final reading, part of a crackdown against LGBT rights under President Vladimir Putin.

The bill would bar Russians from changing their gender on official identity documents, which had been legal since 1997. Health workers would be banned from “performing medical interventions designed to change the sex of a person”, including surgery and prescribing hormone therapy.

State Duma deputies added provisions to the bill in its second reading, approved on Thursday, to ban transgender people from adopting or fostering children, and to annul their marriages if one of the couple subsequently changes gender.

The green light from the Duma all but guarantees the bill’s ultimate passage into law.

Doctors and transgender rights advocates, have warned that the ban would create a black market for hormone substitutes and lead to a spike in attempted suicides among young people unable to access medical care.

“For children and teenagers this situation looks like absolute hopelessness,” Elle Solomina, a Russian transgender woman now living in Georgia, told Reuters before the Duma resumed consideration of the bill this week. “They will not be able to get any help.”

The ban marks the latest phase in a rollback of rights for gay and transgender people in Russia. Putin has repeatedly said that LGBT lifestyles run counter to traditional Russian values, and the West’s acceptance of them is evidence of moral decay.

Last December Putin signed a law expanding restrictions on the promotion of “LGBT propaganda,” effectively banning any public expression of queer life, in public and online, or in films, books or advertising.

Duma speaker Vyacheslav Volodin called gender-affirming surgery a “path to the degeneration of the nation,” writing on the Telegram messenger app on Friday that the law “protects our citizens (and) children.”

Bills must pass three readings in the State Duma lower house of parliament before being sent to the upper house and then to Putin for signing.