Discrimination, stigma and mental health: what's next?

Stigma and discrimination are a major ongoing problem in the field of mental health as these impact on patient outcomes, access to and acceptability of therapeutic interventions, their quality of life, general wellbeing, social inclusion and opportunities. Social stereotypes, culture and prejudices all contribute to continuing discrimination in mental health. Different settings where people function may also be sources of discrimination such as work and educational environments. The lack of knowledge and understanding of mental health/illness by individuals, their families, carers and policymakers as well as the social media reporting also impact on social attitudes to discrimination. It has been also described a relevant impact of stigma among specific social minorities reporting poor mental health such as elderly people, youths, sexual variants, persons with disability. Educational programs, raising awareness trainings and proper public policies may be developed in order to reduce stigma at social level with favourable outcomes for people with mental illness.

Violência por parceiro íntimo entre homens que se relacionam com homens / Intimate partner violence among men who relate with men / Violencia de pareja íntima entre hombres que tienen relaciones con hombres

A violência por parceiro íntimo (VPI) consiste em atos que ameacem causar ou efetivamente causem danos em um parceiro dentro de uma relação afetivo-sexual, independente da configuração ou tempo do relacionamento ou de haver coabitação ou não entre as partes. Nas relações homossexuais, a VPI é invisibilizada de diversas maneiras, mesmo sendo reconhecida como uma grave violação de direitos humanos. O estudo objetivou compreender os significados da VPI para um grupo de homens que se relacionam com homens (HRH). Participaram da pesquisa oito HRH, selecionados através da técnica "bola de neve", utilizada devido à sensibilidade do tema, considerando os estigmas de ser HRH. Os dados foram obtidos através de entrevista semiestruturada e foram analisados pela Análise Temática. Como resultados, foram construídas seis categorias: 1º) O armário; 2º) Homofobia 3º) Racismo, poder e vulnerabilidade a VPI; 4º) Sexualidade; 5º) Infidelidade; 6º) HIV, que discutem a interseccionalidade de diversas formas de opressão na produção de VPI entre HRH. Conclui-se que a VPI vivenciada por esse grupo é influenciada por diversos fatores que envolvem a interseccionalidade de vários marcadores sociais, como os estereótipos de masculinidade em relação a hipersexualização e infidelidade, a homofobia como fator direto do estresse minoritário, o racismo que hierarquiza os corpos e invisibiliza o afeto de homens negros, e o estigma de HIV no imaginário social.(AU)

Intimate partner violence (IPV) consists of acts that threaten to harm or actually harm to a partner within an affective-sexual relationship, regardless of the configuration or duration of the relationship or whether or not there is cohabitation between the parties. In homosexual relationships, IPV is made invisible in several ways, even though it is recognized as a serious violation of human rights. The study aimed to understand the meanings of IPV for a group of men in same sex relationships (MSSR). Eight MSSR participated in the research, selected by snowball sampling, used due to the topic's sensitivity, considering the stigmas involved in being MSSR. Data were constructed via semi-structured interviews and analyzed using Thematic Analysis. As a result, six categories were constructed: 1) The closet persons; 2) Homophobia; 3) Racism, power, and vulnerability to IPV; 4) Sexuality; 5) Infidelity; 6) HIV, which discuss the intersectionality of various forms of oppression in the production of IPV among MSSR. Thus, the IPV experienced by this group is influenced by several factors that involve the intersectionality between different social markers, such as stereotypes of masculinity in relation to hypersexualization and infidelity, homophobia as a direct factor of minority stress, the racism that hierarchizes bodies and makes the affection of Black men and the stigma of HIV invisible in the social imaginary.(AU)

La violencia de pareja (VP) consiste en actos que amenazan con causar o de hecho causan daño a una pareja dentro de una relación afectivo-sexual, independientemente de la configuración o duración de la relación o de si existe o no cohabitación entre las partes. En las relaciones homosexuales, la VP se invisibiliza de varias formas, a pesar de que se reconoce como una grave violación de los derechos humanos. Este estudio tuvo como objetivo comprender los significados de VP para un grupo de hombres que se relacionan con hombres (HRH). Ocho HRH participaron de la investigación, seleccionados mediante la técnica de "bola de nieve", utilizada debido a la sensibilidad del tema, considerando los estigmas de ser HRH. Los datos se construyeron mediante entrevistas semiestructuradas y se sometieron a análisis temático. Como resultado se construyeron seis categorías: 1.ª) El armario; 2.º) Homofobia; 3.º) Racismo, poder y vulnerabilidad a la VP; 4.º) Sexualidad; 5.º) Infidelidad; 6.ª) HIV; que discuten la interseccionalidad de diferentes formas de opresión en la producción de VP entre HRH. Se concluye que la VP vivida por este grupo está influida por varios factores que involucran la interseccionalidad entre distintos marcadores sociales, como los estereotipos de masculinidad en relación con la hipersexualización y la infidelidad, la homofobia como factor directo de estrés minoritario, el racismo que jerarquiza cuerpos e invisibiliza en el imaginario social el afecto de los hombres negros y el estigma del HIV en el imaginario social.(AU)

Um capítulo esquecido na história da psicologia? sexualidades desviantes, psicopatologia e normalidade / A forgotten chapter in the history of psychology? deviant sexualities, psychopathology, and normality / ¿Un capítulo olvidado en la historia de la psicología? sexualidades desviadas, psicopatología y normalidad

Este artigo tem como objetivo produzir uma análise histórica sobre as intersecções entre Psicologia e sexualidade desviantes da norma no Brasil, de fins do século XIX a meados da década de 1980. Esta temporalidade foi escolhida por abarcar o surgimento das pesquisas científicas sobre sexualidade e desvios sexuais, a consolidação dos estudos psicológicos sobre a temática e o processo mais recente de despatologização da homossexualidade. Em termos teóricos e metodológicos, foram adotados os pressupostos da História Social da Psicologia e da historiografia das homossexualidades no Brasil. Desse modo, buscou-se compreender como as ideias, concepções e práticas psicológicas foram mudando ao longo do tempo, em conexão com as transformações socioculturais e políticas que ocorreram durante o século XX. Para isto, foram utilizadas fontes primárias e secundárias de pesquisa com vistas à produção de interpretações sobre as conexões entre as ideias, os atores e os eventos narrados. Argumenta-se, ao longo do artigo, que as ideias e práticas psicológicas estão intrinsecamente conectadas aos contextos socioculturais e políticos de seu tempo, sendo os movimentos dinâmicos e os conflitos presentes nesses contextos fatores determinantes para a sua constituição.(AU)

This article aims to produce a historical analysis of the intersections between Psychology and sexualities that deviate from the norm in Brazil, from the late 19th century to the mid-1980s. This period was chosen because it encompasses the emergence of scientific research on sexuality and sexual deviations, the consolidation of psychological studies on the subject and the most recent process of de-pathologization of homosexuality. Theoretically and methodologically, the assumptions of the Social History of Psychology and the historiography of homosexualities in Brazil were adopted. Therefore, we sought to understand how psychological ideas, conceptions and practices have changed over time, in connection with the sociocultural and political transformations that occurred throughout the 20th century. For this, primary and secondary sources of research were used to produce interpretations about the connections between the ideas, the actors and the narrated events. It is argued, throughout the article, that the psychological ideas and practices are intrinsically connected to the sociocultural and political contexts of their time, being the dynamic movements and conflicts present in these contexts determining factors for their constitution.(AU)

Este artículo tiene como objetivo realizar un análisis histórico de las intersecciones entre la Psicología y las sexualidades desviadas de la norma en Brasil desde finales del siglo XIX hasta mediados de la década de 1980. Esta temporalidad fue elegida por abarcar el surgimiento de las investigaciones científicas sobre sexualidad y desvíos sexuales, la consolidación de los estudios psicológicos sobre el tema y el más reciente proceso de despatologización de la homosexualidad. En el marco teórico y metodológico, se adoptaron los presupuestos de la Historia Social de la Psicología y de la historiografía de las homosexualidades en Brasil. De esta manera, se pretende comprender cómo las ideas, concepciones y prácticas psicológicas han cambiado a lo largo del tiempo, en conexión con las transformaciones socioculturales y políticas ocurridas durante el siglo XX. Para ello, se utilizaron las fuentes de investigación primarias y secundarias con miras a generar interpretaciones sobre las conexiones entre las ideas, los actores y los eventos narrados. Se argumenta, a lo largo de este artículo, que las ideas y las prácticas psicológicas están intrínsecamente conectadas a los contextos socioculturales y políticos de su tiempo, y los movimientos dinámicos y los conflictos presentes en estos contextos fueron los factores determinantes para su constitución.(AU)

Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review.

Sexual delinquency is a global problem where those with paraphilic disorders, such as paedophiles, are more likely to commit and reoffend. Androgen deprivation therapy (ADT) has been suggested as a solution. The objective of this narrative review is to present current information on its risks, benefits and limitations as a treatment for paraphilias. The importance of testosterone in sexual function, the effect of its deficiency by age or by pharmacological treatment (anti-androgens, GnRH agonists and GnRH antagonists) and the effect of testosterone replacement therapy will be reviewed. The relationship between androgens, brain, sexual behaviour and pathophysiology of paraphilic disorders will also be explored. ADT reduces sexual urges, but has adverse effects and, because its reversible nature, it does not ensure less recidivism. Likewise, the research quality of ADT drugs is limited and not enough to support their use. Child sex offenders, and not paraphilic subjects who have not committed assaults, show signs of elevated prenatal exposure to androgens and a higher methylation state of the androgen receptor gene. Sexual behaviour is regulated by subcortical (hypothalamus, brainstem and spinal cord) and cortical structures of the brain, in addition to brain circuits (dopaminergic, serotonergic). Those with paraphilic disorders show abnormalities at these levels that could relate to the risk of sexual offences. In conclusion, androgens represent a significant part of the pathophysiology of paraphilias and therefore, ADT seems promising. Nonetheless, more studies are needed to make definite conclusions about the efficacy of long-term ADT in paraphilic patients.

Os árbitros do desejo e os enteados da natureza: controvérsias e ontologias sobre a categoria pedofilia em torno do DSM - 5 / The arbiters of desire and the stepchildren of nature: controversies and ontologies on the category pedophilia around the DSM - 5

Pedofilia é categoria originada na psiquiatria do final do século XIX para descrever uma espécie das denominadas perversões ou desvios sexuais, hoje parafilias, que conceitua a atração sexual de adultos por crianças pré-púberes. Tornou-se objeto de proibição e punição legal, ligada à categoria "abuso sexual infantil", e de repúdio social extremo, que configurou um dos pânicos morais/sexuais a partir das últimas décadas do século XX, no Brasil a partir do início dos anos 2000. No entanto, é notável constatar que a categoria, suas definições e características e as práticas científicas e políticas decorrentes (de pesquisa, terapêuticas, jurídicas) são objeto de uma ampla literatura e intensas controvérsias acadêmicas, clínicas e forenses em muitos países centrais da Europa e América do Norte. A tese visa delinear controvérsias recentes sobre o diagnóstico psiquiátrico "pedofilia" em torno da revisão do Diagnostic and Statistic Manual of Mental Disorders ­ DSM (Manual Diagnóstico e Estatístico de Transtornos Mentais) ­, da American Psychiatric Association, para a formulação do DSM-5, publicado em 2013, através de uma amostra de artigos de autores presentes nas propostas de revisão do diagnóstico, que expressam epistemologias, ontologias e deontologias diversas e em confronto. Os temas das controvérsias analisadas são a mudança do diagnóstico para "pedohebefilia", a permanência ou remoção das parafilias e da pedofilia do Manual e sua natureza enquanto "orientação", "interesse" ou "preferência" sexual. As vozes presentes nas controvérsias incluem psiquiatras, sexólogos, psicólogos, historiadores e uma organização de "pessoas atraídas por menores" (MAPs), nova designação utilizada por uma vertente do ativismo pedófilo. O delineamento das controvérsias é feito a partir de seus enquadramentos institucionais, políticos, morais, éticos e clínicos, configurando disputas significativas nestas posições e um consenso em torno do "combate" e prevenção ao abuso sexual infantil, categoria forte na quase totalidade das formulações. Apesar disso, há um dissenso ideológico e político sobre se a psiquiatria deve ser um enquadramento deste crime, se este não é, de fato, problema jurídico e penal e não médico, numa crítica à extensão das entidades diagnósticas para fins morais e políticos de contemplar a opinião pública e o aparato judicial. A psiquiatria forense é campo prevalente e determinante, embora não único, da permanência da categoria enquanto diagnóstico médico. Por outro lado, são abordadas as lutas, presentes nas controvérsias e no ativismo, pela desestigmatização desta condição da sexualidade, sua distinção da violência sexual e pelo estabelecimento de cidadania plena para os MAPs, que inclui o respeito de seus direitos no atendimento em serviços de saúde mental.

Pedophilia is a category originated in psychiatry in the late 19th century to describe a species of the so-called sexual perversions or deviations, nowdays paraphilias, which conceptualizes the sexual attraction by adults of pre-pubertal children. It turned the object of legal prohibition and punition, linked to the category of "child sexual abuse", and of extreme social rejection, that shaped one of the moral/sexual panics since the last decades of the 20th century, in Brasil since the early 2000 years. Nevertheless, it's noticeable to verify that the category, its definitions and features, and the scientific and political ensuing practices (of research, therapeutic, legal) are the object of a large literature and intense academic, clinical and forensic controversies in many central countries of Europe and North America. The thesis intends to outline recent controversies on the psychiatric diagnosis "pedophilia" around the revision of the Diagnostic and Statistic Manual of Mental Disorders ­ DSM - of the American Psychiatric Association and the elaboration of the DSM-5, published in 2013, through a sample of papers of acting authors in the proposals of the revision of the diagnosis, which express various epistemologies, ontologies and deontologies in dispute. The themes of the controversies under analysis are the change of the diagnosis to "pedohebephilia", the tenure or removal of paraphilias and pedophilia from the Manual and its nature as a sexual "orientation", "interest" or "preference". The figuring voices in the controversies include psychiatrists, sexologists, psychologists, historians and an organization of "minor-attracted people" (MAPs), new designation used by a branch of the pedophile activism. The delineation of the controversies is made through their institutional, political, moral, ethical and clinical frames, outlining noteworthy disputes in these positions and a consensus around the "combat" and prevention of child sexual abuse, strong category in almost the whole of the formulations. In spite of this, there is an ideological and political dissent on if psychiatry should be a frame to handle a crime, if this one is a juridical and penal problem and not a medical one, in a criticism of the extension of diagnostic entities for moral and political ends to comply with public opinion and the apparatus of Justice. Forensic psychiatry is a prevailing and decisive field, though not the only one, in the maintenance of the category as a medical diagnosis. On the other hand, the struggles, active in the controversies and activism, over the de-stigmatization of this condition of sexuality, its distinction from sexual violence and for the establishment of a full citinzenship for MAPs, including the respect of their rights of assistance in mental health services, are addressed.

A neurose como negativo da perversão: um estudo das perversões em Freud / Neurosis as negative of perversion: a study of perversions in Freud / La neurosis como negativa de la perversión: un estudio de las perversiones en Freud

Resumo Com base na afirmação freudiana de que a neurose seria o negativo da perversão, pretende-se trazer de volta ao contexto acadêmico essa entidade nosológica que paga um preço alto devido ao nome que carrega. O texto se propõe a discutir a perversão no decorrer da obra freudiana, além de desmistificar detalhes da dinâmica perversa, pouco explorada atualmente. Também são abordados os textos de Lacan, em que o psicanalista francês critica a proposta freudiana com outra expressão famosa no meio psicanalítico: a do Inconsciente a céu aberto. Realizou-se uma pesquisa minuciosa em textos nos quais as expressões freudiana e lacaniana surgem, atentando-se para a terminologia original proposta por esses autores. Isto posto e tomando como base a afirmação freudiana, verificou-se a existência de perversões negativas, constituídas por fantasias de conteúdos perversos por vezes causadoras de sintomas neuróticos, em oposição às perversões positivas - ou seja, quando essas fantasias são colocadas em prática sem a presença de sentimentos de asco, vergonha ou pudor. Buscou-se, portanto, entender a dinâmica das perversões em Freud, assim como compreender os critérios delimitadores entre traços perversos e perversões propriamente ditas que ganharam um status clínico ao decorrer de sua obra, servindo de base para o desenvolvimento das demais teorias a respeito do tema em questão.(AU)

Abstract From the Freudian claim that neurosis would be the negative of perversion, this article seeks to bring back to the academic context this nosological entity that pays such a high price because of its name. This article seeks to discuss perversion in the course of Freud's work, besides demystifying details of the perverse dynamics, little explored at present. Moreover, the texts of Lacan will be approached, from which the French psychoanalyst criticizes the Freudian proposal with another famous expression in the psychoanalytic environment: the unconscious in the open. A detailed research was conducted in texts in which the Freudian and Lacanian expressions appear, paying attention to the original terminology proposed by these authors. Having said this, and based on the Freudian assertion, negative perversions were constituted by fantasies of perverse contents, sometimes causing neurotic symptoms, as opposed to positive perversions, that is, when these fantasies are put into practice without the presence of feelings of disgust, shame or indecency. It was sought, therefore, to understand the dynamics of the perversions in Freud and understand the delimitating criteria between perverse traits and actual perversions, which gained a clinical status in the course of his work, serving as base for the development of other theories in respect theme.(AU)

Resumen Con base en la afirmación freudiana de que la neurosis sería lo negativo de la perversión, se pretende traer de vuelta al contexto académico esta entidad nosológica que tiene grandes consecuencias debido al nombre que lleva. El presente artículo intenta discutir la perversión en la obra freudiana, además de desmitificar detalles de la dinámica perversa, poco explorada actualmente. También se abordarán los textos de Lacan que hace críticas a la propuesta freudiana mediante otra expresión famosa en el medio psicoanalítico: la del Inconsciente a cielo abierto. Se realizó una investigación minuciosa en textos de ambos autores en que aparece la expresión, atentándose a la terminología original propuesta por ellos. Dicho esto, y con base en la afirmación freudiana, se encontraron perversiones negativas, constituidas por fantasías de contenido perverso por veces causando síntomas neuróticos, en contraposición a perversiones positivas, es decir, cuando estas fantasías se ponen en práctica sin la presencia de sentimientos de disgusto, vergüenza o pudor. Se buscó entender la dinámica de las perversiones en Freud, así como comprender los criterios delimitadores entre trazos perversos y perversiones propiamente dichas, que ganaron un status clínico en el curso de su obra, sirviendo de base para el desarrollo de otras teorías al respecto del tema en cuestión.(AU)

Profile of patients with penile cancer in the region with the highest worldwide incidence.

To determine the epidemiological, histopathological, and clinical characteristics of patients diagnosed with penile cancer in the Brazilian state of Maranhão, the region with the highest incidence worldwide. One hundred and sixteen penile cancer patients were interviewed from July 2016 to October 2018. The majority of patients lived in a rural area (57%), worked in farming (58%), had a low level of schooling or no schooling (90%), and were married or in a stable relationship (74%). The mean age was 60.4 ± 16.51 years (range, 23-93 years). Phimosis (66%), poor/moderate genital hygiene (73%), history of sexually transmitted infections (55%), and zoophilia (60%) were found in the majority of patients. Most patients had their first sexual encounter at 16.2 ± 2.8 years (range, 10-25 years), and 75% had >6 sexual partners. The most common initial symptom was pruritus (37%), and most patients waited to seek treatment (average time to treatment, 18.9 months; range, 2-84 months). Human papillomavirus (HPV)-related histologies were observed in 62% of patients. Most patients had histological grades II or III (87%), stage ≥T2 disease (84%), and lymphadenopathy at admission (42%). Penectomy was performed in 96% of patients. The population with penile cancer in the region of highest incidence in the world is marked by low socioeconomic status, high prevalence of HPV infection, and phimosis. The delay in seeking treatment is related to a very high rate of advanced cancer and aggressive surgical treatment. The high prevalence of young patients was also a striking feature.

Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders.

INTRODUCTION: The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress. AIM: To analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico. METHODS: An expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO. MAIN OUTCOME MEASURES: The WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues. RESULTS: A variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence. CLINICAL IMPLICATIONS: Evaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation. STRENGTHS & LIMITATIONS: Major strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states. CONCLUSION: The descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required. Martínez-López JNI, Robles R, Fresán A, et al. Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders. J Sex Med 2019;16:1623-1637.

Forensic Implications of the New Classification of ICD-11 Paraphilic Disorders in Brazil.

INTRODUCTION: The World Health Organization (WHO) Department of Mental Health and Substance Abuse appointed a Working Group on Sexual Disorders and Sexual Health in order to revise and propose changes to ICD-10 categories. AIM: Analyze ethical and legal implications in Brazil of the proposed ICD-11 diagnostic criteria for paraphilic disorders. METHODS: A forensic working group of Brazilian experts in collaboration with representatives of WHO reviewed the proposed modifications to the classification of Disorders of Sexual Preference in ICD-10 (F65), which is recommended to be replaced by Paraphilic Disorders in ICD-11. Proposals were reviewed through a medicolegal lens, using a legal and policy analysis guide put forth by WHO. The premise of this review was to understand that, although the ICD classification is intended to provide a basis for clinical and statistical health interventions, medical diagnostics may also be entangled in the complex legal, normative, and political environment of various countries. MAIN OUTCOME MEASURE: The most important proposed change to this section is to limit the concept of paraphilic disorders primarily to patterns of sexual arousal involving a focus on others who are unwilling or unable to consent, but this change has not affected the ethical and legal aspects of psychiatric functioning in the Brazil. RESULTS: Because Brazilian criminal law is directed toward criminal behavior and not to specific psychiatric diagnoses, the changes proposed for ICD-11 are not expected to create obstacles to health services or to modify criminal sentencing. CLINICAL IMPLICATIONS: Although ICD-11 has a number of changes in its content, there are no significant clinical implications in the Brazilian context, but a better clarity of conceptual definitions and diagnostic criteria. STRENGTHS & LIMITATIONS: The study is conducted with people from different Brazilian states, which is important for a comprehensive view. On the other hand, considering that it is a very heterogeneous country, there is the limitation that an even wider scope of the study is not possible. CONCLUSION: In the Brazilian context, the new guidelines for paraphilic disorders contribute to clinical utility and are not expected to create difficulties related to the legal, social, and economic consequences of sexual offenses in the country. Abdalla-Filho E, de Jesus Mari J, Diehl A, et al. Forensic Implications of the New Classification of ICD-11 Paraphilic Disorders in Brazil. J Sex Med 2019; 16:1814-1819.

Transtornos parafílicos: comorbidades e abordagem ética / Paraphilic disorders: comorbidities and ethical approach

As parafilias, antes conhecidas como perversões sexuais, foram, ao longo da história, ora consideradas patologias ora não. Em 2013, o Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-5) estabeleceu a distinção entre parafilias e transtornos parafílicos (TP), a partir da qual somente os últimos passaram a ser considerados doenças e, portanto, passíveis de tratamento. A presença de comorbidades e a farmacologia das medicações utilizadas são de fundamental importância na escolha da abordagem dos TP. Drogas que inibem a atividade sexual (como antidopaminérgicos, serotoninérgicos, antiandrógenos e outras) podem ser prescritas conforme comorbidades sexuais, psiquiátricas ou sistêmicas. Tratar um transtorno exibicionista associado à doença de Wilson e a uma psicose orgânica é diferente de tratar este mesmo TP associado a hipotireoidismo e depressão, por exemplo. É recomendado que o comportamento parafílico seja inibido sem impedir que o sujeito mantenha a função sexual. No entanto, quando o risco de agressão sexual é maior, muitos autores indicam inibição mais intensa, por meio de antiandrógenos potentes, a chamada "castração química", a qual não está autorizada no Brasil.

[Dissident sexualities: an outlook on identity narratives and lifestyle in cyberspace]. / Sexualidades dissidentes: um olhar sobre narrativas identitárias e estilo de vida no ciberespaço.

The subculture of BDSM (Bondage, Discipline, Domination, Submission, Sadism, Masochism) is organized around dissident erotic practices based on consent. Starting with a netnography survey, this study seeks to understand how adepts of BDSM present themselves from the standpoint of identity in cyberspace. In this sense, blogs and sites related to BDSM, as well as social networks, have been observed. Added to this material are interviews of adepts in other media. Techniques of Saturation Sampling and Discourse Analysis were applied. By eroticizing power, they construct erotic games based on hierarchies, where one individual occupies the role of domination and the other of submission. However, beyond a mere sexual role, the adepts argue that both domination and submission are part of their own nature, revealing an essentializing and instituting discourse, which they claim to be a sexual orientation. From specific scenarios, dress and sexual paraphernalia, their practitioners relive their social traumas, particularly those involving gender oppression. In spite of the stigma that is attributed to the subjects involved, their narratives echo from some of the pillars of contemporary subjectivity, such as valuation of experience, of self-development, and of the maximization of pleasure.

A subcultura BDSM (Bondage, Disciplina, Dominação, Submissão, Sadismo, Masoquismo) organiza-se em torno de práticas eróticas dissidentes, pautadas no consentimento. A partir de uma netnografia, este estudo visa apreender como os adeptos de BDSM se apresentam do ponto de vista identitário no ciberespaço. Neste sentido, blogs e sites relacionados ao BDSM foram acompanhados, bem como redes sociais. Somam-se a este material, entrevistas de adeptos em outras mídias. Técnicas de amostragem por saturação e Análise de Discurso foram aplicadas. Ao erotizarem o poder, constroem jogos eróticos pautados em hierarquias, onde um indivíduo ocupa o papel de dominação e o outro, de submissão. Todavia, para além de um mero papel sexual, os adeptos defendem que tanto a dominação quanto a submissão fazem parte de sua própria natureza, revelando um discurso essencializador ou instaurando o que afirmam ser uma orientação sexual. A partir de cenários, vestimentas e apetrechos sexuais específicos, seus praticantes ressignificam traumas sociais, particularmente os que envolvem a opressão de gênero. A despeito do estigma que marca os sujeitos envolvidos, suas narrativas bebem de alguns dos pilares da subjetividade contemporânea, dos quais se destaca, a valorização da experiência, do desenvolvimento de si e da maximização do prazer.

[Review of cases of zoophilia in patients with Parkinson's disease]. / Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.

INTRODUCTION: Parkinson's disease (PD) is characterized by motor symptoms such as bradykinesia, rigidity, alteration of postural reflexes and tremor at rest and other non-motor symptoms such as changes in sleep patterns and sexual behavior. However, little is known about paraphilic sexual behaviors. AIM: To summarize the number of cases of zoophilic behaviors in patients with PD between January 2000 and December 2017. DEVELOPMENT: A review was carried out in PubMed, Scopus and Virtual Health Library. Eleven articles were identified by title; six were excluded because they did not present cases related to zoophilic behavior. We found five cases of men, usually with PD of several years of course, taking dopamine agonists and who presented the zoophilic behaviors followed increasing of the dose. The zoophilic behaviors decreased with reducing doses of dopamine agonists and taking atypical antipsychotic such as clozapine or quetiapine. CONCLUSIONS: It is limited the case reports of zoophilic behaviors in patients with PD. The patients reported are men in whom the dose of dopamine agonists was increased. It is important that the clinical follow-up of patients with PD disease includes a careful review of sexual behaviors including those of the paraphilic spectrum.

TITLE: Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.Introduccion. La enfermedad de Parkinson (EP) se caracteriza por sintomas motores, como bradicinesia, rigidez, alteracion de reflejos posturales y temblor en reposo, y otros sintomas no motores, como cambios en el patron de sueño y el comportamiento sexual. Sin embargo, se conoce poco sobre los comportamientos sexuales parafilicos. Objetivo. Resumir el numero de casos de comportamientos zoofilicos en pacientes con EP entre enero de 2000 y diciembre de 2017. Desarrollo. Se realizo una revision en PubMed, Scopus y la Biblioteca Virtual en Salud. Se identificaron por el titulo 11 articulos; se excluyeron seis porque no presentaban casos relacionados con un comportamiento zoofilico. Se encontraron cinco casos de hombres, generalmente con EP de varios años de curso, polimedicados con agonistas dopaminergicos, quienes presentaron los comportamientos parafilicos despues del incremento de la dosis. Los comportamientos zoofilicos cedieron con la reduccion de la dosis de los agonistas dopaminergicos y antipsicoticos atipicos, como clozapina o quetiapina. Conclusiones. Es limitada la notificacion de casos de comportamientos zoofilicos en pacientes con EP. Los pacientes notificados son hombres en quienes se incremento la dosis de agonistas dopaminergicos. Es importante que el seguimiento clinico de los pacientes con EP incluya una revision de los comportamientos sexuales, incluidos los del espectro parafilico.

Para una genealogía del violador. Prácticas penales, discursos médicos, psiquiátricos y criminológicos en la configuracion del agresor sexual en Argentina en la primera mitad del siglo XX / Para uma genealogia do estuprador. Práticas penais, discursos médicos, psiquiátricos e criminológicos na configuração do agressor sexual na Argentina na primeira metade do século XX / For a genealogy of the rapist. Penal practices, medical, psychiatric, and criminological discourses in the configuration of the sexual attacker in Argentina during the first half of the twentieth century

Resumen El presente trabajo pretende reflexionar en torno a la definición y caracterización de la violencia sexual en Argentina durante la primera mitad del siglo XX. Procurando superar los enfoques tradicionales, proponemos extender el análisis más allá de los aspectos estrictamente jurídicos, inscribiendo el problema al interior del ejercicio de una determinada tecnología política, que articula una multiplicidad de saberes y relaciones de poder, los cuales se cristalizan por medio diversos tipos de discursos y prácticas, insertos en una red institucional público-privada de intervenciones, regulaciones y control. Desde esta perspectiva, investigamos el proceso de implantación de la figura del agresor sexual como un perfil individual definido, buscando hacer eje en las condiciones de emergencia, la integración estratégica y la productividad táctica de un conjunto heterogéneo de clasificaciones cognitivas que buscaban proporcionar una respuesta o solución a los comportamientos sexuales abusivos.

Resumo O presente trabalho tentar refletir acerca da definição e caracterização da violência sexual na Argentina na primeira metade do século XX. Tentando superar as abordagens mais tradicionais, propomos ampliar a análise para além dos aspectos estritamente legais, registrando o problema dentro do exercício de uma certa tecnologia política que articula uma multiplicidade de conhecimentos e relações de poder que cristalizam regulamentos e controles, através de vários tipos de discursos e práticas incorporados em uma rede institucional público-privada de intervenções. Nesta perspectiva, investigamos o processo de implementação da figura do agressor sexual como um perfil específico definido, procurando um eixo em condições de emergência, integração estratégica e produtividade tática de um conjunto heterogêneo de classificações cognitivas que procurou fornecer uma resposta ou solução para comportamentos sexuais abusivos.

Abstract The present research analyzes the definition and characterization of sexual violence in Argentina during the first half of the twentieth century. We propose to extend the analysis beyond the legal aspects, inscribing the problem on the exercise of a complex political technology assembling different kinds of knowledge and power relations crystalized through varied discourses and practices, which are inserted in a public-private institutional network of intervention, regulation, and control. With this perspective, we study the process of implementation of the sexual criminal as a clearly defined individual profile focusing on the emergence conditions, strategic integration and tactic productivity of a heterogeneous group of cognitive classifications which tried to provide an answer or a solution to sexual abusive behaviors.

Sexualidades dissidentes: um olhar sobre narrativas identitárias e estilo de vida no ciberespaço / Dissident sexualities: an outlook on identity narratives and lifestyle in cyberspace

Resumo A subcultura BDSM (Bondage, Disciplina, Dominação, Submissão, Sadismo, Masoquismo) organiza-se em torno de práticas eróticas dissidentes, pautadas no consentimento. A partir de uma netnografia, este estudo visa apreender como os adeptos de BDSM se apresentam do ponto de vista identitário no ciberespaço. Neste sentido, blogs e sites relacionados ao BDSM foram acompanhados, bem como redes sociais. Somam-se a este material, entrevistas de adeptos em outras mídias. Técnicas de amostragem por saturação e Análise de Discurso foram aplicadas. Ao erotizarem o poder, constroem jogos eróticos pautados em hierarquias, onde um indivíduo ocupa o papel de dominação e o outro, de submissão. Todavia, para além de um mero papel sexual, os adeptos defendem que tanto a dominação quanto a submissão fazem parte de sua própria natureza, revelando um discurso essencializador ou instaurando o que afirmam ser uma orientação sexual. A partir de cenários, vestimentas e apetrechos sexuais específicos, seus praticantes ressignificam traumas sociais, particularmente os que envolvem a opressão de gênero. A despeito do estigma que marca os sujeitos envolvidos, suas narrativas bebem de alguns dos pilares da subjetividade contemporânea, dos quais se destaca, a valorização da experiência, do desenvolvimento de si e da maximização do prazer.

Abstract The subculture of BDSM (Bondage, Discipline, Domination, Submission, Sadism, Masochism) is organized around dissident erotic practices based on consent. Starting with a netnography survey, this study seeks to understand how adepts of BDSM present themselves from the standpoint of identity in cyberspace. In this sense, blogs and sites related to BDSM, as well as social networks, have been observed. Added to this material are interviews of adepts in other media. Techniques of Saturation Sampling and Discourse Analysis were applied. By eroticizing power, they construct erotic games based on hierarchies, where one individual occupies the role of domination and the other of submission. However, beyond a mere sexual role, the adepts argue that both domination and submission are part of their own nature, revealing an essentializing and instituting discourse, which they claim to be a sexual orientation. From specific scenarios, dress and sexual paraphernalia, their practitioners relive their social traumas, particularly those involving gender oppression. In spite of the stigma that is attributed to the subjects involved, their narratives echo from some of the pillars of contemporary subjectivity, such as valuation of experience, of self-development, and of the maximization of pleasure.

Considerações sobre o transtorno parafílico: a interface entre a psiquiatria, a psicologia e a justiça criminal / Considerations on paraphilic disorder: the interface between psychiatry, psychology and criminal justice

O presente artigo versa sobre o transtorno parafílico (TP) cuja diferença nas práticas sexuais gera conotação pejorativa na sociedade, o que pode estar associado a dificuldade em compreender manifestações de desejo diferente e a relação entre crime sexual hediondo e parafilia. Indivíduos com TP apresentam interesse sexual intenso e persistente não voltado para a estimulação genital ou para carícias preliminares com parceiros humanos (fenótipo normal e maturidade física) e prévio consentimento para a atividade sexual. A parafilia está presente no repertório sexual individual da população geral com conteúdo de: humilhação, dominação, fetiche e bondage. A prática parafílica não visa à aproximação entre os parceiros e compromete, com o tempo, o relacionamento íntimo e/ou interpessoal e o trabalho. O Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-5) divide o transtorno em: voyeurista, exibicionista, frotteurista, masoquismo sexual, sadismo sexual, pedofílico, fetichista, transvéstico. O comportamento sexual parafílico pode ser dividido do ponto de vista criminal quanto à legalidade e à ilegalidade, com o consentimento e o não consentimento, em casos de adultos e comportamento parafílico com crianças e crianças pré-puberes. Ampliar a compreensão da interface entre a psiquiatria, a psicologia e a justiça criminal para a parafilia e o transtorno parafilico contribui para o diagnóstico (presença ou ausência de sofrimento), a avaliação e a punição do comportamento, com a presença ou não de vítima, e perspectivas psicológicas para o tratamento do transtorno parafílico, com a possibilidade de mudança no processo de excitação sexual, compreensão sintomatológica e desenvolvimento, ampliação do repertório do indivíduo.

A psicopatologia psicanalítica das perversões na atualidade: uma revisão sistemática / The psychoanalytic psychopathology of perversions nowadays: a systematic review / La psicopatología psicoanalítica de las perversiones en la actualidade: uma revisión sistemática

O conceito de perversão sempre esteve impregnado pela concepção da psiquiatria clássica de um desvio moral e sexual, e seu estatuto costuma ser mal compreendido na própria psicanálise. A presente pesquisa teve como objetivo a discussão das perversões no âmbito da psicopatologia psicanalítica. Trata-se de uma pesquisa teórico-conceitual, baseada na revisão bibliográfica sistemática da literatura nacional feita através de um levantamento no portal da Biblioteca Virtual de Psicologia (BVS-PSI) dos artigos de 10 anos (2003 ­ 2013) com os descritores psicanálise, perversão e psicopatologia. Chegou-se a um total de vinte e oito artigos, os quais foram resumidos e categorizados, e levados para a sistematização, a interpretação e discussão. Os resultados mostram que na caracterização psicopatológica a literatura PSI tende a privilegiar os modelos pós-freudianos da perspectiva lacaniana e da perspectiva das relações de objeto. Conclui-se que a literatura atual não tem avançado em novas propostas de constructos teóricos acerca das perversões, demonstrando que o modelo da formação do objeto-fetiche freudiano ainda predomina como parâmetro para o seu entendimento, e que as discussões psicodinâmicas e estruturais têm diminuído em detrimento de uma abordagem ampliada de crítica sociológica e histórica sobre a perversão como produto de uma ordem médico-jurídica própria da modernidade. (AU)

The concept of perversion has always been steeped by the classic psychiatric conception of a sexual and moral deviance and its status is usually poorly understood in psychoanalysis itself. This research aims at discussing the perversions within the psychoanalytic psychopathology. This is a theoretic-conceptual work, based on the Brazilian systematic literature review made through a survey on the website of Virtual Library of Psychology (BVS-PSI) of articles in 10 years (2003 ­ 2013), with the descriptors psychoanalysis, perversion and psychopathology. It was reached a total of twenty eight articles, which were summarized and categorized, leading to a systematization, interpretation and discussion. The results show that regarding the psychopathological characterization, literature tends to emphasize the Lacanian perspective and the object relations perspective post-Freudian models. The discussion often boils down to a historic resumption or a general deconstruction of the concept. It can be concluded that the current literature has not progressed in propose new theoretical constructs about perversions, demonstrating that the Freudian model of the fetish object formation still predominates as parameter for its understanding and that psychodynamic and structural discussions have decreased at the expense of broader sociological and historical criticism about the perversion as a medical-legal product of modernity. (AU)

El concepto de perversión siempre estaba llena de la concepción de la psiquiatría clásica de una desviación moral y sexual y su estado es a menudo mal entendido en la psicoanálisis. Esta investigación tiene como objetivo la discusión de las perversiones dentro de la psicopatología psicoanalítica. Se trata de una investigación teórica y conceptual, basado en revisión bibliográfica sistemática de la literatura nacional realizada mediante de una encuesta en la página web de la Biblioteca Virtual de Psicología (BVS-PSI) de los artículos de 10 años (2003-2013) con descriptores de Psicoanálisis, Perversión y Psicopatología. Llegamos a un total de veinte e ocho artículos que fueron resumidos y categorizados, lo que lleva a una sistematización, interpretación y discusión. Los resultados muestran que sobre la caracterización psicopatológica, la literatura tiende a favorecer los modelos puesto freudianos de la perspectiva lacaniana y la perspectiva de las relaciones de objeto. Llegamos a la conclusión de que la literatura actual no ha avanzado en la propuesta de nueva construcción teórica sobre las perversiones, lo que demuestra que el modelo de la formación de freudiana fetiche a objetos aún prevalece como parámetro para su comprensión, y que las discusiones psicodinámicas y estructurales han disminuido en expensas de un enfoque más amplio a la crítica sociológica e histórica sobre la perversión como un producto de un sistema médico-legal de la propia modernidad. (AU)

Paraphilic Thoughts, Behaviors and Sex Addiction in a Sample of Persons Who Use Drugs: A Cross-Sectional Study.

OBJECTIVE: The aim of this study was to evaluate the prevalence of paraphilic thoughts/behaviors (including paraphilic disorders) with and without sexual addiction and sexual-related conditions in a sample of substance disorder patients. METHODS: This was a cross-sectional study of substance-dependent individuals who sought outpatient treatment in São Paulo, Brazil. Data included sociodemographic information, drug of choice, responses to questions about sexual behavior, and to the following standardized questionnaires: (a) Sexual Addiction Screening Test, and (b) Childhood Trauma Questionnaire. RESULTS: The sample comprised 134 persons who use drug, predominantly men (76.1%), 39.6% were aged between 18 and 29 years, and 54.9% were single. Most were persons who use polydrug, 73.9% were alcohol and cocaine users, 63.4% marijuana users, 81.1% tobacco users, and 5.2% steroid users. Prevalence of paraphilic thoughts/behaviors (including paraphilic disorders) with and without sexual addiction was 47%. The HPV/herpes and hepatitis B rates were 7.9% (P = 0.021) and 6.3% (P = 0.046) respectively. Paraphilic and nonparaphilic thoughts/behaviors were associated to the presence of childhood physical neglect (odds ratios [OR] = 4.7, 95% confidence interval [CI] 1.0 to 21.9), low educational level (OR = 7.2, 95% CI 1.4 to 36), heterosexuality (OR = 3.8, 95% CI 1.1 to 12.8) and youth (age 18 to 20 years) (OR = 5.6, 95% CI 1.4 to 11.8). CONCLUSIONS: The high prevalence of paraphilic thoughts/behaviors with or without sex addiction in persons who use drugs may be related to the experience of physical and emotional neglect during childhood and this possibility should routinely be investigated in clinical practice.

Trastorno parafílico: características clínicas de pacientes masculinos atendidos por Sexología Clínica / Paraphilic Disorder: Clinical Characteristics of Male Patients Served by Clinical Sexology

Introducción: Los trastornos parafílicos han sido poco estudiados en Cuba por lo que se decidió realizar la presente investigación. Objetivo: identificar las características clínicas de pacientes con trastorno parafílico que solicitaron atención a dos servicios de Sexología Clínica de La Habana. Métodos: Se realizó una investigación descriptiva, de corte transversal aplicando el método clínico, el universo estuvo constituido por 30 pacientes masculinos mayores de 18 años que solicitaron atención voluntaria a los servicios de Sexología Clínica del Centro Comunitario de Salud Mental de La Habana Vieja y el Centro Nacional de Educación Sexual en el periodo 2009-2015, en seguimiento sistemático durante seis meses. Los resultados se expresaron en por ciento. Resultados: 50 por ciento de los casos acudió a pedir ayuda por presión externa. El 8 por ciento tuvo antecedentes patológicos familiares de parafilias Los principales tipos de parafilias diagnosticadas fueron: froteurismo 53.33 por ciento, exhibicionismo 43.33 por ciento y voyeurismo 36.67 por ciento. En las comorbilidades del eje I, prevaleció la dependencia al alcohol, a otras drogas y a otras sustancias (23.53 por ciento); para el eje II sólo se diagnosticaron trastornos de personalidad (33.33 por ciento), con un predominio del trastorno antisocial (50 por ciento). Conclusiones: Dentro de las características clínicas predominó el pedido de ayuda por presión externa. Los antecedentes patológicos familiares de parafilias y enfermedades neuropsicosexuales de posible relación etiológica con éstas. El principal tipo de trastorno parafílico fue el froteurismo, seguido del exhibicionismo y el voyeurismo. En las comorbilidades del eje I, prevaleció la dependencia a drogas; para el eje II sólo se diagnosticaron trastornos de personalidad fundamentalmente el antisocial(AU)

Introduction: Paraphilic disorders have been little studied in Cuba and it was decided to carry out the present investigation. Objective: To identify the clinical characteristics of patients with paraphilic disorder who requested attention to two services of Clinical Sexology of Havana. Methods: A descriptive, cross - sectional investigation was carried out applying the clinical method. The universe consisted of 30 male patients over 18 years of age who requested voluntary care from the Clinical Sexology services of the Community Center of Mental Health of Old Havana and the National Center for Sexual Education in the period 2009-2015, in systematic follow-up for six months. The results were expressed in percent. Results: 50 percent of the cases came to ask for help by external pressure. 8 percent had a family history of paraphilias. The main types of paraphilias diagnosed were: 53.33 percent froteurism, 43.33 percent exhibitionism and 36.67 percent voyeurism. Dependence on alcohol, other drugs and other substances (23.53 percent) prevailed in axis 1 comorbidities; For axis II only personality disorders (33.33 percent) were diagnosed, with a predominance of antisocial disorder (50 percent).Conclusions: Within the clinical characteristics, the request for external pressure aid predominated. The familiar pathological history of paraphilias and neuropsychosexual diseases of possible etiological relation with them. The main type of paraphilic disorder was froteurism, followed by exhibitionism and voyeurism. Drug dependence prevailed in axis I comorbidities; For axis II only personality disorders were diagnosed fundamentally the antisocial(AU)

A Preliminary Model of Motivation for Pornography Consumption Among Men Participating in Zoophilic Virtual Environments.

Although zoophilic blogs and websites attract the attention of zoophiles and others who are curious about this sexual activity, the motivations for consuming this type of pornography are not clear. This study aimed to confirm the factorial validity of the Pornography Consumption Inventory in an online sample of men with sexual interest in animals, and to construct an association model between motivations for pornography consumption and the following psychological variables: depression, sexual impulsiveness, and strength of sexual interest in animals. In this cross-sectional study, we located a website that catered to a network of people with a sexual interest in animals. Subsequently, a questionnaire was made available online to members of this network. Results support the 4-factor model of the Pornography Consumption Inventory. Depression and strength of sexual interest in animals were negatively and positively correlated with the sexual curiosity factor, respectively. Sexual impulsiveness was positively associated with the emotional avoidance, excitement seeking, and sexual pleasure factors. Depression and sexual impulsiveness were positively correlated. Psychological factors can differently motivate the consumption of pornography among men who visit zoophilic blogs and websites. With these preliminary data, we can identify some characteristics of this population.