The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders (F65) for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11). Its expected that by January 2022 the ICD-11 may already be used by clinicians and stakeholders in many countries around the world.
The most important change in the new version 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. Furthermore, the ICD-11 brings the concept of consenting behavior, opening the possibility to distinguish between mutual accepted sexual practices and a Paraphilic Disorder, thus expanding the spectrum of normal or proper sexual practices.
In this context, a group of an expert Brazilian forensic advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO in order 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 Brazil.
In the Brazilian context, the changes categories of Paraphilic Disorder are not expected to have an impact in terms of determining sentencing. In Brazil, mentally ill offenders are subject to the Brazilian Penal Code, in which there are only two sections encompassing seven articles (from a total of 361 articles) regarding subjects with mental health issues since the Brazilian law focuses on the punishment of specific sexual behaviors rather than on underlying disorders.
It will not influence in assistance to patients in non-forensic facilities and it would not influence criminal culpability for crimes committed against non-consenting people, and the legal interpretation of criminal laws. The proposals also would not possibly affect the reporting requirements and confidentiality or it will not affect assistance to patients in non-forensic facilities. A variety of factors in Brazil 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.
The main obstacle still is the lack mental health services provision and the law and mental health system poor organization network. Social perception of sexual behaviors are evolving, with constant cultural and historical influences, that demands careful consideration of pathologization of sexuality, that is also the matter of the respect and protection of human rights in relation to sexuality, sexual health and wellbeing. The actual proposals for ICD-11 are positive in recognizing consensual sexual behavior or alternative patterns of arousal as non-pathologic if without distress and not related to crime.
The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behavior. Proper diagnostic assessments to avoid over diagnosis and pathologization of natural variations of sexual expression and behavior, at the same time allowing the provision of quality services for those who are in need for mental health care based on sexual desires that can cause distress and harm to others, is necessary [1-2].
1. Abdalla-Filho E, de Jesus Mari J, Diehl A, Vieira DL, Ribeiro RB, et al. Forensic Implications of the New Classification of ICD-11 Paraphilic Disorders in Brazil (2019) J Sex Med 16: 1814-1819. https://doi.org/10.1016/j.jsxm.2019.07.025
2. Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations (2016) World Psyi 15: 205-221. https://doi.org/10.1002/wps.20354
Alessandra Diehl, Department of Psychiatry, Federal University of São Paulo, Brazil, Tel: 55-11-983453767, Email: firstname.lastname@example.org
Diehl A, Mari JJ and Filho AE. Paraphilic disorders in ICD-11 and the forensic context in Brazil (2019) Edelweiss Psyi Open Access 3: 32.
Paraphilic Disorders, Consenting behavior, Mental health, Psychopathology.