Letter to Editor :
Alessandra Diehl, Jair de Jesus Mari and Elias
Abdalla Filho 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: alediehl@terra.com.br 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.Paraphilic Disorders in ICD-11 and the Forensic context in Brazil
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