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ABSTRACT: CONTEXT AND OBJECTIVE: Care for patients with disorders of sex development (DSD) should be provided in integrated-care centers by a multidisciplinary team. Implementation of this project within the teaching clinic routine presents several challenges: 1) difficulties in relationships between the medical team and patients and their families; 2) age, ethnic and cultural differences; 3) DSD-related prejudice; and 4) physicians' anxiety. We report on a psychologist's work strategy that focused on creating arrangements that could contribute towards development of the relationship between the medical team and patients and their families, as a way of preparing the clinical staff to manage treatment of adult DSD patients. DESIGN AND SETTING: Prospective qualitative study. METHODS: Between February 2010 and April 2015, we conducted a qualitative study in the Adrenal Outpatient Clinic of Escola Paulista de Medicina (São Paulo, Brazil), based on interviews, team discussions and group dynamics with resident physicians, postgraduate students and attending physicians. RESULTS: Implementation of the project allowed residents to build a story of differentiated care for their patients, thus facilitating dialog between them and making it possible to address taboo topics. Sequential care provided by the same resident led patients to feel that their doctor cared for them, with individuality, continuity and a sense of interest in their story. CONCLUSION: Presence of a psychologist in the outpatient routine enabled inclusion of subjective factors in the routine of medical consultations, thus broadening the notion of healthcare for patients with DSD, facilitating bonds and providing support for difficulties faced.

RESUMO: CONTEXTO E OBJETIVO: Pacientes com desordens do desenvolvimento do sexo (DDS) e seus familiares devem ser atendidos em centros de atenção integral, por equipe multidisciplinar. A efetivação desse projeto no cotidiano da clínica-escola apresenta vários desafios: 1) dificuldades nas relações entre equipe médica, paciente e família, 2) diferenças etárias, étnicas e culturais, 3) preconceitos relacionados às DDS, e 4) angústia dos médicos. Relatamos o desenvolvimento de uma estratégia de trabalho do psicólogo, que teve como foco a criação de dispositivos que contribuíssem para o aprimoramento da relação entre equipe médica, paciente e família, preparando o staff clínico para administrar o tratamento de pacientes adultos com DDS. DESENHO E LOCAL: Estudo qualitativo prospectivo. MÉTODOS: De fevereiro de 2010 até abril de 2015, realizamos uma pesquisa qualitativa no Ambulatório de Adrenal da Escola Paulista de Medicina (São Paulo, Brasil), baseada em entrevistas, discussões de equipe e dinâmica de grupo com médicos residentes, pós-graduandos e assistentes. RESULTADOS: A implementação do projeto possibilitou aos residentes construir uma história de atendimento diferenciado com seus pacientes, facilitando o diálogo entre eles e permitindo que temas-tabus fossem abordados. O fato de ter sido atendido seguidamente pelo mesmo residente possibilitou ao paciente a sensação de cuidado, individualidade, continuidade e a sensação de que havia interesse, por parte do médico, sobre a sua história. CONCLUSÃO: A presença do psicólogo no cotidiano do ambulatório permitiu que aspectos subjetivos fossem incluídos na rotina das consultas médicas, ampliando a noção de saúde e cuidado aos pacientes com DDS, facilitando o vínculo e dando suporte para as dificuldades encontradas.

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We report a case of gender dysphoria (GD) in a 62-year-old genetic female patient, raising the pros and cons of performing corrective surgery later in life. This 46,XX DSD patient was registered and reared as a girl; CAH was diagnosed late in childhood. Poor adherence to treatment and lack of proper psychological management contributed to evident GD. Living for years as a male, the patient applied for a legitimate male identification document in his late 50s; thereafter, he requested a sex-reassignment surgery "to disguise his female body upon his death." We informed the patient and family about surgery hazards, while analytical therapy allowed the group to evaluate the actual wish for surgery. When the wish was brought up, the role of death urged the group to rethink the course of treatment. During the process, it became clear that the patient's desire for surgery, more than a wish for changing the genitalia, expressed an impulse related to issues of endorsement and acceptance of his male identity. This report raises interesting questions about sexuality in a social context and prompts the idea that sexuality is broader than sex itself, raising new questions on the psychological risks faced when considering a body change after years of living with a disorder of sex development.

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CONTEXT AND OBJECTIVE: Care for patients with disorders of sex development (DSD) should be provided in integrated-care centers by a multidisciplinary team. Implementation of this project within the teaching clinic routine presents several challenges: 1) difficulties in relationships between the medical team and patients and their families; 2) age, ethnic and cultural differences; 3) DSD-related prejudice; and 4) physicians' anxiety. We report on a psychologist's work strategy that focused on creating arrangements that could contribute towards development of the relationship between the medical team and patients and their families, as a way of preparing the clinical staff to manage treatment of adult DSD patients. DESIGN AND SETTING: Prospective qualitative study. METHODS: Between February 2010 and April 2015, we conducted a qualitative study in the Adrenal Outpatient Clinic of Escola Paulista de Medicina (São Paulo, Brazil), based on interviews, team discussions and group dynamics with resident physicians, postgraduate students and attending physicians. RESULTS: Implementation of the project allowed residents to build a story of differentiated care for their patients, thus facilitating dialog between them and making it possible to address taboo topics. Sequential care provided by the same resident led patients to feel that their doctor cared for them, with individuality, continuity and a sense of interest in their story. CONCLUSION: Presence of a psychologist in the outpatient routine enabled inclusion of subjective factors in the routine of medical consultations, thus broadening the notion of healthcare for patients with DSD, facilitating bonds and providing support for difficulties faced.

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Este artigo visa analisar criticamente a experiência de implantação de um processo de educação permanente pelos profissionais de um Centro de Atenção Psicossocial álcool e outras drogas (CAPS ad) do município de Campinas, SP, Brasil. Os dados obtidos foram coletados por grupos focais com os trabalhadores do referido serviço e a análise do material produzido nestes encontros se utilizou de narrativas.

This paper aims to analyze through a critical view the experience of putting in place a process called continuing education for professionals from a psychosocial care center for alcohol and other drugs use (CAPS ad) in the city of Campinas, SP, Brazil. The data were collected through focus groups of workers of that facility and narratives were used for the analysis of the material produced in these meetings.

Este artículo tiene como objetivo analizar críticamente la experiencia de implementación de un proceso de educación continua para los profesionales de un Centro de Atención Psicosocial referente al Alcohol y Otras Drogas (CAPS ad) en la ciudad de Campinas, San Pablo, Brasil. Los datos fueron recogidos a través de grupos focales con los trabajadores del servicio y para el análisis del material producido en estas reuniones se utilizaron narrativas.

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Until 2005, questions regarding medical treatment and diagnostic information on Disorders of Sex Development (DSD) were not systematically discussed with both the patients and their families; however, the way these patients are currently treated have been changing with time. Interventional changes in the clinical-psychotherapeutic-surgical areas of DSD determine not only different medical recommendations but also help to place the patient and the family into the decisional process of therapy. We must consider two paradigmatic periods that have influenced and transformed the clinical management framework of patients with DSD: a) The "Money era" (1955), which emphasized the role of the gonads as the diagnostic criterion, having the environment as determinant of the sex identity; and b) The Chicago Consensus (2005) phase, in which the role of genetics and molecular biology was critical for an early identification, as well as in building a proper sex identity, emphasizing ethical questions and the "stigma culture". In addition, recent data have focused on the importance of interdisciplinarity and statements on questions concerning Human Rights as key factors in treatment decision making. Despite each of these management models being able to determine specific directions and recommendations regarding the clinical handling of these patients, we verify that a composite of these several models is the clinical routine nowadays. In the present paper, we discuss these several paradigms, and pinpoint clinical differences and their unfolding regarding management of DSD patients and their families.

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Until 2005, questions regarding medical treatment and diagnostic information on Disorders of Sex Development (DSD) were not systematically discussed with both the patients and their families; however, the way these patients are currently treated have been changing with time. Interventional changes in the clinical-psychotherapeutic-surgical areas of DSD determine not only different medical recommendations but also help to place the patient and the family into the decisional process of therapy. We must consider two paradigmatic periods that have influenced and transformed the clinical management framework of patients with DSD: a) The "Money era" (1955), which emphasized the role of the gonads as the diagnostic criterion, having the environment as determinant of the sex identity; and b) The Chicago Consensus (2005) phase, in which the role of genetics and molecular biology was critical for an early identification, as well as in building a proper sex identity, emphasizing ethical questions and the "stigma culture". In addition, recent data have focused on the importance of interdisciplinarity and statements on questions concerning Human Rights as key factors in treatment decision making. Despite each of these management models being able to determine specific directions and recommendations regarding the clinical handling of these patients, we verify that a composite of these several models is the clinical routine nowadays. In the present paper, we discuss these several paradigms, and pinpoint clinical differences and their unfolding regarding management of DSD patients and their families.

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A partir de uma série de experiências de trabalho em situações de desastre, notadamente na região serrana do Rio de Janeiro, Brasil, no início de 2011, este artigo pretende contribuir com a reflexão a respeito da atuação do psicólogo em um contexto de desastres. Inicia-se por uma breve retomada histórico-institucional da questão no Brasil, para, então, apresentar algumas reflexões conceituais e práticas da saúde mental a esse respeito; e, por fim, discutir princípios e diretrizes de intervenção em situações de desastre, tendo como pano de fundo o cenário fluminense de janeiro de 2011. Pretende-se, com isso, argumentar que a intervenção do psicólogo num contexto de desastres deve ser articulada com outras instâncias, contextualizada e descolada da noção de traumatismo como principal operador da clínica.

From a series of work experiences in disaster situations, especially in the mountainous region of the state of Rio de Janeiro, Brazil, in early 2011, this paper aims to present some reflections regarding the actions of psychologists in the context of disasters. It begins with a brief historical-institutional summary of this issue in Brazil and then presents some conceptual and practical reflections on mental health in this regard. Lastly, it discusses the principles and guidelines for interventions in disaster situations, with the backdrop of the scenario in the state of Rio de Janeiro in January 2011. The aim is to argue that interventions by psychologists in the context of disasters need to be linked with interventions of other types, contextualized and detached from the notion of trauma as the main operator in the clinical approach.

A partir de una serie de experiencias de trabajo en situaciones de desastres, especialmente en la región de la sierra de Río de Janeiro, Brasil, a principios de 2011, este artículo intenta contribuir para la reflexión sobre la actuación de psicólogo en un contexto de desastres. Comienza con una breve reanudación histórico-institucional de la cuestión en Brasil para después presentar algunas reflexiones conceptuales y prácticas de la salud mental en ese sentido y, finalmente, discutir principios y directrices de intervención en situaciones de desastre, teniendo como telón de fondo el escenario en Río de Janeiro en el mes de enero de 2011. Se pretende, de esa forma, argumentar que la intervención del psicólogo en un contexto de desastres debe articularse con otras instancias, contextualizarse y separarse de la noción de traumatismo como principal operador de la clínica.

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O diagnóstico de uma doença grave provoca um estado de angústia e seu efeito traumático coloca em questão o território subjetivo. A vivência da doença pode atualizar um modo de des-subjetivação, onde o sujeito “sem sofrer o sofrimento”, se exila, se faz um fora de si (FERENCZI,1932/1992). Reinventa-se uma relação singular com o “estado doente”: fragmenta-se em corpos, opera uma autotomia do corpo. Um corpo é o que a medicina vai cuidar, e outro transita, estranho e neutro, em lugar nenhum. O desafio clínico é seguir as rupturas e, de fragmento em fragmento, escutar as corporalidades que aí emergem

The diagnosis of a severe illness generates a state of anguish and its traumatic effect brings the subjective domain into question. The experience of an illness actualizes a form of des-subjectivation, in which the subject “without suffering the pain”, self-exiles himor herself, turning into something outside oneself (FERENCZI, (FERENCZI,1932/1992). A unique relation with the “state of being ill” is reinvented: one is fragmented into bodies, operating an autotomy of the body. There is a body that will be taken care of by medicine, while other – strange and neuter – inhabits a nowhere. The clinical challenge is to follow the ruptures and, from fragment to fragment, to be able to listen to the corporalities that may emerge

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O diagnóstico de uma doença grave provoca um estado de angústia e seu efeito traumático coloca em questão o território subjetivo. A vivência da doença pode atualizar um modo de des-subjetivação, onde o sujeito “sem sofrer o sofrimento”, se exila, se faz um fora de si (FERENCZI,1932/1992). Reinventa-se uma relação singular com o “estado doente”: fragmenta-se em corpos, opera uma autotomia do corpo. Um corpo é o que a medicina vai cuidar, e outro transita, estranho e neutro, em lugar nenhum. O desafio clínico é seguir as rupturas e, de fragmento em fragmento, escutar as corporalidades que aí emergem

The diagnosis of a severe illness generates a state of anguish and its traumatic effect brings the subjective domain into question. The experience of an illness actualizes a form of des-subjectivation, in which the subject “without suffering the pain”, self-exiles himor herself, turning into something outside oneself (FERENCZI, FERENCZI,1932/1992). A unique relation with the “state of being ill” is reinvented: one is fragmented into bodies, operating an autotomy of the body. There is a body that will be taken care of by medicine, while other – strange and neuter – inhabits a nowhere. The clinical challenge is to follow the ruptures and, from fragment to fragment, to be able to listen to the corporalities that may emerge

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O diagnóstico de uma doença grave provoca um estado de angústia e seu efeito traumático coloca em questão o território subjetivo. A vivência da doença pode atualizar um modo de des-subjetivação, onde o sujeito “sem sofrer o sofrimento”, se exila, se faz um fora de si (FERENCZI,1932/1992). Reinventa-se uma relação singular com o “estado doente”: fragmenta-se em corpos, opera uma autotomia do corpo. Um corpo é o que a medicina vai cuidar, e outro transita, estranho e neutro, em lugar nenhum. O desafio clínico é seguir as rupturas e, de fragmento em fragmento, escutar as corporalidades que aí emergem.(AU)

The diagnosis of a severe illness generates a state of anguish and its traumatic effect brings the subjective domain into question. The experience of an illness actualizes a form of des-subjectivation, in which the subject “without suffering the pain”, self-exiles himor herself, turning into something outside oneself (FERENCZI, FERENCZI,1932/1992). A unique relation with the “state of being ill” is reinvented: one is fragmented into bodies, operating an autotomy of the body. There is a body that will be taken care of by medicine, while other – strange and neuter – inhabits a nowhere. The clinical challenge is to follow the ruptures and, from fragment to fragment, to be able to listen to the corporalities that may emerge.(AU)

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O texto apresenta um projeto de extensão desenvolvido na Faculdade de Psicologia da PUC-SP que teve por objetivo colaborar para o aprimoramento das práticas grupais desenvolvidas por profissionais da rede pública de saúde por meio de atividades de formação e de apoio à sistematização, análise e problematização de algumas dessas práticas. O projeto apoiou dez equipes (UBS, ambulatórios e serviços especializados) na escrita e no debate de suas práticas grupais, tendo contribuído para promover uma rede de troca de saberes entre os serviços e visibilidade para as invenções por eles produzidas. O trabalho discute ainda o estatuto das práticas grupais nos serviços públicos de saúde e as razões do déficit de formação dos seus agentes: um efeito da privatização dos bens públicos, em detrimento de políticas de formação dos profissionais que atuam nas instituições públicas, condenados a práticas pouco valorizadas e pouco legitimadas, com resultados devastadores de ineficácia, precariedade e desqualificação social. Discutem-se também as concepções de formação e extensão que orientam nosso trabalho, na direção de permitir a construção de uma postura de colaboração técnico-teórica que mobilize novas culturas de funcionamento no campo da saúde.

This paper concerns an extension program which was undertaken at Psychology Family of Pontifical University of Sao Paulo (PUC-SP). Its objective was to contribute towards the achievement of a model for best-practices in the work carried out bay public health professionals. The program’s participants went thought training activities and were given support in visualization, analysis and systematization of some healthcare practices. The training project involved ten work teams (among Health Basic Units, Ambulatory Care Centers and Specialized Health Services) in the report on their own medical proceedings, which enabled to promote an exchange of views and knowledge between those health public sectors as well as some visibility of their innovative practices. The paper examines the present situation of group practices in public healthcare services and the reasons for the deficiency in professional instruction. These workers are forced to low-valued and underestimated practices and are faced with devastating standards of inefficacy, precariousness and social discredit. In addition to that, the article discusses the concepts of training and extension programs to guide our investigation as way to offer a theorical and technical contribution that might mobilize new operating cultures in healthcare area.

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O texto apresenta um projeto de extensão desenvolvido na Faculdade de Psicologia da PUC-SP que teve por objetivo colaborar para o aprimoramento das práticas grupais desenvolvidas por profissionais da rede pública de saúde por meio de atividades de formação e de apoio à sistematização, análise e problematização de algumas dessas práticas. O projeto apoiou dez equipes (UBS, ambulatórios e serviços especializados) na escrita e no debate de suas práticas grupais, tendo contribuído para promover uma rede de troca de saberes entre os serviços e visibilidade para as invenções por eles produzidas. O trabalho discute ainda o estatuto das práticas grupais nos serviços públicos de saúde e as razões do déficit de formação dos seus agentes: um efeito da privatização dos bens públicos, em detrimento de políticas de formação dos profissionais que atuam nas instituições públicas, condenados a práticas pouco valorizadas e pouco legitimadas, com resultados devastadores de ineficácia, precariedade e desqualificação social. Discutem-se também as concepções de formação e extensão que orientam nosso trabalho, na direção de permitir a construção de uma postura de colaboração técnico-teórica que mobilize novas culturas de funcionamento no campo da saúde.AU

This paper concerns an extension program which was undertaken at Psychology Family of Pontifical University of Sao Paulo (PUC-SP). Its objective was to contribute towards the achievement of a model for best-practices in the work carried out bay public health professionals. The program’s participants went thought training activities and were given support in visualization, analysis and systematization of some healthcare practices. The training project involved ten work teams (among Health Basic Units, Ambulatory Care Centers and Specialized Health Services) in the report on their own medical proceedings, which enabled to promote an exchange of views and knowledge between those health public sectors as well as some visibility of their innovative practices. The paper examines the present situation of group practices in public healthcare services and the reasons for the deficiency in professional instruction. These workers are forced to low-valued and underestimated practices and are faced with devastating standards of inefficacy, precariousness and social discredit. In addition to that, the article discusses the concepts of training and extension programs to guide our investigation as way to offer a theorical and technical contribution that might mobilize new operating cultures in healthcare area. AU

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Ao conceitualizar de forma inovadora a teoria da situacao analitica, Ferenczi convida o leitor a repensar e a redimensionar a clinica do trauma.

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