RESUMO

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.

Assuntos

RESUMO

Introducción: Los trastornos parafílicos son comportamientos sexuales no tradicionales como la actividad sexual con niñas/os, exhibir los genitales a una persona desprevenida u otros. Objetivo: Sistematizar los referentes teóricos que sustentan la caracterización clínica y el tratamiento de los trastornos parafílicos en el mundo y en Cuba. Métodos: La búsqueda bibliográfica se efectuó en las bases de datos PubMed/Medline y ClinicalKey, además, se utilizaron investigaciones cubanas. Resultados: Parafilias es cualquier interés sexual intenso y persistente que no sea el interés en la estimulación genital o caricias preparatorias con parejas humanas fenotípicamente normales, físicamente maduras, con consentimiento; son trastornos parafílicos cuando las parafilias causan distress o deterioro en lo social, laboral u otros. Características clínicas relevantes: predominan en el sexo masculino, existen distorsiones cognitivas, comorbilidad con trastornos por uso de sustancias, trastornos de personalidad y otras. El tratamiento farmacológico abarca inhibidores selectivos de la recaptación de serotonina, en Cuba se usa la sertralina (100-200 mg/día); análogos de la hormona liberadora de hormona gonadotrópica y antiandrógenos, en el país existe el Androcur (50-100 mg/día). Técnicas de psicoterapia cognitivo-conductual útiles: sensibilización cubierta, desarrollo de empatía hacia las víctimas y reestructuración cognitiva. Conclusiones: Clínicamente es imprescindible diferenciar parafilias de trastornos parafílicos, considerados enfermedades mentales, que tienen un curso por lo general crónico, distorsiones cognitivas, cada paciente habitualmente tiene varios tipos de trastornos parafílicos y otras comorbilidades psiquiátricas. En Cuba, para su tratamiento se usa sertralina o androcur y técnicas de la psicoterapia cognitivo-conductual.

Introduction: Paraphilic disorder are non tradicional sexual behaviors like the sexual activity with the boys/girls, to exhibit the genital to an unaware person or others. Objective: To systematize the theoretical bases that sustain the clinical characterization and the treatment of the paraphilic disorder in the world and in Cuba. Methods: The bibliographical search was made in the electronic databases ClinicalKey and PubMed, Cuban investigations were used. Results: Paraphilia is any intense and persistent sexual interest that is not the interest in the genital stimulation or preparatory caresses with a human normal, mature physically, with consenting persons; they are paraphilics disorders when the paraphilia causes distress or deterioration in the social, labor or others. Excellent clinical characteristics: they prevail in the masculine sex, cognitive distortions exist, comorbidities among different types of paraphilics disorders, dysfunctions for use of substances and disorders personality. The pharmacological treatment embraces the selective serotonin reuptake inhibitors, in Cuba the Sertraline is used (100-200 mg/day); analogues of the hormone Gonadotropin-Releasing Hormone Agonists and antiandrogens used in the country Androcur (50-100 mg/day). Technical of cognitive and behavioral psychotherapy: covered sensitization, empathy development toward the victims and cognitive restructuring. Conclusions: Clinically it is indispensable to differentiate the paraphilia of the paraphilics disorders, considered mental illnesses, with generally chronic course and generally comorbid psychiatric. In Cuba, for their treatment it is used the Sertraline or Androcur and technical of cognitive and behavioral psychotherapy.

RESUMO

RESUMEN Introducción: El conocimiento de la frecuencia de comportamientos zoofílicos en la población general es escaso. Objetivo: Revisar casos, series de casos y estudios de prevalencia de zoofilia en adultos de la población general. Métodos: Se realizó una revisión en las bases de datos de MEDLINE, a través de PubMed, Scopus y la Biblioteca Virtual en Salud de publicaciones desde enero de 2000 hasta diciembre de 2017. Resultados: Se revisaron 13 trabajos (10 informes de casos, 2 series de casos y 1 estudio transversal). Entre los casos se describió a 12 pacientes; las series de casos sumaron a 1.556 personas y el estudio transversal incluyó a 1.015 participantes e informó de una prevalencia de comportamientos zoofílicos del 2%. Conclusiones: Es escasa la información sobre la prevalencia de comportamientos zoofílicos en la población general. Es probable que internet permita investigar mejor estos comportamientos en los próximos años.

ABSTRACT Background: Information about the frequency of zoophilic behaviour in the general population is scarce. Objective: To review cases, case series and prevalence studies of zoophilia in adults in the general population. Methods: A review of publications was carried out in MEDLINE via PubMed, Scopus and the Biblioteca Virtual en Salud [Virtual Health Library] ranging from January 2000 to December 2017. Results: Thirteen papers were reviewed (ten case reports, two case series and one cross-sectional study). Twelve patients were described, the case series totalled 1,556 people and the cross-sectional study included 1,015 participants and reported a prevalence of zoophilic behaviour of 2%. Conclusions: Information on the prevalence of zoophilic behaviour in the general population is limited. The Internet will probably be a valuable tool for further investigating these behaviours in coming years.

Assuntos

RESUMO

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.

Assuntos

RESUMO

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.

Assuntos

RESUMO

La ocurrencia de casos de pedofilia ha motivado que se evalué la implementación de la castración química mediante la terapia hormonal. El objetivo de esta revisión es evaluar los efectos de la terapia con antiandrógenos en agresores sexuales y con desordenes parafílicos. Se buscaron revisiones sistemáticas y guías de práctica clínica sobre la terapia con anti-andrógenos. Se seleccionaron dos revisiones sistemáticas y una guía de práctica clínica cuya evidencia corresponde a reportes de casos y estudios observacionales. El desenlace primario, recaídas sexuales, solo ha sido evaluado en dos estudios comparativos con medroxiprogesterona. El número pequeño de participantes y el alto porcentaje de abandonos no permiten sacar conclusiones en cuanto a la eficacia. Se reportaron efectos adversos frecuentes. La evidencia disponible es escasa y de baja calidad sobre la eficacia de la terapia hormonal con anti-andrógenos esteroideos y análogos de la GnRH en pacientes con desordenes parafílicos.

Occurrence of pedophilia’s cases has led to the evaluation of the implementation of chemical castration through hormonal therapy. The aim of this review is to evaluate the effects of anti-androgen therapy on sexual offenders with paraphilic disorders. We searched for systematic reviews and clinical practice guidelines on anti-androgen therapy. Two systematic reviews and a clinical practice guide were selected whose evidence corresponds to case reports and observational studies. Primary outcome, sexual relapse, has only been evaluated in two comparative studies with medroxyprogesterone. Small number of participants and high percentage of dropouts do not allow conclusions to be drawn as to efficacy. Frequent adverse effects were reported. Available evidence is scant and of low quality on the efficacy of hormonal therapy with antiandrogens steroids and GnRH analogs in patients with paraphilic disorders.