Journal of Forensic Investigation
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Case Report
Military Aspects of Malingering, Sexual and Reproductive Coercion: Report from Russia
Jargin SV*
People’s Friendship University of Russia, Russia
*Address for Correspondence: Jargin SV, People’s Friendship University of Russia, Clementovski
per 6-82, 115184 Moscow, Russia; Phone: +7 495 9516788; E-mail:
sjargin@mail.ru
Submission: 20 June, 2022
Accepted: 25 July, 2022
Published: 29 July, 2022
Copyright: © 2022 Jargin SV. This is an open access article distributed
under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
Abstract
The military service places high demands on mental and physical
health. Mental disorders are among the most frequent causes
of unfitness for military service. A brief case series from Russia on
malingering and aggravation to avoid military service is presented
here along with an overview of literature. The following aspects are
pointed out: malingering and aggravation may entail unnecessary
treatment and misuse of certain drugs for recreational purposes.
Psychiatric diagnosis as a reason for exemption from military service
depends in some cases on the social status of the patient. There are
various positions in the modern army, where citizens with moderate
mental deviations can serve. It can be assumed that individuals with
substance abuse or certain personality disorders could be favorably
influenced by the military ambiance. Another topic tackled here is
the growing influence of the military in Russia, autocratic or military
managerial style that is unfavorable especially for the healthcare,
science and education.
Keywords
Military service; Malingering; Aggravation; Mental disorders;
Psychiatry; Russia
Introduction
In view of the current international tensions, topics related to
the military are of particular importance. Military services place high
demands on mental and physical health. Psychiatric disorders are
among the most frequent causes of unfitness for military service in
Russia [1,21]. A brief review of Russian psychiatry has been published
previously [3]. In principle, exemption from military service must
be based on a long-established and doubtless diagnosis or an expert
evaluation at a specialized institution; however, deviations from
this principle have been observed. It is generally known that some
conscripts resort to malingering and aggravation to be recognized
unfit for the service. In addition, their relatives sometimes use
personal connections and corrupt interactions for this purpose.
Another topic discussed here is the militarist ideology and growing
influence of military functionaries in the Russian society. The
autocratic or military managerial style is unfavorable especially for
science, education and healthcare. A case series is presented here to
illustrate the problems delineated above.
Case 1
A 16-year-old schoolboy (hereafter patient) with mild
communication abnormalities (shyness) was brought to psychiatrist
by his mother. The patient subsequently admitted that the real
goal was exemption from military service. The author observed
this patient for many years, also in stressful situations, and did not
notice any mental abnormalities, apart from alcohol dependence that
developed later on. Aside from shyness during adolescence, the only
notable complaint was the statement that his “nerves were like ropes”.
This was interpreted as cenesthopathy and sluggish schizophrenia was diagnosed. The concept of cenesthopathy was coined to describe
abnormal and strange bodily sensations without objective findings;
it is no longer in the mainstream of contemporary psychiatry [4,5].
However, Russian professional literature has a body of publications on
cenesthopathy culminated in the recognition of cenesthopathic form
of schizophrenia [6-8]. Besides, cenesthopathy has been regarded as
a symptom of “hypochondriacal” and sluggish schizophrenia [9-12].
The over diagnosis of the latter entity in Russia has been discussed
previously [3]. It is known that some forms of adolescence turmoil may
lead clinicians to diagnose a serious condition to be confronted one
day with a completely recovered patient; although, admittedly, severe
disorders in adolescence usually do not disappear with time [13]. The
patient was prescribed a phenothiazine drug and trihexyphenidyl
(known in Russia as Cyclodol). There was no proper control of the
drug intake. The patient brought Cyclodol tablets to school and
offered to classmates with the comment that it was a narcotic drug.
Curious teenagers took it during lessons, which remained unnoticed
by teachers. One of the boys suffered trihexyphenidyl intoxication
with a delirium-like state.
The patient was registered at the psycho-neurological dispensary
(care unit), exempted from military service, denied a driver’s license
and directed to a specialized educational institution, where he
acquired a profession of floriculturist. After that he worked in green
spaces of the city. A short time later, following advice of his friends,
among who were medics, the patient switched to car repair work,
completed an evening technical education, got married, and reduced
his alcohol consumption [14]. The patient suffered from stigma all
his life: registration at the psycho-neurological dispensary was known
by surrounding persons, impaired his relationships and employment
possibilities. Apparently, this contributed to his alcohol abuse.
Case 2
A student (hereafter patient) was expelled for poor academic
performance from a university in one of the Soviet republics and
conscripted to the army. During the first month of his service, the
patient encountered conflicts and appealed to relatives to help him
be recognized as unfit for military service. Some of his relatives were physicians and others belonged to the military establishment.
Soon the patient was dismissed from the army and registered at the
psycho-neurological dispensary with a diagnosis of psychasthenia.
No antipsychotics were prescribed. This case is an example of
aggravation. In the author’s opinion, the patient suffered from
obsessive-compulsive disorder, which is illustrated by his further
biography. The patient married a Moscow resident, pregnant at
that time, who was 13 years older than him with a 7-year-old son.
Sexual coercion with contraception sabotage was at the beginning
of this relationship; more details are in [15]. Under the conditions
of the Soviet registration system, aimed to counteract a mass
migration to the capital, real and fictive marriages were often
used to obtain a residence permit (propiska) in Moscow. Now as
before, the registration and accommodation remain strong motives
especially for large cities attracting immigrants. During later years,
the patient physically abused the child and (less often) his wife. At
the age of 14, the boy ran away and lived with his father’s new family.
Apparently, violence was the patient’s obsessive behavior. Obsessions
of aggression including intimate partner violence have been reported
in studies on obsessive-compulsive disorder [16-21]. The patient
trustworthily claimed that he regretted the violence but was unable
to control himself. However, at conflicts with other persons, he
restrained himself, which indicates imputability and neurotic nature
of his violent attacks. The ethnic factor might have played a role: the
child was ethnic Russian and sometimes emphasized this, which could
cause hostility in the patient. Of note, having migrated to Moscow,
the patient got rid of the registration with the psycho-neurological
dispensary and obtained a driver’s license.
Case 3
During his medical education (1982/83 academic year) the author
attended lectures on psychiatry. The lectures were on a high level;
there was a single incongruity related to the topic of this article. The
lecture included deviant sexual behavior. A young “transsexual” from
one of the Soviet republics was displayed, a strong and corpulent
young man. The author, who did military service in 1975-1977 with
many soldiers from different parts of the former Soviet Union (fSU),
suspected that the patient was not transgender but a malingerer who
did not want to serve in the army. The patient vaguely talked about his
desire to be a woman and seemed to feel ashamed. In this regard, the
author’s memoirs about military service are of interest. Once he was
hospitalized in the medical unit for acute tracheobronchitis. There
were two military and one civilian doctor in the unit, who examined
him and prescribed treatment. Other patients in the ward were
seemingly healthy soldiers from different Soviet republics. Doctors
did not approach them. The “patients” played Nard (table’s game) all
day long. The author was discharged after five days but the “patients”
remained in the medical unit. The explanation came later: money
transfers from their homelands, as well as e.g. for appointments as
cooks.
Case 4
A son of retired general awarded himself a next rank every time
he acquired acute, most probably gonococcal urethritis. In this way he
became a “generalissimo”, illustrating irresponsibility - the patient was
proud of his “career”. He was one of the informal leaders of a company
that, apart from selling to foreigners icons and coins (fartsovka: https://en.wikipedia.org/wiki/Fartsovka), involved adolescents in
the binge drinking and teenage girls into sexual contacts e.g. with
participants of international exhibitions in Moscow and foreign truck
drivers. Individuals infected with N. gonorrheae and other sexually
transmitted infections (STI) avoided the dermato-venereological
dispensaries, where the treatment was lengthy and unpleasant, and
treated themselves with antibiotics [22]. Intramuscular injections of
Hexestrol (known in Russia as Synoestrol) oil solution were used to
induce abortions - a well-known method of self-induced abortions
in fSU [23]. The case was reported to the authorities; the informer
made no secret of that, later he underwent assault and battery. It is
known that some sons of higher officers were prone to promiscuity
regarded as manly behavior. Of note, the patient was exempted from
conscription for a reason unknown to us.
Case 5
Anatomy is a difficult subject in a good medical school; many
students had difficulties with tests and exams. Some female students
were proposed tuition in privacy. As discussed previously, in the
midst of this activity was a deputy dean [24]. Sexual harassment by
lecturers and university officials is a known problem, while some
universities do not recognize the problem and tend to remain
silent, thus indirectly supporting perpetrators [25,26]. Note that
professors have responsibility to be allies of women affected by sexual
misconduct [27]. Later on, when the author started his career as a
lecturer, he participated in agricultural works with students. Medical
students were compulsorily sent to collective farms during semesters
to harvest potatoes. In Moscow Medical Academy it usually occurred
at the third academic year. The agricultural works lasted up to 2
months (September-October), in 1984 even longer. The “commander”
of the agricultural brigade was a son of a first-generation military
surgeon, a high-positioned functionary, known among others as the
Halsted mastectomy was presented in his textbooks, republished in
the 21st century, as a single surgical modality for breast cancer [28].
The son was prone to alcohol consumption during the agricultural
works. Once the author of this report came with some duty to the
commander’s room late in the evening and saw him together with
the above-mentioned deputy dean and two female students. The dean
came to inspect the agricultural brigade. Until recently, he had been
professor of normal anatomy. Alcohol was abundantly consumed;
there were relationships between certain lecturers and students,
sometimes amounting to seduction with the indirect use of authority
or the lecturer’s image. Besides, officers from a nearby military
unit and local functionaries visited the agricultural brigade, where
many students were females, and consumed alcohol with the abovementioned
commander. Admittedly, many students and lecturers
behaved appropriately, having nothing in common with the topics
under discussion.
Discussion
The literature on malingering of mental disorders is abundant;
here are presented some notable points. Malingering is a willful
falsification or profound exaggeration of an illness to gain
external benefits such as avoiding work or responsibility, criminal
prosecution or military service, seeking attention, drugs, etc.
Reasons of malingering can be better understood by examining the
circumstances than the psychological makeup. Malingering is not a psychiatric illness according to DSM-5 albeit it is associated with antisocial
and histrionic personality disorders [29]. However, it should
be considered that malingering can mask a significant psychiatric
disorder [30]. The individuals are often evasive and uncooperative,
show poor compliance with treatment. The presence of secondary
gain is a differential point between malingering and factitious
disorder. Malingerers consciously lie about their condition to get
the benefit, and upon achieving it, they usually stop complaining.
Malingerers have difficulty in sustaining feigned symptoms over
prolonged periods. When out of sight, there is often a falling away
of simulative behavior. Psychological testing can contribute to the
diagnosis of malingering e.g. incorrect answers to easy questions
besides correct answers to difficult ones [29-31].
The Cases 1 and 2 describe exaggeration of existing abnormalities
(milder in Case 1) to avoid military service. The individual with a
low social status (Case 1) was diagnosed with sluggish schizophrenia,
remained registered with the psycho-neurological dispensary
and stigmatized. The violent psychopath and child abuser with
connections in the military establishment (Case 2) was diagnosed
with psychasthenia and got rid of the stigmatizing registration
after relocation. On the contrary to Case 1, no antipsychotics
were prescribed and the patient was permitted to obtain a driver’s
license. The entity of psychasthenia has been vaguely delineated in
the Russian literature, described symptoms partly overlapping with
the overused concept of sluggish schizophrenia [32,33]. The latter
diagnosis entailed more stigma, exclusion from many forms of skilled
and professional work as well as other social consequences. As shown
by Cases 1 and 2, the use of diagnostic entities sometimes depended
on the social status of patients.
Psychopathologic phenomena typical for neuroses and
personality disorders, non-delusional hypochondria, unusual
interests and eccentricity were presented by the Soviet and some
post-Soviet literature as symptoms of schizophrenia [3,9,34-38].
The existence of non-symptomatic, covert or latent disease was
postulated [38-40]. Antipsychotics were recommended for all forms
of schizophrenia, including the sluggish variety and “increasing
shizoidization” [37,41-43]. Smulevich recommended an early start of
the therapy at the prodromal stage [37], whereas the diagnosis may be
questionable. This approach sometimes resulted in overtreatment and
recreational use of psychotropics (Case 1). Sluggish schizophrenia
was reportedly the most common form of the disease [41,44,45]. In
the recent Russian literature, schizotypal personality disorder has
been presented as a synonym of sluggish schizophrenia with in an
attempt to adjust it to international classifications [46]. Schizophrenia
has been regarded as a lifelong disease, persisting despite remissions
[47]. Therefore, patients usually remained registered with psychoneurological
dispensaries lifelong. The procedure of cancellation
of the registration was rare and often unsuccessful [48]. The fact of
registration and exemption from military service because of mental
disease has been a stigma for both patients and their families.
Cases 2, 4 and 5 illustrate another socio-historical aspect. It is
known that the former communist party Numenklatura https://
en.wikipedia.org/wiki/Nomenklatura was the ruling class that
included also higher officers of the army [49,50]. Since the 1980s
the Numenklatura and their relatives actively participated in the economic reforms having privatized the state property. Formally,
the Nomenklatura doesn’t exist in Russia since the early 1990s. As
for the military elite, it has always been influential in fSU, gaining
additional power thanks to current conflicts [51]. This has several
implications. Some sons of higher officers, former or actual military
functionaries have enjoyed far-reaching impunity in the Soviet
and post-Soviet society, becoming involved in immoral and illegal
activities, sexual coercion, etc. The latter has been regarded as a kind
of manly behavior. High social positions held by perpetrators or their
relatives often prevented reporting [52]. The contraceptive sabotage
i.e. reproductive coercion, often by negligence under the impact of
alcohol, was not uncommon [15]. The abortion rate in fSU was the
world highest [53]. Admittedly, this aspect is largely overshadowed
today by migration-related problems [51]. As exemplified by the Case
2, the sexual and reproductive coercion are used for the purpose of
migration, to cement a relationship or marriage, obtain a residence
permit and lodging, or to spread a certain genotype sometimes
with geopolitical motives. In some parts of the Russian Federation,
European and other countries, ethnic minorities tend to become
majorities; but this is beyond the scope of this article. Various
methods are applied: persuasion and seduction, alcohol and drugs,
sexual and reproductive coercion, intimidation and violence. Women
should be aware of these tactics.
Since the 1980s, numerous former party and military
functionaries, their relatives and protégés, have been introduced
into educational, scientific and medical institutions. They applied
“manliness” as a tool of social competence, which has been
indirectly used also for stigmatization of intelligentsia [54]. Being
not accustomed to hard and meticulous work, some of them have
been involved in professional misconduct of different kind [55].
The image of “true men”, propagandized in Russia, is manly indeed,
but gregarious and not independent. The men of this kind know
who are above them and who are below them, forming a hierarchy.
They do not get used to think and act independently, which is one
of the reasons why suboptimal practices are tolerated. Among
mechanisms contributing to the persistence of suboptimal and
outdated methods in medicine has been the lack of professional
autonomy [56], autocratic or military managerial style discouraging
criticism and impartial polemics. Other attributes of this style are
the paternalistic approach to patients, insufficient adherence to the
principle of informed consent, bossy management, rudeness, threats
and harassment of colleagues if they do not follow instructions or not
collaborate e.g. in dubious publications [55,57]. Suboptimal practices
have been used as per instructions and leading experts’ publications;
numerous examples have been discussed previously [58]. To name
but a few: the overuse of Halsted and Patey mastectomy with excision
of pectoral muscles, electrocoagulation of cervical ectropions without
cyto- or histological check for precancerous changes, parabulbar
injections of placebos, extensive gastric resections for peptic ulcers,
thoracic and abdominal surgery for bronchial asthma and diabetes
mellitus [58], overuse of surgery in tuberculosis [59], excessive tooth
preparations during dental checkups at schools without asking
for consent [60], mass bronchoscopy in conscripts with supposed
pneumonia e.g. 1478 procedures in 977 patients 19,5 ± 0,1 years
old [61,62]. Some invasive methods with questionable indications
were introduced or advocated by first generation military surgeons (Babichev, Bogush, Kovanov, Kuzin, Meshalkin, Yudin) [28,63-69].
The personnel training could have been one of the motives to overuse
invasive procedures. Note that military and medical ethics are not the
same. The comparatively short life expectancy in Russia is a strategic
advantage as it necessitates less healthcare investments and pensions.
Actually, Russia needs international help in the matter of healthcare.
In view of the current conflicts, the cooperation in many areas has
been discontinued. Obstacles to the import of medical products,
coupled with increasing influence by the military, may have adverse
consequences for the healthcare. Domestic products are promoted
despite often lower quality and possible counterfeiting [70]. Military
functionaries, their relatives and protégées, occupying many leading
positions at universities, academies, healthcare and other authorities,
will probably become more dominant due to the current conflict in
Ukraine. Those participating in the conflict, factually or on paper,
will obtain the war veteran status and hence privileges over fellow citizens.
At the same time, many young relatives of higher officers
evaded mandatory military service under various pretexts.
Conclusion
There are many positions in the modern army, where citizens
with moderate mental deviations can serve. Reportedly, soldiers with
neuroses benefitted from military service [71]. It may be assumed that
individuals with substance abuse and certain personality disorders
could be favorably influenced by the military ambiance in terms of
milieu therapy. This may become a topic of future research. Evasion
from the military service by means of malingering, aggravation or
other deceit is a criminal act under the Article 339 of the Criminal
Code of Russian Federation. Malingerers, military bureaucrats and
medics condoning them should be approached in accordance with
the law, official instructions and military regulations. Of note, health
professionals may have to give evidence in court while their testimony
is a critical element of proof in many cases [72]. This pertains also to
cases concerning fitness for military service, whereas integrity and
impartiality of experts are essential. It should be stressed in conclusion
that malingering and aggravation are unacceptable forms of behavior
for servicemen [73], which also applies to conscripts.
References
9. Volel BA (2010) Slow-progressive hypochondric schizophrenia. Psikhiatriia - Psychiatry 43: 17-25.