Military Aspects of Malingering, Sexual and Reproductive Coercion: Report from Russia

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.


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 [1,2]. 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. 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][7][8]. Besides, cenesthopathy has been regarded as a symptom of "hypochondriacal" and sluggish schizophrenia [9][10][11][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][17][18][19][20][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][30][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][35][36][37][38]. The existence of non-symptomatic, covert or latent disease was postulated [38][39][40]. Antipsychotics were recommended for all forms of schizophrenia, including the sluggish variety and "increasing shizoidization" [37,[41][42][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][64][65][66][67][68][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 the Ukraine. Those participating in the conflict, factually or on paper, will obtain the war veteran status and hence privileges over fellowcitizens. At the same time, many young relatives of higher officers evaded the 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.