Ethical Issues
- General Principles of Medical Ethics
- LGBT Patient Treatment Issues
- LGBT Therapist Issues
- References
Goal
At the completion of this module, the user will understand the ethical principles underlying the patient-clinician relationship in the treatment of LGBT individuals.
Objectives
In order to reach this goal, the user will:
- Have knowledge of the AMA Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry;
- Understand that because homosexuality is not a mental disorder, LGBT individuals need the same access to mental health services and respect from mental health professionals as any patient;
- Become familiar with the treatment options offered to patients who are conflicted about their sexual orientation and/or identity and the ethical issues raised by some of these treatments.
Pre-Test
- Can a psychiatrist ethically refuse to treat a LGBT patient?
- yes, unconditionally
- yes, with a referral
- no
- According to the American Psychiatric Association is it ethical to try to change a person's sexual orientation?
- no
- yes
- only at the patient's request
- Can a psychiatrist ethically disclose their sexual orientation to a patient?
- yes, under all circumstances
- yes, if it is deemed to be in the best interest of the patient
- no
- Are there different boundary principles for working with LGBT patients than there are with heterosexual patients?
- yes, if the psychiatrist is LGBT
- yes, if the psychiatrist is heterosexual
- no, the same principles apply
General Principles of Medical Ethics
Physicians, as medical professionals, adhere to a code of medical ethics governing the nature of the relationship between patients and their physicians. The American Medical Association's (AMA) Principles of Medical Ethics state the following:Preamble
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
Principles of Medical Ethics
- A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
- A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
- A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
- A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
- A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
- A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
- A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
- A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
- A physician shall support access to medical care for all people.
Adopted by the AMA's House of Delegates, June 17, 2001.
Psychiatry, as a medical specialty, subscribes to these general standards of conduct, but the unique characteristics of psychiatric practice have raised question as to how these general principles apply to our specialty. Beginning in 1973 and revised and updated periodically since that time, the American Psychiatric Association has augmented the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. These annotations include, among others, the following statements which are particularly relevant in the treatment of LGBT patients.
- A psychiatrist shall not gratify his/her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his/her conduct has upon the boundaries of the doctor/patient relationship, and thus upon the well being of the patient. These requirements become particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrists.
- A psychiatrist should not be a party to any policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation.
LGBT Patient Treatment Issues
Can an ethical psychiatrist treat homosexuality as if it were a mental disorder?
No. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) does not contain a diagnosis of homosexuality. The diagnosis was removed from the DSM-II in 1973. In addition, in December 1998, the American Psychiatric Association (APA) Board of Trustees issued a Position Statement that concludes:
The American Psychiatric Association opposes any psychiatric treatment, such as 'reparative' or 'conversion' therapy, which is based upon the assumption that homosexuality per se is a mental disorder, or based upon a prior assumption that the patient should change his/her homosexual orientation.
For additional information sponsored by the APA
How might a psychiatrist advise a patient who is profoundly unhappy about his or her homosexuality and who requests to change it?
There are several ethical issues confronting a psychiatrist in this clinical situation. First, one must clarify the psychiatrist's understanding and formulation of the patient's unhappiness about his or her homosexuality? An underlying and related aspect of this ethical issue will be the psychiatrist's own views on whether homosexuality is pathological. A second ethical issue relates to therapies for changing sexual orientation. Are they effective? Can they cause harm? Given the benefit/risk ratio, what are the ethical implications of recommending a treatment of questionable efficacy that is possibly harmful?
Many individuals who experience homosexual feelings are unhappy or conflicted about them. The causes of this unhappiness include: social stigmatization, fear of rejection by family and community, loss of a desired heterosexual identity and family, and fear of religious or social condemnation, either from others or from the self. In the past, presentations of unhappiness were automatically and mistakenly seen as intrinsic to homosexuality itself, the consequence of a pathological deviation from heterosexual development. Today, both the American Psychiatric Association and the American Psychological Association assert that homosexuality is not a mental disorder and that a patient's sexual orientation should not, in itself, be considered a focus of treatment. Furthermore, the current scientific consensus in the mental health mainstream is that the development of sexual orientation occurs at an early age and results from a complex interaction of environmental, cognitive and biological factors. There is considerable recent evidence to suggest that biology plays a significant role in the development of a person's sexuality. While "biological" may not be a synonym for "immutable," there are a few studies as well as ample anecdotal data suggesting that efforts to change a person's sexual orientation are not benign and can be harmful. Therefore, it is more clinically useful to formulate unhappiness about homosexual or bisexual feelings as the result of social stigmatization of homosexuality, rather than as intrinsic to a homosexual orientation.
Currently, several groups claim to have success at changing sexual orientation. Operating outside the mental health mainstream, these associations are usually affiliated with religious and social conservative political organizations that oppose the cultural normalization of homosexuality and gay and lesbian civil rights. These groups primarily offer services directly to potential patients and their families. Three significant problems with these therapies include: (1) the questionable theories of homosexuality upon which their interventions are based; (2) the questionable efficacy of the interventions; and (3) possibly damaging effects of the interventions.
The theoretical underpinnings of "reparative therapy" assume "pathological" family constellations cause homosexuality. These theories see homosexuality as a developmental arrest or as a severe form of psychopathology; the efficacy of therapies based on these beliefs are questionable. To date, there are no scientifically rigorous outcome studies to determine the efficacy (or harm) of "reparative therapies." Those studies that report success in changing sexual orientation suffer from serious methodological problems, which include lack of scientific rigor in patient selection, defining what constitutes "change," methods of data gathering, outcome measurement, and long-term follow-up.As to the issue of harm caused by therapies designed to change sexual orientation--small studies of individuals who have undergone such therapies report persistent loss of the capacity for sexual responsiveness, intensification of feelings of shame, depression, feelings of failure, impairment of interpersonal relationships and a reduction in the capacity for intimacy.
In 2000, the APA issued a second and more forceful Position Statement on conversion therapy:
As a general principle, a therapist should not determine the goal of treatment either coercively or through subtle influence. Psychotherapeutic modalities to convert or repair homosexuality are based on developmental theories whose scientific validity is questionable. Furthermore, anecdotal reports of "cures" are counterbalanced by anecdotal claims of psychological harm. In the last four decades, reparative therapists have not produced any rigorous scientific research to substantiate their claims of cure. Until there is such research available, COPP recommends that ethical practitioners refrain from attempts to change individuals' sexual orientation, keeping in mind the medical dictum to 'first, do no harm'.
Clinical example
A young Mormon woman suppressed her lesbian attractions throughout adolescence. She is deeply committed to her family and church, both of which condemn homosexual behavior and excommunicate gay men and women. She comes to you requesting help to become straight.
Response
Given that "reparative therapy" have not been proven to be efficacious in changing sexual orientation and that it might even be harmful, it would be ethically questionable to make a patient's achievement of a heterosexual orientation the goal of psychotherapy. Informed consent would include explaining the current state of knowledge about efficacy and harm. This should be done in a way that is sensitive to a patient's cultural and religious values. A receptive patient could be directed to Affirmation (a gay and lesbian Mormon group) for peer support and guidance. If not prepared to go in that direction, the patient can be assisted in considering the option of observing familial and religious dictates, in examining her own values and judgments, and then considering the best actions to take. She can be helped to weigh the anticipated risks and benefits of coming out versus the risks and benefits of remaining secretive about her erotic feelings.
What is the role of an ethical psychiatrist in the evaluation and treatment of gender atypical children? How does a clinician handle the parent’s request to mold a child's sexual orientation, gender role, or gender identity, especially when deeply rooted cultural and religious values are at stake?
Clinical examples
1. Two parents seek psychiatric care for their five-year-old daughter who has always been a tomboy. She refused to wear dresses or frilly girls’ clothes, and preferred light sabers to Barbies. The parents were finally prompted to seek care when she insisted on cutting off her hair braid and insisted she would grow up to be a boy
2. Parents bring their six-year-old son in for evaluation because he has started cross-dressing in front of school mates leading to ostracism. The family found his dress-up games humorous and were amused by his renditions of show tunes.
Response
Given that (1) homosexuality is not a mental disorder, (2) that therapies directed at altering adult sexual orientation are ineffective and potentially harmful, and that (3) one important prospective study showed that three fourths of children with extreme gender atypical behavior grew up to be gay adolescents (Green 1987), the issue of treating children with the goal of guiding them toward a heterosexual orientation might be considered an ethical grey zone. However, Zucker and Bradley (1995) believe it is clinically and ethically valid to treat children with GID to prevent adult transsexualism. Transsexual rights groups argue that transsexualism, like homosexuality, is a natural variant of human sexual identity expression. The ethics of "curing" children of transsexualism requires further study, particularly if there is no clear evidence that childhood interventions in GID can alter either sexual orientation or gender identity. Zucker's and Bradley's (1995) other rationales for treatment, to reduce social ostracism and treatment of underlying psychopathology, are less ethically problematic.
What should an ethical psychiatrist do about an HIV-positive patient who discloses he or she is having unprotected sex? Is it ethical to warn the patient's partners?
Clinical example
A 43 year-old man in a heterosexual marriage is having unprotected sex with other men. He recently learned he is HIV-positive and comes to see you about his anxieties. You learn that he is also having unprotected sex with his wife who does not know about his HIV status or his extramarital activities. What are the ethical responsibilities of the treating psychiatrist?
Response
This case example raises ethical, clinical and legal issues. The ethical issues pit preserving patient confidentiality against a duty to warn a known individual at risk. A primary clinical responsibility is to help the patient come to terms with this new diagnosis. He is likely to fear losing his marriage, his family and his life. He may be at risk for suicide. Hopefully, through psychotherapy, he will be able to realistically address how his condition affects his marriage and this will, in turn, lead him to inform his spouse.
It is important to know what the laws regarding HIV reporting are; they vary from state to state, and may govern what options the treating physician has. Useful ethical guidelines that address this issue are available through the APA and AMA that address this issue. These guidelines suggest that it is ethically appropriate for a psychiatrist to inform the known partner of an HIV positive patient if doing sois discussed with the patient prior to the informing.
The psychiatrist's responsibility, however, is not fulfilled solely by informing the patient's partner. Thre is an obligation to help that patient work through the issues hindering disclosure and the life changes that are required in adapting to the diagnosis. These might include seeking evaluation and treatment for HIV, learning and using safer sex practices, and educating the patient and spouse, if appropriate, about HIV-related illnesses.
Can an ethical psychiatrist decide not to treat LGBT patients?
Clinical example
An LGBT person comes to your office for treatment. You are uncomfortable about taking the patient in to treatment and feel that you cannot provide quality care. What should you do?
Response
Section 1 of the Ethical Guidelines of the American Psychiatric Association speaks of not discriminating against patients because of their sexual orientation. Section 6 of the same Guidelines affirms psychiatrists’ right to refuse treatment (except in emergency situations) if they feel uncomfortable about treating those patients or feel unable to do so because of their own reactions to the issues likely to arise in treatment. Ethical psychiatrists have two courses of action to follow. If they decide to take the patient into treatment, they must arrange for supervision by a colleague with more experience and awareness in treating LGBT patients and the issues likely to arise in their treatment. It would also be appropriate to refer patients to colleagues more comfortable with the issues that are likely to arise in the treatment of LGBT patients rather than providing a less positive treatment experience due to one's own biases or conflicts or their inexperience in dealing with such issues. Such referral must be done with sensitivity, clarifing that it is the psychiatrist's own limitations that are the problem, not the patient.
Given the lack of proven efficacy and the possibility of harm, a referral for reparative therapy would not be appropriate.
LGBT Therapist Issues
What ethical issues arise for LGBT psychiatrists treating LGBT patients?
Should an LGBT Psychiatrist disclose his/her sexual orientation or identity to patients?
Case Example
A third-year medical student is having a great deal of anxiety about coming out. The student health clinic randomly assigns her to a gay male psychiatry resident. In her first session, she asks him if he is gay. What should he do?
Response
Traditionally, psychodynamically-oriented therapies discouraged therapists from disclosing any information about themselves to patients. However, there is a growing clinical and theoretical body of knowledge showing that self-disclosures are not only inevitable but often can be therapeutic (Cole & Drescher 2006) .
LGBT patients may want to know their therapists' sexual identities for many reasons. These may include: fear of being judged, not wanting to explain oneself to an uninformed therapist, not wanting sexual identity to become a clinical issue due to the therapist's issues, etc. In such cases, and others, an LGBT therapist's self-disclosure of sexual identity may be helpful to the patient. However, such self-disclosures require that LGBT therapists:
- understand the limits of how much personal information they wish to disclose
- be prepared to discuss, either before or after, the meaning of any disclosures to the patient
- be prepared to come out to the supervisor and to have a similar discussion in supervision
What boundary issues commonly present for LGBT therapists working with LGBT patients?
Clinical case
You discover in the early treatment of a patient that you have a few friends in common. Can you and should you continue to treat this patient?
Response
When doctor and patient have social connections outside the therapy setting, there is the potential for conflicts of interest, concerns about confidentiality, or misuse of the clinician's privileged position. However, in LGBT communities some social connections may be inevitable. The therapist may need to acknowledge shared social contacts and discuss with the patient whether these impair the patient's ability to be candid in treatment and the therapist's ability to maintain a therapeutic stance.
The boundary issues for an LGBT therapist in this situation are similar to those that emerge among residents of a small town or members of a sub-community (e.g., religious, ethnic, or racial groups) due to the complex friendship, business, and romantic connections that are likely to be present. Here, the ethical challenge is to balance the psychiatrist's community involvement with the interests of the patient's therapy.
What ethical challenges does a closeted LGBT psychiatrist face in treating LGBT patients?
Case example
A lesbian psychiatry resident who has not disclosed her sexual orientation in her training program is assigned to treat the lesbian chair of the college LGBT group.
Response
It may be preferable or even necessary for residents in some training programs not to disclose their sexual orientation. In such situations, the resident fearing professional exposure might experience anxiety when treating LGBT patients or when presenting such cases in supervision. Such anxiety might make it difficult to maintain an open, exploratory stance. If the resident finds herself inhibited either with the patient, her supervisor, or both, she should seek outside consultation or consider referral to another psychiatrist.
What if you heard another physician is conducting reparative therapy or is seeking to change a patient's sexual orientation? Where should you go? Do you have a duty to report the behavior and to whom?
The position of most professional mental health organizations is that reparative or conversion therapy is unethical (see, for example, the statements of the American Psychological Association, the American Psychiatric Association, the American Psychoanalytic Association, and the National Association of Social Workers). One could have consultations with colleagues knowledgeable in ethical issues, refer to the ethics guidelines, and consult with legal affairs consultants or and supervisors (as appropriate).
You may attempt to educate the colleague about the fact that the practice of reparative or conversion therapy is highly controversial, may be unethical, and recommend reformulating the treatment plan.
If you are not satisfied after the aforementioned consultations and attempts at education, and you decide to file a complaint of unethical behavior, this should be addressed to the ethics committee of the professional mental health organization of which the practitioner is a member.
Are there responsibilities for psychiatrists practicing in states with antigay laws?
Section 3 of the AMA Principles of Medical Ethics states that "a physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient." At this time, there are no state laws that have direct impact on the ability of a psychiatrist to treat a gay patient. However, multiple states have amended their constitutions to deny recognition of marriage between gay people.
As stated in the APA's 2004 Same Sex Marriage Resource Document:
Legal marriage can provide important mental health benefits, both to members of same sex couples and to the wider community of lesbians, gay men and bisexuals (Cabaj & Purcell, 1998). The majority of lesbians and gay men report being in a committed relationship (Bradford & Ryan 1998). Wedding ceremonies, though not legally sanctioned, are common. Nevertheless, the couples lack the same legal rights and responsibilities listed above, as those accorded to heterosexual married couples. Although there has not yet been sufficient research into the psychological harm caused by the lack of legal marriage, research on heterosexual couples identifies marital disruption as a precursor for poor mental health (i.e., Williams, 2003; Wade & Pevalin, 2004; Willitts, Benzeval & Stansfield, 2004). It is not difficult to imagine that being denied the right to socially sanctioned and stabilizing relationships can affect the mental health of same sex couples. In addition, same sex couples often endure varying degrees of state-sanctioned discrimination, which necessarily affects the stability of these relationships.
The position of psychiatrists in the military is a particularly complicated one. Currently, the military abides by a federal "Don't ask, don't tell" law; that is, if the military command becomes aware that a member of the armed forces is gay, that member will be discharged from service. If a member comes to see a military psychiatrist to discuss depressive or anxiety symptoms related to being a gay service person, how does the psychiatrist balance duty to the military with Section 1 of the Principles of Medical Ethics ("a psychiatrist should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of … sexual orientation")? Individual psychiatrists will choose their own approach to this dilemma. One approach might be to work to change this discriminatory law that leads to job loss solely based on sexual orientation
If you have a question about an ethical concern, where can you get information?
The American Psychiatric Association is able to provide help with ethical questions through the APA Ethics Committee, (telephone: 703-907-7300, email: apa@psych.org ).
You can also consult:
The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry 2001 Edition (Including November 2003 amendments)
The APA also has an Ethics Primer (written especially for residents and those teaching ethics) which explores several areas in more detail. This includes a practical compilation of ethical thinking regarding the most frequently encountered problems facing all psychiatrists.
Larger district branches of the APA may also have a local ethics committee, which can be consulted as well.
Post-Test
- What action would be inappropriate if a psychiatrist learns that a colleague is engaging in reparative therapy?
- do nothing
- discuss it with the colleague
- consider reporting the colleague to an ethics committee
- What would be an ethical reason for a psychiatrist to disclose sexual orientation to an LGBT patient
- in order to coax the patient to come out in the workplace
- there are no ethical justifications to disclose one's sexual orientation
- to model non-secrecy to the patient
- What is a potentially unethical approach for a psychiatrist treating a child with marked gender-atypical behavior?
- reassuring the parent that the child is unlikely to become an adult transsexual
- reassuring the parents that the treatment will prevent future, adult homosexuality in the child
- helping the child avoid social ostracism
- When is it unethical to break confidentiality about a patient's sexual orientation and/or behavior?
- if parents wants to know whether or not their child is gay
- if a married man tells you he's having unprotected sex with other men
- both
