Psychiatric Ethics and Cultural Sensitivity

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Recently, there has been an emphasis on cultural sensitivity and competence in psychiatry.^1,2 When a psychiatrist evaluates a patient, there is much to be valued in trying to adopt the patient’s internal perspective of cultural mores and world views.

However, what are the limits to such sensitivity? How far can treatment decisions go to support group-endorsed values? Is ethical analysis of psychiatric treatment options more permissive if the patient’s or his or her family’s values are religious in nature? Are the ethical thresholds of inappropriateness different if the psychiatrist personally shares the specific beliefs of the patient’s culture or religion that are at odds with more conventional notions of behavioral health?

These questions are particularly vexing when the issues involve sexuality, as in the following 3 cases.

CASE VIGNETTES

A 30-year-old Catholic priest presents with distress related to homosexual thoughts, attraction to a fellow priest, and masturbation that he cannot resist. “I would like your help to take away my sexual urges, or if that isn’t possible, please help me to at least not have homosexual fantasies, because those are especially unwelcome thoughts. Either one will help me avoid masturbation, which is a sinful behavior.” He admits that part of the reason he went into the priesthood was because of conflicts over homosexual feelings that he had growing up as a devout Catholic. He was hopeful that the vows of chastity would allow him to transcend those feelings through spirituality. At this point in his life, he feels very satisfied with his role as a priest and says that leaving the priesthood is not an option he wishes to explore as a potential solution.

A 28-year-old Orthodox Jewish man is married but has a strong attraction to an unmarried woman in the community. He has romantic and sexual feelings toward her. They have started to meet secretly and exchange affections but haven’t been sexual. He explains that he has always been unhappy in his arranged marriage of 10 years and has a desire to leave his wife for this other woman. He confesses to his rabbi, who arranges for a consultation with a psychiatrist who is a member of their ultra-Orthodox community. The rabbi coaches this man to fabricate a story of a broader “sexual obsession,” with the urge to engage in profligate sex with prostitutes, and not to disclose the actual story of a brewing love affair with a single woman. The rabbi’s hope is that the psychiatrist will diagnose a “sexual addiction” and treat the patient with medications to reduce libido, such as Lupron, as the psychiatrist has done for others in similar situations.³

A 13-year-old Pakistani girl presents with intense anxiety and inability to perform her chores related to an impending female circumcision that her family (and culture) has arranged to occur on a trip back to Pakistan. Her parents explain to her that part of the reason for this procedure is that it is “sinful” for women to have “lustful desires” and that sexual experience for girls should be strictly for the purpose of reproduction, and not for pleasure. It is to be done in a proper health care facility in Pakistan, using sterile surgical techniques.

Normative ideas about human sexuality have been developing in psychiatry, advanced by scientific research in our evidence-based era. Those medical and professional conclusions pertain to healthy sexuality, or healthy sexual expression; the consequences of interfering with those expressions; and the developmental emergence of sexuality. However, some subcultures have significantly different paradigms involving certain sexual thoughts, feelings, and behaviors. Particularly religious beliefs, more than any other culture-bound set of ideas, inform many normative attitudes about sexuality.

More ordinary situations for psychiatrists are patients who engage in sexuality that society and the science of sexuality consider abnormal, dangerous, or exploitative, such as pedophilia or rape. But what about the inverse situation, when a patient is requesting help with sexuality that the patient or the patient’s family and community consider aberrant, but scientific psychiatry considers to be within normal limits-even desirable?

Consider the 3 case vignettes. If supportive of the religious subculture, psychiatrists might choose to give the first 2 patients medications such as an SSRI or Lupron to tamp down libido, although that would be off-label use. In the third case, an anxiolytic treatment might be deployed to shore up the girl’s resilience, allowing her to cope, focus, and function better in her daily life as the culture-ordained ritual circumcision approaches.

Or, non-pharmacological therapies might be used. For example, if the motivated behaviors and preoccupations in the first 2 cases are construed with an addictions paradigm, a referral can be made to treatment groups and 12-step programs designed to change addictive behaviors, such as Sexaholics Anonymous. We can give the girl training in relaxation, self-hypnosis, or cognitive behavioral therapy approaches for anxiety to get her through the procedure.

The general culture of our country is progressing far beyond the behavioral geography of certain subcultures embedded in our larger whole. Nowhere is this growing misalignment more striking than when it comes to sexual norms. American psychiatry, if not always leading these cultural transformations, certainly has been embracing them. This is demonstrated by the emergence of homosexuality, masturbation, and even gender re-identification out of the closet of psychopathology.

These behaviors and many of their accompanying fantasies have come to be de-pathologized, as demonstrated by the evolution of DSM on these topics. With time, the focus of what needs to be treated in some aspects of human sexuality has changed from the goal of altering behavior and fantasy to coping with the distress caused by the friction of disapproval and prejudice generated by the social context in which patients are embedded. Indeed, the American Psychiatric Association (APA) has entered into social advocacy roles to try to mitigate social disapproval, stigma, and laws that might generate distress about certain sexual practices. Opposition to laws that create stress for the transgendered, or practices to “convert” homosexuals to heterosexuals, are just 2 examples of the APA’s public efforts to change society, rather than to change the sexuality of patients.

So, where is the crossover point? When should subcultural and religious sexual values no longer be supported by a psychiatrist? When does it become ethically inappropriate to use our arts and sciences to help a patient better conform to unhealthy values? How can we be aware that we are using our privileges of professional authority (prescription privileges, involuntary treatment, etc) to support subcultural group psychopathology? Of course, this is a very big question at psychiatry’s core, and it can apply to many domains besides sexuality. That was the essential theme in the era when we focused on Soviet psychiatry and its politically motivated diagnoses such as “sluggish schizophrenia.” But focusing on sexuality now in the US is useful, as it has come to be seen as a quintessential domain of self-expression, freedom, and individuation-all motifs dear to the heart of psychiatry and its concepts of mental and emotional wellness.

There are 3 perspectives competing in this conversation: those of the subculture, the patient, and the psychiatrist. The subculture presents with its own norms, often based on tradition. In the context of sexuality, there is commonly-as in our 3 cases-the dictates of religion (eg, God, scripture, religious leadership). Patients present with innate neurobiological processes, developmental trajectories, and values learned from the native or adopted subculture with which they are in such conflict as to need clinical attention. Psychiatrists come with their evidence-based knowledge of human psychology, sexuality, and group dynamics, and a variety of tools-most of which are focused on helping the mental health of an individual.

We are familiar with common situations in which a patient’s presenting distress may be a reaction to an obviously abnormal and pathogenic environment: domestic abuse, sexual abuse, a severely exploitative employer, etc. The usual treatment approach in those situations is to shore up a patient’s survival and coping mechanisms by a variety of means in the short run, while helping to brainstorm an environmental change, either quickly (eg, shelter for domestic abuse, childhood protective services) or over time (eg, job change). If the environment, though, is a religious one, should that get more of a pass or a lighter hand in the goal of extracting a person from that environment?

When should subcultural and religious sexual values no longer be supported by a psychiatrist? When does it become ethically inappropriate to use our arts and sciences to help a patient better conform to unhealthy values?

Does labeling a religious group as a “cult” up the ante? Very often, religious communities have psychiatrists available who are part of that faith and are deeply committed participants in the groupthink of religious sexual and social mores. They would not conceive of the patient’s community with the derogatory construal of a “cult.” The fish can be unaware of the water in which it swims, or it can feel the water in its pond is healthier and fresher than that of the larger social ocean.

Psychiatry, however, is rooted in a level of professionalism that transcends a more limited social subcultural context. Like all of medicine, it aspires to be “transcultural,” embracing definitions of illness, health, and wellness that apply to many subcultures. Psychiatrists are trained in medical schools that uphold both science and a basic ethos of what it means to be a physician. There are even definitions of health and ethical standards that transcend national borders, such as those articulated by the World Health Organization and the World Psychiatric Association (WPA). In training we are exposed to standards of practice, ethical traditions, and institutions that have evolved values codified into formal codes of ethics. Indeed, those standards and codes carry gravitas and consequences.

Deviations result in malpractice suits and/or ethics sanctions. The larger social contract empowers medical schools and professional groups to bestow designations such as MD and board-certified, which lead to social privileges such as licensure and prescription privileges. Thus, a psychiatrist is accountable to a pluralistic society beyond his or her subculture, and there is the expectation that those privileges will be used to help people achieve good health as defined by larger social standards.

Some of the aspirations and values relevant to this situation are embedded in the American Medical Association Principles of Medical Ethics, with Special Annotations for Psychiatry.⁴ An even more international perspective, The Madrid Declaration of the WPA, states: “Psychiatrists should devise therapeutic interventions that are least restrictive to the freedom of the patient.”⁵

Drawing on these principles, psychiatrists who confront situations similar to those in the 3 cases presented above need to proceed with extreme caution. We need to consider patients’ unique vulnerabilities and provide a safe place for them to express sexual thoughts and feelings that are being treated as “deviant” by their subculture, or by their own families. We need to think of the concepts of “freedom” and “dignity” in the establishment of treatment goals. A patient’s sexuality needs to be evaluated in the context of the broader system of scientific research on human sexuality. Our treatment choices should rely on broader definitions of mental health embedded in the social and professional institutions that developed our skill sets in the first place and that granted authority to the deployment of those skills.

If a psychiatrist belongs to a patient’s subculture that repudiates medically accepted conclusions about human sexuality, there is marked vulnerability to reflexively validate one’s personal feelings and beliefs in the guise of “healing” another. Similarly, critical self-examination is called for if the psychiatrist depends on an alliance with that subculture to make a living. These circumstances should signal the need for consultation with a colleague or Ethics Committee that is not part of that intense hermetic subculture.

Enabling a patient to buck mainstream concepts of healthy sexuality to better conform to a subculture’s norms may result in an unconventional use of medications or therapies. It is important to recognize when a treatment is unusual or atypical. The new resource document, “APA Commentary on Ethics in Practice,” notes: “When considering use of clinical innovation, psychiatrists should consider first consulting colleagues and exploring other resources to ensure that careful thought has been given to possible alternatives as well as to the safest and most effective use of innovative interventions.”⁶ As a last resort, a psychiatrist has a right and responsibility to refuse care of a patient or family whose normative sexual values are significantly incongruous with the findings of scientific research on human sexuality and professional concepts of sexual mental health.

The statement, “The welfare of the patient is paramount,”⁴ tilts toward the individual, not the group, which is one of the most fundamental features of the practice of medicine. The notion of non-maleficence is often considered the great ethical postulate on which medicine first distinguished itself via a “professed” value, a “profession.” This idea is basically a protective posture toward the vulnerability of an individual as the default. In the most sensitive, controversial, and contentious area of human behavior-sexuality-this means that the first point of departure is to provide a protective stewardship over a patient’s sexuality. This is especially so when it is considered deviant in the eyes of a family or subculture.

Sexual norms should not get a free pass, or lighter resistance, by psychiatrists merely because they are categorized as religious values in a country where freedom of religion is a cherished principle. If a religious subculture is insisting on an approach to sexuality that scientific psychiatry has acknowledged is unhealthy, a psychiatrist should not be using arts and skills to enable those standards, unless the patient’s behavior violates the secular laws of the land.

Disclosures:

Dr. Komrad is Ethicist-in-Residence for the Sheppard Pratt Health System and a Member of the APA Ethics Committee; he is also on the Faculty of Psychiatry at Johns Hopkins and the University of Maryland. His opinions are his own. He is the author of You Need Help: A Step-by-Step Plan to Convince a Loved One to Get Counseling. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Kohl M. Cultural sensitivity for psychiatrists. Psychiatric Times. December 1998. http://www.psychiatrictimes.com/articles/cultural-sensitivity-psychiatrists. Accessed September 30, 2016.

2. American Psychiatric Association. Cultural Competence Curriculum. https://www.psychiatry.org/psychiatrists/cultural-competency/curriculum. Accessed September 30, 2016.

3. Ungar-Sargon B. Healing Hasidic masturbators and adulterers with psychiatric drugs. Narratively. 2016. http://narrative.ly/healing-hasidic-masturbators-and-adulterers-with-psychiatric-drugs/. Accessed October 3, 2016.

4. American Psychiatric Association. The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry, 2013 Edition. https://www.psychiatry.org/psychiatrists/practice/ethics. Accessed October 6, 2016.

5. World Psychiatric Association. Madrid Declaration on Ethical Standards for Psychiatric Practice. http://www.wpanet.org/detail.php?section_id=5&content_id=48. Accessed September 30, 2016.

6. American Psychiatric Association. APA Commentary on Ethics in Practice. December 2015. https://www.psychiatry.org/psychiatrists/practice/ethics. Accessed October 6, 2016.