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.
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.
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.
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.