A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.
Dr. David Lehman
The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.
One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.
Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.
The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.
This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.
This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.
Dr. Nicolas Badre
After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”
Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.
One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.
One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in.
It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.
Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.
Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.