Friday, 30 May 2014

Another brother

I found that the guest post by two of my brothers recently was far more popular than my usual scribblings, so I thought I would introduce another of my brothers to my delightful and discerning readership.

This is my most highly professionally qualified brother, a senior psychiatrist.

Non Trovato writes:
I was delighted to help with the drafting of the Royal College of Psychiatrists' statement on sexual orientation.
I am proud that my early studying of the works of George Orwell has finally proved worthwhile, and would like to share some of the highlights of my contribution. 
The Royal College of Psychiatrists considers that sexual orientation is determined by a combination of biological and postnatal environmental factors. There is no evidence to go beyond this and impute any kind of choice into the origins of sexual orientation.
Note how we get over the most difficult bits early on. We could not get away with attributing sexual orientation solely to biological factors, as there is no evidence to support that hypothesis and significant evidence against it. But we undo the potential harm of that admission in the very next sentence, with a couple of techniques that I commend to your attention. 
The first is the 'there is no evidence' claim. Of course that is a lie, so is best placed early.  There is, at least, anecdotal evidence in some cases.  But we choose to discount that, and if challenged can say that by 'no evidence' we mean 'no peer-reviewed academic papers which we deem worthy of taking seriously'. That is quite a tenable position (though we use different standards later in this document, but nobody will notice that).  Moreover, 'there is no evidence' is clearly used here to deny the possibility of choice, rather than leave it hanging as an issue that is not yet sufficiently researched. Clever, eh? 
The second is the careful wording of 'choice into the origins of sexual orientation.' Of course, there are massive choices about how an individual responds to experiencing same sex attraction, but we really don't want to go there.  So without actually denying that, we knock that consideration into the long grass. 
So now  I'm sure you understand why I am particularly proud of that first paragraph! However, there are some other gems. 

The College wishes to clarify that homosexuality is not a psychiatric disorder. In 1973 the American Psychiatric Association (APA) concluded there was no scientific evidence that homosexuality was a disorder and removed it from its diagnostic glossary of mental disorders. The International Classification of Diseases of the World Health Organization followed suit in 1992.
A few clever points here; we replay the no evidence trick, of course, and neglect the philosophical question of what counts as evidence with regards to an issue such as this. The fact that we classify 'eating disorders' as 'disorders' precisely because they work against what eating is, biologically, intended to accomplish is one of the unhelpful facts that we gloss over by this elegant manoeuvre.  We also slide seamlessly between the specific ('psychiatric disorder' on which we are, at least theoretically, competent to judge) to the general 'disorder', touching on another category 'mental disorder' in passing.  It was also clever to boost our credibility by citing the APA and the WHO, regardless of the fact that their policies were driven by ideology, not evidence. 
The College holds the view that lesbian, gay and bisexual people are and should be regarded as valued members of society, who have exactly similar rights and responsibilities as all other citizens. This includes equal access to healthcare, the rights and responsibilities involved in a civil partnership/marriage, the rights and responsibilities involved in procreating and bringing up children, freedom to practise a religion as a lay person or religious leader, freedom from harassment or discrimination in any sphere and a right to protection from therapies that are potentially damaging, particularly those that purport to change sexual orientation.
Another clever paragraph here.  We debated long and hard about whether we could get away with 'exactly similar' and I am glad that my view, inspired by Orwell, prevailed. Some of the more academic types were concerned that it was a nonsense, intellectually, from a scientific body, but I helped them to understand that they were rather missing the point.  The paragraph was also cleverly constructed to start with the unarguable, slip the unjustifiable in along the way, and end on a topic about which, once again, we have some professional authority to comment. You see, the tricky point here is that there is no long term evidence to support the rather improbable assumption that same-sex parenting will be exactly as good as parenting by a heterosexual couple. What evidence we have rather suggests the opposite. 
Again we debated long and hard about 'procreating' but again, my view prevailed: it is the impact of the statement that counts, not the literal meaning.  That was also the outcome of the the debate around the words 'potentially damaging.' Of course, any therapy is potentially damaging; there is risk in all areas of life.  But we wanted to make clear our disapproval of this particular type of therapy, without having to cite any evidence to support that view (and we continue in the next...) 
Leading therapy organisations across the world have published statements warning of the ineffectiveness of treatments to change sexual orientation, their potential for harm and their influence in stigmatising lesbian, gay and bisexual people.  
Again, we faced a challenge.  Evidence is hard to come by, and doesn't always indicate what we want it to, so again we glossed that by the association with reputable others line of argument, and that invaluable (and indisputable) phrase potential for harm.
There is now a large body of research evidence that indicates that being gay, lesbian or bisexual is compatible with normal mental health and social adjustment. However, it is eminently reasonable that the experiences of discrimination in society and possible rejection by friends, families and others (such as employers), means that some lesbian, gay and bisexual people experience a greater than expected prevalence of mental health and substance misuse problems. Lifestyle issues may be important in some gay men and lesbians, particularly with respect to higher rates of substance misuse.
Another elegant paragraph, which manages to explain away the rather tricky data that indicate that the gay lifestyle is harmful. Note the compatibility argument: a lovely piece of casuistry! Having defined homosexuality a priori as not a disorder, we can then argue that it is compatible with normal mental health. Of course, we could do the same with Bulimia if that were politically expedient. Neat, huh?  Moreover, given that a priori assumption, we can then attribute all the data that might challenge that as being the result of other factors; confident that nobody will notice either the sleight of hand or the lack of research references at this point. 
It is not the case that sexual orientation is immutable or might not vary to some extent in a person’s life. Nevertheless, sexual orientation for most people seems to be set around a point that is largely heterosexual or homosexual. Bisexual people may have a degree of choice in terms of sexual expression in which they can focus on their heterosexual or homosexual side.  It is also the case that for people who are unhappy about their sexual orientation – whether heterosexual, homosexual or bisexual – there may be grounds for exploring therapeutic options to help them live more comfortably with it, reduce their distress and reach a greater degree of acceptance of their sexual orientation.  
This paragraph was one of my finest contributions, accepted without change by my colleagues.  It manages to pass over the really inconvenient truth that orientation is not immutable, and then proceed to say almost nothing (which means it is not open to critical challenge) whilst sounding very worthy, and promoting the approved attitudes. Why there is no 'potential for harm' in therapy in this direction, when there is in the opposite one, is a question that only the meanest reader would raise. There is of course no hard evidence in support of that proposition, which makes the opening line of the next paragraph a line of pure beauty and genius: 
The College believes strongly in evidence-based treatment. There is no sound scientific evidence that sexual orientation can be changed. Systematic reviews carried out by both the APA and Serovich et al suggest that studies which have shown conversion therapies to be successful are seriously methodologically flawed. 
The joy of nuance! 'Sound' 'suggest'
Furthermore, so-called treatments of homosexuality can create a setting in which prejudice and discrimination flourish, and there is evidence that they are potentially harmful. The College considers that the provision of any intervention purporting to ‘treat’ something which is not a disorder is wholly unethical. 
And again: 'can' 'potentially.' And the beautiful circularity of 'we have decided a priori it is not a disorder, therefore it is wrong to treat it as though it is one.'  I was really getting into my stride here! 
The College would not support a therapy for converting people from homosexuality any more than we would do so from heterosexuality. Psychiatrists should be committed to reducing inequalities, not supporting practices that are explicitly based on pathologising homosexuality. As such, the College remains in favour of legislative efforts to ban such conversion therapies. 
And onto the moral highground. The shift from science to propaganda is an elegant manoeuvre, which few, if any, will spot. 
Good Psychiatric Practice clearly states: ‘A psychiatrist must provide care that does not discriminate and is sensitive to issues of gender, ethnicity, colour, culture, lifestyle, beliefs, sexual orientation, age and disability’ (p. 12). The College expects all its members to follow Good Psychiatric Practice.

In my excitement at receiving my brother's fascinating commentary, I forgot to credit Peter Ould, whose post drew this to my attention, and @PartTimePilgrim who drew my attention to Peter Ould's post.

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