The following appeared in Volume 98, Number 2 (Spring, 1999) of the APA Newsletters

In the summer of 1998 the deputy press secretary for the Democratic candidate for governor of Illinois told the press that doctors had the right to refuse to treat homosexuals. The statement drew a parallel with a doctor’s right to decline participation in abortions. After this statement had been publicized, the candidate fired various campaign personnel, saying the statement did not reflect his views and had been made without his knowledge or authorization.¹

This event was not the only summer flare up between politicians and gay and lesbian citizens. Several prominent politicians volunteered unflattering statements about homosexuality. A ranking Republican in the U.S. Senate compared homosexuality to alcoholism and kleptomania, and other politicians weighed in with other unsavory remarks.² These remarks prefaced a nation-wide media campaign touting the possibility of changing sexual orientation.³ There was no shortage of pundits to discuss the political implications of these anti-gay tactics for November elections. In a sense, that focus eclipses the significance of these developments for the ethics of health care.

If we take the Illinois press release seriously, it asserts the moral right of physicians to turn away homosexual men and women patients. As a practical matter, physicians may be able to avoid gay and lesbian patients to some extent. By choosing geography and specialty carefully, some doctors can reduce the likelihood they will have to deal with gay and lesbian patients. But gay and lesbian patients are hard to avoid entirely. More and more people live outside the closet and bring their chosen families into hospitals with them, authorize same-sex partners to make health care decisions, and involve same-sex partners in reproductive choices. Gay men and lesbians are not confined to distinct urban enclaves, and many gay men and lesbians are not obviously recognizable as such if they choose to pass as straight. Moreover, physicians are not always in a position to select the patients whom they will see. To the extent physicians are employees rather than independent contractors, they serve a specified patient population rather than patients of their choosing. And certainly as medical students, doctors-in-training are not free to pick and choose their patients. Nevertheless, physicians studiously wishing to avoid homosexuality may have some success in minimizing the gay and lesbian people in their care if they were willing to make an active effort to do so.

Suppose, though, that some gay and lesbian people managed to filter into the treatment room of a physician who did not want them there. Would it be morally defensible for the physician to say: "I am morally (or religiously) opposed to homosexuality and am therefore unwilling to offer medical care to you. Please accept my referral to see another physician." Most likely, astute physicians would not offer bald statements like these to patients. It is to be remembered that discrimination on the basis of sexual orientation is illegal in some jurisdictions. Physicians wary of gay and lesbian patients would therefore be tempted to say something like this: "I am not the best physician available to treat your condition. I know of someone much better to take care of you. Besides, I’m too busy right now to be of much use to you. Please accept my referral to see another physician." Even if physicians could get away with this subterfuge, I believe it should be roundly resisted.

To be sure, medical ethics in the United States has always asserted the primacy of choice in health care relations. The American Medical Association (A.M.A.), for example, has said that except in the case of emergencies, physicians should be able to choose their patients and vice versa.⁴ It is not wise to couple physicians and patients in unwanted relationships. In a sense, this free market ethic seems to imply that physicians should retain the right to exclude homosexual men and women from their practice. Yet one of the durable problems with this approach is that whole classes of individuals can experience diminished health care because, for economic and moral reasons, for example their health needs are not attractive to physicians.

While I will not argue the point here, I believe that health care has a status unlike other human commodities, and that society must make some minimally decent effort to secure health care for its members. An example from the AIDS epidemic is instructive in this regard. In the early 1990s, in response to worries about occupational HIV infection, the A.M.A. issued an advisory statement saying physicians were not required to treat patients with HIV infections.⁵ Yet for all the good it may have done to protect physicians, the advisory had every appearance of casting HIV-infected patients out of the health care system. To its credit, the A.M.A. reversed that judgment and now asserts that it is unethical for physicians to refuse to treat HIV-infected patients unless professionally unequipped to do so.⁶ I believe that something like this latter advisory ought to guide physicians in regard to men and women with homosexual interests and identities. If not, a right to refuse treatment politicizes health care in the worst possible way: it conditions access to health care on judgments about the moral worth of patients. This opens gay men and lesbians—who are at the outset already socially vulnerable—to inadequate health care.

As for the claim that the right to refuse treatment of gay and lesbian patients is parallel to the right to refuse to perform an abortion, this comparison does not survive scrutiny. Treating a gay man for diabetes or a lesbian woman for chronic obstructive pulmonary disease, for example, hardly amounts to direct complicity in any alleged immorality of that person’s same-sex behaviors. In performing an abortion, by contrast, a physician is directly performing the very behavior whose morality is in question. Declining to treat gay men and lesbians embodies a moral judgment about the worth of those individuals whereas declining to offer an abortion amounts only to a moral judgment about the worth of that intervention. I suppose one could say that treating gay and lesbian patients helps those patients participate in future behaviors the physician believes to be immoral, that treating gay men and lesbians amounts to indirect complicity in an alleged immorality. But these claims stretch the comparison with abortion to incredulity. Even if a patient’s future behavior will be immoral, it does not follow as a matter of logic that it should be controlled through the withholding of medical treatment. Medical treatment should not be a reward offered in exchange for the promise of future moral behavior, with individual physicians defining the acceptable terms of a patient’s future behavior. That approach would demand too much of patients—to be worthy of their treatment—and demand too much of physicians—to make moral judgments about who deserves treatment.

Having said that professionals should be able to decline to treat gay and lesbian patients if they are professionally unequipped to do so, I also want to say that I think medical professionals should be prepared in exactly this regard. Indeed, I believe that medical schools should equip their graduates with the skills necessary to treat patients across the breadth and depth of humanity. It should be the rare physician able to say that medical education has left him or her unequipped to deal with gay and lesbian patients. Many medical schools around the nation do make some efforts to attune students to the particular health needs of gay and lesbian patients of all ages, mostly by introducing lectures on the topic, panel discussions, and structuring patient interviews in ways that do not presume the heterosexuality of all patients. While the results of these educational interventions are not yet clear, these efforts are worthwhile insofar as they help advance the understanding that not all patients are heterosexual and that homosexual patients may have special health concerns.⁷

At the very time things seem to be getting better for gay men and lesbians in regard to medicine, there hoves into journalistic view a media campaign promising success in sexual orientation therapy. Historically, physicians had been at the forefront of this approach to homosexuality. Indeed, in the last century medicine was the prime mover in defining homosexuality as pathological. The American Psychiatric Association accepted that view with its 1952 declaration that homosexuality was a "sociopathic personality disturbance."⁸ It is to be remembered, however, that for most of Western history homosexuality was not considered an illness. The biomedical search for the "etiology" and "cure" of homosexuality are an extremely recent phenomenon. In 1973 American psychiatry returned to the trajectory of mainstream history and walked away from a definition of homosexuality as pathological.⁹

Pathological or not, it is hard to find evidence that medicine ever found a "cure" for homosexuality. In the course of my research, I have reviewed hundreds of putative etiologies and therapies for homosexuality. These reports advance moral, religious, psychological, hormonal, genetic, anatomical, and neurological explanations for same-sex interests.¹⁰ "Treatment" for homosexuality has involved chemical, behavioral, surgical, hormonal, and all kinds of psychological treatments.¹¹ To be sure, there are reports that treatments have succeeded. None of these reports, however, offers scientifically credible evidence that randomly chosen individuals can undergo a particular intervention and have their erotic interests altered to the point of extinguishing same-sex interests and leaving only opposite-sex interests behind.¹² On the contrary, these reports suffer from methodological flaws, poor sampling technique, inadequate follow-up, inadequate sample size, uncontrolled methods, and over-interpretation of results. This is not to say these various treatments have had no effect, for they do sometimes help improve social skills with opposite-sex partners, sometimes to the point that people are confident enough to enter marriage. (Except for the frequency with which marriage is pointed to as evidence of sexual orientation change, it would otherwise go without saying that entering into marriage is not the same as "becoming heterosexual.") Failed treatments have side effects too, personal bitterness about the methods of therapy and lingering shame at an unreconstructed sexual identity among them. Ironically, undergoing these therapies also confirms for some people that they are in fact gay or lesbian and not straight.

It is against this scientific background that the therapy beat goes on, this time riffed by a slick media campaign. Yet the extent to which sexual orientation therapy is desired and pursued is not well studied. The 1978 Bell and Weinberg study included reports about efforts to alter sexual orientation. That data—collected in the late 1960s and early 1970s—predates the most important social advances made by gay and lesbian people. Interestingly enough, that study shows that even during the heyday of the view of homosexuality as pathological, only a minority of gay and lesbian people ever sought treatment. It is a reasonable extrapolation to expect that the vast majority of gay and lesbian people today neither wants nor seeks therapy. So profound has been the sea change in the social view of homosexuality that some practitioners of sexual orientation therapy now avoid any reference to notions of pathology. They justify therapy in terms of complying with patient preference. On this view, sexual orientation therapists are the cosmetic surgeons of erotic desire. I suppose this is progress.

If adult men and women want to waste their time pursuing unproved therapies, they should be free to do so. But the practitioners of unproved therapies are ethically bound to make clear that their efforts are experimental and unproved. By the same token, there is evidence aplenty that people can integrate same-sex interests into happy, rewarding, and meaningful lives and relationships. This pathway has more successes to its credit than sexual orientation therapy will ever have. These different pathways—experimental and well confirmed—should be made clear to would-be therapy subjects. There is no consumer protection agency, however, that reviews sexual orientation therapy in the way drugs and medical devices are reviewed and licensed for use. Therapists may offer interventions without first having to demonstrate safety and efficacy. The most that can be urged, therefore, is that practitioners come clean about what the scientifically credible literature has to say about the likelihood of sexual orientation rescues. At the very least, a high standard of informed consent can at least begin to sort out the broad social disvalues attached to same-sex interest and identities, disvalues that are worth considering as situationally coercive. I would like to think that a meaningful informed consent process would at least guide some people away from attempts at sexual orientation therapy. If it never does, I would wonder whether conversion therapy practitioners are being fair to the facts.

In its search for legitimacy, gay-baiting will from time to time invoke the authority of medicine to affirm its purposes, whether in asserting the right of physicians to turn away gay and lesbian patients, indirectly reviving the notion of homosexuality as pathological, or in touting sexual orientation therapy. As with most gay-baiting, these ploys will not raise issues important to improving the social and medical lot of gay men and lesbians. Rather, it will work to shore up the authority of straight people over gay men and lesbians as their moral and medical superiors. It is not an agenda concerned with improving health care for adult gay men and lesbians, much less adolescents trying to make sense of their same-sex interests. National media campaigns advertising successes in sexual orientation therapy are deceptive at best and predatory at worst. Trading the entitlement of gay men and lesbians to health care for electoral advantage is tantamount to a political hate crime. The AIDS epidemic and the emerging medical response to breast cancer in lesbians provide evidence that medicine can rise to the challenge of treating gay and lesbian patients. This good work should not be undercut by reviving fears of homosexuality and holding out images of sexual orientation "cures."

1. Ray Long and Rick Person, "2 Spokesmen Quit Poshard Campaign Jobs," Chicago Tribune, Aug. 4, 1998, 2C, 1,5.

2. Alison Mitchell, "Lott Says Homosexuality is a Sin and Compares It to Alcoholism," New York Times, June 16, 1998, A24.

3. See, for example, Washington Post, July 14, 1998, B7.

4. Council on Ethical and Judicial Affairs, American Medical Association, Code of Medical Ethics 1998 – 1999 ed. (Chicago: American Medical Association, 1998), Principle VI, p. xiv.

5. Timothy F. Murphy, Ethics in an Epidemic: AIDS, Culture, and Morality (Berkeley: University of California Press, 1994).

6. A.M.A., Code of Medical Ethics, entries 2.23 and 9.131.

7. American Medical Association, Council on Scientific Affairs. Health care needs of gay men and lesbians, Journal of the American Medical Association, 1996; 272: 1354-1359.

8. American Psychiatric Association, Diagnostic and Statistical Manual: Mental Disorders. (Washington, D.C.: American Psychiatric Association, 1952).

9. Ronald Bayer, Homosexuality and American Psychiatry, 2nd ed. (Princeton: Princeton University Press, 1987).

10. Timothy F. Murphy, Gay Science: The Ethics of Sexual Orientation Research (New York: Columbia University Press, 1997), pp. 75-101.

11. Timothy F. Murphy, "Redirecting Sexual Orientation: Techniques and Justifications," Journal of Sex Research 1992; 29: 501-523.