The Ethics Corner is a regular publication of the ABPP Ethics Committee, featuring clinical vignettes, ethical situations and dilemmas, and coverage of relevant ethical issues which arise in clinical and forensic settings. The ABPP Ethics Committee provides consultation services to ABPP specialists and constituents focused on responding to inquiries related to ethical standards, principles, and guidelines governing the practice of psychology. Contact them by submitting a Consultation Request Form and learn more on their website.
Recent years have seen a surge in the need for LGBTQI+ health services with a significant increase in the number of people who identify as LGBTQI+ including those who identify as nonbinary or transgender (Cass, 2024; SAMSHA, 2023, Twenge et al., 2024). Advocacy for the LGBTQI+ community has been met with significant push back from some political voices across the country (Ramos et al., 2022). Sadly, political and advocacy group agendas and desires can get in the way of quality evidence-based clinical practice when science takes a back seat to politics and advocacy. ABPP specialists, trying to do their very best to provide high-quality evidence-based clinical best practices, can be challenged to do so in rapidly changing and politically polarizing times. Ethical conflicts often arise too.
For example, typical clinical and ethical questions that might arise when working with LGBTQI+ clients may include:
- At what age should gender-affirming care be implemented?
- Should parents or legal guardians approve gender-affirming care when the clients are minors?
- How should gender-affirming care be provided when clients also experience important co-morbidities such as autism spectrum disorder or schizophrenia, for example?
- How should specialists address these issues when adequate research has not yet provided evidence for clinical guidelines?
These difficult questions are complicated by disagreements among diverse health care professionals as well as various perspectives from professional health care associations across the globe (Cass, 2024; SAMSHA, 2023). The APA Ethics Code (American Psychological Association, 2017) may be helpful to at least organize and center our thinking to best assist LGBTQI+ clients and their families.
Informed Consent
Section 10.01 (Informed Consent to Therapy) of the APA Ethics Code states that clients should receive full and informed consent before and during treatment offered by psychologists. Perhaps most relevant to clinical work with LGBTQI+ clients, section 10.01b states: “When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation.”
Psychologists should inform clients of which treatment approaches are well-established with evidence-based best practices and clinical guidelines and which approaches are more experimental. In this way clients can make informed decisions about how to proceed with their treatment.
Beneficence
Principle A (Beneficence and Nonmaleficence) of the APA Ethics Code states, “Psychologists strive to benefit those with whom they work and take care to do no harm… Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence.”
Psychologists must avoid harm to clients or recommended strategies that are harmful. For example, psychologists should be careful recommending non-evidence-based strategies that clients may later regret such as disclosing information to hostile family members, peers, social media or other social networks (e.g., church or community groups). Principle A also mentions problems with social and political influences. This concern is especially important for LGBTQI+ care since there is so much political polarization and agendas regarding how to best provide services to this community. LGBTQI+ treatment issues have become embroiled in our society’s culture wars over gender-affirming care. Politicians now weigh in on medical and psychological care by micromanaging the work of medical and mental health professionals. Thus, we can be influenced by social and political advocacy and news cycles more than by quality evidence-based best practices and clinical guidelines.
Respect
Principle E (Respect for People’s Rights and Dignity) of the APA Ethics Code states, “Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination… Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups.”
Principle E reminds us that everyone is worthy of respect and is entitled to privacy, confidentiality, and self-determination. Principle E further states that we need to be aware of and respect diversity in all forms. We must be sure to obtain whatever training is necessary to serve our clients, including those from LGBTQI+ populations, without bias or prejudice. Fortunately, the American Psychological Association, as well as many other established professional organizations, offer numerous continuing education opportunities to do so.
Competence
Section 2.01 (Boundaries of Competence) of the APA Ethics Code states, “(a) Psychologists provide services…. only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience… e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.”
Section 2.01 of the Code reminds us to stay within our lane of competence. This principle is challenging in areas that are rapidly changing and so specialists must be hypervigilant about their competence and receive consultation from experts when questions and concerns arise. Fortunately, there has been an explosion of research in this area that will likely continue to better inform us in the near future.
ABPP specialists and psychologists in general need to take ethical mandates seriously and provide our clients with the very best that our profession has to offer. Our interventions must be evidence-based and mindful of getting informed consent from our clients and be careful to avoid harm, maintain respect, and ensure competence in our work. Rapidly emerging areas of clinical work influenced by politics and strong feelings without clear best practices and clinical guidelines are especially challenging, but our dedication to quality and ethical professional services demands our vigilance and attention.
Recommended Further Reading
Cass, H. (2024). Independent review of gender identity services for children and young people. London, UK: Author.
Ramos, N., Burgess, A., & Ollen, E. (2022). The current status of sociopolitical and legal issues faced by lesbian, gay, bisexual, transgender, queer, and questioning youth. Adolescent Psychiatry, 12(3), 180-195.
Substance Abuse and Mental Health Services Administration (SAMHSA; 2013). Moving Beyond Change Efforts: Evidence and Action to Support and Affirm LGBTQI+ Youth. United States Department of Health and Human Services, 2021 – 23. https://store.samhsa.gov/product/moving-beyond-change-efforts/pep22-03-12-001
Recommendations for Practice
- Be especially mindful to provide evidence-based best practices when there is conflicting professional and political turmoil regarding diagnostic and treatment approaches.
- Be vigilant as you obtain fully informed consent from all parties before treatment.
- Be careful to avoid harm to anyone.
- Maintain the rights and dignity of all, being respectful to all parties.
- Stay on top of emerging fields with quality continuing education opportunities from reputable professional organizations and expert colleagues.
References
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/
Cass, H. (2024). The Cass Review–implications and reassurance for practitioners. Child and Adolescent Mental Health, 29(3), 311-313.
Ramos, N., Burgess, A., & Ollen, E. (2022). The current status of sociopolitical and legal issues faced by lesbian, gay, bisexual, transgender, queer, and questioning youth. Adolescent Psychiatry, 12(3), 180-195.
Substance Abuse and Mental Health Services Administration (SAMHSA; 2013). Moving Beyond Change Efforts: Evidence and Action to Support and Affirm LGBTQI+ Youth. United States Department of Health and Human Services, 2021 – 23. https://store.samhsa.gov/product/moving-beyond-change-efforts/pep22-03-12-001
Twenge, J. M., Wells, B. E., & Le, J. (2024). Increases in LGB identification among US adults, 2014–2021. Sexuality Research and Social Policy, 21(3), 863-878.
Thomas Plante, PhD, ABPP
Board Certified in Clinical Psychology
Correspondence: tplante@scu.edu