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Chemical castration and homosexuality

Last week the Sydney Herald published details about an Australian Doctor who has been struck off as a GP (although not as a Radiologist) after prescribing Cyprostat to an 18 year man in order to treat his homosexuality.1 Both men were members of the Exclusive Brethren Church and the patient was taken to see Dr Craddock by a member of the church after being advised that there are treatments for homosexuality.

The Medical Council of New South Wales criticized him for not taking an appropriate medical history, not doing a physical examination, not referring his patient for counselling and not ordering medical tests to detect adverse reactions to the drug. Dr Craddock admitted that he did not do these things and, given that his departure from sound clinical skills occurred when using a powerful medical for such a radical purpose, it is not surprising that the court reached a finding of unsatisfactory, professional conduct.

However, there are two features of the court’s deliberation that I found somewhat surprising.

While Dr Craddock admitted that his clinical skills had fallen short of an acceptable level, he objected to the inclusion of evidence about this involvement with the Exclusive Brethren church. The Court defended the inclusion of this evidence on the grounds that it provided ‘context’ to the complaint that had been made. That seems fair enough, but what is a little surprising is the amount of deliberation that they had on this point. While it is clear that the set of beliefs that Dr Craddock and the patient had were an important backdrop to what happened and alarm bells should have been ringing about whether the patient had been coerced into requesting this treatment, it could be argued that the fact both of them were in this church is neither here nor there. Even if the patient had been placed under pressure to see Dr Craddock, the bottom line is that he decided, on the basis of a seriously compromised clinical examination to prescribe Cyprostat for a controversial purpose to a young, vulnerable man.

My second puzzle about this judgment is that the court restricted itself to criticizing his clinical skills when reaching its judgment. The legislation defines unsatisfactory professional conduct as:

Conduct that demonstrates that the knowledge, skill or judgment possessed,
or care exercised, by the practitioner in the practice of practitioner’s profession
is significantly below the standard reasonably expected of a practitioner of an
equivalent level of training or experience.

The Court struck him off as a GP because of where and how he prescribed Cyprostat. They did not cite the fact that he had prescribed this drug to a young man who had discovered that he was gay and was also a member of church where his sexual orientation was likely to lead to him not having a future in that church. While Dr Craddock’s clinical skills are a valid cause for concern, the major wrong here is that he attempted to cure his patient of his homosexuality with a drug that is used to help those who have committed serious sexual offences.

The Court might say that its primary role in such cases is to deliberate upon the evidence that it has before it and to make the most robust finding that it can. Dr Craddock admitted the lapses in his clinical skills and this made the Court’s job relatively straightforward. But perhaps judgments about this kind of event are more significant than merely substantiating guilt or innocence. The wrong in this case was that Dr Craddock misused his ability to prescribe and this hearing was an opportunity for the Medical Council of NSW to state that this also constituted a departure from appropriate professional judgment. I wonder what the patient who made this complaint made of this finding, was his primary concern about the how and where of this medical consultation?


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4 Comment on this post

  1. Very interesting post, thanks John. I have a few half-baked thoughts about it, which you should feel free to stick a fork into. This is a guess, but I wonder whether the Medical Council restricted their evaluation to clinical matters to avoid what seems to me to be a rather complicated debate about what the wrongs may be in this case.

    There do seem to be reasons to doubt the validity of the patient’s consent to this treatment – the highly communitarian religious community, the age of the patient, the fact that he was presumably psychologically distressed and away from close family support. These are clear and strong grounds for criticising the doctor’s conduct.

    Another possibility is that it is wrong for the doctor to use Cyprostat “off-label” to treat homosexuality. It certainly seems like a way to cure a patient of all sexuality, not just to alter sexual orientation from homosexual to heterosexual. Another, and related possibility, is that it is wrong to treat homosexuality as a disease. These seem to require more information to evaluate. A patient who had higher order preferences which conflicted with their homosexuality, and was suffering greatly because of this, may wish to be prescribed a drug that diminished their sexual thoughts, allowing them to satisfy their higher order preference. If we assume that the higher order preference is well-formed (i.e. reflectively endorsed and with a meaningful possibility of changing the preference if it is not endorsed – both of which are called into question by the issues of consent above), and we assume that less aggressive measures for altering the homosexual preference have failed, it seems that prescribing the drug would be beneficial to well-being of the patient.

    There could be reasons to oppose the drug despite the potential benefit it might confer in this case, however. First, some doctors might have values that disincline them to prescribing a treatment such as this and they may conscientiously object, as a Catholic doctor might regarding the provision of abortion services. Second it may be thought that homosexuality is not disease and therefore treating it is not a proper medical matter. However, fertility is not disease and it’s management is accepted as an appropriate use of medicine. Third, it might be thought that it is different from fertility in that its treatment in cases such as the (I would hope very uncommon) example I imagined above could be interpreted to support negative social evaluations of homosexuality as being a disease, or disease-like.

    Finding the doctor guilty of lapsed clinical standards might be a quicker and less controversial option than getting into these sorts of issues.

    As a side note, Robert Veatch visited the Bioethics Centre last year and gave a talk about what he saw as the future of patient-centred medicine. He suggested that patients and doctors should be matched according to their ‘deep values’, so that patients could receive the medical care that suits them best. The case you discuss seems rather like this – perhaps in a superficial way, at least, since the authenticity of the patient’s values is in question. It’s a nice example of how such a system could undermine autonomy in some cases, rather than promote it as Veatch seemed to envision.

  2. Hi Mike, many thanks for the reply, you’ve plucked out some of the more interesting and controversial philosophical issues that I side stepped in my first post!
    It seems plausible to suppose that the Medical Council did avoid the harder questions so as to avoid saying something contentious. Another possibility, that David Worswick (a law lecturer here), suggested is that they might have been mindful that litigation could follow this judgment so were playing it safe in that way. Even so, I think they should have said something about the significant wrong, or lapse in professionalism here, which is that a GP should not be treating the homosexuality of an 18 year old by chemically castrating him.
    Yes, I agree with your points about age etc. If he had been 35, and worked to change his sexual preferences for a number of years so that there was a clear, firmly held preference then the argument becomes harder to make.
    I hadn’t thought much about the relevance of the disease debate for this case. This is partly because I have been writing about castration for sex offenders and many of them would not be considered to have a disease either. If anything that comparison makes what happened seem even worse.
    On the Boorse account of disease, which Norman Daniels continues to endorse, homosexuality is a disease. That’s certainly not my view, but even if it were true, I’m not sure that it would make much difference to the defensibility of what Dr Craddock. I think it is the implicit assumption that homosexuality is something immoral, like being a sex offender, that is more likely to be lurking behind this.
    Of course, this is all speculative, but it is one of the reasons why I think the Medical Council should have taken this issue head on.
    I wasn’t aware the Robert Veatch had been developing a position along those lines. It’s something I would like to think about some more. It is one of those ideas that seems on the face of it intuitively appealing, but it probably wouldn’t be hard and might be quite fun, to come up with a series of real world hard cases for this. This situation might be one, the female genital mutilation cases that are currently being considered in Australia might be another. It is illegal in Australia to provide any form of female circumcision or genital mutilation, even to competent adults.

  3. Please bear with me, I am no expert on this topic, but here are some thoughts (also “half-baked”). In regard to your first issue, it seems necessary, to me, that the Court would spend time deliberating the importance of religion in this case. You say that the legislation states that in order for there to be a breach of professional conduct it must be conduct performed at a lower level than expected. This certainly doesn’t instantly lend itself to including a practitioner’s religious beliefs as evidence of his misconduct. However, if the underlying reason for that misconduct is a misguided belief brought about by religious indoctrination it goes some way to showing why the knowledge, skill, or judgement possessed was so markedly different from standard practice. So, on the one hand, someone might argue that religious affiliation in this case makes no odds because what the doctor did was wrong regardless; as you said, he coerced a young man into taking a drug for a controversial purpose. But, on the other hand, merely looking at the fact that his conduct fell short of demonstrating the level of knowledge, skill, judgement, and care we would expect of someone at that level doesn’t go far enough. It is right to ask why this happened. What possible reason could he have had that would lead to such misconduct? In this case Dr Craddock had a (false) belief about homosexuality and its ‘treatment’ which are in line with his religious beliefs.

    Regarding the second point, the Court did not deal to the issue that is at the heart of this case. I’m not a legal expert so can’t comment in that respect. I will, however, put up a philosophical possibility (more as an exercise in reasoning than anything, because it’s certainly not my view). I have some sympathy with Mike’s comment above; in that I do think that the notion of homosexuality being a disease is at play here. You state that you hadn’t really considered the relevance of the disease debate as the castration of sex offenders would not be carried out because they have a disease. But if we can agree that Dr Craddock’s religious views are a factor in this case then we must also allow for the inclusion of the (false) belief that homosexuality is a disease. You opine that what is more likely “lurking behind” this case is Dr Craddock’s belief that homosexuality is something immoral, and while this probably is the case, it is not necessarily at odds with him also holding the belief that it is a disease that can be cured. It would be perfectly consistent, I would think, for someone to hold the position that God created a man and a woman with the intent that they would reproduce, therefore, if someone was born without the desire to maintain that fundamental aspect of God’s creation then that person must be defective and in need of correction. If a doctor, working from that framework, found himself with the power to do that ‘correcting’ he might feel compelled to act in that way. Unfortunately, for those of us who find that line of reasoning utterly abhorrent, defeating it isn’t easy. We can’t prove that God does not exist, so we would be unable to convince Dr Craddock that his conduct was wrong by that account. Nor can we state categorically, and definitively, that scientifically speaking there will never be any way to ‘turn off’ homosexuality (the implication being that if we could flick some sort of genetic switch then that gene was defective, thereby allowing homosexuality to be categorised as a disease (I’m aware of the dubious logic here)). So, given the philosophical intricacies of a case like this I can see why this particular Court shied away from the real issue. It’s because it’s not nearly as simple as saying Dr Craddock did something wrong because his belief was false (hence why I’ve been bracketing ‘false’ –we only hope it’s false). More work needs to be done to combat the underlying belief, firstly in God, no small feat there, then if it were still necessary we could look at homosexuality as a disease – but I suspect that might not be of so much import if we manage to achieve the first part. Alternatively, we could hope, more realistically, that a higher Court picks up this cause and successfully argues that treating homosexuality as a disease is discriminatory, an affront to personal freedom, and is ultimately dangerous.

  4. Hi Stacey, thanks for this, you’ve made some useful points here that will further my thinking about this.

    Your first point is a good one: the legislation does imply that ‘knowledge, skill, judgment possessed or care exercised’ must fall below a standard that is expected of a medical professional. Dr Craddock’s lapses in clinical skills were not only admitted, but also clearly fell below the expected standard. Thinking that it is appropriate to treat an 18 year old man for homosexuality with this medication might plausibly be thought of as indicating problems in knowledge, judgment or care, but because it is less obvious how this kind of lapse might be of a lower standard, as opposed to just unacceptable, then it might have been a stretch for them to grasp the bull by the horns and criticize him for this reason. While applying the legislation, deliberating in a fair way upon the cases before them and working towards sound legal decisions is a key part of their task, I think they also have a more normative role in communicating with doctors and the public about what the core professional values of the profession are.
    I think they could and should have interpreted this so as to include radical departures from acceptable knowledge, judgment or care. By striking him off because his skills weren’t at the appropriate standard, counterfactually, that implies that if he had chemically castrated this young man after doing a proper history, exam, follow up and his clinic etc, that it would have been acceptable for him to do so.

    Yes, I agree, I think Mike was right to raise the concept of disease point here. I think more digging probably would need to be done to reach a more informed view about that. If it is true that homosexuality is a disease (which it isn’t!) then maybe it would add some legitimacy to using medications so as help those who wanted help to control their sexuality do so. And you must be right that someone could hold that it is both a disease and immoral. On the other hand, I think (and there will be others who have a more informed view about this than me) that the major problem that some religions have with homosexuality is not that it is a disease, but that they think (falsely!) that it is immoral. You’re right, I need to do more to make that claim good, but I think I’m probably right.

    I’m not convinced that we would have to show that God does not exist to defeat that argument. I also don’t think it would follow from a fact about being able to modify sexual preference via genetic manipulation that homosexuality is a disease: we can just as easily cause disease via genetic modification. Many Christians and people from other religions would argue that there are no sound theological grounds for viewing homosexuality as a disease or immoral. What I think you put your finger on here is my implicit, but not stated view, that personal values often need to be put to one side when there are overarching professional values that a Medical Council shouldn’t be afraid to state.

    I don’t know whether this case might reappear in another court, it might end up being litigated, I suspect (but don’t know) that it’s unlikely that it will be considered by a higher court who will grasp the nettle. I still think the Medical Council should have said more!

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