How should religious therapists handle gay and lesbian clients?

Counselors and therapists with strong religious beliefs sometimes refuse to treat gay and lesbian clients. Some even refuse to offer referrals. Can they do that?                                                                                                               

So-called "conscience clauses" are common in health care. They allow professionals to refuse to provide a service within their scope when that service would conflict with the professional's moral or religious values. In reproductive health, for example, this allows gynecologists to refuse to perform abortions, and allows pharmacists to refuse to distribute birth control, if they find these objectionable.

Such provisions are controversial. The Obama administration has moved to (mostly) end them in federally-funded facilities, and there have been several instances where patients have been harmed -- and then filed lawsuits -- over treatment refusals based on conscience clauses.

The debate is now coming to mental health, as a result of religious therapists and students taking a stand against treating gay and lesbian clients. These cases point to an interesting contradiction in professional ethical codes:

• Mental health professionals do not discriminate based on sexual orientation.
• Mental health professionals do not treat clients outside of their scope of competence.

Though the specific wording varies, versions of those statements can be found in the ethical codes of every major mental health association. When a religious therapist, whose beliefs suggest that homosexuality is immoral[*], is asked to treat a gay or lesbian client (or couple), what should the therapist do?

Offering treatment would abide by the non-discrimination sections of professional ethical codes, but could lead to ineffective -- or even harmful -- treatment. Religious therapists who, perhaps by their own choosing, lack the training and experience to work effectively with gay and lesbian clients then should not ethically be treating those clients. On the other hand, refusing to treat a client based on the client's sexual orientation seems to be quite clearly discriminatory.

On issues like this where different parts of a code of ethics conflict, the ethical codes generally do not indicate which standards should take precedence over others. (They also do not allow exceptions based on the therapist's religious beliefs.) The NASW Code even includes a clear statement that it does not prescribe such an ethical hierarchy, as ethical decision-making is centered around process more than outcome. So no one really knows whether it is ethical for a therapist to refuse to treat clients in same-sex relationships.

Again, allowing a health care provider to refuse to treat clients based on the provider's religious beliefs is common in other fields (Pharmacy | Medicine), but it comes with an important caveat: The provider usually must give the patient a referral to another provider who would offer the treatment in question. In theory, that should resolve the issue; patients get the services they need while providers maintain their religious convictions. In practice, it only works if that other provider is close at hand. Patients refused services based on religious "conscience clauses" in rural areas, as well as those needing to be treated immediately for the treatment to be effective, are left without options when their provider refuses to treat them for religious reasons -- which is precisely why many states put exceptions in their "conscience referral" legislation or simply do not allow such referrals.

Some states already have "conscience clause" laws on the books that do not require any referral at all, which has drawn protest from professional associations who worry that they allow a health care provider's religious beliefs to "run roughshod over the profession’s code of ethics." In the Lincoln (Nebraska) Journal-Star, Rev. Christopher Kubat presented the case that religious therapists should be able to turn away same-sex couples without offering referrals:

Since the Catholic Church teaches that sexual relations are meant for one man and one woman in the context of marriage, if a same-sex couple requests therapy to support, validate or enhance their sexual relationship or something akin to marital therapy, it would be inappropriate to provide that specific, narrow service or make a referral for it, as referring for something considered inappropriate or immoral would itself be inappropriate and immoral because of the element of cooperation.

That strikes me as blatantly discriminatory and harmful to those in need of treatment. It also is theologically consistent.

This is the debate I wish had taken place in CAMFT's rightly-maligned (and eventually disowned) same-sex-marriage issue of The Therapist. I think there is a legitimate concern on both sides. Religious therapists have an ethical obligation not to refuse treatment based on a client's sexual orientation. But how can that treatment possibly in the client's best interests when the therapist's religion precludes them from in any way supporting the client's romantic relationship? It seems unlikely. Is there a workable middle ground?

Proposed legislation in California would attempt to at least partially resolve this issue by ensuring all mental health professionals receive training in working with LGBT populations. That may be helpful when it comes to establishing competence, but likely will not change anyone's religious beliefs.

I do not pretend to have the answer here, though I am optimistic such an answer exists. I wish all clients, regardless of sexuality, could receive competent and accepting treatment anywhere they seek it. I also do not want any of the talented religious therapists I know to feel like they need to betray their religious beliefs to work as mental health professionals. I just wish there were a place for honest, genuine, respectful debate on this issue that could land on some ethics code language on which both sides could agree. Is there a place for that?

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* - For clarity's sake, of course not all religious therapists believe that homosexuality is immoral, or would refuse to treat gay or lesbian clients. I personally know many strongly religious therapists who see no conflict at all in offering their professional services to clients regardless of sexual orientation.