The intersection of recent social and legal events with psychiatry highlights the potential contribution of mental health studies to legal and social ones. In this article, I examine four such cases that stirred debate in 2013.
1) Official Statements on Homosexuality Made by the Lebanese Psychiatric Society (LPS), and the Lebanese Psychological Association (LPA)
For the first time in the Arab world, mental health professionals publicly declared in these statements that homosexuality is not a disease, but rather, it is only a sexual orientation. Based on decades of multiple empirical studies (APA, 1987), homosexuality cannot be considered pathological. Moreover, no precise biological, genetic, familial or psychological etiology has been found.
Persons with homosexual orientation may suffer from psychological conditions like everyone else, but studies have shown that these conditions among homosexuals are mostly due to their perception of being the target of stigma, exclusion and marginalization, as well as the shame that follows, thus leading to a higher risk of anxiety and depression (Meyer, 2003).
This public announcement by Lebanese professionals took place in the wake of the “shame examinations” affair, in which medical doctors took part. The August 2012 incident in which a group of arrestees were submitted to shameful examinations to “prove their homosexuality”, led the Lebanese Order of Physicians to issue a statement forbidding any doctor from performing such exams. Unfortunately, the extent to which physicians have abided by this statement remains unclear.
Moreover, some mental health professionals claimed via media outlets that they are able to “cure” homosexuality by conversion therapy. Mental health professionals pointed out that these claims were not supported by scientific evidence and that this kind of therapy can even be deleterious for the person by reinforcing his/her perception of being ostracized, as shown by decades of research studies (APA,1987).
However, is the declaration by medical professionals that homsexuality is a normal state sufficient to make it “natural” by law? Indeed, in Article 534 of the Lebanese Penal Code criminalizing homosexuality, the law punishes any “sexual relation that is contrary to nature”, and does not specify what this means. The concept of “contrary to nature” is itself nonsensical from a purely medical or biological point of view. Studies tend to demonstrate that nature favors multiplicity and variety, rather that standardization/homogenization of sexual orientation and sexuality in general.
2) The Impact of Maltreatment and Exploitation of Foreign Domestic Workers (FDW) on Their Mental Health.
For the first time in Lebanon in 2013, a legal complaint was filed against an employer for provoking a suicidal attempt by a FDW due to continuous ill-treatment. Previous cases concerning suicidal attempts among FDWs were immediately closed and never investigated.
Studies on the Risk Factors of Suicide Reveal the Following Factors:
The presence of a pre-existing psychiatric disorder, especially a depressive or psychotic disorder;
Severe emotional distress in the absence of any previous psychiatric condition, following the chronic exposure to a stressful environment (suicide is then perceived as the only possible way of escape); and
Adverse socio-economic conditions and a more global context of political oppression.
Conditions of abuse, maltreatment and exploitation constitute essential risk factors for severe psychiatric conditions, as well as for severe emotional distress (Thompson et al., 2012). This has been demonstrated by neuroscience studies (the concept of dynamic brain), as well as epigenetics, demonstrating the constant interaction between the genetic potential of the individual and the environment. Furthermore, individuals who have pre-existing psychiatric disorders are even more vulnerable in the face of maltreatment and abuse that constitute risk factors for relapse.
Therefore, a suicidal attempt by a FDW does not absolve the employer of his/her responsibilities, in case a FDW had suffered from maltreatment. It is thus important to investigate the history of abuse after every suicidal attempt or suicide and take it legally into account.
Suicidal behaviors can still occur in the absence of abuse/maltreatment. The work conditions of a FDW, the restrictions imposed on their freedom as well as the prohibition of access to certain public places, are violent and demeaning forms of social discrimination and racism, and constitute risk factors for suicidal behaviors among immigrants (Bursztein Lipsicas, C. et al., 2012).
Moreover, psychiatric hospitalization of foreign domestic workers is usually performed in the absence of any legal supervision. Psychiatrists prescribe electroconvulsive therapy (ECT) more frequently, as well as higher dosages of medications for patients that are FDW in comparison to Lebanese patients (Zahreddine et al., 2013). The patient is then immediately sent back to their native country, along with the psychiatrist’s report. The hospital and the medical system are thus contributing to the rapid deportation of FDWs and the lack of investigation of the employer in question.
3) Decriminalization of Drug Users and the Recent Application of the Principle of Treatment Instead of Prosecution, Following the Activation of the Committee for Combating Addiction.
This decriminalization is based on neurobiological and psychosocial studies that have established that drug addiction is a disorder with a neurobiological basis, reinforced and maintained by the effects of the substance on the brain and by psychological and social factors.
There are evidence-based treatments for disorders relating to substance use, like cognitive behavioral therapy (based on contingency management, prevention of relapse and reinforcement of motivation), as well as opiate substitution treatment (OST), in the case of heroin addiction. OST has been proven to significantly reduce relapse and facilitate the process of social reintegration of the addicted person (Faggiano et al, 2003).
By decriminalizing substance use disorders and giving the right to any drug user to benefit from free treatment, the law finally becomes consistent with scientific data, and prevents stigma caused by detention and incarceration.
4) Orphanages or “Care Institutions” Serving Impoverished Rather than Orphaned Children
This matter was broached following the Mansour Labaki case, which raised the question of the frequency of sexual abuse in care institutions. Placements in orphanages as a substitute for parental care has been demonstrated to have serious deleterious impacts on child development (Johnson et al., 2006). These include:
A higher risk of infectious morbidity among children (notably, due to conditions of promiscuity in the institution);
Nutritional deficiencies and growth delay;
Delay in cognitive and psychomotor development;
Attachment disorders and delay in social and affective development; and
A higher risk of sexual and physical abuse (promiscuity, lack of supervision).
Even when the child is not a victim of physical/sexual abuse in the institution, s/he will not be able to receive individualized care and attention in an institutionalized setting. Child development in all its aspects (physical, emotional, social and cognitive) needs environmental stimulations and a personalized interaction with available and emotionally invested attachment figures.
Results of decades of studies demonstrate that it is far more beneficial for the child to stay within the family environment, with specific intervention programs based on parental guidance. This is essential in order to improve parental skills in the presence of psychosocial adversity, as well as long term social assistance for the family.
In conclusion, numerous social attitudes and legislative facts are inconsistent with international medical and scientific data. Psychiatry can shed light on certain aspects and eventually guide legal decisions. This needs a multidisciplinary collaboration that begins with raising awareness among law professionals on the contribution of human sciences in the above mentioned cases, as well as awareness among medical doctors of their legal obligations.
To view the Arabic version of the article, click here
American Psychological Association. (1987). Policy Statements on Lesbian and Gay Issues. Washington, DC: Author.
Bursztein Lipsicas, C. et al. (2012). Attempted Suicide Among Immigrants in European Countries: an International Perspective. Social Psychiatry and Psychiatric Epidemiology, 47(2): 241-51.
Faggiano F et al. (2003). Methadone Maintenance at Different Dosages for Opioid Dependence. Cochrane Database Systematic Review, 3: CD002208.
Johnson, R. et al. (2006). Young Children in Institutional Care at Risk of Harm. Trauma Violence Abuse, 7(1): 34-60.
Thompson R et al. (2012). Suicidal Ideation in Adolescence: Examining the Role of Recent Adverse Experiences. Journal of Adolescence, 35(1): 175-86.
Zahreddine, N. et al. (July, 2013). Psychiatric Morbidity, Phenomenology and Management in Hospitalized Female Foreign Domestic Workers in Lebanon. Poster session presented at the 21st World Congress of Social Psychiatry, Lisbon, Portugal.