Editor’s note: It is hard to briefly summarize the poignancy, vulnerability, and harrowing beauty of Another Word for Love, an exceptional new memoir from the journalist and podcaster Carvell Wallace, who infuses vignettes of his hardscrabble journey from boyhood to middle age with philosophical ruminations on culture; family, love, sex, inner torment, and just about everything else worth pondering.

In the following short excerpt (printed with the publisher’s permission from a chapter titled “The Finger”) Wallace is a 15-year-old kid in Van Nuys, California, who decides it would be cool to emulate the Black TV detective Sonny Spoon by sidling up to a newspaper box outside a 7-Eleven and copping a free paper off someone else’s quarter. But the indignant quarter-bearer decides to teach Wallace a lesson. —Michael Mechanic, senior editor

I guess I mistimed it or forgot to grab the handle or something because while my hand was in the box the guy tried to slam it shut. He didn’t want me to have a free paper. 

I got most of my hand out, but my finger remained inside the box, trapped between the metal edges of the door. He kept pushing. I didn’t care about the paper anymore. I just wanted my finger out. Neither of us spoke. We looked into each other’s eyes while he pushed with all his weight on my finger, which was now being crushed between the two sharp metal edges of the door and the box. It was a sunny day. I looked for something in his eyes, pity, remorse—maybe if he saw me, saw that I was a child, he would let me go. He did not. I saw a shaking in his eyes, desperate, trembling fear, his face red, his veins popping, his blond mustache vibrating with effort. 

I finally pulled my hand from where it was trapped but not before the flesh was ripped off by the metal, exposing white meat on my middle finger, at first pale and throbbing, then quickly covered in blood, which rose from within my finger like water being squeezed from a dish sponge. A large flag of skin dangled from the bottom of the nail, translucent in the afternoon light. 

We both stood in silence for a moment. Then the man quickly made for his car. “Do you see what you did?” I yelled, waving my finger at him. It was all I could think to say. It felt risky. Confrontational. I normally would not have said anything. I did not like confronting people. But I was shaking. 

He looked at me once more from inside his car, his face flushed, before he backed up and sped out of the parking lot into traffic. 

This was my fault, I reasoned at the time, for wanting to be like a cool detective. What a childish thing to do, playacting stuff I’d seen on a TV show that got canceled after 15 episodes. 

On that day I saw for the first time that there are those who would rather see flesh ripped from a Black child’s body than to see that Black child get away with stealing a newspaper. I looked directly into his eyes. I know what a person like that looks like up close. I know what it’s like when they breathe on you, when they are sweating inches from you, when they are pushing with all their might on you. 

It’s a small thing. My finger healed. I’m not even sure, now, which hand it was. 

But also, a thing like that, it goes on forever. It is almost everything. Not everything, but almost. 

Sometimes I think if you’ve never had a white man look at you the way I was looked at that day, then with all due respect, you may not understand anything, anything at all.

Growing up, Myles Markham always felt like an outsider. Markham was multiracial in small, mostly white Florida towns. And they were queer. “I was swimming in water that told me that who I was, what I was, needed to change if I wanted to be safe,” they say. “I really believed, ‘I am a problem. I need to be fixed.’” 

As a teen, a friend got them interested in evangelical Christianity, which seemed to offer the promise of ­transformation. They joined a church youth group and began studying the Bible. Soon after, Markham found an online forum for a ministry that supports “those affected by unwanted homosexuality.” Markham didn’t identify as transgender at the time, but to their mentors in the conversion therapy program, Markham says, sexuality was inextricable from gender identity. “A woman being attracted to women—she was confused about her gender identity, confused about what it means to be a godly woman,” they explain. “And so what they end up doing, therapeutically, is attempting to police and reform your gender presentation.”

Markham’s experience is far from unique. As professional and legal objections to conversion therapy grew in the 2000s, such “change efforts” were migrated from the clinical realm into religious settings. The vast majority of people who have gone through conversion therapy received it from a religious leader, according to the UCLA School of Law’s Williams Institute. The practice remains shrouded in secrecy, says Simon Kent Fung, a conversion therapy survivor and creator of an award-winning podcast on the subject, Dear Alana. “In religious settings, homosexuality is not just a pathology, but a spiritual brokenness,” he explains. “Conversion therapy today is psychologically manipulative.”

Markham’s time in the ministry’s forums made their emotional state even more fragile. They started experiencing panic attacks almost every day. They would be reading or riding the bus and then be overcome by waves of nausea, a racing heartbeat, and the sense of paralysis. “Something was happening to me internally, where I was [feeling] I was about to die,” they remember. At night, they had terrors of demons suffocating or drowning them.

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First They Tried to “Cure” Gayness. Now They’re Fixated on “Healing” Trans People.

The worse Markham’s anxiety got, the more they became convinced that only God could save them. They enrolled at a small Christian college and found an outside church that offered group therapy. Other members of the group were there to overcome a variety of issues: eating disorders, alcoholism, or depression. “I was there talking about ‘gay,’” Markham recalls bitterly. The counselor, in training to become a licensed practitioner, told Markham to “write out every single same-sex ­attraction or ­gender confusion–related thought, dream, action, behavior that had ever materialized in my life per my memory, and describe the way that it hurt me, it hurt God, and hurt other people.” When they sought help from college administrators, they required Markham to attend biweekly sessions with a women’s chaplain who counseled them on “biblical womanhood” and made them read a book called God’s Little Princess.

At the end of their senior year, Markham received a class assignment to create a plan to convert an “unreached group” to Christianity. They chose LGBTQ people. Conducting interviews with queer students and community members, Markham says, was the first time in their life they developed relationships with out, self-­affirming queer and trans people. 

 




“I fell in love with everybody who consented to doing these interviews with me,” they remember, cracking a smile.




“I just found myself experiencing a sense of comfort, ease, and possibility in the company of other queer people that I did not expect to feel.”

 

Myles Markham in Los AngelesChloe Aftel

When Markham tried to share their feelings, their classmates immediately ostracized them. Markham was banned from participating in school groups, forbidden from leading church services, and pressured to find new housing.

The hostility only deepened their resolve to live an openly queer life. After graduating, Markham took a job living and working at the Equality House, the rainbow-painted protest house across the street from the notoriously anti-LGBTQ Westboro Baptist Church in Topeka, Kansas. They started organizing to pass discrimination protections and prevent youth suicides and met with countless LGBTQ community members. Everything immediately changed. “The night terrors were the first thing that ended,” they say. The panic attacks faded too, eventually. “I was finally in an environment that just allowed me to be who I was.”

They also found a supportive therapist. “It wasn’t just the tools I developed in therapy that [resulted in] this constitutional shift,” they say. “It was once I was comfortable being who I am and being able to share that with other people, and not having to hide, ignore it, or try to diminish it.”

Now, some 10 years later, Markham feels as though the torments of the past are finally put to rest. “I went from a place of constant, albeit quiet, torment into one of vitality,” Markham remembers. “I was able to wake up grateful for my life. I wanted to be alive, and that was something that took me most of my life at that point to be able to say with sincerity.”

The conversion therapists met last November at the south end of the Las Vegas Strip. Behind the closed doors and drawn blinds of a Hampton Inn conference room, a middle-aged woman wearing white stockings and a Virgin Mary blue dress issued a call to arms to the 20-some people in attendance. “In our current culture, in which children are being indoctrinated with transgender belief from the moment they’re out of the womb, if we are confronted with a gender-confused child, you must help,” declared Michelle Cretella, a board member of the Alliance for Therapeutic Choice and Scientific Integrity. “We must do something.”

Cretella was delivering a keynote speech at the first in-person conference in four years of the Alliance, which describes itself as a “professional and scientific organization” with “Judeo-Christian values.” Its purpose: to defend and promote the practice of conversion therapy by licensed counselors.

Not that they’d call what they do “conversion therapy.” That term lacks a precise definition, but it is used colloquially to describe attempts to shift a person’s sexual orientation or gender identity. In the 1960s, some psychologists tried to make gay men straight by pairing aversive stimuli, like electric shocks or chemically induced nausea, with images of gay porn—techniques that ran the risk of causing serious psychological damage even as they failed to change participants’ sexual orientation, researchers eventually concluded. Today, “conversion therapy” generally takes the form of verbal counseling. Participants are typically conservative Christians who engage voluntarily—motivated by internalized stigma, family pressure, and the belief that their feelings are incompatible with their faith. Others are children, brought into therapy by their parents.

The American Psychological Association (APA) has concluded that conversion therapy lacks “sufficient bases in scientific principles” and that people who have undergone it are “significantly more likely to experience suicidality and depression.” Similarly, the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the Department of Health and Human Services, published a report concluding that “none of the existing research supports the premise that mental or behavioral health interventions can alter gender identity or sexual orientation. Interventions aimed at a fixed outcome, such as gender conformity or heterosexual orientation…are coercive, can be harmful, and should not be part of behavioral health treatment.”

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Accordingly, the Alliance and the ideas it promotes have been relegated to the scientific and political fringes. In the 2010s, as acceptance of gay rights grew rapidly, 18 states and dozens of local governments passed laws forbidding mental health professionals from attempting conversion therapy on minors.

Yet by 2020, a new front had opened in the war against LGBTQ people. Republican state legislatures started passing laws targeting transgender and nonbinary children at school—restricting their access to bathrooms, barring them from participating in sports, and stopping educators from teaching about sexual orientation or gender identity. The most intense attacks have banned doctors from providing the treatments for gender dysphoria backed by all major US medical associations. Nearly 114,000 trans youth live in states where access to puberty blockers and hormone therapy has been wiped out.

Last year, I received leaked emails illustrating how these laws are crafted and pushed by a network of anti-trans activists and powerful Christian-right organizations. The Alliance is deeply enmeshed in this constellation of actors. Although small, with an annual budget of under $200,000, it provides both unsubstantiated arguments suggesting LGBTQ identities are changeable and a network of licensed counselors to lend their credibility to these efforts. Among the collaborators were David Pickup, the Alliance’s president-elect; Laura Haynes, an Alliance advocate; and Cretella, the former executive director of an anti-trans pediatrics group who described gender-affirming medical care at the Las Vegas conference as “evil” and part of a “New World Order.” (“I’m not a conspiracy theorist,” she assured attendees. “I’m just someone who has been in the battle of the culture of life versus the culture of death long enough to see the big picture.”) All three have testified before state legislatures against gender-affirming care. When a US senator introduced a pair of bills to restrict trans youth health care in 2021, his press release quoted Cretella calling gender-affirming treatments “eugenics.”

What I couldn’t see from those leaked emails was how the Alliance is resurrecting conversion therapy from the ash heap of history. Its signature fight, to overturn laws prohibiting conversion therapy for minors, is being fueled by the rise of anti-trans politics, which maintains that trans teenagers are simply troubled and need help to embrace the sex they were assigned at birth. In a handful of states, they’ve started winning: Conversion therapy bans have been blocked in Alabama, Florida, Georgia, and Indiana. Nebraska now requires minors interested in transitioning to undergo therapy that doesn’t “merely affirm” their gender identities.

The Alliance has “suddenly become a more prominent force in the anti-LGBTQ movement again,” says Emerson Hodges, a research analyst at the Southern Poverty Law Center, which documents extremism of various sorts. Backers of anti-trans laws have adopted “the conversion therapy premise,” he says, “that being LGBTQ means you experienced some terrible trauma, or some sort of aberrant disorder, and therefore, it’s an illness—which means we can cure it.”

I wanted to get a deeper insight into those who not only see transness as a problem, but also see conversion therapy as a solution. How have they shifted their approach, given the wealth of professional literature undermining their practices? What is their “treatment” like for trans youth? And who are these people?

So when I saw that the Alliance was holding a one-day conference, it seemed like an opportunity to find some answers. I requested media credentials; receiving no response, I bought a regular $203.98 ticket using my Mother Jones contact information. The day before the conference, I received a packet of materials from Alliance board member Keith Vennum, a psychiatrist who specializes in “helping men develop their heterosexual potential,” according to his profile on Focus on the Family’s Christian Counselors Network. They included an article by a gender care specialist who turned against youth medical transition, reading suggestions from Cretella on how to “heal” “transgender belief” in children, and an essay by Fresno psychiatrist Avak Howsepian arguing that supporting “diversity and inclusion” means supporting pedophilia. I packed my bag and flew to Las Vegas.

When I first arrived at the Hampton Inn, a woman smiled and welcomed me to a quiet meeting room where mostly white men in businesswear chatted in small groups like old friends. I signed in and sat next to a large camera pointed at a lectern. The day’s presentations would be available for purchase online and count toward continuing education credits for licensed counselors.

Not that the education on offer would be seen as credible by most therapists. Since the group’s beginnings in 1992, the Alliance has rejected the now-dominant understanding of LGBTQ identities as normal, healthy expressions of human diversity. Its trio of founders includes psychiatrist Charles Socarides, who helped lead the unsuccessful campaign to keep homosexuality classified as a mental illness in the DSM, the bible of psychiatric diagnoses; psychiatrist Benjamin Kaufman, who’d pushed for nonconsensual, nonconfidential HIV testing in Sacramento, California, during the height of the AIDS epidemic; and psychologist Joseph Nicolosi, who ran a clinic in Los Angeles that specialized in “curing” gayness. They started the Alliance, then named the National Association for Research and Therapy of Homosexuality (NARTH), to fight what they called the “scientific censorship” imposed by the “pro-gay lobby.” “As clinicians, we have witnessed the intense suffering caused by homosexuality, which we see as a ‘failure to function according to design,’” one of NARTH’s early policy statements said. “Homosexuality…works against society’s essential male/female design and the all-­important family unit.”

Within a few years, NARTH was claiming hundreds of members. In conferences and publications, it used its members’ status as licensed clinicians to project an ethos of scientific expertise, helping to prop up the “ex-gay” movement of religious groups like Exodus International, which urged LGBTQ Christians to “pray away the gay” in support groups and counseling. Nicolosi, in particular, brought anti-gay pseudoscience to the public, publishing books like A Parent’s Guide to Preventing Homosexuality. He proclaimed that same-sex attraction came from childhood trauma, distant fathers, and overbearing mothers, and called his work “reparative therapy.”

The veneer of scientific rigor was peeling by 2009, when the APA published a landmark report finding no compelling evidence supporting the idea that sexual orientation could be altered with psychological interventions. Robert Spitzer, a leading psychiatrist, apologized for a major study he’d authored that had claimed to show NARTH’s and Exodus’ methods were effective, admitting that he didn’t really know whether anyone in his study had changed their sexual orientation. Then, NARTH board member George Rekers was caught in the Miami airport returning from a vacation to Europe with a gay sex worker he’d hired on Rentboy.com. (He resigned from NARTH and insisted that he had “not engaged in any homosexual behavior whatsoever.”)

Public awareness was growing about the damage conversion therapy could inflict. In a lawsuit against a New Jersey clinic called Jews Offering New Alternatives to Homosexuality, former clients alleged that they’d been made to strip naked, touch themselves in front of a counselor, or reenact sexual abuse scenes as part of their treatment. (A jury would eventually hold the clinic and its NARTH-affiliated founder liable for consumer fraud and “unconscionable commercial practice.”) In 2012, California passed the country’s first ban on conversion therapy for minors. Exodus President Alan Chambers acknowledged that its methods had hurt people and that “the majority of people that I have met, and I would say the majority meaning 99.9 percent of them, have not experienced a change in their orientation.” Exodus folded soon after.

Yet NARTH persisted. In 2014, it rebranded as the Alliance for Therapeutic Choice and Scientific Integrity. The group soon began to shed loaded terminology for more neutral euphemisms about its work. “The board has come to believe that terms such as reorientation therapy, conversion therapy, and even sexual orientation change efforts (SOCE) are no longer scientifically or politically tenable,” Christopher Rosik, a clinical psychologist in Fresno, California, wrote in an Alliance statement in 2016. These descriptors sounded too coercive and categorical, he wrote, and “imply that sexual orientation is an actual entity.” Instead, the board endorsed a new phrase: “Sexual Attraction Fluidity Exploration in Therapy”—a.k.a. the inelegant backronym SAFE-T.

Getting the new name to stick has been a losing battle. During a presentation at the Las Vegas conference, Rosik—a small, intense, bespectacled man who speaks at a rapid clip—shared that he couldn’t get the term SAFE-T published in an APA journal. Mainstream psychologists tend to use a technically accurate term for conversion therapy, “sexual orientation change efforts,” which Rosik has appropriated into “self-initiated sexual orientation change efforts,” to underscore that the individuals he studies are choosing to participate.

During Rosik’s talk, Joseph Nicolosi Jr., the son of the Alliance’s now-deceased co-founder, was seated in the front row in a sharp black suit. At his side was his wife, with whom he occasionally held hands. “We shouldn’t even use the word ‘orientation,’” he argued when Rosik finished. Sexual orientation couldn’t be measured or disproved, he continued, but sexual attractions or feelings could. “They talk about pseudoscience. That term—orientation—is a pseudoscience.”

“I agree,” Laura Haynes, the Alliance advocate, broke in from the back. “We should not reify it.”

“Could the same thing be said of the term ‘gay’?” someone else wondered.

“Possibly,” Nicolosi Jr. said. “At what point is a person gay? Do they have one homosexual thought a year? Fifty? One thousand?”

Earlier in the day, Nicolosi Jr. had told colleagues that he’d registered his own term, Reintegrative Therapy®, with the US Patent and Trademark Office. His website contains a 12-point chart on how Reintegrative Therapy® differs from conversion therapy. The chart makes clear that changing sexual orientation is not the objective; rather, the goal is to “resolve trauma.” “Spontaneous” changes in sexuality are a “byproduct,” the website says. In 2021, Nicolosi Jr. sued a pair of Canadian academics for defamation over a paper that listed “reintegrative therapy” as one of several pseudoscientific practices that fell under the conversion therapy umbrella. (The suit was dismissed on jurisdictional grounds. He is appealing. Neither Nicolosi Jr. nor anyone else from the Alliance responded to my requests for comment on how this article characterizes their work.)

Yet Nicolosi Jr.’s website is full of testimonials about clients’ sexual attractions changing. And it repeatedly cites a study that purports to show Reintegrative Therapy® decreasing clients’ same-sex attractions and improving their overall­ ­wellbeing.­ The study’s publisher? The Alliance’s Journal of Human Sexuality.

Another euphemism in Alliance circles is “change allowing therapy”—a phrase whose gentle ambiguity suggests openness to personal growth. In a similar vein, Michael Gasparro, one of the youngest Alliance board members, told attendees about a technique he and Nicolosi Jr. called “mindfulness,” which they became interested in “because of its ubiquitousness in the mental health field as a term that is generally just accepted carte blanche,” Gasparro explained.

They then showed us a “mindfulness” video in which a young adult client, played by an actor, sits nervously across from Nicolosi Jr. in a room filled with books. Nicolosi Jr. asks him to describe his ideal sexually attractive man. The client responds that the man would be strong, confident, informal. “I would definitely say a guy who’s like, um, on the taller side,” he says.

Then, Nicolosi Jr. asks the client what he would change about himself: Shorter or taller? Stronger or weaker arms? More or less confident? He urges the client to compare himself to the imagined man, and the client says he feels inadequate. “How do you feel about the fact that you feel that inferiority, weakness?” Nicolosi Jr. asks.

“Sadness,” the client says.

“Feel your sadness as you continue looking at that guy,” Nicolosi Jr. urges. “And as you hold them together right now, zero to 10, how strong is your sexual attraction toward him?”

It was Nicolosi Jr.’s dad who championed the idea that queerness comes from childhood trauma, one of the same narratives weaponized today to explain why kids come out as trans. The APA has slammed both ideas as unfounded.

Yet these kinds of claims are familiar to trans survivors of conversion therapy interviewed by Mother Jones. “The idea was that you don’t find boys and men to be safe, and so in order to protect yourself, you want to become a boy or a man,” recalls Myles Markham, who participated in group conversion therapy in high school and college, when they were struggling with their feelings around sexuality and gender. Yet to Markham, those explanations “never resonated,” they say: “I’m not a person who has experienced acute or direct misogynistic violence. I grew up with emotionally intelligent and gentle masculine figures.”

Other survivors say their therapists tried to attribute their transness to negative childhood experiences. “For me, it was daddy issues,” says Arielle Rebekah, a diversity, equity, and inclusion trainer in Chicago, recounting how counselors at a residential boarding school for troubled teens tried to force them to abandon their trans identity. “They basically tried to pin it on, ‘You’ve never had a positive male role model.’” Lillian Lennon, a 25-year-old organizer in Alaska, says her parents sent her to a similar residential program after she told them she was trans at age 14. According to an affidavit she filed in a custody lawsuit involving another LGBTQ student, the therapist Lennon was paired with at the school said her transness was a form of “lashing out” and “seeking attention” in the face of turmoil at home, such as financial problems and her parents separating.

None of this therapy “worked.” Today, Lennon, Rebekah, and Markham have all transitioned and have become activists or consultants supporting other LGBTQ people. Yet they all still deal with nightmares, panic, and other mental health struggles they attribute to the conversion efforts. “A lot of thoughts [were] placed into my head about how disturbing and gross and creepy people like me were,” Lennon says. “I internalized a lot of these projections.” Today, she deals with depression and loneliness. “I’ve never shaken the consequences of my time there,” she says.

Still, multiple counselors I met at the Alliance conference endorsed the concept that queerness and transness are the result of trauma or bad parenting. After the morning’s sessions, David Pickup, a towering man who identifies as a “reintegrative” therapist, approached the table where I was sitting with a group of clinicians. Pickup mainly practices in Texas and says he only works with clients who truly want to change their sexuality or gender identity. He has publicly attributed his own same-sex attractions and discomfort with his gender in part to sexual abuse. Pulling aside a chair from a neighboring table and folding his lanky frame into it, he patiently explained his belief that being trans is the same as being gay, except with “more severe” trauma, from earlier in life, and worse family environments. “I have yet to see one case where there’s not been trauma underneath every single homoerotic or transgender issue.” His theory on trans youth: “Basically, what happens is those kids don’t attach to their same-sex parent, and so they don’t attach to themselves in their own biological sex.”

At her session, “Healing Gender Incongruence in a Hostile Environment,” Cretella also urged attendees to focus on parenting and underlying trauma when working with trans teenagers. She described trans identity as a “maladaptive defense mechanism” in response to events like divorce and sexual abuse.

Her evidence: a 2018 Pediatrics study that examined medical records from youth enrolled in Kaiser Permanente health plans in California and Georgia. The researchers identified 1,082 minors between the ages of 10 and 17 whose records indicated that they were trans. Some 70 percent had mental health problems like depression, anxiety, and attention disorders that predated the first sign of gender dysphoria in their medical record. “They are not suicidal because of us,” Cretella said, giggling before hitting a somber note, “but because they are traumatized beforehand.”

Cretella’s interpretation of the research—that poor mental health led people to identify as trans—relies on a “fundamental” error, according to Michael Goodman, an Emory University professor and one of the study’s authors. Researchers, himself included, didn’t know when their subjects first identified as trans, only when they talked to their doctors about it. “It takes years, usually, before the child or adolescent, or an adult, presents to the health care provider with gender dysphoria issues,” Goodman told me. “It might as well be the other way around: The gender dysphoria leads to all of those mental health problems, which is a far more reasonable interpretation.”

Yet Alliance affiliates have been using Goodman’s research to lobby against conversion therapy bans and gender-affirming care. In 2019, Laura Haynes distributed his paper to colleagues working on anti-trans legislation. “It may be the first research that found onset dates of psychiatric disorders and first-evidence date of gender non­conforming identity,” she emphasized.

“Laura, thank you! I’m testifying soon for a case in Colorado and this data will be very useful,” replied psychiatrist Miriam Grossman, a senior fellow at the anti-trans group Do No Harm. A group co-founded by Pickup called the National Task Force for Therapy Equality drafted letters to legislators citing Goodman’s study to claim that “gender dysphoria may have pathological causes.” And when Pickup testified in support of an early gender-affirming care ban in South Dakota, he said there was a “rapidly growing body of literature suggesting that psychological issues play a crucial role in many young people’s trans identification.”

This isn’t the only example of scientific spin from Alliance figures. Last year, in what he called an “adversarial collaboration” with queer researchers, Rosik got a study published in the peer-reviewed APA journal Psychology of Sexual Orientation and Gender Diversity. The paper looked at attempts to “reduce, change and/or eliminate” same-sex attractions, behavior, or orientation, either on one’s own or with a counselor, and found that 326 people currently undergoing conversion therapy had greater depression than those who’d stopped or never tried it. Yet Rosik and his co-authors concluded that the differences “may be of uncertain practical significance and interpretive meaning.”

It didn’t take long for others to point out the contradiction. “Basically, what they were saying is that even though there’s [evidence] of harm, the harm isn’t grave enough to be concerned about,” explains David Rivera, a psychology professor at Queens College in New York who co-authored a rebuttal to the Rosik paper. Soon, with the authors’ agreement, the journal retracted the study, saying it wanted to provide “greater accuracy and interpretive clarity to sensitive findings that might be misused.”

Rosik is used to fighting criticism: He edits the Alliance’s Journal of Human Sexuality. The very first issue, in 2009, was devoted to rebutting the APA report on the lack of evidence behind sexual orientation change efforts. Since then, its articles, interviews, and book reviews have defended “SAFE-T” and attacked the anti–conversion therapy consensus. At the conference, Rosik asserted that mainstream research institutions are “ideologically captured.”

Indeed, many of the Alliance speakers seemed to take it as a given that the medical and scientific communities were in thrall to LGBTQ activists. In a question that seemed intended to ridicule, Pickup asked during one of Cretella’s talks if the doctors who provide gender-affirming care to trans youth are personally “suffering from a disorder of some kind.” Appreciative laughter scattered throughout the room.

“Yes,” she replied, becoming serious. “Many of the physicians who are in leadership positions are themselves on the LGBTQ spectrum.” Then she referred to the disorder in which a caregiver imposes an ailment on a child to gain attention for themselves: “I would hypothesize that we were dealing with Munchausen by proxy in many cases.”

Outrageous claims like these are a common weapon among anti-trans activists and their right-wing political allies, who often describe trans health doctors as butchers mutilating kids. In 2022, Texas Attorney General Ken Paxton classified gender-affirming care for minors as a form of child abuse and equated parents who sought such care for their children with those suffering from Munchausen syndrome by proxy. Using this theory, Texas’ Department of Family and Protective Services opened at least nine investigations into parents before an ACLU lawsuit put a halt to them.

Similarly extreme language also comes from the small cohort of paid expert witnesses often called upon to support gender-affirming care bans—like endocrinologist Michael Laidlaw, who compared such care to Nazi experimentation and the Tuskegee syphilis study when testifying for anti-trans legislation in South Dakota. (In a court case about Medicaid coverage of gender-affirming care in Florida, a federal judge concluded that Laidlaw was “far off from the accepted view” on transgender issues, in part because Laidlaw had said he wouldn’t use patients’ correct pronouns.)

To Cretella, the solution to gender dysphoria is obvious: Transition people’s minds, not their bodies. She described this project in religious terms. “In a Judeo-Christian worldview,” she explained during her talk, “one of the functions of the brain is to accurately perceive” the physical reality created by God.

“If my thinking is contrary to physical reality, that’s the abnormality that must be understood,” she continued. “We try to ­understand the abnormal thinking and come to help the person attain flourishing, by analyzing and shaping thinking to embrace the physical reality.”

In other words, if a person’s sense of self doesn’t match their physical body, their sense of self requires fixing.

During the break after Cretella’s presentation, I overheard two women chatting on their way into the restroom. “Talk about a wealth of knowledge,” one remarked.

“True science will always back up true religion,” the other replied. “God’s truth and science, if it’s true, will always match up. That’s what I tell my students.”

If the Las Vegas conference made one thing clear, it’s that conversion therapy is alive and well, even in places where it’s been banned. One counselor told me he makes it a habit not to document his treatment plans in writing to avoid getting in trouble and simply treats “family dynamics” in states with conversion therapy bans.

In a 2015 survey of more than 27,000 trans adults, nearly 1 in 7 said that a professional, such as a therapist, doctor, or religious adviser, had tried to make them not transgender; about half of respondents said they were minors at the time. By applying this rate to population estimates, the Williams Institute at UCLA projects that more than 135,000 trans adults nationwide have experienced some form of conversion therapy.

Despite the data, lawmakers frequently don’t believe that conversion therapy is still happening in their community, says Casey Pick, director of law and policy at the Trevor Project, the LGBTQ suicide prevention group. “We’re constantly running up against this misconception that this is an artifact of the past,” she says. So, five years ago, the Trevor Project began scouring psychologists’ websites and books, records of public testimony, and known conversion therapy referral services, looking for counselors who said they could alter someone’s gender identity or sexual orientation.

As the research stretched on, Pick noticed webpages being revised to reflect changing times. “We saw many folks who seemed to leave the industry entirely,” she says. “But others changed their website, changed their keywords, [from] talking about creating ex-gays to talking about ex-trans.” Last December, Pick’s team published their report documenting active conversion therapists. They found more than 600 were licensed health care professionals and an additional 716 were clergy, lay ministers, or other unlicensed religious counselors.

According to Pick, some conversion therapists have embraced a new label for what they do: “gender exploratory therapy.” It’s a term that Cretella used to describe the approach she recommended, and unlike the other euphemisms thrown around at the conference, this has gained traction. In 2021, a group of therapists, who ranged from conflicted about medical interventions for kids with gender dysphoria to skeptical of the very concept of transgender identity, formed the Gender Exploratory Therapy Association (GETA) to promote an approach they characterize as neither conversion nor affirmation.

Some current and former leaders of the group, which claims a membership of 300 mental health providers, have been involved in influential organizations lobbying against gender-affirming care across the world, such as the Ireland-based Genspect and the Society for Evidence-Based Gender Medicine, a nonprofit registered in Idaho. They’ve notched some big wins: In November 2023, the UK Council for Psychotherapy—the nation’s top professional association—declared that it was fine for counselors to take GETA’s “exploratory” approach to gender. This April, a long-awaited review of gender-related care for youth in England’s National Health Service endorsed exploratory therapy, according to Alex Keuroghlian, an associate psychiatry professor at Harvard Medical School. And in the United States, in cases in which families of trans children have sued states for banning gender-affirming care, the state often calls expert witnesses who endorse “exploratory” psychotherapy as their preferred alternative treatment.

After all, the idea of “exploring” one’s gender identity sounds benign. The World Professional Association for Transgender Health, which issues guidelines on gender-­affirming treatment, recommends that clinicians working with teens “facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.” Yet, as with mindfulness, “that term has now been hijacked by folks on the other side,” says Judith Glassgold, a clinical psychologist who chaired the APA task force that in 2009 documented the lack of science behind conversion therapy.

GETA’s guidelines instruct therapists to dig deep into “the entire landscape of the young person’s life and subjective experience,” probing all possible reasons they might identify as transgender. The catch, says Glassgold, is that “exploration” means “trying to find negative reasons why someone’s diverse.” Last year, SAMHSA issued a report saying that “approaches that discourage youth from identifying as transgender or gender-diverse, and/or from expressing their gender identity” are sometimes “misleadingly referred to as ‘exploratory therapy.’” These approaches are “harmful and never appropriate,” the report concluded.

GETA rebranded as Therapy First late last year, saying exploratory therapy was really no different from standard psychotherapy. The group’s membership statement still disavows conversion therapy. But its co-founder Stella O’Malley told me she believes bans on conversion therapy should apply only to sexual orientation. And in Las Vegas, Cretella drew a direct connection between the old work of the Alliance and the new work of gender-exploratory therapists. “It truly is very similar to how the Alliance has always approached unwanted SSA [same-sex attraction],” she told the assembled therapists. “You approach it as ‘change therapy’—or, even less triggering, ‘exploratory therapy.’”

At lunch, I headed over to a discussion convened by Robert Vazzo, a red-faced man with a buzz cut. While picking at his rice pilaf, he recalled working with a trans-feminine 14-year-old. Vazzo referred to them as a “young man” who “complained of being trans.” He complimented their biceps and tried to get them to be “more assertive” with their mother. The goal, he explained, was to get the teen to connect with some inner masculinity. “The bulk of our work is trying to get people to value who they really are,” Vazzo told me. “Who they really are,” in this view, is cisgender.

In 2017, Vazzo filed a lawsuit against the city of Tampa, Florida, after it imposed a fine on licensed counselors who attempt conversion therapy on minors. Vazzo says he was represented pro bono by the Christian-right law firm Liberty Counsel, which also represented Kim Davis, the Kentucky clerk who refused to grant marriage licenses for gay couples in 2015. Liberty Counsel argued that the city was infringing on Vazzo’s right to free speech, because his treatment consists of talk therapy. In late 2019, a federal judge appointed by former President Donald Trump agreed with Vazzo and overturned the Tampa ordinance, concluding that the state, not the city, should determine health care regulations and discipline.

Between 2012 and 2023, the Alliance and connected groups filed a combined 11 federal lawsuits challenging conversion therapy bans in eight states. Vazzo’s was the first to succeed. The next year, the 11th Circuit Court of Appeals shut down a similar ordinance in Boca Raton, Florida, which had been challenged by former Alliance President Julie Hamilton and another therapist. The court concluded that it violated the First Amendment. The decision blocked youth conversion therapy bans in Alabama, Florida, and Georgia.

So far, the 11th Circuit is the only federal appeals court to agree with the idea that conversion therapy is protected by the First Amendment, says Shannon Minter, legal director of the National Center for Lesbian Rights. Minter notes that federal courts have previously considered clinicians’ words in mental and medical health care settings to be a form of professional conduct and fair game for state regulation.

At the time of the conference, the Supreme Court was deciding whether to hear a similar case brought by Brian Tingley, who sued Washington state with the help of the Alliance Defending Freedom, the powerful conservative Christian legal organization behind many recent anti-trans bills and attacks on abortion, in order to practice conversion therapy. The Supreme Court declined to take the case, but a similar lawsuit, also filed by ADF, is making its way through the Colorado court system.

In his dissent to the court’s decision not to take the Tingley case, Justice Clarence Thomas, joined by Justice Samuel Alito, described bans on conversion therapy for minors as “viewpoint-based and content-based discrimination in its purest form.” Thomas even foreshadowed a future ruling overturning conversion therapy bans: “Although the Court declines to take this particular case, I have no doubt that the issue it presents will come before the Court again. When it does, the Court should do what it should have done here…consider what the First Amendment requires.”

Meanwhile, the fight over conversion therapy bans is continuing in state legislatures. In 2023, Indiana passed a law halting enforcement of local bans. This year, legislators in two more states, Iowa and West Virginia, introduced similar bills.

The West Virginia bill went further than the one in Indiana—attempting to stop mental health professionals from providing anything except conversion therapy to trans minors. The bill, which suggested trans people have “delusion[s],” would have prohibited providers “from attempting to induce or exacerbate gender dysphoria in a minor…with no intent of cure or cure-pursuing recovery.”

That measure failed. But in Nebraska, a similar—though less explicit—bill has already become law. The “Let Them Grow Act,” passed last year, mandates that trans kids receive therapy before they get any medical treatments for gender dysphoria. On its face, the law appears to preserve some access to treatments; its language emphasizes the need to protect kids. “What we got was a version that ends up sounding more compassionate,” says Abbi Swatsworth, the executive director of OutNebraska, an organization that coordinated community opposition to the bill. “But in actuality, it is much worse.”

After it passed, Nebraska’s health department was tasked with issuing guidelines on implementing it. The state’s chief medical officer, Timothy Tesmer, an ear, nose, and throat doctor, assembled a team of “experts”—but didn’t include anyone who specialized in transgender medical care, local practitioners and advocacy groups say.

The rules crafted by Tesmer’s department require that trans kids receive 40 hours of therapy that “do not merely affirm the patient’s beliefs” before the kids can move forward with medical interventions like puberty blockers. The therapy recommendations are “not in the standard of care, they’re not in any of the pediatrics or psychiatry literature,” says Alex Dworak, a pediatrician who works with trans youth in Nebraska. Florence Ashley, a bioethicist at the University of Toronto who focuses on trans issues, points to the regulations’ instruction not to “merely affirm” a client. “What does that mean, in the actual therapy room?” Ashley asks. “Does that mean they can’t use your name and pronouns? Because then that’s very much privileging a specific outcome.”

Camie Nitzel, the founder of Kindred Psychology in Lincoln, is wondering the same thing. “If the artwork in my office reflects gender-­diverse faces, is that overly affirming?” she asked Tesmer in a letter opposing the regulations. Nitzel, who has been working with trans Nebraskans for 29 years, uses the clinical approach recommended by the APA. Under the Nebraska regulations, therapists “are going to be forced to choose between practicing ethically and practicing legally,” she warns. Already, some other providers have begun to refuse to see trans youth because of the risk. “We’re now getting referrals from providers who have worked with trans youth before, but they’re sending their clients here because they don’t feel comfortable,” Nitzel says. “Providers are faced with the decision about the safety of continuing to do work.”

Meanwhile, the trans community in Nebraska is just plain scared. Andrew Farias, a lobbyist in Lincoln, is so worried about the possibility of future restrictions on adult trans health care that he temporarily stopped testosterone just to see if he could bear it. “I want to make sure that I’m prepared in terms of my own safety and mental health,” he says. “I wanted to test myself and see: Could I do this?…Or do I have to move?”

I left the last session of the conference with my head spinning. In the world of the Alliance, down was up, harm was help, expert conclusions were lies—or were they? As I made my way out of the hotel lobby, where the therapists were gathering to walk together to a nearby diner, I had the feeling of exiting an alternate reality.

No one had distilled that feeling better than the Alliance’s incoming leader, David Pickup. “There is such a thing as a man born in a woman’s body,” he’d declared in a speech, delivering the line with sarcastic bravado. “There is such a thing as homosexual marriage.” Then he parodied what was happening in the Hampton Inn: “The small conferences that are held by these fringe groups across the country are all right-wing, unscientific, no-research-given, closeted Christians who try to prod and force people to do therapy.” The audience laughed with uncertainty. Had their comrade gone soft on them?

No one need worry; Pickup cut to his point: “The Alliance tells you the truth. And none of those statements I just said—even though the world tends to now believe in that—has anything to do with truth,” he assured them. In Pickup’s view, “the transgender movement is actually crumbling. In part, that’s due to the Alliance.” Then he asked the audience to take out their phones and laptops to donate. “Good things are coming,” he promised. “I think the truth will one day win out, more than ever.”

There is an urgency behind Pickup’s words. His truth must win out because the opposite would be devastating. To concede that trans people are real, let alone happy, would strip away the Alliance’s last best hope of a comeback. 

Read more about Myles Markham’s story of surviving conversion therapy—and finding self-love—here.

If you or someone you care about may be at risk of suicide, contact the 988 Suicide and Crisis Lifeline by calling or texting 988, or go to 988lifeline.org.

Last month, the UK’s four-year-long review of medical interventions for transgender youth was published. The Cass Review, named after Hilary Cass, a retired pediatrician appointed by the National Health Service to lead the effort, found that “there is not a reliable evidence base” for gender-affirming medicine. As a result, the report concludes, trans minors should generally not be able to access hormone blockers or hormone replacement therapy (HRT) and instead should seek psychotherapy. While the review does not ban trans medical care, it comes concurrently with the NHS heavily restricting puberty blockers for trans youth.

The conclusions of the Cass Review differ from mainstream standards of care in the United States, which recommend medical interventions like blockers and HRT under certain circumstances and are informed by dozens of studies and backed by leading medical associations. The Cass Review won’t have an immediate impact on how gender medicine is practiced in the United States, but both Europe’s “gender critical” movement and the anti-trans movement here in the US cited the report as a win, claiming it is the proof they need to limit medical care for trans youth globally. Notable anti-trans group the Society for Evidence Based Gender Medicine called the report “a historic document the significance of which cannot be overstated,” and argued that “it now appears indisputable that the arc of history has bent in the direction of reversal of gender-affirming care worldwide.”

Most media coverage of the report has been positive. But by and large that coverage has failed to examine extensive critiques from experts in the US and elsewhere. Research and clinical experts I interviewed explained that the Cass Review has several shortcomings that call into question many of its findings, especially around the quality of research on gender medicine. They also question the credibility and bias underpinning the review. I spoke with four clinical and research experts in pediatric medicine for gender-diverse youth to dive into the criticisms.

“I urge readers of the Cass Review to exercise caution,” said Dr. Jack Turban, director of the gender psychiatry program at the University of California, San Francisco and author of the forthcoming book Free to Be: Understanding Kids & Gender Identity. 

The Cass Report’s bar for evaluating research is too high

In scientific research, the randomized control trial (RCT) is often considered the gold standard. In a randomized control trial, study subjects are randomly split up into two groups. One group gets the treatment being examined. The other group doesn’t, and is used as a baseline with which compare the effects of the treatment.

But there are ethical limits to this setup, says Dr. Meredithe McNamara, a professor of pediatrics at Yale School of Medicine who co-leads the Integrity Project, a Yale research hub meant to bridge the gap between policy and science. RCT’s are great when “it is not known whether or not the intervention might be beneficial,” McNamara says. “Having pre-knowledge of benefits means that we would never consider randomizing somebody to no treatment.” In other words, RCTs are a great option when there is not a lot of data pointing to the efficacy of a certain drug or treatment program. But when that data does exist, using RCTS would be considered “unethical” and “coercive,” says McNamara.

In the case of gender-affirming care, decades of research exists showing “gender-affirming care confers key benefits to those who desire and qualify for this care, including youth,” McNamara explains. “It would not make sense ethically to conduct a randomized control trial.” The Federal Drug Administration suggested as much last year, when it told researchers conducting a study on estrogen for trans patients not to use an RCT. That clinical study may include youth as young as 13, per suggestion from the FDA.

The evidence supporting medical interventions for trans youth comes from primarily observational studies, meaning those conducting the research collected data on people undergoing gender-affirming medical care. These kinds of studies are used 70 percent of the time in research on health care, McNamara explains. Alex Keuroghlian, an associate professor of psychiatry at Harvard Medical School and a clinic psychiatrist and director of education at Fenway Health in Boston, emphasizes that gender-medicine providers are not making choices arbitrarily or without robust research. “It’s really setting a double standard in terms of expectations for evidence supporting medical intervention. It is not the standard we expect in other contexts,” they say.

Cass’ systematic evidence reviews used the “somewhat subjective”—as Turban puts it—Newcastle-Ottawa scale rating system to evaluate research on gender-affirming care, which is a rating system to evaluate observational studies. (More precisely, the review actually commissioned researchers at the University of York to conduct the ratings, which Cass then discusses at length in her own report).

The reviewers from York evaluated the research on a scale from “low quality” to “high quality” and found that “much of the research rated as moderate or even sometimes high quality,” explains Turban. But the Cass Review diverged from these findings. Some experts suspect that may be because she compared the research to RCTs despite their inappropriateness. There is “actually wider understanding of the evidence than the Cass Review presents,” says Streed. Cass categorically denies that the review “set a higher bar for evidence than would normally be expected.”

“It’s a bad faith claim that we don’t have enough evidence for pubertal suppressants or gender-affirming hormones,” says Keuroghlian, who has worked with over 2,000 trans and gender-diverse patients in their career. “Gender-affirming medical interventions have been used for adolescent gender dysphoria for decades, and we have a large body of evidence linking them to improved mental health outcomes,” says Turban.

Cass doesn’t apply important terminology consistently or accurately

Multiple experts told me that the language in the review diverged from technical standards and may confuse readers. McNamara explains: “There is a lot of terminology-switching throughout the report.” “Low-quality evidence” is a technical term with specific technical meanings that can be interpreted by researchers, she says. “Weak” or “poor quality,” on the other hand, are “subjective terms that might strike a chord with the lay public but don’t have any concrete meaning.” This means that a reader who is not an expert in medical research may assume that the there are dangers or uncertainties around this health care when there are not. 

Perhaps because of the loose use of terminology, the Cass report describes some gender-medicine research as “poor” even though those same studies were rated “moderate” or “high quality” by reviewers at the University of York. The studies downgraded by Cass all demonstrated the efficacy of gender-affirming medical interventions. On the other hand, other studies that didn’t come to such strong conclusions in favor of intervention were not similarly downgraded. 

Carl Streed, the research lead for the GenderCare Center at Boston Medical Center and president of the US Professional Association for Transgender Health, clarifies that just because a study is classified as “low-quality” in the report does not mean the data is not robust or rigorous. “It doesn’t actually mean the evidence itself is not to be trusted,” he explains. “It is just that you have to understand the nuance of the methods to understand the context of the results.” 

Cass endorses questionable therapeutic treatment  

The Cass review recommends psychotherapy as the main and frontline treatment for gender-diverse youth, in place of medical interventions like puberty blockers. But the experts I spoke to say the evidence shows psychotherapy alone doesn’t do enough. Clinicians have been trying “psychotherapy as the way to solve issues around gender since at least the late 1800s” explains Streed. “It wasn’t working. It wasn’t leading to any kind of significant success, people still had significant distress.” 

“No contemporary evidence whatsoever shows that people who receive only psychotherapy experience improvements in gender dysphoria,” says McNamara. “There is an abundance of evidence showing that medically affirming interventions confer key benefits and there is none regarding psychotherapy alone.”

What’s more, the therapeutic approach Cass seems to suggests has close ties to conversion therapy. While Cass does not recommend a specific modality, she repeatedly advocates for an “exploratory” approach. She writes: “The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and to help alleviate distress.” 

Fair enough. Except that these are the same talking points that conversion therapists use to describe their work. There’s even a group, Therapy First, devoted to pushing the idea of “gender exploratory therapy.” Therapy First’s co-founder has advocated to make conversion therapy bans more lenient to make room for an “exploratory” approach. The US Substance Abuse and Mental Health Services Administration has stated that gender change efforts are often “misleadingly referred to as ‘exploratory therapy.’” 

Streed explains that “at best, gender exploratory therapy is just delaying people’s access to the care they need, and at worst, it is conversion therapy. That is what we’ve seen in multiple studies, and it is associated with harm.” Keuroghlian puts it more bluntly: “Not providing gender affirming care in a timely way” is “trafficking in conversion efforts.” 

“It feels like a double standard to say, ‘Oh, there’s no evidence for medical and surgical interventions with regards to gender-affirming care or affirmation,’ but then, ‘Oh, let’s turn around and offer this other therapy that has absolutely no evidence,’” says Streed.

In a follow-up Q&A, Cass said she “believes that no LGBTQ+ group should be subjected to conversion practice.” At the same time, she stands behind her inclusion of exploratory therapies, saying, “young people with gender dysphoria may have a range of complex psychosocial challenges and/or mental health problems impacting on their gender-related distress. Exploration of these issues is essential.”

The Cass Report shows signs of bias 

Cass does a fair amount of work at the outset of the report to make clear that she’s not attempting to undermine “the validity of trans identities” or rollback “people’s rights to healthcare.”

But Cass goes too far in her attempts to remain neutral. The review cites sources that lack credibility or are from anti-trans actors, including an article written a college undergraduate, a pamphlet funded by an anti-trans group, and a YouTube channel run by right-wing commentators. More than once she cites notable exploratory therapists like Ken Zucker.

Further, experts note the report does not disclose all the people who collaborated on the project and their affiliations. Streed says, for similar reviews, “every author has to have their name on it and say what their conflicts of interests are, where they are getting their funding from. The Cass Report does not offer that information. For me, that is a big red flag.” Some of those connections have become clearer since the report was published. For example, the blog Growing Up Transgender uncovered a 2022 meeting between the US Department of Health and Human Services and the Society for Evidence-Based Gender Medicine, which the Southern Poverty Law Center has dubbed “the hub” of the “anti-LGBT pseudoscience network.”  Representing SEGM were Richard Byng and R. Stephens, who were identified in the meeting as part of NHS’ “working group on Gender Dysphoria.” 

More broadly, Keuroghlian and McNamara both argue that Cass’ conclusions undermining the observational studies is itself a form of bias. “The review’s conclusions are discriminatory,” says Keuroghlian. “It’s an intentional misapplication of science to deny a minoritized group access to medically necessary evidence-based care.” “Any deviation from basic principles of evidence-based medicine suggests bias,” says McNamara. 

Allegations of bias in the report are not new. In November 2023, Zinnia Jones, who runs the website and web series Gender Analysis, surfaced court documents in GLAD’s constitutional challenge to Florida’s ban on gender-affirming care for youth. The documentation showed that in 2022, Cass met with Patrick Hunter, a DeSantis appointee to the Florida Board of Medicine, member of SEGM, and big proponent of banning gender affirming medical care for transgender youth.

Hunter sent Cass materials from Florida’s thoroughly discredited 2022 review of gender medicine. That review had gotten edits from Andre Van Mol, a member of a fringe, conservative doctors group that calls itself the American College of Pediatricians (ACPeds). (Read more about Van Mol and his partners in my colleague Madison Pauly’s investigation.) Cass passed along research from her in-progress review and was even invited to do a presentation in front of the Florida Board of Medicine, which was then putting together specific regulations on youth access to HRT and puberty blockers. The Florida review and Cass reports draw similar conclusions about the “weak” research on gender-affirming care. 

The experts I spoke to hope the report is not set in stone. “This report and its systematic reviews were just released, and experts are actively reviewing their contents,” Turban says. “Our team has already identified an error with the systematic review on gender-affirming hormones and has notified the journal, requesting a correction be issued.” 

“There are no neutral decisions to be made for transgender youth.” McNamara explains, “We have to recognize that physical change that does not align with a person’s gender identity is a source of harm for people who experience gender diversity and dysphoria. Simply watching that happen, feel feels like doing harm.”

Correction: An earlier version of this story misstated the relationship between the Newcastle-Ottawa scale and RCTs. 

The city of New York is discriminating against its gay male employees by denying them the same health care benefits as women and straight men, a new lawsuit alleges. Under the city’s insurance, employees are entitled to coverage for up to three rounds of in vitro fertilization (IVF) in their quest to have children—that is, unless they are gay men.

In a class action lawsuit filed Thursday, which appears to be the first federal case specifically about gay men’s access to IVF, a former city employee and his spouse claim that by denying them benefits available to all other employees, the city is engaging in discrimination based on sex and sexual orientation. Nothing else, they argue, explains why they were treated differently. 

“There is no legitimate, non-discriminatory explanation for why the City’s healthcare plan offers IVF benefits when the male plan participant’s partner is female but withholds IVF benefits when the male plan participant’s partner is male,” the complaint, filed in federal court in New York, states. 

New York City offers generous IVF benefits to its 300,000 employees and their dependents, including for single women, women in same-sex relationships, and men with female partners. This coverage extends to couples that plan to use donor eggs. The only exception is for gay men. 

The city requires people wanting to access IVF services to be infertile, which it defines as an inability to conceive through heterosexual sex or intrauterine insemination—a set of criteria which disqualifies only gay men. Last year, the American Society of Reproductive Medicine updated its definition of infertility to include LGBTQ people, but New York City has not yet followed suit. The city’s infertility requirement, according to the complaint, leads to sex discrimination in violation of Title VII of the 1964 Civil Rights Act, state and city human rights laws, and the New York and United States constitutions.

The story behind the lawsuit goes back to 2017, when Corey Briskin began working as a prosecutor at the Manhattan district attorney’s office. He and his husband, Nicholas Maggipinto, were ready to start a family and looked forward to taking advantage of the city’s IVF benefits. They were surprised and deeply saddened when their request to use those benefits was quickly denied. The couple petitioned the city to change its policy to no avail. 

The city’s refusal was both a financial and an emotional blow. There was “an additional kind of pain which was rooted in my sacrifice that I had made to be a public servant,” Briskin told Mother Jones. “To know that I was working alongside other public servants who had made a similar sacrifice, but yet were being given the opportunity to grow their families with the support of our employer, of the city—that had a uniquely profound impact on me.”

They also felt that the city was sending the couple a message it didn’t want them to be parents, when compared to colleagues who had no trouble getting IVF covered. “‘You’re just outside of what we support,'” Maggipinto said. “That’s the way it felt.” 

In 2020, New York state mandated that health care plans serving over 100 employees offer IVF benefits, and barred discrimination based on sexual orientation. That same year, in the landmark case Bostock v. Clayton County, the United States Supreme Court ruled that Title VII the 1964 Civil Rights Act prohibited workplace discrimination on the basis of sexual orientation and gender identity. But despite these developments, the city refused to change its policy and cover IVF for Briskin and Maggipinto. So in 2022, the couple filed a class action charge with the Equal Employment Opportunity Commission, a necessary step before filing a Title VII case in federal court.

At first, the city’s only response to the EEOC proceedings was a statement defending its policy on the grounds that it does not provide benefits to surrogates. But not only had Briskin and Maggipinto not asked the city to cover the cost of a surrogate, according to Peter Romer-Friedman, the couple’s lawyer, the EEOC discovered that the city would provide IVF benefits to couples using a surrogate—as long as it wasn’t a gay male couple. The EEOC investigation dragged on for two years. In March, officials greenlit the couple’s lawsuit.

“The city should be embarrassed by what they filed at the EEOC,” says Romer-Friedman. “It didn’t grapple with the actual allegations. It didn’t provide real facts or real law when it comes to these issues.”

While members of New York’s city council have twice introduced legislation to make its IVF policy inclusive of gay men, including this year, it has not passed. Romer-Friedman believes that Mayor Eric Adams and the city’s Office of Labor Relations could change the policy unilaterally, and, under the state law mandating IVF coverage, have a responsibility to do so.

“Whether or not they agree with us legally, it’s wrong and unfair,” says Romer-Friedman. “And it’s not as if the cost of these benefits would make a difference to the city. It’s a rounding error when you consider how much money the city spends on health care for city employees, spouses, children, retirees.” 

The complaint names the city as the defendant along with Adams, his predecessor Bill deBlasio, and the current and former commissioners of the Office of Labor Relations. The mayor’s office did not immediately respond to a request for comment.

The city’s intransigence has been both baffling and hurtful to Briskin and Maggipinto. “I was actually really hopeful that this was an issue of oversight, that they just didn’t realize,” says Maggipinto. “I still am stunned that this is going on for this long. It really makes me question the motives of the individuals making the decisions at City Hall.” 

In 2022, Briskin left the district attorney’s office for a clerkship. The following year, the couple began paying for IVF. That’s when “I made the tough decision to jump ship and move into the private sector, mainly because we had mounting bills related to our family building journey,” Briskin said. “Yet another impact of the policy on our lives.” 

In filing this class action, the couple hope not only to recoup their expenses and change New York City’s policy, but to set precedent under Title VII that would help countless other gay people trying to start families. As employers increasingly include IVF in benefits packages, including for LGBTQ employees, in recent months, courts have begun to see workplaces that deny such benefits to LGBTQ people as a form of sex discrimination. Last week, Aetna settled a lawsuit filed by a lesbian couple that had to pay out of pocket for fertility treatments. As of last fall, 21 states require some employers to provide fertility coverage of some kind, but only eight of them include LGBTQ and single people. New York is one.

“This is one of the most important questions after the Bostock decision that federal courts could answer about the rights of gay and lesbian employees,” says Romer-Friedman. The city’s current policy, the lawsuit points out, encourages all groups to start a family except gay men—the one group that will always need IVF in order to have biological children.

On Wednesday, the United Methodist Church repealed its 1984 ban on LGBTQ clergy with an overwhelming 692–51 vote by church leaders at its general conference. The conference, which ends on May 3, has also resulted in the church rolling back several other anti-LGBTQ policies, including bans on performing gay marriage and funding queer-friendly ministries. 

The passage of these measures heralded a new era for the church. At the convention in 2019, delegates, made up of both clergy and laypeople, voted 438 to 384 to affirm the bans struck down in this year’s conference and heightened penalties for breaking them. But 2024 marks the first convention after an ideological schism between conservative and progressive Methodists led some parishes to buck restrictions on LGBTQ worshippers while others doubled down. 

Between 2019 and 2023, one-quarter of US Methodist denominations disaffiliated from the United Methodist Church. As the progressive arm of the church gained strength, many conservative parishes disaffiliated from the United Methodist Church, clearing the path for progressives to reverse anti-LGBTQ bans with overwhelming support. 

Still, the fight for parity is not over. Wednesday’s repeal does not mandate that all parishes accept queer clergy. It would also apply only to Methodist churches in the US, since parishes from other countries control their own governance. Yet even this measured win sparked an enthusiastic reaction from the crowd. Advocates embraced and applauded teary-eyed, according to the Associated Press, and celebrations rang out outside the convention center. 

Guthrie Graves-Fitzsimmons, author of Just Faith: Reclaiming Progressive Christianity, wrote in a NBC News op-ed that these changes should mark a shift in the cultural understanding of queerness in religion. “We can put to rest the idea that religion and LGBTQ rights are inherently in conflict,” he wrote. “Just as positive views on LGBTQ rights have trended upward, so, too, have Christian groups evolved their theological understandings of human sexuality and gender identity.”

The ripple effects of Dobbs continue to emerge in unexpected places—and to threaten other civil liberties.

Yesterday, Uganda’s constitutional court, the country’s second-highest judicial body, cited the US Supreme Court decision overturning Roe v. Wade in its ruling to uphold the majority of a sweeping anti-gay law that criminalizes homosexuality and same-sex marriage, and allows for convictions of up to life in prison and the death penalty in some cases.

The court wrote that Dobbs constitutes a recent development “in human rights jurisprudence…where the Court considered the nation’s history and traditions, as well as the dictates of democracy and rule of law, to over-rule the broader right to individual autonomy.”

In the ruling, which came after the challenges to the “Anti-Homosexuality Act” passed by President Yoweri Museveni last year, the court repealed certain sections of the law, including those that criminalized renting property to LGBTQ people and mandated reporting “acts of homosexuality” to police. 

But the fact that the court upheld most of the law obviously amounts to a massive setback for LGBTQ Ugandans—and offers a striking look at how Dobbs might be marshaled to restrict other rights both in the US and around the world.

“We have been saying in the United States that the decision in Dobbs could easily be extended to the context of personal liberties, like the choice to engage in sex with a person of the same sex, to marry a person of the same sex, to use contraception,” Melissa Murray, a professor at New York University’s School of Law and a leading legal expert on reproductive rights and justice, told me. “The fact that a high court in another country used it in that way suggests how easily it might be deployed in our country for the same thing.”

“Folks in this country ought to take a page out of it—this is really alarming,” she added. 

The UN’s High Commissioner for Human Rights, Volker Türk, condemned the high court’s ruling in a statement yesterday, noting that nearly 600 people “have been subjected to human rights violations and abuses” based on gender identity or sexual orientation since the law took effect last year. The law, Türk said, “must be repealed in its entirety or unfortunately this number will only rise,” adding that it was also contrary to “Uganda’s own constitution and international human rights treaty obligations.” Amnesty International also notes that, since the law passed, there have also been more than 250 evictions of people suspected to be LGBTQ or to associate with LGBTQ people, and more than 200 “other cases of actual or threatened violence.”

Human Rights Watch called the law “abusive” and “radical,” alleging that it “further entrenches discrimination against [LGBTQ] people, and makes them prone to more violence.” National Security Advisor Jake Sullivan said it’s “deeply disappointing, imperils human rights, and jeopardizes economic prosperity for all Ugandans.” And Secretary of State Antony Blinken said the country’s “international reputation and ability to increase foreign investment depend on equality under the law.” (Homosexuality is criminalized in more than 30 of Africa’s 54 countries, the Associated Press reports.) 

This is, of course, not the first time that Dobbs has been used to restrict rights beyond abortion access—including here at home. Dobbs was cited throughout the Alabama Supreme Court decision last month that effectively banned IVF procedures. (The Alabama Legislature subsequently passed a bill, which the governor signed, to protect IVF access, but it didn’t address the legal status of frozen embryos.) And Justice Clarence Thomas used the Dobbs decision to call for the court to revoke the rights to marriage equality, intimate sexual relationships, and contraception, all of which he called “demonstrably erroneous.”

Dobbs has also been cited by anti-abortion activists seeking to roll back legal rights in Kenya, Nigeria, and India, according to research compiled by the advocacy organization Fòs Feminista. Globally, though, most countries have actually liberalized their abortion laws over the past few decades, with only four—the U.S., Nicaragua, El Salvador, and Poland—restricting them, according to the Center for Reproductive Rights. And last month, France became the only country to explicitly guarantee a right to abortion in its constitution, which President Emmanuel Macron and other French lawmakers promised to prioritize just hours after the Dobbs ruling dropped in June 2022. 

The fact that the US rollback of abortion rights could give rise to both France’s protection of them and Uganda’s elimination of LGBTQ rights, Murray said, shows that Dobbs “is viewed as authoritarian”: Its power, in other words, lies in the hands of whoever gets to interpret—or resist—it.

The ripple effects of Dobbs continue to emerge in unexpected places—and to threaten other civil liberties.

Yesterday, Uganda’s constitutional court, the country’s second-highest judicial body, cited the US Supreme Court decision overturning Roe v. Wade in its ruling to uphold the majority of a sweeping anti-gay law that criminalizes homosexuality and same-sex marriage, and allows for convictions of up to life in prison and the death penalty in some cases.

The court wrote that Dobbs constitutes a recent development “in human rights jurisprudence…where the Court considered the nation’s history and traditions, as well as the dictates of democracy and rule of law, to over-rule the broader right to individual autonomy.”

In the ruling, which came after the challenges to the “Anti-Homosexuality Act” passed by President Yoweri Museveni last year, the court repealed certain sections of the law, including those that criminalized renting property to LGBTQ people and mandated reporting “acts of homosexuality” to police. 

But the fact that the court upheld most of the law obviously amounts to a massive setback for LGBTQ Ugandans—and offers a striking look at how Dobbs might be marshaled to restrict other rights both in the US and around the world.

“We have been saying in the United States that the decision in Dobbs could easily be extended to the context of personal liberties, like the choice to engage in sex with a person of the same sex, to marry a person of the same sex, to use contraception,” Melissa Murray, a professor at New York University’s School of Law and a leading legal expert on reproductive rights and justice, told me. “The fact that a high court in another country used it in that way suggests how easily it might be deployed in our country for the same thing.”

“Folks in this country ought to take a page out of it—this is really alarming,” she added. 

The UN’s High Commissioner for Human Rights, Volker Türk, condemned the high court’s ruling in a statement yesterday, noting that nearly 600 people “have been subjected to human rights violations and abuses” based on gender identity or sexual orientation since the law took effect last year. The law, Türk said, “must be repealed in its entirety or unfortunately this number will only rise,” adding that it was also contrary to “Uganda’s own constitution and international human rights treaty obligations.” Amnesty International also notes that, since the law passed, there have also been more than 250 evictions of people suspected to be LGBTQ or to associate with LGBTQ people, and more than 200 “other cases of actual or threatened violence.”

Human Rights Watch called the law “abusive” and “radical,” alleging that it “further entrenches discrimination against [LGBTQ] people, and makes them prone to more violence.” National Security Advisor Jake Sullivan said it’s “deeply disappointing, imperils human rights, and jeopardizes economic prosperity for all Ugandans.” And Secretary of State Antony Blinken said the country’s “international reputation and ability to increase foreign investment depend on equality under the law.” (Homosexuality is criminalized in more than 30 of Africa’s 54 countries, the Associated Press reports.) 

This is, of course, not the first time that Dobbs has been used to restrict rights beyond abortion access—including here at home. Dobbs was cited throughout the Alabama Supreme Court decision last month that effectively banned IVF procedures. (The Alabama Legislature subsequently passed a bill, which the governor signed, to protect IVF access, but it didn’t address the legal status of frozen embryos.) And Justice Clarence Thomas used the Dobbs decision to call for the court to revoke the rights to marriage equality, intimate sexual relationships, and contraception, all of which he called “demonstrably erroneous.”

Dobbs has also been cited by anti-abortion activists seeking to roll back legal rights in Kenya, Nigeria, and India, according to research compiled by the advocacy organization Fòs Feminista. Globally, though, most countries have actually liberalized their abortion laws over the past few decades, with only four—the U.S., Nicaragua, El Salvador, and Poland—restricting them, according to the Center for Reproductive Rights. And last month, France became the only country to explicitly guarantee a right to abortion in its constitution, which President Emmanuel Macron and other French lawmakers promised to prioritize just hours after the Dobbs ruling dropped in June 2022. 

The fact that the US rollback of abortion rights could give rise to both France’s protection of them and Uganda’s elimination of LGBTQ rights, Murray said, shows that Dobbs “is viewed as authoritarian”: Its power, in other words, lies in the hands of whoever gets to interpret—or resist—it.

Florida’s Supreme Court issued a pair of major rulings today on abortion that will both further restrict access in the short-term and allow voters to decide whether or not to expand abortion rights this November. 

One of the court’s rulings will allow a six-week abortion ban—signed into law by Republican Gov. Ron DeSantis last April—to take effect, according to the Associated Press. 

And in the other ruling, the court decided that Floridians could vote on a ballot measure to expand abortion rights in the elections this November. Voters will weigh a constitutional amendment that would guarantee a right to abortion in the state prior to the point of so-called fetal viability, which is generally understood to be around 24 weeks’ gestation. 

The dueling rulings essentially make Florida a microcosm of our fraught national abortion politics, defined by anti-abortion Republicans seeking to curtail access at all costs and abortion rights advocates fighting to restore access—often successfully through ballot measures—following the devastation of the Dobbs ruling. 

In allowing the six-week ban to take effect, the court makes Florida one of the strictest anti-abortion states in the nation: Only two other states, Georgia and South Carolina, currently have six-week bans, and 14 others ban abortion more or less entirely. Six weeks is before most people know they’re pregnant, so the law will effectively eliminate the option of abortion for Florida’s 4.6 million women of reproductive age, along with the state’s trans and nonbinary people who seek abortions.

The new ban will also decimate Florida’s status as a “rare haven for abortion rights” in the South, as my Reveal colleague, Laura Morel, reported back in 2022, the same year that a 15-week ban took effect in the state. Even with that law, the state remained a crucial access point for the South, since the majority of abortions occur before 13 weeks’ gestation. There were 8,940 more abortions in Florida last year compared to 2020, amounting to a 12 percent increase, largely driven by out-of-state patients, according to the Guttmacher Institute. 

The ruling on the ballot measure presents more of a reason for optimism for abortion rights supporters: As my colleague Madison Pauly has reported, voters have chosen to uphold abortion rights in every post-Dobbs ballot measure on the matter. And public opinion polling has shown that most Florida voters believe abortion should be legal in all or most cases—just like voters across the country. 

Grassroots organizers in Florida collected nearly one million signatures last year to petition for the amendment that would guarantee the right to abortion before fetal viability. But the Florida attorney general asked the court to block the measure, alleging it was “too complicated” for voters to understand. Following Monday’s ruling, Floridians Protecting Freedom, the grassroots group that brought the proposed amendment, promised that “Floridians will vote and we will win,” adding that it’s the only way to stop the six-week ban in its tracks. 

The Center for Reproductive Rights, a legal advocacy organization, called the ballot measure ruling “a win for democracy.” “This ballot measure could fundamentally reshape abortion access across the US South and now, the power to make that happen is in the people’s hands,” the group said in a post on X. 

But the excitement was tempered by the additional restrictions the court also imposed on access. 

In a statement released Tuesday, President Biden called the decision that will enact the six-week ban “outrageous” and “extreme.” 

“Florida’s bans—like those put forward by Republican elected officials across the country—are putting the health and lives of millions of women at risk,” Biden continued. “These extreme laws take away women’s freedom to make their own health care decisions and threaten physicians with jail time simply for providing the medical care that they were trained to provide.”

A statement from the Tampa Bay Abortion Fund said its leaders anticipate the six-week ban will impact almost all of its callers, who are “already facing one or more barriers to care, such as a lack of funding, transportation, childcare, or a nearby abortion clinic in their community.” The group also said it expects “a significant increase in callers and thus a subsequent rise in costs” given that most Floridians will now have to travel out-of-state to get abortions. 

A Guttmacher spokesperson said that while the ballot measure ruling was a “monumental win,” the six-week ban “is a devastating loss for Floridians and may cause massive chaos and confusion for patients and providers on the ground.”

“Once Florida’s six-week ban goes into effect in 30 days, anyone from nearby states who needs care after six weeks must now travel longer distances, pushing care further out of reach for many—especially for those with the fewest resources or otherwise marginalized by structural racism and economic insecurity,” Kelly Baden, Guttmacher’s vice president of public policy, continued in a statement. 

Update, April 2: This story has been updated with a statement from President Biden. 

Across social media, right-wing posters are complaining that President Joe Biden has usurped Easter. “Joe Biden just proclaimed that ‘Transgender Visibility Day’ is on Sunday,” once-presidential candidate Vivek Ramaswamy posted on X, “I wonder how he came up with that date.”

Except Biden, of course, did not come up with this date, he just issued a pretty standard proclamation recognizing it. (His administration also recently issued proclamations recognizing National Sexual Assault Awareness and Prevention Month, Cesar Chavez Day, and Care Workers Recognition Month.)

Trans Day of Visibility has fallen on March 31 since it was created in 2010 by Rachel Crandall-Crocker, the executive director of Transgender Michigan. Crandall-Crocker recently told NPR she was hoping the day would be an opportunity for the trans community to come together and feel joy. That mission is important as ever as legislation across the country takes aim at the rights and safety of trans people, some of which, as my colleague Henry Carnell reported, cites anti-trans reporting coming from our country’s largest and most important newspaper, the New York Times. 

Meanwhile, Easter can fall on any Sunday from late March to mid-April. So basically, Easter falling on Trans Day of Visibility is no different from when Hannukah fell on Thanksgiving in 2013. Which was actually pretty cool! My mom got custom boxes of mints that commemorated “Thanksgivukkah,” and we had latkes with our turkey, which is a delicious combination and a concept I think we as a culture should revisit. And sometimes my birthday falls on Mother’s Day, which is less cool because it should really be about me, but then again, my mom was here first.

Point being, sometimes two holidays are on the same date. And Biden does not control the calendar or whatever forces dictate when Easter comes. So have a lovely Easter, and a lovely Trans Day of Visibility, and while you’re at, it remember what Crandall-Crocker learned from organizing the latter: “I changed the world. You don’t have to be perfect. Come and change it along with me.” 

Across social media, right-wing posters are complaining that President Joe Biden has usurped Easter. “Joe Biden just proclaimed that ‘Transgender Visibility Day’ is on Sunday,” once-presidential candidate Vivek Ramaswamy posted on X, “I wonder how he came up with that date.”

Except Biden, of course, did not come up with this date, he just issued a pretty standard proclamation recognizing it. (His administration also recently issued proclamations recognizing National Sexual Assault Awareness and Prevention Month, Cesar Chavez Day, and Care Workers Recognition Month.)

Trans Day of Visibility has fallen on March 31 since it was created in 2010 by Rachel Crandall-Crocker, the executive director of Transgender Michigan. Crandall-Crocker recently told NPR she was hoping the day would be an opportunity for the trans community to come together and feel joy. That mission is important as ever as legislation across the country takes aim at the rights and safety of trans people, some of which, as my colleague Henry Carnell reported, cites anti-trans reporting coming from our country’s largest and most important newspaper, the New York Times. 

Meanwhile, Easter can fall on any Sunday from late March to mid-April. So basically, Easter falling on Trans Day of Visibility is no different from when Hannukah fell on Thanksgiving in 2013. Which was actually pretty cool! My mom got custom boxes of mints that commemorated “Thanksgivukkah,” and we had latkes with our turkey, which is a delicious combination and a concept I think we as a culture should revisit. And sometimes my birthday falls on Mother’s Day, which is less cool because it should really be about me, but then again, my mom was here first.

Point being, sometimes two holidays are on the same date. And Biden does not control the calendar or whatever forces dictate when Easter comes. So have a lovely Easter, and a lovely Trans Day of Visibility, and while you’re at, it remember what Crandall-Crocker learned from organizing the latter: “I changed the world. You don’t have to be perfect. Come and change it along with me.” 

On Tuesday, Alabama provided even more evidence of what we already know to be true: Abortion rights win elections. 

Democrat Marilyn Lands won a special election for an Alabama state House seat, flipping a Republican-held seat by campaigning on abortion rights in the deep-red state that bans abortion with no exceptions for rape or incest. Lands won 62 percent of the nearly 6,000 votes cast, while her challenger, Republican Teddy Powell, won 37.5 percent, according to the unofficial election night results from the Alabama Secretary of State. The candidates were running to replace Republican David Cole, who resigned last year after he was arrested on a voting fraud charge. (Lands ran against Cole in 2022 and lost by just under 1,000 votes, or about 7 percentage points—making her win last night all the more significant.)

Lands—a licensed professional counselor whose website says her “Christian values deeply influence her life and work”—campaigned on repealing the state’s abortion ban, as well as expanding Medicaid, investing in community mental health resources, and improving the local economy and education. Days after the state Supreme Court‘s decision threatening IVF last month, Lands released a campaign ad in which she and another Alabama woman, Alyssa Gonzales, each shared their personal stories of getting emergency abortions following nonviable pregnancies. For Lands, it happened 20 years ago; for Gonzales, it happened after the Dobbs decision was handed down in 2022. 

“We will not stand by and watch our most basic human rights be stripped from us,” Lands says in the ad.  

I’m sharing my abortion story because Alabama's no exceptions abortion ban is putting lives at risk. We must repeal this legislation, and if I'm elected on March 26th, I'll work tirelessly to do just that.

Learn more at https://t.co/VQKTW9Ivob pic.twitter.com/n7fZDB2Eqx

— Marilyn for Alabama (@MarilynForAL) February 20, 2024

Tuesday’s election results once again demonstrated the far-reaching effects that abortion bans can have in galvanizing voters in decisive elections around the country. The trend can be directly traced to the Supreme Court’s Dobbs ruling, which was repeatedly cited throughout the Alabama Supreme Court decision that effectively banned IVF procedures. (The Alabama Legislature subsequently passed a bill, which the governor signed, to protect IVF access, but it didn’t address the legal status of frozen embryos.) 

While Alabama is reliably red—and the state legislature remains majority Republican—Lands’ district, the state’s 10th District, has been a battleground: Trump won it by only one percentage point in 2020, the Washington Post reported, while he won the state by more than 35 percentage points. Voters told the 19th earlier this month that they were going to vote for Lands because of her stance on abortion and reproductive rights. 

Lands told local CBS affiliate WHNT that she saw her victory as “a victory…for women, for families,” adding that she wanted to “repeal the bad ban on no-exceptions abortion” and “protect IVF and contraception.” 

“It feels like the start of a change here, and I think we’ll see more change in 2026. I think Alabama is changing,” she said.

Former Alabama Sen. Doug Jones (D) agreed, telling CNN that the results were “a huge win for Alabama, not just for Democrats.”

Lands’ win seems to send a clear message—one that advocates have been trying to send President Biden and other Democrats for some time: it’s reproductive justice that wins elections in the post-Roe era. And as long as Republicans’ anti-abortion policies continue to harm pregnant people—including those who aren’t seeking abortions—they’ll likely continue losing to Democrats like Lands.

On Tuesday, Alabama provided even more evidence of what we already know to be true: Abortion rights win elections. 

Democrat Marilyn Lands won a special election for an Alabama state House seat, flipping a Republican-held seat by campaigning on abortion rights in the deep-red state that bans abortion with no exceptions for rape or incest. Lands won 62 percent of the nearly 6,000 votes cast, while her challenger, Republican Teddy Powell, won 37.5 percent, according to the unofficial election night results from the Alabama Secretary of State. The candidates were running to replace Republican David Cole, who resigned last year after he was arrested on a voting fraud charge. (Lands ran against Cole in 2022 and lost by just under 1,000 votes, or about 7 percentage points—making her win last night all the more significant.)

Lands—a licensed professional counselor whose website says her “Christian values deeply influence her life and work”—campaigned on repealing the state’s abortion ban, as well as expanding Medicaid, investing in community mental health resources, and improving the local economy and education. Days after the state Supreme Court‘s decision threatening IVF last month, Lands released a campaign ad in which she and another Alabama woman, Alyssa Gonzales, each shared their personal stories of getting emergency abortions following nonviable pregnancies. For Lands, it happened 20 years ago; for Gonzales, it happened after the Dobbs decision was handed down in 2022. 

“We will not stand by and watch our most basic human rights be stripped from us,” Lands says in the ad.  

I’m sharing my abortion story because Alabama's no exceptions abortion ban is putting lives at risk. We must repeal this legislation, and if I'm elected on March 26th, I'll work tirelessly to do just that.

Learn more at https://t.co/VQKTW9Ivob pic.twitter.com/n7fZDB2Eqx

— Marilyn for Alabama (@MarilynForAL) February 20, 2024

Tuesday’s election results once again demonstrated the far-reaching effects that abortion bans can have in galvanizing voters in decisive elections around the country. The trend can be directly traced to the Supreme Court’s Dobbs ruling, which was repeatedly cited throughout the Alabama Supreme Court decision that effectively banned IVF procedures. (The Alabama Legislature subsequently passed a bill, which the governor signed, to protect IVF access, but it didn’t address the legal status of frozen embryos.) 

While Alabama is reliably red—and the state legislature remains majority Republican—Lands’ district, the state’s 10th District, has been a battleground: Trump won it by only one percentage point in 2020, the Washington Post reported, while he won the state by more than 35 percentage points. Voters told the 19th earlier this month that they were going to vote for Lands because of her stance on abortion and reproductive rights. 

Lands told local CBS affiliate WHNT that she saw her victory as “a victory…for women, for families,” adding that she wanted to “repeal the bad ban on no-exceptions abortion” and “protect IVF and contraception.” 

“It feels like the start of a change here, and I think we’ll see more change in 2026. I think Alabama is changing,” she said.

Former Alabama Sen. Doug Jones (D) agreed, telling CNN that the results were “a huge win for Alabama, not just for Democrats.”

Lands’ win seems to send a clear message—one that advocates have been trying to send President Biden and other Democrats for some time: it’s reproductive justice that wins elections in the post-Roe era. And as long as Republicans’ anti-abortion policies continue to harm pregnant people—including those who aren’t seeking abortions—they’ll likely continue losing to Democrats like Lands.

Next week, the Supreme Court will hear oral arguments in the case brought by anti-abortion activists seeking to restrict the availability of mifepristone, the first of the two pills taken in a medication abortion.

The basis of the arguments against the pill rests on myriad falsehoods, which have already been disproven: Contrary to anti-abortion activists’ claims, more than 100 studies have shown that medication abortion—which accounts for more than half of all abortions nationwide, according to the Guttmacher Institute—is safe and effective. That includes a study published in February in the journal Nature Medicine that found medication abortion is just as safe when it’s prescribed virtually as it is in person, as I reported at the time.

But there’s another, lesser-reported piece of misinformation that anti-abortion activists are peddling before the high court. They’re alleging that the availability of telehealth abortions—in which providers prescribe the pills by phone or video call and then mail them to patients—harms people experiencing intimate partner violence by enabling abusers to force people to have abortions. This could potentially impact how the Supreme Court rules on whether the FDA acted improperly in 2016 and 2021, when the agency relaxed some rules around how mifepristone can be prescribed—including allowing it to be prescribed virtually and sent by mail. Versions of this narrative—that telehealth abortion facilitates abuse—are present within 9 of the more than 80 “friend of the court” briefs (which also include arguments for preserving mifepristone) filed in the case, according to my review. These briefs are essentially statements of interest from parties—individuals or organizations—who are not part of the court case but are seeking to influence the court’s decision. 

And like many arguments from the anti-abortion side, the claim that medication abortion prescribed through telehealth contributes in any significant way to domestic abuse is baseless: Experts told me it’s unsupported by evidence and ignores many of the ways reproductive coercion actually manifests—as well as the many benefits telehealth abortion can provide for people experiencing intimate partner violence.

But making up their own facts is nothing new to anti-abortion activists. Two studies that claimed to show the dangers of mifepristone and were cited in the Texas court ruling that led to the forthcoming Supreme Court case were retracted in February after an independent peer review uncovered unsupported conclusions due to flaws with the study design, methodology, and data analysis—along with possible conflicts of interest given the lead author’s affiliation with the Charlotte Lozier Institute, an anti-abortion advocacy organization.

“There’s no basis in facts or medical science for any parts of this case,” Elisa Wells, co-director and co-founder of Plan C, a campaign focused on medication abortion access, told me. And the risks of intimate partner violence that the anti-abortion side claims to worry about in their briefs, she added, “are created by the abuser—not by telehealth abortion.” 

One of the main claims in the anti-abortion briefs is that the majority of abortions are coerced, and that telehealth abortions—which now account for up to sixteen percent of all abortions nationwide—help perpetuate coercion by making it easier to terminate a pregnancy and harder for providers to screen for signs of coercion.

But Diana Greene Foster, a professor at the University of California, San Francisco, told me that it’s “extremely rare” for people to be coerced into abortion—and that it’s far more common for people to report being coerced into pregnancy by an abusive partner. One of Foster’s papers, based on more than 5,100 women seeking abortions at one clinic in 2008, found that only one percent of respondents said they were seeking an abortion because someone else wanted them to get one, with minors feeling more likely to report feeling pressured than adults. Another paper Foster co-authored, published in 2013, found that most people seeking abortions do so for multiple reasons, and that the top ones include financial reasons, timing and partner-related reasons, including not having a stable relationship or wanting to be married first. 

“Most abortion patients are not being coerced,” Foster said. “They are making the decision for themselves based on their own life circumstances.” 

Rebecca Gomperts, a physician and the founder of Aid Access, which provides telehealth abortions across the country, agreed. While she said Aid Access “regularly” hears from pregnant people dealing with partners trying to force them to keep the pregnancy, she added that they’ve “never seen the other way around, where a women is forced to have an abortion against her will.” Gomperts shared with me via e-mail a note from a client who reached out to Aid Access after her boyfriend tracked her down at a local Planned Parenthood—where she had gone to obtain an abortion—and brought her home; notes from two other clients she shared with me thanked the service with helping them leave abusive relationships.

As the National Domestic Violence Hotline points out in its own friend of the court brief arguing for the preservation of the FDA approval of mifepristone, “traveling for abortion care may not be an option, and having options for discreetly accessing abortion care helps survivors maintain safety and privacy.” The costs of travel and childcare can also be “prohibitive” for people experiencing financial abuse, that brief adds. And as several other briefs filed by reproductive rights organizations note, medication abortion can help survivors of intimate partner violence avoid unwanted physical contact in a doctor’s office, which may be a priority for some based on their past experiences of abuse.

And because an abortion at home “appears very much like a miscarriage,” it’s unlikely to attract the level of scrutiny that traveling to an in-person abortion may bring from an abusive partner, according to Ondine Quinn, the director of program development at Provide, an organization that trains advocates for people experiencing domestic and sexual violence on how to help survivors safely access medication abortion.

But you don’t get this sense from the briefs filed by the anti-abortion side—several of which paint sinister pictures of abusers regularly lurking behind phones and computer screens and abusing telehealth abortions by forcing pregnant people to obtain them against their will while providers remain oblivious. There’s the brief from the Charlotte Lozier Institute, which says, for example: “With limited visibility and an inability to detect unspoken body language, there is no way to ensure that an abuser standing off-screen is not pressuring the woman to request an action that she does not desire.” 

Experts say that while such a scene is theoretically possible, these arguments also ignore the fact that coercion can also occur during in person health care appointments, where abusive partners can insist on being present. “That’s the nature of the controlling relationship,” according to Liz Tobin-Tyler, an associate professor of health services, policy, and practice at Brown University who has written about the interactions between abortion restrictions and intimate partner violence. And health care providers aren’t necessarily always screening for intimate partner violence even when they do see patients in person: A literature review of 35 studies published in the journal Trauma, Violence & Abuse in 2016 found that “overall, health-care workers remain challenged in screening and appropriately responding to IPV.” 

It’s also possible for telehealth abortion providers to make efforts to screen for intimate partner violence by phone or computer, Tobin-Tyler noted. She pointed me to a June 2021 paper published in JAMA by a professor of obstetrics and gynecology from Northwestern University, who argued that telehealth clinicians should ask yes or no questions—including whether patients are alone and can safely speak—to determine if a patient is experiencing intimate partner violence, and that providers should be prepared to refer patients to hotlines and other resources if necessary.

Aid Access asks clients if they are requesting medication abortion through their own free will, and asks them to submit proof of identification, Gomperts said. Hey Jane, another major telehealth abortion provider, also has “protocols in place” to screen for intimate partner violence, according to a spokesperson. A spokesperson for Wisp, a telehealth provider that provides a range of services including medication abortion, said that while the service doesn’t screen for domestic violence, they do provide resources if people disclose they’re experiencing it or other forms of abuse. Spokespeople for other major telehealth abortion providers—including Carafem, Twentyeight Health, Cambridge Reproductive Health Consultants, and Honeybee Health—didn’t respond to my requests for comment by publication time.

As I’ve written, new data in fact suggests that rising abortion restrictions will disproportionately impact people experiencing intimate partner violence—who are already more likely to be people of color, LGBTQ people, and disabled people compared to the general population. 

A study published in February in the Journal of the American College of Surgeons found that, under Roe, pregnant and postpartum people in states with abortion restrictions had a 75 percent higher rate of homicide than those in states that protected abortion access; pregnant and postpartum people were also at higher risk for homicide due to intimate partner violence compared to homicide victims who weren’t pregnant. And a study published in JAMA Internal Medicine in January estimated that there were more than 64,500 pregnancies as a result of rape in 14 states with abortion bans after the Dobbs decision, with the majority—nearly 59,000—occurring in nine states with abortion bans that lack exceptions for rape or incest.

Research that shows the significance of abortion access for survivors of intimate partner violence isn’t new. A 2014 study co-authored by Foster found that women who were unable to get wanted abortions were more likely to experience “sustained physical violence” and “sustained contact” with an abuser over time, while those who were able to obtain abortions experienced less physical violence and ended their relationships with their abusive partners sooner than those who gave birth.

As Tobin-Tyler told me: “Protecting people that are experiencing domestic violence is intimately tied to their reproductive autonomy.” Whether the justices are prepared to recognize the facts that support that remains to be seen. 

Next week, the Supreme Court will hear oral arguments in the case brought by anti-abortion activists seeking to restrict the availability of mifepristone, the first of the two pills taken in a medication abortion.

The basis of the arguments against the pill rests on myriad falsehoods, which have already been disproven: Contrary to anti-abortion activists’ claims, more than 100 studies have shown that medication abortion—which accounts for more than half of all abortions nationwide, according to the Guttmacher Institute—is safe and effective. That includes a study published in February in the journal Nature Medicine that found medication abortion is just as safe when it’s prescribed virtually as it is in person, as I reported at the time.

But there’s another, lesser-reported piece of misinformation that anti-abortion activists are peddling before the high court. They’re alleging that the availability of telehealth abortions—in which providers prescribe the pills by phone or video call and then mail them to patients—harms people experiencing intimate partner violence by enabling abusers to force people to have abortions. This could potentially impact how the Supreme Court rules on whether the FDA acted improperly in 2016 and 2021, when the agency relaxed some rules around how mifepristone can be prescribed—including allowing it to be prescribed virtually and sent by mail. Versions of this narrative—that telehealth abortion facilitates abuse—are present within 9 of the more than 80 “friend of the court” briefs (which also include arguments for preserving mifepristone) filed in the case, according to my review. These briefs are essentially statements of interest from parties—individuals or organizations—who are not part of the court case but are seeking to influence the court’s decision. 

And like many arguments from the anti-abortion side, the claim that medication abortion prescribed through telehealth contributes in any significant way to domestic abuse is baseless: Experts told me it’s unsupported by evidence and ignores many of the ways reproductive coercion actually manifests—as well as the many benefits telehealth abortion can provide for people experiencing intimate partner violence.

But making up their own facts is nothing new to anti-abortion activists. Two studies that claimed to show the dangers of mifepristone and were cited in the Texas court ruling that led to the forthcoming Supreme Court case were retracted in February after an independent peer review uncovered unsupported conclusions due to flaws with the study design, methodology, and data analysis—along with possible conflicts of interest given the lead author’s affiliation with the Charlotte Lozier Institute, an anti-abortion advocacy organization.

“There’s no basis in facts or medical science for any parts of this case,” Elisa Wells, co-director and co-founder of Plan C, a campaign focused on medication abortion access, told me. And the risks of intimate partner violence that the anti-abortion side claims to worry about in their briefs, she added, “are created by the abuser—not by telehealth abortion.” 

One of the main claims in the anti-abortion briefs is that the majority of abortions are coerced, and that telehealth abortions—which now account for up to sixteen percent of all abortions nationwide—help perpetuate coercion by making it easier to terminate a pregnancy and harder for providers to screen for signs of coercion.

But Diana Greene Foster, a professor at the University of California, San Francisco, told me that it’s “extremely rare” for people to be coerced into abortion—and that it’s far more common for people to report being coerced into pregnancy by an abusive partner. One of Foster’s papers, based on more than 5,100 women seeking abortions at one clinic in 2008, found that only one percent of respondents said they were seeking an abortion because someone else wanted them to get one, with minors feeling more likely to report feeling pressured than adults. Another paper Foster co-authored, published in 2013, found that most people seeking abortions do so for multiple reasons, and that the top ones include financial reasons, timing and partner-related reasons, including not having a stable relationship or wanting to be married first. 

“Most abortion patients are not being coerced,” Foster said. “They are making the decision for themselves based on their own life circumstances.” 

Rebecca Gomperts, a physician and the founder of Aid Access, which provides telehealth abortions across the country, agreed. While she said Aid Access “regularly” hears from pregnant people dealing with partners trying to force them to keep the pregnancy, she added that they’ve “never seen the other way around, where a women is forced to have an abortion against her will.” Gomperts shared with me via e-mail a note from a client who reached out to Aid Access after her boyfriend tracked her down at a local Planned Parenthood—where she had gone to obtain an abortion—and brought her home; notes from two other clients she shared with me thanked the service with helping them leave abusive relationships.

As the National Domestic Violence Hotline points out in its own friend of the court brief arguing for the preservation of the FDA approval of mifepristone, “traveling for abortion care may not be an option, and having options for discreetly accessing abortion care helps survivors maintain safety and privacy.” The costs of travel and childcare can also be “prohibitive” for people experiencing financial abuse, that brief adds. And as several other briefs filed by reproductive rights organizations note, medication abortion can help survivors of intimate partner violence avoid unwanted physical contact in a doctor’s office, which may be a priority for some based on their past experiences of abuse.

And because an abortion at home “appears very much like a miscarriage,” it’s unlikely to attract the level of scrutiny that traveling to an in-person abortion may bring from an abusive partner, according to Ondine Quinn, the director of program development at Provide, an organization that trains advocates for people experiencing domestic and sexual violence on how to help survivors safely access medication abortion.

But you don’t get this sense from the briefs filed by the anti-abortion side—several of which paint sinister pictures of abusers regularly lurking behind phones and computer screens and abusing telehealth abortions by forcing pregnant people to obtain them against their will while providers remain oblivious. There’s the brief from the Charlotte Lozier Institute, which says, for example: “With limited visibility and an inability to detect unspoken body language, there is no way to ensure that an abuser standing off-screen is not pressuring the woman to request an action that she does not desire.” 

Experts say that while such a scene is theoretically possible, these arguments also ignore the fact that coercion can also occur during in person health care appointments, where abusive partners can insist on being present. “That’s the nature of the controlling relationship,” according to Liz Tobin-Tyler, an associate professor of health services, policy, and practice at Brown University who has written about the interactions between abortion restrictions and intimate partner violence. And health care providers aren’t necessarily always screening for intimate partner violence even when they do see patients in person: A literature review of 35 studies published in the journal Trauma, Violence & Abuse in 2016 found that “overall, health-care workers remain challenged in screening and appropriately responding to IPV.” 

It’s also possible for telehealth abortion providers to make efforts to screen for intimate partner violence by phone or computer, Tobin-Tyler noted. She pointed me to a June 2021 paper published in JAMA by a professor of obstetrics and gynecology from Northwestern University, who argued that telehealth clinicians should ask yes or no questions—including whether patients are alone and can safely speak—to determine if a patient is experiencing intimate partner violence, and that providers should be prepared to refer patients to hotlines and other resources if necessary.

Aid Access asks clients if they are requesting medication abortion through their own free will, and asks them to submit proof of identification, Gomperts said. Hey Jane, another major telehealth abortion provider, also has “protocols in place” to screen for intimate partner violence, according to a spokesperson. A spokesperson for Wisp, a telehealth provider that provides a range of services including medication abortion, said that while the service doesn’t screen for domestic violence, they do provide resources if people disclose they’re experiencing it or other forms of abuse. Spokespeople for other major telehealth abortion providers—including Carafem, Twentyeight Health, Cambridge Reproductive Health Consultants, and Honeybee Health—didn’t respond to my requests for comment by publication time.

As I’ve written, new data in fact suggests that rising abortion restrictions will disproportionately impact people experiencing intimate partner violence—who are already more likely to be people of color, LGBTQ people, and disabled people compared to the general population. 

A study published in February in the Journal of the American College of Surgeons found that, under Roe, pregnant and postpartum people in states with abortion restrictions had a 75 percent higher rate of homicide than those in states that protected abortion access; pregnant and postpartum people were also at higher risk for homicide due to intimate partner violence compared to homicide victims who weren’t pregnant. And a study published in JAMA Internal Medicine in January estimated that there were more than 64,500 pregnancies as a result of rape in 14 states with abortion bans after the Dobbs decision, with the majority—nearly 59,000—occurring in nine states with abortion bans that lack exceptions for rape or incest.

Research that shows the significance of abortion access for survivors of intimate partner violence isn’t new. A 2014 study co-authored by Foster found that women who were unable to get wanted abortions were more likely to experience “sustained physical violence” and “sustained contact” with an abuser over time, while those who were able to obtain abortions experienced less physical violence and ended their relationships with their abusive partners sooner than those who gave birth.

As Tobin-Tyler told me: “Protecting people that are experiencing domestic violence is intimately tied to their reproductive autonomy.” Whether the justices are prepared to recognize the facts that support that remains to be seen. 

In October, Admiral Rachel Levine gave the keynote address at the national convention for the Parents, Families, and Friends of Lesbians and Gays, or “PFLAG,” as it’s been known since its founding in the 1970s. Standing before a backdrop patterned with rainbow hearts and queer rights slogans, Levine’s long gray hair was tied back in a bun, and she wore a dark blue skirt-suit uniform befitting her role as Assistant Secretary for Health, in which she oversees the US Public Health Service Commissioned Corps, a 6,000 member agency that leads the charge on a wide range of initiatives, from family planning clinics to toxic waste clean-up. (Though Levine does not serve in the armed forces, her title is still Admiral.) Levine is the first trans woman to ever serve in a Senate-confirmed office, and the most prominent trans official in any branch of government—a position that forces her to balance the responsibilities of being a bureaucrat with the burdens of being a symbol.

The PFLAG audience had gathered at a hotel in Arlington Virginia amid an ugly backlash against trans Americans, and during the Q&A, Levine was asked for tips on keeping ones cool. “My clinical training as a pediatrician has always been very helpful,” she said. “You have to take whatever emotions come up and put them aside, to compartmentalize them, and then treat the patient and the family in front of you. That’s what I do when I am at a Senate confirmation hearing or other challenging situations,” she said. In an earnest if somewhat clipped cadence, she called her audience to action. “We need all of you to work at the local and state level,” Levine said. “Teacher by teacher, county commissioner by county commissioner, superintendent by superintendent — to educate them about all of our collective humanity,” she said, stopping for applause. She asked her audience to engage with the sympathetic but uninformed, and cited statistics showing that just one supportive adult can keep a queer kid from trying to kill themselves. It was rousing, but also an admission of the limits of her power: Levine, perhaps better than any other Biden official, shows what representation can and can’t do.

Rachel Levine grew up in Boston in the 1970s, the child of two lawyers. On Saturdays she went to Hebrew school; during the week she attended the elite all-male Belmont Hill prep school. She was involved in theater, and still remembers her parents suffering through her performance in a 3-hour Chekhov play. Levine’s mother, among the first generation of women to graduate law school, represented widows and orphans of Boston dock workers who’d died from asbestos exposure. After graduating from Harvard, Levine attended Tulane Medical School, and fell in love with pediatrics. She moved to New York City for residency at Mt. Sinai, where in 1986, she was selected as chief resident of her pediatrics program. It was the early years of the AIDS crisis, so in addition to performing well-child exams and discussing immunization schedules, Levine also saw many newborns with a rare and aggressive pneumonia that resisted all treatment. The disease was initially labeled a “gay-related” immunodeficiency, but Levine saw many mothers pass the illness on to their children.

“There was a siege mentality,” Levine told me. “Every single one of those babies died. Every single one of those mothers died.” she said. Residency forced her to compartmentalize; Levine learned to shelve societal concerns, as she went room to room, patient to patient, addressing one problem at a time.

After finishing training, she moved with her family to Hershey, Pennsylvania for a position at Penn State. She became chief of their adolescent medicine division, running the eating disorder clinic for two decades. She became active in the Pennsylvania Medical Society and participated in community theater. (Levine jokes that she hopes someday to be the first person in Hershey to ever play both Captain Von Trapp and Fraulein Maria, before conceding that she doesn’t have Maria’s soprano range.)

Though Levine knew that she was trans from the time she was a child, she didn’t come out and begin her transition until 2011, when she was in her mid 50s. In conversations with her therapist, she compared her feelings about transitioning to Alice in Wonderland and The Matrix — journeys of exploration and self-reflection from which there is no return. She couldn’t compartmentalize anymore, and her family and colleagues were supportive as she began wearing more feminine clothes, growing her hair out. Her hospital even expanded its non-discrimination policy to include gender expression, despite the fact that trans issues were still peripheral to national gay rights groups. (President Obama hadn’t yet endorsed same-sex marriage, which remained illegal in many states.) “I was told I was going to lose everything. My job. My family. Everything. I was determined not to do that. And I was successful,” Levine told me. She says she has “no regrets” about when she transitioned, but acknowledged falling through the looking glass comes with tradeoffs. “I never got to be a 25-year-old woman.” Levine told me, but “I cannot imagine a life without my children,” While she believes gender affirming care should be available to all people who want it, she says young peoples’ reproductive potential needs to be carefully considered.

Levine’s rise in public life happened entirely after her transition. In 2015, Democratic Gov.-elect Tom Wolf asked her to join his transition team, and later nominated her to be the state’s physician general. She was unanimously confirmed by the GOP-controlled state Senate.

Levine quickly established herself as a creative and capable bureaucrat. At the height of the opioid epidemic, she expanded access to naloxone, a behind the counter overdose medication, by personally prescribing it to every person in the commonwealth. “It was an out of the box concept,” Levine told me. “Why can’t I do that?” When the state’s health secretary stepped down in 2017, Levine got the job. “People trusted her because she was straightforward,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Public health is often done through a political lens, but she was not a partisan.” Like many queer trailblazers, Levine got ahead by being consummately respectable.

When Covid hit and the governor began daily press conferences, she appeared at his side, quickly becoming one of the state’s most recognizable and influential officials. As ICU beds dwindled, Levine was praised for her “unflappable” demeanor, as she issued masking orders and mandated tests for out-of-staters.

Being a trans woman enforcing pandemic restrictions put Levine in the crossfire of two culture wars. One bar in Tioga County protested statewide closures by printing menus offering “Levine balls,” while a fair in Columbia County had a dunk tank where attendees could soak a wigged man impersonating the state health secretary. Levine addressed the abuse at one of the daily press conferences. “I want to emphasize that while these individuals may think they are only expressing their displeasure with me, they are in fact hurting the thousands of LGBTQ Pennsylvanians who suffer directly from these current demonstrations of harassment.” It was a lesson in doing a job while being a symbol.

After Biden won the 2020 election, Levine submitted her name for a role in the administration. “I literally got a text,” Levine told me. When she answered it, her life quickly began to change, as she left her job, prepared a replacement, and submitted herself to senate confirmation hearings, where Senator Rand Paul (R-Ky.) accused her of supporting “surgical destruction of a minor’s genitalia.” She was confirmed with every Senate Republican, save Lisa Murkowski and Susan Collins, voting against her. While Levine likened her confirmation process to a colonoscopy, she was never too concerned: “I’ve only ever had one secret in my life,” she told me.

The Assistant Secretary for Health can’t hire or fire staff or move money—let alone give anyone rights. Yet Levine does administer public programs funded with billions of dollars, while advising many people who have more power. When she shows up in uniform, there’s no escaping that she represents the government, and people are excited she’s there.

Like any middle manager, her job entails turning an endless parade of meetings into results. In June, I tagged along with Levine on a three-day trip to St. Louis, It was the one-year anniversary of the Dobbs decision, and just a week after Missouri state legislators had banned gender affirming care for minors, and she was doing panels with her boss, HHS Sec. Xavier Becerra, and Rep. Cori Bush (D-Mo.) at two area Planned Parenthoods. She also met with residents of Cahokia Heights, a Black neighborhood outside St. Louis, to address the summer rains that fill their houses with sewage, and with Jackie Joyner-Kersee and officials from the Department of Agriculture to discuss ways to expand nutrition programs in the Olympian’s East St. Louis neighborhood.

At most of these meetings Levine would introduce herself and then listen for long stretches, occasionally nodding or adjusting her glasses with an index finger. When she did finally speak, she often gave her diagnosis of the problem, suggested a few possible avenues of reform, and then—like so many doctor’s appointments—left with a promise to follow up, but with few sure solutions.

So it went at Vivient Health, where Levine appeared on another panel with Rep. Bush. After a tour of the LGBTQ clinic, we settled into a sterile meeting room with Diet Coke cans and wheeled office chairs. Though it was a bright, hot day, the mood was grim. Ben Greene, a 24-year-old trans activist, said that the trans children he works with had been despondent since Missouri passed its gender affirming care ban. “Kids have reached out to me to say that they don’t want to be here. They feel like they aren’t wanted.” Greene had helped the kids testify against the bill, and was shocked by the contempt Republican legislators showed, either by leaving the chamber or scrolling on their phones as the kids pleaded and cried. “The trans kids I work with don’t know that trans people live into our 30s,” said Greene. “They call me a ‘trans elder.’ That’s horrifying.”

Michaela Joy Kraemer, executive director of St. Louis’s Metro Trans Umbrella Group, said that she had felt hollow after a friend’s suicide, and was bogged down in finding a health insurance program that would cover gender affirming care for the group’s employees.

Levine waited 20 minutes before speaking.  “Well, I’m actually a trans elder,” she began, and the room let out a laugh. Then she launched into her spiel—part diagnosis, part policy prescription, part call to action. “I think that it is important to push back in the state legislature, but I would not expect that to be successful at this time. But I think that other people can be educated, and that we can change the narrative.” As the meeting wrapped up, she listed sources of funding at HHS and new policy initiatives — anything that might be able to help. “I don’t mean to put the onus on you,” she said. But she was. It was a stark example of the limits of representation: the most powerful trans bureaucrat in the country was, literally, offering people fighting for their rights and lives the chance to fill out paperwork.

In November, I checked back with Greene and Joy Kraemer on whether anything—funding, support—had come of the meeting. Both said no. “But that’s not a fair expectation to have,” Kraemer told me. Greene agreed: “When we have someone on the inside we have these infinite expectations, but bureaucracy is meant to be slow and hard to change…She’s doing everything she can, but that won’t be enough,” he said, before adding that he found solace in simply seeing a trans person live to old age. “The most exciting thing was that she had grey hair.”  

On my last day with Levine, as we crossed a bridge over the Mississippi River, I asked her if she ever got frustrated with incrementalism. “Sure,” she replied. “It’s a big country.”

“Sometimes you can develop programs that will help a bunch of people,” she continued, “That’s the goal of public service and public health—but it doesn’t change the importance of helping one person. I think that is one of the most valuable things you can do.”

In October, Admiral Rachel Levine gave the keynote address at the national convention for the Parents, Families, and Friends of Lesbians and Gays, or “PFLAG,” as it’s been known since its founding in the 1970s. Standing before a backdrop patterned with rainbow hearts and queer rights slogans, Levine’s long gray hair was tied back in a bun, and she wore a dark blue skirt-suit uniform befitting her role as Assistant Secretary for Health, in which she oversees the US Public Health Service Commissioned Corps, a 6,000 member agency that leads the charge on a wide range of initiatives, from family planning clinics to toxic waste clean-up. (Though Levine does not serve in the armed forces, her title is still Admiral.) Levine is the first trans woman to ever serve in a Senate-confirmed office, and the most prominent trans official in any branch of government—a position that forces her to balance the responsibilities of being a bureaucrat with the burdens of being a symbol.

The PFLAG audience had gathered at a hotel in Arlington Virginia amid an ugly backlash against trans Americans, and during the Q&A, Levine was asked for tips on keeping ones cool. “My clinical training as a pediatrician has always been very helpful,” she said. “You have to take whatever emotions come up and put them aside, to compartmentalize them, and then treat the patient and the family in front of you. That’s what I do when I am at a Senate confirmation hearing or other challenging situations,” she said. In an earnest if somewhat clipped cadence, she called her audience to action. “We need all of you to work at the local and state level,” Levine said. “Teacher by teacher, county commissioner by county commissioner, superintendent by superintendent — to educate them about all of our collective humanity,” she said, stopping for applause. She asked her audience to engage with the sympathetic but uninformed, and cited statistics showing that just one supportive adult can keep a queer kid from trying to kill themselves. It was rousing, but also an admission of the limits of her power: Levine, perhaps better than any other Biden official, shows what representation can and can’t do.

Rachel Levine grew up in Boston in the 1970s, the child of two lawyers. On Saturdays she went to Hebrew school; during the week she attended the elite all-male Belmont Hill prep school. She was involved in theater, and still remembers her parents suffering through her performance in a 3-hour Chekhov play. Levine’s mother, among the first generation of women to graduate law school, represented widows and orphans of Boston dock workers who’d died from asbestos exposure. After graduating from Harvard, Levine attended Tulane Medical School, and fell in love with pediatrics. She moved to New York City for residency at Mt. Sinai, where in 1986, she was selected as chief resident of her pediatrics program. It was the early years of the AIDS crisis, so in addition to performing well-child exams and discussing immunization schedules, Levine also saw many newborns with a rare and aggressive pneumonia that resisted all treatment. The disease was initially labeled a “gay-related” immunodeficiency, but Levine saw many mothers pass the illness on to their children.

“There was a siege mentality,” Levine told me. “Every single one of those babies died. Every single one of those mothers died.” she said. Residency forced her to compartmentalize; Levine learned to shelve societal concerns, as she went room to room, patient to patient, addressing one problem at a time.

After finishing training, she moved with her family to Hershey, Pennsylvania for a position at Penn State. She became chief of their adolescent medicine division, running the eating disorder clinic for two decades. She became active in the Pennsylvania Medical Society and participated in community theater. (Levine jokes that she hopes someday to be the first person in Hershey to ever play both Captain Von Trapp and Fraulein Maria, before conceding that she doesn’t have Maria’s soprano range.)

Though Levine knew that she was trans from the time she was a child, she didn’t come out and begin her transition until 2011, when she was in her mid 50s. In conversations with her therapist, she compared her feelings about transitioning to Alice in Wonderland and The Matrix — journeys of exploration and self-reflection from which there is no return. She couldn’t compartmentalize anymore, and her family and colleagues were supportive as she began wearing more feminine clothes, growing her hair out. Her hospital even expanded its non-discrimination policy to include gender expression, despite the fact that trans issues were still peripheral to national gay rights groups. (President Obama hadn’t yet endorsed same-sex marriage, which remained illegal in many states.) “I was told I was going to lose everything. My job. My family. Everything. I was determined not to do that. And I was successful,” Levine told me. She says she has “no regrets” about when she transitioned, but acknowledged falling through the looking glass comes with tradeoffs. “I never got to be a 25-year-old woman.” Levine told me, but “I cannot imagine a life without my children,” While she believes gender affirming care should be available to all people who want it, she says young peoples’ reproductive potential needs to be carefully considered.

Levine’s rise in public life happened entirely after her transition. In 2015, Democratic Gov.-elect Tom Wolf asked her to join his transition team, and later nominated her to be the state’s physician general. She was unanimously confirmed by the GOP-controlled state Senate.

Levine quickly established herself as a creative and capable bureaucrat. At the height of the opioid epidemic, she expanded access to naloxone, a behind the counter overdose medication, by personally prescribing it to every person in the commonwealth. “It was an out of the box concept,” Levine told me. “Why can’t I do that?” When the state’s health secretary stepped down in 2017, Levine got the job. “People trusted her because she was straightforward,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Public health is often done through a political lens, but she was not a partisan.” Like many queer trailblazers, Levine got ahead by being consummately respectable.

When Covid hit and the governor began daily press conferences, she appeared at his side, quickly becoming one of the state’s most recognizable and influential officials. As ICU beds dwindled, Levine was praised for her “unflappable” demeanor, as she issued masking orders and mandated tests for out-of-staters.

Being a trans woman enforcing pandemic restrictions put Levine in the crossfire of two culture wars. One bar in Tioga County protested statewide closures by printing menus offering “Levine balls,” while a fair in Columbia County had a dunk tank where attendees could soak a wigged man impersonating the state health secretary. Levine addressed the abuse at one of the daily press conferences. “I want to emphasize that while these individuals may think they are only expressing their displeasure with me, they are in fact hurting the thousands of LGBTQ Pennsylvanians who suffer directly from these current demonstrations of harassment.” It was a lesson in doing a job while being a symbol.

After Biden won the 2020 election, Levine submitted her name for a role in the administration. “I literally got a text,” Levine told me. When she answered it, her life quickly began to change, as she left her job, prepared a replacement, and submitted herself to senate confirmation hearings, where Senator Rand Paul (R-Ky.) accused her of supporting “surgical destruction of a minor’s genitalia.” She was confirmed with every Senate Republican, save Lisa Murkowski and Susan Collins, voting against her. While Levine likened her confirmation process to a colonoscopy, she was never too concerned: “I’ve only ever had one secret in my life,” she told me.

The Assistant Secretary of Health can’t hire or fire staff or move money—let alone give anyone rights. Yet Levine does administer public programs funded with billions of dollars, while advising many people who have more power. When she shows up in uniform, there’s no escaping that she represents the government, and people are excited she’s there.

Like any middle manager, her job entails turning an endless parade of meetings into results. In June, I tagged along with Levine on a three-day trip to St. Louis, It was the one-year anniversary of the Dobbs decision, and just a week after Missouri state legislators had banned gender affirming care for minors, and she was doing panels with her boss, HHS Sec. Xavier Becerra, and Rep. Cori Bush (D-Mo.) at two area Planned Parenthoods. She also met with residents of Cahokia Heights, a Black neighborhood outside St. Louis, to address the summer rains that fill their houses with sewage, and with Jackie Joyner-Kersee and officials from the Department of Agriculture to discuss ways to expand nutrition programs in the Olympian’s East St. Louis neighborhood.

At most of these meetings Levine would introduce herself and then listen for long stretches, occasionally nodding or adjusting her glasses with an index finger. When she did finally speak, she often gave her diagnosis of the problem, suggested a few possible avenues of reform, and then—like so many doctor’s appointments—left with a promise to follow up, but with few sure solutions.

So it went at Vivient Health, where Levine appeared on another panel with Rep. Bush. After a tour of the LGBTQ clinic, we settled into a sterile meeting room with Diet Coke cans and wheeled office chairs. Though it was a bright, hot day, the mood was grim. Ben Greene, a 24-year-old trans activist, said that the trans children he works with had been despondent since Missouri passed its gender affirming care ban. “Kids have reached out to me to say that they don’t want to be here. They feel like they aren’t wanted.” Greene had helped the kids testify against the bill, and was shocked by the contempt Republican legislators showed, either by leaving the chamber or scrolling on their phones as the kids pleaded and cried. “The trans kids I work with don’t know that trans people live into our 30s,” said Greene. “They call me a ‘trans elder.’ That’s horrifying.”

Michaela Joy Kraemer, executive director of St. Louis’s Metro Trans Umbrella Group, said that she had felt hollow after a friend’s suicide, and was bogged down in finding a health insurance program that would cover gender affirming care for the group’s employees.

Levine waited 20 minutes before speaking.  “Well, I’m actually a trans elder,” she began, and the room let out a laugh. Then she launched into her spiel—part diagnosis, part policy prescription, part call to action. “I think that it is important to push back in the state legislature, but I would not expect that to be successful at this time. But I think that other people can be educated, and that we can change the narrative.” As the meeting wrapped up, she listed sources of funding at HHS and new policy initiatives — anything that might be able to help. “I don’t mean to put the onus on you,” she said. But she was. It was a stark example of the limits of representation: the most powerful trans bureaucrat in the country was, literally, offering people fighting for their rights and lives the chance to fill out paperwork.

In November, I checked back with Greene and Joy Kraemer on whether anything—funding, support—had come of the meeting. Both said no. “But that’s not a fair expectation to have,” Kraemer told me. Greene agreed: “When we have someone on the inside we have these infinite expectations, but bureaucracy is meant to be slow and hard to change…She’s doing everything she can, but that won’t be enough,” he said, before adding that he found solace in simply seeing a trans person live to old age. “The most exciting thing was that she had grey hair.”  

On my last day with Levine, as we crossed a bridge over the Mississippi River, I asked her if she ever got frustrated with incrementalism. “Sure,” she replied. “It’s a big country.”

“Sometimes you can develop programs that will help a bunch of people,” she continued, “That’s the goal of public service and public health—but it doesn’t change the importance of helping one person. I think that is one of the most valuable things you can do.”

Telehealth abortions continue to grow in popularity, even in states where anti-abortion activists try to ban them, according to new data published today.

Abortions obtained through virtual providers accounted for 15 to 16 percent of all abortions conducted between July and September of last year—amounting to about 14,000 abortions each month—up from 11 percent of abortions, or about 8,500, in December of 2022, according to the report, prepared by researchers from Ohio State University, the University of California, San Francisco, and the Society of Family Planning. The increase is partly thanks to the rise of shield laws, which protect providers who virtually prescribe and mail abortion pills to people in states with abortion bans, according to one of the report’s co-authors, Ushma Upadhyay, a researcher at the University of California, San Francisco. 

Five states—Massachusetts, Colorado, Washington, New York, and Vermont—passed laws last year that protect telehealth providers who help people elsewhere in the country get abortions, according to Upadhyay. California enacted its shield law last month. As the New York Times reported last week, while these laws have not yet faced legal challenges, many expect them to. But in the meantime, they’re serving as the key to abortion access for people across the country: The Times reports that Aid Access, one of three main organizations providing telehealth abortions, serves about 7,000 patients a month, about 90 percent of whom are in states with abortion bans or severe restrictions. Advocates say telehealth abortion can also be particularly significant for low-income people and those in rural areas who may otherwise have difficulty accessing abortion clinics. 

The new data from Upadhyay and her colleagues—part of a recurring study known as #WeCount, aimed at providing quarterly updates on abortion access post-Dobbs—comes just weeks before the Supreme Court is slated to hear oral arguments in a case brought by anti-abortion activists arguing against the FDA approval of mifepristone, one of two pills taken in a medication abortion. That case—billed as the biggest abortion case since Dobbs, since medication abortions account for more than half of all abortions nationwide, according to the Guttmacher Institute—will go before the high court despite the fact that more than 100 studies have shown that medication abortion is safe and effective. One of those studies was also conducted by Upadhyay, and was published in the journal Nature Medicine this month; it showed the pills are just as safe when prescribed virtually and mailed as when they’re prescribed and obtained in-person, as I previously reported. As I wrote then: 

If the court restricts the accessibility of mifepristone through telehealth, it could have a significant effect. With abortion restrictions on the rise, obtaining abortion pills from virtual clinics has continued to grow in popularity. After the Supreme Court handed down the Dobbs decision in June 2022, abortions obtained through telehealth increased drastically—from 3,610 in April 2022 to 8,540 by December of that year, according to research published last year by the Society of Family Planning. And as I reported last month, a study published in the journal JAMA Internal Medicine shows that more Americans are using telehealth to stockpile abortion pills in case they need them in the future. 

Despite the threat of the new Supreme Court case, the latest data has left Elisa Wells—co-founder and co-director of Plan C, an organization that provides information about accessing medication abortion—feeling optimistic. 

“We want people to know that they now have a safe and effective option for early abortion that does not require them to totally disrupt their lives and endure the expense and inconvenience of traveling to another state for care,” said Wells, who was not involved with the #WeCount study. “Abortion pills are now everywhere through telehealth, even in states with bans.”

In ruling that frozen embryos should be legally considered the same as children under a wrongful death law, the Alabama Supreme Court furthered a growing movement hoping to enshrine “fetal personhood”—the idea that a fetus or embryo should have the same rights as a child—into law.

In Alabama, one consequence of such a doctrine became clear immediately. In the days following the decision, multiple in vitro fertilization, or IVF, clinics in the state paused their services over concerns that they could be prosecuted for disposing of unused embryos. But enacting fetal personhood to curtail abortion adds more complexities than hindering IVF. If a fetus is a child, what does it mean for miscarriages? What happens with tort law—can a fetus’ estate sue for harm?

Republicans seemed to openly admit that they had not considered what fetal personhood could entail. “I’m not sure everybody has really thought about what all the potential problems are,” Texas Governor Greg Abbott admitted after the Alabama ruling. (Soon after, Florida delayed a law giving an “unborn child” new protections.)

Dr. Michele Bratcher Goodwin has been writing about embryos, fetal personhood, and the criminalization of pregnancy for decades. Her book, Policing the Womb, published before the fall of Roe v. Wade, details how states can abuse laws and infringe on civil rights to police reproductive freedom. Dr. Goodwin, who is currently a constitutional law and global health policy professor at Georgetown Law, and I spoke about the court’s decision in Alabama and what it means if fetal personhood is enacted. 

Were you surprised by the Alabama Supreme Court’s ruling? 

No. For a very long time, I’ve not been surprised.

It’s been probably close to 20 years since I first made trips to Alabama and began looking at the anti-abortion movement. The personhood efforts have intensified over the last 15 years or so. 

I’m curious what other ramifications about fetal personhood you see happening that maybe aren’t so blatant? 

It’s undeniable we could see policing of reproduction. Think about Brittany Watts and her toilet being busted open and police searching through fecal and fetal remains to see if she had a miscarriage.

Now, also think about with this Alabama ruling, where the court says embryos are children: What does that mean for a woman in a relationship?

We know that the risk of domestic violence is intensified when a person is pregnant. We’ve also seen that in the wake of anti-abortion lawmaking, there have been boyfriends and husbands who have acted in abusive and criminal ways, believing that they have some authority over the bodies of the women in their lives. [Fetal personhood] creates an atmosphere where any time in which a pregnancy may not occur when sex has occurred, there is the presumption or question: Did she do something to cause menstruation?

Consider that in Burwell v. Hobby Lobby Stores, the Supreme Court basically said that IUDs and Plan B are abortifacients [a substance used to terminate a pregnancy]—which they are not, they’re contraception. When you combine the Supreme Court’s ruling in that case, along with this Alabama case, then you get this nightmare situation where the presumption ends up being that an abortion is taking place…

Immediately after sex.

That’s right. The idea is that a pregnancy is taking place immediately after sex. And if that pregnancy isn’t sustained, well, then something must have happened. She must have done something and we need to investigate.

This seems far-fetched in the way that the slow fall of Roe seemed far-fetched. 

In the same way that I wrote an article published seven years ago, “If Embryos and Fetuses Have Rights.” I talked exactly about the moment that we’re in. I can’t make it up.  

What we see in a decision like this is this alarming disregard for the constitutional citizenship of women, but also more than that, it means a disregard for the lives of the most vulnerable people who most cry out for civil liberties and civil rights and to be respected under the law. It’s LGBTQ couples who are also vulnerable here. It’s women who lack fertility who are implicated in this. And in terms of criminal policing, the communities that are more likely to be surveilled, more likely to experience the harshest blows of the law, are always, unfortunately, going to be poor people. And amongst them women of color.

What’s interesting in Alabama that has been going on for not quite a generation, but nearly so, is this prurient policing of poor white women, which has largely been ignored, but which I’ve written about—these are vulnerable white women who do not have political clout, who are not wealthy. And they’ve come under intense, intense scrutiny by prosecutors. 

There’s been a lot less noise about heavily policed groups of women, both in Alabama and nationally, being charged with things like child endangerment or feticide. What do you make of the difference in attention given to the Alabama Supreme Court ruling? 

IVF has been a resource available to people who have usually been more wealthy, educated, and white—and who’ve been able to have access to these technologies. And in some ways, what one sees in the wake of this ruling has been political elites who’ve been articulating their discontent with this case. Because they are constituents that are listened to. They themselves have utilized these technologies. That’s quite distinct from ignoring the concerns of people who are not the elites, the people who are poor and suffering under the weight of this kind of harsh pronatalism that we see in the United States.

Over the past week, we’ve seen pushback from all sides of the political spectrum. Republicans have been saying: We ought not to be going after people with fertility issues who want to get pregnant. Why such a broad outcry? And why this ruling? 

Infertility does not have a political party. Being LGBTQ and needing assisted reproductive technologies is not a political party. Being older and wanting to start a family does not have a political party. When one understands that, then you can see why there has been pushback across myriad areas.

Nikki Haley has come forward to say that she needed to use assisted reproductive technologies for the birth of her son. The Chief Justice John Roberts and his family did not conceive biological children. Mike Pence has come forward expressing that his family utilized these technologies. It exposed how harmful the rule that embryos are children is and that it might make it difficult for families to utilize these technologies. One could see that immediately with various campuses shutting down their IVF clinics and organizations saying that they would not ship cryopreserved embryos to and from the state.

What else is on your mind right now? 

The chilling effect.  

For example, if one thinks about the era of Jim Crow and the civil rights movement, if a state has said, Okay, we’ve done away with laws that ban your ability to go in the parks and ban your ability to go into swimming pools. But we’re going to have armed guards and police officers studying your every move. It was understood that there’s a chilling effect. Even though you’ve now said it’s legal to walk into the school, we’re going to have guards and guns pointed at you while you try to walk into the school.

We have to worry about now the chilling effect—that even when there should be legal protections, when they may exist on paper, they may be more illusory than real. What then are those reproductive freedoms if it comes at the cost of being policed, experiencing vulnerability, and the risks of punishment?

This interview has been edited for length and clarity.