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.
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.”
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.”) Allthreehave 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 bothideas 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 atthe 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.”
Ibrahim Rayintakath
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 amembership 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 callsexpertwitnesses 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 connectedgroups 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 recentanti-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.
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 Supreme Court on Wednesday will consider its third major abortion case in two years—and the third brought with the help of a legal nonprofit attempting to infuse American life with its far-right brand of Christianity.
Not only is the group, Alliance Defending Freedom, behind legislation to ban abortion, it is also increasingly representing state governments in their efforts to protect and enforce the bans. The result is an ethically fraught arrangement that puts legal representation of the public in the hands of a religious organization that hauls in more than $100 million per year in tax-exempt donations, largely from undisclosed sources. (Though the group is not required to disclose its donors, the New Yorker reported last year that the family behind the Hobby Lobby craft store—which sued successfully against the contraception coverage mandate in the Affordable Care Act, with ADF’s help—is a significant donor.)
ADF lawyers are now helping Idaho defend its abortion ban against a suit from the Biden administration. The administration claims that Idaho’s law, which criminalizes emergency abortions unless the mother’s life is in danger, conflicts with the Emergency Medical Treatment and Labor Act, a federal lawthat compels hospitals to provide appropriate care in emergencies. Whether Idaho’s ban can take precedence over federal law will be argued before the Supreme Court on Wednesday, raising the possibility that the justices will allow states to place pregnant people in mortal peril to prevent them from ending their pregnancies.
In December, legal journalist Chris Geidner reported that Idaho attorney general Raul Labrador had brought on ADF to represent the state in three separate matters, including the abortion dispute. ADF is also representing Idaho in a case seeking to enforce its anti-trans bathroom bill and a third brought by multiple Republican attorneys general who aim to thwart a lawsuit by their Democratic counterparts to preserve access to the abortion drug mifepristone. ADF also appears to be representing Idaho in its effort to enforce a ban on gender-affirming care for minors, and according to local press reports, it has consulted on additional Idaho anti-trans bills and other legislation as well.
“ADF has a well rooted presence in Idaho, and that is showing up in legislation, in litigation,” says Cathryn Oakley, senior director of legal policy at the nonprofit Human Rights Campaign. Given the group’s history litigating against rights for LGBTQ people and abortion access, its involvement is not surprising, she told me, although “the extent to which elected representatives are ceding their responsibilities…to unelected far-right folks is a little alarming.”
The contracts Labrador signed with ADF raise ethical concerns. The group is representing Idaho pro bono, which saves taxpayers money, the AG says. But donating services to a state agency or officer may undermine the legislature’s budgetary jurisdiction, and the arrangement allows ADF to advance a religious agenda from a privileged position. This point was raised by University of Texas at Austin Law School professor Stephen Vladeck in his Substack newsletter, One First. State attorneys general, he wrote, enjoy privileges as litigants because they represent the people. But even when ADF represents a state, it is representing its own agenda, and not necessarily the people’s will. (In fact, Idahoans want greater access to abortion.)
The group also benefits from its representation of Idaho by, as the contract stipulates, using “non-confidential information in materials intended to communicate with supporters of ADF and in furtherance of the mission of ADF.” Indeed, the group’s relationship with Labrador’s office is almost certainly attractive to its funders.
Another sign the arrangement may conflict with public interest is that the contract gives ADF some control over the information the AG’s office makes public. Labrador agrees “to consult with ADF regarding public statements related to the Representation and when interacting and communicating with the media.”
ADF has worked since 1994 to deprive LGBTQ people of equal rights, which in 2016 prompted the Southern Poverty Law Center to designate it a “hate group.” Just last year, it won a Supreme Court case that allows some businesses to discriminate against LGBTQ clients. Overall, the group has notched more than a dozen Supreme Court victories, and played an instrumental role in overturning Roe v. Wade. One of its prominent attorneys, Erin Hawley, recently argued the case that could restrict the availability of Mifepristone and is involved in the Idaho abortion case now before the court. In 2016 and then again last year, Mother Jones ran stories detailing how ADF pushes anti-trans bills across the country.
Despite ADF’s efforts to impose far-right Christian values on secular American life, Oakley says, “I think that they have been mainstreamed because the folks who have been in positions of power in these state legislatures, in even the federal government under the Trump administration—many of those peoples have ties to ADF.”
Like many political opponents of abortion rights, ADF doesn’t always broadcast its true goals. After the Supreme Court overturned Roe v. Wade, Hawley told a congressional panel that the Dobbs ruling would not jeopardize emergency care for pregnant women. “An abortion is a situation in which a child is purposefully put to death,” she testified. “Neither miscarriages nor medical emergencies nor ectopic pregnancies involve that situation.” Yet Hawley is defending Idaho’s denial of abortion care during medical emergencies, even though it has been widelyreported that the refusal to treat miscarriages, ectopic pregnancies, and other dangerous pregnancy conditions is putting lives in danger.
Part of the mainstreaming Oakley cites involves ADF’s shift from representing private interests to representing public ones. A decade ago, the group successfully defended Greece, New York, in a case that allowed its leaders to open town meetings with a prayer. ADF’s alliances with state and local governments have since expanded. It helped Mississippi defend its abortion ban in the Dobbs case—a ban it helped craft. It also is working closely with West Virginia to defend an anti-trans sports bill, although ADF isn’t representing the state directly. In Oklahoma, the group is defending the Statewide Virtual Charter School Board, a state agency under fire for its decision to award public school funds to a Catholic charter school. (Oklahoma’s attorney general has refused to defend the board, because he believes its actions violate both state and US constitutions.)
ADF describes its mission as protecting religious freedom. For example, its case against mifepristone relies on the moral objections of a handful of doctors who claim they could be called upon to help a person suffering adverse effects from the drug. But in Wednesday’s case, ADF purports to represent the people of Idaho, whatever their religious views.
“They are taking advantage of any vehicle to impose religion into our laws,” says Rachel Laser, president and CEO of Americans United for Church and State, which often litigates opposite ADF in cases involving the mingling of religion and government. “What makes this feel weird is in America, the government is supposed to take as a given that it can’t impose one narrow set of religious views on citizens of all religions.”
By enlisting ADF, Laser adds, state officials are “showing their cards”—namely, they are “seeking to undermine what is a foundational part of our democracy, church-state separation.”
Jaelyn was 19 weeks and five days into a much-wanted pregnancy when the cramping began—slowly at first, then in an insistent rhythm that signaled she was in labor. Several excruciating hours later, emergency doctors delivered a heart-wrenching diagnosis. The amniotic sac was protruding from her cervix; her baby was doomed. “There’s nothing we can do,” Jaelyn recalled the on-call OB-GYN telling her, “because if we try to push it back in, it’s very likely you’re going to get an infection. And the baby will die. And it puts you at risk too. So, we have to see this thing through.”
Overwhelmed, Jaelyn begged the doctor, “Can we just get it over with?” Meaning: Could they do a procedure to hasten the inevitable and terminate a pregnancy that was no longer viable and could only lead to more unnecessary suffering? But the doctor told her no. “We cannot assist in it, we have to wait until the baby’s heart stops.” The nursing staff hooked Jaelyn up to a fetal monitor. She and her husband spent the next eight hours watching the machine as their son’s life ebbed away. When there was no longer a heartbeat, the doctor finally intervened.
It’s a scenario that has become horrifyingly common in conservative states since the end of Roe v Wade. Near-total bans on abortion have made it almost impossible for doctors to terminate pregnancies in an emergency, even when the mother’s life is in danger or there’s no chance the fetus will survive. As lawyers for Idaho face off against the Biden administration over the federal statute that requires hospitals to treat and stabilize any patient experiencing a medical emergency, the downstream consequences of pregnant women being denied necessary care areat the heart of what could be the most significant reproductive rights ruling from the Supreme Court since Dobbs.
Jaelyn wasn’t from Idaho or Texas; she lived in a city in the liberal Northeast. The hospital where she went for emergency care wasn’t being forced to comply with a draconian state ban dreamed up by anti-abortion lawmakers; it was a Catholic provider, obliged to follow Catholic teachings even when they conflicted with reproductive protections enshrined in state law. Her story highlights a largely overlooked aspect of the SCOTUS fight over the federal Emergency Medical Treatment and Labor Act (EMTALA). The decision won’t just affect the ability of red states to regulate medical care for pregnant patients. It also has enormous ramifications for a health care sector that is heavily concentrated in blue states with strong abortion protections: Catholic hospitals.
Catholic systems make up the largest group of nonprofit health care providers in the US, caring for one in seven hospital patients every day and accounting for 17.5 million emergency room visits a year. According to the watchdog group Community Catalyst, about 16 percent of acute-care hospitals around the country are Catholic. But in some states, Catholic providers account for a much bigger share of the health care infrastructure, including in such reproductive safe havens as Washington (almost 50 percent), Colorado (around 40 percent), and Oregon and Illinois (about 30 percent each).
Those hospitals—as well as their clinics, pharmacies, and physician practices—follow the Ethical and Religious Directives for Catholic Health Care Services, issued by the US Conference of Catholic Bishops, which ban or limit abortion, contraception, sterilization, fertility treatments, trans care, and physician-assisted suicide. Under the ERDs, Catholic hospitals—even in liberal parts of the country—have long treated pregnancy emergencies in ways that have become chillingly familiar in abortion-ban states. For decades, Catholic hospitals have been “doing as a norm what has now become the post-Dobbs landscape,” Georgetown Law professor and reproductive justice scholar Michele Bratcher Goodwin told my Mother Jones colleague Pema Levy. A SCOTUS decision in favor of Idaho could “further weaponize the arguments used by Catholic hospitals to deny emergency care,” Goodwin warns.
The ERDs ban “direct” abortions, which are defined as any procedure that intentionally results in the death of the fetus. At the same time, the directives do permit “operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman.” Or, as the Catholic Health Care Leadership Alliance summarizes in an amicus brief in the Idaho case, “medical treatments to save the life of the mother that unintentionally cause the death of the unborn child are permitted.”
How this plays out in Catholic hospital emergency rooms can get complicated, to say the least. Consider a relatively rare but devastating complication known as pre-viable PPROM, when the pregnant patient’s water breaks too early for the fetus to survive. According to leading medical groups such as the American College of Obstetricians and Gynecologists, the standard of care in such cases is to offer the patient a choice: She can wait and see if her condition improves long enough for the fetus to become viable, or she can receive treatment that amounts to an emergency abortion. Any delay in appropriate care can lead to the mother suffering agonizing pain, massive bleeding, and a potentially life-threatening infection.
By contrast, under the ERDs, Catholic providers are not allowed to terminate the pregnancy as long as the fetus is alive—even if it has no possibility of surviving—until the woman’s life is in danger, says Lori Freedman, a professor and researcher at the University of California, San Francisco, whose 2023 book, Bishops and Bodies: Reproductive Care in American Catholic Hospitals, is based on interviews with dozens of medical practitioners and patients. “They cannot treat her [with medications or procedures that will terminate the pregnancy], but watch her and wait for signs of infection to develop,” she says. “They have this requirement—if there is a fetal heartbeat, wait till there’s a threat to the mother’s life. Then they have to save her life. That is a low standard of care.”
Freedman notes that something very similar happened to Jaelyn, whose story she recounts in her book. In dire cases such as hers—which took place pre-Dobbs—the widely accepted standard of care is to terminate the pregnancy if the mother decides that’s what she wants. Instead, Jaelyn was forced to endure hours of agonizing physical pain as her baby slowly died; the emotional pain lasted much longer. “She really felt it to be torture,” Freedman says.
To be fair, Catholic providers often look for workarounds to get pregnant patients the care they need—for example, by sending them to another hospital. But depending on the circumstances, this could run counter to EMTALA’s requirement to provide emergency care, says Elizabeth Sepper, a University of Texas law professor who writes often about reproductive health care and religion. “It’s fair to say that Catholic hospitals have sometimes been violating EMTALA through transfers,” she says, “in ways that patients were probably not aware were caused by the religious identity of those institutions.”
Those hospitals have been able to get away with it because, even in states with strong laws ensuring reproductive access, religious providers are protected by what are known as “conscience” clauses sprinkled throughout numerous state and federal laws. The ACLU has sued Catholic hospitals at leastthreetimes in the past decade over their treatment of pregnant patients under the ERDs—and lost.
Now, in the EMTALA case, Catholics and other religious groups are raising the religious freedom argument in a new context. They claim that the Biden administration’s efforts to force hospitals to perform emergency abortions “violates the conscience rights” of providers who have “medical, ethical, or moral objections to the intentional killing of unborn children.” And they threaten that if the Supreme Court rules against the Idaho ban, the result would be “a regulatory domino effect” that would only add to the chaos for pregnant patients around the country. As their amicus brief states, “Over time, many…Catholic healthcare entities would feel pressure to opt out of programs covered by EMTALA so as to avoid the loss of medical licenses, the threat of crushing legal fines, and a hostile regulatory environment…It is hard to overstate the devastating impact that such a scenario would have on the delivery of health care in the United States.”
Meanwhile, the leading Catholic ethics organization advising health care providers has doubled down on its interpretation of the ERDs since the end of Roe. As evidence that Catholic providers can treat emergency pregnancy complications without resorting to abortion, the EMTALA briefs cite a commentary issued by the National Catholic Bioethics Center in August 2022. “When there is no moral certitude that the child has died, surgical abortion procedures of any type…are never permitted,” the NCBC says. Nor, according to the group, is it legitimate to induce labor before a fetus is viable merely because the mother-to-be suffers from a chronic condition such as pulmonary hypertension (a type of high blood pressure that affects the lungs) or cardiomyopathy (when the heart starts to fail) that happens to make her pregnancy exceptionally dangerous.
In cases of ectopic pregnancy—when the embryo implants outside the uterus, usually in the fallopian tube—the NCBC’s preferred approach is “expectant waiting” even though medical experts say any delay in surgery can lead to catastrophic bleeding. In the strange logic of the ERDs, it’s also acceptable to remove the entire fallopian tube, whether or not the embryo inside is still alive. What’s not permitted is any procedure or medication that destroys the living embryo while preserving the fallopian tube. Never mind that an embryo in a fallopian tube has zero chance of survival, or that the removal of the tube could have serious effects on future fertility. “It’s really shocking,” says Elizabeth Reiner Platt, director of Columbia Law School’s Law, Rights, and Religion Project, “that in defending their right to deny emergency stabilizing treatment and claiming that they have other protocols that work, their number one recommendation is to do nothing, and the next best option is a procedure that could reduce someone’s fertility for their entire lifetime when there’s an option that could preserve their fertility. I find that galling.”
To be clear, the conscience rights of religious hospitals aren’t the main focus of the Idaho EMTALA fight. But the Supreme Court’s ultra-conservative majority includes five Catholics—John Roberts, Clarence Thomas, Samuel Alito, Brett Kavanaugh, and Amy Coney Barrett—who have shown themselves to be very receptive to arguments about religious freedom. In this term’s other major abortion case, the conservative challenge to the FDA’s regulation of mifepristone, EMTALA came up repeatedly in oral arguments, Sepper points out. “It certainly does seem like it’s on their minds—how do the conscience protections and EMTALA interact? So I actually think that [the religious argument] will be top of mind even though it’s not really relevant to the legal conflict before them.”
Eli. Underwood likes the experience of voting in person, but they now have to vote by mail. Underwood went to a Detroit church to cast a ballot in the 2022 general elections, but chronic health conditions meant the two flights of stairs to the basement taxed them badly; living with Long Covid as well, Underwood was frustrated by the unventilated space and unmasked poll workers.
“It caused me great physical pain and anxiety, which made me angry and sad,” Underwood said. “It communicated to me that my vote doesn’t matter and I shouldn’t bother.” Extreme fatigue, pain, nausea, and headaches followed.
Polling locations are supposed to be accessible to all voters, including disabled and aging ones. But nearly one in five polling locations in the United States is a church, and religious entities are exempt from the Americans with Disabilities Act, key civil rights legislation that helped establish that protection. A 2022 survey by Detroit Disability Power and the Carter Center found that only around 10 percent of church polling places in Detroit, where Underwood voted, and its suburbs, were considered fully accessible. The prevalence of inaccessible polling places is particularly alarming for disabled and aging people in states that have moved to quash mail-in voting—including Oklahoma and Arkansas, where churches make up over 50 percent of voting locations.
“A lot of times, a bill trying to prevent [alleged] vote fraud will have a disproportionate impact on people with disabilities by saying ‘You can’t actually submit an absentee ballot,'” said University of Pennsylvania disability law scholar Jasmine Harris.
When a church becomes a polling place, it's acting on the government's behalf, Harris said. In those situations, according to Harris, religious buildings need to follow the ADA, and the district's election officer has a responsibility "to make sure preemptively that it has general accessibility."
Election officials "should be striving for locations that are already completely ADA compliant," Michelle Bishop, the National Disability Rights Network's voter access and engagement manager, told Mother Jones, but it also the case that "a lot of the places that are willing to serve are churches."
Accessibility isn't just helpful for the roughly 60 million American adults who have a permanent disability; though permanent disabilities are also increasing in part due to Long Covid. "You can become injured and not be able to go up steps," said Mia Ives-Rublee, who directs the Center for American Progress' disability justice initiative. "Making polling locations accessible isn't just going to affect the people who have permanent disabilities."
Counties are responsible for choosing the locations where their residents vote. The right response to inaccessible voting locations is not to have fewer of them—polling place closures disproportionately impact voters of color—but to find more locations that are accessible. The Department of Justice also provides guidance on temporary solutions to make sure disabled people can vote, such as installing a ramp and keeping doors propped open.
The ADA is not the only federal legislation that protects disabled people’s right to vote—there's also the Voting Rights Act, the Voting Accessibility for the Elderly and Handicapped Act, and the national Help America Vote Act, which all should support disabled people's right to vote. Bishop said that disabled voters can submit complaints under the Help America Vote Act, which requires state officials to respond by a deadline, although exact procedures can vary by state.
But not all disabled voters want or have the energy to file complaints about access issues. For Underwood, it didn't seem worth it: they felt that "nobody listens or cares."
As of now, no state mandates that poll workers be trained in accommodating disabled voters. That kind of training could help some disabled people vote more easily, Bishop said, regardless of their polling place.
Those resources do exist: the US Election Assistance Commission, established by the Help America Vote Act, offers a series of short videos on accessible voting, covering accommodations as straightforward as offering a chair to voters who have trouble standing for long periods of time—whether or not they disclose a disability.
Even with trained poll workers at an ADA-compliant polling place, disabled people can still face issues with in-person voting, Ives-Rublee said, since the ADA's voting accessibility guidelines "doesn't include things like accessible transportation." Counties should involve people with lived experience with disability, and those knowledgeable about the ADA, when taking steps to improve accessibility, Ives-Rublee said. Accounting for accessibility from the start could help poll workers keep voting locations like churches accessible without altering the building drastically, Bishop, of the National Disability Rights Network, said. Poll workers new to a building might not know about options as easy as "an accessible entrance around the corner," Bishop said, "so they never set it up, and they never put up signage, so the voters don't know."
What may be accessible to some disabled people may not be for others. That's why it's crucial to move towards more accessible options both in-person and by mail—mail-in voting with paper ballots isn't accessible, for example, to people who are Blind and have low vision, the subject of a lawsuit filed in Wisconsin this month arguing that disabled voters should be able to vote electronically.
Whatever they do, counties should involve people with lived experience of disability as well as ADA experts when taking steps to improve voting accessibility in-person or by mail. Whether that's one person, separate people, or a group, Ives-Rublee said, "it's important to have both factors when addressing accessibility."
Not all solutions on offer are favored by disabled voters. One contentious issue is proxy voting, where a poll worker votes on a person's behalf—a concern for voters who can't verify that the poll worker didn't alter their voting decisions. That's what Jermaine Greaves had to do. Greaves, who uses an electric wheelchair and lives with cerebral palsy, went to a Manhattan church to vote for Barack Obama in 2012. He ended up not even being able to enter the building. "Somebody had to end up voting for me," Greaves said. "I filled out the [paperwork that] they had to submit." That took away Greaves' ability to vote confidentially, a fundamental right for American voters.
"That just is the least private, least independently secure way to get the job done," Bishop said. "There should be good options in place that voters are comfortable with."
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