Congress Holds Hearings on Abstinence-Only

John Santelli MD MPH

Senator Henry Waxman tomorrow convenes the first-ever Congressional hearings on abstinence-only education. Read an excerpt from Dr. John Santelli's testimony.

Editor's note: John Santelli, MD, MPH, will testify at the April 23, 2008, Hearing on Abstinence-Only Programs before the Committee on Oversight and Government Reform, U.S. House of Representatives. The following is excerpted from his testimony.

Numerous scientific and ethical critiques have been raised about abstinence-only education for young people. These concerns are articulated in reports by the Society for Adolescent Medicine, the American Public Health Association, and others.

Key critiques include

  • Many abstinence-only programs withhold critical information or include misinformation, particularly about important health topics such as contraception and condoms. This puts young people at risk of sexually transmitted disease and unintended pregnancy. Such restrictions on health information are contrary to the medical ethical principle of informed consent and are a violation of human rights principles.

Demographic Trends

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Evidence from the past several decades indicates that establishing abstinence until marriage as a normative behavior is a highly challenging policy goal. In 1970, there was a gap of only one and a half years between first sex and marriage; by 2002 this gap was a full eight years. Research has shown that over the past 40 years, the median age at first intercourse has dropped (and stabilized) at around age 17 in most developed countries. At the same time, the median age at marriage has risen dramatically. Thus, expecting people to wait until marriage to engage in sexual intercourse is increasingly unrealistic. Almost all Americans initiate sexual intercourse before marriage. By the time they reach age 44, 99 percent of Americans have had sex, and 95 percent have done so before marriage.

Trends in Adolescent Sexual Activity and Teen Pregnancy

Recent declines in teen sexual activity appear to be unrelated to federal abstinence programs. According to the Centers for Disease Control and Prevention, rates of sexual experience declined from 54 percent in 1991 to 46 percent in 2001 and have been unchanged since 2001. Note that much of the reduction in rates of adolescent sex occurred before the federal government began widespread funding of abstinence-only education in FY1998.

Teen birth and pregnancy rates declined impressively between 1991 and 2005.

Two behaviors contribute directly to teen pregnancy: engaging in sexual intercourse and contraceptive use. From the 1960s through 1990, increasing involvement in sexual activity by teenagers in Western Europe and the United States was accompanied by sharply lower teen birth and pregnancy rates in most countries, due to greatly improved contraceptive use. Today, better use of contraceptives is the major behavioral difference between European and U.S. teenagers. Rates of sexual activity are similar, but European teens have much higher use of oral contraceptives and use of the "double Dutch" method-simultaneous use of condoms and hormonal methods.

Throughout the 1990s, teen sexual activity in the U.S. decreased and contraceptive use improved. Much of the improvement in contraceptive use was related to increasing condom use: between 1991 and 2001 condom use at last intercourse by young women rose from 38 percent to 51 percent. Increases in teen condom use in the 1980s were even more dramatic.

My own research suggests that 86 percent of the decline in teen pregnancy rates among 15-19 year olds between 1995 and 2002 was the result of improved contraceptive use.

Among younger teens (15-17 years old), three-quarters of the decline was the result of improved contraceptive use. My colleagues and I have recently repeated this calculation for 1991 to 2003 using data from the Youth Risk Behavior Survey which is conducted nationwide with high schools students and found similar results. Improvements in contraceptive use between 1991 and 2003 were responsible for 70 percent of the decline in teen pregnancy.

Thus, while an increase in abstinence (i.e., fewer teens having sexual intercourse) explains some of the decline in teen pregnancy rates in the 1990s, more recently there appears to be little impact of abstinence on teen birth or pregnancy rates. Unfortunately these positive trends in contraceptive use reversed in 2005. Both no use of contraception and decreases in condom use occur in the most recent data. These reversals coincide with increases in teen birth rates in 2006 – after steady declines over the previous 14 years.

Evaluations of Comprehensive Sexuality Education and Abstinence-Only Programs

There is now an extensive body of research that demonstrates that comprehensive sexuality education programs that include information about both abstinence and contraception and share several other key characteristics, are effective in helping young people to delay the onset of sexual intercourse and to use contraception and/or condoms when they do have intercourse. Dr. Douglas Kirby conducted an analysis for the National Campaign to Prevent Teen and Unintended Pregnancy that examined well-designed studies and evaluated whether or not programs designed to reduce teen pregnancy and sexually transmitted infections, including HIV, actually worked in changing behavior. That meta-analysis shows compelling evidence that programs that include information on both abstinence and contraception and display a number of other characteristics are effective in helping young people to abstain or protect themselves from pregnancy and STDs.

In contrast, rigorous evaluations of abstinence-only programs find little evidence of efficacy for abstinence-only education. None of the well-designed evaluations of abstinence-only programs has presented strong evidence of an impact on behaviors.

The Mathematica evaluation of the Title V program, released in April 2007, found no measurable impact on increasing abstinence or delaying sexual initiation among participating youth or on other important health behaviors such as condom use. This well funded and well conducted evaluation examined four abstinence-only programs, tracking youth over four years. One of the few measurable impacts of the programs was a decrease in adolescent confidence regarding the ability of condoms to prevent HIV and other sexually transmitted diseases.

In other words, comprehensive sexuality education programs are actually better than abstinence-only programs at helping young people to abstain from sex.

Virginity Pledges

Virginity pledging, which is one approach to encouraging abstinence until marriage among youth, appears to have little long-term benefit in preventing outcomes such as sexually transmitted infections. A longitudinal study by Bruckner and Bearman found that teens who signed abstinence pledges, when compared to non-pledgers, experienced similar rates of sexually transmitted infection (Bruckner and Bearman, 2005). Pledgers did delay sexual intercourse for a limited period, but when they did start having sex, they were less likely to use condoms. They were also less likely to seek reproductive health care compared to non-pledgers leaving them at increased risk for unintended pregnancy and sexually transmitted infections.

Medical Accuracy and Complete Information for Youth

A December 2004 Congressional report on federal abstinence programs from the U.S.

House of Representatives' Committee on Government Reform Minority Staff found that 11 of the 13 most frequently used curricula contained false, misleading or distorted information about reproductive health – including inaccurate information about contraceptive effectiveness, purported health risks of abortion, and other scientific errors. Concerns about the accuracy of information included in abstinence-only programs have also been raised by many different professional organizations. Over the past several years, my colleagues and I at Columbia University have explored this issue. Our recent review of abstinence-only curricula found similar inaccuracies, particularly misinformation about the efficacy of condoms and contraception.

Ethical and Human Rights Concerns

As a physician, I am expected to provide information this is both accurate and complete to my patients. The premise of federal abstinence-only programs is antithetical to this basic principle of medical ethics. Abstinence-only programs require teachers and health educators to conceal information about risk reduction measures such as condoms and contraception-or risk loss of federal funding. Misinformation about condoms is of particular concern given the high rates of sexually transmitted diseases among young people in the United States.

For all of these reasons and more, the leading medical and health organizations in this country have taken the position that abstinence-only education is inappropriate for young people. On this panel you are hearing from two of the key organizations with concerns about abstinence-only approaches, the American Public Health Association and the American Academy of Pediatrics. Abstinence-only education is also opposed by the American Medical Association, the Society for Adolescent Medicine, the Institute of Medicine, and the American Foundation for AIDS Research.

Recommendations

As someone who is deeply committed to the well-being of young people, I urge the committee to encourage policies that will better serve the needs of America's youth.

  • Congress should develop policies to improve adolescent reproductive health based on sound scientific evidence and the realities of adolescents' lives. Policies should support what we know works in helping young people to stay healthy.
  • Congress should require medical accuracy in all federally-supported health education activities.
  • Congress should end federal support for abstinence-only programs that require withholding potentially life-saving information. Teachers should be allowed to teach. Indeed, policy makers have an ethical obligation to ensure that young people have the critical information they need to protect their health.
  • Congress should help ensure that every American adolescent has access to age appropriate, comprehensive sexuality education and comprehensive health care services to help young people to avoid HIV, other STDs and unplanned pregnancy. This approach is consistent with the scientific evidence about what works and echoes the overwhelming support of America's parents and physicians.

News Sexual Health

State with Nation’s Highest Chlamydia Rate Enacts New Restrictions on Sex Ed

Nicole Knight Shine

By requiring sexual education instructors to be certified teachers, the Alaska legislature is targeting Planned Parenthood, which is the largest nonprofit provider of such educational services in the state.

Alaska is imposing a new hurdle on comprehensive sexual health education with a law restricting schools to only hiring certificated school teachers to teach or supervise sex ed classes.

The broad and controversial education bill, HB 156, became law Thursday night without the signature of Gov. Bill Walker, a former Republican who switched his party affiliation to Independent in 2014. HB 156 requires school boards to vet and approve sex ed materials and instructors, making sex ed the “most scrutinized subject in the state,” according to reproductive health advocates.

Republicans hold large majorities in both chambers of Alaska’s legislature.

Championing the restrictions was state Sen. Mike Dunleavy (R-Wasilla), who called sexuality a “new concept” during a Senate Education Committee meeting in April. Dunleavy added the restrictions to HB 156 after the failure of an earlier measure that barred abortion providers—meaning Planned Parenthood—from teaching sex ed.

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Dunleavy has long targeted Planned Parenthood, the state’s largest nonprofit provider of sexual health education, calling its instruction “indoctrination.”

Meanwhile, advocates argue that evidence-based health education is sorely needed in a state that reported 787.5 cases of chlamydia per 100,000 people in 2014—the nation’s highest rate, according to the Centers for Disease Control and Prevention’s Surveillance Survey for that year.

Alaska’s teen pregnancy rate is higher than the national average.

The governor in a statement described his decision as a “very close call.”

“Given that this bill will have a broad and wide-ranging effect on education statewide, I have decided to allow HB 156 to become law without my signature,” Walker said.

Teachers, parents, and advocates had urged Walker to veto HB 156. Alaska’s 2016 Teacher of the Year, Amy Jo Meiners, took to Twitter following Walker’s announcement, writing, as reported by Juneau Empire, “This will cause such a burden on teachers [and] our partners in health education, including parents [and] health [professionals].”

An Anchorage parent and grandparent described her opposition to the bill in an op-ed, writing, “There is no doubt that HB 156 is designed to make it harder to access real sexual health education …. Although our state faces its largest budget crisis in history, certain members of the Legislature spent a lot of time worrying that teenagers are receiving information about their own bodies.”

Jessica Cler, Alaska public affairs manager with Planned Parenthood Votes Northwest and Hawaii, called Walker’s decision a “crushing blow for comprehensive and medically accurate sexual health education” in a statement.

She added that Walker’s “lack of action today has put the education of thousands of teens in Alaska at risk. This is designed to do one thing: Block students from accessing the sex education they need on safe sex and healthy relationships.”

The law follows the 2016 Legislative Round-up released this week by advocacy group Sexuality Information and Education Council of the United States. The report found that 63 percent of bills this year sought to improve sex ed, but more than a quarter undermined student rights or the quality of instruction by various means, including “promoting misinformation and an anti-abortion agenda.”

Analysis Law and Policy

Do Counselors-in-Training Have the Right to Discriminate Against LGBTQ People?

Greg Lipper

Doctors can't treat their patients with leeches; counselors can't impose their beliefs on patients or harm them using discredited methods. Whatever their views, medical professionals have to treat their clients competently.

Whether they’re bakers, florists, or government clerks, those claiming the right to discriminate against LGBTQ people have repeatedly sought to transform professional services into constitutionally protected religious speech. They have grabbed headlines for refusing, for example, to grant marriage licenses to same-sex couples or to make cakes for same-sex couples’ weddings-all in the name of “religious freedom.”

A bit more quietly, however, a handful of counseling students at public universities have challenged their schools’ nondiscrimination and treatment requirements governing clinical placements. In some cases, they have sought a constitutional right to withhold treatment from LGBTQ clients; in others, they have argued for the right to directly impose their religious and anti-gay views on their clients.

There has been some state legislative maneuvering on this front: Tennessee, for instance, recently enacted a thinly veiled anti-LGBTQ measure that would allow counselors to deny service on account of their “sincerely held principles.” But when it comes to the federal Constitution, providing medical treatment—whether bypass surgery, root canal, or mental-health counseling—isn’t advocacy (religious or otherwise) protected by the First Amendment. Counselors are medical professionals; they are hired to help their clients, no matter their race, religion, or sexual orientation, and no matter the counselors’ beliefs. The government, moreover, may lawfully prevent counselors from harming their clients, and universities in particular have an interest, recognized by the U.S. Supreme Court, in preventing discrimination in school activities and in training their students to work with diverse populations.

The plaintiffs in these cases have nonetheless argued that their schools are unfairly and unconstitutionally targeting them for their religious beliefs. But these students are not being targeted, any more than are business owners who must comply with civil rights laws. Instead, their universities, informed by the rules of the American Counseling Association (ACA)—the leading organization of American professional counselors—merely ask that all students learn to treat diverse populations and to do so in accordance with the standard of care. These plaintiffs, as a result, have yet to win a constitutional right to discriminate against or impose anti-LGBTQ views on actual or prospective clients. But cases persist, and the possibility of conflicting court decisions looms.

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Keeton v. Anderson-Wiley

The first major challenge to university counseling requirements came from Jennifer Keeton, who hoped to receive a master’s degree in school counseling from Augusta State University. As detailed in the 2011 11th Circuit Court of Appeals decision considering her case, Keeton entered her professional training believing that (1) “sexual behavior is the result of personal choice for which individuals are accountable, not inevitable deterministic forces”; (2) “gender is fixed and binary (i.e., male or female), not a social construct or personal choice subject to individual change”; and “homosexuality is a ‘lifestyle,’ not a ‘state of being.'”

It wasn’t those views alone, however, that sunk her educational plans. The problem, rather, was that Keeton wanted to impose her views on her patients. Keeton had told both her classmates and professors about her clinical approach at a university-run clinic, and it wasn’t pretty:

  • She would try to change the sexual orientation of gay clients;
  • If she were counseling a sophomore student in crisis questioning his sexual orientation, she would respond by telling the student that it was not OK to be gay.
  • If a client disclosed that he was gay, she would tell him that his behavior was wrong and try to change it; if she were unsuccessful, she would refer the client to someone who practices “conversion therapy.”

Unsurprisingly, Keeton also told school officials that it would be difficult for her to work with LGBTQ clients.

Keeton’s approach to counseling not only would have flouted the university’s curricular guidelines, but also would have violated the ACA’s Code of Ethics.

Her conduct would have harmed her patients as well. As a school counselor, Keeton would inevitably have to counsel LGBTQ clients: 57 percent of LGBTQ students have sought help from a school professional and 42 percent have sought help from a school counselor. Suicide is the leading cause of death for LGBTQ adolescents; that’s twice or three times the suicide rate afflicting their heterosexual counterparts. And Keeton’s preferred approach to counseling LGBTQ students would harm them: LGBTQ students rejected by trusted authority figures are even more likely to attempt suicide, and anti-gay “conversion therapy” at best doesn’t work and at worst harms patients too.

Seeking to protect the university’s clinical patients and train her to be a licensed mental health professional, university officials asked Keeton to complete a remediation plan before she counseled students in her required clinical practicum. She refused; the university expelled her. In response, the Christian legal group Alliance Defending Freedom sued on her behalf, claiming that the university violated her First Amendment rights to freedom of speech and the free exercise of religion.

The courts disagreed. The trial court ruled against Keeton, and a panel of the U.S. Court of Appeals for the 11th Circuit unanimously upheld the trial court’s ruling. The 11th Circuit explained that Keeton was expelled not because of her religious beliefs, but rather because of her “own statements that she intended to impose her personal religious beliefs on clients and refer clients to conversion therapy, and her own admissions that it would be difficult for her to work with the GLBTQ population and separate her own views from those of the client.” It was Keeton, not the university, who could not separate her personal beliefs from the professional counseling that she provided: “[F]ar from compelling Keeton to profess a belief or change her own beliefs about the morality of homosexuality, [the university] instructs her not to express her personal beliefs regarding the client’s moral values.”

Keeton, in other words, crossed the line between beliefs and conduct. She may believe whatever she likes, but she may not ignore academic and professional requirements designed to protect her clients—especially when serving clients at a university-run clinic.

As the court explained, the First Amendment would not prohibit a medical school from requiring students to perform blood transfusions in their clinical placements, nor would it prohibit a law school from requiring extra ethics training for a student who “expressed an intent to indiscriminately disclose her client’s secrets or violate another of the state bar’s rules.” Doctors can’t treat their patients with leeches; counselors can’t impose their beliefs on patients or harm them using discredited methods. Whatever their views, medical professionals have to treat their clients competently.

Ward v. Polite

The Alliance Defending Freedom’s follow-up case, Ward v. Polite, sought to give counseling students the right to withhold service from LGBTQ patients and also to practice anti-gay “conversion therapy” on those patients. The case’s facts were a bit murkier, and this led the appeals court to send it to trial; as a result, the student ultimately extracted only a modest settlement from the university. But as in Keeton’s case, the court rejected in a 2012 decision the attempt to give counseling students the right to impose their religious views on their clients.

Julea Ward studied counseling at Eastern Michigan University; like Keeton, she was training to be a school counselor. When she reviewed the file for her third client in the required clinical practicum, she realized that he was seeking counseling about a romantic relationship with someone of the same sex. As the Court of Appeals recounted, Ward did not want to counsel the client about this topic, and asked her faculty supervisor “(1) whether she should meet with the client and refer him [to a different counselor] only if it became necessary—only if the counseling session required Ward to affirm the client’s same-sex relationship—or (2) whether the school should reassign the client from the outset.” Although her supervisor reassigned the client, it was the first time in 20 years that one of her students had made such a request. So Ward’s supervisor scheduled a meeting with her.

Then things went off the rails. Ward, explained the court, “reiterated her religious objection to affirming same-sex relationships.” She told university officials that while she had “no problem counseling gay and lesbian clients,” she would counsel them only if “the university did not require her to affirm their sexual orientation.” She also refused to counsel “heterosexual clients about extra-marital sex and adultery in a values-affirming way.” As for the professional rules governing counselors, Ward said, “who’s the [American Counseling Association] to tell me what to do. I answer to a higher power and I’m not selling out God.”

All this led the university to expel Ward, and she sued. She claimed that the university violated her free speech and free exercise rights, and that she had a constitutional right to withhold affirming therapy relating to any same-sex relationships or different-sex relationships outside of marriage. Like Keeton, Ward also argued that the First Amendment prohibited the university from requiring “gay-affirmative therapy” while prohibiting “reparative therapy.” After factual discovery, the trial court dismissed her case.

On appeal before the U.S. Court of Appeals for the Sixth Circuit, Ward eked out a narrow and temporary win: The court held that the case should go to a jury. Because the university did not have a written policy prohibiting referrals, and based on a few troubling faculty statements during Ward’s review, the court ruled that a reasonable jury could potentially find that the university invoked a no-referrals policy “as a pretext for punishing Ward’s religious views and speech.” At the same time, the court recognized that a jury could view the facts less favorably to Ward and rule for the university.

And although the decision appeared to sympathize with Ward’s desire to withhold service from certain types of clients, the court flatly rejected Ward’s sweeping arguments that she had the right to stray from the school curriculum, refuse to counsel LGBTQ clients, or practice anti-gay “conversion therapy.” For one, it said, “Curriculum choices are a form of school speech, giving schools considerable flexibility in designing courses and policies and in enforcing them so long as they amount to reasonable means of furthering legitimate educational ends.” Thus, the problem was “not the adoption of this anti-discrimination policy, the existence of the practicum class or even the values-affirming message the school wants students to understand and practice.” On the contrary, the court emphasized “the [legal] latitude educational institutions—at any level—must have to further legitimate curricular objectives.”

Indeed, the university had good reason to require counseling students—especially those studying to be school counselors—to treat diverse populations. A school counselor who refuses to counsel anyone with regard to nonmarital, nonheterosexual relationships will struggle to find clients: Nearly four in five Americans have had sex by age 21; more than half have done so by the time they turn 18, while only 6 percent of women and 2 percent of men are married by that age.

In any event, withholding service from entire classes of people violates professional ethical rules even for nonschool counselors. Although the ACA permits client referrals in certain circumstances, the agency’s brief in Ward’s case emphasized that counselors may not refuse to treat entire groups. Ward, in sum, “violated the ACA Code of Ethics by refusing to counsel clients who may wish to discuss homosexual relationships, as well as others who fail to comport with her religious teachings, e.g., persons who engage in ‘fornication.'”

But Ward’s approach would have been unethical even if, in theory, she were permitted to withhold service from each and every client seeking counseling related to nonmarital sex (or even marital sex by same-sex couples). Because in many cases, the need for referral would arise well into the counseling relationship. And as the trial court explained, “a client may seek counseling for depression, or issues with their parents, and end up discussing a homosexual relationship.” No matter what the reason, mid-counseling referrals harm clients, and such referrals are even more harmful if they happen because the counselor disapproves of the client.

Fortunately, Ward did not win the sweeping right to harm her clients or otherwise upend professional counseling standards. Rather, the court explained that “the even-handed enforcement of a neutral policy”—such as the ACA’s ethical rules—”is likely to steer clear of the First Amendment’s free-speech and free-exercise protections.” (Full disclosure: I worked on an amicus brief in support of the university when at Americans United.)

Ward’s lawyers pretended that she won the case, but she ended up settling it for relatively little. She received only $75,000; and although the expulsion was removed from her record, she was not reinstated. Without a graduate counseling degree, she cannot become a licensed counselor.

Cash v. Hofherr

The latest anti-gay counseling salvo comes from Andrew Cash, whose April 2016 lawsuit against Missouri State University attempts to rely on yet murkier facts and could wind up, on appeal, in front of the more conservative U.S. Court of Appeals for the Eighth Circuit. In addition to his range of constitutional claims (freedom of speech, free exercise of religion, equal protection of law), he has added a claim under the Missouri Religious Freedom Restoration Act.

The complaint describes Cash as “a Christian with sincerely-held beliefs”—as opposed to insincere ones, apparently—”on issues of morality.” Cash started his graduate counseling program at Missouri State University in September 2007. The program requires a clinical internship, which includes 240 hours of in-person client contact. Cash decided to do his clinical internship at Springfield Marriage and Family Institute, which appeared on the counseling department’s list of approved sites. Far from holding anti-Christian bias, Cash’s instructor agreed that his proposed class presentation on “Christian counseling and its unique approach and value to the Counseling profession” was an “excellent” idea.

But the presentation itself revealed that Cash intended to discriminate against LGBTQ patients. In response to a question during the presentation, the head of the Marriage and Family Institute stated that “he would counsel gay persons as individuals, but not as couples, because of his religious beliefs,” and that he would “refer the couple for counseling to other counselors he knew who did not share his religious views.” Because discrimination on the basis of sexual orientation violates ACA guidelines, the university determined that Cash should not continue counseling at the Marriage and Family Institute and that it would be removed from the approved list of placements. Cash suggested, however, that he should be able to withhold treatment from same-sex couples.

All this took place in 2011. The complaint (both the original and amended versions) evades precisely what happened between 2012 and 2014, when Cash was finally expelled. You get the sense that Cash’s lawyers at the Thomas More Society are trying to yadda-yadda-yadda the most important facts of the case.

In any event, the complaint does acknowledge that when Cash applied for a new internship, he both ignored the university’s instructions that the previous hours were not supposed to count toward his requirement, and appeared to be “still very much defend[ing] his previous internship stating that there was nothing wrong with it”—thus suggesting that he would continue to refuse to counsel same-sex couples. He continued to defend his position in later meetings with school officials; by November 2014, the university removed him from the program.

Yet in challenging this expulsion, Cash’s complaint says that he was merely “expressing his Christian worldview regarding a hypothetical situation concerning whether he would provide counseling services to a gay/homosexual couple.”

That’s more than just a worldview, though. It also reflects his intent to discriminate against a class of people—in a manner that violates his program’s requirements and the ACA guidelines. Whether hypothetically or otherwise, Cash stated and reiterated that he would withhold treatment from same-sex couples. A law student who stated, as part of his clinic, that he would refuse to represent Christian clients would be announcing his intent to violate the rules of professional responsibility, and the law school could and would remove him from the school’s legal clinic. And they could and would do so even if a Christian client had yet to walk in the door.

But maybe this was just a big misunderstanding, and Cash would, in practice, be willing and able to counsel same-sex couples? Not so, said Cash’s lawyer from the Thomas More Society, speaking about the case to Christian news outlet WORLD: “I think Christians have to go on the offensive, or it’s going to be a situation like Sodom and Gomorrah in the Bible, where you aren’t safe to have a guest in your home, with the demands of the gay mob.” Yikes.

Although Cash seems to want a maximalist decision allowing counselors and counseling students to withhold service from LGBTQ couples, it remains to be seen how the case will turn out. The complaint appears to elide two years’ worth of key facts in order to present Cash’s claims as sympathetically as possible; even if the trial court were to rule in favor of the university after more factual development, Cash would have the opportunity to appeal to the U.S. Court of Appeals for the Eighth Circuit, one of the country’s most conservative federal appeals courts.

More generally, we’re still early in the legal battles over attempts to use religious freedom rights as grounds to discriminate; only a few courts across the country have weighed in. So no matter how extreme Cash or his lawyers may seem, it’s too early to count them out.

* * *

The cases brought by Keeton, Ward, and Cash not only attempt to undermine anti-discrimination policies. They also seek to change the nature of the counselor-client relationship. Current norms provide that a counselor is a professional who provides a service to a client. But the plaintiffs in these cases seem to think that counseling a patient is no different than lecturing a passerby in the town square, in that counseling a patient necessarily involves expressing the counselor’s personal and religious beliefs. Courts have thus far rejected these attempts to redefine the counselor-patient relationship, just as they have turned away attempts to challenge bans on “reparative therapy.”

The principles underlying the courts’ decisions protect more than just LGBTQ clients. As the 11th Circuit explained in Keeton, the university trains students to “be competent to work with all populations, and that all students not impose their personal religious values on their clients, whether, for instance, they believe that persons ought to be Christians rather than Muslims, Jews or atheists, or that homosexuality is moral or immoral.” Licensed professionals are supposed to help their clients, not treat them as prospective converts.