Get Real! Why Can’t I Orgasm?

Heather Corinna

The very best thing I can tell you to do when it comes to becoming orgasmic is to masturbate.

jms91 asks:

really difficult for me to orgasm. As a female, I know it’s a lot to
expect to orgasm from intercourse, but it seems like everyone at least
does from oral. But I’ve been with my boyfriend for over a year and he
has yet to ever make me orgasm – even through oral sex. Why can’t I

Heather replies:

There is no one sexual activity which we can brings everyone to orgasm or even almost everyone.

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Even though plenty of people certainly enjoy oral sex, not everyone
reaches orgasm that way, nor from any other one activity. You ideas
about that aren’t accurate, though I can certainly understand how you
might get the impression that they are.

Many young women in their teens and even their twenties are and have been anorgasmic or pre-orgasmic:
they don’t yet experience orgasm. Studies on this usually show a range
of anywhere from 30% to 50% or more of women in that age group as
having not experienced orgasm. There are a lot of likely reasons for
that, including:

  • Women’s sexual partners being centered on their own pleasure,
    uninformed about women’s bodies and sexuality, hasty or rushed in the
    sex that’s happening, or focusing most on sexual activities which are
    least pleasurable for women
  • Relationship problems or conflicts or a lack of sexual chemistry with partners
  • Women themselves being uninformed or misinformed about their own
    bodies, about sexuality, about pleasure, which would include
    unrealistic expectations about desire, sex and pleasure
  • Young women not masturbating or really taking the time (or having
    the space to) explore their bodies and minds fully with masturbation
  • Self-image and/or body image issues, or negative attitudes about sex and sexuality, such as shame, guilt or performance anxiety
  • A lack of earnest desire for sex in the first place
  • Physical or psychological issues such as depression, neurological
    diseases, endocrine imbalances or pain with any given kind of sex. Some
    medications — like some medications to treat depression — can also
    inhibit arousal or orgasm
  • Use of alcohol or certain recreational drugs
  • Previous sexual trauma

What age you are can play a role with many of those factors, just
because some of them have to do with life experience, with a growing
knowledge of yourself and your body — and also a comfort and
confidence in both — and also with the level of experience and
maturity of your sexual partners. As well, not everyone is at a point
with puberty where their sexual development has them at the right place
for wanting sex, for feeling that strong want for sex. (It should also
be added that no matter someone’s age, some people find that,
temporarily or lifelong, they just don’t feel either that desire at
all, or the desire to do anything about it. For more information on
that, you can have a look at this or this.)

If you are looking for the one thing where most people of all
genders reach orgasm, more than from any other sexual activity, that’s
been shown to be masturbation in all study on the subject of sexuality
we’ve got (but even with that, we’re usually looking at around 60% –
70% of people, just so you understand how we can never say "everyone"
when it comes to anything to do with sex). That is also the way a
majority of people report reaching orgasm for the first time.

The very best thing I can tell you to do when it comes to becoming
orgasmic is to masturbate. Knowing what I know about the study of
women’s sexuality, I can actually say that if you don’t, and don’t
really spend some quality time with that, you’re unlikely to reach
orgasm or to have the kind of sex life you probably want. Mind, your
motivation there does have some import: if you only do it to try and
make orgasm happen, rather than doing it when you are really feeling
sexual desires strongly, and doing it with the intent to simply
experience pleasure, orgasm or no, it may well be fruitless.
Product-oriented masturbation isn’t going to do you any harm, but it’s
also unlikely to help.

Now and then, I will have young women tell me, when I advise this,
that they just have zero interest in masturbation, and only have
interest in partnered sex. While certainly, another person we have
feelings for tends to up the ante and often heighten how we feel with
sex (as well as providing other angles and stimulus we might just be
unable to physically do for ourselves) my impression is that the women
who say that either a) just aren’t at a point in their lives or
development yet where their sexuality is in real play, c) feel shame in
masturbation, or like saying only sex with a partner feels good is the
"right" answer or the "right" motivation for sex and/or b) aren’t yet
experiencing sexual desire so much as a desire for emotional closeness
to and intimacy with a partner.

I draw those conclusions particularly when someone voices both not
feeling any sexual desire by themselves and tells me that most or all
of what they get out of sex is emotional. There’s certainly nothing
wrong with that kind of motivation for sex, but it also — all by
itself — is going to be unlikely to result in a lot of physical
pleasure and/or orgasm. Too, I personally think it might be wise for
those who feel that way to check in with themselves and make sure that
their emotional needs are really being met, all around and with sex. It
may well be that if, in fact, there isn’t any actual sexual desire
present, sex may not be what those people even really want or need with
a partner (and that they go that route because that’s what the partner
wants or is offering for intimacy, or because they have the idea that’s
what their motivation for sex is supposed to be, or what sex will
result in, whether or not it actually does or is the best way to have
those needs met) or for themselves.

Something huge to understand about orgasm, which often gets lost in
the media and how people talk about sex as peers or even as partners,
is that what tends to be most important is what leads up to orgasm, and
what your experiences are like whether you have an orgasm or not, right
from the start.

Desire — a strong want or feeling of need for sexual activity — is
no minor player in any of this, either by yourself or with a partner.
Some people can reach orgasm sometimes without it, but that is pretty
unusual. Most people simply need to feel that strong, growly, loud,
hungry, achy, loin-tingly urge to get arousal going, to get aroused, to
stay aroused and get more aroused as sex of any kind starts and
continues, and, when it happens, to reach orgasm. Feeling desire also
has a lot to do with feeling satisfied with sexual experiences: orgasm
alone may or may not result in feelings of deep satisfaction. Sometimes
people get so hung up about the idea of orgasm as what they need to
feel satisfied that they forget, or don’t realize, that a few seconds
of neurological pistons firing may feel mighty awesome sometimes, but
sexual satisfaction is so much more than that: it’s about the whole
journey and process and how we feel throughout, not just at the very

And it may be you not only need to learn about what gets you to
arousal or orgasm, but also what gets you to desire! So many people
talk about foreplay being about what gets us "ready" for sex, but what
they’re really talking about with those various sexual activities are
things we start doing when we are already starting to have sex,
and already interested and becoming aroused. Those activities are kinds
of sex themselves, after all. Getting to our desire tends to involve
more than that, kinds of emotional, intellectual and sensory foreplay,
as it were.

Finding out where your desire lives and when it is and isn’t present
may involve things like evaluating if you and your boyfriend actually
have any strong sexual chemistry or not: if you do actually have sexual
feelings for him, strong physical desires for him. If you don’t feel
some kind of zingy feeling in your pants or other parts of your body
when you’re with him, you probably don’t have that chemistry, and alas,
it often isn’t something we can make happen. It tends to either be
there or just not be there, and is one of the things we’re going to
look TO be there if we are going to pursue a sexual relationship with
someone. That chemistry is a major issue, and it’s not something we’ll
tend to have with just anyone, and we may not tend to always have it
with the people we wish we did. We can love someone, like someone,
think someone is the hottest thing we have ever seen ever, even have
all that be mutual but still not feel a sexual chemistry with them:
that tends to often be somewhat random, and at times, even really
surprising. Many women are raised with the idea that chemistry isn’t
important for us (but only for men), that sex being good for us is just
about if we love someone or not, and those are ideas our cultures tend
to also like to support but which aren’t often in alignment with
women’s experiences of fulfilling sex lives.

It also means discovering what turns you on, all by yourself. Is it
about daydreaming or fantasizing? We hear people talk about what is
sexual for them a lot, but we often hear less about the sensual. I
recognize that word can tend to be used in some really cheesy ways, but
when I say sensual, know that I just mean what’s about your senses. Are
there things which make you feel excited, be they visual — certain
kinds of images or visual cues — textual — like reading certain
things — auditory — hearing certain songs, sounds or words —
gustatory or olfactory — what certain smells or tastes bring up for
you — kinestetic (physical) — like going out to dance, having a run
or a swim, cooking a meal, taking a bath, doing some yoga? How about
what things in your memory of times you have felt desire before can
bring up if those memories are stimulated? I’m not just talking here
about overtly sexual things, either: some of these sensory things may
not seem sexual by a given standard at all, but may evoke a sexual
response because you have associated them with something sexual, had a
sexual experience that involved them, or just because they resonate
with your own unique sexuality. So, while you might find that seeing a
fine bottom brings on feelings of desire, you might also find the same
happens with the sound of a given chord, the smell of a given spice, or
how hot chocolate tastes or a given stretch feels to you.

Over time (and it does often take some time) we will learn these
things about ourselves and develop a sort of bank of various different
things which are our own personal turn-ons. Those don’t always stay the
same over the years, some may change or fall away, and we often will
develop new ones, but there do tend to be some consistencies through
time, and as time passes, and we have more life experience, that bank
tends to grow larger. Our recognition of when we are and are not
feeling desire also is something that, with time, we’ll become better
and better attuned to.

So, you start with your desire, and with the various things that
stir it up and make it grow deeper. Once you’re feeling that in a big
way, and getting more in touch with that, then you’re in a good
place to explore your own sexuality (be it alone or with a partner),
become aroused by touch, and take matters into your own hands. Sex
therapists often make a strong point, too – and a good point — about
giving yourself real time with masturbation: not trying to fit it into
small segments of a few minutes, or rush with it. I know it can be
tougher as a young person to find the time and privacy for that, but my
feeling is that if you can find it for sex with a partner, you can find
it for sex with yourself. You just have to recognize it’s important and
make it important. Here’s some basic information for you about
masturbation: How Do You Masturbate?

Once you start to really take that time and be open to exploring any
number of things, and do that over time, you will begin to learn some
more about your body and your sexuality by yourself, you’ll be likely
to find you are in a far better position to bring those experiences and
that knowledge to the table with a partner, and better able to
communicate to a partner — with your words, by showing them with your
own hands — what does and doesn’t feel good, what does and doesn’t
work for you, what is and is not most likely to bring you to orgasm.
Heck, even just learning how to take care of yourself sexually takes a
lot of the stress and the pressure off of experiences with partners.

Do be sure, though, that with your newfound knowledge, you also
check in and be sure that sex with a partner is even a place you’re at
at this point. Leave room for discovering that you may need or want
some more time with your sexuality for yourself before you’re at a
point of being able to feel able to explore it with someone else. With
that, I’d also evaluate if your relationship is at the point of being
ready for sexual partnership: can you two openly communicate about sex?
Are you both able to be open-minded and respond to what both of you
tells the other you like and want to do? Are you both mutually invested
in one another’s pleasure, not just orgasm or getting sex? If you feel
like you are (and talking about that together would be a great way to
be sure), then great. If not, you might just want to put sex on hold
for a while until you do feel like you’re both really at that place.

If you look back to that list I made for you up top about things
that tend to inhibit orgasm, and you find other things on the list you
might need to address, tend to those as well. For instance, if you’re
suffering from depression, do some work on that and get what care you
need. If your self-esteem or body image needs some work, invest some
energy there. Working on any of those things in that list not only may
help with orgasm, they’ll certainly help with the whole of your life.

How you think about all of this also matters. It matters a lot.

If you come to any kind of sex — alone or with someone else — full
of anxiety or frustration, or if you’re fixated on sex as a product,
not a process, you’re both unlikely to reach orgasm AND unlikely to
enjoy yourself very much. One thing we know is a huge barrier to orgasm
for many people who are otherwise doing everything right is getting
their head stuck in a place during sex where all they are thinking
about is how to get to orgasm, if they’ll get to orgasm, how may times
they have not reached orgasm, how their partner will feel if they don’t
reach orgasm, and where the heck is that bloody freaking orgasm for the love of… ARRRRRGH!
You can perhaps see how that kind of thinking, that kind of feeling,
hardly creates an environment for pleasure. It’s totally unpleasant and
completely crazymaking. I think we can all agree that it is in no way a
sexy feeling.

Sex is a place to destress, to release stress, not the place
to get stressed out. So, do what you can to let go of attachment to
orgasm, and invest yourself instead in just doing what feels good for
you, physically and emotionally. That way, not only are you more likely
to orgasm, you’re also more likely to feel satisfied even when you

I have some links to pass on to you, but I also have some books I’d
like to suggest you find and spend some time with. I think they’ll all
be helpful for you. I’d advise you get your hands on Sex for One: The Joy of Selfloving by Betty Dodson, I Love Female Orgasm: An Extraordinary Orgasm Guide by Dorian Solot and Marshall Miller, For Yourself : The Fulfillment of Female Sexuality by Lonnie Barbach, and/or Women Who Love Sex: Ordinary Women Describe Their Paths to Pleasure, Intimacy, and Ecstasy
by Gina Ogden. I’d also suggest, while you’re at the bookstore, finding
something just utterly delicious to read that is not nonfiction, but
some kind of very sensory poetry or prose. Buy your desire a nice
birthday present.

Here are some more links to round all of this out for you. Have a
read, and then the very last thing you’re going to need is just some
patience for yourself. While I understand how frustrated you seem to
feel, and understand why any of us wants to reach orgasm, I also know
that for some folks, this takes time. If you can start to do all of
this stuff and cultivate some patience with yourself in the process,
you will very likely get to the place you want to be, and once you’re
there, you’re unlikely to find yourself caring very much about whatever
time it took you to get there.


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.

Culture & Conversation Maternity and Birthing

On ‘Commonsense Childbirth’: A Q&A With Midwife Jennie Joseph

Elizabeth Dawes Gay

Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Jennie Joseph’s philosophy is simple: Treat patients like the people they are. The British native has found this goes a long way when it comes to her midwifery practice and the health of Black mothers and babies.

In the United States, Black women are disproportionately affected by poor maternal and infant health outcomes. Black women are more likely to experience maternal and infant death, pregnancy-related illness, premature birth, low birth weight, and stillbirth. Beyond the data, personal accounts of Black women’s birthing experiences detail discrimination, mistreatment, and violation of basic human rights. Media like the new film, The American Dream, share the maternity experiences of Black women in their own voices.

A new generation of activists, advocates, and concerned medical professionals have mobilized across the country to improve Black maternal and infant health, including through the birth justice and reproductive justice movements.

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Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

At her clinics, which are located in central Florida, a welcoming smile and a conversation mark the start of each patient visit. Having a dialogue with patients about their unique needs, desires, and circumstances is a practice Joseph said has contributed to her patients having “chunky,” healthy, full-term babies. Dialogue and care that centers the patient costs nothing, Joseph told Rewire in an interview earlier this summer.

Joseph also offers training to midwives, doulas, community health workers, and other professionals in culturally competent, patient-centered care through her Commonsense Childbirth School of Midwifery, which launched in 2009. And in 2015, Joseph launched the National Perinatal Task Force, a network of perinatal health-care and service providers who are committed to working in underserved communities in order to transform maternal health outcomes in the United States.

Rewire spoke with Joseph about her tireless work to improve maternal and perinatal health in the Black community.

Rewire: What motivates and drives you each day?

Jennie Joseph: I moved to the United States in 1989 [from the United Kingdom], and each year it becomes more and more apparent that to address the issues I care deeply about, I have to put action behind all the talk.

I’m particularly concerned about maternal and infant morbidity and mortality that plague communities of color and specifically African Americans. Most people don’t know that three to four times as many Black women die during pregnancy and childbirth in the United States than their white counterparts.

When I arrived in the United States, I had to start a home birth practice to be able to practice at all, and it was during that time that I realized very few people of color were accessing care that way. I learned about the disparities in maternal health around the same time, and I felt compelled to do something about it.

My motivation is based on the fact that what we do [at my clinic] works so well it’s almost unconscionable not to continue doing it. I feel driven and personally responsible because I’ve figured out that there are some very simple things that anyone can do to make an impact. It’s such a win-win. Everybody wins: patients, staff, communities, health-care agencies.

There are only a few of us attacking this aggressively, with few resources and without support. I’ve experienced so much frustration, anger, and resignation about the situation because I feel like this is not something that people in the field don’t know about. I know there have been some efforts, but with little results. There are simple and cost-effective things that can be done. Even small interventions can make such a tremendous a difference, and I don’t understand why we can’t have more support and more interest in moving the needle in a more effective way.

I give up sometimes. I get so frustrated. Emotions vie for time and energy, but those very same emotions force me to keep going. I feel a constant drive to be in action and to be practical in achieving and getting results.

Rewire: In your opinion, what are some barriers to progress on maternal health and how can they be overcome?

JJ: The solutions that have been generated are the same, year in and year out, but are not really solutions. [Health-care professionals and the industry] keep pushing money into a broken system, without recognizing where there are gaps and barriers, and we keep doing the same thing.

One solution that has not worked is the approach of hiring practitioners without a thought to whether the practitioner is really a match for the community that they are looking to serve. Additionally, there is the fact that the practitioner alone is not going to be able make much difference. There has to be a concerted effort to have the entire health-care team be willing to support the work. If the front desk and access points are not in tune with why we need to address this issue in a specific way, what happens typically is that people do not necessarily feel welcomed or supported or respected.

The world’s best practitioner could be sitting down the hall, but never actually see the patient because the patient leaves before they get assistance or before they even get to make an appointment. People get tired of being looked down upon, shamed, ignored, or perhaps not treated well. And people know which hospitals and practitioners provide competent care and which practices are culturally safe.

I would like to convince people to try something different, for real. One of those things is an open-door triage at all OB-GYN facilities, similar to an emergency room, so that all patients seeking maternity care are seen for a first visit no matter what.

Another thing would be for practitioners to provide patient-centered care for all patients regardless of their ability to pay.  You don’t have to have cultural competency training, you just have to listen and believe what the patients are telling you—period.

Practitioners also have a role in dismantling the institutionalized racism that is causing such harm. You don’t have to speak a specific language to be kind. You just have to think a little bit and put yourself in that person’s shoes. You have to understand she might be in fear for her baby’s health or her own health. You can smile. You can touch respectfully. You can make eye contact. You can find a real translator. You can do things if you choose to. Or you can stay in place in a system you know is broken, doing business as usual, and continue to feel bad doing the work you once loved.

Rewire: You emphasize patient-centered care. Why aren’t other providers doing the same, and how can they be convinced to provide this type of care?

JJ: I think that is the crux of the matter: the convincing part. One, it’s a shame that I have to go around convincing anyone about the benefits of patient-centered care. And two, the typical response from medical staff is “Yeah, but the cost. It’s expensive. The bureaucracy, the system …” There is no disagreement that this should be the gold standard of care but providers say their setup doesn’t allow for it or that it really wouldn’t work. Keep in mind that patient-centered care also means equitable care—the kind of care we all want for ourselves and our families.

One of the things we do at my practice (and that providers have the most resistance to) is that we see everyone for that initial visit. We’ve created a triage entry point to medical care but also to social support, financial triage, actual emotional support, and recognition and understanding for the patient that yes, you have a problem, but we are here to work with you to solve it.

All of those things get to happen because we offer the first visit, regardless of their ability to pay. In the absence of that opportunity, the barrier to quality care itself is so detrimental: It’s literally a matter of life and death.

Rewire: How do you cover the cost of the first visit if someone cannot pay?

JJ: If we have a grant, we use those funds to help us pay our overhead. If we don’t, we wait until we have the women on Medicaid and try to do back-billing on those visits. If the patient doesn’t have Medicaid, we use the funds we earn from delivering babies of mothers who do have insurance and can pay the full price.

Rewire: You’ve talked about ensuring that expecting mothers have accessible, patient-centered maternity care. How exactly are you working to achieve that?

JJ: I want to empower community-based perinatal health workers (such as nurse practitioners) who are interested in providing care to communities in need, and encourage them to become entrepreneurial. As long as people have the credentials or license to provide prenatal, post-partum, and women’s health care and are interested in independent practice, then my vision is that they build a private practice for themselves. Based on the concept that to get real change in maternal health outcomes in the United States, women need access to specific kinds of health care—not just any old health care, but the kind that is humane, patient-centered, woman-centered, family-centered, and culturally-safe, and where providers believe that the patients matter. That kind of care will transform outcomes instantly.

I coined the phrase “Easy Access Clinics” to describe retail women’s health clinics like a CVS MinuteClinic that serve as a first entry point to care in a community, rather than in a big health-care system. At the Orlando Easy Access Clinic, women receive their first appointment regardless of their ability to pay. People find out about us via word of mouth; they know what we do before they get here.

We are at the point where even the local government agencies send patients to us. They know that even while someone’s Medicaid application is in pending status, we will still see them and start their care, as well as help them access their Medicaid benefits as part of our commitment to their overall well-being.

Others are already replicating this model across the country and we are doing research as we go along. We have created a system that becomes sustainable because of the trust and loyalty of the patients and their willingness to support us in supporting them.

Photo Credit: Filmmaker Paolo Patruno

Joseph speaking with a family at her central Florida clinic. (Credit: Filmmaker Paolo Patruno)

RewireWhat are your thoughts on the decision in Florida not to expand Medicaid at this time?

JJ: I consider health care a human right. That’s what I know. That’s how I was trained. That’s what I lived all the years I was in Europe. And to be here and see this wanton disregard for health and humanity breaks my heart.

Not expanding Medicaid has such deep repercussions on patients and providers. We hold on by a very thin thread. We can’t get our claims paid. We have all kinds of hoops and confusion. There is a lack of interest and accountability from insurance payers, and we are struggling so badly. I also have a petition right now to ask for Medicaid coverage for pregnant women.

Health care is a human right: It can’t be anything else.

Rewire: You launched the National Perinatal Task Force in 2015. What do you hope to accomplish through that effort?

JJ: The main goal of the National Perinatal Task Force is to connect perinatal service providers, lift each other up, and establish community recognition of sites committed to a certain standard of care.

The facilities of task force members are identified as Perinatal Safe Spots. A Perinatal Safe Spot could be an educational or social site, a moms’ group, a breastfeeding circle, a local doula practice, or a community center. It could be anywhere, but it has got to be in a community with what I call a “materno-toxic” area—an area where you know without any doubt that mothers are in jeopardy. It is an area where social determinants of health are affecting mom’s and baby’s chances of being strong and whole and hearty. Therein, we need to put a safe spot right in the heart of that materno-toxic area so she has a better chance for survival.

The task force is a group of maternity service providers and concerned community members willing to be a safe spot for that area. Members also recognize each other across the nation; we support each other and learn from each others’ best practices.

People who are working in their communities to improve maternal and infant health come forward all the time as they are feeling alone, quietly doing the best they can for their community, with little or nothing. Don’t be discouraged. You can get a lot done with pure willpower and determination.

RewireDo you have funding to run the National Perinatal Task Force?

JJ: Not yet. We have got the task force up and running as best we can under my nonprofit Commonsense Childbirth. I have not asked for funding or donations because I wanted to see if I could get the task force off the ground first.

There are 30 Perinatal Safe Spots across the United States that are listed on the website currently. The current goal is to house and support the supporters, recognize those people working on the ground, and share information with the public. The next step will be to strengthen the task force and bring funding for stability and growth.

RewireYou’re featured in the new film The American Dream. How did that happen and what are you planning to do next?

JJ: The Italian filmmaker Paolo Patruno got on a plane on his own dime and brought his cameras to Florida. We were planning to talk about Black midwifery. Once we started filming, women were sharing so authentically that we said this is about women’s voices being heard. I would love to tease that dialogue forward and I am planning to go to four or five cities where I can show the film and host a town hall, gathering to capture what the community has to say about maternal health. I want to hear their voices. So far, the film has been screened publicly in Oakland and Kansas City, and the full documentary is already available on YouTube.

RewireThe Black Mamas Matter Toolkit was published this past June by the Center for Reproductive Rights to support human-rights based policy advocacy on maternal health. What about the toolkit or other resources do you find helpful for thinking about solutions to poor maternal health in the Black community?

JJ: The toolkit is the most succinct and comprehensive thing I’ve seen since I’ve been doing this work. It felt like, “At last!”

One of the most exciting things for me is that the toolkit seems to have covered every angle of this problem. It tells the truth about what’s happening for Black women and actually all women everywhere as far as maternity care is concerned.

There is a need for us to recognize how the system has taken agency and power away from women and placed it in the hands of large health systems where institutionalized racism is causing much harm. The toolkit, for the first time in my opinion, really addresses all of these ills and posits some very clear thoughts and solutions around them. I think it is going to go a long way to begin the change we need to see in maternal and child health in the United States.

RewireWhat do you count as one of your success stories?

JJ: One of my earlier patients was a single mom who had a lot going on and became pregnant by accident. She was very connected to us when she came to clinic. She became so empowered and wanted a home birth. But she was anemic at the end of her pregnancy and we recommended a hospital birth. She was empowered through the birth, breastfed her baby, and started a journey toward nursing. She is now about to get her master’s degree in nursing, and she wants to come back to work with me. She’s determined to come back and serve and give back. She’s not the only one. It happens over and over again.

This interview has been edited for length and clarity.