Analysis Contraception

The World at Seven Billion: A Global Milestone That Reflects the Needs of Seven Billion Individuals

Susan A. Cohen

Reaching seven billion people on planet Earth has prompted renewed debates about the balance between population size and consumption of natural resources, about age structure and political stability, and about the consequences of rapid population growth rates for poor countries' ability to develop economically. To a large extent, however, these macro-level dilemmas reflect a micro-level problem about which there is a universal consensus and where the solution is relatively straightforward.

Cross-posted with permission from the Guttmacher Institute.

This fall, world population will reach 7 billion people at a time of accelerated environmental disruption. This article is part of a series commissioned by Rewire to examine the causes and consequences of population and environmental change from various perspectives and the policies and actions needed to both avoid and mitigate the inevitable impacts of these changes.

All of the articles in this series can be found here.

According to the United Nations, the world’s population will reach seven billion later this year and, if current trends continue, will rise to more than nine billion by the middle of this century.1 This new population milestone—and the projection—prompt renewed debates about the balance between population size and consumption of natural resources, about age structure and political stability, and about the consequences of rapid population growth rates for poor countries’ ability to develop economically.

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These relationships and others pertaining to population size and the rate of population growth are complex and their implications often controversial. To a large extent, however, these macro-level dilemmas reflect a micro-level problem about which there is a universal consensus and where the solution is relatively straightforward. Millions of women and couples, especially in the developing world, are still unable to control for themselves the timing, spacing and total number of their children. Recognition of this fact provides a road map for moving forward that can address the needs of the people and the planet at the same time.

That path forward must include a central focus on increasing access and eliminating barriers to voluntary contraceptive services. Responding directly to individual people’s needs and desires to determine for themselves whether and when to have a child will contribute significantly toward their ability to lead healthier, more productive lives. In turn, these benefits for individuals and families accrue to their communities and to society at large. Ultimately, the impact would be felt at the global level. Meeting the stated desires of all women around the world to space or limit births would result in the world’s population peaking within the next few decades—and then actually starting to decline.

Unmet Need: Origins, Levels and Consequences

Women and men worldwide are marrying later and wanting smaller families than their parents and grandparents did.2 Declines in fertility rates have followed: As of the early 2000s, the average number of children per woman in the developing world is three, compared with six in the 1960s.3 These demographic trends have accompanied increases in education and economic development. Wide variations continue to exist within and across regions, but in most places in the developing world, the desire for smaller families still outpaces the availability and use of modern contraception, which leads to unwanted births as well as high rates of abortion—usually illegal, clandestine and therefore unsafe.

At any given time, about 818 million women in developing countries—more than half of all those within the reproductive ages of 15 to 49—want to avoid becoming pregnant for at least two years.2 Owing in large part to the existence of family planning programs, more than 600 million are using modern contraceptives; however, 215 million are not. (Although some of these women use traditional methods, such as withdrawal or periodic abstinence, their pregnancy rate is so high that they are considered to be in need of modern methods as much as women who do not use birth control at all.) These 215 million women with an unmet need for contraception (i.e., those who are sexually active and want to stop or postpone childbearing, but are not using a modern contraceptive) account for more than 80% of all unintended pregnancies in the developing world each year (see chart).2

MODERN METHODS MATTER
Most women who want to avoid pregnancy use a modern method of birth control; however, the relatively small group who do not account for more than eight in 10 of the 75 million unintended pregnancies worldwide each year.
MODERN METHODS MATTER
Source: Reference 2.

Just over half of all women of reproductive age in the developing world live in three regions: Sub-Saharan Africa, South Central Asia and Southeast Asia.4 However, about seven in 10 of the 215 million women with an unmet need for modern contraception live in these areas. Not surprisingly, therefore, a disproportionate share (66%) of all unintended pregnancies in the developing world occurs to women living in these regions; virtually all (93%) maternal deaths take place here. Accordingly, the Guttmacher Institute studied these three regions more closely to gain a better understanding of the extent and reasons why so many women wishing to postpone or stop childbearing are not using modern methods of contraception.

Reasons and Remedies

In Contraceptive Technologies: Responding to Women’s Needs, Guttmacher researchers analyzed data from nationally representative Demographic and Health Surveys (DHS), surveys from the U.S. Centers for Disease Control and Prevention, and other independent surveys.4 The report details the levels of unmet need in Sub-Saharan Africa, South Central Asia and Southeast Asia, and provides an overview of the reasons women living in these areas who are at risk of unintended pregnancy are not using a modern method. The authors conclude that women’s reasons for nonuse often are multiple and interrelated, and they identify several steps for overcoming the existing barriers—the most important being the availability of new and better contraceptive technology.

According to the report, the characteristics of women with an unmet need for contraception vary according to their childbearing intentions (whether they want to delay having their first child, space subsequent births or have no more children at all), marital status, age, income and whether they live in urban or rural areas. In the three focus regions, the “typical” woman with unmet need for modern contraception is 25 or older, is married, has one or more children and lives in a rural area; about four in 10 are poor. If the woman lives in Sub-Saharan Africa, she likely wants more children after a delay of two or more years; however, if she lives in South Central or Southeast Asia, she probably has already had all the children she wants.

The reasons that so many women who want to avoid becoming pregnant are not using modern contraceptives also vary widely. Yet, notably, seven in 10 of these women express concerns related in some way to the methods themselves. This includes women concerned about the health risks or side effects of contraceptives, both real and perceived. It also includes those who mistakenly believe that they are at low risk of pregnancy, namely those who have sex infrequently, are postpartum or are breastfeeding; all of these women would benefit from better information about pregnancy risk and better counseling about methods compatible with their circumstances. And it includes women whose partners oppose contraception, for whom efforts to gain partner support are important but for whom the availability of methods that could be used without their partners’ knowledge also would be beneficial. The report’s authors conclude, therefore, that much greater investment in overcoming these method-related barriers is essential to making any real headway in reducing the unmet need.

Many of the remaining reasons women in these regions give for not using contraception could be remedied in the short term by improving access to the contraceptive methods that already exist. Those who indicate that they do not know where to go for services, that services are too far away or that their method of choice is too costly could benefit immediately. Women who are unaware of modern methods at all, as well as a small number who do not believe they could become pregnant, could benefit too.

Nevertheless, the most headway in reducing unintended pregnancy could be made by addressing the reasons for nonuse related to the problems women have with their current method choices, by better matching them with highly effective methods appropriate to their life circumstances—either methods available today or new, more advanced ones. If this could be accomplished, unintended pregnancy in the three developing regions could fall by as much as 59% (see chart).4 Unintended births and abortions could decline by a similar amount, and 70,000 maternal deaths could be averted.

IF NEED WERE MET
Addressing women’s concerns about modern contraceptive methods and finding new methods they can use consistently and correctly could reduce unintended pregnancies in Sub-Saharan Africa, South Central Asia and Southeast Asia by nearly 60%.
IF NEED WERE MET
Note: Estimates for the “improved use” scenario assume that 71% of women with unmet need for modern methods (i.e., the proportion of women with unmet need who report method-related reasons for nonuse) adopt a new method with a use-effectiveness rate equal to that of the IUD. Source: Reference 4.

“We can make headway immediately toward satisfying unmet need,” the authors state, “by ensuring that women who currently have unmet need for modern contraception receive accurate information about their risk of unintended pregnancy, have access to quality services that offer a range of methods, and receive counseling and care that helps them initiate and sustain method use.”4 However, given that the majority of women at risk of unintended pregnancy who are not using modern contraceptives—as well as a substantial proportion of those who discontinue use—have concerns or problems related to currently available methods, current methods need to be adapted to make them easier to use, and investment in the discovery and development of new and better methods is essential. Ultimately, the authors note, the goal is to increase the availability of methods “that do not cause systemic side effects, can be used on demand, and do not require partner participation or knowledge.”

People and the Planet

Evidence and experience make clear that most women in the developing and developed worlds alike want to have children. But they also want to control when they have them and how many they have. The ability and access to services necessary to act on this basic desire have increased dramatically over the last few decades. Still, for many women and couples, a multitude of barriers conspire to block or impede use of modern contraceptives. The consequences of inaction, meanwhile, continue to take a heavy toll on the health and lives of women and newborns. Moreover, if the current concerns of the women in Sub-Saharan Africa, South Central Asian and Southeast Asia are not addressed, the sheer numbers of women with an unmet need in these areas will continue to rise due to population growth alone (see chart, page 5).4

RISING TIDE
Without changes in desired family size and contraceptive use, the number of women with an unmet need for more effective and acceptable modern methods in three developing world regions will rise to 161 million by 2050, with the sharpest increase occurring in Sub-Saharan Africa.
RISING TIDE
Source: Reference 4.

Increased political and financial commitment at the global level to achieving universal access to reproductive health is necessary if there is to be progress, for women and for the planet. The fact that the United Nations’ Millennium Development Goal aimed at improving maternal health, MDG 5, specifically calls for universal access to reproductive health care by 2015 is an important marker. It reflects the global consensus that this is a priority especially for poor countries. Even during this worldwide recession, it is noteworthy that donors, including the United States, and host-country governments are committing substantial resources to the global effort, though not enough to keep up with the need and demand for services. Fulfilling the unmet need for modern contraception, including the necessary information and counseling services, would contribute significantly toward meeting MDG 5. Indeed, it would aid progress toward all of the MDGs, which together represent a global antipoverty action plan.2 And in the process of meeting the unmet need, the effect on world population growth would be major.

In 2010, the Futures Group analyzed the demographic impact of meeting the unmet need for contraceptive services in 99 developing countries (excluding China) and the United States, whose combined population in 2005 was 4.3 billion.5 According to the model, if unmet need were fully met, the average fertility rate would drop to just below the replacement level by 2050. The Worldwatch Institute’s Robert Engelman considers the implications potentially “momentous.”6 Fully meeting the existing unmet need, says Engelman, could end world population growth. This does not even take into account the possible added fertility declines that could result among women who currently still desire large families, but who could change their minds because of the effects of increased girls’ education levels, enhanced women’s empowerment, improved maternal and newborn health and survival rates, and overall economic development.

Engleman maintains that “there is nothing fated about a world of 9 billion people—in 2050, or ever.” It is eminently possible, he asserts, to make policy choices that would lead to a world population size that is more environmentally and socially sustainable, and does not in any way involve “control” or coercion, let alone forcing individuals to forswear the benefits of economic advancement. These choices, he notes, “are rooted in human development and human rights, specifically the right of all, and most directly of women, to decide for themselves when it is the right time to bring a new child into the world.”

REFERENCES

1. United Nations, World population to reach 10 billion by 2100 if fertility in all countries converges to replacement level, May 3, 2011, <http://esa.un.org/unpd/wpp/other-information/Press_Release_ WPP2010.pdf>, accessed Aug. 10, 2011.

2. Singh S et al., Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, New York: Guttmacher Institute and United Nations Population Fund, 2009, <http://www.guttmacher.org/pubs/AddingItUp2009.pdf>, accessed Aug. 10, 2011.

3. Bruce J and Bongaarts J, The new population challenge, in: Mazur L, ed., A Pivotal Moment: Population, Justice, and the Environmental Challenge, Washington, DC: Island Press, 2009, <http://www.popcouncil.org/pdfs/2009PGY_NewPopChallenge.pdf>, accessed Aug. 10, 2011.

4. Darroch JE, Sedgh G and Ball H, Contraceptive Technologies: Responding to Women’s Needs, New York: Guttmacher Institute, 2011, <http://www.guttmacher.org/pubs/Contraceptive-Technologies.pdf>, accessed Aug. 10, 2011.

5. Futures Group, World Population Prospects and Unmet Need for Family Planning, 2010, <http://www.futuresgroup.com/wp-content/uploads/2010/04/Research-Brief_World-Population-Prospects-and-Unmet-Need-for-Family-Planning-10.07.10.pdf>, accessed Aug. 10, 2011.

6. Engelman R, An end to population growth: why family planning is key to a sustainable future, Solutions, 2011, Vol. 2, No. 3, <http:// www.thesolutionsjournal.com/node/919>, accessed Aug. 10, 2011.

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.

Commentary Politics

No, Republicans, Porn Is Still Not a Public Health Crisis

Martha Kempner

The news of the last few weeks has been full of public health crises—gun violence, Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography.

The news of the last few weeks has been full of public health crises—gun violence, the Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography. Without much debate, a subcommittee of Republican delegates agreed to add to a draft of the party’s 2016 platform an amendment declaring pornography is endangering our children and destroying lives. As Rewire argued when Utah passed a resolution with similar language, pornography is neither dangerous nor a public health crisis.

According to CNN, the amendment to the platform reads:

The internet must not become a safe haven for predators. Pornography, with its harmful effects, especially on children, has become a public health crisis that is destroying the life [sic] of millions. We encourage states to continue to fight this public menace and pledge our commitment to children’s safety and well-being. We applaud the social networking sites that bar sex offenders from participation. We urge energetic prosecution of child pornography which [is] closely linked to human trafficking.

Mary Frances Forrester, a delegate from North Carolina, told Yahoo News in an interview that she had worked with conservative Christian group Concerned Women for America (CWA) on the amendment’s language. On its website, CWA explains that its mission is “to protect and promote Biblical values among all citizens—first through prayer, then education, and finally by influencing our society—thereby reversing the decline in moral values in our nation.”

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The amendment does not elaborate on the ways in which this internet monster is supposedly harmful to children. Forrester, however, told Yahoo News that she worries that pornography is addictive: “It’s such an insidious epidemic and there are no rules for our children. It seems … [young people] do not have the discernment and so they become addicted before they have the maturity to understand the consequences.”

“Biological” porn addiction was one of the 18 “points of fact” that were included in a Utah Senate resolution that was ultimately signed by Gov. Gary Herbert (R) in April. As Rewire explained when the resolution first passed out of committee in February, none of these “facts” are supported by scientific research.

The myth of porn addiction typically suggests that young people who view pornography and enjoy it will be hard-wired to need more and more pornography, in much the same way that a drug addict needs their next fix. The myth goes on to allege that porn addicts will not just need more porn but will need more explicit or violent porn in order to get off. This will prevent them from having healthy sexual relationships in real life, and might even lead them to become sexually violent as well.

This is a scary story, for sure, but it is not supported by research. Yes, porn does activate the same pleasure centers in the brain that are activated by, for example, cocaine or heroin. But as Nicole Prause, a researcher at the University of California, Los Angeles, told Rewire back in February, so does looking at pictures of “chocolate, cheese, or puppies playing.” Prause went on to explain: “Sex film viewing does not lead to loss of control, erectile dysfunction, enhanced cue (sex image) reactivity, or withdrawal.” Without these symptoms, she said, we can assume “sex films are not addicting.”

Though the GOP’s draft platform amendment is far less explicit about why porn is harmful than Utah’s resolution, the Republicans on the subcommittee clearly want to evoke fears of child pornography, sexual predators, and trafficking. It is as though they want us to believe that pornography on the internet is the exclusive domain of those wishing to molest or exploit our children.

Child pornography is certainly an issue, as are sexual predators and human trafficking. But conflating all those problems and treating all porn as if it worsens them across the board does nothing to solve them, and diverts attention from actual potential solutions.

David Ley, a clinical psychologist, told Rewire in a recent email that the majority of porn on the internet depicts adults. Equating all internet porn with child pornography and molestation is dangerous, Ley wrote, not just because it vilifies a perfectly healthy sexual behavior but because it takes focus away from the real dangers to children: “The modern dialogue about child porn is just a version of the stranger danger stories of men in trenchcoats in alleys—it tells kids to fear the unknown, the stranger, when in fact, 90 percent of sexual abuse of children occurs at hands of people known to the victim—relatives, wrestling coaches, teachers, pastors, and priests.” He added: “By blaming porn, they put the problem external, when in fact, it is something internal which we need to address.”

The Republican platform amendment, by using words like “public health crisis,” “public menace” “predators” and “destroying the life,” seems designed to make us afraid, but it does nothing to actually make us safer.

If Republicans were truly interested in making us safer and healthier, they could focus on real public health crises like the rise of STIs; the imminent threat of antibiotic-resistant gonorrhea; the looming risk of the Zika virus; and, of course, the ever-present hazards of gun violence. But the GOP does not seem interested in solving real problems—it spearheaded the prohibition against research into gun violence that continues today, it has cut funding for the public health infrastructure to prevent and treat STIs, and it is working to cut Title X contraception funding despite the emergence of Zika, which can be sexually transmitted and causes birth defects that can only be prevented by preventing pregnancy.

This amendment is not about public health; it is about imposing conservative values on our sexual behavior, relationships, and gender expression. This is evident in other elements of the draft platform, which uphold that marriage is between a man and a women; ask the U.S. Supreme Court to overturn its ruling affirming the right to same-sex marriage; declare dangerous the Obama administration’s rule that schools allow transgender students to use the bathroom and locker room of their gender identity; and support conversion therapy, a highly criticized practice that attempts to change a person’s sexual orientation and has been deemed ineffective and harmful by the American Psychological Association.

Americans like porn. Happy, well-adjusted adults like porn. Republicans like porn. In 2015, there were 21.2 billion visits to the popular website PornHub. The site’s analytics suggest that visitors around the world spent a total of 4,392,486,580 hours watching the site’s adult entertainment. Remember, this is only one way that web users access internet porn—so it doesn’t capture all of the visits or hours spent on what may have trumped baseball as America’s favorite pastime.

As Rewire covered in February, porn is not a perfect art form for many reasons; it is not, however, an epidemic. And Concerned Women for America, Mary Frances Forrester, and the Republican subcommittee may not like how often Americans turn on their laptops and stick their hands down their pants, but that doesn’t make it a public health crisis.

Party platforms are often eclipsed by the rest of what happens at the convention, which will take place next week. Given the spectacle that a convention headlined by presumptive nominee (and seasoned reality television star) Donald Trump is bound to be, this amendment may not be discussed after next week. But that doesn’t mean that it is unimportant or will not have an effect on Republican lawmakers. Attempts to codify strict sexual mores are a dangerous part of our history—Anthony Comstock’s crusade against pornography ultimately extended to laws that made contraception illegal—that we cannot afford to repeat.