In April of 2023, right-wing podcaster Steven Crowder announced that he and his wife, Hilary, were divorcing—an event, he explained to listeners of Louder with Crowder, to which he did not consent. She “didn’t want to be married anymore,” he said, “and in the state of Texas, that is completely permitted.”  

Crowder, upset, lamented: “My beliefs don’t matter.” 

His venting—which did not include the context of potential abuse he inflicted; a video from 2021 surfaced soon after Crowder’s podcast posted showing him restricting Hilary from access to a car because she would not do “wifely things”—was a watershed moment.

The right has long pushed policies to enshrine a specific view of marriage. But the open discussion of making divorce harder has—in large part because of dudes online with podcasts and politicians who want to appeal to dudes who listen to dudes on podcasts—become more obvious over the last year. Crowder’s rant was a crossover point in uncovering a renewed push by the GOP to roll back no-fault divorce laws. It gave more mainstream attention to a burgeoning men’s movement centered on family values.

“I think divorce should basically be outlawed, or it should be at least greatly restricted,” The Daily Wire host Michael Knowles said, while referencing Crowder. Podcaster Tim Pool said no-fault divorce is “ruining relationships,” on an episode where he cites Jordan Peterson and jokes that, “maybe we would just be better if, I don’t know, women just had to wear red dresses and bonnets.”  

Over the past year, I’ve been following this effort for Mother Jones. During that time, I have written about how conservatives, both elected and not, have been trying to make divorce harder. These arguments are often deeply influenced by religion and depend on misogynistic understandings of marriage, women, and money.

When I initially set up a Google Alert for “no-fault divorce” last summer, the news was pretty sparse. Now, I’m getting updates daily.  

Just as rolling back abortion rights was a concerted effort of religious groups, conservative provocateurs, and legislators, so is this anti-no-fault-divorce movement. The growing crowd of anti-woke Republicans, stewarded by men like Crowder, has taken up making divorce harder and turned it into a perfect recruiting tool to bring young misogynists into the fold. By pairing the moral panics about the changing norms of marriage and wokeness, with a hefty splash of masculinity-baiting, the GOP can appeal to some of the most conservative young male voters in generations.

Young women, according to research by Gallup, are becoming more liberal than previous generations. But young men have trended toward conservatism. This group of voters is increasingly available to, and coveted by, Republican candidates. Sen. Josh Hawley (R-Mo.) released a book, Manhood: The Masculine Virtues America Needs, to speak to them. Donald Trump Jr. launched a hunting magazine, Field Ethos, that, according to co-founder and CEO Jason Vincent appeals to the “unapologetic male mindset” (which is a draw for women, too, he told Politico). Tucker Carlson released a documentary called The End of Men.

Return, right-wing conservatives seem to say in these works, to the world before society decayed into the libidinous lawlessness of abortion and divorce. Be a good man—and enter a marriage. Have children. Provide for “the family.” This nostalgia is fundamentally wrapped up with a backslide on rights won by women since the mid-20th century.

Women are more likely to initiate divorces, and, historically, no-fault divorce has been specifically beneficial for wives seeking separation. A 2003 working paper in the National Bureau of Economic Research found that, in states that allowed one partner to unilaterally push for divorce, total female suicide declined by around 20 percent. There was no similar decline for men. Keeping divorce simpler also benefits those experiencing domestic abuse. Fault-based systems are costly and take more time—two resources that victims often lack.

This rhetorical push from the right is happening online and in homes across the country, but also in statehouses, and from the mouths of some of the most powerful people in politics. Just this week, the Texas GOP doubled down on their support for rolling back no-fault divorce in their official party platform. The Nebraska GOP’s website notes, “We believe no-fault divorce should be limited to situations in which the couple has no children of the marriage.”  

“For the sake of families,” Ben Carson, former Secretary of Housing and Urban Development and current Republican vice-presidential hopeful, wrote in his book, The Perilous Fight, released this month, “we should enact legislation to remove or radically reduce incidences of no-fault divorce.” Sen. J.D. Vance (R-Ohio) has suggested he abides strictly to the “’til death do us part” view of divorce, even in unhappy or violent marriages. Sen. Tom Cotton (R-Ark.) has questioned no-fault divorce since he was a Harvard undergraduate in 1997. 

And of course, there’s current Speaker of the House Mike Johnson: one of the most prominent people in the country to get a “covenant marriage.”

In 1997, Louisiana—the Johnson’s home state—became the first in the country to pass a covenant marriage law, which allowed newlyweds to opt for a religion-based contract that makes it significantly harder to get divorced. Arizona and Arkansas followed. These unions provide an alternative to regular marriage certificates, which permit couples to get no-fault divorces.

If the Johnsons ever sought divorce, they would legally need to seek counseling first. Then, they would still only be able to separate if they proved one of the following requirements: adultery, “commission of a felony,” abandonment for one year, physical or sexual abuse of the spouse or of a child, or living apart for two years. 

Those seeking a no-fault divorce don’t have to do any of that—no wrongdoing needs to occur for couples to part ways. Starting in 1969, when then–California Gov. Ronald Reagan signed the country’s first no-fault divorce law, these statutes have provided a way out for couples wanting to go their separate ways. While Reagan, according to his son, would later consider supporting no-fault divorce his “greatest regret” in life, these laws have stuck around and helped change how we view divorce nationwide.   

In 2001, Johnson and his wife Kelly went on Good Morning America to talk about what made their nuptials special. Host Diane Sawyer was curious about this new thing called “covenant marriage,” and wanted to ask the Johnsons, who were one of the first couples to try it out, about the appeal.

“Critics of this again say, ‘you should be able to promise and mean it and not have to bring the law in,’” Sawyer said. “You’re letting states legislate something that is really a religious or a personal commitment.”  

“That’s true,” Johnson responds, “but I’m not sure why they oppose it. Because society, we have a vested interest in preserving marriages because all of the social ills that come from the root cause of divorce and the law, the state, is going to sanction some type of marriage, so why not have an option that’s more binding?” 

This is the regular argument of many on the right, that marriage should be held sacred in the law. What’s the harm in making divorce harder?

Hearing that, I can’t help but think of a woman I spoke with last fall.

Eleanor, who chose to conceal her name for safety, told me about one harm—how complicated it was, already, for her to leave her abusive partner and file successfully for divorce, and how much worse it would have been if she had to prove the abuse. A mother, Eleanor lives in Texas and while going through her divorce in 2020, was balancing keeping her and her children safe from her husband, who she says sexually assaulted and strangled her.

“I almost died,” Eleanor told me. “The notion that this could even be made any more difficult than it already is,” she explained of divorce, baffled and scared her.

That’s one of the central findings of a new report released Tuesday, which found that there were nearly 86,000 average abortions per month in 2023, compared to about 82,000 a month in 2022. The rise is due, in part, to the increasing popularity of telehealth abortions, in which providers in blue states virtually prescribe and mail abortion pills—including to patients in red states—thanks to so-called shield laws that protect them from prosecution. According to the report, telehealth abortions accounted for nearly 1 in 5 abortions nationwide—about 19 percent—from October to December of last year.

The new report is part of a recurring study sponsored by the Society of Family Planning and known as #WeCount, which is aimed at providing quarterly updates on abortion access post-Dobbs. Earlier #WeCount reports found telehealth abortions accounted for 15 to 16 percent of all abortions conducted between July and September of last year, or about 14,000 abortions each month. This is a marked increase from April 2022, when telehealth abortions only accounted for about 4 percent of abortions nationwide, or about 3,600 a month, or December 2022, when they accounted for about 8,500 abortions every month, or 11 percent of the total. 

Medication abortions have long been a target of the anti-abortion movement, which has perpetrated myths about the so-called dangers of abortion pills. The recent case before the Supreme Court—FDA v. Alliance for Hippocratic Medicine—seeks to drastically restrict access to mifepristone, the first pill in the two-drug regimen, even as more than 100 studies have affirmed its safety and effectiveness. And recent research—including a paper published just this week in the journal JAMA Internal Medicine—has confirmed that the pills are just as safe when they’re prescribed virtually as in person.

Ushma Upadhyay, a professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, and co-author of the #WeCount report, says, “As the word gets out, as more people talk about it—on Reddit, online—and feel more comfort with this model, I expect that the numbers will increase.” 

A decision in the Supreme Court case on mifepristone—including the attempt to restrict telehealth access—is expected at the end of June. As my colleague Pema Levy has written, during the oral arguments in March, the justices appeared to be unlikely to roll back access to mifepristone. Upadhyay agrees but notes that even if the justices do place some restrictions on the drug, it’s “very possible” providers would continue mailing the pills from states that have enacted shield laws.

The latest #WeCount data also sheds light on the importance of shield laws during the post-Dobbs era. From July to December of last year, about 40,000 people—most of whom were in states with abortion bans—were able to access reproductive healthcare thanks to shield laws. Data from five states that had shield laws in effect last year—Massachusetts, Colorado, Washington, New York, and Vermont—are included in the latest #WeCount report. California only enacted a shield law for telehealth abortion providers in January.

These laws, Upadhyay says, seek to “minimize legal risks for those providing abortion care,” but do not “reduce the risk of criminalization, of being prosecuted because of perceived laws against self-managed abortion.” While only Nevada has a law that explicitly criminalizes self-managed abortions, Upadhyay said that people may assume that a state abortion ban may also criminalize receiving medication abortion in their state. There have not been any prosecutions of providers who have sent abortion pills to red states under shield laws, though court challenges to the laws are expected. Still, as restrictions mount—Florida, for instance, which was a haven for abortion access in the South, just imposed a 6-week ban on May 1—Upadhyay says “more people may turn to abortions provided under shield laws.” 

Other reasons for the overall increase in abortions post-Dobb include new clinics in blue states, increased funding for abortion care—from some blue state governments, private foundations, and individual people giving to abortion funds—and the destigmatization of abortion in states with fewer restrictions. But the new data should not be interpreted to suggest Dobbs hasn’t had a disastrous impact. As #WeCount co-author Alison Norris, a researcher at the Ohio State University, pointed out to reporters on Tuesday, the report found that nearly 180,000 fewer abortions were provided in-person in states that had total or 6-week abortion bans. In other words, telehealth abortion and shield laws are not adequate replacements for brick-and-mortar clinics. 

“People need trusted, in-person care locally,” Norris said. “They shouldn’t have to drive hours.”

Clinics are essential options for people who only learn about their pregnancy at, or after, 10 to 12 weeks at which point they are no longer eligible for medication abortions. Telemedicine is also not an option for those who learn something about their pregnancy after the first trimester that makes them need or want to terminate it. Teens and low-income people, in particular, also face major barriers to traveling for in-person care if they reside in states that no longer have operating clinics. 

“Our biggest concern is that with the rising numbers, people will interpret this as, ‘everybody’s getting their abortion,'” Upadhyay says. “It’s so important to highlight that there’s a lot of unmet need…there are people who are just not getting the abortions and continue to be forced to carry unwanted pregnancies to term.”

“For the sake of families,” the former Secretary of Housing and Urban Development wrote in his book, The Perilous Fight, released Tuesday, “we should enact legislation to remove or radically reduce incidences of no-fault divorce.” 

Over the past year, I have been tracking the rise of men on the right, both elected and civilian, who think it ought to be harder to get divorced in this country. These men often cite family values, their religious beliefs, or women’s changing desires to justify rolling back the current no-fault system that exists in all 50 states.  

Since 1969, when then–California Gov. Ronald Reagan signed the nation’s first no-fault divorce law—granting couples a separation without having to prove that one side had committed wrongdoing—these statutes have provided a way out of both banal and toxic relationships. Though Reagan, per his son, would later call backing no-fault divorce his “greatest regret” in life, these laws have had a positive impact on women’s lives and autonomy. A 2003 working paper from the National Bureau of Economic Research found that when states allowed one partner alone to push for divorce, there was a 20 percent decline in female suicide. As I have reported previously, no-fault divorce laws are often essential to those attempting to escape domestic violence. 

While some people have been clamoring about rolling back no-fault divorce laws for decades—read Sen. Tom Cotton’s 1997 article in the Harvard Crimson for his thoughts on the matter—there has been a marked increase in disdain both online and in places of power, about states’ current divorce laws. These men—Johnson, failed Republican presidential candidate Vivek Ramaswamy, Oklahoma State Sen. Dusty Deevers, Sen. J.D. Vance, right-wing activist and influencer Steven Crowder, and PragerU host Michael Knowles, to name a few—are normalizing attacks on whether and how people should be able to separate.

“The reason this matters is that no-fault divorce legally allows marriages to end much more quickly than in previous decades,” Carson wrote in the book.  

Should Carson be chosen as Donald Trump’s running mate, and should he further become second in line for the presidency come November, it’s unclear if and how he’d attempt to limit access to divorce. These kinds of laws are handled state-by-state, and an overwhelming majority of Americans think that divorce is “morally acceptable.” 

This isn’t the first time Carson has written about divorce, either.

Throughout Carson’s books, he references difficulties from his childhood. He details growing up in Detroit, speaking fondly of the rug he sat on in kindergarten to learn new songs. “I was an average student, and life was peaceful,” Carson wrote in his 2011 book America the Beautiful.

That changed when he turned eight years old and his parents divorced. According to Carson, “it wasn’t his job that had kept my father away from our family. He had been living a double life for years—complete with a second wife and another set of children.” 

He, his mom, and his brother moved to Massachusetts. “There were four grades in each classroom, and all eight grades were taught by only two teachers,” Carson wrote. “By the time … I moved back to Detroit, I had essentially lost a year of school while in Boston, my academic performance lagging far behind that of my new classmates.”  

Carson laments seeing his mother Sonya go through this time in his 2007 book Take the Risk. “She suddenly found herself all alone in the world, devastated and disillusioned by the end of her marriage,” he wrote. In a section of his 1992 book Think Big dedicated to his mother, she described the financial difficulties that arose after the divorce. “At one point we did get food stamps, but only for a few months. I wanted to be independent and pay my own way. According to the divorce decree, Mr. Carson was supposed to support our sons, but he provided very little money.”  

Fast forward to Carson’s book released this week, in which he writes, “When there are relatively few legal or financial consequences connected with divorce, it’s natural for people to gravitate toward that option when their marriage hits a rough patch.”

“What those people often don’t consider, however,” he goes on, “is the harm—both present and future—inflicted on their children once a divorce is finalized.”

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

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

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

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

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

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

 




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




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

 

Myles Markham in Los AngelesChloe Aftel

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

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

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

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

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

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

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

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Learning to Love My Trans Self After Conversion Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Sadness,” the client says.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Correction, May 17: A previous version of this story misstated Alex Dworak’s medical specialty.

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

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

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

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

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

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

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

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

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

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

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

Cass doesn’t apply important terminology consistently or accurately

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

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

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

Cass endorses questionable therapeutic treatment  

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

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

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

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

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

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

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

The Cass Report shows signs of bias 

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

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

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

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

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

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

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

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

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

In the book, Lamb, the chief foreign correspondent for the Sunday Times in Britian, tried to change that. She investigated the history, and human impact, of rape as a weapon of war—documenting its use by Pakistani soldiers against Bangladeshis in the 1971 war for independence; by Serbian paramilitary soldiers against Bosnian Muslims in 1992; and by ISIS against the Yazidis during and after the 2014 genocide, among many other conflicts throughout history.  

After the October 7 attack on Israel by Hamas, Lamb went to Israel to investigate allegations of sexual violence. She published a report in early December, highlighting Israeli activists’ frustrations with the initial silence on the allegations of widespread rape from the United Nations and other international bodies. 

Earlier this month, the office of UN Special Representative of the Secretary-General on Sexual Violence in Conflict, led by Pramila Patten, released a report that found “reasonable grounds” to believe sexual violence—including rape and gang rape—occurred during the Oct. 7 attack. It did not establish the prevalence of sexual assault or attribute it to Hamas or other specific individual actors. The report also said there is “clear and convincing information” that sexual violence occurred against Israeli hostages—and likely remains ongoing for those still held in captivity; last week, the New York Times published the account of the first former Israeli hostage to say she was sexually abused while held by Hamas. 

But the release of the report hasn’t quelled critiques—including from Lamb, who told me she thought it was “inexcusable” that the UN didn’t respond sooner to Israeli women’s groups who allegedly requested months ago for the body to look into the allegations of sexual violence on and after Oct. 7. American officials also said the UN erred, alleging in December that they were ignoring reports of sexual violence against Israelis in the conflict, the New York Times reported. (Patten’s report recommends a full investigation.) 

Still, the investigation and discussions of rape during the war have been fraught. Historically, the abuse of women has been used to justify conflict—including the US’s role in Afghanistan, as my colleague Madison Pauly reported back in 2021. Since the beginning of the war, critics have questioned how reports of sexual violence on Oct. 7 are being used by Israel and its allies to legitimize its campaign in Gaza.

On International Women’s Day earlier this month, Israel released an ad showing women around the world saying that they are “unite[d] in soldiarity with their Israeli sisters, who were kidnapped, raped, and brutally murdered on Oct. 7th. No woman should endure such horrors at the hands of terrorists.”

Last month, protesters confronted former Secretary of State Hillary Clinton and US Ambassador to the UN Linda Thomas-Greenfield at an event on sexual violence in conflict at Columbia University, alleging the panelists were “exploiting” the allegations to justify Israel’s actions, which have killed more than 32,000 people.

There has also been heavy criticism of a December investigation in the New York Times, based on more than 150 interviews, which alleged “Hamas weaponized sexual violence on Oct. 7.” The story drew criticism from within the Times, according to The Intercept, and from readers who pointed to discrepancies in some of the accounts. The reporters subsequently addressed some of the critiques. But last week, separate journalists from the Times uncovered video evidence that undercuts an allegation from an Israeli source featured in the December investigation, who alleged two teenagers killed on Oct. 7 were subjected to sexual violence. 

Critics have also alleged the focus on sexual violence in the war has ignored how abuse and harassment also affects Palestinian women. The UN report included claims that in the occupied West Bank sexual violence has been perpetrated by Israeli officials and settlers against Palestinians in detention, in their homes, and at checkpoints. And on Thursday, Reuters published a story alleging that dozens of social media posts show Israeli troops in Gaza playing with women’s underwear. (The IDF said in a statement to Reuters it investigates incidents of inappropriate behavior but did not clarify whether it was referring to any of the incidents reported by the news agency or whether it had taken action against any of the soldiers featured in the posts.)

Lamb, for her part, resents how allegations of sexual violence have become political pawns in discussions of the war. On a Zoom call and over email this past month, I spoke with Lamb about the difficulties of reporting on sexual violence in conflict, why it’s so seldom prosecuted as a war crime, and what she makes of the recent discourse around sexual violence in the conflict between Israel and Hamas.

This interview has been lightly condensed and edited. 

What have you made of the discussions of sexual violence in the context of Israel’s war on Gaza since Oct. 7? 

This is a very particular situation, I would say, because it’s a very polarizing conflict. Not that that isn’t the case, I suppose, with Russia and Ukraine, but people outside of the main countries involved seem to have taken positions in a way that isn’t always the case [with other wars]. A lot of people seem to think it’s not possible to think—as I do—that what happened on October 7 is absolutely horrific, but also what Israel is doing in Gaza is horrific.

After I covered the UN report earlier this month, the main critiques I heard from people critical of Israel were that the UN team didn’t speak to the survivors of sexual violence [the report says the ones who are still alive are “undergoing specialized treatment” for severe trauma]; that the UN team had the full cooperation of the Israeli government in producing this report, and could therefore have been presented with pro-Israeli propaganda; and that the UN team couldn’t establish the prevalence of sexual violence on or after Oct. 7, which would require further investigation. How should critics balance their skepticism of the UN’s findings, given Israel’s history of propaganda, with an understanding of some of the difficulties of actually gathering evidence of this kind of crime?

I’m the last person to be an apologist for the Israeli government and what they’re doing. I was also a bit concerned when I wrote my piece, you know, the last thing you want is for it to be used in any way as a sort of justification for what they are doing and terrible things that they’re doing in Gaza. 

But I don’t think we should say, “Well, we’re not going to report this because we’re worried that it could be used as justification.” That would be wrong—people have said, “Why are we not reporting what Israel is doing to the Palestinian women?” I think we should report that too.

But in terms of the critiques of the [UN] evidence—often, women don’t come forward for years. I mean, I’ve written about women who’ve taken 60 years to come forward and talk about this. This is a really difficult thing to talk about. It’s very personal. We all know that rape is sadly the one crime where the victim is often made to feel that they’ve done something wrong, so they don’t want people to know. I think it’s possible that the majority of the victims in this case were killed or taken hostage. My understanding is that there are some survivors but they’re deeply traumatized and in psychiatric care. I’d also say that you don’t always have to have the body. You can write about and report on a murder without having the body. 

I can see why the women in Israel were angry at the beginning because they wrote to all these bodies, like hers, which is supposed to look into these things. There was no response. 

[Editor’s note: Lamb is referring to the office of Pramila Patten, the UN’s Special Representative of the Secretary-General on Sexual Violence in Conflict. Reporting from the New York Times said that Israeli women reached out to the office of UN Women—which is technically separate from Patten’s office—and got no response. UN Women directed our questions to Patten’s office, which did not respond to a request for comment to verify if Israeli women had contacted the UN about investigating sexual assault and if there had been a response.]

I think that that is actually inexcusable. I think, when these different women’s organizations contacted [the UN], they should’ve responded, they shouldn’t have just been completely silent. As these Israeli women’s groups said, [the UN] supported women in Iraq, Ukraine, Afghanistan, and all these other places.

Can you help parse the distinction between individual acts of sexual violence that the UN says it has “reasonable grounds” to believe occurred on October 7, versus the systemic use of it, which they’ve said they can’t yet establish because that would require further investigation?

Both cases are horrific. But there is a difference between rape happening because of the breakdown of society and people actually being ordered to go and rape. It seems to me, unfortunately, in recent years, we’re seeing this happening more and more, so [in my book] I specifically looked at cases where people had been ordered to rape.

The IDF claims that they’ve got intercepts and they’ve interrogated people who said that they were sent to do it. Now, some people have said to me, “Hamas says they respect women, they would never do this.” I’m sorry, but I have many cases in other countries where it’s been Islamic groups that carried out [rape]—for example, the Yazidis, that was [ISIS]. You can’t say, “This religion honors women and therefore wouldn’t do it,” which is an argument I’ve had a surprising number of people make. Unfortunately, every religion is doing it, every conflict, every kind of ethnicity, pretty much—it’s just a very effective and cheap weapon. The real problem, the real question we should be asking, is: Why isn’t anything being done, really, to bring perpetrators to justice so that this [rape] isn’t used? 

You’ve written about how rape wasn’t prosecuted as a war crime until 1998, when the International Criminal Tribunal for Rwanda handed down the conviction for rapes during the Rwandan genocide. And there’s still been no prosecution of Boko Haram’s sexual violence against Nigerian girls and women, and only one prosecution of an ISIS fighter for sexual violence against Yazidis. Why is sexual violence in conflict so rarely prosecuted as a war crime? 

I think that one of the main reasons is because it’s something that happens to women. Doctor [Denis] Mukwege, who is one of my heroes, who got the Nobel Peace Prize [in 2018] for his work in the Democratic Republic of the Congo, treating rape victims and raising this issue—and his hopsital has treated thousands of women and girls who’ve been raped—he says if this was happening to men on a wide scale and men were being, you know, sexually mutilated and traumatized by women, do we really think that the world would have stayed silent?

Also, people don’t see any upside, really, in reporting [their experience of sexual violence to authorities] because they fear that they will be castigated and seen in a bad light, but also they don’t believe that it will achieve anything, because they don’t think anyone will be brought to justice. 

You wrote about how there has been barely any media coverage of sexual violence as part of the war in the Democratic Republic of Congo; the UN says there were more than 31,000 cases in the first three months of last year alone. Sexual violence perpetrated by Russians against Ukrainians, on the other hand, has been widely covered in the media, as you’ve said. Why are some instances of sexual violence in conflict more widely acknowledged than others? 

To be fair, with the DRC, the whole kind of war there was very little covered anyway. Around five million people died, and there was very little coverage. [Editor’s note: The Times notes some estimates even put the death toll in the Congo at over six million.]

I think it’s complicated to cover, it’s difficult to get there—there was a lot of discussion of, why have we covered so much of what’s happening to Ukraine? Is it because they’re people that look like “us”? 

But I feel very strongly that we should cover all of these things, and it worries me a lot that, because there’s so much focus on Ukraine and Israel, that we start neglecting [other places]. 

How do we know if sexual violence is not happening in certain conflicts, or if it’s just not being adequately covered or researched? 

I’ve been a war correspondent for 36 years, yet until I started looking into this, I had no idea how widespread it was. And once I started looking into it, I realized there’s pretty much no conflict where it doesn’t happen, and that lots of wars widely reported in the past actually had a lot of rape happening, yet it wasn’t reported. Look at the Spanish Civil War, where a lot of female reporters went for the first time—such as Martha Gellhorn, Virginia Cowles, and Lee Miller (who I grew up idolizing) yet they didn’t report on this, and that intrigues me. Did they not see? Because, actually, many, many women were raped. Now I look at their reporting and I think, you must have seen that this was happening to women, because it was happening so much, and yet you never wrote about it—why? 

Do you have a sense of how these questions apply to sexual violence experienced by Palestinians? The UN report seems to suggest there are structural barriers to Palestinian victims coming forward that lead to a perception of little sexual violence inflicted upon them by Israelis.

Well that’s true, in many societies and it’s always difficult for women to talk about these things—rape is the one crime where the victim is often made to feel they did something wrong. That’s why I feel so angry when they do come forward and we don’t do anything.

But also, I think we’re talking about two different things—sexual violence in conflict as a weapon of war and people being raped or sexually abused in detention, which we’ve seen happening to protesters in detention in Iran and Belarus. I think there has been coverage, though I must admit, when I reached out to Palestinian groups on this in December, they did not put me in touch with any women who would speak about it.

Ironically, in my book I wrote—quoting academic research—that the Israel-Palestinian conflict was one conflict where [sexual violence] seemed to happen less, and I speculated that this was because there were a lot more women involved on both sides. It’s clear to me, the more women you have in the military or as peacekeepers, then you have a less macho culture, and it seems to make a difference. But you know, unfortunately, everywhere that I looked, it seems to happen. 

Update, April 1: This story has been updated with a response from UN Women.

The four-part docuseries aired on Max and Investigation Discovery earlier this month, and a surprise fifth episode is in the works for next week. The show explores the dark side of Dan Schneider’s tenure at Nickelodeon, painting him as a temperamental, manipulative boss with a disturbing habit of inserting sexual innuendos into scenes with child actors. Details of Schneider’s conduct began to leak out in 2018, when Schneider left Nickelodeon amid allegations of abusive behavior. The New York Times reported in 2021 that an internal investigation had found Schneider was verbally abusive to staff, while a 2022 Business Insider investigation highlighted his controlling demeanor and sexism in the writers room. 

On set, Schneider’s crew included two now-convicted sex offenders. In 2004, Jason Handy, a production assistant, was sentenced to six years in prison after pleading no contest to performing lewd acts on a child, distributing sexually explicit material, and child exploitation. The same year, dialogue coach Brian Peck pleaded no contest to two charges related child sexual abuse against an anonymous child actor and was sentenced to 16 months in prison. Quiet on Set’s biggest bombshell is that Peck’s victim was Drake Bell, a star of Drake & Josh and a regular on The Amanda Show. 

The documentary chronicles the Schneider years at Nickelodeon through interviews with former cast and crew members, journalists who reported on the scandal, and the parents of child actors. It also resurfaces moments of inappropriate humor from Schneider’s shows that seem alarming in retrospect: In one scene, a 16-year-old Ariana Grande, a cast member on Schneider’s Victorious, attempts to “juice” a potato while moaning suggestively. 

The fourth episode, originally slated to be the last in the series, ends with Bell sharing how the abuse impacted him emotionally. In the last shots, we see Bell and his dad walking off the documentary set, then the camera cuts to a sunset. As the credits rolled, I felt a mix of anger and hopelessness. While the filmmakers had done a skillful job of laying out the allegations against Schneider, the show also left many questions unanswered. Schneider declined to be interviewed for the documentary, though it included a written statement from him, saying his content went through many levels of approval before it aired. (Nickelodeon provided a statement to the documentary saying it “investigates all formal complaints as part of our commitment to foster a safe and professional workplace.”) After the documentary, Schneider offered a lackluster mea culpa in a softball interview with a former iCarly cast member, where he muddled his apology with asides that his behavior was caused by “inexperience” and letting pressures get to him.

Nickelodeon’s decision to sever ties with Schneider was necessary and long overdue, but it’s unsettling to think that he can continue to live his life quietly without taking full accountability. And what cuts deeper is that so many people in the industry allowed such a toxic environment to fester—from the parents of child stars who failed to speak up to the industry insiders who wrote letters in support of Peck before his sentencing, including actor James Marsden.

Meanwhile, though Bell has rightfully received an outpouring of support for speaking out, the renewed good will toward the star treads a fine line. In 2021, Bell pleaded guilty to attempted child endangerment charges related to sexual conversations he had with a 15-year-old fan. In a victim impact statement, she claimed Bell groomed and sexually assaulted her multiple times. (Bell was charged only with attempted child endangerment and a misdemeanor for disseminating harmful material to a juvenile. He denies the allegations of sexual assault.) The documentary only mentions these allegations briefly in the context of Bell’s downward spiral after his own abuse, emphasizing that “he was not charged with doing anything physical.” 

The abuse on Nickelodeon happened before the eyes of an entire generation, tainting media intertwined with our childhood nostalgia. After Quiet on Set aired, emotions ran high online. “Jail is not enough!!!” wrote one X user, whose post received almost 5,000 likes. Social media users demanded that Drake Bell’s former costar, Josh Peck (no relation to Brian Peck), speak out. Bell released a statement saying that Josh Peck had personally reached out to him and asked fans to “take it a little easy on him.” On The View, host Sunny Hostin questioned Ariana Grande’s silence about the documentary, saying, “She is an adult now, so is silence complicity or not?” In the wake of this explosive reaction, Investigation Discovery announced that a bonus fifth episode of Quiet on Set would premiere on April 7.  The new episode, a discussion with former child actors moderated by Soledad O’Brien, is billed as “digging deeper into the crucial conversations the docuseries ignited and exploring the lingering questions left in their wake to provide further insight from the brave voices who’ve spoken out.” 

The decision to add a fifth episode felt like a tacit acknowledgement of the fact the final episode of the show had left many questions unanswered. But while the new episode is an opportunity to channel outrage into productive conversations about how to protect child actors from abuse, it may not answer every burning question. As viewers, there’s some uncertainty we have to accept: Public outrage should not come at the cost of victims’ decision to tell their stories if and when they’re ready. It’s possible we may never know everything that happened at Nickelodeon, or how every former child star was affected—and that’s okay. Justice might not come swiftly, and it may not look like what viewers expect. It might look like victims remaining nameless, going about their lives in private, and just trying to pick up the pieces. 

But there’s just one problem: more than 100 scientific studies show that abortion pills are safe and effective, as my colleagues and I have reported.

Alito made the comments this morning during oral arguments in FDA v. Alliance for Hippocratic Medicine. In 2000, the Food and Drug Administration approved mifepristone. The drug was made more widely available in 2016, when the FDA allowed it to be used through 10 weeks’ gestation rather than 7 weeks’ gestation; in 2021, the agency relaxed additional rules around how it could be prescribed, including allowing it to be given virtually. The stakes of the case are significant, given that medication abortion accounts for more than half of all abortions nationwide, according to the Guttmacher Institute, and that telehealth abortions—in which providers virtually prescribe and mail pills—continue to rise, even in banned states.

In questioning today, Alito prodded at the FDA’s regulation of mifepristone by trying to explore the possibility that despite years of safety, there were hidden adverse effects not being tracked.

“Has the FDA ever approved a drug and then pulled it after experience showed that it had a lot of really serious, adverse consequences?” Alito asked Jessica Ellsworth, the lawyer representing Danco Laboratories, a manufacturer of mifepristone. 

Ellsworth said yes, noting that the FDA collects data on the impacts of the drugs it approves.

“Don’t you think the FDA should’ve continued to require reporting of non-fatal consequences?” Alito continued, referring to the FDA’s 2016 decision that prescribers didn’t need to report adverse events from mifepristone because of the drug’s safety record. As Ellsworth told Alito, the FDA made that decision “based on more than 15 years of a well-established safety profile when that reporting was required.” 

Alito, though, remained undeterred. “So why would that be a bad thing? You don’t want to sell a product that causes very serious harm to the people that take your product, relying on your tests and the FDA’s tests—wouldn’t you want that data?” 

This idea that there is some secret data not being harvested ignores all the clear data we do have showing that mifepristone is safe.

Study after study has shown that the drug does not, in fact, produce “a lot of really serious, adverse consequences.” The FDA, and other large studies, have reported low rates of serious adverse events. And research published in February—which I reported on at the time—showed that medication abortion is not only safe, but just as safe when it’s prescribed virtually as in person.

Alito’s line of questioning comes after two research papers claimed to show the dangers of mifepristone and were cited in the Texas court ruling that led to the Supreme Court case. But both of those reports have since been retracted after an independent peer review uncovered unsupported conclusions due to flaws with the study design, methodology, and data analysis—along with possible conflicts of interest given the lead author’s affiliation with the Charlotte Lozier Institute, an anti-abortion advocacy organization.

Ellsworth addressed the retracted studies this morning after Justice Ketanji Brown Jackson asked her if the company had “concerns about judges parsing medical and scientific studies.” 

Referring to the retracted studies, Ellsworth replied: “Those sorts of errors can infect judicial analyses precisely because judges are not experts in statistics, they are not experts in the methodology used in scientific studies, for clinical trials. That is why FDA has many hundreds of pages of analysis in the record of what the scientific data showed, and courts are just not in a position to parse through and second-guess that.” 

Whether the justices humble themselves accordingly, though, remains to be seen: their decision in the case is expected by the end of June. 

Correction, March 27: This post has been revised to correct the year the FDA allowed mifeprestone to be used through 10 weeks’ gestation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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