Tingley v. Ferguson Motion To Preliminary Injunction and Memo in Support

Case 3:21-cv-05359 Document 2 Filed 05/13/21 Page 1 of 30
7
UNITED STATES DISTRICT COURT
8 WESTERN DISTRICT OF WASHINGTON
AT TACOMA
9
BRIAN TINGLEY, ) 3:21-cv-5359
Case No. _______________
10 )
Plaintiff, )
11
)
12 v. ) PLAINTIFF’S MOTION FOR
) PRELIMINARY INJUNCTION AND
13 ROBERT W. FERGUSON, in his official ) MEMORANDUM IN SUPPORT
capacity as Attorney General for the State of )
14 Washington; UMAIR A. SHAH, in his official NOTE ON MOTION CALENDAR:
)
capacity as Secretary of Health for the State of ) Friday, June 4, 2021
15 Washington; and KRISTIN PETERSON in her )
16 official capacity as Assistant Secretary of the )
Health Systems Quality Assurance division of the ) ORAL ARGUMENT REQUESTED
17 Washington State Department of Health, )
)
18 Defendants.
)
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Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

Mem. in Supp. i 15100 N. 90th Street
3:21-cv-5359
Case No. ________________ Scottsdale, Arizona 85260
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1 TABLE OF CONTENTS
2
Preliminary Statement ..................................................................................................................... 1
3
Statement of Facts ........................................................................................................................... 2
4
A. Plaintiff Tingley and his clients .............................................................................. 2
5
B. Religious beliefs concerning sexuality, identity, and the possibility of change ..... 3
6
7 C. Scientific knowledge and lack of knowledge concerning changes in sexual

attractions and gender identity ................................................................................ 4
8
D. Tingley’s counseling relating to sexual attractions and gender identity ................. 5
9
E. The Counseling Censorship Law ............................................................................ 6
10
Argument ........................................................................................................................................ 7
11
Governing Legal Standard .............................................................................................................. 7
12
I. The Counseling Censorship Law Violates the Free Speech Rights of Plaintiff
13
Tingley Because it Bans Protected Speech Based on Content and Viewpoint. .................. 7
14
A. The Law regulates speech, not conduct. ................................................................. 7
15
B. The Law is subject to strict scrutiny because it censors speech based on
16 content and viewpoint. ............................................................................................ 8
17 1. The Law censors speech based on content. ................................................ 8
18 2. The Law discriminates based on viewpoint. ............................................... 9
19
3. The speech targeted by the Law is not less protected because it is
20 speech by professionals or it is directed at minors. .................................. 10
21 C. The Counseling Censorship Law cannot survive strict scrutiny. .......................... 11
22 1. The Counseling Censorship Law cannot survive strict scrutiny

because, as enforced against pure speech, it does not further any
23 cognizable governmental interest. ............................................................ 12
25 because it is not narrowly tailored. ........................................................... 13

because it is not the least-restrictive alternative. ...................................... 15
27

Mem. in Supp. ii 15100 N. 90th Street
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1 II. The Counseling Censorship Law Violates the Free Speech Rights of Clients of
Plaintiff Tingley. ............................................................................................................... 16
2
A. Plaintiff has standing to assert the First Amendment rights of his clients. ........... 16
3
B. The Counseling Censorship Law violates the First Amendment right of
4
clients of Tingley to receive desired information and counsel. ............................ 17
5
III. The Counseling Censorship Law Violates the Due Process Rights of Plaintiff
6 Because It Grants Unbridled Discretion in Enforcement. ................................................ 17
7 IV. The Counseling Censorship Law Violates the Free Exercise Rights of Mr. Tingley
and His Clients. ................................................................................................................. 18
8
A. The Counseling Censorship Law violates free exercise rights because it is
9 not neutral. ............................................................................................................ 19
10
B. The Counseling Censorship Law violates free exercise rights regardless
11 of whether it is “neutral and of general applicability.” ......................................... 20
12 V. The Remaining Factors Favor Granting a Preliminary Injunction. .................................. 21
13 Conclusion .................................................................................................................................... 21
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Mem. in Supp. iii 15100 N. 90th Street
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1 TABLE OF AUTHORITIES
2 CASES
3 American Beverage Association v. City and County of San Francisco,

916 F.3d 749 (9th Cir. 2019) ...............................................................................................7
4
Ashcroft v. ACLU,
5
542 U.S. 656 (2004) ...........................................................................................................11
6
Brandenburg v. Ohio,
7 395 U.S. 444 (1969) ...........................................................................................................12
8 Brown v. Entertainment Merchants Association,

564 U.S. 786 (2011) .....................................................................................................11, 14
9
Church of the Lukumi Babalu Aye, Inc. v. City of Hialeah,
10
508 U.S. 520 (1993) .....................................................................................................14, 19
11
Conant v. Walters,
12 309 F.3d 629 (9th Cir. 2002) .................................................................................10, 11, 13
13 Eisenstadt v. Baird,
405 U.S. 438 (1972) .....................................................................................................13, 16
14
Employment Division, Department of Human Resources of Oregon v. Smith,
15 494 U.S. 872 (1990) ...........................................................................................................19
16
FCC v. League of Women Voters of California,
17 468 U.S. 364 (1984) ...........................................................................................................12
18 Florida Star v. B.J.F.,

491 U.S. 524 (1989) ...........................................................................................................14
19
Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal,
20 546 U.S. 418 (2006) ...........................................................................................................12
21 Griswold v. Connecticut,
22 381 U.S. 479 (1965) ...........................................................................................................17
23 Herceg v. Hustler Magazine, Inc.,

814 F.2d 1017 (5th Cir. 1987) ...........................................................................................12
24
Holder v. Humanitarian Law Project,
25 561 US 1 (2010) .................................................................................................................17
26 Hosanna-Tabor Evangelical Lutheran Church & School v. EEOC,
565 U.S. 171 (2012) .....................................................................................................19, 20
27

Mem. in Supp. iv 15100 N. 90th Street
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1 Hurley v. Irish-American Gay, Lesbian & Bisexual Group of Boston,

515 U.S. 557 (1995) ...........................................................................................................13
2
IMDb.com v. Becerra,
3 962 F.3d 1111 (9th Cir. 2020) .......................................................................................8, 10
4
Kolender v. Lawson,
5 461 U.S. 352 (1983) ...........................................................................................................17
6 Kowalski v. Tesmer,
543 U.S. 125 (2004) ...........................................................................................................16
7
Linmark Associates, Inc. v. Willingboro Township,
8 431 U.S. 85 (1977) .............................................................................................................15
9 Maryland v. Joseph H. Munson Co.,
10 467 U.S. 947 (1984) .....................................................................................................16, 17
11 McCullen v. Coakley,
573 U.S. 464 (2014) .......................................................................................................8, 12
12
Miller v. Reed,
13 176 F.3d 1202 (9th Cir. 1999) ...........................................................................................21
14 NAACP v. Button,
15 371 U.S. 415 (1963) .............................................................................................................8
16 National Institute of Family & Life Advocates v. Becerra,

138 S. Ct. 2361 (2018) ...................................................................................1, 8, 10, 13, 16
17
Otto v. City of Boca Raton,
18 981 F.3d 854 (11th Cir. 2020) ...........................................................................1, 2, 8, 9, 10
19 Pickup v. Brown,
728 F.3d 1042 (9th Cir. 2013) .............................................................................................7
20
21 Reed v. Town of Gilbert,

576 U.S. 155 (2015) .............................................................................................8, 9, 10, 11
22
Republican Party of Minnesota v. White,
23 416 F.3d 738 (8th Cir. 2005) .............................................................................................11
24 Rosenberger v. Rector & Visitors of University of Virginia,
515 U.S. 819 (1995) .............................................................................................................9
25
Sammartano v. First Judicial District Court,
26
303 F.3d 959 (9th Cir. 2002) ...............................................................................................7
27

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1 Simon & Schuster, Inc. v. Members of New York State Crime Victims Board,
502 U.S. 105 (1991) ...........................................................................................................14
2
Snyder v. Phelps,
3 562 U.S. 443 (2011) ...........................................................................................................13
4
Texas v. Johnson,
5 491 U.S. 397 (1989) .......................................................................................................2, 13
6 Trinity Lutheran Church of Columbia, Inc. v. Comer,

137 S. Ct. 2012 (2017) .......................................................................................................20
7
United States v. Alvarez,
8 567 U.S. 709 (2012) .....................................................................................................12, 15
9 United States v. Playboy Entertainment Group, Inc.,
10 529 U.S. 803 (2000) .....................................................................................................15, 16
11 United States v. Stevens,

559 U.S. 460 (2010) ...........................................................................................................14
12
United States v. Swisher,
13 811 F.3d 299 (9th Cir. 2016) .............................................................................................13
14 United States v. Williams,
15 553 U.S. 285 (2008) ...........................................................................................................17
16 Victory Processing, LLC v. Fox,

937 F.3d 1218 (9th Cir. 2019) .......................................................................................8, 11
17
Video Software Dealers Association v. Schwarzenegger,
18 556 F.3d 950 (9th Cir. 2009) .............................................................................................15
19 Virginia State Board of Pharmacy v. Virginia Citizens Consumer
Council, Inc.,
20
425 U.S. 748 (1976) ...........................................................................................................17
21
Warth v. Seldin,
22 422 U.S. 490 (1975) ...........................................................................................................17
23 West Virginia State Board of Education v. Barnette,

319 U.S. 624 (1943) .............................................................................................................9
24
Whitney v. California,
25 274 U.S. 357 (1927) ...........................................................................................................15
26
Winter v. Natural Resources Defense Council, Inc.,
27 555 U.S. 7 (2008) .................................................................................................................7

Mem. in Supp. vi 15100 N. 90th Street
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1 Wollschlaeger v. Governor, Fla.,

848 F.3d 1293 (11th Cir. 2017) ...........................................................................................8
2
STATUTES
3
Wash. Admin. Code § 246.490.075 .................................................................................................6
4
5 Wash. Rev. Code § 18.130.020................................................................................................1, 6, 9
6 Wash. Rev. Code § 18.130.160........................................................................................................6
7 Wash. Rev. Code § 18.130.180....................................................................................................1, 6
8 Wash. Rev. Code § 26.04.010..........................................................................................................6

9 Wash. Rev. Code § 9.02.100............................................................................................................6
10 Wash. Rev. Code § 9A.44 ................................................................................................................6
11
OTHER AUTHORITIES
12
Richard M. Weaver, Ideas Have Consequences (Univ. Chi. Press, 1948) ....................................12
13
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25
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27

Mem. in Supp. vii 15100 N. 90th Street
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1 Plaintiff Brian Tingley moves under Fed. R. Civ. P. 65 to preliminarily enjoin
2 Defendants’ enforcement of Senate Bill 5722, codified at Wash. Rev. Code §§ 18.130.020 and
3 18.130.180 (the “Counseling Censorship Law”), both facially and as applied to Plaintiff, because
4 the Counseling Censorship Law censors private conversations between a counselor and his
5 clients in violation of the rights of both Brian Tingley and his clients secured under the First and
6 Fourteenth Amendments of the U.S. Constitution.
7 Preliminary Statement
8 “Speech is not unprotected merely because it is uttered by ‘professionals.’” Nat’l Inst. of
9 Family & Life Advocates v. Becerra (NIFLA), 138 S. Ct. 2361, 2371-72 (2018). Brian Tingley, a
10 licensed marriage and family counselor, moves this Court to enjoin the enforcement, both on its
11 face and as applied, of Washington State’s Senate Bill 5722, codified at Wash. Rev. Code §§
12 18.130.020 and 18.130.180 (“the Counseling Censorship Law” or “the Law”)—a law that
13 censors private conversations between individuals and their chosen counselors in violation of the
14 First and Fourteenth Amendment rights of both Mr. Tingley and his clients.
15 The client-counselor relationship requires trust and openness between client and
16 counselor as they explore together the client’s most intimate concerns and personal goals. It is
17 the last place where government agents should intrude to declare disfavored topics and ideas off
18 limits. Yet the Counseling Censorship Law does just that. More, many people believe that
19 matters of sexuality and gender identity implicate not merely neutral feelings and desires, but
20 morality and indeed obedience to God. Yet if a client is experiencing same-sex attractions, or a
21 sense of gender identity that is discordant with his or her biological sex, the Counseling
22 Censorship Law flatly prohibits the counselor from offering any thoughts to assist the client in
23 pursuing even a personally chosen goal of reducing same-sex attraction, or achieving comfort in
24 a gender identity congruent with the client’s physical body and reproductive nature.
25 The Washington State legislature may find such beliefs or counsel archaic, objectionable,
26 or even dangerous. But “[i]f there is a bedrock principle underlying the First Amendment, it is
27 that the government may not prohibit the expression of an idea simply because society finds the

Mem. in Supp. 1 15100 N. 90th Street
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1 idea itself offensive or disagreeable.” Otto v. City of Boca Raton, 981 F.3d 854, 872 (11th Cir.
2 2020), quoting Texas v. Johnson, 491 U.S. 397, 414 (1989).
3 Because even the prospect of enforcement chills free and open discussion between Mr.
4 Tingley and his clients, and because as detailed below Mr. Tingley has a strong probability of
5 prevailing on the merits, enforcement of the Counseling Censorship Law should be preliminarily
6 enjoined pending resolution of this case on the merits.
7 Statement of Facts
8 A. Plaintiff Tingley and his clients
9 Plaintiff Brian Tingley is a licensed Marriage and Family Therapist who has 20 years’
10 experience counseling clients on a wide range of complex and sensitive topics. (Cmpl. ¶ 70;
11 Tingley Decl. ¶ 3.) Mr. Tingley works with his clients to provide support, challenge, and
12 feedback to help achieve the life and personal goals that they choose for themselves. (Cmpl. ¶
13 79; Tingley Decl. ¶ 14.) Mr. Tingley counsels both adults and minors. In all cases, his counseling
14 consists of nothing but conversation: asking his clients questions, listening empathetically, and
15 offering suggestions as to how they can better understand themselves and their relationships and
16 emotions, so that they can make changes that they desire, become the people they want to be, and
17 live the lives that they want to live. (Cmpl. ¶ 76; Tingley Decl. ¶ 13-14, 66.)
18 Mr. Tingley is a Christian. He does not seek to impose his faith or priorities on his
19 clients, but his faith inevitably informs his understanding of human nature. (Cmpl. ¶ 27; Tingley
20 Decl. ¶ 9.) Mr. Tingley’s website states that his practice group consists of Christian counselors,
21 who share a goal of helping clients achieve “personal and relational growth as well as healing for
22 the wounded spirit, soul, and body through the healthy integration of relational, psychological,
23 and spiritual principles with clinical excellence.” (Cmpl. ¶ 70; Tingley Decl. ¶ 8.)
24 Most of Mr. Tingley’s clients share his Christian faith, and many select him and trust his
25 counsel precisely because he shares their faith-based convictions and worldview. (Cmpl. ¶ 71-74;
26 Tingley Decl. ¶ 10-12.) Mr. Tingley only works with clients who attend voluntarily, and in
27 pursuit of the goals or objectives that they have set for themselves. (Cmpl. ¶ 79-80; Tingley

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1 Decl. ¶ 14-15.) No client has ever filed any complaint against Mr. Tingley. (Cmpl. ¶ 174;
2 Tingley Decl. ¶ 16.)
3 B. Religious beliefs concerning sexuality, identity, and the possibility of change
4 Many Christians, including Mr. Tingley and many of his clients, believe that their
5 identity is primarily defined by who God has created them to be, and what God has said about
6 them, as revealed through biblical teaching, as opposed to being founded on their own feelings,
7 determinations or wishes. (Cmpl. ¶ 127-128; Tingley Decl. ¶ 26-30, 32.) Thus, many Christians
8 believe that living consistently with their faith is more fundamental to achieving their own
9 happiness, stability, and satisfaction than pursuing subjective desires or feelings that would
10 conflict with biblical teaching. (Cmpl. ¶ 67-68, 129-130, 155-158; Tingley Decl. ¶ 21-22, 40.)
11 This central tenet of the Christian faith has many applications, including leading Christians to
12 prioritize the teachings of their faith over their romantic and sexual desires both because they
13 believe this to be a divine command, and in the belief that doing so will lead to their own
14 flourishing and well-being. (Cmpl. ¶ 126-127, 129, 147; Tingley Decl. ¶ 23-24, 60.)
15 Moreover, Christians believe that they are to obey God’s laws and instruction regardless
16 of whether they experience conflicting desires or feelings. They accept biblical teachings that
17 pursuing a life of faith necessarily requires Christians to “deny themselves” in many aspects of
18 life (Matthew 16:24), and to give up behaviors that might otherwise appear desirable. (Cmpl. ¶
19 126-128, 130, 146-147; Tingley Decl. ¶ 30, 72.)
20 Also central to Christian faith is the belief that change–even radical change–is possible:
21 that God transforms the hearts and minds of faithful Christians so that they can live more
22 consistently with the teachings of their faith. Christians believe that they are not captive to their
23 own desires, but rather that with God’s help, they can change to live a life that is faithful to
24 God’s commandments. (Cmpl. ¶ 127-129, 147; Tingley Decl. ¶ 31-32.)
25 Biblical teaching specifically addresses sex and sexuality. Consistent with that teaching,
26 Mr. Tingley and many of his Christian clients believe that the sex that each of us receives at the
27

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1 moment of conception is not an accident, an insignificant detail, or a personal choice, but rather
2 is a gift of God. (Tingley Decl. ¶ 27.) Thus obedience, well-being, and happiness for each
3 individual will include acceptance of and gratitude for the particular sex that God has given to
4 him or her. (Cmpl. ¶ 111; Tingley Decl. ¶ 26-27, 40, 51.)
5 Likewise, many Christians believe that sexual relationships are right and healthy only in a
6 very specific context—namely between a man and a woman, committed to each other for life in
7 marriage. (Cmpl. ¶ 126; Tingley Decl. ¶ 29.) The joining of male and female in marriage to
8 conceive children and raise up each next generation is believed to be a great blessing, a great
9 calling, and a sacred thing. (Cmpl. ¶ 125; Tingley Decl. ¶ 28.) For many believers, any sexual
10 relationship outside of this context–regardless of how much it might be desired–is believed to be
11 contrary to the teachings of the Christian faith. (Cmpl. ¶ 126-127; Tingley Decl. ¶ 30.)
12 C. Scientific knowledge and lack of knowledge concerning changes in sexual
13 attractions and gender identity
14 Contrary to what is commonly asserted, the possibility of change in sexual orientation
15 and gender identity is not an area in which science and faith are in conflict.
16 As Dr. Rosik details in his declaration, in recent years leading researchers in the field
17 have acknowledged–indeed proclaimed–that it is no longer possible to maintain that change in
18 sexual orientation is impossible or even rare. (Rosik Decl. ¶¶ 7-9, 15-28.)
19 Notably, internationally respected authors Professors Lisa Diamond and Clifford Rosky,
20 who count themselves advocates for LGBTQ issues, reviewed the scientific literature in 2016
21 and concluded that “arguments based on the immutability of sexual orientation are unscientific,
22 given that scientific research does not indicate that sexual orientation is uniformly biologically
23 determined at birth or that patterns of same-sex and other-sex attractions remain fixed over the
24 life course.” Instead, Diamond and Rosky reported that “Studies unequivocally demonstrate that
25 same-sex and other-sex attractions do change over time in some individuals,” and that the
26 evidence for this is now even “indisputable.” (Rosik Decl. ¶¶ 17.) Indeed, Diamond and Rosky
27 cite multiple longitudinal studies which found that many teens and young adults who initially

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1 experience some degree of same-sex attractions identified as exclusively heterosexual within a
2 few years. (Rosik Decl. ¶¶ 22.)
3 Similarly, as Dr. Levine details in his declaration, many young people who experience
4 gender dysphoria or feelings of cross-gender identification ultimately resolve to identifying with
5 their biological sex—as many as 80-98%, in the case of young children. (Levine Decl. ¶¶ 60.)
6 Thus, even apart from faith considerations, an individual who experiences some same-sex
7 attractions but hopes to ultimately stabilize with predominately heterosexual attractions, or who
8 experiences gender dysphoria but hopes to ultimately achieve comfort with an identity aligned
9 with his or her biological sex and reproductive potential, is not hoping for an impossible thing.
10 And such individuals may well and reasonably desire to have a trained and trusted counselor
11 assist them as they pursue that personal goal.
12 D. Tingley’s counseling relating to sexual attractions and gender identity
13 Among the wide range of problems and goals that clients bring into his office, some
14 clients—including clients younger than 18—have asked Mr. Tingley to assist them to reduce
15 same-sex attractions, to achieve comfort with their biological sex, or to desist from sexual
16 behaviors such as addiction to pornography, or ongoing sexual activity, which the clients believe
17 are wrong. (Cmpl. ¶ 108-122, 158-165, 167-172; Tingley Decl. ¶¶ 37-51, 53-64, 67-72.) As Dr.
18 Rosik explains in his accompanying expert declaration, such goals frequently derive from the
19 client’s wishes to live consistently with his or her religious beliefs. (Rosik Decl. ¶¶ 36, 48.) Mr.
20 Tingley currently has and expects to continue to receive clients with similar wishes, objectives,
21 and motivations. (Cmpl. ¶ 123, 164-166, 173; Tingley Decl. ¶ 52, 57, 66, 73.) Mr. Tingley
22 wishes to continue supporting these clients for professional, religious, and human reasons.
23 (Cmpl. ¶ 175; Tingley Decl. ¶ 74.)
24 Mr. Tingley never promises clients that he can solve the issues they bring to him, but he
25 has often seen his clients make progress toward their goals on these issues. (Cmpl. ¶ 116, 163,
26 165, 169, 172-173; Tingley Decl. ¶ 45, 62-64, 69, 72.)
27

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1 E. The Counseling Censorship Law
2 The Counseling Censorship Law restricts “performing conversion therapy on a patient
3 under age eighteen” to the list of conduct, acts, or conditions that would constitute
4 “unprofessional conduct” for a “license holder.” Wash. Rev. Code (“RCW”) § 18.130.180.
5 While the Law defines “Conversion therapy” as “a regime that seeks to change an
6 individual's sexual orientation or gender identity”—which specifically includes “efforts to
7 change behaviors or gender expressions, or to eliminate or reduce sexual or romantic attractions
8 or feelings toward individuals of the same sex,” RCW § 18.130.020—it excepts “counseling. . .
9 that provide[s] acceptance, support, and understanding of clients or the facilitation of clients’
10 coping, social support, and identity exploration and development that do[es] not seek to change
11 sexual orientation or gender identity.” Id. Yet the Law does not define a boundary between
12 “change” and “exploration and development.”
13 The Law threatens severe penalties, including fines up to $5,000 for each violation,
14 suspension from practice, and even the loss of license and livelihood. RCW § 18.130.160.
15 Thus, the Counseling Censorship Law expressly prevents counselors from speaking, and
16 minor clients from hearing, proscribed ideas and messages even if the counselor (and client)
17 believes them to be true. It further prevents clients who desire a prohibited goal from obtaining
18 help from trained and trusted counselors as they pursue their goals.
19 Washington State seeks to deprive minor clients of these rights even as it authorizes these
20 same minors (from age 16 upwards) to engage in sexual activity with a person of any older age–
21 entailing the potentially lifechanging implications of becoming a parent (RCW § 9A.44); to
22 obtain an abortion without parental consent (at any age) (RCW § 9.02.100); to change their
23 gender on their birth certificate (at any age) (Wash. Admin. Code § 246.490.075); and even to
24 marry (from age 17) (RCW § 26.04.010). Moreover, there is no bar in Washington State on
25 minors at any age undergoing irreversible and life-altering hormonal or surgical measures that
26 would purport to “affirm” a transgender identity.
27

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1 Argument
The Counseling Censorship Law infringes rights of Mr. Tingley, and of his clients, that
2
are protected by the First and Fourteenth Amendments. At a minimum a preliminary injunction
3
should be entered categorically enjoining enforcement of the law due to its violation of Due
4
Process, and enjoining enforcement of the Law against Mr. Tingley due to its violations of the
5
First Amendment.
6
7 Governing Legal Standard
8 To obtain a preliminary injunction, the plaintiff must show that (1) he is “likely to
9 succeed on the merits,” (2) he is “likely to suffer irreparable harm,” (3) “the balance of equities
10 tips in his favor,” and (4) the requested injunction “is in the public interest.” Am. Beverage Ass’n
11 v. City and County of San Francisco, 916 F.3d 749, 754 (9th Cir. 2019) (quoting Winter v. Nat.
12 Res. Def. Council, Inc., 555 U.S. 7, 20 (2008). But when First Amendment rights are at risk, the
13 analysis essentially reduces to a single question—whether the plaintiff is likely to succeed on the
14 merits. This is because even the brief loss of First Amendment rights causes “irreparable injury”
15 and tilts “the balance of hardships … sharply in [the plaintiff’s] favor,” and “it is always in the
16 public interest to prevent the violation of a party’s constitutional rights.” Id. at 758 (emphasis
17 added) (cleaned up); see also Sammartano v. First Judicial Dist. Ct., 303 F.3d 959, 974 (9th Cir.
18 2002) (“Courts considering requests for preliminary injunctions have consistently recognized the
19 significant public interest in upholding First Amendment principles.”).
20 Because Plaintiff has a high likelihood of success on the merits, enforcement of the
21 Counseling Censorship law should be preliminarily enjoined.
22 I. The Counseling Censorship Law Violates the Free Speech Rights of Plaintiff Tingley
23 Because it Bans Protected Speech Based on Content and Viewpoint.
24 A. The Law regulates speech, not conduct.
25 In Pickup v. Brown, 728 F.3d 1042, 1055-1056 (9th Cir. 2013), a panel of the Ninth
26 Circuit held that prohibited counseling was conduct, not speech. But as the Eleventh Circuit
27 observed when confronted with an attempt to restrict what doctors might say to their patients,

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1 “characterizing speech as conduct is a dubious constitutional enterprise,” see Wollschlaeger v.
2 Governor, Fla., 848 F.3d 1293, 1308-1309 (11th Cir. 2017), and the logic of Pickup has since
3 been rejected by the Supreme Court. NIFLA, 138 S. Ct. at 2373-74; see also NAACP v. Button,
4 371 U.S. 415, 439 (1963) (“[A] State may not, under the guise of prohibiting professional
5 misconduct, ignore constitutional rights.”).
6 The Counseling Censorship Law regulates speech facially and as applied here. All that
7 Mr. Tingley does with his clients is speak with them. Yet these conversations are prohibited by
8 the Counseling Censorship Law. Putting it bluntly, “[i]f speaking to clients is not speech, the
9 world is truly upside down.” Otto, 981 F.3d at 866.

10 B. The Law is subject to strict scrutiny because it censors speech based on content
11 and viewpoint.
12 1. The Law censors speech based on content.
13 A law that restricts speech based on its content is presumptively unconstitutional and
14 must overcome strict scrutiny. Reed v. Town of Gilbert, 576 U.S. 155, 163 (2015); see also
15 IMDb.com v. Becerra, 962 F.3d 1111, 1120 (9th Cir. 2020).
16 A restriction is content-based if it facially draws distinctions based on a speaker’s
17 message; it cannot be justified without reference to speech’s content; or it was adopted because
18 of disagreement with the message conveyed. Reed, 576 U.S. at 163-164. See also IMDb.com,
19 962 F.3d at 1120 (A statute is content-based “if it, by its very terms, singles out particular
20 content for differential treatment.”) (cleaned up); Victory Processing, LLC v. Fox, 937 F.3d
21 1218, 1226 (9th Cir. 2019) (“[A] law is content-based because it explicitly draws distinctions
22 based on the message a speaker conveys.”). A reliable way of determining whether a restriction
23 is content-based is if enforcement authorities must necessarily “examine the content of the
24 message that is conveyed” to know whether the Law has been violated. McCullen v. Coakley,
25 573 U.S. 464, 479 (2014) (citation omitted).
26 The Counseling Censorship Law discriminates based on content under any of these
27 articulations. The first step in any enforcement investigation under the Law must be to inquire

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1 into the content of what was discussed in confidence behind the closed door of the counseling
2 room. See Otto, 981 F.3d at 861 (“[B]ecause the ordinances depend on what is said, they are
3 content-based restrictions that must receive strict scrutiny.”).
4 2. The Law discriminates based on viewpoint.
5 A law discriminates based on viewpoint when it regulates speech “based on ‘the specific
6 motivating ideology or the opinion or perspective of the speaker.’” Reed, 576 U.S. at 168-69
7 (quoting Rosenberger v. Rector & Visitors of Univ. of Va., 515 U.S. 819, 829 (1995)). Such an
8 application is a particularly “egregious form of content discrimination.” Id. The Supreme Court
9 has condemned viewpoint discrimination in the strongest possible terms; warning that “Those
10 who begin coercive elimination of dissent soon find themselves exterminating dissenters.” W.
11 Va. State Bd. of Educ. v. Barnette, 319 U.S. 624, 641 (1943).
12 The Counseling Censorship Law discriminates based on viewpoint. The Law does not
13 ban all counseling concerning sexual orientation, gender identity, or sexual “behaviors.” Quite
14 the contrary, it explicitly excepts “counseling or psychotherapies that provide acceptance,
15 support, and understanding . . . of clients’ . . . identity exploration” so long as they “do not seek
16 to change sexual orientation or gender identity.” Wash. Rev. Code. § 18.130.020(4)(b).
17 But it threatens severe punishment and even loss of license and livelihood if a counselor
18 dares to provide counsel—desired and requested by his client—that “seek[s] to change [an
19 individual's] sexual orientation or gender identity.” Id. The law very expressly seeks to silence
20 one viewpoint in the counseling room: the viewpoint that feelings and behaviors relating to
21 sexual orientation and gender identity can change; that individuals are not necessarily prisoners
22 of undesired feelings; and that individuals are not irrevocably predestined to violate their own
23 religious convictions. “The [Law] thus codif[ies] a particular viewpoint . . . and prohibit[s] the
24 therapist[] from advancing any other perspective when counseling clients.” Otto, 981 F.3d at
25 864.
26 But this the Washington legislature may not do. “The First Amendment exists precisely
27 so that speakers with unpopular ideas do not have to lobby the government for permission before

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1 they speak.” Otto, 981 F.3d at 864. Instead, “[t]he test of truth is the power of an idea to get itself
2 accepted in a competitive marketplace of ideas and the people lose when the government is the
3 one deciding which ideas should prevail.” NIFLA, 138 S. Ct. at 2375 (cleaned up).
4 3. The speech targeted by the Law is not less protected because it is

5 speech by professionals or it is directed at minors.
6 The strict scrutiny which such a content- and viewpoint-based law must survive can
7 neither be excused nor lessened based on an argument that the law censors only a less protected
8 category of “professional speech,” as was suggested in Pickup. The Supreme Court in NIFLA
9 expressly rejected the idea that professional speech is less protected, emphasizing that it has
10 “long protected the First Amendment rights of professionals,” “stressed the danger of content-
11 based regulations in the fields of medicine and public health” where “[d]octors help patients
12 make deeply personal decisions and . . . candor is crucial,” and noted that attempts to censor the
13 content of “doctor-patient discourse” have historically been characteristic of totalitarian regimes
14 such as those of Nazi Germany, China under the Cultural Revolution, and Romania’s Nicolae
15 Ceausescu. 138 S. Ct. at 2374 (cleaned up). “States cannot choose the protection that speech
16 receives under the First Amendment [by electing to regulate a profession], as that would give
17 them a powerful tool to impose invidious discrimination of disfavored subjects.” Id. at 2375
18 (cleaned up); see also IMDb.com, 962 F.3d at 1121 (“[S]tate legislatures do not have
19 freewheeling authority to declare new categories of speech outside the scope of the First
20 Amendment.”) (cleaned up).
21 Following NIFLA, the Eleventh Circuit recently held that an ordinance nearly identical to
22 the Counseling Censorship Law was “presumptively unconstitutional,” Otto, 981 F.3d at 868,
23 quoting Reed, 576 U.S. at 163, and in fact could not stand. “[T]he First Amendment does not
24 allow communities to determine how their neighbors may be counseled about matters of sexual
25 orientation or gender.” Otto, 981 F.3d at 871.
26 Similarly, with Pickup’s rationale now rejected, this Court’s strong teaching in Conant v.
27 Walters, 309 F.3d 629 (9th Cir. 2002), stands and is directly on point. There, striking a law that

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1 sought to censor what advice physicians could give to patients about the medical use of
2 marijuana, the Ninth Circuit emphasized “the core First Amendment values of the doctor-patient
3 relationship,” and that “professional speech may be entitled to the strongest protection our
4 Constitution has to offer.” Conant, 309 F.3d at 637 (cleaned up). It found the restriction on the
5 speech between doctor and patient there to be both content- and viewpoint-based, applied strict
6 scrutiny, and invalidated the law. Id. at 637-639.
7 Nor is the Law excused from strict scrutiny because it limits its censorship to
8 conversations with minors. Minors themselves “are entitled to a significant measure of First
9 Amendment protection,” and a legislature does not possess “a free-floating power to restrict the
10 ideas to which children may be exposed.” Brown v. Ent. Merchs. Ass’n, 564 U.S. 786, 794
11 (2011) (cleaned up). Speech cannot be suppressed “solely to protect the young from ideas or
12 images that a legislative body thinks unsuitable for them.” Id. at 795 (cleaned up).
13 C. The Counseling Censorship Law cannot survive strict scrutiny.
14 To survive strict scrutiny, Defendants must prove that the Counseling Censorship Law
15 “furthers a compelling interest and is narrowly tailored.” Reed, 576 U.S. at 171 (cleaned up).
16 Defendants bear the burden of establishing this both on the merits and for purposes of defeating a
17 request for preliminary injunction. Ashcroft v. ACLU, 542 U.S. 656, 660-61, 666 (2004). The
18 State must “specifically identify an ‘actual problem’” and show that restricting “speech [is]
19 actually necessary to the solution.” Brown, 564 U.S. at 799 (cleaned up).
20 “A narrowly tailored regulation … actually advances the state’s interest (is necessary),
21 does not sweep too broadly (is not overinclusive), does not leave significant influences bearing
22 on the interest unregulated (is not underinclusive), and” cannot “be replaced” by a regulation
23 “that could advance the interest as well with less infringement of speech (is the least-restrictive
24 alternative).” Republican Party of Minn. v. White, 416 F.3d 738, 751 (8th Cir. 2005); see Victory
25 Processing, 937 F.3d at 1227-1228 (same).
26 In an as-applied challenge to a restriction of First Amendment rights, government must
27 also prove that the compelling interest would be injured if an exception were granted to the

(480) 444-0020
1 challenger. Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal, 546 U.S. 418, 430-32
2 (2006) (applying the compelling interest test in the context of RFRA). Otherwise, application of
3 the law in that particular setting cannot further the interest.
4 The Counseling Censorship Law fails these requirements at every point.

because, as enforced against pure speech, it does not further any cognizable
6 governmental interest.
7 The Counseling Censorship Law fails strict scrutiny at the threshold because it serves no
8 cognizable interest at all as applied against counseling speech. There is no statistically valid
9 evidence that counseling of the type that Mr. Tingley provides is either harmful or ineffective.
10 (See Rosik Decl. ¶¶ 29-53; Levine Decl. ¶¶ 38-44, 83-85.) But more fundamentally, arguments
11 about harm and efficacy are irrelevant as a matter of law. It is a lodestar of First Amendment
12 jurisprudence that censorship cannot be justified on the plea that bad ideas cause harm. No doubt
13 “ideas have consequences,” 1 but under our laws this provides no footing for censorship unless
14 and until that risk of harm rises to the high and immediate urgency defined by the “clear and
15 present danger” test. See Brandenburg v. Ohio, 395 U.S. 444, 447-49 (1969) (per curiam)
16 (general advocacy of armed resistance not sufficient to justify punishment for speech); see also
17 Herceg v. Hustler Magazine, Inc., 814 F.2d 1017, 1024 (5th Cir. 1987) (rejecting the suggestion
18 that “a less stringent standard than the Brandenburg test be applied in cases involving non-
19 political speech that has actually produced harm”)
20 It is equally clear that the State of Washington does not have a cognizable interest in
21 preventing the dissemination of ideas concerning personal, philosophical, scientific, and
22 religious topics on the grounds that such ideas are (or it believes them to be) false or offensive.
23 McCullen, 573 U.S. at 476 (citing FCC v. League of Women Voters of Cal., 468 U.S. 364, 377
24 (1984)) (“[T]he First Amendment’s purpose” is “to preserve an uninhibited marketplace of ideas
25 in which truth will ultimately prevail.”); United States v. Alvarez, 567 U.S. 709, 729 (2012)
26
27 1
See Richard M. Weaver, Ideas Have Consequences (Univ. Chi. Press, 1948).

(480) 444-0020
1 (“Truth needs neither handcuffs nor a badge for its vindication.”); United States v. Swisher, 811
2 F.3d 299, 317-18 (9th Cir. 2016) (adopting the Alvarez finding that “lies do not fall into a
3 category of speech that is excepted from First Amendment protection”); Texas v. Johnson, 491
4 U.S. 397, 414 (1989) (The “bedrock principle underlying the First Amendment . . . is that the
5 government may not prohibit the expression of an idea simply because society finds the idea
6 itself offensive or disagreeable.”); Snyder v. Phelps, 562 U.S. 443, 458, (2011) (“[S]peech cannot
7 be restricted simply because it is upsetting or arouses contempt.”); Hurley v. Irish-Am. Gay,
8 Lesbian & Bisexual Grp. of Bos., 515 U.S. 557, 574 (1995) (“[T]he point of all speech protection
9 . . . is to shield just those choices of content that in someone’s eyes are misguided, or even
10 hurtful.”).
11 However much the State of Washington may dislike the ethics, goals, and even religious
12 beliefs of clients seeking counsel for unwanted sexual attractions and identity, “the [client’s]
13 freedom to learn about them, fully to comprehend their scope and portent, and to weigh them
14 against the tenets of the ‘conventional wisdom,’ may not be abridged.” Eisenstadt v. Baird, 405
15 U.S. 438, 457 (1972) (Douglas, J., concurring). The Ninth Circuit has made the same point,
16 denying that the state has power to paternalistically regulate speech between doctor and patient
17 to prevent individuals from making “bad decisions.” Conant, 309 F.3d at 637.
because it is not narrowly tailored.
19
The Counseling Censorship Law in its present form must also fail because it is not
20
narrowly tailored. “Precision must be the touchstone when it comes to regulations of speech,
21
which so closely touch our most precious freedoms.” NIFLA, 138 S. Ct. at 2376 (cleaned up).
22
The Senate Bill Report behind SB 5722 expressed concern about supposed practices that
23
“induce nausea, vomiting, and other responses from youth, while showing them erotic images.”
24
No specific instances are documented in the Report. (Cmpl. ¶ 56.) The House Report further
25
asserted that problematic practices include “physical abuse of children.” (Cmpl. ¶ 56.) Perhaps
26
Washington State has the power to regulate such conduct and procedures. But the scope of the
27

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1 State’s power to regulate such conduct by health professionals is not before this Court. Instead,
2 the Counseling Censorship Law prohibits even simple, voluntary conversation if that
3 conversation is directed toward a goal and viewpoint of which the legislature disapproves. The
4 Counseling Censorship Law is sweepingly overbroad with respect to any legitimate
5 governmental interest. United States v. Stevens, 559 U.S. 460, 473 (2010) (a law is overbroad if
6 “a substantial number of its applications are unconstitutional, judged in relation to the statute’s
7 plainly legitimate sweep”) (citation omitted); Simon & Schuster, Inc. v. Members of N.Y. State
8 Crime Victims Bd., 502 U.S. 105, 121 (1991) (law requiring a criminal to pay income derived
9 from describing crime into an escrow account was overbroad because it applied to any reference
10 to crimes).
11 The Law is also underinclusive with respect to its claimed goals. If a statute is
12 underinclusive, this negates the legitimacy of the law in at least three distinct ways. First, it
13 contradicts the claim that the law is “narrowly tailored” to the harm it purports to address.
14 Brown, 564 U.S. at 799-804. Second, the poor fit between the law and the alleged harm “raises
15 serious doubts about whether [the government] is, in fact, serving, with this statute, the
16 significant interests which [it] invokes” to justify the law. Florida Star v. B.J.F., 491 U.S. 524,
17 540 (1989). Third, underinclusiveness may justify an inference that the law was in fact targeted
18 against religiously motivated practices, rather than being genuinely “of general applicability.”
19 Church of the Lukumi Babalu Aye, Inc. v. City of Hialeah, 508 U.S. 520, 542-43, 545 (1993).
20 Such is the case here.
21 The Counseling Censorship Law is severely underinclusive as a means toward the goal it
22 purports to serve, triggering each of these concerns. Based on the recitations of the legislative
23 record, the harm that the law purportedly seeks to avoid is the psychic distress to individuals
24 caused by what the State deems to be misguided counsel. (Compl. ⁋ 56-61.) Even if this were a
25 legitimate basis for governmental censorship (it is not), our world–and Washington State–is
26 filled with sexual and relational advice pointing in every conceivable direction, much of which
27 may cause distress to those who follow it. No doubt misguided counseling on other topics (e.g.,

(480) 444-0020
1 recommendations to use hallucinogenic drugs, websites or YouTube videos that encourage
2 minors to adopt transgender identities, or promotion of extreme diets) could equally lead to
3 adverse impacts and distress for some clients. Yet the Washington legislature has not launched a
4 general inquiry into such risks, nor banned “counseling that may lead to psychological distress.”
5 Instead, it has exclusively named, targeted, and censored from counseling conversations only a
6 narrow category and a specific viewpoint, defined by current political fashion rather than by any
7 demonstration of unique harm.

because it is not the least-restrictive alternative.
9
A law subject to strict scrutiny is also not “narrowly tailored” if the purported interests
10
could have been served by a less restrictive alternative. The government bears the burden to
11
prove that available alternatives would have been ineffective. United States v. Playboy Ent. Grp.,
12
Inc., 529 U.S. 803, 817 (2000). Where speech which the government considers harmful is at
13
issue, the “least restrictive alternative” is unlikely to involve censorship. “The remedy for speech
14
that is false is speech that is true. This is the ordinary course in a free society. The response to the
15
unreasoned is the rational; to the uninformed, the enlightened; to the straightout lie, the simple
16
truth.” Alvarez, 576 U.S. at 727. “[M]ore speech, not enforced silence” is the best response to
17
perceived falsehoods or misguided ideas. Whitney v. California, 274 U.S. 357, 377 (1927); see
18
also Video Software Dealers Ass’n v. Schwarzenegger, 556 F.3d 950, 965 (9th Cir. 2009)
19
(California failed to show that an education campaign could not equally serve its asserted
20
interest).
21
Alternatives in addition to “more speech” were also evident. Washington State could
22
have crafted a voluntary certification program for professionals who agree not to offer
23
counseling of the type the legislature dislikes. See Linmark Assocs., Inc. v. Willingboro Twp.,
24
431 U.S. 85, 97 (1977) (government could have used financial incentives, rather than speech
25
restrictions, to advance its interests).
26
27

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1 There is no sign that the Washington legislature considered these alternatives. Given the
2 existence of these plausible, less restrictive alternatives to Washington’s content-based
3 restriction on speech, the Law is not narrowly tailored. Playboy Ent. Grp., 529 U.S. at 816;
4 McCullen, 573 U.S. at 479.
5 II. The Counseling Censorship Law Violates the Free Speech Rights of Clients of Plaintiff
6 Tingley.
7 A. Plaintiff has standing to assert the First Amendment rights of his clients.
8 Mr. Tingley has standing to assert the rights of his clients that are violated by the
9 Counseling Censorship Law. Such standing should be recognized where the party “has a ‘close’
10 relationship with the person who possesses the right,” and where there is also some “‘hindrance’
11 to the possessor’s ability to protect his own interests.” Kowalski v. Tesmer, 543 U.S. 125, 130
12 (2004). These considerations exist strongly here.
13 First, as a counselor Mr. Tingley has an extremely close relationship with clients who
14 seek his assistance with goals relating to relationships and sexual attractions. (Tingley Decl. ⁋
15 84.) Counseling conversations relating to such topics are intensely sensitive, intimate, and
16 important for clients, and “candor is crucial.” NIFLA, 138 S. Ct. at 2374; see also Maryland v.
17 Joseph H. Munson Co., 467 U.S. 947, 958 (1984) (fund-raising company may assert free speech
18 rights of client charities, where the protected interest was “at the heart of the . . . relationship
19 between Munson and its clients”).
20 Second, there are multiple obstacles here to counseling clients “protect[ing] [their] own
21 interests.” As was true in Eisenstadt, the Counseling Censorship Law does not prohibit receiving
22 counsel, so even while Mr. Tingley’s clients are denied access to ideas that they desire to hear,
23 they “are not themselves subject to prosecution and, to that extent, are denied a forum in which
24 to assert their own rights.” 405 U.S. at 446.
25 Third, it is extremely difficult or even impossible for these clients to step forward to
26 vindicate their own rights to engage in therapeutic conversations with Mr. Tingley. (Tingley
27 Decl. ⁋ 85.) These clients already experience emotional turmoil, and it is hardly speculative to

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1 predict that putting their personal difficulties into the spotlight of litigation would cause
2 additional anguish and harm. (Tingley Decl. ⁋ 86.)
3 Finally, where First Amendment rights are threatened, the rules for representative
4 standing are relaxed. Joseph H. Munson Co., 467 U.S. at 956. Courts find standing “when
5 enforcement of the challenged restriction against the litigant would … indirectly [violate] third
6 parties’ rights.” Warth v. Seldin, 422 U.S. 490, 510 (1975); see also Va. State Bd. of Pharmacy v.
7 Va. Citizens Consumer Council, Inc., 425 U.S. 748, 757 (1976) (advertisers may assert readers’
8 right to receive information). This concern is present here.
9 B. The Counseling Censorship Law violates the First Amendment right of clients of
10 Tingley to receive desired information and counsel.
11 “The right of freedom of speech and press includes not only the right to utter or to print,
12 but . . . the right to receive, the right to read” Griswold v. Connecticut, 381 U.S. 479, 482 (1965);
13 see also Va. State Bd. of Pharmacy, 425 U.S. at 756 (“[T]he protection afforded is to the
14 communication, to its source and to its recipients both.”). Thus, for all the reasons that the Law
15 violates Mr. Tingley’s free speech rights, “enforcement of the challenged restriction against [Mr.
16 Tingley] would . . . indirectly [violate] third parties’ rights.” Warth, 422 U.S. at 510.
17 III. The Counseling Censorship Law Violates the Due Process Rights of Plaintiff Because It
Grants Unbridled Discretion in Enforcement.
18
The government is prohibited from imposing or threatening punishment based on a law
19
that is “so standardless that it authorizes or encourages seriously discriminatory enforcement.”
20
United States v. Williams, 553 U.S. 285, 304 (2008); see also Kolender v. Lawson, 461 U.S. 352,
21
357-358 (1983) (striking statute that required persons “loitering” on the street to “account for
22
their presence” upon request by an officer). And where an ordinance “interferes with the right of
23
free speech or of association, a more stringent vagueness test should apply.” Holder v.
24
Humanitarian Law Project, 561 US 1, 19 (2010) (citation omitted).
25
The Counseling Censorship Law is unconstitutionally vague on its face in critical
26
respects. First, it provides no standards or guidance to define the line between speech that
27

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1 permissibly seeks to “facilitat[e]” a client’s “identity exploration and development,” and speech
2 that unlawfully seeks to “change” that person’s gender identity or sexual orientation. The
3 boundary between “exploration” and “change” is unknowable. (Cmpl. ¶ 46, 220-221.) Second,
4 critical terms in the Counseling Censorship Law, including “gender identity”, “gender
5 expressions”, “identity exploration”, and “identity development” are undefined in the Law itself,
6 and also undefined in science, and indeed have more in common with slogans than with a fixed
7 standard identifying what counseling speech is prohibited and subject to punishment under the
8 Law, and what is not. (Cmpl. ¶ 45, 222-232.) Third, there is no indication whether the
9 prohibition on any “regime that seeks to change . . .” sexual orientation or gender identity refers
10 to the subjective intent of the client, or that of the counselor. (Cmpl. ¶ 47, 233-234.)
11 These factors combine to afford effectively unbounded discretion to those authorized to
12 bring enforcement actions under the Law. Essentially any exploratory discussion on matters of
13 gender, gender expression, sexual orientation, sexual behaviors, or sexual or romantic attractions
14 could be accused after the fact as a violation of the Law. (Cmpl. ¶ 181; Tingley Decl. ⁋ 81.) And
15 just as the Law itself targets a disfavored viewpoint, counselors who share that disfavored
16 viewpoint must fear that they themselves will be targeted, and that the unbounded discretion
17 afforded by the vague statutory language will be used to bring discriminatory and harassing
18 enforcement actions against themselves. (Cmpl. ¶ 177-178; Tingley Decl. ⁋ 78.)
19 This fear is necessarily multiplied by the extraordinary provision of this law which
20 authorizes “any . . . person” to bring enforcement actions–potentially including ideological
21 opponents or activists with no connection whatsoever to either the counselor or his client. (Cmpl.
22 ¶ 55). Enforcement power in such hands, “defined” only by undefined terms at the very center of
23 the Law’s prohibitions, cannot satisfy the demands of Due Process.
24 IV. The Counseling Censorship Law Violates the Free Exercise Rights of Mr. Tingley and
25 His Clients.
26 For the reasons explained above, the Counseling Censorship Law is unconstitutional as
27 applied to anyone. And it is unconstitutional as applied to Mr. Tingley for the additional reason

(480) 444-0020
1 that it restricts the religious exercise of Mr. Tingley and his clients. The right to “free exercise”
2 includes not merely the right to believe, but to live one’s faith. This includes the right to “the
3 performance of (or abstention from) physical acts,” as well as the right to “profess whatever
4 religious doctrine one desires,” Employment Div., Dept. of Human Resources of Ore. v. Smith,
5 494 U.S. 872, 877 (1990), along with “communicating” these teachings to others so that they
6 may live according to that faith. Hosanna-Tabor Evangelical Lutheran Church & Sch. v. EEOC,
7 565 U.S. 171, 199 (2012) (Alito, J., concurring). Professionals such as counselors do not
8 surrender this “first freedom” by accepting a professional license.
9 A. The Counseling Censorship Law violates free exercise rights because it is not
neutral.
10
A law that burdens religious conduct is subject to strict scrutiny unless it is “neutral.”
11
Smith, 494 U.S. at 879. To assess neutrality, courts start with the law’s text and its effect “in its
12
real operation.” Lukumi, 508 U.S. at 532-36. Here, the targeting is in plain view. As detailed in
13
the Complaint, it is well known that counseling of the type the legislature has tarred as
14
“conversion therapy” is principally sought by religiously motivated clients, provided by
15
counselors who share similar religious convictions, and is both sought and provided for the
16
purpose of bringing feelings and/or behaviors into line with faith-based views of human nature,
17
morals, and a life well lived. (Cmpl. ¶¶ 62-68.)
18
For example, the 2009 task force of the American Psychological Association reported
19
that “most [sexual orientation change efforts or “SOCE”] currently seem directed to those
20
holding conservative religious and political beliefs, and recent research on SOCE includes
21
almost exclusively individuals who have strong religious beliefs.” (Emphasis added) (Cmpl. ¶
22
67.) A 2013 statement issued by the American Counseling Association asserted that “conversion
23
therapy . . . is a religious . . . practice.” (Cmpl. ¶ 63.) And in the important 2016 paper quoted
24
above, Prof. Lisa Diamond and Prof. Clifford Rosky cited multiple peer-reviewed papers to
25
conclude that “the majority of individuals seeking to change their sexual orientation report doing
26
so for religious reasons rather than to escape discrimination.” (Cmpl. ¶ 68.)
27

(480) 444-0020
1 Thus, as has been known for more than a decade, it is people of faith who are standing
2 where the legislature has chosen to target. This is not neutrality; this is hostility. Under Smith and
3 Lukumi, strict scrutiny must be applied. For all the reasons reviewed above, the Counseling
4 Censorship Law cannot survive that rigorous test. See supra at p. 11-16.
5 B. The Counseling Censorship Law violates free exercise rights regardless of

whether it is “neutral and of general applicability.”
6
While satisfying the Smith test is necessary to justify a law that restricts free exercise, it is
7
not always sufficient. The Supreme Court has expressly rejected the idea “that any application of
8
a valid and neutral law of general applicability is necessarily constitutional under the Free
9
Exercise Clause,” Trinity Lutheran Church of Columbia, Inc. v. Comer, 137 S. Ct. 2012, 2021
10
n.2 (2017). In Hosanna-Tabor, 565 U.S. at 182-187, for example, the Court unanimously barred
11
application of a neutral and generally applicable employment discrimination law against a
12
religious school, on free exercise grounds, without applying the Smith test. Notably, the Court
13
has never applied the Smith test to permit censorship of faith-motivated speech because the
14
government dislikes the purpose or message of that speech.
15
Questions about the nature of men, women, sexuality, sexual relations, and marriage—
16
what will lead toward a whole life and what will not—have been a central concern of religions
17
including at least Judaism, Christianity, and Islam since ancient times. Teaching and counsel
18
directed to a right ordering of one’s relationship to one’s body and gender, and to sex, marriage,
19
and family, are central to the content and propagation of religious faith. For this reason,
20
notwithstanding Smith, the First Amendment flatly denies Washington State the power to tell a
21
Christian that he cannot seek the help of a trusted counselor to pursue a path of conduct in his
22
life consistent with his faith. Nor can it tell Mr. Tingley that he cannot provide counsel that is
23
informed by and consistent with his own faith and that of his client concerning sexuality and
24
personal identity.
25
Perhaps coming at the same point by a different route, the hybrid rights exception
26
expressly carved out by the Supreme Court in Smith likewise dictates that the Counseling
27

(480) 444-0020
1 Censorship Law—as applied to Mr. Tingley and his faith-motivated clients—must undergo strict
2 scrutiny regardless of whether it is “neutral and generally applicable,” because it implicates both
3 free exercise and free speech rights. See Miller v. Reed, 176 F.3d 1202, 1207 (9th Cir. 1999)
4 (noting that Smith “excepts a hybrid-rights claim from its rational basis test”). In order to invoke
5 that exception, the plaintiff must demonstrate only a “fair probability” or “likelihood” but not
6 “certitude” of success on the companion claim. Miller, 176 F.3d at 1207 (cleaned up). The
7 Plaintiff here has surpassed this marginal threshold, see supra at p. 7-11, so strict scrutiny
8 applies—and is fatal. See supra at p. 11-16.
9 V. The Remaining Factors Favor Granting a Preliminary Injunction.

10 For all the reasons reviewed above, Plaintiff Tingley has demonstrated likelihood of
11 success on the merits. Once a likelihood of success in establishing a First Amendment violation
12 has been established, no separate “balance of equities” analysis is necessary to conclude that a
13 preliminary injunction should issue. (See supra at p. 7.) The violation of First Amendment rights
14 of Mr. Tingley and his clients constitutes irreparable harm, and the State of Washington has no
15 cognizable interest in preventing the “harms from ideas” to citizens that the Counseling
16 Censorship Law purports to avert. (See supra at p. 12-13).
17 Conclusion
18 For the reasons set forth above, Plaintiff Brian Tingley respectfully requests that this
19 Court issue a preliminary injunction prohibiting any enforcement action both facially and as-
20 applied against Plaintiff under the Counseling Censorship Law pending entry of a final order in
21 this case.
22
23
24
25
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27

(480) 444-0020
1 Respectfully submitted this 13th day of May, 2021.
3 By: s/ Gregory D. Esau By: s/ Kristen K. Waggoner
4 Gregory D. Esau (WSBA #22404) Kristen Waggoner (WSBA #27790)

ELLIS | LI | MCKINSTRY Roger G. Brooks* (NC Bar #16317)
5 1700 Seventh Avenue, Suite 1810 ALLIANCE DEFENDING FREEDOM
Seattle, WA 9810 15100 N. 90th Street
6
206-682-0565 (T) Scottsdale, AZ 85260
7 [email protected] 480-444-00204 (T)
480-444-0028 (F)
8 [email protected]
[email protected]
9
10 David A. Cortman* (GA Bar #188810)
ALLIANCE DEFENDING FREEDOM
11 1000 Hurricane Shoals Rd. NE
Ste. D-1100
12 Lawrenceville, GA 30043
(770) 339-0774 (T)
13 (770) 339-6744 (F)
14 [email protected]
15 *Pro Hac Vice applications filed concurrently
16
Attorneys for Plaintiff
17
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(480) 444-0020
1 CERTIFICATE OF SERVICE
2 I hereby certify that on May 13, 2021, I electronically filed the foregoing document with
3 the Clerk of Court using the CM/ECF system. The foregoing document will be served via private
4 process server with the Summons and Complaint to all Defendants.
6 DATED: May 13, 2021
7 s/ Kristen K. Waggoner
8 Kristen Waggoner (WSBA #27790)
Roger G. Brooks*(NC Bar #16317)
9
ALLIANCE DEFENDING FREEDOM
10 15100 N. 90th Street
Scottsdale, AZ 85260
11 480-444-0020 (T)
480-444-0028 (F)
14 Attorney for Plaintiff
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Case 3:21-cv-05359 Document 2-1 Filed 05/13/21 Page 1 of 20
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9 AT TACOMA
10 BRIAN TINGLEY, ) 3:21 cv-5359

Civil No. ____-________
)
11 Plaintiff, ) DECLARATION OF BRIAN
) TINGLEY IN SUPPORT OF
12 v. PLAINTIFF’S MOTION FOR
)
13 ) PRELIMINARY INJUNCTION
ROBERT W. FERGUSON, in his official
)
14 capacity as Attorney General for the State
)
of Washington; UMAIR A. SHAH, in his
)
15 official capacity as Secretary of Health for
)
the State of Washington; and KRISTIN
16 )
PETERSON in her official capacity as
)
17 Assistant Secretary of the Health Systems
)
Quality Assurance division of the
)
18 Washington State Department of Health,
)
19 Defendants. )
20
21 I, Brian Tingley, declare as follows:
22 1. I am a licensed Marriage and Family Therapist in the State of
23 Washington. I live in Washington State, and practice in Fircrest, Washington. I
24 obtained a Master of Science in Marriage and Family Therapy from Seattle Pacific
25 University in 2001.
26
27
Decl. of Brian Tingley in Supp. of MPI ALLIANCE DEFENDING FREEDOM

3:21 cv-5359
Civil No. _____-__________ 1 15100 N. 90th Street
Scottsdale, Arizona 85260
(480) 444-0020
1 2. I am an Approved Supervisor by the State of Washington and the
2 American Association for Marriage and Family Therapy, as well as a Clinical
3 Fellow Member of the American Association for Marriage and Family Therapy.
4 3. I founded my own private counseling practice in 2002, and since that
5 time have offered a wide range of counseling services to adolescents, adults, couples,
6 and families, addressing interpersonal and family conflict, communication issues,
7 marital and post-divorce issues, emotional management including depression and
8 anxiety, anger and stress management, and adult Attention Deficit Hyperactivity
9 Disorder, among many other matters. Distress and struggles relating to gender
10 identity and sexual attractions and behaviors are some of the many issues about
11 which clients ask for my assistance. I also have experience in crisis intervention and
12 have worked alongside child protective services and law enforcement where
13 children have been placed in protective custody.
14 4. I have taught college courses in Psychology and Human Relations, and
15 have facilitated training seminars and workshops at the request of local therapist
16 groups.
17 5. I have provided both in-person and written testimony to the
18 Washington State Legislature on issues pertaining to teenage sexuality and identity
19 on several occasions, including in connection with the bill that was ultimately
20 passed as the Counseling Censorship Law.
21 6. I have been a committed believer in the Christian faith for many years.
22 I received a Diploma in Ministry and Biblical Studies in 1984. I am regularly asked
23 to provide seminars and workshops to local churches on challenges facing children
24 and families that take into account a biblical perspective as well as my professional
25 expertise.
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1 A. Practice and counseling methodology
2 7. I work with both Christian and non-Christian clients, including clients
3 from a different faith background or no faith at all. I approach counseling of any
4 clients who choose my services in a consistent way.
5 8. As a general practitioner, I encounter in my clients a wide scope of the
6 emotional, family, relational, and mental difficulties to which members of any
7 human community are vulnerable. In this regard, my practice is similar to that of
8 any general practice counselor. However, on our website our practice group
9 identifies itself as a “group of Christian providers” who assist clients to pursue
10 “personal and relational growth as well as healing for the wounded spirit, soul, and
11 body through the healthy integration of relational, psychological, and spiritual
12 principles with clinical excellence.” Many of my clients are referred to me by local
13 churches, and the majority of my clients share my Christian faith. Many of my
14 clients tell me that they have chosen to come to me precisely because they want to
15 speak to a counselor who shares and respects their Christian beliefs and worldview
16 about the issues that are affecting their lives.
17 9. While I never impose my Christian faith on anyone, my faith informs
18 my understanding of human nature, healthy relationships, and what paths and
19 ways of thinking will be most likely to enable my clients to achieve comfort with
20 themselves and live happy and satisfied lives.
21 10. I am not a pastor, and do not consider it part of my role as a counselor
22 to rebuke or pass moral judgment on my clients, to tell them that how they are
23 feeling or what they are doing is wrong, nor to tell them how they should live their
24 lives. Instead, my counseling approach is to provide a safe environment for each
25 client to allow for his or her own self exploration. My first priority is ensuring that I
26 establish trust with my clients, so that they feel safe in opening up to discuss all
27 kinds of sensitive issues. Once rapport is established, I can help the client to

(480) 444-0020
1 identify his or her own objectives and then, through discussion over time, work
2 together to accomplish those objectives.
3 11. Because I am Christian myself, I am able to engage with my Christian
4 clients in a manner that is particularly understanding and respectful of, and
5 informed by, faith convictions and personal goals of the client that are guided by the
6 client’s faith convictions, or by the client’s desire to live a life of integrity in his or
7 her family and relationships.
8 12. In my experience, where clients have a strong faith, it can be of
9 particular importance to them to know that there are no unspoken concerns or
10 suspicions about their beliefs on the part of their counselor. This is because of the
11 central role that faith plays in their lives—touching on all aspects of their life—as
12 well as their prior life experience of varying degrees of opposition to their faith from
13 those who do not share their beliefs.
14 13. Working with my clients, all I do is sit and talk with them. I spend
15 time listening to their stories, their fears, and their hopes—at times probing with
16 questions to aid their own self-discovery. This process allows clients to reflect on
17 their identity and their beliefs, as well as enabling them to identify personal goals
18 and objectives which may not have been clear to them when they began this
19 process.
20 14. In this process, I see my role as that of an encourager and facilitator,
21 walking alongside my client to provide support, to challenge, and to provide
22 feedback on the road they have chosen. I work with them to overcome or change
23 mental, emotional, or relationship issues that they identify, and to achieve stability.
24 Ultimately, my goal as a professional counselor is to help my clients achieve the
25 lives and the personal goals that they have set out for themselves based on their
26 own beliefs and wishes.
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1 15. I work only with willing clients—clients who voluntarily and willingly
2 talk with me about their problems, thoughts, and concerns.
3 16. No client has ever filed any complaint against me relating to any
4 counseling that I have provided, related to any issue of gender identity, sexual
5 attraction, sexual behaviors, or any other topic.
6 17. Given my expertise and my family-oriented practice, a significant part
7 of my practice is dedicating to counseling minors. I work with minors on a wide
8 variety of issues as they transition into adulthood, but my basic approach to them
9 as clients remains the same as I have described above. That is, I seek to offer
10 minors a listening ear and the support and encouragement that they need to
11 achieve goals and objectives that they set for themselves.
12 18. In most cases a minor will initially come to my office brought by and at
13 the prompting of his or her parent or parents. However, I will only continue to see a
14 minor as a client if the minor is willing to work with me, and participates
15 voluntarily.
16 19. I counsel minors who are struggling with a very wide range of
17 problems, including depression, anxieties, stress, anger, insecurity, and lack of
18 purpose or direction. Topics about which I have counseled minors also include
19 concerns or confusion about gender identity, unwanted same-sex attraction, and
20 other unwanted sexual behaviors such as addiction to pornography.
21 20. In these cases, as with any other, I do nothing but talk with my clients.
22 I simply listen to what they are willing and able to share, ask them questions, and
23 talk with them.
24
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1 B. Faith-based beliefs concerning gender, sex, sexual conduct, and the
2 possibility of change
3 21. The majority of clients who seek my assistance to reduce unwanted
4 same-sex attraction and develop or increase opposite-sex attraction are motivated at
5 least in part by a desire to live in accordance with the teachings of their faith.
6 22. These individuals believe that it is more important to live consistently
7 with their religious values than to conform their lives to their subjective feelings.
8 Because I share that faith and those convictions, I am able to provide counsel that
9 understands, respects, and assists these clients towards their goals.
10 23. Many Christians, including many of my clients, hold similar beliefs,
11 grounded in biblical teachings, about personal identity, self-worth, what it means to
12 live life well, sexual activity and relationships between the sexes, the importance of
13 obedience to God’s law, and the possibility of change in both feelings and actions.
14 These beliefs often have great influence on how Christians understand themselves,
15 what they want their lives to look like, and what personal goals they set for
16 themselves.
17 24. Both my clients’ personal goals and my counsel are often informed by
18 these beliefs that are grounded in our shared Christian faith and acceptance of
19 biblical teachings.
20 25. While I have modest theological training, I am not a theologian.
21 However, I will summarize some of these beliefs as I understand and hold them.
22 26. First, Christians believe that the division of the species into male and
23 female is not a minor detail or accident, but is a wonderful fact of humanity, and
24 integral to our very being. As it says in the Book of Genesis, “in the image of God He
25 created them; male and female He created them. . . . and it was very good.” (Genesis
26 28-31.)
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1 27. Second, Christians believe that the sex—male or female—that each of
2 us receives from the moment of conception, is a gift. It is not an accident, an
3 insignificant detail, a problem, or a potential mistake. Each of us is individually
4 known and intended by God even before we are conceived: “Before I formed you in
5 the womb I knew you” (Jeremiah 1:5). Each child is “the work of [God’s] hands”
6 (Isaiah 29:23), made according to God’s purpose: “For you created my inmost being;
7 you knit me together in my mother’s womb.” (Psalm 139:13.) And each of us is so
8 “fearfully and wonderfully made” that we should be moved to rejoice and give
9 thanks. (Psalm 139:14.) Thus, many Christians believe, as a teaching of their faith,
10 that obedience, well-being, and happiness for each of us will include acceptance of
11 and gratitude for the particular sex that God has given us.
12 28. Third, Christians believe that the joining of male and female in
13 marriage to conceive children and raise up each next generation is a great blessing,
14 a great calling, and a sacred thing. Thus, God’s first instruction and “blessing” to
15 Adam and Eve was that they should “Be fruitful, and increase in number.” (Gen
16 1:29.) The Apostle Paul taught that the children of believing parents are themselves
17 “holy.” (1 Corinthians 7:14.) And the Book of Deuteronomy imposes on parents the
18 high duty of instructing the next generation in the truths and law of God: “You shall
19 teach them diligently to your children, and shall talk of them when you sit in your
20 house, when you walk by the way, when you lie down, and when you rise up.”
21 (Deuteronomy 6:7.)
22 29. Fourth, many Christians believe that sexual relationships belong only
23 between man and woman, and only within marriage. Thus, the Apostle Paul taught
24 that “among you there must not be even a hint of sexual immorality.” (Ephesians
25 5:3.) Of course, one aspect of this “law” has been embodied since ancient times in
26 the Ten Commandments, which include the commandment that “You shall not
27 commit adultery.” (Exodus 20:14.)

(480) 444-0020
1 30. Fifth, Christians believe that we are to obey God’s laws and instruction
2 regardless of conflicting desires or feelings we may have. Jesus told his disciples,
3 “Anyone who loves me will obey my teaching.” (John 14:23.) Peter emphasized that
4 “We must obey God rather than human beings.” (Acts 5:29.) And Paul taught that
5 we must choose between being “slaves to sin, which leads to death, or to obedience,
6 which leads to righteousness.” (Romans 6:16.) For example, we are commanded not
7 to commit adultery regardless of what desires we may feel, and regardless of how
8 “right” it might seem to us. Our often-misguided desires do not define what is right
9 or healthy for us, and should not define who we are.
10 31. Finally, and absolutely critically, Christians believe that change that
11 aligns our heart with God’s will is always possible by God’s power, however difficult
12 it may seem. Long before Christ, the prophet Ezekiel declared God’s promise that “I
13 will give you a new heart and put a new spirit in you.” (Ezekiel 36:26.) Jesus,
14 speaking of a deeply difficult heart change, told his disciples that ‘With man this is
15 impossible, but not with God; all things are possible with God.’” (Mark 10:27.) And
16 Paul urged believers to “be transformed by the renewing of your mind” (Romans
17 12:2), and promised that “if any man be in Christ, he is a new creature: old things
18 are passed away; behold, all things are become new” (2 Cor. 5:17).
19 32. In sum, Christians do not believe that we are ever irrevocably trapped
20 and our identity defined by desires and feelings that are in conflict with God’s
21 instructions. With God’s help, change is always possible.
22 33. The Counseling Censorship law appears to be premised on a belief that
23 change in areas of sexual orientation, sexual behaviors (an extremely expansive
24 term), or gender identity is either impossible or undesirable.
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1 34. Based on both my religious conviction and my own professional
2 experience and discussions with colleagues over the years, I believe that the
3 Washington legislature is mistaken in its understanding of human nature, and the
4 Christian teachings and convictions concerning the possibility of change that I have
5 summarized above are correct.
6 35. If a client seeks my assistance in reducing unwanted same-sex
7 attraction and developing or increasing opposite-sex attraction, I cannot—consistent
8 with my conscience, my religious convictions, or my general client-oriented
9 approach to psychotherapy—counsel that individual that such change is impossible,
10 or that the individual should not pursue it. My Christian faith teaches exactly the
11 opposite.
12 36. For human, professional, and religious reasons, I desire to continue to
13 help both current and future clients who request my help to enable them to change
14 their sexual attractions by reducing unwanted same-sex attraction and developing
15 or increasing opposite-sex attraction.
16 C. Counseling of minors suffering from gender dysphoria
17 37. I have worked with minors who may be suffering from gender
18 dysphoria as clinically defined in DSM-5, and who express discomfort with their
19 biological sex and are struggling with questions and feelings around their gender
20 identity.
21 38. In one incidence since the enactment of the Counseling Censorship
22 Law, parents brought their teenage minor daughter who had been exposed to
23 websites advocating transgender identification for girls, and who had begun
24 expressing unhappiness with her female gender identity, and even asserting a male
25 gender identity. This girl had been previously diagnosed with high-functioning
26 autism and was facing various social difficulties at school with her peers. In earlier
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1 years, according to the parents, she had appeared comfortable in her identity as a
2 girl.
3 39. The parents were aware that gender dysphoria is often accompanied
4 by mental health co-morbidities, that gender identity in young people is not
5 necessarily fixed, and that long-term adoption of a transgender identity by their
6 daughter would likely lead to sterilization, lifelong dependence on extraordinary
7 medical care including cross-sex hormones, and an increased risk of physical, social,
8 and mental health difficulties.
9 40. As Christians, the parents also believed that God had created their
10 daughter female, and that she would therefore find the path to a happy and
11 fulfilling life by learning to accept herself as the girl and future woman that God
12 had made her.
13 41. The parents’ desire was thus to find a counselor who would assist their
14 daughter in understanding herself and exploring the reasons for her unhappiness
15 with her sex and identity as a girl, and hopefully enable her to return to comfort
16 with her female body and reproductive potential, and with a gender identity as a
17 female, girl, and in years to come, woman.
18 42. The parents expressed these thoughts and goals to me, and sought my
19 professional expertise as a counselor to work with their daughter towards that goal.
20 The daughter also expressed a willingness to meet and talk with me. Accordingly, I
21 entered into this counseling relationship, taking the girl on as a client.
22 43. My counseling of this client mainly consisted of private discussions,
23 consisting for the most part of prompting questions, and sympathetic listening. It
24 also included discussions with the girl and her parents together.
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1 44. At no point did my client indicate that she was talking with me against
2 her will, or that she felt that I was coercing her in any manner. Instead, she actively
3 participated in talking and sharing her feelings and worries with me.
4 45. After several counseling sessions, this minor client expressed a desire
5 to become more comfortable with her biological sex, notwithstanding her previous
6 claims of a male gender identity. I did not tell her that such change is impossible or
7 undesirable—both of which I believe to be false. Instead, I worked with her toward
8 that goal. Over the course of several years of observing and talking with this girl, I
9 saw a notable improvement in her demeanor and self-esteem. Based on things that
10 both she and her parents told me, I understood that she was more comfortable
11 identifying herself as a girl, and seemed to be much happier with her direction in
12 life.
13 46. Another recent instance occurred when a Christian family came to me
14 after their minor daughter had begun expressing discomfort with her biological sex
15 and asserting a male gender identity. This girl had exhibited no signs associated
16 with gender dysphoria as a young child, but had begun to assert a transgender
17 identity only after exposure to online material advocating transgender
18 identification.
19 47. As with the parents I described above, this girl’s parents were aware
20 that gender dysphoria is often accompanied by mental health co-morbidities, that
21 gender identity in young people is not necessarily fixed, and that long-term
22 adoption of a transgender identity by their daughter would likely lead to
23 sterilization and lifelong medical complications.
24 48. These parents also sought a counselor who would assist their daughter
25 in understanding herself and exploring the reasons for her unhappiness with her
26 sex and identity as a girl, and hopefully enable her to return to comfort with her
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1 female body, and with a gender identity as a female, girl, and in years to come,
2 woman.
3 49. However, while the parents of this minor client expressed their faith-
4 based hopes and goals for their daughter’s counseling regarding gender identity,
5 they also discussed the Counseling Censorship Law with me. They expressed great
6 fear about what being accused of being involved in a violation of that Law might do
7 to their family, including their fear that it could lead to the intrusion of Child
8 Protective Services between themselves and their daughter.
9 50. As the daughter was willing to meet and talk with me, I agreed to
10 work with her as a client. However after a few sessions, without expressing any
11 dissatisfaction with my counseling, the parents terminated the counseling
12 relationship. It was my impression that the parents could not get over their fear of
13 what might happen to their family if they were accused of bringing their daughter
14 for counseling that violated the Counseling Censorship Law.
15 51. I have now supported several adolescent clients in similar
16 circumstances who have sought my help in addressing questions and concerns
17 surrounding their gender identity. In some of those cases, during counseling the
18 clients have specifically expressed their desire to accept and achieve comfort with
19 their God-given sex as a motivation for their goals in counseling. In other cases,
20 neither the parents nor the minor client have expressed any religious motivation for
21 their goal that the minor achieve comfort with an identity that corresponded to his
22 or her biological sex.
23 52. Many sources report that the number of children and teens
24 experiencing gender dysphoria and/or experiencing an attraction to a transgender
25 identity has increased greatly over the last decade. I have seen this issue arise with
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1 increasing frequency in my own practice. As a result, I expect with great confidence
2 that other minor clients will seek my assistance in dealing with gender dysphoria
3 and gender identity issues in the months and years ahead. Given the deep distress
4 that these children and their families experience, it is my strong desire to provide
5 such counseling for minors who are willing to engage with me in such
6 conversational counseling on a strictly voluntary basis.
7 D. Counseling relating to sexual orientation
8 53. Over the years, I have had multiple clients, including minor clients,
9 who experienced unwanted same-sex attraction and desired my help in reducing
10 those attractions so that they could successfully enter into heterosexual romantic
11 relationships, and also so that they could live in a manner consistent with the moral
12 teachings of their Christian faith.
13 54. While I share the widely held professional view that changing sexual
14 attraction is often difficult, it is my professional opinion that this is a topic on which
15 scientific knowledge is far from complete, on which professionals can and do have a
16 host of good-faith disagreements, and in which it is therefore all the more
17 essential—for the good of clients—that an uninhibited discussion of ideas,
18 therapies, and professional experiences continue.
19 55. Both my understanding of human nature as informed by my faith, and
20 my own professional experience, lead me to believe that change in sexual
21 attractions is possible and does occur.
22 56. Conversations with colleagues as well as published reports from other
23 practitioners over many years, have confirmed to me that it has been their
24 experience, also, that some clients who are strongly motivated to reduce same-sex
25 attraction and achieve stable opposite-sex attractions and relationships, and who
26 obtain professional counseling to assist them, do succeed in achieving those goals.
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1 57. While client confidentiality precludes disclosing details, I am currently
2 providing counseling to multiple minor teens who have experienced unwanted
3 same-sex attraction, and who have asked me to work with them towards a
4 personally chosen goal of seeking to change the attractions they experience by
5 reducing or eliminating same-sex attraction, and increasing a sense of attraction to
6 the opposite sex. I am willing to, and currently do, provide counseling to these
7 clients to help them achieve their goals.
8 58. For example, in recent years I counseled an older teen on this topic.
9 This teen’s parents first brought him to my office, but over time, this client himself
10 has sought my counsel on a number of topics including attraction to pornography
11 and unwanted same-sex attractions.
12 59. Like many young people, this individual first fell into a pattern of
13 repeated access to online pornography. In time, he encountered online pornography
14 depicting same-sex conduct, and believes that this pornography stirred up same-sex
15 attractions in himself that he did not previously experience and would never have
16 experienced had he not been exposed to this pornography.
17 60. The client has a personal Christian faith, and desires to live his life in
18 accordance with what he understands to be the teachings of his faith. He is of the
19 opinion that he will flourish—spiritually, emotionally and in relationships—through
20 obedience to the teachings of his faith. He believes that his faith in God is a
21 personal priority over his sexual attractions, and that God has determined his
22 identity according to the body he was given and what is revealed in the Bible,
23 rather than his own desires and perceptions.
24 61. For this reason, the client asked me to provide counseling to help him
25 achieve his personal goal of reducing his same-sex attractions and strengthening his
26 attraction to women.
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1 62. I never promise clients that I will be able to solve the problems they
2 bring to me, and made no such promises to this young man. However, I have
3 provided and continue to provide sympathetic counseling that is respectful of the
4 client’s faith and his personal goals and desires. Through ordinary techniques of
5 counseling, including caring listening and questions to help the client understand
6 himself and his personal history, I am supporting this client as he works towards
7 the change he desires to see in his own life. And indeed this particular client tells
8 me that he feels that he has made, and is making, progress towards his goals.
9 63. The experience of this client is not unique. Over the years, I have
10 worked with several minors—both male and female—who have revealed similar
11 thoughts and circumstances, and have sought my help in reducing same-sex
12 attractions and developing their sense of attraction to the opposite sex. Often, these
13 young people’s experiences of same-sex attraction are associated with pornography
14 use.
15 64. Some former clients who sought my counseling aid on this topic as
16 minors achieved their goals, and as adults are now living stable and happy lives in
17 heterosexual marriages.
18 65. Based on my many years of experience, I expect that additional minor
19 clients experiencing similar distress, and sharing similar life goals, will continue to
20 seek my counseling assistance towards those goals in the months and years ahead.
21 66. In counseling clients who desire to decrease same-sex attraction or
22 increase their attraction to the opposite sex, I do nothing except talk with my client,
23 offering ways of thinking about themselves and others that may help them make
24 progress towards the change they desire. I do not use electro-shock therapy. I do not
25 recommend that clients view pornography of any sort. I do not recommend that
26 clients subject themselves to painful or other adverse stimulations in response to
27 undesired sexual thoughts.

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1 E. Counseling relating to sexual “behaviors”
2 67. From time to time I also work with minor teens who have expressed a
3 desire to desist from ongoing sexual behaviors which they consider harmful to
4 themselves and inconsistent with their religious beliefs about sexual morality.
5 68. Several minor clients have sought my help to break out of a pattern of
6 frequent viewing of pornography for sexual gratification. For example, I recently
7 worked with a minor who came for counseling after his mother had initially sought
8 help for him. The client had become obsessed with watching pornography, and
9 despite the efforts of the mother to restrict access to computers and the internet, the
10 client would still find ways to get online and view pornography.
11 69. This client came from a Christian home and attended church regularly.
12 During our discussion, the client said that he did not like the fact that he was so
13 drawn to pornography, and personally expressed the belief that it is wrong to look
14 at pornography. He further expressed feeling out of control in his viewing of
15 pornography, and told me that he wanted to stop. I worked with the client towards
16 a goal of ending his regular viewing of pornography, and the client made good
17 progress towards that goal during the time that our counseling relationship
18 continued.
19 70. Unfortunately, pornography addiction is a common problem among
20 young people today thanks to easy access through the internet. I have supported
21 other clients in similar circumstances who have asked my counseling help to assist
22 them to stop viewing pornography because they believe it to be wrong and
23 unhealthy for them to engage in.
24 71. I have also worked with clients who have wanted to cease engaging in
25 sexual activities that they believe are wrong. One example occurred with a teenage
26 client who initially came to me because he was experiencing academic difficulties
27 and loss of focus at school. This young man was a Christian, involved with his

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1 church youth group and with church mission trips to serve other communities. After
2 several counseling sessions, the client on his own initiative raised concerns about
3 the way in which he viewed girls, and in particular his ongoing sexual relationship
4 with his girlfriend.
5 72. The client believed that it was not right for him to be sexually active
6 with his girlfriend, and felt that his thoughts and behaviors were in conflict with his
7 faith and morals. He expressed frustration that he repeatedly fell into conduct that
8 he believed was wrong and harmful to both himself and his girlfriend, and
9 expressed a desire to align his sexual thoughts and actions with his faith. I worked
10 with this young man to help him change the thoughts, actions, and lack of self-
11 control that were distressing him, as part of a wider effort on the part of the client
12 to become a more healthy and stable individual. Over time, I observed the client
13 becoming happier, with better self-esteem and drive, as he addressed these
14 behaviors that he believed to be wrong and harmful.
15 73. Based on my experience and my understanding of adolescents and
16 teens, I expect with high confidence that minor clients will continue to seek my
17 counseling assistance to change sexual behaviors that they believe are harmful and
18 inconsistent with their personal life goals and religious convictions.
19 F. The impact of the Counseling Censorship Law on my practice and
20 clients
21 74. For professional, religious, and human reasons, I wish to continue to
22 support current and future clients who seek my help with issues relating to gender
23 identity, sexual attractions, and sexual behaviors.
24 75. In my understanding, the Counseling Censorship Law seeks to prevent
25 me from providing counsel in these areas that my clients desire, that is consistent
26 with their own religious beliefs and with mine, and that is consistent with my
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1 professional judgment as to what path will lead these clients into healthy, fulfilled,
2 and stable lives over the long term.
3 76. When I provide such counsel, the Counseling Censorship Law
4 threatens me with harassment, investigation, and severe penalties potentially
5 including the loss of my license and my livelihood.
6 77. As a result, when a client raises concerns or goals relating to any of
7 these subjects with me, I cannot help wondering whether at some point in the
8 future the client might file a complaint against me, and I cannot help fearing the
9 possible implications for me and my ability to support my family if that happens.
10 78. Given how politicized this issue is, I also cannot help fearing that
11 hostile activists will maliciously and dishonestly present themselves as clients in an
12 effort to entrap me and accuse me of violating the Counseling Censorship Law.
13 Similarly, even in the case of a client who seeks my assistance in good faith, and
14 who appreciates and values my counsel, I cannot avoid fearing that some other
15 individual—even a completely unrelated individual—will learn of the nature of such
16 counseling and from ideological motivations will file a complaint against me, or
17 even initiate a third-party enforcement action against me, as is authorized by the
18 Counseling Censorship Law.
19 79. Merely going through an investigative process if accused of a violation
20 of the Counseling Censorship Law—likely accompanied by hostile and uninformed
21 publicity—would be extremely stressful and disruptive of my practice and
22 livelihood, regardless of whether a violation was ultimately found.
23 80. In practice, these well-founded fears mean that my conversations with
24 clients on matters of gender, gender expression, sexual orientation, sexual
25 behaviors, or sexual or romantic attractions—particularly at the outset of
26
27

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1 conversations with a new client, or when these issues are first raised by an existing
2 client—are inevitably more guarded and cautious than would otherwise be the case.
3 Yet openness, candor, and trust are essential to a successful counseling
4 relationship.
5 81. In fact, because the terms used in the Counseling Censorship Law to
6 define what is prohibited are so broad and undefined, I must and do fear that
7 someone could later accuse me of a violation of the Law based on almost any
8 exploratory discussions I might have with clients on matters of gender, gender
9 expression, sexual orientation, sexual behaviors, or sexual or romantic attractions.
10 Since these are common matters of concern for troubled teens, this amounts to
11 serious interference with my counseling conversations.
12 82. Not only does the Counseling Censorship Law chill discussions that I
13 have with my clients, but it also makes it too hazardous for me to actively publicize
14 my willingness to work with minors on these issues (for example, on our practice
15 website), as I would otherwise like to do.
16 83. Furthermore, to counsel clients on these topics without running a
17 substantial risk of violating the law, I would have to counsel and speak to my
18 clients on the premise that seeking to reduce same-sex attraction, or to achieve
19 comfort with their biological sex, could not be successful, and would instead harm
20 their physical and psychological well-being. In my opinion, the law is designed to
21 compel me to speak to my clients and conduct my counseling in a manner that
22 reflects those beliefs. Not only are these viewpoints directly contrary to my beliefs
23 and the beliefs of many of my clients, but they are also contradicted by science and
24 by the experience of many of my clients.
25 84. In any successful counseling relationship relating to the sensitive and
26 important topics of sexual attractions, behaviors, and orientation, openness and
27

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7
9 AT TACOMA
10 BRIAN TINGLEY, ) 3:21-cv-5359

Case No. ____________
)
11 Plaintiff, ) EXPERT DECLARATION OF
) CHRISTOPHER ROSIK, PH.D.
12 v. IN SUPPORT OF PLAINTIFF’S
)
13 ) MOTION FOR PRELIMINARY
ROBERT W. FERGUSON, in his official INJUNCTION
)
)
)
15 official capacity as Secretary of Health for
)
16 )
)
)
)
18 Washington State Department of Health,
)
19 Defendants. )
20
21 I, Dr. Christopher Rosik, hereby declare as follows:
22 1. I hold a Ph.D. in clinical psychology from an APA-approved program at
23 Fuller Graduate School of Psychology in Pasadena, California.
24 2. I have been a licensed clinical psychologist for over thirty years, and I
25 currently practice at the Link Care Center in Fresno, California, where I am the
26 Director of Research.
27
Expert Decl. of Christopher Rosik, Ph.D. in ALLIANCE DEFENDING FREEDOM

Supp. of MPI 1 15100 N. 90th Street
3:21-cv-5359
Case No. _______________ Scottsdale, Arizona 85260
(480) 444-0020
1 3. I am a clinical faculty member of Fresno Pacific University, as well as
2 a member of the American Psychological Association, International Society for the
3 Study of Trauma and Dissociation, and the National Association of Social Workers.
4 4. A fuller review of my professional experience and publications is
5 provided in my curriculum vitae, a copy of which is attached hereto as Exhibit A.
6 5. I have further identified the academic, scientific, and other materials
7 referenced in this declaration in the references attached hereto as Exhibit B.
8 6. In this declaration, I provide my expert views, with reference to recent
9 scientific publications, on three questions:
10 • Whether current science supports the belief that same-sex

attraction is genetically determined? As I explain in Section I
11
below, it does not, but rather contradicts that belief.
12 • Whether current science supports the belief that individuals who
13 experience some same-sex attraction rarely experience any change
in those attractions. As I explain in Section I below, it does not.
14 Instead, many studies document that these individuals very often
15 experience significant changes in their experienced sexual
attractions.
16
• Whether current science supports the assertion that voluntary,
17 conversational counseling to assist individuals who wish to achieve
a reduction in same-sex attractions or an increase in opposite-sex
18
attractions is harmful to most or even many participants. As I
19 explain in Section II below, no methodologically sound study
supports that conclusion, and some more careful recent studies find
20
that such counseling is beneficial to mental health on average.
21
I. The available science indicates that same-sex attraction is not
22 genetically determined and often changes.
23 7. It is often asserted that sexual attractions or orientation are fixed and

24 not subject to change. In my opinion, this is incorrect, and indeed is unsustainable
25 in the face of modern science.
26
27

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1 8. In fact, a much-cited recent review of the relevant scientific literature
2 by prominent LGBTQ-advocate authors concluded that “[A]rguments based on the
3 immutability of sexual orientation are unscientific, given that scientific research
4 does not indicate that sexual orientation is uniformly biologically determined at
5 birth or that patterns of same-sex and other-sex attractions remain fixed over the
6 life course.” (Diamond & Rosky, 2016, p.2). I agree with these authors.
7 9. Diamond and Rosky conclude that rather than resting on science,
8 assertions that sexual orientation cannot change “rely on unspoken legal and moral
9 premises whose validity must be questioned.” (Diamond & Rosky, 2016, p.11).
10 A. Same-sex attraction is not genetically determined.
11 10. In the past, many authors have hypothesized that same-sex attractions
12 are biologically determined. However, no such causes have been found. A 2019
13 large-scale study by a team of authors from Harvard, MIT, and several other
14 prestigious institutions analyzed the genomes of almost half a million individuals,
15 along with self-reported information about heterosexual and same-sex sexual
16 behaviors from these individuals. This massive study found only “very small”
17 correlations between any genes and same-sex behavior. The authors concluded that
18 the impact of genetic factors on sexual orientation were so small that they “do not
19 allow meaningful prediction of an individual’s sexual preference.” (Ganna et al.,
20 2019. p.6).
21 11. Before the extensive genomic work of Ganna et al. published in 2019,
22 some studies had attributed a somewhat higher influence of genetics on the
23 formation of sexual orientation. But even these studies attributed only minority
24 influence to genetics, leaving sexual orientation no more genetically determined
25 than “a range of characteristics that are not widely considered immutable, such as
26 being divorced, smoking, having lower back pain, and feeling body dissatisfaction.”
27 (Diamond & Rosky, 2016, p.4).

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1 12. Rather than being biologically predestined, many individuals who
2 identify as other than heterosexual believe that they possessed and exercised choice
3 in their sexual orientation. Surveying the literature again, Diamond and Rosky
4 reject the claims of “[b]oth scientists and laypeople . . . that same-sex sexuality is
5 rarely or never chosen,” instead concluding that “individuals who perceive that they
6 have some choice in their same-sex sexuality are more numerous than most people
7 think.” (Diamond & Rosky, 2016, p.20). In my own counseling experience, I have
8 worked with patients who likewise perceive that they initially made choices that led
9 to or strengthened their same-sex attractions.
10 13. Suggesting there is much left to learn about the complex origins of
11 same-sex attractions and behavior, even the APA’s own stance on the biological
12 origin of sexual orientation has shifted over the years. In 1998, the APA appeared to
13 support the theory that homosexuality is innate and people were simply “born that
14 way,” asserting that “There is considerable recent evidence to suggest that biology,
15 including genetic or inborn hormonal factors, plays a significant role in a person's
16 sexuality” (APA, 1998).
17 14. But just ten years later, in 2008, the APA described the matter
18 differently:
19 “There is no consensus among scientists about the exact

reasons that an individual develops a heterosexual, bisexual,
20 gay, or lesbian orientation. Although much research has
21 examined the possible genetic, hormonal, developmental,
social, and cultural influences on sexual orientation, no
22 findings have emerged that permit scientists to conclude that
sexual orientation is determined by any particular factor or
23 factors. Many think that nature and nurture both play complex
24 roles....” (APA, 2008; emphasis added).
25
26
27

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1 B. Same-sex attraction frequently changes.
2 15. It has often been assumed or asserted in the literature in the past, and
3 is still often asserted by non-scientists or in the popular press today, that sexual
4 orientation is fixed and unchanging.
5 16. In my opinion, based both on my own clinical experience and more
6 recent scientific research, this assumption is not just unfounded, but provably false.
7 17. Writing in 2016, Diamond and Rosky concluded, after surveying the
8 scientific literature, that “Studies unequivocally demonstrate that same-sex and
9 other-sex attractions do change over time in some individuals,” and that the
10 evidence for this is now so clear as to be “indisputable.” (Diamond
11 & Rosky, 2016, p.6-7).
12 18. Empirically, the frequency of change in sexual orientation is
13 particularly high among those who experience same-sex attraction.
14 19. Thus, after reviewing and summarizing extensive scientific literature,
15 chapters in the American Psychological Association Handbook of Sexuality and
16 Psychology conclude that “research on sexual minorities [i.e., all those who do not
17 identify as exclusively heterosexual] has long documented that many recall having
18 undergone notable shifts in their patterns of sexual attractions, behaviors, or
19 identities over time” (636), and that “Youth who are unsure or uncertain of their
20 identity predominantly transition to a heterosexual identity” (562).
21 20. Many individual articles and studies reach the same conclusion.
22 21. A study by authors from the Harvard School of Public Health and
23 other respected institutions examined “gender- and age-related changes in sexual
24 orientation identity from early adolescence through emerging adulthood” in over
25 13,000 youth from 12 to 25 years of age, examining data collected for each
26
27

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1 participant at four times over a period of seven years. (Ott et al., 2011). On this
2 sample, Diamond and Rosky note that “Of the 7.5% of men and 8.7% of women who
3 chose a nonheterosexual descriptor at ages 18 to 21, 43% of the men and 46% of the
4 women chose a different category by age 23. Among the same-sex-attracted youth
5 who changed, 57% of the men’s changes and 62% of the women’s changes involved
6 switching to completely heterosexual.” (Diamond & Rosky, 2016, p.7-8).
7 22. Diamond and Rosky gather the results of the Ott et al. study along
8 with two separate “longitudinal” studies (i.e., studying the same individuals over
9 time), done by different researchers at different times on different samples, and
10 report that, for young adult populations (starting ages from 18 to 26), of those who
11 initially reported “any same sex attractions,” every study found that between 40% to
12 60% of each sex reported a “change in attractions” when resurveyed a few years
13 later. Of those who experienced a “change,” at least half and as high as 83%
14 “changed to heterosexuality at the second assessment.” (Diamond
15 & Rosky, 2016, p.7).
16 23. In another review of the literature, Diamond provided the following
17 summary: “The other major conclusion that we can draw from these studies is that
18 change in patterns of same-sex and other-sex attraction is a relatively common
19 experience among sexual minorities. Across the subgroups represented [taken from
20 several large datasets], between 25 and 75% of individuals reported substantial
21 changes in their attractions over time, and these findings concord with the results
22 of retrospective studies showing that gay, lesbian, and bisexual-identified
23 individuals commonly recall having undergone previous shifts in their attractions.
24 Such findings pose a powerful corrective to previous oversimplifications of sexual
25 orientation as a fundamentally stable and rigidly categorical phenomenon.”
26 (Diamond, 2016, p.253).
27

(480) 444-0020
1 24. Authors analyzing data collected for approximately 2500 individuals as
2 part of the National Survey of Midlife Development in the United States found that,
3 of those of any age who identified at the start of the study as bisexual, a decade
4 later approximately 32% identified as exclusively heterosexual, while of those who
5 identified at the start of the study as homosexual (that is, exclusively attracted to
6 the same sex), a decade later 28% identified as attracted to the opposite sex
7 (heterosexual or bisexual). (Mock & Eibach, 2012, Table 2). Heterosexual identity
8 was far more stable: among those who identified as heterosexual at the start of the
9 study, only 0.78% of men and 1.36% of women identified a different orientation a
10 decade later. (Mock & Eibach, 2012, p.645).
11 25. Another often-cited paper by prominent researchers summarized
12 scholarship and cautioned that “there was little evidence of true bipolarity in sexual
13 orientation” and that sexual orientation is instead “a continuous construct.” These
14 authors observed that one study found that “Only 38% of exclusive same-sex
15 attracted females stayed in this group [between ages 21 and 26], with the rest
16 moving into ‘occasional’ same-sex attraction (38%) or exclusive opposite-sex
17 attraction (25%),” while another found that across a multi-year study period “Most
18 (62%) of young women changed their identity labels at least once. . . Over time,
19 lesbian and bisexual identities lost the most adherents and heterosexual and
20 unlabeled identities gained the most.” In short, this paper’s literature review found
21 that “Evidence to support sexual orientation stability among nonheterosexuals is
22 surprisingly meager.” (Savin-Williams & Ream, 2007, p.386).
23 26. Savin-Williams’ and Ream’s own study of adolescents and young adults
24 pointed to the same conclusion, “highlight[ing] the high proportion of participants
25 with same- and both-sex attraction and behavior that migrated into opposite-sex
26 categories between [interview periods].” (Savin-Williams & Ream, 2007, p.388).
27

(480) 444-0020
1 27. Meanwhile, other noted scholars argue that the “sexual orientation”
2 categories of “gay” or “straight” are to some extent socially defined, such that
3 surrounding “cultural press” may in essence coerce an adolescent boy who merely
4 experiences “affectional bonding” with another male to categorize and thus
5 understand himself through the rigid binary category of “gay,” whereas that same
6 type of affection would not lead the boy to think of himself that way in a different
7 cultural setting. (Hammack, 2005).
8 28. My observations in my own professional experience are consistent with
9 the findings of the many studies cited above concerning the inconstancy of same-sex
10 attraction or identification. Over the years I have provided counseling support for
11 several individuals who came to me experiencing unwanted same-sex attractions
12 and behaviors, some of whom over time came to reduce same-sex attractions and
13 behaviors, increase opposite-sex attractions, and, in general, further develop their
14 heterosexual potential.
15
II. There is no statistically valid evidence that voluntary counseling is
16 harmful.
17 29. It is often asserted that “conversion therapy” or other forms of “sexual
18 orientation change efforts” (or “SOCE”) are severely harmful. In fact, there is no
19 meaningful evidence that conversational counseling with willing clients to explore
20 possibilities of change in unwanted same-sex attractions and behaviors is harmful
21 to most or even many participants.
22
A. The conclusions of the 2009 task force of the American Psychological
23
Association.
24
30. In a major 2009 report based on a review of many studies, a task force
25
of the American Psychological Association concluded:
26
27

(480) 444-0020
1 “Although the recent studies do not provide valid causal

evidence of the efficacy of SOCE or of its harm, some recent
2 studies document that there are people who perceive that they
3 have been harmed through SOCE… just as other recent studies
document that there are people who perceive that they have
4 benefited from it. . . . . We conclude that there is a dearth of
scientifically sound research on the safety of SOCE. Early and
5 recent research studies provide no clear indication of the
6 prevalence of harmful outcomes among people who have
undergone efforts to change their sexual orientation or the
7 frequency of occurrence of harm because no study to date of
adequate scientific rigor has been explicitly designed to do so.
8 Thus, we cannot conclude how likely it is that harm will occur
9 from SOCE.” (42) b) “[I]t is still unclear which techniques or
methods may or may not be harmful.” (91)
10
31. This statement is twelve years old. However, writing in 2021 a group
11
of proponents of “SOCE” bans affirmed that the pertinent research base remains
12
sparse up to the present, providing an insufficient basis on which to make confident
13
judgments about SOCE. As they wrote, “There is limited SOGIECE [sexual
14
orientation and gender identity and expression change efforts]-related research—a
15
critical knowledge gap . . . . Rigorous research syntheses to support or refine
16
legislative proposals related to SOCIECE are not available at this time.” (Kinitz et
17
al., 2021, p. 3.)
18
19 B. Recent studies purporting to show harm contain fatal methodological

errors.
20
32. There have in fact been a number of recent papers attempting to link
21
what the authors broadly label “SOCE” to psychological harms.1 However, abundant
22
methodological limitations mean that these attempts are unable to establish harm
23
from voluntary counseling relationships, or to change the conclusion reached by the
24
APA in 2009. Two key examples are sufficient to illustrate the problem.
25
26
27 1 Blosnich et al., 2020; Green et al., 2020; Meanley et al., 2020; Ryan et al., 2018; Salway et al., 2020.

(480) 444-0020
1 1. Sample bias
2 33. Firstly, multiple recent studies fall into the methodological error of
3 improper generalization. These studies are conducted on samples exclusively made
4 up of those who self-identify as LGBT at the time the study subjects are recruited.2
5 This, however, excludes two groups whose experiences and results are extremely
6 relevant to the claims made, and are likely to be quite different than those of
7 individuals who self-identify as LGBT.
8 34. First, recruiting methods or screens that focus on those who self-
9 identify as LGBT exclude those who have never identified themselves in this way.
10 But research suggests a significant subpopulation of sexual minorities (including
11 those who experience opposite-sex attractions) choose not to be defined by those
12 attractions, and so do not identify themselves as LGBT if asked, and are unlikely to
13 be found in the LGBT-identified networks and venues often utilized by researchers
14 for participant recruitment.3 These individuals tend to be more traditionally
15 religious, more active in their religion, less engaged in same-sex behavior regardless
16 of experienced attractions, and more interested in a child- and family-centered life.
17 35. This was noted a generation ago by Shidlo and Schroeder (2002), but
18 has seemingly been ignored in the recent studies. Those authors commented “. . . on
19 the basis of the conversion therapy literature and our own empirical research, we
20 have found that conversion therapists and many clients of conversion therapy
21 steadfastly reject the use of lesbian and gay. Therefore, to have used gay-affirmative
22 words would have been inaccurate and unfaithful to their views.” (249)
23 36. Thus, given the widespread recognition that most individuals who seek
24 counseling to assist in reducing same-sex attractions are motivated by goals,
25
26
2 For example, Ryan et al., 2018.
27 3 Lefevor et al., 2020; Rosik et al., 2021a.

(480) 444-0020
1 morality, and a conception of self that are shaped by religious conviction,4 it appears
2 that studies that recruit subjects exclusively within the self-identifying LGBTQ
3 community are thereby excluding from their samples a large number—perhaps a
4 majority—of those who seek out and participate in voluntary counseling with the
5 goal of reducing same-sex attractions or behaviors. There is no reason to believe
6 that the experiences and reactions of the self-identifying LGBTQ subjects whom
7 they have surveyed—even if accurately self-reported—reflect the experiences of a
8 large number of sexual minorities. On the contrary, it would be reasonable to
9 hypothesize that such counseling is likely to be more effective for, and appreciated
10 by, precisely those who do not consider experienced sexual attractions to define who
11 they are.
12 37. The exclusion of these sexual minorities from the study samples makes
13 any generalization of harm reported in these recent studies to counseling of
14 individuals who do not self-identify as LGBTQ a scientifically improper research
15 practice.
16 38. In a related but separate biasing effect, recruitment of subjects for non-
17 longitudinal studies from among those who self-identify as LGBT also excludes
18 those who did at one time identify in that way, but for whom therapy was
19 sufficiently effective that they no longer identify as LGBT, or at least no longer
20 frequent LBGT-identified networks and venues used for recruitment. One scholar
21 has identified and criticized the sample of a recent major study as suffering from
22
23
4 The APA’s 2009 task force report noted “most SOCE currently seem directed to those holding
24 conservative religious and political beliefs, and recent research on SOCE includes almost exclusively
individuals who have strong religious beliefs.” The report further reported that those who seek
25 counseling with a goal of moving away from same-sex attractions are “predominately . . . men who
are strongly religious and participate in conservative faiths.” (25) Several years later, Professors
26 Diamond and Rosky, after surveying the literature, reached the same conclusion, writing that
“majority of individuals seeking to change their sexual orientation report doing so for religious
27 reasons . . . .” Diamond & Rosky, 2016 p. 6.

(480) 444-0020
1 this flaw, noting that “those who may have attained the goal of SOCE—to adopt
2 heterosexual identity, orientation or sexual function—were systematically screened
3 from the survey sample, which only included those currently identifying as a sexual
4 minority.” Sullins, 2020. In other words, unless this error is avoided, the sample
5 precisely excludes those who are likely to report that therapy was satisfactory,
6 effective, and/or not experienced as harmful.
7 39. These structural biases in the samples used by such studies are all the
8 more critical given that self-reported, unverified information is itself recognized to
9 present an important risk of distortion and bias. As the 2009 APA Task Force report
10 noted, “People find it difficult to recall and report accurately on feelings, behaviors,
11 and occurrences from long ago and, with the passage of time, will often distort the
12 frequency, intensity, and salience of things they are asked to recall.” (29) By
13 utilizing samples whose participants come from diverse religious and socio-political
14 outlooks, not just those who self-identify as LGBTQ, the impact of inaccurate
15 reports distorted by a combination of inaccurate memory and the personal advocacy
16 goals of participants and researchers could be significantly mitigated.
17 Unfortunately, such diverse samples are exceedingly rare in this literature.
18 2. Failure to conduct before-and-after comparisons
19 40. Secondly, none of the recent studies that attempt to link “SOCE” to
20 increased distress and suicidality reported and compared against participants’ level
21 of distress prior to their engaging in “SOCE.” That is, these studies report that the
22 study subjects suffered from mental health issues after engaging in “SOCE,” but
23 they do not report what level of mental health issues those same subjects suffered
24 before engaging in “SOCE.”5 Basic research methodology dictates any study
25 attempting to attribute a cause (e.g., “SOCE”) to an effect (e.g., harm) must take
26
27 5 Blosnich et al., 2020; Green et al., 2020; Flentje et al., 2013; Salway et al., 2020.

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1 into account important and potentially confounding factors. The lack of a control for
2 pre-“SOCE” distress makes it impossible for studies that suffer from this defect to
3 reach any valid conclusions about causation.
4 41. In one striking example, data that permits an answer to the “before
5 ‘SOCE’” question is available but was disregarded in a research paper published by
6 Blosnich et al., 2020. That data negates and even inverts the hypothesis of
7 causation advanced in the published paper. Blosnich et al., utilized a dataset (the
8 Generations survey) available to other scholars. Oddly, Blosnich and colleagues did
9 not take into account data concerning the subjects’ pre-“SOCE” distress in their
10 study design even though such information was available in the same dataset, yet
11 nevertheless these authors purported to find that “SOCE” had “insidious
12 associations with suicide risk” and “may compound or create…suicidal ideation and
13 suicide attempts.” I will note that “insidious associations” is a rhetorical rather than
14 a scientific statement, while “may compound or create” describes a hypothesis that
15 should be tested, not a scientific finding.
16 42. More recently, Professor Donald Sullins performed a re-analysis of the
17 original study of Blosnich et al. but took into account the “SOCE” distress levels
18
experienced by the study subjects before they participated in what Blosnich
19
designates as “SOCE.” (Sullins, 2020 (preprint).) Sullins’ reanalysis discovered a
20
21 very different reality. While the effect of controlling for pre-“SOCE” suicidality was
22 larger for adults than for minors, Sullins reported:

23
24
25
26
27

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1 After controlling for pre-existing conditions, there no longer

remained any positive associations of SOCE with suicidality in
2 the Generations data. Far from increasing suicidality, recourse
3 to SOCE generally reduced it. For the most part the observed
reduction in suicidality is not small, especially for those who
4 received SOCE treatment as adults. Following SOCE, the odds
of suicide ideation were reduced by two-thirds (AOR of .30) for
5 adults and by one-third (AOR of .67) for minors. Suicide
6 attempts were reduced by four-fifths (AOR of .20) for adults
following SOCE, though they were not reduced for minors . . .
7 (14)
8 The reduced propensity to progress to suicide attempts
following SOCE therapy after previous suicide morbidity was
9
even greater. When followed by SOCE treatment, suicide
10 ideation was less than a fifth as likely (AOR .18, Table 4) and
suicide planning less than a seventh as likely (AOR .13, Table
11 4) to lead to a suicide attempt. Adults who experienced SOCE
intervention following suicidal thoughts or plans were 17-25
12
times (AOR .06-.04, Table 4) less likely to attempt suicide.
13 Minors undergoing SOCE were no more likely (AOR .43-.52,
not significant, Table 4) to attempt suicide after initial
14 thoughts or plans of suicide compared to their peers who did
not undergo SOCE. (14-15)
15
16 43. Sullins goes on to observe that “On the question of SOCE and
17 suicidality, in fact Blosnich et al. may have stated the case exactly backwards.” (15).
18 44. Finally, Sullins goes on to provide an illustrative analogy:
19 “Imagine a study that finds that most persons using anti-

depressants also have had depressive symptoms, thereby
20 concluding that persons “exposed” to anti-depressants were
21 much more likely to experience depression, and recommending
that anti-depressants therefore be banned. This imagined
22 study would have used the same flawed logic as Blosnich et al.’s
study, with invidious consequences for persons suffering from
23 depression.” (20)
24
25
26
27

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1 45. More scholarly criticism of these and other recent studies that suffer
2 from these profound methodological flaws continues to emerge.6
3
III. Available evidence indicates that voluntary counseling to change
4 sexual orientation can be effective in motivated individuals.
5 46. It is also frequently asserted—despite the extensive evidence that
6 change in the components of sexual orientation is not only possible but frequent—
7 that counseling to assist an individual toward desired change is never effective.
8 Again, the available science does not support this assertion.
9
A. The conclusions of the 2009 task force of the American Psychological
10
Association.
11
47. The 2009 APA Task Force report acknowledged that “There are no
12
studies of adequate scientific rigor to conclude whether or not recent SOCE do or do
13
14 not work to change a person’s sexual orientation.” (120) More specifically:
15 “We found that nonaversive and recent approaches to SOCE

have not been rigorously evaluated. Given the limited amount
16 of methodologically sound research, we cannot draw a
17 conclusion regarding whether recent forms of SOCE are or are
not effective.” (43)
18
48. The Task Force report further stated:
19
“Former participants in SOCE reported diverse evaluations of
20
their experiences: Some individuals perceived that they had
21 benefited from SOCE, . . . [These] individuals reported that
SOCE was helpful—for example, it helped them live in a
22 manner consistent with their faith. Some individuals described
finding a sense of community through religious SOCE and
23
valued having others with whom they could identify.” (3)
24
25 6D’Angelo et al., 2021 (critique of Turban et al.’s (2020) study on the effects of gender identity
conversion efforts); Kalin, 2020 (critique of Bränström & Pachankis (2019) study on the mental
26 health impacts of ‘gender-affirming treatments’); Rosik, 2021 (critique of Ryan et al., (2018) study on
the effects of ‘SOCE’); Rosik et al., 2021b (critique of the Blosnich et al.(2020) study attributing
27 suicidality to “SOCE”).

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1 B. Available evidence shows that voluntary counseling is effective for

some individuals.
2
49. Authors from a variety of perspectives acknowledge that there is
3
evidence that voluntary counseling is effective for at least some individuals who are
4
highly motivated to change sexual attractions and behaviors.
5
50. A six-year longitudinal study considering willing participants who
6
were motivated at least in part by religious beliefs and goals concluded that “The
7
attempt to change sexual orientation did not appear to be harmful on average for
8
these participants. The only statistically significant trends that emerged…indicated
9
improving psychological symptoms.” (Jones & Yarhouse, 2011, p.424).
10
51. This longitudinal study found that about half of participants reported
11
progress toward their desired goal, with 23% of study participants reporting
12
substantial reduction in homosexual attraction and substantial increase in
13
heterosexual attraction and functioning, while an additional 30% of participants
14
reported that same-sex attraction remained present only incidentally or in a way
15
that did not seem to bring about distress.
16
52. A 2010 study surveyed 117 men who participated in some form of
17
secular or religious counseling or support group activities designed to reduce same-
18
sex attraction. Of these, some were single and some were in heterosexual
19
marriages. 88% were motivated at least in part by what they perceived as conflict
20
between their same-sex desires and conduct and the teachings of their faith. Within
21
the whole study group, responses indicated a “large effect” in decrease of same-sex
22
attractions and behavior, and also a “large effect” in increase of heterosexual
23
attraction and behavior. (Karten & Wade, 2010).
24
25
26
27

(480) 444-0020
Appendix A: Curriculum Vitae
Christopher Hastings Rosik

1734 W. Shaw Avenue
Fresno, California 93711
I. Education.
B. A. University of Oregon (Honors college), Eugene, Oregon, 1980 (psychology).

M.A. Fuller Theological Seminary, Pasadena, California, 1984 (theological studies).
Ph.D. Fuller Graduate School of Psychology, Pasadena, California, 1986 (clinical psychology - APA
approved program).
II. Honors.
Phi Beta Kappa, Alpha of Oregon, 1980.

Exemplary Paper in Humility Theology Award, John Templeton Foundation, 1998.
III. Professional Experiences.
9/85 - 8/ 86 Clinical psychology intern, Camarillo State Hospital, Camarillo, California (APA
approved internship).
11/86 - 5/88 Postdoctoral intern, Link Care Center, Fresno, California.
5/88 - Present Licensed clinical psychologist, Link Care Center, Fresno, California.
11/94 - 6/96 Assistant Clinical Director, Link Care Center, Fresno, California.
7/96 - 12/99 Clinical Director, Link Care Center, Fresno, California.
1/01 – Present Clinical Faculty, Fresno Pacific University
1/05 – Present Director of Research, Link Care Center, Fresno, California
IV. Professional Affiliations.
1/84 - Present Member, American Psychological Association.

1/86 - Present Member, Christian Association for Psychological Studies (CAPS).
6/90 - 6/93 Member, board of directors, CAPS-Western region.
6/01 – 5/05 President-Elect, President, and Past-President, CAPS-Western Region
1/92 - Present Member, International Society for the Study of Dissociation.
7/99 – Present Member, Alliance for Therapeutic Choice and Scientific Integrity (Alliance)
1/11 – 12/17 President-Elect, President, and Past President, Alliance
1/11 - Present Member, National Association of Social Workers.
V. Recent Litigation Engagements.
Vazzo v. City of Tampa, Florida, Expert declaration submitted May 6, 2019, rebuttal declaration submitted
July 17, 2019. Expert testimony by deposition. (M.D. Fla. 2019)
VI. Selected Publications.
Rosik, C.H. (1989). The impact of religious orientation on conjugal bereavement among older adults.
International Journal of Aging and Human Development, 28, 251-260.
Rosik, C.H. (1992). Multiple personality disorder: An introduction for pastoral counselors. The Journal of
Pastoral Care, 46, 291-298.
19
Rosik, C.H. (1992). On introducing multiple personality disorder to the local church. Journal of
Psychology and Christianity, 11, 263-268.
Rosik, C.H. (Ed.) (1993). Counseling Christians in Ministry [Special issue]. Journal of Psychology and
Christianity, 12(2).
Rosik, C.H. (1993). Mission-affiliated versus non-affiliated counselors: A brief research report on
missionary preferences with implications for member care. Journal of Psychology and Christianity, 12, 159-164.
Ritchey, J.K., & Rosik, C.H. (1993). Clarifying the interplay of developmental and contextual factors in the
counseling of missionaries. Journal of Psychology and Christianity, 12, 151-158.
Rosik, C.H. (1995). The misdiagnosis of MPD by Christian counselors: Vulnerabilities and safeguards.
Journal of Psychology and Theology, 23, 72-86.
Rosik, C.H. (1995). The impact of religious orientation in conjugal bereavement among older adults. In J.
Hendricks (Ed.), The Ties of Later Life (pp. 87-96). New York: Baywood Publishing Company.
Rosik, C.H. (1995). The unification of consciousness: Approaches to the healing of dissociation. Journal of
Religion and Health, 34, 233-246.
Rosik, C.H. (1996). “Outing” the moral dimension in research on homosexuality. Journal of Psychology
and Christianity, 15, 377-388.
Rosik, C.H. (1997). Geriatric Dissociative Identity Disorder. Clinical Gerontologist, 17, 63-66.
Rosik, C. H. (1998). Religious Contributions to the Healing of Dissociative Disorders. Many Voices, 10, 6-
8.
Rosik, C.H., & Killbourne-Young, K. (1999). Dissociative disorders in adult missionary kids: Report on
five cases. Journal of Psychology and Theology, 27, 163-170.
Rosik, C.H. (2000). Utilizing religious resources in treating dissociative trauma symptoms: Rationale,
current status, and future directions. Journal of Trauma and Dissociation, 1, 69-89.
Rosik, C. H. (Ed.) (2000). Dissociative Identity Disorder [Special Issue]. Journal of Psychology and
Christianity, 19(2).
Rosik, C.H. (2000). Some effects of world view on the theory and treatment of DID. Journal of
Psychology and Christianity, 19, 166-180.
Rosik, C.H. (2001). Conversion therapy revisited: Parameters and rationale for ethical care. Journal of
Pastoral Care, 55, 47-67.
Brown, S. W., Gorsuch, R. L., Rosik, C. H., & Ridley, C. R. (2001). The development of a forgiveness
scale. Journal of Psychology and Christianity, 20, 40-52.
Rosik, C. H., & Brown, R. K. (2001). Professional Use of the Internet: Legal and Ethical Issues in a
Member Care Environment. Journal of Psychology and Theology, 29, 106-120.
Rosik, C. H. (2003). Motivational, ethical, and epistemological foundations in the treatment of unwanted
homoerotic attraction. Journal of Marital and Family Therapy, 29, 13-28.
Rosik, C. H. (2003). When therapists do not acknowledge their moral values: Green’s response as a case
study. Journal of Marital and Family Therapy, 29, 39-46.
20
Rosik, C. H. (2003). Critical Issues in the Dissociative Disorders Field: Six Perspectives from Religiously-
Sensitive Practitioners. Journal of Psychology and Theology, 31, 113-128.
Rosik, C. H., Richards, A., & Fannon, T. (2005). Member care experiences and needs: Findings from a
study of East African missionaries. Journal of Psychology and Christianity, 24, 36-45.
Rosik, C. H. (2005). Psychiatric symptoms among prospective bariatric patients: Rates of prevalence and
their relation to social desirability, pursuit of surgery and follow-up attendance. Obesity Surgery, 15(5), 677-683.
Rosik, C. H., Griffith, L. K., & Cruz, Z. (2007). Homophobia and conservative religion: Toward a more
nuanced understanding. American Journal of Orthopsychiatry, 77, 10-19.
Rosik, C. H. (2007). Ideological concerns in the operationalization of homophobia, Part 1: An analysis of

Herek’s ATLG-R scale. Journal of Psychology and Theology, 35, 132-144
Rosik, C. H. (2007). Ideological concerns in the operationalization of homophobia, Part II: The need for
interpretive sensitivity with conservatively religious persons. Journal of Psychology and Theology, 35, 134-152.
Rosik, C. H., & Byrd, A. D. (2007). Marriage and the civilizing of male sexual nature. American
Psychologist, 62, 711-712.
Cousineau, A. E., Hall, M. E., Rosik, C. H., & Hall, T. W. (2007). The 16PF and Marital Satisfaction
Inventory as predictors of missionary job success. Journal of Psychology and Theology, 35(4), 317-327.
Rosik, C. H., & Pandzic, J. (2008). Marital satisfaction among missionaries: A longitudinal analysis from
candidacy to second furlough. Journal of Psychology and Christianity, 27, 3-15.
Rosik, C. H., & Smith, L. L. (2009). Perceptions of religiously-based discrimination among Christian
students in a secular versus Christian university setting. Psychology of Religion and Spirituality, 1(4), 207-217.
Rosik, C. H., Summerford, A., & Tafoya, J. (2009). Assessing the effectiveness of intensive outpatient care
for Christian missionaries and clergy. Mental Health, Religion, & Culture, 12, 687-700.
Jones, S. L., Rosik, C. H., Williams, R. N., & Byrd, A. D. (2010). A Scientific, Conceptual, and Ethical
Critique of the Report of the APA Task Force on Sexual Orientation. The General Psychologist, 45(2), 7-18.
Cousineau, A.E., Hall, M.E.L, Rosik, C.H., & Hall, T.W. (2010). Predictors of missionary job success: A
review of the literature and research proposal. Journal of Psychology and Christianity, 29(4), 354-363.
Rosik, C. H. (2011). Long-Term Outcomes of Intensive Outpatient Psychotherapy for Missionaries and
Clergy. Journal of Psychology and Christianity, 30(3), 175-183.
Rosik, C. H., & Soria, A. (2012). Spiritual well-being, dissociation and alexithymia: Examining direct and
moderating effects. Journal of Trauma and Dissociation., 13(1), 69-87.
Rosik, C. H., Renteria, T., & Pitman, A. (2012). Psychological Profiles of Individuals Seeking Ordination
in the Episcopal or Presbyterian (PCUSA) Churches: Comparisons and Contrasts. Pastoral Psychology, 61(3), 359-
373.
Rosik, C. H. (2012). Opposite-gender identity states in Dissociative Identity Disorder: Psychodynamic
insights into a subset of same-sex behavior and attractions. Journal of Psychology and Christianity. 31(3), 278-284.
Rosik, C. H., Jones, S. L., & Byrd, A. D. (2012). Knowing what we do not know about sexual orientation
change efforts. American Psychologist. 67 (6), 498-499.
Rosik, C. H., & Byrd, A. D. (2013). Moving back to science and self-reflection in the debate over SOCE.
Social Work, 58 (1), 83-85.
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Rosik, C. H., Dinges, L., & Saavedra, N. (2013). Moral Intuitions and Attitudes toward Gay Men:
Can Moral Psychology Add to Our Understanding of Homonegativity? Journal of Psychology and Theology.41(4),
315-326.
Rosik, C. H., & Popper, P. (2014). Clinical Approaches to Conflicts Between Religious Values and Same-
Sex Attractions: Contrasting Gay-Affirmative, Sexual Identity, and Change-Oriented Models of Therapy.
Counseling & Values, 59, 222-237.
Rosik, C. H. (2014). Same-Sex Marriage and the Boundaries of Diversity: Will Marriage and
Family Therapy Remain Inclusive of Religious and Social Conservatives? Marriage & Family Review, 50(8), 714-
737.
Rosik, C. H., Teraoka, N. K., & Moretto, J. D. (2016). Experiences of Religiously-based Prejudice and
Self-censorship among Christian Therapists and Educators. Journal of Psychology and Christianity, 35, 52-67.
Rosik, C. H., Silvoskey, M. M., Odgon, K. M., Kincaid, T. M., Roos, I. K., & Castanon, M. R. (2016).
Toward normative MMPI-2 profiles for evangelical missionaries in candidate and clinical settings: Examining
differences by setting, generation, and marital status. Journal of Psychology & Theology, 44, 315-328.
Rosik, C. H., Rosel, G., Silvoskey, M. M., Odgon, K. M., Kincaid, T. M., Roos, I. K., & Castanon, M. R.
(2017). MMPI-2 Profiles Among Asian American Missionary Candidates: Gendered Comparisons for Ethnicity and
Population Norms. Asian American Journal of Psychology, 8, 167-175.
Rosik, C. H. (2017). An unfortunate comparison of apples to oranges: Comment on Jensma (2016). Journal
of Psychology & Theology, 43, 233-236.
Rosik, C. H. (2017). Sexual orientation change efforts, professional psychology, and the law: A brief
history and analysis of a therapeutic prohibition. BYU Journal of Public Law, 32, 47-84. Retrieved from
https://digitalcommons.law.byu.edu/jpl/vol32/iss1/3
Lefevor, G. T., Beckstead, L. A., Schow, R. L., Raynes, M., Mansfield, T. R., & Rosik, C. H. (2019).
Satisfaction and health with four sexual identity relationship options. Journal of Sex & Marital Therapy, 45(5), 355-
369. https://doi.org/10.1080/0092623X.2018.1531333
Cretella, M. A., Rosik, C. H., & Howsepian, A. A. (2019). Sex and gender are distinct variables critical to
health: Comment on Hyde, Bigler, Joel, Tate, & van Anders (2019). American Psychologist, 74, 842–844.
http://dx.doi.org/10.1037/amp0000524
Bridges, J. G., Lefevor, G. T., Schow, R. L., & Rosik, C. H. (2020). Identity affirmation and mental health
among sexual minorities: A raised-Mormon sample. Journal of GLBT Family Studies, 16(3), 293-311.
http://doi.org/10.1080/1550428X.2019.1629369
Lefevor, G. T., Blaber, I. P., Huffman, C. E., Schow, R. L., Beckstead, A. L, Raynes, M., & Rosik, C. H.
(2020). The role of religiousness and beliefs about sexuality in well-being among sexual minority Mormons.
Psychology of Religion and Spirituality, 12(4), 460-470. http://dx.doi.org/10.1037/rel0000261
Lefevor, G. T., Sorrell, S. A., Kappers, G., Plunk, A., Schow, R. L., Rosik, C. H., & Beckstead, A. L.
(2020). Same-sex attracted, not LGBT: The associations of sexual identity labeling on religiousness, sexuality, and
health among Mormons. Journal of Homosexuality, 67(7), 940-964.
https://doi.org/10.1080/00918369.2018.1564006
Rosik, C. H. (2021): RE: Ryan, Toomey, Diaz, and Russell (2021). Journal of Homosexuality, 68(2), 181-
184. http://dx.doi.org/10.1080/00918369.2019.1656506
22
Rosik, C. H., Lefevor, G. T., & Beckstead, A. L. (2021). Sexual minorities who reject an LGB identity:
Who are they and why does it matter? Issues in Law & Medicine, 36(1): 27-43.
Rosik, C. H., Sullins, D. P., Schumm, W. R., & Van Mol, A. (2021). Sexual orientation change efforts,
adverse childhood experiences, and suicidality [Letter to the Editor]. American Journal of Public Health, 111(4),
e19-e20. https://doi.org/10.2105/AJPH.2021.306156
23
Appendix B: References
American Psychological Association (1998). Answers to your questions for a better

understanding of sexual orientation and homosexuality. Washington, DC: Author
American Psychological Association (2008). Answers to your questions for a better

understanding of sexual orientation and homosexuality. Washington, DC: Author
Retrieved from www.apa.org/topics/sorientation.pdf
American Psychological Association. (2009). Report of the APA Task Force on Appropriate
Therapeutic Responses to Sexual Orientation. Retrieved from
http://www.apa.org/pi/lgbt/resources/therapeuticresponse.pdf
Blosnich, J. R., Henderson, E. R., Coulter, R. W. S., Golbach, J. T., & Meyer, I. H. (2020).
Sexual orientation change efforts, adverse childhood experiences, and suicide ideation
and attempt among sexual minority adults, United States, 2016-2018. American Journal
of Public Health, 110(7), 1024-1030. http://doi.org/10.2105/AJPH.2020.305637
D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2021). One
size does not fit all: In support of psychotherapy for gender dysphoria. Archives of Sexual
Behavior, 50, 7-16. https://doi.org/10.1007/s10508-020-01844-2
Diamond, L. M., & Rosky, C. J.. (2016) Scrutinizing Immutability: Research on Sexual
Orientation & U.S. Legal Advocacy for Sexual Minorities. Journal of Sex Research,
53:4-5, 363-91. https://doi.org/10.1080/00224499.2016.1139665
Diamond, L. M. (2016). Sexual fluidity in male and females. Current Sexual Health Reports, 8,
249-256. https://doi.org/1007/s11930-016-0092-z
Ganna, A., Verweji, K.J. Nivard, M. G., Mair, R., & Wedwo, R., et al., (2019) Large-scale
GWAS reveals insights into the genetic architecture of same-sex sexual behavior, Science
(New York, N.Y.), 365(6456), eaat7693. https://doi.org/10.1126/science.aat7693
Green, A. E., Prince-Feeney, M., Dorison, S. H., & Pick, C. J. (2020). Self-reported conversion
efforts and suicidality among US LGBTQ youths and young adults, 2018. American
Journal of Public Health, 110(8), 1221-1227. http://doi.org/10.2105AJPH.2020.305701
Hammack, P. (2005). The Life Course Development of Human Sexual Orientation: An
Integrative Paradigm. Human Development, 48(5), 267-290.
http://doi.org/10.1159/000086872
Jones, S. L., & Yarhouse, M. A. (2011). A Longitudinal Study of Attempted Religiously Mediated
Sexual Orientation Change. Journal of Sex & Marital Therapy, 37, 404-427.
http://dx.doi.org/10.1080/0092623X.2011.607052
Lefevor, G. T., Sorell, S. A., Kappers, G., Plunk, A., Schow, R. L., Rosik, C. H., & Beckstead,
A. L. (2020). Same-sex attracted, not LGBQ: The associations of sexual identity labeling
on religiousness, sexuality, and health among Mormons. Journal of Homosexuality,
67(7), 940-964. http://doi.org/10.1080/00918369.2018.1564006
24
Kalin, N. H. (2020). Reassessing Mental Health Treatment Utilization Reduction in Transgender

Individuals After Gender-Affirming Surgeries: A Comment by the Editor on the
Process." American Journal of Psychiatry, 177(8), p. 764.
https://doi.org/10.1176/appi.ajp.2020.20060803
Karten, E. Y., & Wade, J. C. (2010). Sexual Orientation Change Efforts in Men: A Client
Perspective. The Journal of Men’s Studies, 18(1), 84–102.
https://doi.org/10.3149/jms.1801.84
Kinitz, D. J., Salway, T., Dromer, E., Giustini, D., Ashley, F., Goodyear, T., Ferlatte, O., Kia, H.,
& Abramovich, A. (2021). The scope and nature of sexual orientation and gender identity
and expression change efforts: A systemic review protocol. Systemic Reviews, 10, 14.
https://doi.org/10.1186/s13643-020-01563-8
Meanley, S., Haberlen, S. A., Okafor, C. N., Brown, A., Brennan-Ing, M., Ware, D.,…Plankey,
M. W. (2020). Lifetime exposure to conversion therapy and psychosocial health among
midlife and older adult men who have sex with men. The Gerontologist. Advance online
publication. http://doi.org/10.1093/geront/gnaa069
Mock, S. E., & Eibach, R. P. (2012). Stability and change in sexual orientation identity over a
10-year period in adulthood. Archives of sexual behavior, 41(3), 641–648.
https://doi.org/10.1007/s10508-011-9761-1
Nyamathi, A., Reback, D. J., Shoptaw, S., Salem, B. E., Zhang, S., & Yadav, K. (2017). Impact
of tailored interventions to reduce drug use and sexual risk behaviors among homeless
gay and bisexual men. American Journal of Men’s Health, 11(2) 208-220.
https://journals.sagepub.com/doi/abs/10.1177.1557988315590837
Ott, M. Q., Corliss, H. L., Wypij, D., Rosario, M., & Austin, S. B. (2011). Stability and change
in self-reported sexual orientation identity in young people: application of mobility
metrics. Archives of sexual behavior, 40(3), 519–532. https://doi.org/10.1007/s10508-
010-9691-3
Reback, C. J., & Shoptaw, S. (2014). What’s unique about lesbian, gay, bisexual, and
transgender (LGBT) youth and young adults suicide? Findings from the National Violent
Death Reporting System. Journal of Adolescent Health, 64, 602e607.
https://doi.org/10.1016/j.jadohealth.2018.10.303
Rosik, C. H. (2021): RE: Ryan, Toomey, Diaz, and Russell (2018). Journal of Homosexuality,
68(2), 181-184. http://doi.org/10.1080/00918369.2019.1656506
Rosik, C. H., Lefevor, G. T., & Beckstead, A. L. (2021a). Sexual minorities who reject an LGB
identity: Who are they and why does it matter. Issues in Law & Medicine, 36(1), 27-43.
Rosik, C. H., Sullins, D. P., Schumm, W. R., & Van Mol, A. (2021b). Sexual orientation change
efforts, adverse childhood experiences, and suicidality. American Journal of Public
Health, 111(4), e19-20. https://doi.org/10.2105/AJPH.2021.306156
Ryan, C., Toomey, R. B., Diaz, R. M., & Russell, S.T. (2018). Parent-Initiated sexual orientation
change efforts with LGBT adolescents: Implications for young adult mental health and
adjustment. Journal of Homosexuality, 67(2), 159-173.
http://doi.org/10.1080/00918369.2018.1538407
25
Salway, T., Ferlatte, O., Gesink, D., & Lachowsky, N. J. (2020). Prevalence of exposure to
sexual orientation change efforts and associated sociodemographic characteristics among
Canadian sexual minority men. The Canadian Journal of Psychiatry, 65(7), 502-509.
http://doi.org/10.1177/0706743720902629
Savin-Williams, R. C., & Ream, G. L. (2007). Prevalence and stability of sexual orientation
components during adolescence and young adulthood. Archives of Sexual Behavior, 36,
385-349. http://dx.doi.org/10.10007/s10508-006-9088-5
Shidlo, A., & Schroeder, M. (2002). Changing sexual orientation: A consumer’s report.
Professional Psychology: Research and Practice, 33(3), 249-259.
https://doi.org/10.1037//0735-7028.33.3.249
Shoptaw, R., Reback, C. J., Larkins, S., Wang, P., Rotheram-Fuller, E., Dang, J., & Yang, X.
(2008). Outcomes using tow tailored behavioral treatments for substance abuse in urban
gay and bisexual men. Journal of Substance Abuse Treatment, 35, 285-293.
https://doi.org/10.1016/j.jsat.2007.11.004; https://europepmc.org/article/MED/15845315
Shoptaw, R., Reback, C. J., Peck, J. A., Yan, X., Rotheram-Fuller, E., Larkens, S., Veniegas, R.
C., Freese, T. E., & Hucks-Ortiz, C. (2005). Behavioral treatment approaches for
methamphetamine dependence and HIV-related sexual risk behaviors among urban gay
and bisexual men. Drug and Alcohol Dependence, 78, 125-134.
https://ucdavis.pure.elsevier.com/en/publications/behavioral-treatment-approaches-for -
methamphetamine-dependence-an
Sullins, D. (2020). Sexual orientation change efforts (SOCE) strongly reduce suicidality: A
critique of Blosnich et al., “Sexual orientation change efforts, adverse childhood
experiences, and suicide ideation and attempts among sexual minority adults, United
States, 2016-2018”, American Journal of Public Health, 110(7): 1024-1030 (October 7,
2020). Available at SSRN: https://ssrn.com/abstract=3729353 or
http://doi.org/10.2139/ssrn.3729353
Tolman, D. L., Diamond, L. M., Bauermeister, J. A., George, W. H., Pfaus, J. G., & Ward, L. M.
(Eds.). (2014). APA handbooks in psychology®.APA handbook of sexuality and
psychology, Vol. 1. Person-based approaches. American Psychological Association.
https://doi.org/10.1037/14193-000
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7
9 AT TACOMA
10 BRIAN TINGLEY, ) 3:21 cv-5359

Civil No. ____-________
)
11 Plaintiff, ) EXPERT DECLARATION OF
) DR. STEPHEN B. LEVINE
12 v. ) IN SUPPORT OF PLAINTIFF’S
13 ) MOTION FOR PRELIMINARY
ROBERT W. FERGUSON, in his official INJUNCTION
)
)
15 )
official capacity as Secretary of Health for
)
16 )
)
)
18 )
Washington State Department of Health,
)
19 Defendants. )
20
21
22
23
24
25
26
27
Expert Decl. of Dr. Stephen B. Levine ALLIANCE DEFENDING FREEDOM
in Supp. of MPI 15100 N. 90th Street
3:21 cv-5359
Civil No. _____-__________ Scottsdale, Arizona 85260
(480) 444-0020
1
I. CREDENTIALS & SUMMARY .......................................................................... 1
2
II. BACKGROUND ON THE FIELD ...................................................................... 7
3
A. The biological baseline of sex ................................................................... 7
4
5 B. Definition and diagnosis of gender dysphoria ......................................... 9
6 C. Impact of gender dysphoria on minority and vulnerable groups ......... 13
7 D. Three competing conceptual models of gender dysphoria and

transgender identity............................................................................... 14
8
E. Four competing models of therapy ........................................................ 19
9
10 (1) The “watchful waiting” therapy model ....................................... 19
11 (2) The psychotherapy model: Alleviate distress by identifying and

addressing causes (model #3) ...................................................... 20
12
(3) The affirmation therapy model (model #4) ................................. 23
13
F. Patients differ widely and must be considered individually. ............... 26
14
15 III. GENDER IDENTITY, GENDER DYSPHORIA, AND THERAPIES FOR

GENDER DYSPHORIA IN YOUNGER CHILDREN ..................................... 27
16
A. Natural desistance is by far the most frequent resolution of gender
17 dysphoria in young children absent social transition. .......................... 27
18 B. Social transition of young children is a powerful psychotherapeutic
19 intervention that changes outcomes. ..................................................... 29
20 C. The administration of puberty blockers to children as a treatment for

gender dysphoria is experimental, presents obvious medical risks, and
21 appears to affect identity outcomes. ...................................................... 33
22 IV. THE AVAILABLE DATA DOES NOT SUPPORT THE CONTENTION THAT
23 “AFFIRMATION” OF TRANSGENDER IDENTITY IN CHILDREN AND
ADOLESCENTS REDUCES SUICIDE OR RESULTS IN BETTER
24 PHYSICAL OR MENTAL HEALTH OUTCOMES GENERALLY. ................ 37
25 V. KNOWN, LIKELY, OR POSSIBLE DOWNSIDE RISKS ATTENDANT ON
MOVING QUICKLY TO “AFFIRM” TRANSGENDER IDENTITY IN
26
CHILDREN AND ADOLESCENTS. ................................................................ 46
27
in Supp. of MPI i 15100 N. 90th Street
(480) 444-0020
1 A. Physical risks associated with transition .............................................. 48
2 B. Social risks associated with transition .................................................. 51

3 C. Mental health costs or risks ................................................................... 52
4
D. The risk of regret following transition .................................................. 56
5
10
11
12
13
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15
16
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18
19
20
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22
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24
25
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in Supp. of MPI ii 15100 N. 90th Street
(480) 444-0020
1 I, Dr. Stephen B. Levine, declare as follows:

2 I. CREDENTIALS & SUMMARY
3
1. I am Clinical Professor of Psychiatry at Case Western Reserve
4
University School of Medicine and maintain an active private clinical practice. I
5
6 received my MD from Case Western Reserve University in 1967 and completed a
7 psychiatric residency at the University Hospitals of Cleveland in 1973. I became an
8 Assistant Professor of Psychiatry at Case Western in 1973 and became a Full

9
Professor in 1985.
10
2. Since July 1973, my specialties have included psychological problems
11
12 and conditions relating to individuals’ sexuality and sexual relations, therapies for
13 sexual problems, and the relationship between love, intimate relationships, and
14 wider mental health. In 2005, I received the Masters and Johnson Lifetime
15
Achievement Award from the Society of Sex Therapy and Research which
16
“recognizes extraordinary contributions to clinical sexuality and/or sexual research
17
18 over the course of a lifetime and achievement of excellence in clinical and/or
19 research areas of sexual disorders.” 1 I am a Distinguished Life Fellow of the
20 American Psychiatric Association.

21
3. I have served as a book and manuscript reviewer for numerous
22
professional publications. I have been the Senior Editor of the first (2003), second
23
24 (2010), and third (2016) editions of the Handbook of Clinical Sexuality for Mental
25 Health Professionals. In addition to five previously solo-authored books for
26
27 1 Society for Sex Therapy & Research Awards, https://sstarnet.org/awards/.

in Supp. of MPI 1 15100 N. 90th Street
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1 professionals, I have recently published Psychotherapeutic Approaches to Sexual
2 Problems (2020). The book has a chapter titled “The Gender Revolution.”
3
4. I first encountered a patient suffering what we would now call gender
4
dysphoria in July 1973. In 1974, I founded the Case Western Reserve University
5
6 Gender Identity Clinic and have served as Co-Director of that clinic since that time.
7 Across the years, our Clinic treated hundreds of patients who were experiencing a
8 transgender identity. An occasional child was seen during this era. I was the
9
primary psychiatric care-giver for several dozen of our patients and supervisor of
10
the work of other therapists. As the incidence of gender dysphoria has increased
11
12 among children and youth in recent years, larger numbers of minors presenting
13 with actual or potential gender dysphoria have presented to our clinic. I currently
14 am providing psychotherapy for several minors in this area. I also counsel
15
distressed parents of these teens.
16
5. I was an early member of the Harry Benjamin International Gender
17
18 Dysphoria Association (now known as the World Professional Association for
19 Transgender Health or WPATH) and served as the Chairman of the committee that
20 developed the 5th version of its Standards of Care. The vast majority of the 6th
21
version contains the exact prose that my committee wrote for the 5th version. In
22
1993 our Gender Identity Clinic was renamed, moved to a new location, and became
23
24 independent of Case Western Reserve University. I continue to serve as Co-
25 Director.
26
27

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1 6. In 2006, Judge Mark Wolf of the Eastern District of Massachusetts
2 asked me to serve as an independent, court-appointed expert in litigation involving

3
the treatment of a transgender inmate within the Massachusetts prison system. I
4
have been retained by the Massachusetts Department of Corrections as a
5
6 consultant on the treatment of transgender inmates since 2007.
7 7. In 2019, I was qualified as an expert and testified concerning the

8 diagnosis, understanding, developmental paths and outcomes, and therapeutic
9
treatment of transgenderism and gender dysphoria, particularly as it relates to
10
children, in the matter of In the Interest of J.A.D.Y. and J.U.D.Y., Case No. DF-15-
11
12 09887-S, 255th Judicial District, Dallas County, TX.
13 8. A fuller review of my professional experience, publications, and awards

14 is provided in my curriculum vitae, a copy of which is attached hereto as Exhibit A.
15
9. My many years of experience in working with adults or older young
16
adults who are living in a transgender identity or who suffer from gender dysphoria
17
18 provide a wide lifecycle view which, along with my familiarity with the literature
19 concerning them, provides an important cautionary perspective. The psychiatrist or

20 psychologist treating a trans child or adolescent of course seeks to make the young
21
patient happy, but the overriding consideration is the creation of a happy, highly
22
functional, mentally healthy person for the next 50 to 70 years of life. I refer to
23
24 treatment that keeps this goal in view as the “life course” perspective.
25 10. A summary of the key points that I explain in this statement is as

26 follows:
27

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1 a. Sex as defined by biology and reproductive function cannot be
2 changed. While hormonal and surgical procedures may enable a female-

3
identifying male to “pass” as being female (or vice versa) during some or all of
4
their lives, such procedures carry with them physical, psychological, and
5
6 social risks, and no procedures can enable an individual to perform the
7 reproductive role of the opposite sex. (Section II.A.)

8 b. The diagnosis of “gender dysphoria” encompasses a diverse array of
9
conditions, with widely differing pathways and characteristics depending on
10
age of onset, biological sex, mental health, intelligence, motivations for
11
12 gender transition, socioeconomic status, country of origin, etc. Data from one
13 population (e.g., adults) cannot be assumed to be applicable to others (e.g.,

14 children). (Section II.B.) Generalizations about the treatment children in one
15
country (e.g., Holland) do not necessarily apply to another (e.g., United
16
States).
17
18 c. Among psychiatrists and psychotherapists who practice in the area,
19 there are currently widely varying views concerning both the causes of and
20 appropriate therapeutic response to gender dysphoria in children. Existing
21
studies do not provide a basis for a scientific conclusion as to which
22
therapeutic response results in the best long-term outcomes for affected
23
24 individuals. (Sections II.E, II.F.)
25 d. A majority of children (in several studies, a large majority) who are

26 diagnosed with gender dysphoria “desist”—that is, their gender dysphoria
27

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1 does not persist—by puberty or adulthood unless transgender-affirming
2 therapeutic or medical interventions modify the normal course of maturation.

3
It is not currently known how to distinguish children who will persist from
4
those who will not. (Section III.)
5
6 e. Some recent studies suggest that active affirmation of transgender
7 identity in young children will substantially reduce the number of children

8 who would desist from transgender identity through the course of puberty.
9
This raises the ethical concern that this will increase the number of
10
individuals who suffer the multiple long-term physical, mental, and social
11
12 harms and limitations that are strongly associated with living life as a
13 transgender person. (Sections III, V.)

14 f. Typically, social transition is a first step in gender affirmation. It is
15
itself an important intervention with profound implications for the long-term
16
mental and physical health of the child. When a mental health professional
17
18 (MHP) evaluates a child or adolescent and then recommends social
19 transition, that professional should be available to help with interpersonal,

20 familial, and psychological problems that may already exist and will likely
21
arise after transition. However, today many children are started on puberty
22
blockers, and adolescents are medically transitioned, without a thorough,
23
24 long-lasting mental health assessment and psychological ongoing care,
25 leaving themselves and their families on their own to deal with ongoing and
26 subsequent problems. (Sections III, V.)
27

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1 g. The knowledge base concerning the cause and treatment of gender
2 dysphoria available today has low scientific quality. (Section IV.)

3
h. There are no studies that show with any methodological and
4
statistical validity that affirmation of transgender identity in young children
5
6 reduces suicide or suicidal ideation, or improves long-term outcomes as
7 compared to other therapeutic approaches. Meanwhile, multiple studies show

8 that adult individuals living transgender lives suffer much higher rates of
9
suicidal ideation, completed suicide, and negative physical and mental health
10
conditions than does the general population before and after transition,
11
12 hormones, and surgery. There are no randomized studies that compare
13 outcomes among older teens and adults with gender dysphoria who have
14 affirmation treatment with those who do not. (Section IV.)
15
i. In light of what is known and not known about the impact of
16
affirmation on the incidence of suicide, suicidal ideation, and other indicators
17
18 of mental and physical health, it is scientifically baseless, and therefore
19 unethical, to assert that a child or adolescent who expresses an interest in a

20 transgender identity will kill him- or herself unless adults and peers affirm
21
that child in a transgender identity. (Section IV.)
22
j. Putting a child or adolescent on a pathway towards life as a
23
24 transgender person puts that individual at risk of a wide range of long-term
25 or even life-long harms, including: sterilization (first chemical, then surgical)

26 and associated regret and sense of loss; inability to experience orgasm (for
27

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1 trans women); physical health risks associated with exposure to elevated
2 levels of cross-sex hormones; surgical complications and life-long after-care;

3
alienation of family relationships; inability to form lasting romantic
4
relationships and attract a desirable mate; and elevated mental health risks
5
6 of depression, anxiety, and substance abuse. (Section V.)
7 II. BACKGROUND ON THE FIELD

8 A. The biological baseline of sex
9 11. Gender identity advocates commonly refer to the sex of an individual
10
as “assigned at birth.” This phrase is misleading. The sex of a human individual at
11
its core structures the individual’s biological reproductive capabilities—to produce
12
13 ova and bear children as a mother, or to produce semen and beget children as a
14 father. As physicians know, sex determination occurs at the instant of conception,

15 depending on whether a sperm’s X or Y chromosome fertilizes the egg. Medical
16
technology can now determine a fetus’s sex before birth almost as easily as after
17
birth. It is thus not correct to assert that doctors “assign” the sex of a child at birth.
18
19 Instead, they simply recognize the existing fact of that child’s sex. Barring rare
20 disorders of sexual development, anyone can identify the sex of an infant by genital
21 inspection. What the general public may not understand, however, is that every
22
nucleated cell of an individual’s body is chromosomally identifiably male or
23
female—XY or XX.
24
25 12. The self-perceived gender of a child, in contrast, arises in part from
26 how others label the infant: “I love you, son (daughter).” This designation occurs
27 thousands of times in the first two years of life when a child begins to show

(480) 444-0020
1 awareness of the two possibilities. As acceptance of the designated gender
2 corresponding to the child’s sex is the outcome in >99% of children everywhere,

3
anomalous gender identity formation begs for understanding. Is it biologically
4
shaped? Is it biologically determined? Is it the product of how the child was
5
6 privately regarded and treated? Does it stem from trauma-based rejection of
7 maleness or femaleness, and if so, flowing from what trauma? Does it derive from a
8 tense, chaotic interpersonal parental relationship without physical or sexual abuse?
9
Is it a symptom of another, as of yet unrevealed, emotional disturbance or
10
neuropsychiatric condition such as autism? The answers to these relevant questions
11
12 are not scientifically known.
13 13. Under the influence of hormones secreted by the testes or ovaries,

14 numerous additional sex-specific differences between male and female bodies
15
continuously develop postnatally, culminating in the dramatic maturation of the
16
primary and secondary sex characteristics with puberty. These include differences
17
18 in hormone levels, height, weight, bone mass, shape and development, musculature,
19 body fat levels and distribution, and hair patterns, as well as physiological
20 differences such as menstruation. These are genetically programmed biological
21
consequences of sex, which also serve to influence the consolidation of gender
22
identity during and after puberty.
23
24 14. Despite the increasing use of cross-sex hormones and various surgical
25 procedures to reconfigure some male bodies to visually pass as female, or vice versa,
26 the biology of the person remains as defined by his (XY) or her (XX) chromosomes,
27

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1 including cellular, anatomic, and physiologic characteristics and the particular
2 disease vulnerabilities associated with that chromosomally-defined sex. For

3
instance, the XX (genetically female) individual who takes testosterone to stimulate
4
certain male secondary sex characteristics will nevertheless remain unable to
5
6 produce sperm and father children. Thus in critical respects, gender affirmation
7 changes can only be anatomically “skin deep.” Contrary to assertions and hopes that
8 medicine and society can fulfill the aspiration of the trans individual to become “a
9
complete man” or “a complete woman,” this is not biologically attainable. 2 It is
10
possible for some adolescents and adults to pass unnoticed in daily life as the
11
12 opposite sex that they aspire to be—but with limitations, costs, and risks, as I detail
13 later. These risks include a continuing sense of inauthenticity as a member of the

14 opposite sex.
15
B. Definition and diagnosis of gender dysphoria
16
15. Specialists have used a variety of terms over time, with somewhat
17
shifting definitions, to identify and speak about a distressing incongruence between
18
19 an individual’s sex as determined by their chromosomes and their thousands of
20 genes, and the gender with which they eventually subjectively identify or to which
21
they aspire. Today’s American Psychiatric Association Diagnostic and Statistical
22
Manual of Mental Disorders (“DSM-5”) employs the term Gender Dysphoria and
23
24
25
26 2 S. Levine (2018), Informed Consent for Transgendered Patients, J. OF SEX & MARITAL THERAPY at 6
(“Informed Consent”); S. Levine (2016), Reflections on the Legal Battles Over Prisoners with Gender
27 Dysphoria, J. AM. ACAD. PSYCHIATRY LAW 44, 236 at 238 (“Reflections”).

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1 defines it with separate sets of criteria for adolescents and adults on the one hand,
2 and children on the other.

3
16. There are at least five distinct pathways to gender dysphoria: early
4
childhood onset; onset near or after puberty with no prior cross gender patterns;
5
6 onset after defining oneself as gay or lesbian for several or more years and
7 participating in a homosexual life style; adult onset after years of heterosexual

8 transvestism; and onset in later adulthood with few or no prior indications of cross-
9
gender tendencies or identity.
10
17. Gender dysphoria has very different characteristics depending on age
11
12 and sex at onset. Young children who are living a transgender identity commonly
13 suffer materially fewer symptoms of concurrent mental distress than do older

14 patients. 3 The developmental and mental health patterns for each of these groups
15
are sufficiently different that data developed in connection with one of these
16
populations cannot be assumed to be applicable to another.
17
18 18. The criteria used in DSM-5 to identify Gender Dysphoria include a
19 number of signs of discomfort with one’s natal sex and vary somewhat depending on
20 the age of the patient, but in all cases require “clinically significant distress or
21
impairment in . . . important areas of functioning” such as social, school, or
22
occupational settings.
23
24
25
26 3K. Zucker (2018), The Myth of Persistence: Response to “A Critical Commentary on Follow-Up
Studies & ‘Desistance’ Theories about Transgender & Gender Non-Conforming Children” by Temple
27 Newhook et al., INT’L J. OF TRANSGENDERISM at 10 (“Myth of Persistence”).

(480) 444-0020
1 19. When these criteria in children (or adolescents, or adults) are not met,
2 two other diagnoses may be given. These are: Other Specified Gender Dysphoria
3
and Unspecified Gender Dysphoria. Specialists sometimes refer to children who do
4
not meet criteria as being “subthreshold.”
5
6 20. Children who conclude that they are transgender are often unaware of
7 a vast array of adaptive possibilities for how to live life as a man or a woman—
8 possibilities that become increasingly apparent over time to both males and
9
females. A boy or a girl who claims or expresses interest in pursuing a transgender
10
identity often does so based on stereotypical notions of femaleness and maleness
11
12 that reflect constrictive notions of what men and women can be. 4 A young child’s—
13 or even an adolescent’s—understanding of this topic is quite limited. Nor can they

14 grasp what it may mean for their future to be sterile. These children and
15
adolescents consider themselves to be relatively unique; they do not realize that
16
discomfort with the body and perceived social role is neither rare nor new to
17
18 civilization. What is new is that such discomfort is thought to indicate that they
19 must be a trans person.

20 21. “Gender identity,” as that term is commonly used in public discourse
21
as well as academic publication, is distinct from sex. Unfortunately, “gender
22
identity” has no distinct objective definition by which a subject’s gender identity
23
24 may be confirmed. The Department of Health and Human Services has defined
25
26 4S. Levine (2017), Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria, J.
OF SEX & MARITAL THERAPY at 7 (“Ethical Concerns”) (available at
27 http://dx.doi.org/10.1080/0092623X.2017.1309482.)

(480) 444-0020
1 “gender identity” as “an individual’s internal sense of gender, which may be male,
2 female, neither, or a combination of male and female, and which may be different
3
from an individual’s sex assigned at birth. 5 A publication sponsored by the ACLU,
4
National Center for Lesbian Rights, Human Rights Campaign, and National
5
6 Education Association asserts that gender identity encompasses any “deeply-felt
7 sense of being male, female, both or neither,” and can include a “gender spectrum”
8 “encompassing a wide range of identities and expressions.” That source goes on to
9
say that an individual may have an “internal sense of self as male, female, both or
10
neither,” and that “each person is in the best position to define their own place on
11
12 the gender spectrum.” 6 The medical text Principles of Transgender Medicine and
13 Surgery, states that “Gender identity can be conceptualized as a continuum, a

14 Mobius, or patchwork.” 7
15
22. In sum, gender identity is said to refer to an individual’s subjective
16
perceptions of where that person falls on a continuum of genders ranging from very
17
18 masculine gender to very feminine, but is also said to include genders which are
19 some of either or something else entirely, or no gender at all (e.g., agender). There
20 are no objective indicia that define or establish one’s gender within this paradigm.
21
22
23
24 5 Nondiscrimination in Health Programs and Activities, 81 Fed. Reg. 31,376 (May 18, 2016) at
31,384.
25
6Asaf Orr et al., NATIONAL CENTER FOR LESBIAN RIGHTS, Schools in Transition: A Guide for
26 Supporting Transgender Students in K-12 Schools, at 5-7 (2015), https://www.nclrights.org/wp-
content/uploads/2015/08/Schools-in-Transition-2015-Online.pdf.
27 7 R. Ettner, et al. (2016), Principles of Transgender Medicine and Surgery (Routledge 2nd ed.) at 43.

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1 23. In clinical experience, I observe patients experiencing gender identity
2 as an often-evolving mixture of male and female identification, which may be

3
influenced by the patient’s reactions to cultural stereotypes, and/or by the patient’s
4
past and present family dynamics. The gender identity composite, however, is just
5
6 one-third of the self-labels that constitute sexual identity. The other two
7 components are the dimensions of sexual orientation—heterosexual, homosexual,

8 and bisexual--and the generally avoided dimension of sexual intention—what one
9
wants to do with a partner’s body and what one wants done to his or her body. In
10
my view gender identity is merely a part of sexual identity, and an even smaller
11
12 part of the individual’s total self-identification.
13 C. Impact of gender dysphoria on minority and vulnerable groups

14 24. In considering the appropriate response to gender dysphoria, it is
15
important to know that certain groups of children and adolescents have an
16
increased prevalence and incidence of trans identities. These include: children of
17
color, 8 children with mental developmental disabilities, 9 including children on the
18
19 autistic spectrum (at a rate more than 7x the general population), 10 children
20 residing in foster care homes, adopted children (at a rate more than 3x the general
21
22
23 8 G. Rider et al. (2018), Health and Care Utilization of Transgender/Gender Non-Conforming Youth:
A Population Based Study, PEDIATRICS 141:3 at 4 (In a large sample, non-white youth made up 41%
24 of the set who claimed a transgender or gender-nonconforming identity, but only 29% of the set who
had a gender identity consistent with their sex.).
25
9D. Shumer & A. Tishelman (2015), The Role of Assent in the Treatment of Transgender Adolescents,
26 INT. J. TRANSGENDERISM at 1 (available at doi: 10.1080/15532739.2015.1075929).
10 D. Shumer et al. (2016), Evaluation of Asperger Syndrome in Youth Presenting to a Gender
27 Dysphoria Clinic, LGBT HEALTH, 3(5) 387 at 387.

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1 population), 11 children with a prior history of psychiatric illness, 12 and more
2 recently adolescent girls (in a large recent study, at a rate more than 2x that of
3
boys) (Rider, 2018 at 4).
4
25. The social transitioning, hormonal, and surgical paths often
5
6 recommended and facilitated by gender clinics may lead to sterilization by the time
7 the patient reaches young adulthood. They may add a future source of despair in an
8 already vulnerable person. Caution and time to reflect as the patient matures are
9
prudent when dealing with a teen’s sense of urgency about transition.
10
D. Three competing conceptual models of gender dysphoria and
11 transgender identity
12
26. Discussions about appropriate responses by MHPs to actual or sub-
13
threshold gender dysphoria are complicated by the fact that various speakers and
14
advocates (or a single speaker at different times) view transgenderism through at
15
16 least three very different paradigms, often without being aware of, or at least
17 without acknowledging, the distinctions.

18
19
20
D. Shumer et al. (2017), Overrepresentation of Adopted Adolescents at a Hospital-Based Gender
11
21 Dysphoria Clinic, TRANSGENDER HEALTH Vol. 2(1) 76 at 77.

12 L. Edwards-Leeper et al. (2017), Psychological Profile of the First Sample of Transgender Youth
22 Presenting for Medical Intervention in a U.S. Pediatric Gender Center, PSYCHOLOGY OF SEXUAL
ORIENTATION AND GENDER DIVERSITY, 4(3) 374 at 375; R. Kaltiala-Heino et al. (2015), Two Years of
23 Gender Identity Service for Minors: Overrepresentation of Natal Girls with Severe Problems in
Adolescent Development, CHILD & ADOLESCENT PSYCHIATRY & MENTAL HEALTH 9(9) 1 at 5. (In 2015
24 Finland gender identity service statistics, 75% of adolescents assessed “had been or were currently
undergoing child and adolescent psychiatric treatment for reasons other than gender dysphoria.”); L.
25 Littman (2018), Parent Reports of Adolescents & Young Adults Perceived to Show Signs of a Rapid
Onset of Gender Dysphoria, PLoS ONE 13(8): e0202330 at 13 (Parental survey concerning
26 adolescents exhibiting Rapid Onset Gender Dysphoria reported that 62.5% of gender dysphoric
adolescents had “a psychiatric disorder or neurodevelopmental disability preceding the onset of
27 gender dysphoria.”).

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1 27. Gender dysphoria is conceptualized and described by some
2 professionals and laypersons as though it were a serious, physical medical

3
illness that causes suffering, comparable, for example, to prostate cancer, a
4
disease that is curable before it spreads. Within this paradigm, whatever is causing
5
6 distress associated with gender dysphoria—whether secondary sex characteristics
7 such as facial hair, nose and jaw shape, presence or absence of breasts, or the
8 primary anatomical sex organs of testes, ovaries, penis, or vagina—should be
9
removed to alleviate the illness. The promise of these interventions is the cure of
10
the gender dysphoria.
11
12 28. It should be noted, however, that gender dysphoria is a psychiatric, not
13 a medical, diagnosis even though that is how it is often introduced into court
14 settings. Since its inception in DSM-III in 1983, it has always been specified in the
15
psychiatric DSM manuals and is not specified in medical diagnostic manuals.
16
Notably, gender dysphoria is the only psychiatric condition to be treated by surgery,
17
18 even though no endocrine or surgical intervention package corrects any identified
19 biological abnormality. (Levine, Reflections, at 240.) This medicalization of gender

20 dysphoria is at some level at odds with psychologists’ longstanding concerns about
21
or even opposition to “practice guidelines that recommend the use of medications
22
over psychological interventions in the absence of data supporting such
23
24 recommendations. 13
25
26
13 AM. PSYCH. ASS’N (2005) Report of the 2005 Presidential Task Force on Evidence-Based Practice at
27 2 (available at https://www.apa.org/practice/resources/evidence/evidence-based-report.pdf.)

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1 29. Gender dysphoria is alternatively conceptualized in
2 developmental terms, as an adaptation to a psychological problem that was first

3
manifested as a failure to establish a comfortable conventional sense of self in early
4
childhood or confusion about the self that intensifies with puberty. This paradigm
5
6 starts from the premise that all human lives are influenced by past processes and
7 events. Trans lives are not exceptions to this axiom. (Levine, Reflections at 238.)
8 MHPs who think of gender dysphoria through this paradigm may work both to
9
identify and address the apparent causes of the basic problem of the deeply
10
uncomfortable self, and also to ameliorate suffering when the underlying problem
11
12 cannot be solved. They work with the patient and (ideally) the patient’s family to
13 inquire what forces may have led to the trans person repudiating the gender
14 associated with his sex. The developmental paradigm is mindful of temperamental,
15
parental bonding, psychological, sexual, and physical trauma influences, and the
16
fact that young children work out their psychological issues through fantasy and
17
18 play. The developmental paradigm does not preclude a biological temperamental
19 contribution to some patients’ lives; it merely objects to assuming these problems

20 are biological in origin. All sexual behaviors and experiences involve the brain and
21
the body.
22
30. In addition, the developmental paradigm recognizes that, with the
23
24 important exception of genetic sex, essentially all aspects of an individual’s identity
25 evolve—often markedly—across the individual’s lifetime. This includes gender.

26
27

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1 31. Some advocates assert that a transgender identity is biologically
2 caused, fixed from early life, and invariably persists through life in an unchanging
3
manner. This assertion, however, is not supported by science. 14 Although numerous
4
studies have been undertaken to attempt to demonstrate a distinctive physical
5
6 brain structure associated with transgender identity, as of yet there is no evidence
7 that these patients have any defining abnormality in brain structure that precedes
8 the onset of gender dysphoria. The belief that gender dysphoria is the consequence
9
of brain structure is challenged by the sudden increase in incidence of child and
10
adolescent gender dysphoria over the last twenty years in North America and
11
12 Europe. Meanwhile, multiple studies have documented rapid shifts in gender ratios
13 of patients presenting for care with gender-related issues, pointing to cultural

14 influences, 15 while a recent study documented “clustering” of new presentations in
15
specific schools and among specific friend groups, pointing to social influences. 16
16
Both of these findings strongly suggest cultural factors. From the beginning of
17
18 epidemiological research into this arena, there have always been some countries
19 (Poland and Australia, for example) where the sex ratios were reversed as compared
20 to North America and Europe, again demonstrating a powerful effect of cultural
21
influences.
22
23
24 14 Even the advocacy organization The Human Rights Campaign asserts that a person can have “a
fluid or unfixed gender identity.” https://www.hrc.org/resources/glossary-of-terms.

25
15Levine, Ethical Concerns, at 8 (citing M. Aitken et al. (2015), Evidence for an Altered Sex Ratio in
26 Clinic-Referred Adolescents with Gender Dysphoria, J. OF SEXUAL MED.12(3) 756 at 756-63.)
16Lisa Littman (2018), Parent reports of adolescents and young adults perceived to show signs of a
27 rapid onset of dysphoria, PLoS ONE 13(8): e0202330.

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1 32. Further, as I detail later below, many studies and clinical observations
2 confirm that gender identity can and does change or evolve over time for many
3
individuals. And recent studies and anecdotal reports provide strong if preliminary
4
evidence that therapeutic choices can have a powerful effect on whether and how
5
6 gender identity does change, or gender dysphoria desists.
7 33. In recent years, for adolescent patients, intense involvement with

8 online transgender communities or “friends” is the rule rather than the exception,
9
and the MHP will also be alert to this as a potentially significant influence on the
10
identity development of the patient. Finally, the large accumulating reports of late
11
12 adolescent and young adult individuals who return to their natally assigned gender
13 identity highlight the error of assuming a trans identity is a permanent feature 17.
14 34. The third paradigm through which gender dysphoria is alternatively
15
conceptualized is from a sexual minority rights perspective. Under this
16
paradigm, any response other than medical and societal affirmation and
17
18 implementation of a patient’s claim to “be” the opposite gender is a violation of the
19 individual’s civil right to self-expression. Any effort to ask “why” questions about
20 the patient’s condition, or to address underlying causes, is viewed as a violation of
21
autonomy and civil rights. Any attempt to slowly review the risks of affirmative and
22
alternative interventions in detail is viewed as irrelevant. In the last few years, this
23
24 paradigm has been successful in influencing public policy and the education of
25
26
17 P. Expósito-Campos (2021). A Typology of Gender Detransition and Its Implications for Healthcare
27 Providers. J. OF SEX & MARITAL THERAPY, 47(3), 270–280.

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1 pediatricians, endocrinologists, and many mental health professionals. Obviously,
2 however, this is not a medical, psychiatric, or scientific perspective.

3
E. Four competing models of therapy
4
35. Because of the complexity of the human psyche and the difficulty of
5
running controlled experiments in this area, substantial disagreements among
6
7 professionals about the causes of psychological disorders, and about the appropriate
8 therapeutic responses, are not unusual. When we add to this the very different
9
paradigms for understanding transgender phenomena discussed above, it is not
10
surprising that such disagreements also exist with regard to appropriate therapies
11
for patients experiencing gender-related distress. I summarize below the leading
12
13 approaches, and offer certain observations and opinions concerning them.
14 (1) The “watchful waiting” therapy model

15 36. I review below the uniform finding of follow-up studies that the large
16
majority of children who present with gender dysphoria will desist from desiring a
17
transgender identity by adulthood if left untreated. (Section III.A)
18
19 37. When a pre-adolescent child presents with gender dysphoria, a
20 “watchful waiting” approach seeks to allow for the fluid nature of gender identity in
21 children to naturally evolve—that is, take its course from forces within and
22
surrounding the child. Watchful waiting has two versions:
23
a. Treating any other psychological co-morbidities—that is, other
24
25 mental illnesses as defined by DSM-5—that the child may exhibit (e.g.,
26 separation anxiety, bedwetting, attention deficit disorder, obsessive-

27 compulsive disorder) without a focus on gender (model #1); and

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1 b. No treatment at all for anything but a regular follow-up
2 appointment. This might be labeled a “hands off” approach (model #2).

3
(2) The psychotherapy model: Alleviate distress by identifying and
4 addressing causes (model #3)
5 38. One of the foundational principles of psychotherapy has long been to
6
work with a patient to identify the causes of observed psychological distress and
7
then to address those causes as a means of alleviating the distress. The National
8
Institute of Mental Health has promulgated the idea that 75% of adult
9
10 psychopathology has its origins in childhood experience.
11 39. Many experienced practitioners in the field of gender dysphoria,

12
including myself, have believed that it makes sense to employ these long-standing
13
tools of psychotherapy for patients suffering gender dysphoria, asking the question
14
as to what factors in the patient’s life are the determinants of the patient’s
15
16 repudiation of his or her natal sex. (Levine, Ethical Concerns, at 8.) I and others
17 have reported success in alleviating distress in this way for at least some patients,
18
whether or not the patient’s sense of discomfort or incongruence with his or her
19
natal sex entirely disappeared. Relieving accompanying psychological co-morbidities
20
leaves the patient freer to consider the pros and cons of transition as he or she
21
22 matures.
23 40. Among other things, the psychotherapist who is applying traditional

24
methods of psychotherapy may help—for example—the male patient appreciate the
25
wide range of masculine emotional and behavioral patterns as he grows older. He
26
may discuss with his patient, for example, that one does not have to become a
27

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1 “woman” in order to be kind, compassionate, caring, noncompetitive, and devoted to
2 others’ feelings and needs. 18 Many biologically male trans individuals, from
3
childhood to older ages, speak of their perceptions of femaleness as enabling them to
4
discuss their feelings openly, whereas they perceive boys and men to be constrained
5
6 from emotional expression within the family and larger culture. Men, of course, can
7 be emotionally expressive, just as they can wear pink. Converse examples can be
8 given for girls and women. These types of ideas regularly arise during
9
psychotherapies.
10
41. As I note above, many gender-nonconforming children and adolescents
11
12 in recent years derive from minority and vulnerable groups who have reasons to feel
13 isolated and have an uncomfortable sense of self. A trans identity may be the
14 individual’s hopeful attempt to redefine the self in a manner that increases their
15
comfort and decreases their anxiety. The clinician who uses traditional methods of
16
psychotherapy may not focus on their gender identity, but instead work to help
17
18 them to address the actual sources of their discomfort. Success in this effort may
19 remove or reduce the desire for a redefined identity. This often involves a focus on
20 disruptions in their attachment to parents in vulnerable children, for instance,
21
those in the foster care system.
22
42. Because “watchful waiting” can include treatment of accompanying
23
24 psychological co-morbidities, and the psychotherapist who hopes to relieve gender
25
26
18 S. Levine (2017), Transitioning Back to Maleness, ARCH. OF SEXUAL BEHAVIOR 47(4) at 7
27 (“Transitioning”) (available at https://link.springer.com/article/10.1007/s10508-017-1136-9.)

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1 dysphoria may focus on potentially causal sources of psychological distress rather
2 than on the gender dysphoria itself, there is no sharp line between “watchful
3
waiting” and the psychotherapy model in the case of prepubescent children.
4
43. To my knowledge, there is no evidence beyond anecdotal reports that
5
6 psychotherapy can predictably enable a return to male identification for gender
7 dysphoric genetically male boys, adolescents, and men, or return to female

8 identification for gender dysphoric genetically female girls, adolescents, and women.
9
On the other hand, anecdotal evidence of such outcomes does exist. I and other
10
clinicians have witnessed reinvestment in the patient’s biological sex in some
11
12 individual patients who are undergoing psychotherapy. And from the earliest days
13 of my career, traditional psychotherapy showed both promise and beneficial

14 outcomes in reducing the distress of gender dysphoria. It did so without presuming
15
gender affirmation as a preferred or mandated approach. When distress is
16
significantly lessened, the person may find some comfortable adaptation short of
17
18 bodily change.
19 44. More recently, I myself have published a paper on a patient who

20 sought my therapeutic assistance to reclaim his male gender identity after 30 years
21
living as a woman and is in fact living as a man today, (Levine, Transitioning), I
22
have seen children desist even before puberty in response to thoughtful parental
23
24 interactions and a few meetings of the child with a therapist. I have seen patients
25 desist when their intimate relationships change.

26
27

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1 (3) The affirmation therapy model (model #4)
2 45. While it is widely agreed that the therapist should not directly
3
challenge a claimed transgender identity in a child, some advocates and
4
practitioners go much further, and promote and recommend that any expression of
5
transgender identity should be immediately accepted as decisive, and thoroughly
6
7 affirmed by means of consistent use of clothing, toys, pronouns, etc., associated with
8 the transgender identity to which the child expresses an attraction. These advocates
9
treat any question about the causes of the child’s transgender identification as
10
inappropriate and assume that observed psychological co-morbidities in the children
11
or their families are unrelated or will get better with transition and need not be
12
13 addressed by the MHP who is providing supportive guidance concerning the child’s
14 gender identity.
15
46. Some advocates, indeed, assert that unquestioning affirmation of any
16
claim of transgender identity in children is essential, and that the child will
17
otherwise face a high risk of suicide or severe psychological damage. I address
18
19 claims about suicide and health outcomes in Sections IV and V below.
20 47. The idea that social transition is the only accepted treatment for
21
prepubertal children is not correct. On the contrary, one respected academic in the
22
field has recently written that “almost all clinics and professional associations in
23
the world” do not use “gender affirmation” for prepubescent children and instead
24
25 “delay any transitions after the onset of puberty.” 19 This approach is widely
26
19 J. Cantor (2020), Transgender and Gender Diverse Children and Adolescents: Fact-Checking of
27 AAP Policy, J. OF SEX & MARITAL THERAPY VOL. 46, NO. 4, 307-313.

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1 practiced because when the intrapsychic, biological, and social developmental
2 processes of puberty are allowed to act unimpaired (but accompanied by supporting

3
therapy), resolution of the gender dysphoria is by far the most common outcome. 20
4
Natural desistance offers a reasonable likelihood of sparing the individual the life-
5
6 long physical, mental, and social stresses associated with living in a transgender
7 identity, which I discuss in Section V.

8 48. It is notable that even the Standards of Care published by WPATH, an
9
organization which in general leans strongly towards affirmation in the case of
10
adults, do not specify affirmation of transgender identity as the indicated
11
12 therapeutic response for young children. Instead, the WPATH Standards of Care
13 recognize that social transition in early childhood “is a controversial issue, and
14 divergent views are held by health professionals”; state that “[t]he current evidence
15
base is insufficient to predict the long-term outcomes of completing a gender role
16
transition during early childhood”; and acknowledge that “previously described
17
18 relatively low persistence rates of childhood gender dysphoria” are “relevant” to the
19 wisdom of social transition in childhood. 21

20
21 20D. Singh et al. (2021), A Follow-Up Study of Boys With Gender Identity Disorder, FRONTIERS IN
PSYCHIATRY Vol. 12:632784 at 12 (available at https://www.ncbi.nlm.nih.gov
22 /pmc/articles/PMC8039393/.)
21 WORLD PROF’L ASS’N FOR TRANSGENDER HEALTH (2011), Standards of Care for the Health of
23 Transsexual, Transgender, and Gender-Nonconforming People (7th Version) at 17. I note that I
regretfully resigned from the precursor organization of WPATH in 2002 after concluding that many
24 of its positions of enthusiastic and unqualified support of transition for individuals suffering from
gender dysphoria were dictated by politics and ideology, rather than by any scientific basis. WPATH
25 is composed of a mix of practitioners and transgender activists with little or no scientific training,
and its most recent self-designated “Standards of Care” are not reflective of the practices of a large
26 number of psychiatrists and Ph.D. psychologists who practice in this area. For this reason, WPATH’s
cautious position with regard to transition of children who suffer from gender dysphoria is all the
27 more notable.

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1 49. In contrast to WPATH’s cautious position with respect to children, in
2 2018 the American Academy of Pediatrics issued a statement asserting that “gender
3
transition” “is safe, effective, and medically necessary treatment for the health and
4
wellbeing of children and adolescents suffering from gender dysphoria.” 22 But in a
5
6 peer-reviewed paper, based on a careful review of the sources cited in the AAP
7 statement, prominent researcher James Cantor concluded that “In its policy
8 statement, AAP told neither the truth nor the whole truth, committing sins both of
9
commission and of omission, asserting claims easily falsified by anyone caring to do
10
any fact-checking at all,” and described Rafferty 2018 as “a systematic exclusion
11
12 and misrepresentation of entire literatures.” (Cantor at 312.) Based on my
13 professional expertise and my review of the literature, I agree with Dr. Cantor’s
14 evaluation of Rafferty 2018.
15
50. In fact, the DSM-5 added—for both children and adolescents—a
16
requirement that a sense of incongruence between biological and felt gender must
17
18 last at least six months as a precondition for a diagnosis of gender dysphoria,
19 precisely because of the risk of “transitory” symptoms and “hasty” diagnosis that
20 might lead to “inappropriate” treatments. 23
21
51. I do not know what proportion of practitioners are using which model.
22
However, in my opinion, in the case of young children, prompt and thorough
23
24
22J. Rafferty (2018), Committee on Psychosocial Aspects of Child and Family Health, Committee on
25 Adolescence and Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness,
PEDIATRICS 142(4): 2018-2162.
26 23 K. Zucker (2015), The DSM-5 Diagnostic Criteria for Gender Dysphoria, in C. Trombetta et al.
(eds.), MANAGEMENT OF GENDER DYSPHORIA: A MULTIDISCIPLINARY APPROACH (Springer-Verlag

27 Italia).

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1 affirmation of a transgender identity disregards the principles of child development
2 and family dynamics and is not supported by science. Rather, the MHP must focus
3
attention on the child’s underlying internal and familial issues. Ongoing
4
relationships between the MHP and the parents, and the MHP and the child, are
5
6 vital to help the parents, child, other family members, and the MHP to understand
7 over time the issues that need to be dealt with over time by each of them.
8 52. Likewise, since the child’s sense of gender develops in interaction with
9
his parents and their own gender roles and relationships, the responsible MHP will
10
almost certainly need to delve into family and marital dynamics.
11
12 F. Patients differ widely and must be considered individually.
13 53. In my opinion, it is not possible to make a single, categorical statement
14 about the proper treatment of children or adolescents presenting with gender

15
dysphoria or other gender-related issues. There is no single pathway of development
16
and outcomes governing transgender identity, nor one that predominates over the
17
large majority of cases. Instead, as individuals grow up and age, depending on their
18
19 differing psychological, social, familial, and life experiences, their outcomes differ
20 widely.
21
54. As to causes in children and adolescents, details about the onset of
22
gender dysphoria may be found in an understanding of family relationship
23
dynamics. In particular, the relationship between the parents and each of the
24
25 parents and the child, and each of the siblings and the child, should be well known
26 by the MHP. Further, a disturbingly large proportion of children and adolescents

27
who seek professional care in connection with gender issues have a wider history of
(480) 444-0020
1 psychiatric co-morbidities. (See supra n. 12.) A 2017 study from the Boston
2 Children’s Hospital Gender Management Service program reported that:

3
“Consistent with the data reported from other sites, this investigation documented
4
that 43.3% of patients presenting for services had significant psychiatric history,
5
6 with 37.1% having been prescribed psychotropic medications, 20.6% with a history
7 of self-injurious behavior, 9.3% with a prior psychiatric hospitalization, and 9.3%

8 with a history of suicide attempts.” (Edwards-Leeper at 375.) It seems likely that an
9
even higher proportion will have had prior undiagnosed psychiatric conditions.
10
55. In the case of adolescents, as I have noted above, there is evidence that
11
12 peer social influences through “friend groups” (Littman) or through the internet can
13 increase the incidence of gender dysphoria or claims of transgender identity, so the

14 responsible MHP will want to probe these potential influences to better understand
15
what is truly deeply tied to the psychology of this particular individual, and what
16
may instead be “tried on” by the youth as part of the adolescent process of self-
17
18 exploration and self-definition.
19 III. GENDER IDENTITY, GENDER DYSPHORIA, AND THERAPIES FOR

GENDER DYSPHORIA IN YOUNGER CHILDREN
20
A. Natural desistance is by far the most frequent resolution of gender
21
dysphoria in young children absent social transition.
22
56. A distinctive and critical characteristic of juvenile gender dysphoria is
23
that multiple studies from separate groups and at different times have reported
24
25 that in the large majority of patients, absent a substantial intervention such as
26 social transition and/or hormone therapy, the dysphoria does not persist through
27 puberty. A recent article reviewed all existing follow-up studies that the author

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1 could identify of children diagnosed with gender dysphoria (11 studies) and reported
2 that “every follow-up study of GD children, without exception, found the same
3
thing: By puberty, the majority of GD children ceased to want to transition.”
4
(Cantor at 307.) Another author reviewed the existing studies and reported that in
5
6 “prepubertal boys with gender discordance . . . the cross gender wishes usually fade
7 over time and do not persist into adulthood, with only 2.2% to 11.9% continuing to
8 experience gender discordance.” 24 A third summarized the existing data as showing
9
that “Symptoms of GID at prepubertal ages decrease or disappear in a considerable
10
percentage of children (estimates range from 80-95%).” 25 As cited above, a 2021
11
12 extended follow-up of originally evaluated prepubertal boys found a persistence rate
13 of only 12 percent. (Singh 2021.)

14 57. It is not yet known how to distinguish those children who will desist
15
from that small minority whose trans identity will persist. (Levine, Ethical
16
Concerns, at 9.)
17
18 58. Desistance within a relatively short period may also be a common
19 outcome for post-pubertal youths who exhibit recently described “rapid onset gender
20 disorder.” I observe an increasingly vocal online community of young women who
21
have reclaimed a female identity after claiming a male gender identity at some
22
23
24
24S. Adelson & American Academy of Child & Adolescent Psychiatry (2012), Practice Parameter on
25 Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in
Children and Adolescents, J. AM. ACAD. CHILD ADOLESCENT PSYCHIATRY 51(9) 957 at 963 (“Practice
26 Parameter”).
25 P. T. Cohen-Kettenis et al. (2008), The Treatment of Adolescent Transsexuals: Changing Insights,
27 J. SEXUAL MED. 5(8) 1892 at 1895.

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1 point during their teen years. However, data on outcomes for this age group with
2 and without therapeutic interventions is not yet available to my knowledge.

3
B. Social transition of young children is a powerful psychotherapeutic
4 intervention that changes outcomes.
5 59. In contrast, there is now data that suggests that a therapy that
6
encourages social transition before or during puberty dramatically changes
7
outcomes. A prominent group of authors has written that “The gender identity
8
affirmed during puberty appears to predict the gender identity that will persist into
9
10 adulthood,” and “Youth with persistent TNG [transgender, nonbinary, or gender-
11 nonconforming] identity into adulthood . . . are more likely to have experienced

12
social transition, such as using a different name . . . which is stereotypically
13
associated with another gender at some point during childhood.” 26 Similarly, a
14
comparison of recent and older studies suggests that when an “affirming”
15
16 methodology is used with children, a substantial proportion of children who would
17 otherwise have desisted by adolescence—that is, achieved comfort identifying with

18
their sex—instead persist in a transgender identity. (Zucker, Myth of Persistence, at
19
7). 27
20
60. Indeed, a review of multiple studies of children treated for gender
21
22 dysphoria across the last three decades found that early social transition to living as
23
24
C. Guss et al. (2015), Transgender and gender nonconforming adolescent care: psychosocial and
26
25 medical considerations. CURR. OPIN. PEDIATR. 27(4):421 (“TGN Adolescent Care”).

27 One study found that social transition by the child was found to be strongly correlated with
26 persistence for natal boys, but not for girls. (Zucker, Myth of Persistence, at 5 (citing T. D. Steensma,
et al. (2013), Factors Associated with Desistance & Persistence of Childhood Gender Dysphoria: A
27 Qualitative Follow-up Study, J. OF THE AM. ACAD. OF CHILD & ADOLESCENT PSYCHIATRY 52, 582.))

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1 the opposite sex severely reduces the likelihood that the child will revert to
2 identifying with the child’s natal sex, at least in the case of boys. That is, while, as I
3
review above, studies conducted before the widespread use of social transition for
4
young children reported desistance rates in the range of 80-98%, a more recent
5
6 study reported that fewer than 20% of boys who engaged in a partial or complete
7 social transition before puberty had desisted when surveyed at age 15 or older.
8 (Zucker, Myth of Persistence, at 7; Steensma (2013).)28 Some vocal practitioners of
9
prompt affirmation and social transition even claim that essentially no children who
10
come to their clinics exhibiting gender dysphoria or cross-gender identification
11
12 desist in that identification and return to a gender identity consistent with their
13 biological sex. As one internationally prominent practitioner stated, “In my own

14 clinical practice . . . of those children who are carefully assessed as transgender and
15
who are allowed to transition to their affirmed gender, we have no documentation of
16
a child who has ‘desisted’ and asked to return to his or her assigned gender.” 29
17
18 Given the consensus that no method exists to reliably predict which children
19 suffering from gender dysphoria will desist and which persist, and given the
20 absence of any study demonstrating the validity of any such method, this is a
21
disconcerting statement. Certainly, it reflects a very large change as compared to
22
the desistance rates documented apart from social transition.
23
24
28Only 2 (3.6%) of 56 of the male desisters observed by Steensma et al. had made a complete or
25 partial transition prior to puberty, and of the twelve males who made a complete or partial
transition prior to puberty, only two had desisted when surveyed at age 15 or older. Steensma (2013)
26 at 584.
29D. Ehrensaft (2015), Listening and Learning from Gender-Nonconforming Children, THE
27 PSYCHOANALYTIC STUDY OF THE CHILD 68(1) 28 at 34.

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1 61. Accordingly, I agree with noted researcher in the field Ken Zucker,
2 who has written that social transition in children must be considered “a form of
3
psychosocial treatment.” (Zucker, Debate, at 1.)
4
62. I also agree with Dr. Zucker’s further observation that “…we cannot
5
6 rule out the possibility that early successful treatment of childhood GID [Gender
7 Identity Disorder] will diminish the role of a continuation of GID into adulthood. If
8 so, successful treatment would also reduce the need for the long and difficult
9
process of sex reassignment which includes hormonal and surgical procedures with
10
substantial medical risks and complications.” 30
11
12 63. By the same token, a therapeutic methodology for children that
13 increases the likelihood that the child will continue to identify as the opposite
14 gender into adulthood will increase the need for the long and potentially
15
problematic processes of hormonal and genital and cosmetic surgical procedures.
16
64. Given these facts, it is the cross-gender affirming methods endorsed by
17
18 gender identity advocates that are changing the identity outcomes that would
19 otherwise naturally result for the large majority of prepubertal children who suffer
20 from gender dysphoria. It is thus these methods that could most properly be
21
described as “conversion therapy.” By contrast, the watchful waiting approach
22
which monitors the child’s mental health while working to resolve co-morbidities
23
24 and reduce life stress, and while allowing time for the natural psychosocial
25
26 30 Zucker, Myth of Persistence, at 8 (citing H. Meyer-Bahlburg (2002), Gender Identity Disorder in
Young Boys: A Parent- & Peer-Based Treatment Protocol, CLINICAL CHILD PSYCHOLOGY &
27 PSYCHIATRY 7, 360 at 362.)

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1 developmental processes of adolescence to shape the child’s identity, is properly
2 seen as the far less invasive therapeutic approach.

3
65. Not surprisingly, given these facts, encouraging social transition in
4
children remains controversial. Supporters of such transition acknowledge that
5
6 “Controversies among providers in the mental health and medical fields are
7 abundant. . . . These include differing assumptions regarding . . . the age at which

8 children . . . should be encouraged or permitted to socially transition . . . . These are
9
complex and providers in the field continue to be at odds in their efforts to work in
10
the best interests of the youth they serve.” 31
11
12 66. In sum, therapy for young children that encourages transition
13 (including use of names, pronouns, clothing, and restrooms associated with the
14 opposite sex) cannot be considered to be neutral, but instead is an experimental
15
procedure that has a high likelihood of changing the life path of the child, with
16
highly unpredictable effects on mental and physical health, suicidality, and life
17
18 expectancy. Claims that a civil right is at stake do not change the fact that what is
19 proposed is a social and medical experiment. (Levine, Reflections, at 241.) Ethically,

20 then, it should be undertaken only subject to standards, protocols, and reviews
21
appropriate to such experimentation. In my judgment, many gender clinics today
22
are encouraging and assisting children to transition without following these
23
24 ethically required procedures.
25
26 31 A. Tishelman et al. (2015), Serving Transgender Youth: Challenges, Dilemmas and Clinical
Examples, PROF. PSYCHOL. RES. PR. at 11 (“Serving TG Youth”) (available at

27 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4719579/pdf/nihms706503.pdf).

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1 67. Moreover, it is not clear how these clinics could create a legal, ethical,
2 and practical informed consent process. Parents would need to understand the risks
3
and benefits of the recommended therapy and of alternative approaches, and to
4
grapple with the scientific deficiencies in this arena, including: the absence of
5
6 randomized controlled studies, the absence of long follow-up studies of previous
7 children who have undergone these interventions, and the rates of success and
8 failure of the intervention. And it is a difficult question when either minors or
9
parents can ethically (and perhaps legally) grant consent to a medical or
10
therapeutic pathway that carries a high probability of leading to prescription of
11
12 potentially sterilizing drugs while the child is still a minor. In every case, the
13 professional has an ethical obligation to ensure that meaningful and legal informed
14 consent is obtained.
15
C. The administration of puberty blockers to children as a treatment for
16 gender dysphoria is experimental, presents obvious medical risks, and
appears to affect identity outcomes.
17
68. Gender clinics are increasingly prescribing puberty blockers for
18
19 children as young as ten, as a component of a regime that commonly includes social
20 transition. Puberty blockers are often described as merely providing a completely

21
reversible “pause,” which supposedly gives the child additional time to determine
22
his or her gender identity while avoiding distress which would be caused by
23
pubertal development of the body consistent with the child’s biological sex. The
24
25 language used about puberty blockers often states or implies that this major
26 hormonal disruption of some of the most basic aspects of ordinary human

27
development is a small thing, and entirely benign.
(480) 444-0020
1 69. In fact, it is important to recognize that the available (limited)
2 evidence suggests that clinically, puberty blockers administered to children at these

3
ages, for this purpose, and in conjunction with social transition, do not operate as a
4
“pause.” After reviewing the evidence provided by experts from different
5
6 perspectives, including an expert declaration that I submitted, the U.K. High Court
7 recently concluded that “the vast majority of children who take [puberty blockers]
8 move on to take cross-sex hormones,” and thus that puberty blockers in practice act
9
as a “stepping stone to cross-sex hormones.” 32 In my opinion, this finding accurately
10
summarizes the available data.
11
12 70. It is equally important to recognize that administration of puberty
13 blockers as a treatment for gender dysphoria is an off-label use of these powerful

14 drugs which is entirely experimental. This application can by no means be
15
considered equivalent to the only application for which puberty blockers have been
16
tested for efficacy and safety and approved—which is for the delay of precocious
17
18 puberty until the normal time for pubertal development. The U. K. High Court
19 panel accurately summarized the science when they described the use of puberty
20 blockers as “experimental” and as putting children on a “clinical pathway” which is
21
a “lifelong and life changing treatment . . . with very limited knowledge of the
22
degree to which it will or will not benefit them.” (Tavistock, ¶¶136, 143.)
23
24
25
32 Opinion of the United Kingdom High Court of Justice Administrative Court, Divisional Court
26 (December 1, 2020), in Bell and A. v. Tavistock and Portman NHS Trust and Others, Case No:
CO/60/2020, at ¶¶136-137 (available at https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-
27 Tavistock-Judgment.pdf.)

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1 71. This is a very profound experiment being conducted on children. It is
2 well known that the hormonal changes associated with ordinary puberty drive not
3
only the obvious physical and sexual changes in the adolescent, but also drive
4
important steps in cognitive development—that is, in brain functioning—as well as
5
6 increases in bone density. As the bodies and interests of peers change, the trans
7 adolescent who—as a result of puberty blockade hormones— maintains a puerile

8 appearance and development, risks isolation and social anxiety. This risk is not
9
given adequate weight when the treatment is justified as creating merely a useful
10
pause.
11
12 72. We simply do not have meaningful data concerning the long-term
13 effects on brain, bone, and other organs of interrupting or preventing this natural
14 developmental process between the ages of 10 and 16. Psychology likewise does not
15
know the long-term effects on coping skills, interpersonal comfort, and intimate
16
relationships of pubertal blockade and, as it were, standing on the sideline in the
17
18 years when one’s peers are undergoing their maturational gains in these vital
19 arenas of future mental health.

20 73. A number of recent papers have claimed to report beneficent or at least
21
neutral short-term effects of use of puberty blockers. None of these even purports to
22
address long-term effects as the subjects mature into adulthood, and even as to
23
24 short-term effects these studies suffer from methodological deficiencies that prevent
25 them from supporting such conclusions. Recently, the British National Health
26 Service commissioned the respected National Institute for Health and Care
27

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1 Excellence (NICE) to conduct a thorough evidence review of all available studies
2 that touch on the efficacy and safety of use of puberty blockers for children with
3
gender dysphoria. The exhaustive, 130-page results of this review were published in
4
October 2020. While of course this report provides extensive detail, its overall
5
6 summary was that, according to widely accepted criteria for measuring the
7 reliability of clinical evidence, “The quality of evidence for [all claims concerning
8 safety and efficacy of this use of puberty blockers] was assessed as very low
9
certainty.” 33 They found that “the studies all lack appropriate controls” and “were
10
not reliable,” that “the studies that reported safety outcomes provided very low
11
12 certainty evidence,” and that studies that claimed marginally positive outcomes
13 “could represent changes that are either of questionable clinical value, or the
14 studies themselves are not reliable and changes could be due to confounding bias or
15
chance.” (NICE at 13.)
16
74. So far as I am aware, no study yet reveals whether the life-course
17
18 mental and physical health outcomes for the relatively new class of “persisters”
19 (that is, those who would have desisted absent a transgender-affirming social and/or
20 pharmaceutical intervention, but instead persisted as a result of such interventions)
21
are more similar to those of the general non-transgender population, or to the
22
notably worse outcomes exhibited by the transgender population generally.
23
24
25
26 33NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2020), Evidence review: Gonadotrophin
releasing hormone analogues for children and adolescence with gender dysphoria (available at
27 https://arms.nice.org.uk/resources/hub/1070905/attachment.)

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1 75. Taking into account the risks, the lack of any reliable evidence
2 concerning long-term outcomes from the use of puberty blockers, and the inability of
3
pre-adolescents and even adolescents to comprehend the physical, relational, and
4
emotional significance of life as a sexually mature adult, I also agree with the
5
6 conclusion of the U. K. High Court that “it is highly unlikely that a child age 13 or
7 under would ever be . . . competent to give consent to being treated with [puberty
8 blockers],” and that it is “very doubtful” that a child of 14 or 15 “could understand
9
the long-term risks and consequences of treatment in such a way as to have
10
sufficient understanding to give consent.” (Tavistock, ¶ 145.)
11
12 IV. THE AVAILABLE DATA DOES NOT SUPPORT THE CONTENTION THAT
“AFFIRMATION” OF TRANSGENDER IDENTITY IN CHILDREN AND
13 ADOLESCENTS REDUCES SUICIDE OR RESULTS IN BETTER
PHYSICAL OR MENTAL HEALTH OUTCOMES GENERALLY.
14
76. I am aware that organizations including The Academy of Pediatrics
15
16 and Parents and Friends of Lesbians and Gays (PFLAG) have published statements
17 that suggest that all children who express a desire for a transgender identity should
18
be promptly supported in that claimed identity. Recently, the governing counsel of
19
the American Psychological Association adopted the APA Resolution on Gender
20
Identity Change Efforts, which broadly (and wrongly) categorizes any approach to
21
22 gender dysphoria other than gender affirming methods as unethical and dangerous.
23 These positions appear to rest on the belief—which is widely promulgated by

24
certain advocacy organizations—that science has already established that prompt
25
“affirmance” is best for all patients, including all children and adolescents, who
26
27

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1 present indicia of transgender identity. 34 As I have discussed above and further
2 discuss later below, this belief is scientifically incorrect, and ignores both what is
3
known and what is unknown.
4
77. The knowledge base concerning the causes and treatment of gender
5
6 dysphoria has low scientific quality.
7 78. In evaluating claims of scientific or medical knowledge, it is important

8 to understand that it is axiomatic in science that no knowledge is absolute, and to
9
recognize the widely-accepted hierarchy of reliability when it comes to “knowledge”
10
about medical or psychiatric phenomena and treatments. Unfortunately, in this
11
12 field opinion is too often confused with knowledge, rather than clearly locating what
13 exactly is scientifically known. In order of increasing confidence, such “knowledge”

14 may be based upon data comprising:
15
a. Expert opinion—it is perhaps surprising to educated laypersons
16
that expert opinion standing alone is the lowest form of knowledge, the least
17
18 likely to be proven correct in the future, and therefore does not garner as
19 much respect from professionals as what follows;

20 b. A single case or series of cases (what could be called anecdotal
21
evidence) (Levine, Reflections, at 239.);
22
c. A series of cases with a control group;
23
24 d. A cohort study;
25
26
34 The APA Resolution on Gender Identity Change Efforts (APA GICE Resolution) is available at
27 https://www.apa.org/about/policy/ resolution-gender-identity-change-efforts.pdf.

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1 e. A randomized double-blind clinical trial;
2 f. A review of multiple trials;

3
g. A meta-analysis of multiple trials that maximizes the number of
4
patients treated despite their methodological differences to detect trends
5
6 from larger data sets.
7 79. The strongest forms of scientific knowledge emerge from the latter
8 three types of research—randomized, blind trials; reviews of multiple randomized,
9
blind trials, and meta-analyses. When the APA Task Force on Promotion and
10
Dissemination of Psychological Procedures considered what criteria would
11
12 empirically validate a treatment, the task force relied heavily on whether a
13 procedure had been “tested in randomized controlled trials (RCT) with a specific
14 population and implemented using a treatment manual.” 35 Social affirmation of
15
children, use of puberty blockers as a treatment for gender dysphoria, and
16
administration of cross-sex hormones to adolescents, have never been clinically
17
18 tested and validated in this way.
19 80. Critically, “there are no randomized control trials with regard to

20 treatment of children with gender dysphoria.” (Zucker, Myth of Persistence, at 8.)
21
On numerous critical questions relating to cause, developmental path if untreated,
22
and the effect of alternative treatments, the knowledge base remains primarily at
23
24 the level of the practitioner’s exposure to individual cases, or multiple individual
25
26
35 Am. Psych. Assoc’n (2006), Evidence-Based Practice in Psychology, AM. PSYCHOLOGIST, Vol. 61, No.
27 4, 271 at 272.

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1 cases. As a result, claims to certainty are not justifiable. (Levine, Reflections, at
2 239.)
3
81. Unfortunately, advocates of unquestioning affirmation further
4
complicate efforts to understand the available science by speaking indistinctly,
5
6 ignoring differences between approaches that are likely to be clinically important.
7 For example, the recent APA resolution speaks of “individuals who have
8 experienced pressure or coercion to conform to their sex assigned at birth.” (APA
9
GICE at 1.) “Pressure or coercion” does not describe either the “watchful waiting”
10
or psychotherapy models I have described above, nor therapy structured around a
11
12 patient’s own desire to become comfortable with his or her natal sex. Nor is it
13 possible to extrapolate from outcomes experienced by those who have been

14 subjected to “coercive” techniques to predict outcomes for patients who receive
15
responsible “watchful waiting” or psychotherapeutic care as I have described and as
16
many experienced practitioners practice.
17
18 82. Unsurprisingly, prominent voices in the field have emphasized the
19 severe lack of scientific knowledge in this field. The American Academy of Child and
20 Adolescent Psychiatry has recognized that “Different clinical approaches have been
21
advocated for childhood gender discordance. . . . There have been no randomized
22
controlled trials of any treatment. . . . [T]he proposed benefits of treatment to
23
24 eliminate gender discordance … must be carefully weighed against … possible
25 deleterious effects.” (Adelson et al., Practice Parameter, at 968–69.) Similarly, the

26 APA has stated, “because no approach to working with [transgender and gender
27

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1 nonconforming] children has been adequately, empirically validated, consensus does
2 not exist regarding best practice with pre-pubertal children.” 36

3
83. Contrary to the impression that statements in the recent APA GICE
4
Resolution might leave, recent published research has not changed this situation. It
5
6 remains the case that no randomized controlled trials of any treatment for gender
7 dysphoria have been conducted, and recently published studies suffer from other
8 serious methodological defects as well.
9
84. For example, the APA GICE Resolution cites Turban et al. (2020),
10
Association between recalled exposure to gender identity conversion efforts and
11
12 psychological distress and suicide attempts among transgender adults, 37
13 (“Association”), and this article has been cited to support claims that failing to
14 affirm a transgender identity in children presenting with gender dysphoria results
15
in a higher risk of their attempting suicide.
16
85. But the sample and methodology of Turban, Association (2020) are
17
18 profoundly flawed and cannot support such a conclusion. A group of researchers has
19 published a detailed critique of these defects, 38 which I will not attempt to replicate
20 here. To highlight the most obvious defects, however, Association (2020) relied
21
entirely on data drawn from an online convenience sampling of transgender-
22
identified and genderqueer adults recruited from trans-affirming websites. It is well
23
24
36 Am. Psych. Assoc’n (2015), Guidelines for Psychological Practice with Transgender & Gender
25 Nonconforming People, AM. PSYCHOLOGIST 70(9) 832 at 842.
26 37 77 JAMA PSYCHIATRY 77(1) 68-76.

38 R. D’Angelo, et al., One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria
27 (2021), ARCH. SEX BEHAV. 50, 7-16.

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1 known that one “cannot make statistical generalizations from research that relies
2 on convenience sampling.” 39 Nor did the authors of Association (2020) control for the
3
subjects’ mental health status prior to the reported exposure to what the study
4
deemed a “gender identity change effort.” I agree with D’Angelo et al. (2021) that
5
6 “failure to control for the subjects’ baseline mental health makes it impossible to
7 determine whether the mental health or the suicidality of subjects worsened, stayed
8 the same, or potentially even improved after the non-affirming encounter.”
9
(D’Angelo (2021) at 10.)
10
86. Looking at the literature in this area more broadly, a review of 28
11
12 studies of outcomes from hormonal therapy in connection with sex reassignment
13 reported that these studies provided only “very low quality evidence” for a variety of
14 reasons. 40 Large gaps exist in the medical community’s knowledge regarding the
15
long-term effects of sex-reassignment surgery (SRS) and other gender identity
16
disorder treatments in relation to their positive or negative correlation to suicidal
17
18 ideation, attempts, and completion.
19 87. What is known is not encouraging. With respect to suicide, individuals

20 with gender dysphoria are well known to commit suicide or otherwise suffer
21
increased mortality before and after not only social transition, but also before and
22
23
24 39 Handbook of Survey Methodology for the Social Sciences (2021) (Lior Gideon, ed. Springer).
40 H. Murad et al. (2010), Hormonal therapy and sex reassignment: a systematic review and meta-
25 analysis of quality of life and psychosocial outcomes. CLINICAL ENDOCRINOLOGY; 72(2): 214-231. See
also R. D’Angelo (2018), Psychiatry’s ethical involvement in gender-affirming care, AUSTRALASIAN
26 PSYCHIATRY Vol 26(5) 460-463, noting the large number of non-responders in follow-up outcome
studies, and observing that “it is generally not known whether they are alive or dead,” and that “it is
27 . . . pure speculation to assume that none committed suicide.”

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1 after SRS. (Levine, Reflections, at 242.) For example, in the United States, the
2 death rates of trans veterans are comparable to those with schizophrenia and
3
bipolar diagnoses—20 years earlier than expected. These crude death rates include
4
significantly elevated suicide rates. (Levine, Ethical Concerns, at 10.) Similarly,
5
6 researchers in Sweden and Denmark have reported on almost all individuals who
7 underwent sex-reassignment surgery over a 30-year period. 41 The Swedish follow-

8 up study found a suicide rate in the post-SRS population 19.1 times greater than
9
that of the controls; both studies demonstrated elevated mortality rates from
10
medical and psychiatric conditions. (Levine, Ethical Concerns, at 10.)
11
12 88. Advocates of immediate and unquestioning affirmation of social
13 transition in children who indicate a desire for a transgender identity sometimes

14 assert that any other course will result in a high risk of suicide in the affected
15
children and young people. Contrary to these assertions, no studies show that
16
affirmation of children (or anyone else) reduces suicide, prevents suicidal ideation,
17
18 or improves long-term outcomes, as compared to either a “watchful waiting” or a
19 psychotherapeutic model of response, as I have described above. 42

20 89. In considering “suicide,” mental health professionals distinguish
21
between suicidal thoughts (ideation), suicide gestures, suicide attempts with a
22
23
41C. Dhejne et al. (2011), Long-Term Follow-Up of Transsexual Persons Undergoing Sex
24 Reassignment Surgery: Cohort Study in Sweden, PLOS ONE 6(2) e16885 (“Long Term”); R. K.
Simonsen et al. (2016), Long-Term Follow-Up of Individuals Undergoing Sex Reassignment Surgery:
25 Psychiatric Morbidity & Mortality, NORDIC J. OF PSYCHIATRY 70(4):241-7
42 A recent article, J. Turban et al. (2020), Puberty Suppression for Transgender Youth and Risk of
26 Suicidal Ideation, PEDIATRICS 145(2), has been described in press reports as demonstrating that
administration of puberty-suppressing hormones to transgender adolescents reduces suicide or
27 suicidal ideation. The paper itself does not make that claim, nor permit that conclusion.

(480) 444-0020
1 lethal potential, and completed suicide. Numerous studies have found suicidal
2 ideation to have been present at some time in life in ~40-50% of trans-identifying

3
persons. This figure is approximately twice that reported in gay and lesbian
4
communities. In the heteronormative communities, ideation is approximately 4%.
5
6 Mental health professionals distinguish clearly between gestures and potentially
7 lethal attempts, which often result in hospitalization.

8 90. I will also note that any discussion of suicide when considering
9
younger children involves very long-range and very uncertain prediction. Suicide in
10
pre-pubescent children is rare and the existing studies of gender identity issues in
11
12 pre-pubescent children do not report significant incidents of suicide. The estimated
13 suicide rate of trans adolescents is the same as teenagers who are in treatment for
14 serious mental illness. What trans teenagers do demonstrate is more suicidal
15
ideation and attempts (however serious) than other teenagers. 43 Their completed
16
suicide rates are not known.
17
18 91. In sum, claims that affirmation will reduce the risk of suicide for
19 children are not based on science. Such claims overlook the lack of even short-term
20 supporting data as well as the lack of studies of long-term outcomes resulting from
21
the affirmation or lack of affirmation of transgender identity in children. They also
22
overlook the other tools that the profession does have for addressing depression and
23
24
25
26 43 A. Perez-Brumer, et al. (2017), Prevalence & Correlates of Suicidal Ideation Among Transgender
Youth in Cal.: Findings from a Representative, Population-Based Sample of High Sch. Students, J.
27 AM. ACAD. CHILD ADOLESCENT PSYCHIATRY 56(9) at 739.

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1 suicidal thoughts in a patient once that risk is identified. (Levine, Reflections, at
2 242.)
3
92. A number of data sets have also indicated significant concerns about
4
wider indicators of physical and mental health, including ongoing functional
5
6 limitations; 44 substance abuse, depression, and psychiatric hospitalizations; 45 and
7 increased cardiovascular disease, cancer, asthma, and COPD. 46 Worldwide

8 estimates of HIV infection among transgendered individuals are up to 17-fold
9
higher than the cisgender population. (Levine, Informed Consent, at 6.)
10
93. Meanwhile, no studies show that affirmation of pre-pubescent children
11
12 or adolescents leads to more positive outcomes (mental, physical, social, or
13 romantic) by, e.g., age 25 or older than does “watchful waiting” or ordinary therapy.
14 Because affirmation and social transition for children and adolescents, and the use
15
of puberty blockers for transgender children, are a recent phenomenon, it could
16
hardly be otherwise.
17
18 94. Given what is known and what is not known about the incidence and
19 causes of suicide attempts and suicide in children and adolescents who suffer from
20 gender dysphoria, and what is known about the incidence of suicide attempts and
21
suicide in individuals who have transitioned to live in a transgender identity, it is in
22
23
24 44 G. Zeluf, et al. (2016), Health, Disability and Quality of Life Among Trans People in Sweden—A
Web-Based Survey, BMC PUBLIC HEALTH 16, 903.

25
45 C. Dhejne, et al. (2016), Mental Health & Gender Dysphoria: A Review of the Literature, INT’L REV.
26 OF PSYCHIATRY 28(1) 44.
46 C. Dragon, et al. (2017), Transgender Medicare Beneficiaries & Chronic Conditions: Exploring Fee-
27 for-Service Claims Data, LGBT HEALTH 4(6) 404.

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1 my view unethical for a mental health professional to tell a young patient, or the
2 parents of a young patient, that social transition, puberty blockers, or use of cross-
3
sex hormones will reduce the likelihood that the young person will commit suicide.
4
95. Instead, transition of any sort must be justified, if at all, as a life-
5
6 enhancing measure, not a lifesaving measure. (Levine, Reflections, at 242.) In my
7 opinion, this is an important fact that patients, parents, and even many MHPs fail
8 to understand.
9
V. KNOWN, LIKELY, OR POSSIBLE DOWNSIDE RISKS ATTENDANT ON
10 MOVING QUICKLY TO “AFFIRM” TRANSGENDER IDENTITY IN
CHILDREN AND ADOLESCENTS.
11
96. As I have detailed above, enabling and affirming social transition in a
12
13 prepubescent child appears to be highly likely to increase the odds that the child
14 will in time pursue pubertal suppression and persist in a transgender identity into
15
adulthood. This means that the MHP, patient, and in the case of minors, parents
16
must consider long-term as well as short-term implications of life as a transgender
17
individual when deciding whether to permit or encourage a child to socially
18
19 transition.
20 97. Indeed, given the very high rates of children who desist from desiring a
21
trans identity through the course of uninterrupted puberty, it is efforts to “affirm” a
22
sex-discordant gender identity in prepubescent children that should be understood
23
as the therapeutic path that is most likely to “change” or “convert” the child’s adult
24
25 gender identification, diverting the child from his or her probable maturation away
26 from trans-identification.
27

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1 98. The APA and other gender identity advocates argue that gender
2 affirmation practices are safe and effective. (APA GICE Resolution at 3.) But if we
3
consider the long term—a life course perspective— a great deal of data point in the
4
opposite direction. The multiple studies from different nations (including societies
5
6 which pride themselves on being actively inclusive of sexual minorities, such as
7 Sweden and Denmark) that have documented the increased vulnerability of the
8 adult transgender population to substance abuse, mood and anxiety disorders,
9
suicidal ideation, and other health problems warn us that assisting the child or
10
adolescent down the road to becoming a transgender adult is a very serious
11
12 decision, and stand as a reminder that a casual assumption that transition will
13 improve the young person’s life is not justified based on numerous scientific
14 snapshots of cohorts of trans adults and teenagers. American public health
15
professionals repeatedly have published descriptions of trans populations as
16
marginalized and vulnerable to many adversities. 47
17
18 99. The possibility that steps along this pathway, while lessening the pain
19 of gender dysphoria, could lead to additional sources of crippling emotional and

20 psychological pain, are too often not considered by advocates of social transition and
21
not considered at all by the trans child. (Levine, Reflections, at 243.)
22
100. I detail below several classes of predictable, likely, or possible harms to
23
24 the patient associated with transitioning to live as a transgender individual.
25
47K. L. Ard, & A. S. Keuroghlian (2018), Training in Sexual and Gender Minority Health - Expanding
26 Education to Reach All Clinicians. NEW ENGLAND J. OF MED, 379(25), 2388–2391; W. Liszewski et al.
(2018), Persons of Nonbinary Gender - Awareness, Visibility, and Health Disparities. NEW ENGLAND J.
27 OF MED., 379(25), 2391–2393.

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1 A. Physical risks associated with transition
2 101. Sterilization. It is not uncommon for patients who begin down the path
3
defined by puberty blockers and social transition to end up feeling the need to
4
undergo surgical treatment to alleviate gender dysphoria. As I have noted above,
5
there is not good scientific evidence that SRS results in better long-term mental
6
7 health outcomes. What is certain, however, is that SRS that removes testes, ovaries,
8 or the uterus is inevitably sterilizing, and irreversible. While some patients who
9
have experienced regret after undergoing SRS have then undergone reconstructive
10
surgery, such surgery cannot restore fertility. And while by no means all
11
transgender adults elect SRS, many patients do ultimately feel compelled to take
12
13 this serious step in their effort to live fully as the opposite sex.
14 102. More immediately, practitioners recognize that the administration of

15
cross-sex hormones, which is often viewed as a less “radical” measure, and is now
16
increasingly done to minors, creates at least a risk of irreversible sterility. The U.K.
17
High Court in the Tavistock litigation, after reviewing the evidence, concluded that
18
19 cross-sex hormones “may well lead to a loss of fertility,” and in my opinion that
20 finding accurately summarizes the present medical understanding. 48 As a result,

21
even when treating a child, the MHP, patient, and parents must consider loss of
22
reproductive capacity—sterilization—to be one of the major risks of starting down
23
the road. The risk that supporting social transition may put the child on a pathway
24
25
48 Bell v. Tavistock Opinion (December 1, 2020), ¶138. See also C. Guss et al., TGN Adolescent Care
26 at 4 (“a side effect [of cross-sex hormones] may be infertility”) and 5 (“cross-sex hormones . . . may
have irreversible effects”); Tishelman et al., Serving TG Youth at 8 (Cross-sex hormones are
27 “irreversible interventions” with “significant ramifications for fertility”).

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1 that leads to intentional or unintentional permanent sterilization is particularly
2 concerning given the disproportionate representation of minority and other

3
vulnerable groups among children reporting a transgender or gender-
4
nonconforming identity. (See supra ¶ 24.)
5
6 103. Loss of sexual response. Puberty blockers prevent maturation of the
7 sexual organs and response. Some, and perhaps many, transgender individuals who
8 transitioned as children and thus did not go through puberty consistent with their
9
sex face significantly diminished sexual response as they enter adulthood and are
10
unable ever to experience orgasm. In the case of males, the cross-sex administration
11
12 of estrogen limits penile genital function. Much has been written about the negative
13 psychological and relational consequences of anorgasmia among non-transgender

14 individuals that is ultimately applicable to the transgendered. (Levine, Informed
15
Consent, at 6.)
16
104. Other effects of hormone administration. I have discussed the risks
17
18 and unknowns associated with puberty blockers above, noting that most children
19 who are started on puberty blockers continue on the pathway to cross-sex hormones.
20 It is well known that many effects of cross-sex hormones cannot be reversed should
21
the patient later regret his transition. After puberty, the individual who wishes to
22
live as the opposite sex will in most cases have to take cross-sex hormones for most
23
24 of their life, even after undergoing sex reassignment surgery.
25
26
27

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1 105. The long-term health risks of this major alteration of hormonal levels
2 have not yet been quantified in terms of exact risk. 49 However, a recent study found
3
greatly elevated levels of strokes and other acute cardiovascular events among
4
male-to-female transgender individuals taking estrogen. Those authors concluded,
5
6 “it is critical to keep in mind that the risk for these cardiovascular events in this
7 population must be weighed against the benefits of hormone treatment.” 50 Another

8 group of authors similarly noted that administration of cross-sex hormones creates
9
“an additional risk of thromboembolic events”—which is to say blood clots (Guss et
10
al., TGN Adolescent Care at 5), which are associated with strokes, heart attacks,
11
12 and lung and liver failure. Clinicians must distinguish the apparent short-term
13 safety of hormones from likely or possible long-term consequences, and help the
14 patient or parents understand these implications as well. The young patient may
15
feel, “I don’t care if I die young, just as long I get to live as a woman.” The mature
16
adult may take a different view.
17
18 106. Health risks inherent in complex surgery. Complications of surgery
19 exist for each procedure, 51 and complications in surgery affecting the reproductive
20 organs and urinary tract can have significant anatomical and functional
21
complications for the patient’s quality of life.
22
23
49 See Tishelman et al., Serving TG Youth at 6-7 (Long-term effect of cross-sex hormones “is an area
24 where we currently have little research to guide us.”).
25 50D. Getahun et al. (2018), Cross-Sex Hormones and Acute Cardiovascular Events in Transgender
Persons: A Cohort Study, ANN. OF INTERN. MED. 169(4) 205 at 8.
26 51 Levine, Informed Consent, at 5 (citing T. van de Grift, G. Pigot et al. (2017), A Longitudinal Study
of Motivations Before & Psychosexual Outcomes After Genital Gender-Confirming Surgery in

27 Transmen, J. SEXUAL MED.14(12) 1621).

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1 107. Disease and mortality generally. The MHP, the patient, and in the
2 case of a child, the parent must also be aware of the wide sweep of strongly negative
3
health outcomes among transgender individuals, as I have detailed above.
4
B. Social risks associated with transition
5
108. Family and friendship relationships. Gender transition routinely leads
6
7 to isolation from at least a significant portion of one’s family in adulthood. In the
8 case of a juvenile transition, this will be less dramatic while the child is young, but
9
commonly increases over time as the child and his siblings mature into adulthood.
10
By adulthood, the friendships of transgender individuals tend to be confined to
11
other transgender individuals (often “virtual” friends known only online) and the
12
13 generally limited set of others who are comfortable interacting with transgender
14 individuals. (Levine, Ethical Concerns, at 5.)

15
109. Long term psychological and social impact of sterility. The life-long
16
negative emotional impact of infertility on both men and women has been well
17
studied. While this impact has not been studied specifically within the transgender
18
19 population, the opportunity to be a parent is likely a human, emotional need, and so
20 should be considered an important risk factor when considering gender transition

21
for any patient. However, it is particularly difficult for parents of a young child to
22
seriously contemplate that child’s potential as a future parent and grandparent.
23
This makes it all the more critical that the MHP spend substantial and repeated
24
25 time with parents to help them see the implications of what they are considering.
26 110. Sexual-romantic risks associated with transition. After adolescence,

27
transgender individuals find the pool of individuals willing to develop a romantic
(480) 444-0020
1 and intimate relationship with them to be greatly diminished. When a trans person
2 who passes well reveals his or her natal sex, many potential cisgender mates lose
3
interest. When a trans person does not pass well, he discovers that the pool of those
4
interested consists largely of individuals looking for exotic sexual experiences rather
5
6 than genuinely loving relationships. (Levine, Ethical Concerns, at 5, 13.) Nor is the
7 problem all on the other side; transgender individuals commonly become strongly
8 narcissistic, unable to give the level of attention to the needs of another that is
9
necessary to sustain a loving relationship. 52
10
111. Social risks associated with delayed puberty. The social and
11
12 psychological impacts of remaining puerile for, e.g., three to five years while one’s
13 peers are undergoing pubertal transformations, and of undergoing puberty at a

14 substantially older age, have not been systematically studied, although clinical
15
mental health professionals often hear of distress and social awkwardness in those
16
who naturally have a delayed onset of puberty. In my opinion, individuals in whom
17
18 puberty is delayed multiple years are likely to suffer at least subtle negative
19 psychosocial and self-confidence effects as they stand on the sidelines while their
20 peers are developing the social relationships (and attendant painful social learning
21
experiences) that come with adolescence. (Levine, Informed Consent, at 9.)
22
C. Mental health costs or risks
23
112. One would expect the negative physical and social impacts reviewed
24
25 above to adversely affect the mental health of individuals who have transitioned. In
26
27 52 S. Levine, Barriers to Loving: A Clinician’s Perspective (Routledge, New York 2013) at 40.

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1 addition, adult transitioned individuals find that living as the other (or, in a
2 manner that is consistent with the stereotypes of the other as the individual
3
perceives them) is a continual challenge and stressor, and many find that they
4
continue to struggle with a sense of inauthenticity in their transgender identity.
5
6 (Levine, Informed Consent, at 9.)
7 113. In addition, individuals often pin excessive hope in transition,

8 believing that transition will solve what are in fact ordinary social stresses
9
associated with maturation, or mental health co-morbidities. Thus, transition can
10
result in deflection from mastering personal challenges at the appropriate time or
11
12 addressing conditions that require treatment.
13 114. Whatever the reason, transgender individuals including transgender

14 youth certainly experience greatly increased rates of mental health problems. I have
15
detailed this above with respect to adults living under a transgender identity.
16
Indeed, Swedish researchers in a long-term study (up to 30 years since SRS, with a
17
18 median time since SRS of > 10 years) concluded that individuals who have SRS
19 should have postoperative lifelong psychiatric care. (Dhejne, Long Term, at 6-7.)
20 With respect to youths a cohort study found that transgender youth had an elevated
21
risk of depression (50.6% vs. 20.6%) and anxiety (26.7% vs. 10.0%); a higher risk of
22
suicidal ideation (31.1% vs. 11.1%), suicide attempts (17.2% vs. 6.1%), and self-harm
23
24 without lethal intent (16.7% vs. 4.4%) relative to the matched controls; and a
25 significantly greater proportion of transgender youth accessed inpatient mental

26
27

(480) 444-0020
1 health care (22.8% vs. 11.1%) and outpatient mental health care (45.6% vs. 16.1%)
2 services. 53
3
115. The responsible MHP cannot focus narrowly on the short-term
4
happiness of the patient, but must instead consider the happiness and health of the
5
6 patient from a “life course” perspective. The many studies that I have cited here
7 warn us that as we look ahead to the patient’s life as a young adult and adult, the
8 prognosis for the physical health, mental health, and social well-being of the child
9
or adolescent who transitions to live in a transgender identity is not good.
10
116. A study published in 2019 by the American Journal of Psychiatry
11
12 reported the high mental health utilization patterns of adults for ten years after
13 surgery for approximately 35% of patients. 54 That is a very high level of mental
14 health distress, compared to the general population.
15
117. This same 2019 study received considerable attention for its claim to
16
discern “a statistically significant relationship between time since surgery and
17
18 mental health status” based upon the researchers observing “that as of 2015,
19 patients who had surgeries further in the past had better mental health than
20 patients whose surgeries were more recent.” 55 But this claim is another example of
21
the grave methodological defects that are too common in recent publications in this
22
23 53 S. Reisner et al. (2015), Mental Health of Transgender Youth in Care at an Adolescent Urban
Community Health Center: A Matched Retrospective Cohort Study, J. OF ADOLESCENT HEALTH 56(3)
24 at 6; see also supra ¶ 24.
25 54Bränström & Pachankis, (2019), Reduction in Mental Health Treatment Utilization Among
Transgender Individuals After Gender-Affirming Surgeries, AM. J. OF PSYCHIATRY 177(8) 727-734.
26 55 Correction of a Key Study: No Evidence of “Gender-Affirming” Surgeries Improving Mental Health,
Society for Evidence Based Gender Medicine (Aug. 30, 2020), https://www.segm.org
27 /ajp_correction_2020 (citing and summarizing professional critiques of the Reduction article).

(480) 444-0020
1 field. Shortly after publication, the study’s analysis and conclusion were trenchantly
2 criticized, among other reasons because of the study’s failure to compare subjects’
3
post-surgery mental health with those subjects’ mental health before undergoing
4
SRS.
5
6 118. As a result of two post-publication reviews by independent statisticians
7 that rejected the interpretation of the data and additional critical letters to the
8 editor, the authors corrected the article to retract the claim of a statistically
9
significant relationship between gender affirmation surgery and later-improved
10
mental health (while leaving intact a finding of “no evidence of benefits of hormonal
11
12 treatments”). Specifically, the American Journal of Psychiatry stated that “the
13 results [of the reanalysis] demonstrated no advantage of surgery in relation to

14 subsequent mood or anxiety disorder-related health care visits or prescriptions or
15
hospitalizations following suicide attempts.” 56
16
119. The Reduction article is notable for another, and positive, reason, as its
17
18 authors acknowledged valid critiques and corrected the claims in their published
19 work. 57 This is the way science should work—contending views testing the data and
20 conclusions—something that is increasingly difficult to do in the gender identity
21
field when its advocates insist that only gender affirmation treatments are to be
22
contemplated.
23
24
25
56Correction to Bränström and Pachankis (2020), AM. J. OF PSYCHIATRY 177:8 at 734.
26 57 R. Bränström and J. E. Pachankis (2020), Toward Rigorous Methodologies for Strengthening
Causal Inference in the Association Between Gender-Affirming Care and Transgender Individuals’
27 Mental Health: Response to Letters, 177 AM. J. OF PSYCHIATRY 769-772.

(480) 444-0020
1 D. The risk of regret following transition
2 120. The large numbers of children and young adults who have desisted as
3
documented in both group and case studies each represent “regret” over the initial
4
choice in some sense.
5
121. The phenomenon of desistance or regret experienced later than
6
7 adolescence or young adulthood, or among older transgender individuals, has to my
8 knowledge not been quantified or well-studied. However, it is a real phenomenon. I

9
myself have worked with multiple individuals who have abandoned trans female
10
identity after living in that identity for years, and who would describe their
11
experiences as “regret.”
12
13 122. I have seen several Massachusetts inmates and trans individuals in
14 the community abandon their [trans] female identity after several years. (Levine,
15
Reflections, at 239.) In the gender clinic which I founded in 1974 and to this day, in
16
a different location, continue to co-direct, we have seen many instances of
17
individuals who claimed a transgender identity for a time, but ultimately changed
18
19 their minds and reclaimed the gender identity congruent with their sex.
20 123. More dramatically, a surgical group prominently active in the SRS

21
field has published a report on a series of seven male-to-female patients requesting
22
surgery to transform their surgically constructed female genitalia back to a male
23
form. 58
24
25
26
58 Djordjevic et al. (2016), Reversal Surgery in Regretful Male-to-Female Transsexuals After Sex
27 Reassignment Surgery, J. SEX MED. 13(6) 1000.

(480) 444-0020
EXHIBIT A
Stephen B. Levine, M.D. Curriculum Vitae
Brief Introduction
Dr. Levine is a Clinical Professor of Psychiatry at Case Western Reserve University
School of Medicine. He is the author or coauthor of numerous books on topics relating to human
sexuality and related relationship and mental health issues. Dr. Levine has been teaching,
providing clinical care, and writing since 1973, and has generated original research, invited
papers, commentaries, chapters, and book reviews. He has served as a journal manuscript and
book prospectus reviewer for many years. Dr. Levine has been co-director of the Center for
Marital and Sexual Health/ Levine, Risen & Associates, Inc. in Beachwood, Ohio from 1992 to
the present. He received a lifetime achievement Masters and Johnson’s Award from the Society
for Sex Therapy and Research in March 2005.
Personal Information
Date of birth 1/14/42
Medical license no. Ohio 35-03-0234-L
Board Certification 6/76 American Board of Neurology and Psychiatry
Education
1963 BA Washington and Jefferson College
1967 MD Case Western Reserve University School of Medicine
1967-68 Internship in Internal Medicine University Hospitals of Cleveland
1968-70 Research associate, National Institute of Arthritis and Metabolic Diseases,
Epidemiology Field Studies Unit, Phoenix, Arizona, United States Public Health Service
1970-73 Psychiatric Residency, University Hospitals of Cleveland
1974-77 Robert Wood Johnson Foundation Clinical Scholar
Appointments at Case Western Reserve University School of Medicine
1973- Assistant Professor of Psychiatry
1979-Associate Professor
1982-Awarded tenure
1985-Full Professor
1993-Clinical Professor
Honors
Summa Cum Laude, Washington & Jefferson
Teaching Excellence Award-1990 and 2010 (residency program)
Page 1 of 22
Visiting Professorships
• Stanford University-Pfizer Professorship program (3 days)–1995
• St. Elizabeth’s Hospital, Washington, DC –1998
• St. Elizabeth’s Hospital, Washington, DC--2002
Named to America’s Top Doctors consecutively since 2001
Invitations to present various Grand Rounds at Departments of Psychiatry and Continuing
Education Lectures and Workshops
Masters and Johnson Lifetime Achievement Award from the Society of Sex Therapy and
Research, April 2005 along with Candace Risen and Stanley Althof
2006 SSTAR Book Award for The Handbook of Clinical Sexuality for Mental Health
Professionals: Exceptional Merit
2018—Albert Marquis Lifetime Achievement Award from Marquis Who’s Who. (exceling
in one’s field for at least twenty years)
Professional Societies
1971- American Psychiatric Association; fellow; #19909
2005-American Psychiatric Association- Distinguished Life Fellow
1973- Cleveland Psychiatric Society
1973-Cleveland Medical Library Association
1985-Life Fellow
2003 Distinguished Life Fellow
1974-Society for Sex Therapy and Research
1987-89-President
1983- International Academy of Sex Research
1983- Harry Benjamin International Gender Dysphoria Association
1997-8 Chairman, Standards of Care Committee
1994- 1999 Society for Scientific Study of Sex
Community Boards
1999-2002 Case Western Reserve University Medical Alumni Association
1996-2001 Bellefaire Jewish Children’s Bureau
1999-2001 Physicians’ Advisory Committee, The Gathering Place (cancer rehabilitation)
Page 2 of 22
Editorial Boards
1978-80 Book Review Editor Journal Sex and Marital Therapy
Manuscript Reviewer for:
a. Archives of Sexual Behavior
b. Annals of Internal Medicine
c. British Journal of Obstetrics and Gynecology
d. JAMA
e. Diabetes Care
f. American Journal of Psychiatry
g. Maturitas
h. Psychosomatic Medicine
i. Sexuality and Disability
j. Journal of Nervous and Mental Diseases
k. Journal of Neuropsychiatry and Clinical Neurosciences
l. Neurology
m. Journal Sex and Marital Therapy
n. Journal Sex Education and Therapy
o. Social Behavior and Personality: an international journal (New Zealand)
p. International Journal of Psychoanalysis
q. International Journal of Transgenderism
r. Journal of Urology
s. Journal of Sexual Medicine
t. Current Psychiatry
u. International Journal of Impotence Research
v. Postgraduate medical journal
w. Academic Psychiatry
Prospectus Reviewer
a. Guilford
b. Oxford University Press
c. Brunner/Routledge
Page 3 of 22
d. Routledge
Administrative Responsibilities
Principal Investigator of approximately 70 separate studies involving pharmacological
interventions for sexual dysfunction since 1989.
Co-leader of case conferences at DELRLLC.com
Recent Expert Witness Appearances
Served as court-appointed expert for US District Court, Judge Mark L.Wolf in Michelle
Kosilek vs. Massachusetts Dept of Corrections et al. (transsexual issue) in Boston 2007.
Testified by deposition in Battista vs. Massachusetts Dept of Corrections (transsexual issue)
in Cleveland October 2009.
Witness for Massachusetts Dept. of Corrections in their defense of a lawsuit brought by
prisoner Katheena Soneeya. March 22, 2011 Deposition in Boston and October 2018 in
Cleveland.
Witness for State of Florida in Florida vs. Reyne Keohane July 2017.
Expert testimony by deposition and at trial in In the Interests of the Younger Children,
Dallas, TX, 2019.
Consultancies
Massachusetts Department of Corrections—evaluation of 12 transsexual prisoners and the
development of a Gender Identity Disorders Program for the state prison system. Monthly
consultation with the GID treatment team since February 2009 and the GID policy committee
since February 2010
California Department of Corrections and Rehabilitation; 2012-2015; education, inmate
evaluation, commentary on inmate circumstances, suggestions on future policies
Virginia Department of Corrections –evaluation of an inmate
New Jersey Department of Corrections—evaluation of an inmate
Idaho Department of Corrections—workshop 2016
Grant Support/Research Studies
TAP–studies of Apomorphine sublingual in treatment of erectile dysfunction
Pfizer–Sertraline for premature ejaculation
Pfizer–Viagra and depression; Viagra and female sexual dysfunction; Viagra as a treatment
for SSRI-induced erectile dysfunction
NIH- Systemic lupus erythematosis and sexuality in women
Sihler Mental Health Foundation
Page 4 of 22
a. Program for Professionals

b. Setting up of Center for Marital and Sexual Health
c. Clomipramine and Premature ejaculation
d. Follow-up study of clergy accused of sexual impropriety
e. Establishment of services for women with breast cancer
Alza–controlled study of a novel SSRI for rapid ejaculation
Pfizer–Viagra and self-esteem
Pfizer- double-blind placebo control studies of a compound for premature ejaculation
Johnson & Johnson – controlled studies of Dapoxetine for rapid ejaculation
Proctor and Gamble: multiple studies to test testosterone patch for post menopausal sexual
dysfunction for women on and off estrogen replacement
Lilly-Icos—study of Cialis for erectile dysfunction
VIVUS – study for premenopausal women with FSAD
Palatin Technologies- studies of bremelanotide in female sexual dysfunction—first intranasal
then subcutaneous administration
Medtap – interview validation questionnaire studies
HRA- quantitative debriefing study for Female partners of men with premature ejaculation,
Validation of a New Distress Measure for FSD,
Boehringer-Ingelheim- double blind and open label studies of a prosexual agent for
hypoactive female sexual desire disorder
Biosante- studies of testosterone gel administration for post menopausal women with HSDD
J&J a single-blind, multi-center, in home use study to evaluate sexual enhancement effects of
a product in females.
UBC-Content validity study of an electronic FSEP-R and FSDS-DAO and usability of study
PRO measures in premenopausal women with FSAD, HSDD or Mixed FSAD/HSDD
National registry trial for women with HSDD
Endoceutics—two studies of DHEA for vaginal atrophy and dryness in post menopausal
women
Palatin—study of SQ Bremelanotide for HSDD and FSAD
Trimel- a double-blind, placebo controlled study for women with acquired female orgasmic
disorder.
S1 Biopharma- a phase 1-B non-blinded study of safety, tolerability and efficacy of Lorexys
in premenopausal women with HSDD
Page 5 of 22
HRA – qualitative and cognitive interview study for men experiencing PE

Publications
A) Books
1) Pariser SR, Levine SB, McDowell M (eds.), Clinical Sexuality, Marcel
Dekker, New York, 1985
2) Sex Is Not Simple, Ohio Psychological Publishing Company, 1988;
Reissued in paperback as: Solving Common Sexual Problems: Toward a Problem
Free Sexual Life, Jason Aronson, Livingston, NJ. 1997
3) Sexual Life: A Clinician’s Guide. Plenum Publishing Corporation. New
York, 1992
4) Sexuality in Midlife. Plenum Publishing Corporation. New York, 1998
5) Editor, Clinical Sexuality. Psychiatric Clinics of North America, March,
1995.
6) Editor, (Candace Risen and Stanley Althof, associate editors) Handbook of
Clinical Sexuality for Mental Health Professionals. Routledge, New York, 2003
1. 2006 SSTAR Book Award: Exceptional Merit
7) Demystifying Love: Plain Talk For The Mental Health Professional.
Routledge, New York, 2006
8) Senior editor, (Candace B. Risen and Stanley E. Althof, Associate editors),
Handbook of Clinical Sexuality for Mental Health Professionals, 2nd edition.
Routledge, New York, 2010.
9) Barriers to Loving: A Clinician’s Perspective. Routledge, New York, 2014.
10) Senior editor Candace B. Risen and Stanley E. Althof, Associate editors),
Handbook of Clinical Sexuality for Mental Health Professionals. 3rd edition
Routledge, New York, 2016
B) Research and Invited Papers
When his name is not listed in a citation, Dr. Levine is either the solo or the senior
author.
1) Sampliner R. Parotid enlargement in Pima Indians. Annals of Internal
Medicine 1970; 73:571-73
2) Confrontation and residency activism: A technique for assisting residency
change: World Journal of Psychosynthesis 1974; 6: 23-26
3) Activism and confrontation: A technique to spur reform. Resident and Intern
Consultant 173; 2
4) Medicine and Sexuality. Case Western Reserve Medical Alumni Bulletin
Page 6 of 22
1974:37:9-11.
5) Some thoughts on the pathogenesis of premature ejaculation. J. Sex &
Marital Therapy 1975; 1:326-334
6) Marital Sexual Dysfunction: Introductory Concepts. Annals of Internal
Medicine 1976;84:448-453
7) Marital Sexual Dysfunction: Ejaculation Disturbances 1976; 84:575-579
8) Yost MA: Frequency of female sexual dysfunction in a gynecology clinic:
An epidemiological approach. Archives of Sexual Behavior 1976;5:229-238
9) Engel IM, Resnick PJ, Levine SB: Use of programmed patients and
videotape in teaching medical students to take a sexual history. Journal of Medical
Education 1976;51:425-427
10) Marital Sexual Dysfunction: Erectile dysfunction. Annals of Internal
Medicine 1976;85:342-350
11) Male Sexual Problems. Resident and Staff Physician 1981:2:90-5
12) Female Sexual Problems. Resident and Staff Physician 1981:3:79-92
13) How can I determine whether a recent depression in a 40 year old married
man is due to organic loss of erectile function or whether the depression is the
source of the dysfunction? Sexual Medicine Today 1977;1:13
14) Corradi RB, Resnick PJ Levine SB, Gold F. For chronic psychologic
impotence: sex therapy or psychotherapy? I & II Roche Reports; 1977
15) Marital Sexual Dysfunction: Female dysfunctions 1977; 86:588-597
16) Current problems in the diagnosis and treatment of psychogenic impotence.
Journal of Sex & Marital Therapy 1977;3:177-186
17) Resnick PJ, Engel IM. Sexuality curriculum for gynecology residents.
Journal of Medical Education 1978; 53:510-15
18) Agle DP. Effectiveness of sex therapy for chronic secondary psychological
impotence Journal of Sex & Marital Therapy 1978;4:235-258
19) DePalma RG, Levine SB, Feldman S. Preservation of erectile function after
aortoiliac reconstruction. Archives of Surgery 1978;113-958-962
20) Conceptual suggestions for outcome research in sex therapy Journal of Sex
& Marital Therapy 1981;6:102-108
21) Lothstein LM. Transsexualism or the gender dysphoria syndrome. Journal of
Sex & Marital Therapy 1982; 7:85-113
22) Lothstein LM, Levine SB. Expressive psychotherapy with gender dysphoria
patients Archives General Psychiatry 1981; 38:924-929
Page 7 of 22
23) Stern RG Sexual function in cystic fibrosis. Chest 1982; 81:422-8

24) Shumaker R. Increasingly Ruth: Towards understanding sex reassignment
surgery Archives of Sexual Behavior 1983;12:247-61
25) Psychiatric diagnosis of patients requesting sex reassignment surgery.
Journal of Sex & Marital Therapy 1980; 6:164-173
26) Problem solving in sexual medicine I. British Journal of Sexual Medicine
1982;9:21-28
27) A modern perspective on nymphomania. Journal of Sex & Marital Therapy
1982;8:316-324
28) Nymphomania. Female Patient 1982;7:47-54
29) Commentary on Beverly Mead’s article: When your patient fears impotence.
Patient Care 1982;16:135-9
30) Relation of sexual problems to sexual enlightenment. Physician and Patient
1983 2:62
31) Clinical overview of impotence. Physician and Patient 1983; 8:52-55.
32) An analytical approach to problem-solving in sexual medicine: a clinical
introduction to the psychological sexual dysfunctions. II. British Journal of Sexual
Medicine
33) Coffman CB, Levine SB, Althof SE, Stern RG Sexual Adaptation among
single young adults with cystic fibrosis. Chest 1984;86:412-418
34) Althof SE, Coffman CB, Levine SB. The effects of coronary bypass in
female sexual, psychological, and vocational adaptation. Journal of Sex & Marital
Therapy 1984;10:176-184
35) Letter to the editor: Follow-up on Increasingly Ruth. Archives of Sexual
Behavior 1984;13:287-9
36) Essay on the nature of sexual desire Journal of Sex & Marital Therapy 1984;
10:83-96
37) Introduction to the sexual consequences of hemophilia. Scandanavian
Journal of Haemology 1984; 33:(supplement 40).75-
38) Agle DP, Heine P. Hemophila and Acquired Immune Deficiency Syndrome:
Intimacy and Sexual Behavior. National Hemophilia Foundation; July, 1985
39) Turner LA, Althof SE, Levine SB, Bodner DR, Kursh ED, Resnick MI.
External vacuum devices in the treatment of erectile dysfunction: a one-year study
of sexual and psychosocial impact. Journal of Sex & Marital Therapy
40) Schein M, Zyzanski SJ, Levine SB, Medalie JH, Dickman RL, Alemagno
SA. The frequency of sexual problems among family practice patients. Family
Page 8 of 22
Practice Research Journal 1988; 7:122-134

41) More on the nature of sexual desire. Journal of Sex & Marital Therapy
1987;13:35-44
42) Waltz G, Risen CB, Levine SB. Antiandrogen treatment of male sex
offenders. Health Matrix 1987; V.51-55.
43) Lets talk about sex. National Hemophilia Foundation January, 1988
44) Sexuality, Intimacy, and Hemophilia: questions and answers . National
Hemophilia Foundation January, 1988
45) Prevalence of sexual problems. Journal Clinical Practice in Sexuality
1988;4:14-16.
46) Kursh E, Bodner D, Resnick MI, Althof SE, Turner L, Risen CB, Levine
SB. Injection Therapy for Impotence. Urologic Clinics of North America 1988;
15(4):625-630
47) Bradley SJ, Blanchard R, Coates S, Green R, Levine S, Meyer-Bahlburg H,
Pauly I, Zucker KJ. Interim report of the DSM-IV Subcommittee for Gender
Identity Disorders. Archives of Sexual Behavior 1991;;20(4):333-43.
48) Sexual passion in mid-life. Journal of Clinical Practice in Sexuality 1991
6(8):13-19
49) Althof SE, Turner LA, Levine SB, Risen CB, Bodner DR, Resnick MI.
Intracavernosal injections in the treatment of impotence: A prospective study of
sexual, psychological, and marital functioning. Journal of Sex & Marital Therapy
1987; 13:155-167
50) Althof SE, Turner LA, Risen CB, Bodner DR, Kursh ED, Resnick MI. Side
effects of self-administration of intracavernosal injection of papaverine and
phentolamine for treatment of impotence. Journal of Urology 1989;141:54-7
51) Turner LA, Froman SL, Althof SE, Levine SB, Tobias TR, Kursh ED,
Bodner DR. Intracavernous injection in the management of diabetic impotence.
Journal of Sexual Education and Therapy 16(2):126-36, 1989
52) Is it time for sexual mental health centers? Journal of Sex & Marital
Therapy 1989
53) Althof SE, Turner LA, Levine SB, Risen CB, Bodner D, Kursh ED, Resnick
MI. Sexual, psychological, and marital impact of self injection of papaverine and
phentolamine: a long-term prospective study. Journal of Sex & Marital Therapy
54) Althof SE, Turner LA, Levine SB, Risen CB, Bodner D, Kursh ED, Resnick
MI. Why do so many men drop out of intracavernosal treatment? Journal of Sex &
Marital Therapy. 1989;15:121-9
55) Turner LA, Althof SE, Levine SB, Risen CB, Bodner D, Kursh ED, Resnick
Page 9 of 22
MI. Self injection of papaverine and phentolamine in the treatment of psychogenic

impotence. Journal of Sex & Marital Therapy. 1989; 15(3):163-78
56) Turner LA, Althof SE, Levine SB, Risen CB, Bodner D, Kursh ED, Resnick
MI. Treating erectile dysfunction with external vacuum devices: impact upon
sexual, psychological, and marital functioning. Journal of Urology 1990;141(1):79-
82
57) Risen CB, Althof SE. An essay on the diagnosis and nature of paraphilia
Journal of Sex & Marital Therapy 1990; 16(2):89-102.
58) Althof SE, Turner LA, Levine SB, Risen CB, Bodner DB, Kursh ED,
Resnick MI. Through the eyes of women: the sexual and psychological responses of
women to their partners’ treatment with self-injection or vacuum constriction
therapy. International Journal of Impotence Research (supplement 2)1990;346-7.
Resnick MI. A comparison of the effectiveness of two treatments for erectile
dysfunction: self injection vs. external vacuum devices. International Journal of
Impotence Research (supplement 2)1990;289-90
60) Kursh E, Turner L, Bodner D, Althof S, Levine S. A prospective study on
the use of the vacuum pump for the treatment of impotence. International Journal of
Impotence Research (supplement 2)1990;340-1.
Resnick MI. Long term use of intracavernous therapy in the treatment of erectile
dysfunction in Journal of Sex & Marital Therapy 1991; 17(2):101-112
Resnick MI. Long term use of vacuum pump devices in the treatment of erectile
dysfunction in Journal of Sex & Marital Therapy 1991;17(2):81-93
63) Turner LA, Althof SE, Levine SB, Bodner DB, Kursh ED, Resnick MI. A
12-month comparison of the effectiveness of two treatments for erectile
dysfunction: self injection vs. external vacuum devices. Urology 1992;39(2):139-44
64) Althof SE, The pathogenesis of psychogenic impotence. J. Sex Education
and Therapy. 1991; 17(4):251-66
65) Mehta P, Bedell WH, Cumming W, Bussing R, Warner R, Levine SB.
Letter to the editor. Reflections on hemophilia camp. Clinical Pediatrics 1991;
30(4):259-260
66) Successful Sexuality. Belonging/Hemophilia. (Caremark Therapeutic
Services), Autumn, 1991
67) Psychological intimacy. Journal of Sex & Marital Therapy 1991; 17(4):259-
68
68) Male sexual problems and the general physician, Georgia State Medical
Page 10 of 22
Journal 1992; 81(5): 211-6

69) Althof SE, Turner LA, Levine SB, Bodner DB, Kursh E, Resnick MI.
Through the eyes of women: The sexual and psychological responses of women to
their partner’s treatment with self-injection or vacuum constriction devices. Journal
of Urology 1992; 147(4):1024-7
70) Curry SL, Levine SB, Jones PK, Kurit DM. Medical and Psychosocial
predictors of sexual outcome among women with systemic lupus erythematosis.
Arthritis Care and Research 1993; 6:23-30
71) Althof SE, Levine SB. Clinical approach to sexuality of patients with spinal
cord injury. Urological Clinics of North America 1993; 20(3):527-34
72) Gender-disturbed males. Journal of Sex & Marital Therapy 19(2):131-141,
1993
73) Curry SL, Levine SB, Jones PK, Kurit DM. The impact of systemic lupus
erythematosis on women’s sexual functioning. Journal of Rheumatology 1994;
21(12):2254-60
74) Althof SE, Levine SB, Corty E, Risen CB, Stern EB, Kurit D.
Clomipramine as a treatment for rapid ejaculation: a double-blind crossover trial of
15 couples. Journal of Clinical Psychiatry 1995;56(9):402-7
75) Risen CB, Althof SE. Professionals who sexually offend: evaluation
procedures and preliminary findings. Journal of Sex & Marital Therapy 1994;
20(4):288-302
76) On Love, Journal of Sex & Marital Therapy 1995; 21(3):183-191
77) What is clinical sexuality? Psychiatric Clinics of North America 1995;
18(1):1-6
78) “Love” and the mental health professions: Towards an understanding of
adult love. Journal of Sex & Marital Therapy 1996; 22(3)191-202
79) The role of Psychiatry in erectile dysfunction: a cautionary essay on the
emerging treatments. Medscape Mental Health 2(8):1997 on the Internet.
September, 1997.
80) Discussion of Dr. Derek Polonsky’s SSTAR presentation on
Countertransference. Journal of Sex Education and Therapy 1998; 22(3):13-17
81) Understanding the sexual consequences of the menopause. Women’s Health
in Primary Care, 1998
82) Fones CSL, Levine SB. Psychological aspects at the interface of diabetes
and erectile dysfunction. Diabetes Reviews 1998; 6(1):1-8
83) Guay AT, Levine SB, Montague DK. New treatments for erectile
dysfunction. Patient Care March 15, 1998
Page 11 of 22
84) Extramarital Affairs. Journal of Sex & Marital Therapy 1998; 24(3):207-216
85) Levine SB (chairman), Brown G, Cohen-Kettenis P, Coleman E, Hage JJ,
Petersen M, Pfäfflin F, Shaeffer L, van Masdam J, Standards of Care of the Harry
Benjamin International Gender Dysphoria Association, 5th revision, 1998.
International Journal of Transgenderism at http://www.symposion.com/ijt
1. Reprinted by the Harry Benjamin International Gender Dysphoria
Association, Minneapolis, Minnesota
86) Althof SE, Corty E, Levine SB, Levine F, Burnett A, McVary K, Stecher V,
Seftel. The EDITS: the development of questionnaires for evaluating satisfaction
with treatments for erectile dysfunction. Urology 1999;53:793-799
87) Fones CSL, Levine SB, Althof SE, Risen CB. The sexual struggles of 23
clergymen: a follow-up study. Journal of Sex & Marital Therapy 1999
88) The Newly Devised Standards of Care for Gender Identity Disorders.
Journal of Sex Education and Therapy 24(3):1-11,1999
89) Levine, S. B. (1999). The newly revised standards of care for gender
identity disorders. Journal of Sex Education & Therapy, 24, 117-127.
90) Melman A, Levine SB, Sachs B, Segraves RT, Van Driel MF. Psychological
Issues in Diagnosis of Treatment (committee 11) in Erectile Dysfunction (A.
Jarden, G. Wagner, S. Khoury, F. Guiliano, H. Padma-nathan, R. Rosen, eds.)
Plymbridge Distributors Limited, London, 2000
91) Pallas J, Levine SB, Althof SE, Risen CB. A study using Viagra in a mental
health practice. J Sex&Marital Therapy.26(1):41-50, 2000
92) Levine SB, Stagno S. Informed Consent for Case Reports: the ethical
dilemma between right to privacy and pedagogical freedom. Journal of
Psychotherapy: Practice and Research, 2001, 10 (3): 193-201.
93) Alloggiamento T., Zipp C., Raxwal VK, Ashley E, Dey S. Levine SB,
Froelicher VF. Sex, the Heart, and Sildenafil. Current Problems in Cardiology 26
June 2001(6):381-416
94) Re-exploring The Nature of Sexual Desire. Journal of Sex and Marital
Therapy 28(1):39-51, 2002.
95) Understanding Male Heterosexuality and Its Disorders in Psychiatric Times
XIX(2):13-14, February, 2002
96) Erectile Dysfunction: Why drug therapy isn’t always enough. (2003)
Cleveland Clinic Journal of Medicine, 70(3): 241-246.
97) The Nature of Sexual Desire: A Clinician’s Perspective. Archives of Sexual
Behavior 32(3):279-286, 2003 .
98) Laura Davis. What I Did For Love: Temporary Returns to the Male Gender
Page 12 of 22
Role. International Journal of Transgenderism, 6(4), 2002 and

http://www.symposion.com/ijt
99) Risen C.B., The Crisis in the Church: Dealing with the Many Faces of
Cultural Hysteria in The International Journal of Applied Psychoanalytic Studies,
1(4):364-370, 2004
100) Althof SE, Leiblum SR (chairpersons), Chevert-Measson M. Hartman U.,
Levine SB, McCabe M., Plaut M, Rodrigues O, Wylie K., Psychological and
Interpersonal Dimensions of Sexual Function and Dysfunction in World Health
Organization Conference Proceedings on Sexual Dysfunctions, Paris, 2003.
Published in a book issued in 2004.
101) Commentary on Ejaculatory Restrictions as a Factor in the Treatment of
Haredi (Ultra-Orthodox) Jewish Couples: How Does Therapy Work? Archives of
Sexual Behavior, 33(3):June 2004
102) What is love anyway? J Sex & Marital Therapy 31(2):143-152,2005.
103) A Slightly Different Idea, Commentary on Y. M. Binik’s Should
Dyspareunia Be Retained as a Sexual Dysfunction in DSM-V? A Painful
Classification Decision. Archives of Sexual Behavior 34(1):38-39, 2005.
http://dx.doi.org/10.1007/s10508-005-7469-3
104) Commentary: Pharmacologic Treatment of Erectile Dysfunction: Not
always a simple matter. BJM USA; Primary Care Medicine for the American
Physician, 4(6):325-326, July 2004
105) Leading Comment: A Clinical Perspective on Infidelity. Journal of Sexual
and Relationship Therapy, 20(2):143-153, May 2005.
106) Multiple authors. Efficacy and safety of sildenafil citrate (Viagra) in men
with serotonergic antidepressant-associated erectile dysfunction: Results from a
randomized, double-blind, placebo-controlled trial. Submitted to Journal of Clinical
Psychiatry Feb 2005
107) Althof SE, Leiblum SR, Chevert-Measson M, Hartman U, Levine SB,
McCabe M, Plaut M, Rodrigues O, Wylie K. Psychological and Interpersonal
Dimensions of Sexual Function and Dysfunction. Journal of Sexual Medicine, 2(6):
793-800, November, 2005
108) Shifren JL, Davis SR, Moreau M, Waldbaum A, Bouchard C., DeRogatis L.,
Derzko C., Bearnson P., Kakos N., O’Neill S., Levine S., Wekselman K., Buch A.,
Rodenberg C., Kroll R. Testosterone Patch for the Treatment of Hypoactive Sexual
Desire Disorder in Naturally Menopausal Women: Results for the INTIMATE
NM1 Study. Menopause: The Journal of the North American Menopause Society
13(5) 2006.
109) Reintroduction to Clinical Sexuality. Focus: A Journal of Lifelong Learning
in Psychiatry Fall 2005. III (4):526-531
Page 13 of 22
110) PDE-5 Inhibitors and Psychiatry in J Psychiatric Practice 12 (1): 46-49,

2006.
111) Sexual Dysfunction: What does love have to do with it? Current Psychiatry
5(7):59-68, 2006.
112) How to take a Sexual History (Without Blushing), Current Psychiatry 5(8):
August, 2006.
113) Linking Depression and ED: Impact on sexual function and relationships in
Sexual Function and Men’s Health Through the Life Cycle under the auspices of
the Consortium for Improvement of Erectile Function (CIEF),12-19, November,
2006.
114) The First Principle of Clinical Sexuality. Editorial. Journal of Sexual
Medicine,4:853-854, 2007
115) Commentary on David Rowland’s editorial, “Will Medical Solutions to
Sexual Problems Make Sexological Care and Science Obsolete?” Journal of Sex
and Marital Therapy, 33(5), 2007
116) Real-Life Test Experience: Recommendations for Revisions to the
Standards of Care of the World Professional Association for Transgender Health
International Journal of Transgenderism, Volume 11 Issue 3, 186-193, 2009
117) Sexual Disorders: Psychiatrists and Clinical Sexuality. Psychiatric Times
XXIV (9), 42-43, August 2007
118) I am not a sex therapist! Commentary to I. Binik and M. Meana’s article Sex
Therapy: Is there a future in this outfit? Archives of Sexual Behavior, Volume 38,
Issue 6 (2009), 1033-1034
119) Solomon A (2009) Meanings and Political Implications of
“Psychopathology” in a Gender Identity Clinic: Report of 10 cases. Journal of Sex
and Marital Therapy 35(1): 40-57.
120) Perelman, MA., Levine SB, Fischkoff SA. Randomized, Placebo-
Controlled, Crossover Study to Evaluate the Effects of Intranasal Bremelanotide on
Perceptions of Desire and Arousal in Postmenopausal Women with Sexual Arousal
Disorder submitted to Journal of Sexual Medicine July 2009, rejected
121) What is Sexual Addiction? Journal of Sex and Marital Therapy.2010
May;36(3):261-75
122) David Scott (2010) Sexual Education of Psychiatric Residents. Academic
Psychiatry, 34(5) 349-352.
123) Chris G. McMahon, Stanley E. Althof, Joel M. Kaufman, Jacques Buvat,
Stephen B. Levine, Joseph W. Aquilina, Fisseha Tesfaye, Margaret Rothman,
David A. Rivas, Hartmut Porst. Efficacy and Safety of Dapoxetine for the
Treatment of Premature Ejaculation: Integrated Analysis of Results From 5 Phase 3
Page 14 of 22
Trials Journal of Sexual Medicine 2011 Feb;8(2):524-39.

124) Commentary on Consideration of Diagnostic Criteria for Erectile
Dysfunction in DSM V. Journal of Sexual Medicine July 2010
125) Hypoactive Sexual Desire Disorder in Men: Basic types, causes, and
treatment. Psychiatric Times 27(6)4-34. 2010
126) Male Sexual Dysfunctions, an audio lecture, American Physician Institute
2013
127) Fashions in Genital Fashion: Where is the line for physicians? Commentary
on David Veale and Joe Daniels’ Cosmetic Clitoridectomy in a 33-year-old woman.
Arch Sex Behav (2012) 41:735–736 DOI 10.1007/s10508-011-9849-7
128) Review: Problematic Sexual Excess. Neuropsychiatry 2(1):1-12, 2012
129) The Essence of Psychotherapy. Psychiatric Times 28 (2): August 2, 2012 t
130) Parran TV, Pisman, AR, Youngner SJ, Levine SB.Evolution of
remedial CME course in professionalism: Addressing learner needs,
developing content, and evaluating outcomes. Journal of Continuing
Education in the Health Professions, 33(3): 174-179, 2013.
131) Love and Psychiatry. Psychiatric Times November 2013
132) Orgasmic Disorders, Sexual Pain Disorders, and Sexual Dysfunction Due to
a Medical Condition. Board Review Psychiatry 2013-2014 Audio Digest CD 27.
Audio recording of a one-hour lecture available October 2013.
133) Towards a Compendium of the Psychopathologies of Love. Archives of
Sexual Behavior Online First December 25, 2013 DOI 10.1007/s10508-013-0242-6
43(1)213-220.
134) Flibanserin. (editorial) Archives of Sexual Behavior 44 (8), 2015 November
2015. DOI: 10.1007/s10508-015-0617-y
135) Martel C, Labrie F, Archer DF, Ke Y, Gonthier R, Simard JN, Lavoie L,
Vaillancourt M, Montesino M, Balser J, Moyneur É; other participating members of
the Prasterone Clinical Research Group. (2016) Serum steroid concentrations
remain within normal postmenopausal values in women receiving daily 6.5mg
intravaginal prasterone for 12 weeks.J Steroid Biochem Mol Biol. 2016
May;159:142-53. doi: 10.1016/j.jsbmb.2016.03.016
136) Reflections of an Expert on the Legal Battles Over Prisoners with Gender
Dysphoria. J Am Acad Psychiatry Law 44:236–45, 2016
137) Cooper E, McBride J, Levine SB. Does Flibanserin have a future?
Psychiatric Times accepted October 23, 2015.
138) Levine SB, Sheridan DL, Cooper EB. The Quest for a Prosexual Medication
for Women, Current Sexual Health Reports (2016) 8: 129. doi:10.1007/s11930-016-
Page 15 of 22
0085-y
139) Why Sex Is Important: Background for Helping Patients with Their Sexual
Lives., British Journal of Psychiatry Advances (2017), vol. 23(5) 300-306; DOI:
10.1192/apt.bp.116.016428
140) Commentary on "Asexuality: Orientation, paraphilia, dysfunction, or none
of the above? Archives Sexual Behavior, Archives of Sexual Behavior April 2017,
Volume 46, Issue 3, pp. 639–642 DOI: 10.1007/s10508-017-0947-z
141) Sexual Dysfunction in Clinical Psychiatry, Psychiatric Times, March 2017
142) Ethical Concerns About the Emerging Treatment of Gender Dysphoria,
Journal of Sex and Marital Therapy, 44(1):29-44. 2017. DOI
10.1080/0092623X.2017.1309482
143) The Psychiatrist’s Role in Managing Transgender Youth: Navigating
Today’s Politicized Terrain. CMEtoGO Audio Lecture Series, May 2017
144) Transitioning Back to Maleness, Archives of Sexual Behavior, 2017 Dec
20. doi: 10.1007/s10508-017-1136-9; 47(4), 1295-1300, May 2018
145) Informed Consent for Transgender Patients, Journal of Sex and Marital
Therapy, 2018 Dec 22:1-12. doi: 10.1080/0092623X.2018.1518885. [
C) Book Chapters
1) Overview of Sex Therapy. In Sholevar GP (ed) The Handbook of Marriage
and Marital Therapy. New York. Spectrum Publications, 1981 pp. 417-41
2) Why study sexual functioning in diabetes? In Hamburg BA, Lipsett LF,
Inoff GE, Drash A (eds) Behavioral & Psychosocial Issues in Diabetes: Proceedings
of a National conference. Washington, DC. US Dept. of Health & Human Services.
PHS NIH, Pub. #80-1933
3) Sexual Problems in the Diabetic in Bleicher SJ, Brodoff B (eds) Diabetes
Mellitus and Obesity. Williams and Wilkins, 1992
4) Clinical Introduction to Human Sexual Dysfunction. In Pariser SF, Levine
SB, McDowell M (eds) Clinical Sexuality. New York, Marcel Dekker Publisher,
1983.
5) Psychodynamically-oriented clinician’s overview of psychogenic
impotence. In RT Segraves (ed) Impotence. New York, Plenum, 1985
6) Origins of sexual preferences. In Shelp EE (ed) Sexuality and Medicine. D.
Reidel Publishing co. 1987. pp. 39-54.
7) Hypoactive Sexual Desire and Other Problems of Sexual Desire. In H. Lief
(ed). The Treatment of Psychosexual Dysfunctions/ III. American Psychiatric Press,
chapter 207, pp. 2264-79, 1989
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8) Psychological Sexual Dysfunction. In Sudak H (ed) Clinical Psychiatry.

Warren H. Green. St. Louis, 1985
9) Male sexual dysfunction. In Sudak H (ed) Clinical Psychiatry. Warren H.
Green. St. Louis, 1985
10) Sexuality and Aging. In Sudak H (ed) Clinical Psychiatry. Warren H. Green.
St. Louis, 1985
11) Homosexuality. In Sudak H (ed) Clinical Psychiatry. Warren H. Green. St.
Louis, 1985
12) Individual and intrapsychic factors in sexual desire. In Leiblum SR, Rosen
RC (eds). Clinical Perspectives on Sexual Desire Disorders. Guilford Press, New
York, 1988, pp. 21-44
13) Gender Identity Disorders. In Sadock B, Kaplan H(eds). Comprehensive
Textbook of Psychiatry, Baltimore, William and Wilkins, 1989, pp. 1061-9
14) Intrapsychic and Interpersonal Aspects of Impotence: Psychogenic Erectile
Dysfunction. In Leiblum SR, Rosen RC (eds). Erectile Disorders: Assessment and
Treatment. Guilford Press, New York, 1992
15) Psychological Factors in Impotence. In Resnick MI, Kursh ED, (eds.)
Current Therapy in Genitourinary Surgery, 2nd edition. BC Decker, 1991, pp. 549-
51
16) The Vagaries of Sexual Desire. In Leiblum SR, Rosen RC (eds). In Case
Studies in Sex Therapy. Guilford Press, New York, 1995
17) Rosenblatt EA. Sexual Disorders (chapter 62). In Tasman A, Kay J,
Liberman JA (eds). Psychiatry Volume II, W.B.Saunders, Philadelphia. 1997, pp.
1173-2000.
18) Althof SE. Psychological Evaluation and Sex Therapy. In Mulcahy JJ (ed)
Diagnosis and Management of Male Sexual Dysfunction Igaku-Shoin, New York,
1996, pp. 74-88
19) Althof SE, Levine SB. Psychological Aspects of Erectile Dysfunction. In
Hellstrum WJG (ed) Male Infertility and Dysfunction. Springer-Verlag, New York,
1997. pp. 468-73
20) Paraphilias. In Comprehensive Textbook of Psychiatry/VII. Sadock BJ,
Sadock VA (eds.) Lippincott Williams & Wilkins, Baltimore, 1999, pp. 1631-1645.
21) Women’s Sexual Capacities at Mid-Life in The Menopause: Comprehensive
Management B. Eskind (ed). Parthenon Publishing, Carnforth, UK, 2000.
22) Male Heterosexuality in Masculinity and Sexuality:Selected Topics in the
Psychology of Men, (Richard C. Friedman and Jennifer I. Downey, eds) Annual
Review of Psychiatry, American Psychiatric Press, Washington, DC, W-18. pp. 29-
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54.
23) R.T.Segraves. Introduction to section on Sexuality: Treatment of Psychiatric
Disorders-III (G.O.Gabbard, ed), American Psychiatric Press, Washington, DC,
2001
24) Sexual Disorders (2003) in Tasman A, Kay J, Liberman JA (eds). Psychiatry
2nd edition, Volume II, W.B.Saunders, Philadelphia. Chapter 74
25) What Patients Mean by Love, Psychological Intimacy, and Sexual Desire
(2003) in SB Levine, CB Risen, SE Althof (eds) Handbook of Clinical Sexuality for
Mental Health Professionals, Brunner-Routledge, New York, pp. .21-36.
26) Infidelity (2003) in SB Levine, CB Risen, SE Althof (eds) Handbook of
Clinical Sexuality for Mental Health Professionals, Brunner-Routledge, New York,
pp. 57-74
27) Preface (2003) in SB Levine, CB Risen, SE Althof (eds) Handbook of
Clinical Sexuality for Mental Health Professionals, Brunner-Routledge, New York,
pp. xiii-xviii
28) A Psychiatric Perspective on Psychogenic Erectile Dysfunction (2004) in
T.F. Lue (ed) Atlas of Male Sexual Dysfunction, Current Medicine, Philadelphia
Chapter 5
29) Levine, SB., Seagraves, RT. Introduction to Sexuality Section, Treatment of
Psychiatric Disorders, 3rd edition (Gabbard GO, editor), American Psychiatric
Press, 2007
30) Risen CB, (2009)Professionals Who Are Accused of Sexual Boundary
Violations In Sex Offenders: Identification, Risk Assessment, Treatment, and Legal
Issues edited by Fabian M. Saleh, Albert J. Grudzinskas, Jr., and John M. Bradford,
Oxford University Press, 2009
31) What Patients Mean by Love, Intimacy, and Sexual Desire, in Handbook of
Clinical Sexuality for Mental Health Professionals edited by Levine SB, Risen, CB,
and Althof, SE, Routledge, New York, 2010
32) Infidelity in Handbook of Clinical Sexuality for Mental Health Professionals
edited by Levine SB, Risen, CB, and Althof, SE, Routledge, New York, 2010
33) Scott DL, Levine, SB. Understanding Gay and Lesbian Life in Handbook of
Clinical Sexuality for Mental Health Professionals edited by Levine SB, Risen, CB,
and Althof, SE, Routledge, New York, 2010
34) Levine, SB, Hasan, S., Boraz M. (2009) Male Hypoactive Sexual Desire
Disorder (HSDD) in Clinical Manual of Sexual Disorders (R. Balon and RT
Segraves, eds), American Psychiatric Press, Washington, DC.
35) Levine, SB. Sexual Disorders in Fundamentals of Psychiatry (by Allan
Tasman and Wanda Mohr, eds.)
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<http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470665777.html>, .
36) Infidelity in Principles and Practices of Sex Therapy (I Binik, K. Hall,
editors), 5th edition, Guilford Press, New York, 2014.
37) Why is Sex Important? In Handbook of Clinical Sexuality for Mental Health
Professionals 3rd ed. [SB Levine, CB Risen, SE Althof, eds] New York. Routledge,
2016, Chapter 1
38) The Rich Ambiguity of Key Terms: Making Distinctions. In Handbook of
Clinical Sexuality for Mental Health Professionals 3rd ed. [SB Levine, CB Risen,
SE Althof, eds] New York. Routledge, 2016. Chapter 4
39) The Mental Health Professional’s Treatment of Erection Problems . In
Handbook of Clinical Sexuality for Mental Health Professionals 3rd ed. [SB
Levine, CB Risen, SE Althof, eds] New York. Routledge, 2016 Chapter 11
40) Why is Sex Important? In Sexual Health in the Couple: Management of
Sexual Dysfunction in Men and Women [L Lipshultz, A Pastuszak, M Perelman, A
Giraldi, J Buster, eds.] New York, Springer, 2016.
41) Sommers, B., Levine, S.B., Physician’s Attitude Towards Sexuality, in
Psychiatry and Sexual Medicine: A Comprehensive Guide for Clinical
Practitioners, 2020.
42) Boundaries And The Ethics Of Professional Misconduct in A. Steinberg, J.
L. Alpert, C A. Courtois( Eds.) Sexual Boundary Violations In Psychotherapy:
Therapist Indiscretions, & Transgressions, & Misconduct American Psychological
Association, 2021.
D) Book Reviews
1) Homosexualities: A Study of Diversity Among Men and Women by Alan P.
Bell and Martin S. Weinberg, Simon and Schuster, New York, 1978. In Journal of
Sex & Marital Therapy 1979; 5:
2) Marriage and Marital Therapies: Psychoanalytic, Behavioral & System
Theory Perspectives by TJ Paolino and BS McCrady. Brunner/Mazel, New York,
1978. In Journal of Sex & Marital Therapy 1979; 5:
3) Management of Male Impotence. Volume 5 International Perspectives in
Urology AH Bennett, (ed) Williams and Wilkins, Baltimore, 1992. In American
Journal of Psychiatry, 1984
4) The Sexual Relationship by DE Scharff, Routledge & Kegan Paul, 1982 in
Family Process 1983;22:556-8
5) Phenomenology and Treatment of Psychosexual Disorders, by WE Fann, I
Karacan, AD Pokorny, RL Williams (eds). Spectrum Publications, New York,
1983. In American Journal of Psychiatry 1985;142:512-6
Page 19 of 22
6) The Treatment of Sexual Disorders: Concepts and Techniques of Couple

Therapy, G Arentewicz and G Schmidt. Basic Books, New York, 1983. In
American Journal of Psychiatry 1985;142:983-5
7) Gender Dysphoria: Development, Research, Management. BN Steiner (ed).
Plenum Press, 1985 in Journal of Clinical Psychiatry, 1986
8) Gender Dysphoria: Development, Research, Management. BN Steiner (ed).
Plenum Press, 1985 in Contemporary Psychology 1986:31:421-2 [titled, The
Limitations of Science, the Limitations of Understanding]
9) Psychopharmacology of Sexual Disorders by M Segal (ed) John Libbey &
Co Ltd, London, 1987 in American Journal of Psychiatry 1987;144:1093
10) “The Sissy Boy Syndrome” and the Development of Homosexuality by R
Green. Yale University Press, New Haven, 1987. In American Journal of Psychiatry
1988;145:1028
11) Male Homosexuality: A contemporary psychoanalytic perspective by RC
Friedman, Yale University Press, New Haven, 1988 in Journal of Clinical
Psychiatry 1989;50:4, 149
12) Sexual Landscapes: Why we are what we are, why we love whom we love.
By JD Weinrich, Charles Schribner’s Sons, New York, 1987 in Archives of Sexual
Behavior 21 (3):323-26, 1991
13) How to Overcome Premature Ejaculation by HS Kaplan, Brunner/Mazel,
New York, 1989 in Journal of Clinical Psychiatry 51(3):130, 1990
14) Clinical Management of Gender Identity Disorders in Children and Adults
R. Blanchard, BN Steiner (eds) American Psychiatry Press, Washington, DC, 1990.
In Journal of Clinical Psychiatry 52(6):283, 1991
15) Psychiatric Aspects of Modern Reproductive Technologies. NL Stotland
(ed) American Psychiatric Press, Washington DC, 1990. In Journal of Clinical
Psychiatry 1991;52(9):390
16) Homosexualities: Reality, Fantasy, and the Arts. CW Socarides, VD Volkan
(eds). International Universities Press, Madison, Connecticut, 1990. In Journal of
Clinical Psychiatry 1992;(10)
17) Reparative Therapy of Male Homosexuality: A New Clinical Approach. J
Nicolosi, Jason Aronson, Northvale NJ, 1992. In Contemporary Psychology
38(2):165-6, 1993 [entitled Is Evidence Required?]
18) Male Victims of Sexual Assault, GC Mezey, MB King (eds) Oxford
University Press, New York, 1992. In Journal of Clinical Psychiatry
1993;54(9):358,
19) AIDS and Sex: An Integrated Biomedical and Biobehavioral Approach. B
Voeller, JM Reinisch, M Gottlieb, Oxford University Press, New York, 1990. In
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American Journal of Psychiatry

20) Porn: Myths for the Twentieth Century by RJ Stoller, Yale University Press,
New Haven, 1991. In Archives of Sexual Behavior 1995;24(6):663-668
21) Sexual Dysfunction: Neurologic, Urologic, and Gynecologic Aspects. R
Lechtenberg, DA Ohl (eds) Lea & Febiger, Philiadelphia, 1994. In Neurology
22) The Sexual Desire Disorders: Dysfunctional Regulation of Sexual
Motivation. HS Kaplan Brunner/Mazel, New York, 1995. In Neurology 1996;
47:316
23) Femininities, Masculinities, Sexualities: Freud and Beyond. N. Chodorow.
The University Press of Kentucky, Lexington, 1994. Archives of Sexual Behavior
28(5):397-400,1999
24) Sexual Function in People with Disability and Chronic Illness: A Health
Professional’s Guide by ML Sipski, CJ Alexander. Aspen Publishers, Gaitersburg,
Md, 1997. In Journal of Sex Education and Therapy, 1998;23(2):171-2
25) Sexual Aggression by J Shaw (ed). American Psychiatric Press,
Washington, DC, 1998. In American Journal of Psychiatry, May, 1999
26) The Wounded Healer: Addiction-Sensitive Approach to the Sexually
Exploitative Professional by Richard Irons and Jennifer P. Schneider. Jason
Aronson, Northvale, N.J., 1999 in American Journal of Psychiatry 157(5):8-9,2000.
27) Culture of the Internet by Sara Kiesler (editor), Lawrence Erlbaum
Associates, Mahway, New Jersey, 1997. 463pp in Journal of Sex Research, 2001
28) Psychological Perspectives on Human Sexuality. Lenore T. Szuchman and
Frank Muscarella (editors), Wiley and Sons, New York, American Journal of
Psychiatry, April, 2002
29) “How Sexual Science Operates” a review of Sex, Love, and Health in
America: Private Choices and Public Policies. EO Laumann and RT Michael,
editors. Chicago, University of Chicago, 2001 in Second Opinion, The Park Ridge
Center for the Study of Health, Faith, and Ethics, 11:82-3, April, 2004.
30) Sexual Orientation and Psychoanalysis: Sexual Science and Clinical
Practice. R.C. Friedman and J.I. Downey (eds). New York. Columbia University
Press. in Archives of Sexual Behavior (2003) 31(5):473-474
31) Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs,
Jonathon Michel Metzl. Duke University Press, Durham, 2003 in American Journal
of Psychiatry, November, 2004.
32) Sex and Gender by M. Diamond and A. Yates Child Psychiatric Clinics of
North America W. B. Saunders, Philadelphia, Pennsylvania, 2004, 268 pp. in Archives
of Sexual Behavior April 2007 online publication in Dec.2006 at
http://dx.doi.org/10.1007/s10508-006-9114-7
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33) Getting Past the Affair: A program to help you cope, heal, and move on—
together or apart by Douglas K. Snyder, Ph.D, Donald H. Baucom, Ph.D, and
Kristina Coop Gordon, Ph.D, New York, Guilford Press, 2007 in Journal of Sex and
Marital Therapy,34:1-3, 2007
34) Dancing with Science, Ideology and Technique. A review of Sexual
Desire Disorders: A casebook Sandra R. Leiblum editor, Guilford Press, New York,
2010. In Journal of Sex Research 2011.
35) What is more bizarre: the transsexual or transsexual politics? A review of
Men Trapped in Men’s Bodies: Narratives of Autogynephilic Transsexualism by
Anne A. Lawrence, New York, Springer, 2014. In Sex Roles: a Journal of Research,
70, Issue 3 (2014), Page 158-160, 2014. DOI: 10.1007/s11199-013-0341-9
36) There Are Different Ways of Knowing. A review of: How Sexual Desire
Works: The Enigmatic Urge by Frederick Toates, Cambridge, UK, Cambridge
University Press, in Sexuality and Cu1ture (2015) 19:407–409 DOI
10.1007/s12119-015-9279-0
37) The Dynamics of Infidelity: Applying Relationship Science to Clinical
Practice by Lawrence Josephs, American Psychological Association, Washington,
DC, 2018, pp. . 287, $69.95 in Journal of Sex and Marital
Therapy10.1080/0092623X.2018.1466954, 2018. For free access:
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38) Transgender Mental Health by Eric Yarbrough, American Psychiatric
Association Publications, 2018, Journal and Marital & Sexual Therapy,
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Page 22 of 22
8
9
WESTERN DISTRICT OF WASHINGTON
10 AT TACOMA
11 BRIAN TINGLEY, ) Case No. 3:21-cv-5359

)
12 Plaintiff, )
13 )
v. ) [PROPOSED] ORDER
14 )
ROBERT W. FERGUSON, in his official
)
)
16 )
official capacity as Secretary of Health for
)
17 )
)
)
19 )
Washington State Department of Health,
)
20 Defendants. )
21 Upon consideration of the motion for preliminary injunction filed by Plaintiff
22 Brian Tingley, and the Court having reviewed the Motion, the Defendants’
23 Opposition, and Plaintiff’s Reply, and having heard argument on the Motion and
24 being fully familiar with the record,
25 IT IS ORDERED that the motion for preliminary injunction is GRANTED
26 and that Defendants, and all those acting in concert with Defendants, are enjoined
27
[Proposed] Order Granting ALLIANCE DEFENDING FREEDOM

Motion for Preliminary Injunction 1 15100 N. 90th Street
(480) 444-0020
1 from enforcing Senate Bill 5722, codified at Wash Rev. Code §§ 18.130.020 and
2 18.130.180 (the “Counseling Censorship Law”), during the pendency of this case
3 until further order of this court.
4 DATED this ____ day of _______, 2021.
6 __________________________
United States District Judge
7
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(480) 444-0020
4 Presented by:
s/ Kristen K. Waggoner
5 Kristen K. Waggoner (WSBA #27790)
6 Roger Brooks (NC BAR #16317)*
David A. Cortman (GA Bar #188810)*
7 Gregory D. Esau (WSBA #22404)
8
9 Attorneys for Plaintiff Brian Tingley
10 *Pro hac vice applications pending

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(480) 444-0020

Tingley v. Ferguson Motion To Preliminary Injunction and Memo in Support

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Case 3:21-cv-05359 Document 2 Filed 05/13/21 Page 1 of 30

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

7 C. Scientific knowledge and lack of knowledge concerning changes in sexual

21 C. The Counseling Censorship Law cannot survive strict scrutiny. .......................... 11

22 1. The Counseling Censorship Law cannot survive strict scrutiny

26 3. The Counseling Censorship Law cannot survive strict scrutiny

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

12 V. The Remaining Factors Favor Granting a Preliminary Injunction. .................................. 21

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

3 American Beverage Association v. City and County of San Francisco,

8 Brown v. Entertainment Merchants Association,

18 Florida Star v. B.J.F.,

23 Herceg v. Hustler Magazine, Inc.,

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 Hurley v. Irish-American Gay, Lesbian & Bisexual Group of Boston,

16 National Institute of Family & Life Advocates v. Becerra,

21 Reed v. Town of Gilbert,

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

6 Trinity Lutheran Church of Columbia, Inc. v. Comer,

11 United States v. Stevens,

16 Victory Processing, LLC v. Fox,

23 West Virginia State Board of Education v. Barnette,

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 Wollschlaeger v. Governor, Fla.,

5 Wash. Rev. Code § 18.130.020................................................................................................1, 6, 9

6 Wash. Rev. Code § 18.130.160........................................................................................................6

7 Wash. Rev. Code § 18.130.180....................................................................................................1, 6

8 Wash. Rev. Code § 26.04.010..........................................................................................................6

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 Plaintiff Brian Tingley moves under Fed. R. Civ. P. 65 to preliminarily enjoin

6 Fourteenth Amendments of the U.S. Constitution.

8 “Speech is not unprotected merely because it is uttered by ‘professionals.’” Nat’l Inst. of

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

2 2020), quoting Texas v. Johnson, 491 U.S. 397, 414 (1989).

6 enjoined pending resolution of this case on the merits.

8 A. Plaintiff Tingley and his clients

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

2 Tingley Decl. ¶ 16.)

3 B. Religious beliefs concerning sexuality, identity, and the possibility of change

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

4 him or her. (Cmpl. ¶ 111; Tingley Decl. ¶ 26-27, 40, 51.)

14 Contrary to what is commonly asserted, the possibility of change in sexual orientation

17 have acknowledged–indeed proclaimed–that it is no longer possible to maintain that change in

18 sexual orientation is impossible or even rare. (Rosik Decl. ¶¶ 7-9, 15-28.)

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 experience some degree of same-sex attractions identified as exclusively heterosexual within a

2 few years. (Rosik Decl. ¶¶ 22.)

4 gender dysphoria or feelings of cross-gender identification ultimately resolve to identifying with

23 (Cmpl. ¶ 175; Tingley Decl. ¶ 74.)

26 165, 169, 172-173; Tingley Decl. ¶ 45, 62-64, 69, 72.)

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 E. The Counseling Censorship Law

2 The Counseling Censorship Law restricts “performing conversion therapy on a patient

6 individual's sexual orientation or gender identity”—which specifically includes “efforts to

7 change behaviors or gender expressions, or to eliminate or reduce sexual or romantic attractions

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

7 Governing Legal Standard

24 A. The Law regulates speech, not conduct.

Plaintiff’s Mot. for Prelim. Inj. and ALLIANCE DEFENDING FREEDOM

1 “characterizing speech as conduct is a dubious constitutional enterprise,” see Wollschlaeger v.

5 misconduct, ignore constitutional rights.”).

9 world is truly upside down.” Otto, 981 F.3d at 866.

12 1. The Law censors speech based on content.