Court Opinion

ID: 9365290
Source: CourtListenerOpinion
Date Created: 2023-01-23 18:00:38.393987+00
Date Added: 2024-06-11T17:15:44.526295
License: Public Domain

FOR PUBLICATION

   UNITED STATES COURT OF APPEALS
        FOR THE NINTH CIRCUIT

BRIAN TINGLEY,                            No. 21-35815

                  Plaintiff-Appellant,   D.C. No. 3:21-cv-
                                            05359-RJB
 v.
                                             ORDER
ROBERT W. FERGUSON, in his
official capacity as Attorney General
for the State of Washington; UMAIR
A. SHAH, in his official capacity as
Secretary of Health for the State of
Washington; KRISTIN PETERSON,
in her official capacity as Assistant
Secretary of the Health Systems
Quality Assurance division of the
Washington State Department of
Health,

              Defendants-Appellees,

EQUAL RIGHTS WASHINGTON,

              Intervenor-Defendant-
              Appellee.
2                    TINGLEY V. FERGUSON

BRIAN TINGLEY,                              No. 21-35856

               Plaintiff-Appellee,         D.C. No. 3:21-cv-
                                              05359-RJB
    v.

ROBERT W. FERGUSON, in his
official capacity as Attorney General
for the State of Washington; UMAIR
A. SHAH, in his official capacity as
Secretary of Health for the State of
Washington; KRISTIN PETERSON,
in her official capacity as Assistant
Secretary of the Health Systems
Quality Assurance division of the
Washington State Department of
Health,

               Defendants-Appellants,

               and

EQUAL RIGHTS WASHINGTON,

               Intervenor-Defendant.

                  Filed January 23, 2023

    Before: Kim McLane Wardlaw, Ronald M. Gould, and
              Mark J. Bennett, Circuit Judges.
                       TINGLEY V. FERGUSON                          3

                            Order;
               Statement by Judge O’Scannlain;
                  Dissent by Judge Bumatay

                          SUMMARY *

                           Civil Rights

    The panel denied on behalf of the court a petition for
rehearing en banc in a case in which the panel affirmed the
district court’s dismissal of an action challenging a
Washington state licensing scheme that disciplines health
care providers for practicing conversion therapy on minors.
    Respecting the denial of rehearing en banc, Judge
O’Scannlain, joined by Judges Ikuta, R. Nelson and
VanDyke, stated that although the result in this case was
reached by faithfully applying this court’s precedent in
Pickup v. Brown, 740 F.3d 1208, 1221 (9th Cir. 2014), which
held that a California ban on “sexual orientation change
efforts” was a regulation of professional conduct only
incidentally burdening speech, the Supreme Court has
rejected Pickup by name. Nat’l Inst. of Family & Life
Advocates v. Becerra, 138 S. Ct. 2361, 2372 (2018). And
other circuits have rejected Pickup’s holding, concluding
instead that therapeutic speech is speech, entitled to some
First Amendment protection. The court should have granted

*
  This summary constitutes no part of the opinion of the court. It has
been prepared by court staff for the convenience of the reader.
4                   TINGLEY V. FERGUSON

rehearing en banc to reconsider Pickup and to resolve this
circuit split.
    Additionally, the court should have granted rehearing en
banc to clarify that regulation of the medical profession is
not a First-Amendment-free zone; the First Amendment’s
protections continue to apply even when a state legislature
exercises its traditional police power.
    Dissenting from the denial of rehearing en banc, Judge
Bumatay wrote that because the speech underpinning
conversion therapy is overwhelmingly—if not exclusively—
religious, the court should have granted plaintiff Tingley’s
petition for en banc review to evaluate his Free Speech claim
under a more exacting standard. It may well be the case that,
even under heightened review, Washington’s interest in
protecting minors would overcome Tingley’s Free Speech
challenge. But the court plainly erred by subjecting the
Washington law to mere rational-basis scrutiny.
                         TINGLEY V. FERGUSON                            5

                               ORDER

    The full court was advised of the petition for rehearing
en banc. A judge requested a vote on whether to rehear the
matter en banc. The matter failed to receive a majority of
the votes of the nonrecused active judges in favor of en banc
consideration. See Fed. R. App. P. 35. Judges Collins and
Lee did not participate in the deliberations or vote in this
case.
    The petition for rehearing en banc is DENIED.

O’SCANNLAIN, Circuit Judge, 1 joined by IKUTA, R.
NELSON, and VANDYKE, Circuit Judges, respecting the
denial of rehearing en banc:

    Is therapeutic speech speech? Does a tradition of
licensing a given profession override all First Amendment
limits on licensing requirements? The three-judge panel
answered ‘no’ to the first question, and a majority of the
panel answered ‘yes’ to the second. In my view, both
holdings are erroneous and significant constitutional
misinterpretations, and I respectfully dissent from our court's
regrettable failure to rehear this case en banc. 2

1
  As a judge of this court in senior status, I no longer have the power to
vote on calls for rehearing cases en banc or formally to join a dissent
from failure to rehear en banc. See 28 U.S.C. § 46(c); Fed. R. App. P.
35(a). Following our court’s general orders, however, I may participate
in discussions of en banc proceedings. See Ninth Circuit General Order
5.5(a).
2
  Although the panel’s treatment of religious liberty is also concerning,
this statement focuses on the free speech issue.
6                    TINGLEY V. FERGUSON

    First, the panel said that therapeutic speech is non-speech
conduct and so protected only by rational basis review.
Tingley v. Ferguson, 47 F.4th 1055, 1077 (9th Cir. 2022).
True, it reached this result by faithfully applying our
decision in Pickup v. Brown, which held that a California ban
on “sexual orientation change efforts” was a regulation of
professional conduct only incidentally burdening speech.
740 F.3d 1208, 1221 (9th Cir. 2014). But the Supreme Court
has rejected Pickup by name. Nat’l Inst. of Family & Life
Advocates v. Becerra (“NIFLA”), 138 S. Ct. 2361, 2372
(2018). And other circuits have rejected Pickup’s holding,
concluding instead that therapeutic speech is—speech,
entitled to some First Amendment protection. See King v.
Governor of New Jersey, 767 F.3d 216, 224-29 (3d Cir.
2014); Otto v. City of Boca Raton, 981 F.3d 854, 865-66
(11th Cir. 2020). The panel’s defense of Pickup’s continuing
viability is unconvincing. We should have granted rehearing
en banc to reconsider Pickup and so to resolve this circuit
split.
    Second, a majority of the panel purported to discover a
“long (if heretofore unrecognized) tradition of regulation”
which warrants applying only rational basis review to laws
burdening therapeutic speech. Tingley, 47 F.4th at 1080
(2022) (quoting NIFLA, 138 S. Ct. at 2372). In reality, the
majority drew out a gossamer thread of historical evidence
into a sweeping new category of First Amendment
exceptions. If new traditions are so easily discovered,
speech-burdening laws can evade any level of scrutiny
simply by identifying some legitimate purpose which they
might serve. We should have granted rehearing en banc also
to clarify that regulation of the medical profession is not a
First-Amendment-free zone.
                     TINGLEY V. FERGUSON                     7

                               I
    Brian Tingley, a licensed Washington therapist,
challenged a 2018 Washington law prohibiting “conversion
therapy.” The case turns entirely on the language of the
statute and the First Amendment to the United States
Constitution.
                              A
    In 2018, the Washington legislature enacted S.B. 5722,
which made “[p]erforming conversion therapy on a patient
under age eighteen” a form of unprofessional conduct
subject to discipline. S.B. 5722, 65th Leg., Reg. Sess. (Wash.
2018), codified at Wash. Rev. Code §§ 18.130.020(4),
18.130.180(27). “[C]onversion therapy” is defined as any
“regime that seeks to change an individual’s sexual
orientation or gender identity.” Wash. Rev. Code
§ 18.130.020(4)(a). The statute clearly applies to conversion
therapy performed entirely through speech.
    Tingley’s therapeutic work consists of conversations
with his patients. These conversations are informed by his
belief that a person’s biological sex should not be changed,
and that sexual relationships ought to occur “between one
man and woman committed to each other through marriage.”
Tingley, 47 F.4th at 1065. He “has worked with several
minors … who have ‘sought his help in reducing same-sex
attractions,’ and others ‘who have expressed discomfort with
their biological sex.’” Id. at 1067. He plans to continue
working with minor patients along these lines despite S.B.
5722. Id. at 1068. He sought injunctive relief against state
officials (“Washington”), alleging, inter alia, that the threat
that Washington will enforce S.B. 5722 against him
unconstitutionally chills his right to free speech.
8                    TINGLEY V. FERGUSON

                              B
    The district court dismissed Tingley’s claims, and
Tingley appealed. The panel affirmed, and in particular held
that Tingley’s free speech claim was foreclosed by our
holding in Pickup. A majority of the panel affirmed on the
additional grounds that S.B. 5722 belonged to a longstanding
tradition of regulating medical practice.
                              1
    In Pickup, our court held that a California conversion
therapy ban similar to the Washington law at issue here was
a regulation of “the conduct of state-licensed professionals,”
and that “any effect it may have on free speech interests is
merely incidental.” 740 F.3d 1208, 1230-31. The panel here
applied Ninth Circuit precedent to conclude that Tingley’s
talk therapy was conduct, not speech, thereby effectively
putting him at risk of professional discipline. Id. at 1073.
    Although the Supreme Court in NIFLA criticized Pickup
by name, the three-judge panel concluded that Pickup’s
relevant holding remained good law because it and NIFLA
were not “clearly irreconcilable.” Tingley, 47 F.4th at 1074-
75 (quoting Miller v. Gammie, 335 F.3d 889, 899 (9th Cir.
2003) (en banc)). Pickup described a continuum of
constitutional protection for speech by licensed
professionals, from most-protected “public dialogue,” to
least-protected “professional conduct,” with “professional
speech ‘within the confines of a professional relationship’”
somewhere in between. The “conversion therapy” ban,
according to Pickup, was in the least-protected category: a
mere “regulation of conduct,” protected only by “rational
basis review.” Id. at 1072-73 (quoting Pickup, 740 F.3d at
1228). Since “NIFLA only abrogated the theoretical
‘midpoint’ of Pickup’s continuum,” the panel here reasoned
                     TINGLEY V. FERGUSON                     9

that “Pickup’s approach survives for regulations of
professional conduct.” Id. at 1075.
                              2
    A majority of the panel identified a second reason to
uphold the ban: a “long (if heretofore unrecognized)
tradition of regulation governing the practice of those who
provide health care within state borders.” Id. at 1080; see id.
at 1092 (Bennett, J., concurring in part) (declining to join
this “unnecessary” “dicta”). The panel majority’s primary
purported evidence was a handful of turn-of-the-century
cases upholding regulations of medical practice, without
reference to medical practitioner speech. Id. at 1080-81. The
panel majority then held that medical regulations burdening
such speech are within the tradition, and so receive no First
Amendment scrutiny, but are subject only to rational basis
review.
                              II
    Our decision in Pickup is, I suggest, no longer viable.
While Pickup may have seen no distinction between
“treatments … implemented through speech” and those
implemented “through scalpel,” Tingley, 47 F.4th at 1064,
the First Amendment recognizes the obvious difference, and
protects therapeutic speech in a way it does not protect
physical medical procedures. NIFLA further clarifies that
Pickup’s oxymoronic characterization of therapeutic speech
as non-speech conduct was incorrect. Other circuits have
noted Pickup’s error and declined to follow its reasoning.
We should have done the same here.
10                   TINGLEY V. FERGUSON

                              A
    The Supreme Court has already ruled: the First
Amendment cannot be evaded by regulating speech “under
the guise” of regulating conduct. NAACP v. Button, 371 U.S.
415, 439 (1963). “[I]ncidental speech” is permissibly
burdened when regulated conduct “‘was in part initiated,
evidenced, or carried out by means of language,’” Pickup,
740 F.3d at 1229 (quoting Giboney v. Empire Storage & Ice
Co., 336 U.S. 490, 502 (1949))—but the key phrase is “in
part.” There must be some “separately identifiable” conduct
to which the speech was incidental. Cohen v. California, 403
U.S. 15, 18 (1971). Even when a law “generally functions as
a regulation of conduct,” it merits First Amendment scrutiny
insofar as it burdens conduct which “consists of
communicating a message” and nothing more. Holder v.
Humanitarian L. Project (“HLP”), 561 U.S. 1, 28 (2010). In
sum, under binding Supreme Court precedents, conversion
therapy consisting entirely of speech cannot be prohibited
without some degree of First Amendment scrutiny.
    In reaching the contrary conclusion, Pickup erred. Along
the way, it grievously misinterpreted most of the precedents
on which it most heavily relied:
     •   The Supreme Court in HLP held that the First
         Amendment protected expert instruction and advice
         by licensed professionals. 561 U.S. at 27. Pickup
         wrongly claimed that HLP involved only “political
         speech” by “ordinary citizens.” 740 F.3d at 1230.
     •   Our court has held that medical practitioners cannot
         be prohibited from recommending marijuana use
         because doing so would “alter[] the traditional role
         of medical professionals by prohibiting speech
         necessary to the proper functioning” of the medical
                 TINGLEY V. FERGUSON                    11

    profession. Conant v. Walters, 309 F.3d 629 (9th Cir.
    2002) (cleaned up). Pickup mistakenly distinguished
    Conant as turning on whether the law burdened
    speech “wholly apart from the actual provision of
    treatment.” Pickup, 740 F.3d at 1229. While Conant
    considered the ban’s effect on speech outside the
    treatment context, it did so only after concluding that
    the ban must be subject to strict scrutiny.
•   Our court has said that, while psychoanalytic practice
    per se is not entitled to First Amendment protection,
    “[t]he communication that occurs during
    psychoanalysis is.” Nat’l Ass’n for the Advancement
    of Psychoanalysis v. California Bd. of Psychology
    (“NAAP”), 228 F.3d 1043, 1054 (9th Cir. 2000).
    NAAP then applied mere rational basis review to the
    law at issue only because it did “not dictate what can
    be said between psychologists and patients during
    treatment.” Id. at 1054. Pickup contradicted NAAP
    by applying neither intermediate nor strict scrutiny,
    despite the obvious fact that a conversion therapy ban
    does dictate the content of therapeutic speech.
•   Pickup misleadingly cited Supreme Court precedent
    for the proposition that some speech “is not ‘an act
    of communication’.” Pickup, 740 F.3d at 1230
    (citing Nevada Comm’n on Ethics v. Carrigan, 564
    U.S. 117, 126 (2011)). Carrigan was not about
    speech, but expressive conduct: it held that a vote
    does not communicate because it has a direct legal
    effect and no generally understood meaning beyond
    that effect. Speech uttered during therapy, in
    contrast, has no effect other than through what it
12                   TINGLEY V. FERGUSON

       communicates. Carrigan gives no support for the
       proposition that such speech is not speech at all.
Given the flaws in Pickup’s reasoning and its misreading of
relevant precedents, it is unsurprising that the Supreme
Court in NIFLA rejected—not only Pickup’s professional-
speech doctrine—but also its analysis of the line between
speech and conduct.
                              B
    NIFLA distinguished speech from conduct, but it
rejected Pickup’s analysis of the speech-conduct distinction.
Pickup asked if the speech burdened fell under the vague
heading “‘treatment of emotional suffering and
depression,’” in which case it was “‘not speech.’” 740 F.3d
at 1231 (quoting NAAP, 228 F.3d at 1054, but see discussion
of NAAP supra). NIFLA rejected recategorizing speech as
professional conduct merely because it took place in a
professional context. 138 S. Ct. at 2373. Instead, NIFLA
asked if the speech was incidental to some discrete instance
of non-speech conduct, such as a “medical procedure”
whose commission “‘without the patient’s consent’” would
constitute “‘assault.’” 138 S. Ct. at 2373 (quoting
Schloendorff v. Soc’y of N.Y. Hosp., 211 N.Y. 125, 129-30
(1914) (Cardozo, J.)). Under NIFLA, a law regulating
medical professional speech “regardless of whether a
medical procedure is ever sought, offered, or performed,”
and not incidental to some other discrete instance of
professional conduct, receives at least intermediate scrutiny,
and likely strict scrutiny. Id. at 2373, 2375.
    Especially after NIFLA, it is clear that simply labeling
therapeutic speech as “treatment” cannot turn it into non-
speech conduct. Pickup’s efforts to effect this transformation
were unpersuasive, and the panel here fared no better. The
                     TINGLEY V. FERGUSON                   13

panel alludes to two further reasons why talk therapy might
be non-speech conduct, but neither is convincing.
    First, the panel notes that the Washington legislature
reasonably believed conversion therapy to have negative
effects on “physical and psychological wellbeing,” id. at
1078, suggesting that therapeutic speech is not speech
because it is reasonably thought to risk physical harm. But it
would make no sense for the First Amendment to protect
speech through heightened scrutiny while subjecting
legislative determinations of the line between speech and
conduct only to rational basis review. The panel cites no
evidence for the implausible proposition that conversion
therapy conducted entirely by means of speech risks direct
physical harm. Id. Speech which risks psychological harm
does not thereby become non-speech conduct entirely
without First Amendment protections. Snyder v. Phelps, 562
U.S. 443, 450 (2011) (protecting speech which a jury had
found “outrageous,” and which experts testified “had
resulted in severe depression and had exacerbated pre-
existing health conditions”).
    Second, the panel finds that conversion therapy bans are
in line with “the medical recommendations of expert
organizations,” Tingley, 47 F.4th at 1078, suggesting that
therapeutic speech is not speech because it is not public
discourse, but belongs to the realm of expertise. Two panel
members go further, pointing out that therapists use
professional reference books, follow “established practice
standards,” and apply “theories and techniques.” Id. at 1082
(quoting Wash. Rev. Code §§ 18.19.010, 18.19.020). But if
these features transformed speech into conduct, the First
Amendment would not protect legal advice (attorneys make
use of authoritative references), education (teachers follow
established practice standards), or advertising (marketing
14                  TINGLEY V. FERGUSON

professionals apply theories and techniques). Actually, the
First Amendment offers at least some protection to all of
these forms of expert speech. See HLP, 561 U.S. 1, 27 (legal
advice); Pac. Coast Horseshoeing Sch., Inc. v. Kirchmeyer,
961 F.3d 1062, 1069 (9th Cir. 2020) (teaching); Thompson
v. W. States Med. Ctr., 535 U.S. 357, 366 (2002)
(advertising).
                             C
    Other circuits analyzing the issue have uniformly
rejected our Pickup case. Considering a closely analogous
challenge to a conversion therapy ban, the Eleventh Circuit
held that the ‘conduct’ involved in talk therapy “consists—
entirely—of words,” and that calling it non-speech conduct
was mere “relabeling.” Otto v. City of Boca Raton, 981 F.3d
854, 865 (11th Cir. 2020). Further noting that “NIFLA
directly criticized Pickup,” the Eleventh Circuit concluded
that there was “not … much question that, even if some type
of professional speech might conceivably fall outside the
First Amendment,” therapeutic speech did not. Id. at 867.
    Even before NIFLA, other circuits had found Pickup’s
analysis of the speech-content distinction both incoherent
and foreclosed by Supreme Court precedent. “[I]t would be
strange indeed,” the Third Circuit reasoned, if “the same
words, spoken with the same intent, somehow become
‘conduct’ when the speaker is a licensed counselor” rather
than a student—and in any case “the argument that verbal
communications become ‘conduct’ when they are used to
deliver professional services was rejected by Humanitarian
Law Project.” King v. Governor of New Jersey, 767 F.3d
216, 228 (3d Cir. 2014). While the Third Circuit did
ultimately uphold a conversion therapy ban, it did so only
after applying intermediate scrutiny, and it had “serious
                    TINGLEY V. FERGUSON                   15

doubts that anything less than intermediate scrutiny would
adequately protect the First Amendment interests inherent”
in professional speech. Id. at 236. In any event, King’s
holding that intermediate scrutiny applies did not survive
NIFLA, and King now stands only for the proposition that
therapeutic speech is entitled to some First Amendment
protection.
    In addition to these emphatic rejections, many circuits
including our own have noticed that NIFLA rejected Pickup,
including its version of the speech-content distinction. EMW
Women’s Surgical Ctr., P.S.C. v. Beshear, 920 F.3d 421, 436
(6th Cir. 2019) (noting that NIFLA “did not adopt any of the
‘different rules’ applied in Pickup”); Pac. Coast
Horseshoeing, 961 F.3d at 1068 (9th Cir.) (rejecting
Pickup’s version of the speech-conduct distinction, and
noting Pickup’s abrogation by NIFLA); see also Cap.
Associated Indus., Inc. v. Stein, 922 F.3d 198, 207 (4th Cir.
2019) (noting in passing Pickup’s abrogation); Vizaline,
L.L.C. v. Tracy, 949 F.3d 927, 932 (5th Cir. 2020) (same).
By reaching the opposite conclusion, the panel here
perpetuated a circuit split that many had thought resolved.
This error should have been corrected through en banc
rehearing.
                             III
    Unrelated to its reliance on Pickup, the panel majority
also erred in holding that a previously unknown tradition of
regulation authorizes Washington’s conversion therapy ban.
The majority purported to identify a new entry in the “long
familiar” catalog of carve-outs such as “obscenity,
defamation, fraud, incitement, and speech integral to
criminal conduct.” United States v. Stevens, 559 U.S. 460,
468 (2010) (citations omitted). But the majority’s purported
16                      TINGLEY V. FERGUSON

evidence simply does not demonstrate a long tradition of
regulating therapeutic speech, but only what everyone
already knew, that the police power extends to regulating
medical practice. That a law exercises the police power does
not exempt it from First Amendment scrutiny.
                                   A
    The majority’s analysis radically underestimated both
the burden of proof facing any purported discovery of a new
tradition of regulation, and the narrowness with which any
such tradition must be defined.
    To start, the majority failed to grapple with the Supreme
Court’s “especial[] reluctan[ce]” to recognize new
traditional exceptions. NIFLA, 138 S. Ct. at 2372. In the
dozen years since Stevens, the Supreme Court has never once
found the requisite “persuasive evidence” of a new tradition.
Brown v. Ent. Merchants Ass’n, 564 U.S. 786, 792 (2011)
(no traditional exception for depictions of violence); see
NIFLA, 138 S. Ct. at 2371 (nor for professional speech);
Williams-Yulee v. Fla. Bar, 575 U.S. 433, 446 (2015) (nor
for campaign finance). 3 Circuit courts have been similarly
reluctant, rejecting almost all purported new traditions—
most often sub silentio, sometimes explicitly. E.g.,
IMDb.com Inc. v. Becerra, 962 F.3d 1111, 1124 (9th Cir.
2020) (no traditional exception for biographical
information); Otto v. City of Boca Raton, 41 F.4th 1271,
1274 (11th Cir. 2022) (Grant, J., concurring in denial of
rehearing en banc) (nor for medical practitioner speech); see

3
  Even when a new tradition would only reduce the level of scrutiny from
strict to intermediate, the Court has required an “unbroken tradition” of
regulation dating to the “late 1860s.” City of Austin v. Reagan Nat’l
Advert. of Austin, LLC, 142 S. Ct. 1464, 1469 (2022).
                     TINGLEY V. FERGUSON                   17

also State v. Casillas, 952 N.W.2d 629, 637 (Minn. 2020)
(nor for non-consensual transmittals of sexual images). And
for good reason: a new tradition requires extensive historical
evidence. E.g., NetChoice LLC v. Paxton, 49 F.4th 439, 469-
480 (5th Cir. 2022) (opinion of Oldham, J.) (surveying
evidence for a tradition of common carrier regulations of the
communications industry).
    Further, the panel majority severely underestimates the
narrowness with which any new regulatory tradition must be
defined. It must be—not just “not too broad,” Tingley, 47
F.4th at 1080—but as narrow as the existing exceptions,
whose narrowness the Supreme Court has repeatedly
emphasized. E.g., United States v. Alvarez, 567 U.S. 709,
718-19 (2012) (tradition does not recognize a broad
exception for all false speech, but narrow exceptions for
defamation, fraud, invasion of privacy, and the like); New
York Times Co. v. Sullivan, 376 U.S. 254, 269 (1964) (a law
cannot merely bear the “epithet” of a traditional regulatory
category, it must fall into the category as “measured by
standards that satisfy the First Amendment”). Following the
Supreme Court’s lead, circuits have not allowed laws to
evade means-end scrutiny through loose analogies to
traditional categories. E.g., United States v. Anderson, 759
F.3d 891, 894 (8th Cir. 2014) (child-pornography category
limited to images of actual abuse); Am. Meat Inst. v. U.S.
Dep’t of Agric., 760 F.3d 18, 31 (D.C. Cir. 2014)
(Kavanaugh, J., concurring) (required-disclosure category
limited to disclosures preventing deception or ensuring
health or safety).
    In sum, a content-discriminatory law has two ways to
survive a First Amendment challenge: it must either pass
“rigorous” means-end scrutiny, or fit within a carefully
“delimit[ed]” long-standing tradition. Bennett v. Metro.
18                   TINGLEY V. FERGUSON

Gov’t of Nashville & Davidson Cnty. 977 F.3d 530, 553 (6th
Cir. 2020) (Murphy, J., concurring in the judgment). Both
routes require not one, but two showings: either the
regulation must be narrowly tailored to serve a compelling
interest, or it must belong to a narrowly delimited and
longstanding tradition. The panel majority erred in
concluding that S.B. 5722 could traverse the second route
without clear showings of narrowness and longevity.
                               B
    The panel majority ran afoul of the Supreme Court’s
requirement that regulatory traditions be defined narrowly.
It defined its new tradition broadly, as including all
“regulation governing the practice of those who provide
health care within state borders,” Tingley, 47 F.4th at 1080—
a definition so broad as not even to be a tradition of
regulating speech. To be sure, certain subcategories of
speech related to medical practice may well be unprotected.
The Supreme Court has acknowledged, for example, that
professional malpractice torts “fall within the traditional
purview of state regulation of professional conduct.” NIFLA,
138 S. Ct. at 2373 (quoting NAACP, 371 U.S. at 438, and
preempting the panel majority’s argument that malpractice
laws will be “endanger[ed]” absent a new tradition, Tingley,
47 F.4th at 1082). But a narrow exception for malpractice
does not imply a broad exception for all speech related to
medical practice, any more than the narrow exception for
fraud implies a broad exception for all false speech, or for all
speech inviting detrimental reliance. See Alvarez, 567 U.S.
at 718; cf. NIFLA, 138 S. Ct. at 2373 (quoting NAACP, 371
U.S. at 439). Traditional exceptions to First Amendment
scrutiny aren’t defined at such a high level of generality—
or, at least, shouldn’t be.
                     TINGLEY V. FERGUSON                   19

    Even setting aside the narrowness requirement, the panel
majority’s proposed tradition makes little sense on its own
terms. That regulations of medical practice get rational basis
review cannot on its own save a regulation of therapeutic
speech from First Amendment scrutiny. After all, building
regulations, too, get rational basis review. Village of Euclid
v. Ambler Realty Co., 272 U.S. 365 (1926). Contra Tingley,
47 F.4th at 1083 (suggesting that medicine and architecture
differ in this regard). But a state cannot evade First
Amendment scrutiny for signage regulations simply by
pointing out that building regulation is within the police
power, cf. Reagan Nat’l Advert., 142 S. Ct. at 1473 (applying
intermediate scrutiny to signage regulation), let alone evade
scrutiny of restrictions on the speech of licensed architects
by redescribing it as “building castles in air.”
    The panel majority’s argument produces the absurd
implication that any speech-burdening regulation which can
be characterized as an exercise of the police power is exempt
from First Amendment scrutiny.
                              C
    Even construing the panel majority to intend a more
narrowly defined tradition of regulating medical practitioner
speech within the treatment context, there simply is no
evidence of any such tradition. Though the panel majority
cited various Supreme Court precedents, none involves such
a regulation:
   •   Dent v. West Virginia upheld a medical licensing
       requirement against a substantive due process
       challenge. 129 U.S. 114 (1889). But the regulation
       did not burden speech. Although it did “prohibit[]
       ‘swearing falsely to any question which may be
       propounded’” to a license applicant, Tingley, 47
20                    TINGLEY V. FERGUSON

         F.4th at 1080 (citing Dent, 129 U.S. at 126) (cleaned
         up), the panel majority gained nothing from
         emphasizing this fact—fraud has always been
         recognized as a traditional regulatory category. See
         Alvarez, 567 U.S. at 718.
     •   Hawker v. New York upheld a law barring convicted
         felons from medical practice based on their lack of
         good character. 170 U.S. 189 (1898). More recent
         Supreme Court decisions establish that good
         character requirements in professional licensing are
         generally permissible—unless they burden speech,
         in which case they receive constitutional scrutiny.
         See Konigsberg v. State Bar of Cal., 353 U.S. 252,
         263 (1957).
     •   Collins v. Texas upheld application of a medical
         licensing law to an osteopath. 223 U.S. 288, 296
         (1912). The Supreme Court found the application
         “intelligible” because the osteopath engaged in
         purportedly “scientific manipulation affecting the
         nerve centers,” Collins, 223 U.S. at 296—in other
         words, it did not regulate his speech, but his physical
         contact with patients.
     •   Collins also contains what the panel majority called
         a “long list of cases from state courts,” Tingley, 47
         F.4th at 1080—really four Supreme Court cases
         appealed from state courts. Two upheld medical
         licensing laws, Hawker, 170 U.S. 189; Meffert v.
         Packer, 195 U.S. 625 (1904), while another upheld a
         vaccine mandate, Jacobson v. Massachusetts, 197
         U.S. 11 (1905). The fourth case regulated speech, but
         not medical speech in particular; it targeted
         advertising not just of medical practices, but also of
                 TINGLEY V. FERGUSON                    21

    “hotels, lodging houses, eating houses, [and] bath
    houses.” Williams v. Arkansas, 217 U.S. 79, 89
    (1910). It is well-established that medical advertising
    enjoys some degree of First Amendment protection.
    Thompson v. W. States Med. Ctr., 535 U.S. 357, 366
    (2002).
•   Lambert v. Yellowley upheld a Prohibition-era
    limitation on medical prescriptions of alcohol. 272
    U.S. 581 (1926). Although prescriptions do involve
    words, they are also legally efficacious acts, and so
    can be regulated as conduct. See Conant, 309 F.3d at
    634. And although this case does show that the
    practice of medicine has long been regulated despite
    good-faith disagreement about which regulations are
    desirable, Tingley, 47 F.4th at 1080-81, this fact is
    irrelevant. It shows only that medical regulations
    generally get rational basis review—not that medical
    regulations burdening speech receive no more
    scrutiny than other medical regulations.
•   Dobbs v. Jackson Women’s Health Organization
    included an appendix cataloging nineteenth-century
    abortion laws, 142 S. Ct. 2228, 2285-2300 (2022),
    which the panel majority describes as “apply[ing] to
    health care professionals and impact[ing] their
    speech,” Tingley, 47 F.4th at 1082. But really, the
    laws in question only burdened speech
    “suggest[ing],” “advis[ing],” “direct[ing],” or
    otherwise incidental to the procuring of an abortion,
    itself a criminal act at the time. It has long been
    understood that speech which aids and abets criminal
    conduct is not protected speech. See United States v.
    Freeman, 761 F.2d 549, 551 (9th Cir. 1985).
22                      TINGLEY V. FERGUSON

A later section of the majority opinion includes additional
citations, but these are even less relevant to the tradition-of-
regulation analysis, being dated a century too late to support
a longstanding constitutional tradition. Tingley, 47 F.4th at
1081-82 (citing a Washington statute enacted in 1984 and a
2007 law review article discussing recent caselaw). And in
any event, the regulations they contain are easily cognizable
under well-understood First Amendment categories such as
fraud, informed consent, and aiding and abetting liability. In
sum, the panel majority’s scattershot citations are not merely
insufficient evidence—they are not even relevant evidence.
They do not so much as give reason to suspect a long-
standing tradition of regulating therapeutic speech. 4
                                   D
    While there is no longstanding tradition of regulating
therapeutic speech, there is a constitutional tradition relevant
here—namely, that of protecting religious speech.
Unfortunately, the panel did not consider it.
    The Supreme Court has repeatedly emphasized that
protections for religious speech are at the core of the First
Amendment. E.g., Capitol Square Review & Advisory Bd. v.
Pinette, 515 U.S. 753, 760 (1995) (“[A] free-speech clause

4
  Judge Rosenbaum’s dissental in Otto, which similarly argued for new
tradition of regulation, cited only three pre-1970 cases not cited by the
panel majority here—and they are equally unavailing. 41 F.4th at 1291-
95. Two concern equal protection challenges to licensing law
exemptions, Crane v. Johnson, 242 U.S. 339 (1917) (upholding prayer
healer exemption); Watson v. Maryland, 218 U.S. 173 (1910) (upholding
grandfather exemption), while the third involved medical advertising,
Semler v. Oregon State Bd. of Dental Examiners, 294 U.S. 608 (1935).
As already shown, neither type of law supports a broader tradition of
regulating medical practitioner speech.
                     TINGLEY V. FERGUSON                    23

without religion would be Hamlet without the prince.”). As
the very term “conversion therapy” suggests, the speech
Washington’s law singles out for opprobrium is religious
speech. Cf. Church of the Lukumi Babalu Aye, Inc. v. City of
Hialeah, 508 U.S. 520, 534 (1993) (an ordinance’s “use of
the words ‘sacrifice’ and ‘ritual’” indicates that it targeted
religion). S.B. 5722’s carve-out for “[n]on-licensed
counselors acting under the auspices of a religious [group]”
implicitly acknowledges the constitutional issue, 2018
Wash. Sess. Laws, ch. 300, § 2, but it cannot save the law
from constitutional challenge. Many licensed therapists take
seriously the origins of “psychotherapy” in the religious
“cure of souls.” Institute for Faith & Family Amicus Br. at
13-14 (quoting Thomas Szasz, The Myth of Psychotherapy
28 (1978)). Tingley is among them. “[H]is Christian views
inform his work,” including his practice of conversion
therapy, in which he speaks to his patients about “what he
believes to be true,” such as that a person’s biological sex is
“‘a gift of God’ that should not be changed.” Tingley, 47
F.4th at 1065, 1068. Tingley’s religious speech does not lose
its constitutional protection simply because he is subject to a
licensing requirement. Cf. Fulton v. City of Philadelphia,
141 S. Ct. 1868, 1884 (2021) (Alito, J., concurring) (arguing
that traditional religious practices merit constitutional
protection even when the state has imposed licensing
requirements).
    Yet the panel majority here entirely ignored the First
Amendment’s special solicitude for religious speech.
Instead, it commended Washington for concluding “that
health care providers should not be able to treat a child by
such means as telling him that he is ‘the abomination we had
heard about in Sunday school’.” Tingley, 47 F.4th at 1083
(quoting a law review note quoting an op-ed). Far from
24                       TINGLEY V. FERGUSON

showing that conversion therapy bans are constitutionally
innocuous, this passage in the panel majority opinion
unwittingly reveals why First Amendment scrutiny is
necessary. 5
                                   IV
    The Supreme Court has already spoken: a legislature
cannot evade First Amendment scrutiny simply by labeling
therapeutic speech as conduct, and the First Amendment’s
protections continue to apply even when a state legislature
exercises its traditional police power. Because the panel
failed to apply binding Supreme Court precedent, I
respectfully dissent from the court’s decision not to rehear
this case en banc.

5
  This section of the panel majority, Tingley, 47 F.4th at 1083-84,
contains more rhetoric than law. It cites only two binding authorities, one
about coerced consent to police search of a vehicle, Schneckloth v.
Bustamonte, 412 U.S. 218, 228 (1973), the other about the right to
conduct one’s own criminal defense, Faretta v. California, 422 U.S. 806,
834 (1975). It concludes: “We uphold Washington’s law and reject
Tingley’s free speech challenge because the Washington law permissibly
honors individual identity.” Tingley, 47 F.4th at 1084. That a law burdens
speech in order to “honor[] individual identity” does not, as far as I am
aware, exempt it from First Amendment scrutiny.
                     TINGLEY V. FERGUSON                   25

BUMATAY, Circuit Judge, dissenting from the denial of
rehearing en banc:

    The issues at the heart of this case are profoundly
personal. Many Americans and the State of Washington find
conversion therapy—the practice of seeking to change a
person’s sexual orientation or gender identity—deeply
troubling, offensive, and harmful. They point to studies that
show such therapy ineffective. Even worse, they claim that
conversion therapy correlates with high rates of severe
emotional and psychological trauma, including suicidal
ideation. Under the appropriate level of judicial review,
these concerns should not be ignored.
    But we also cannot ignore that conversion therapy is
often grounded in religious faith. According to plaintiff
Brian Tingley, a therapist licensed by the State of
Washington, his practice of conversion therapy is an
outgrowth of his religious beliefs and his understanding of
Christian teachings. Tingley treats his clients from the
perspective of a shared faith, which he says is conducive to
establishing trust. And as part of his therapeutic treatment,
Tingley counsels his clients to live their lives in alignment
with their religious beliefs and teachings.
    To be sure, the relationship between the LGBT
community and religion may be a complicated one. But as
with any community, members of the LGBT community
have different experiences with faith. According to one
2013 survey, 42% of LGBT adults identify as “Christian.”
Forty-three percent consider religion to be important in their
lives—including 20% who say it is “very important” to
them. A Survey of LGBT Americans, Pew Research Center,
26                        TINGLEY V. FERGUSON

91–92, 96 (June 13, 2013). 1 A more recent study found that
46.7% of LGBT adults, or 5.3 million LGBT Americans, are
religious. Kerith J. Conron et al., Religiosity Among LGBT
Adults in the US, UCLA Williams Institute, 2, 5 (Oct.
2020). 2 Thus, for many who voluntarily seek conversion
therapy, faith-based counseling may offer a unique path to
healing and inner peace. Indeed, Tingley only works with
clients who freely accept his faith-based approach.
    Ordinarily, under traditional police powers, States have
broad authority to regulate licensed professionals like
Tingley. Under that authority, the State of Washington has
banned the practice of conversion therapy on minors. See
Wash. Rev. Code §§ 18.130.020(4), 18.130.080(27). The
prohibition applies to all forms of the treatment, including
voluntary, non-aversive, and non-physical therapy. Id. 3 In
other words, Washington outlaws pure talk therapy based on
sincerely held religious principles. As a result, Tingley
cannot discuss traditional Christian teachings on sexuality or
gender identity with his minor clients, even if they seek that
counseling.     While States’ regulatory authorities are

1
 Available at: https://www.pewresearch.org/social-trends/wp-
content/uploads/sites/3/2013/06/SDT_LGBT-Americans_06-2013.pdf.
2
 Available at: https://williamsinstitute.law.ucla.edu/wp-
content/uploads/LGBT-Religiosity-Oct-2020.pdf.
3
  Washington notes that conversion therapy may encompass more
pernicious practices, such as electric shock treatment or the use of
nausea-inducing drugs. I have little doubt that a law prohibiting
coercive, physical, or aversive treatments on minors would survive a
constitutional challenge under any standard of review.              But
Washington’s law proscribes a broad range of counseling, some of which
would clearly be classified as voluntary, religious, and speech. Under
Tingley’s constitutional challenge, we must focus on the law’s impact on
these aspects of conversion therapy.
                     TINGLEY V. FERGUSON                   27

generally broad, they must give way to our Constitution.
    And here, the First Amendment protects against
government abridgment of the “freedom of speech.” U.S.
Const. amend. I. No matter our feelings on the matter, the
sweep of Washington’s law limits speech motivated by the
teachings of several of the world’s major religions. Such
laws necessarily trigger heightened levels of judicial review.
After all, “religious and philosophical objections” to matters
of sexuality and gender identity “are protected views and in
some instances protected forms of expression.” Masterpiece
Cakeshop v. Colo. Civ. Rts. Comm’n, 138 S. Ct. 1719, 1727
(2018). As Judge O’Scannlain writes, religious speech gains
“special solicitude” under the First Amendment. See also
Capitol Square Rev. & Advisory Bd. v. Pinette, 515 U.S. 753,
760 (1995). And those protections don’t dissipate merely
because Tingley is a licensed therapist. In the free exercise
context, the Court has recently remarked that the First
Amendment protects “the ability of those who hold religious
beliefs of all kinds to live out their faiths in daily life.”
Kennedy v. Bremerton Sch. Dist., 142 S. Ct. 2407, 2421
(2022). That principle applies equally when faith takes the
form of speech.
    Because the speech underpinning conversion therapy is
overwhelmingly—if not exclusively—religious, we should
have granted Tingley’s petition for en banc review to
evaluate his Free Speech claim under a more exacting
standard. It may well be the case that, even under heightened
review, Washington’s interest in protecting minors would
overcome Tingley’s Free Speech challenge. But our court
plainly errs by subjecting the Washington law to mere
rational-basis scrutiny. See Tingley v. Ferguson, 47 F.4th
1055, 1077–78 (9th Cir. 2022).
28                  TINGLEY V. FERGUSON

    It is a “bedrock principle” of the First Amendment that
the government cannot limit speech “simply because society
finds the idea itself offensive or disagreeable.” Texas v.
Johnson, 491 U.S. 397, 414 (1989). While I recognize that
the speech here may be unpopular or even offensive to many
Americans, it is in these cases that we must be most vigilant
in adhering to constitutional principles. Those principles
require a heightened review of Tingley’s Free Speech claim.
It may be easier to dismiss this case under a deferential
review to Washington’s law, but the Constitution commands
otherwise.
   I respectfully dissent from the denial of rehearing en
banc.