Court Opinion

ID: 1039309
Source: CourtListenerOpinion
Date Created: 2013-08-29 21:18:32.1174+00
Date Added: 2024-06-11T12:45:22.290327
License: Public Domain

FOR PUBLICATION

  UNITED STATES COURT OF APPEALS
       FOR THE NINTH CIRCUIT

DAVID H. PICKUP; CHRISTOPHER H.           No. 12-17681
ROSICK; JOSEPH NICOLOSI; ROBERT
VAZZO; NATIONAL ASSOCIATION                  D.C. No.
FOR RESEARCH AND THERAPY OF              2:12-CV-02497-
HOMOSEXUALITY, a Utah non-profit            KJM-EFB
organization; AMERICAN
ASSOCIATION OF CHRISTIAN
COUNSELORS, a Virginia non-profit
association; JACK DOE 1, Parent of
John Doe 1; JANE DOE 1, Parent of
John Doe 1; JOHN DOE 1, a minor,
guardian ad litem Jane Doe, guardian
ad litem Jack Doe; JACK DOE 2,
Parent of John Doe 2; JANE DOE 2,
Parent of John Doe 2; JOHN DOE 2, a
minor, guardian ad litem Jack Doe,
guardian ad litem Jane Doe,
                Plaintiffs-Appellants,

                  v.

EDMUND G. BROWN, JR., Governor
of the State of California, in his
official capacity; ANNA M.
CABALLERO, Secretary of the
California State and Consumer
Services Agency, in her official
capacity; SHARON LEVINE, President
of the Medical Board of California,
in her official capacity; KIM
2                     PICKUP V. BROWN

MADSEN, Executive Officer of the
California Board of Behavioral
Sciences, in her official capacity;
MICHAEL ERICKSON, President of the
California Board of Psychology, in
his official capacity,
                Defendants-Appellees,

                and

EQUALITY CALIFORNIA,
    Intervenor-Defendant-Appellee.

     Appeal from the United States District Court
        for the Eastern District of California
     Kimberly J. Mueller, District Judge, Presiding

DONALD WELCH; ANTHONY DUK;               No. 13-15023
AARON BITZER,
              Plaintiffs-Appellees,         D.C. No.
                                        2:12-CV-02484-
                 v.                        WBS-KJN

EDMUND G. BROWN, JR., Governor
of the State of California, in his         OPINION
official capacity; ANNA M.
CABALLERO, Secretary of California
State and Consumer Services
Agency, in her official capacity;
DENISE BROWN, Case Manager,
Director of Consumer Affairs, in her
official capacity; CHRISTINE
                   PICKUP V. BROWN                      3

WIETLISBACH, PATRICIA LOCK-
DAWSON, SAMARA ASHLEY, HARRY
DOUGLAS, JULIA JOHNSON, SARITA
KOHLI, RENEE LONNER, KAREN
PINES, CHRISTINA WONG, in their
official capacities as members of the
California Board of Behavioral
Sciences; SHARON LEVINE, MICHAEL
BISHOP, SILVIA DIEGO, DEV
GNANADEV, REGINALD LOW, DENISE
PINES, JANET SALOMONSON, GERRIE
SCHIPSKE, DAVID SERRANO SEWELL,
BARBARA YAROSLAVSKY, in their
official capacities as members of the
Medical Board of California,
               Defendants-Appellants.

     Appeal from the United States District Court
          for the Eastern District of California
   William B. Shubb, Senior District Judge, Presiding

                 Argued and Submitted
       April 17, 2013—San Francisco, California

                 Filed August 29, 2013

Before: Alex Kozinski, Chief Judge, and Susan P. Graber,
         and Morgan Christen, Circuit Judges.

                Opinion by Judge Graber
4                        PICKUP V. BROWN

                           SUMMARY*

                            Civil Rights

    Reversing an order granting preliminary injunctive relief
in Welch v. Brown, 13-15023, and affirming the denial of
preliminary injunctive relief in Pickup v. Brown, 12-17681,
the panel held that California Senate Bill 1172, which bans
state-licensed mental health providers from engaging in
“sexual orientation change efforts” with patients under 18
years of age, does not violate the free speech rights of
practitioners or minor patients, is neither vague nor
overbroad, and does not violate parents’ fundamental rights.

    The panel held that Senate Bill 1172 regulates
professional conduct, not speech and therefore was subject
only to a rational basis review. The panel held that under its
police power, California has authority to prohibit licensed
mental health providers from administering therapies that the
legislature has deemed harmful, and the fact that speech may
be used to carry out those therapies does not turn the
prohibitions of conduct into prohibitions of speech. The
panel further concluded that the First Amendment does not
prevent a state from regulating treatment even when that
treatment is performed through speech alone. The panel
concluded that the record demonstrated that the legislature
acted rationally when it decided to protect the well-being of
minors by prohibiting mental health providers from using
“sexual orientation change efforts” on persons under 18.

  *
    This summary constitutes no part of the opinion of the court. It has
been prepared by court staff for the convenience of the reader.
                     PICKUP V. BROWN                        5

    The panel further held that: (1) SB 1172 did not implicate
the right to freedom of association because freedom of
association does not encompass the therapist-client
relationship; (2) SB 1172 was neither void for vagueness nor
overbroad because the text of SB 1172 was clear to a
reasonable person and any incidental effect that the ban had
on speech was small in comparison to its legitimate sweep;
and (3) the ban did not infringe on the fundamental rights of
parents because parents do not have the right to choose a
specific type of provider for a specific medical or mental
health treatment that the state has reasonably deemed
harmful.

                        COUNSEL

                       No. 12-17681

Mathew D. Staver (argued) and Anita L. Staver, Liberty
Counsel, Maitland, Florida; Mary E. McAlister, Stephen M.
Crampton, and Daniel J. Schmid, Liberty Counsel,
Lynchburg, Virginia, for Plaintiffs-Appellants David H.
Pickup et al.

Alexandra Robert Gordon (argued), Deputy Attorney
General, Kamala D. Harris, Attorney General of California,
Douglas J. Woods, Senior Assistant Attorney General, Tamar
Pachter, Supervising Deputy Attorney General, and Daniel J.
Powell and Rei R. Onishi, Deputy Attorneys General, San
Francisco, California, for Defendants-Appellees Edmund G.
Brown, Jr., et al.
6                    PICKUP V. BROWN

Shannon P. Minter (argued), National Center for Lesbian
Rights, San Francisco, California; David C. Dinielli, Munger,
Tolles & Olson LLP, Los Angeles, California, for
Intervenor/Defendant-Appellee.

Robert P. Taylor, Arnold & Porter LLP, San Francisco,
California, for Amici Curiae American Association for
Marriage and Family Therapy-California Division, et al.;
Elizabeth O. Gill, ACLU Foundation of Northern California,
Inc., San Francisco, California, for Amicus Curiae American
Civil Liberties Union Foundation of Northern California; Eric
Alan Isaacson, San Diego, California, and Stacey M. Kaplan,
San Francisco, California, for Amici Curiae California Faith
for Equality, et al.; Brad W. Seiling, Benjamin G. Shatz, and
Justin Jones Rodriquez, Manatt, Phelps & Phillips, LLP, Los
Angeles, California, and Hayley Gorenberg, Lambda Legal
Defense and Education Fund, Inc., New York, New York,
and Shelbi D. Day, Lambda Legal Defense and Education
Fund, Inc., Los Angeles, California, for Amici Curiae
Children’s Law Center of California, et al.; Jay Rapaport,
Covington & Burling LLP, San Francisco, California, for
Amicus Curiae Dr. Jack Drescher, M.D.; Jon B. Eisenberg
and Barry R. Levy, Encino, California, for Amicus Curiae
First Amendment Scholars; Eileen R. Ridley, Thomas F.
Carlucci, Patrick T. Wong, and Kristy K. Marino, Foley &
Lardner LLP, San Francisco, California, for Amicus Curiae
Health Law Scholars; Adam L. Gray and James Maxwell
Cooper, Kirkland & Ellis LLP, San Francisco, California, for
Amici Curiae Medical Professionals Tonya Chaffee, MD,
MPH, et al.; Tara M. Steeley, Deputy City Attorney, and
Dennis J. Herrera, City Attorney, and Therese Stewart, Mollie
Lee, and Sara Eisenberg, Deputy City Attorneys, San
Francisco, California, for Amicus Curiae The City and
County of San Francisco; and Sanford Jay Rosen, Rosen Bien
                     PICKUP V. BROWN                       7

Galvan & Grunfeld LLP, San Francisco, California, for
Amicus Curiae Survivors of Sexual Orientation Change
Efforts.

                       No. 13-15023

Alexandra Robert Gordon (argued), Deputy Attorney
General, Kamala D. Harris, Attorney General of California,
Douglas J. Woods, Senior Assistant Attorney General, Tamar
Pachter, Supervising Deputy Attorney General, and Daniel J.
Powell and Rei R. Onishi, Deputy Attorneys General, and
Craig J. Konnoth, Deputy Solicitor General, San Francisco,
California, for Defendants-Appellants Edmund G. Brown, Jr.,
et al.

Kevin T. Snider (argued), Matthew B. McReynolds, and
Michael J. Peffer, Pacific Justice Institute, Sacramento,
California, for Plaintiffs-Appellees Donald Welch et al.

Elizabeth O. Gill, ACLU Foundation of Northern California,
Inc., San Francisco, California, for Amicus Curiae American
Civil Liberties Union Foundation of Northern California;
Peter D. Lepiscopo, William P. Morrow, James M. Griffiths,
and Michael W. Healy, Lepiscopo & Associates Law Firm,
San Diego, California, for Amicus Curiae American College
of Pediatricians; Eric Alan Isaacson, San Diego, California,
and Stacey M. Kaplan, San Francisco, California, for Amici
Curiae California Faith for Equality, et al.; Brad W. Seiling
and Benjamin G. Shatz, Manatt, Phelps & Phillips, LLP, Los
Angeles, California, and Hayley Gorenberg, Lambda Legal
Defense and Education Fund, Inc, New York, New York, and
Shelbi D. Day, Lambda Legal Defense and Education Fund,
Inc., Los Angeles, California, for Amici Curiae Children’s
Law Center of California, et al.; Shannon P. Minter, National
8                    PICKUP V. BROWN

Center for Lesbian Rights, San Francisco, California, and
David C. Dinielli, Munger, Tolles & Olson LLP, Los
Angeles, California, for Amicus Curiae Equality California;
Jon B. Eisenberg and Barry R. Levy, Encino, California, for
Amicus Curiae First Amendment Scholars; John A. Eidsmoe
and Joshua M. Pendergrass, Foundation for Moral Law,
Montgomery, Alabama, for Amicus Curiae Foundation for
Moral Law; Eileen R. Ridley, Thomas F. Carlucci, Patrick T.
Wong, and Kristy K. Marino, Foley & Lardner LLP, San
Francisco, California, for Amicus Curiae Health Law
Scholars; Dean R. Broyles, The National Center for Law &
Policy, Escondido, California, for Amicus Curiae Parents and
Friends of Ex-Gays & Gays; and Sanford Jay Rosen, Rosen
Bien Galvan & Grunfeld LLP, San Francisco, California, for
Amicus Curiae Survivors of Sexual Orientation Change
Efforts.

                         OPINION

GRABER, Circuit Judge:

    The California legislature enacted Senate Bill 1172 to ban
state-licensed mental health providers from engaging in
“sexual orientation change efforts” (“SOCE”) with patients
under 18 years of age. Two groups of plaintiffs sought to
enjoin enforcement of the law, arguing that SB 1172 violates
the First Amendment and infringes on several other
constitutional rights.

    In Welch v. Brown, No. 13-15023, the district court ruled
that Plaintiffs were likely to succeed on the merits of their
First Amendment claim and that the balance of the other
preliminary-injunction factors tipped in their favor; thus, the
                     PICKUP V. BROWN                         9

court granted a preliminary injunction. In Pickup v. Brown,
No. 12-17681, the district court ruled that Plaintiffs were
unlikely to succeed on the merits of any of their claims and
denied preliminary relief. The losing parties timely appealed.
We address both appeals in this opinion.

    Although we generally review for abuse of discretion a
district court’s decision to grant or deny a preliminary
injunction, we may undertake plenary review of the issues if
a district court’s ruling “‘rests solely on a premise as to the
applicable rule of law, and the facts are established or of no
controlling relevance.’” Gorbach v. Reno, 219 F.3d 1087,
1091 (9th Cir. 2000) (en banc) (quoting Thornburgh v. Am.
Coll. of Obstetricians & Gynecologists, 476 U.S. 747, 755–57
(1986)). Because those conditions are met here, we
undertake plenary review and hold that SB 1172, as a
regulation of professional conduct, does not violate the free
speech rights of SOCE practitioners or minor patients, is
neither vague nor overbroad, and does not violate parents’
fundamental rights. Accordingly, we reverse the order
granting preliminary relief in Welch and affirm the denial of
preliminary relief in Pickup.

   FACTUAL AND PROCEDURAL BACKGROUND

A. Sexual Orientation Change Efforts (“SOCE”)

    SOCE, sometimes called reparative or conversion
therapy, began at a time when the medical and psychological
community considered homosexuality an illness. SOCE
encompasses a variety of methods, including both aversive
and non-aversive treatments, that share the goal of changing
an individual’s sexual orientation from homosexual to
heterosexual. In the past, aversive treatments included
10                   PICKUP V. BROWN

inducing nausea, vomiting, or paralysis; providing electric
shocks; or having an individual snap an elastic band around
the wrist when aroused by same-sex erotic images or
thoughts. Even more drastic methods, such as castration,
have been used. Today, some non-aversive treatments use
assertiveness and affection training with physical and social
reinforcement to increase other-sex sexual behaviors. Other
non-aversive treatments attempt “to change gay men’s and
lesbians’ thought patterns by reframing desires, redirecting
thoughts, or using hypnosis, with the goal of changing sexual
arousal, behavior, and orientation.” American Psychological
Association, Appropriate Therapeutic Responses to Sexual
Orientation 22 (2009). The plaintiff mental health providers
in these cases use only non-aversive treatments.

    In 1973, homosexuality was removed from the Diagnostic
and Statistical Manual of Mental Disorders. Shortly
thereafter the American Psychological Association declared
that homosexuality is not an illness. Other major mental
health associations followed suit. Subsequently, many mental
health providers began questioning and rejecting the efficacy
and appropriateness of SOCE therapy. Currently, mainstream
mental health professional associations support affirmative
therapeutic approaches to sexual orientation that focus on
coping with the effects of stress and stigma. But a small
number of mental health providers continue to practice, and
advocate for, SOCE therapy.
                         PICKUP V. BROWN                              11

B. Senate Bill 1172

    Senate Bill 1172 defines SOCE as “any practices by
mental health providers[1] that seek to change an individual’s
sexual orientation[,] . . . includ[ing] efforts to change
behaviors or gender expressions, or to eliminate or reduce
sexual or romantic attractions or feelings toward individuals
of the same sex.” Cal. Bus. & Prof. Code § 865(b)(1).
SOCE, however,

        does not include psychotherapies that: (A)
        provide acceptance, support, and
        understanding of clients or the facilitation of
        clients’ coping, social support, and identity
        exploration and development, including
        sexual orientation-neutral interventions to
        prevent or address unlawful conduct or unsafe
        sexual practices; and (B) do not seek to
        change sexual orientation.

  1
    California Business and Professions Code section 865(a) defines
“mental health provider” as

        a physician and surgeon specializing in the practice of
        psychiatry, a psychologist, a psychological assistant,
        intern, or trainee, a licensed marriage and family
        therapist, a registered marriage and family therapist,
        intern, or trainee, a licensed educational psychologist,
        a credentialed school psychologist, a licensed clinical
        social worker, an associate clinical social worker, a
        licensed professional clinical counselor, a registered
        clinical counselor, intern, or trainee, or any other person
        designated as a mental health professional under
        California law or regulation.
12                    PICKUP V. BROWN

Id. § 865(b)(2). A licensed mental health provider’s use of
SOCE on a patient under 18 years of age is “considered
unprofessional conduct,” which will subject that provider to
“discipline by the licensing entity for that mental health
provider.” Id. § 865.2.

     Importantly, SB 1172 does not do any of the following:

     •   Prevent mental health providers from communicating
         with the public about SOCE

     •   Prevent mental health providers from expressing their
         views to patients, whether children or adults, about
         SOCE, homosexuality, or any other topic

     •   Prevent mental health providers from recommending
         SOCE to patients, whether children or adults

     •   Prevent mental health providers from administering
         SOCE to any person who is 18 years of age or older

     •   Prevent mental health providers from referring minors
         to unlicensed counselors, such as religious leaders

     •   Prevent unlicensed providers, such as religious
         leaders, from administering SOCE to children or
         adults

     •   Prevent minors from seeking SOCE from mental
         health providers in other states

    Instead, SB 1172 does just one thing: it requires licensed
mental health providers in California who wish to engage in
“practices . . . that seek to change a [minor’s] sexual
                      PICKUP V. BROWN                         13

orientation” either to wait until the minor turns 18 or be
subject to professional discipline. Thus, SB 1172 regulates
the provision of medical treatment, but leaves mental health
providers free to discuss or recommend treatment and to
express their views on any topic.

    The legislature’s stated purpose in enacting SB 1172 was
to “protect[] the physical and psychological well-being of
minors, including lesbian, gay, bisexual, and transgender
youth, and [to] protect[] its minors against exposure to
serious harms caused by sexual orientation change efforts.”
2012 Cal. Legis. Serv. ch. 835, § 1(n). The legislature relied
on the well documented, prevailing opinion of the medical
and psychological community that SOCE has not been shown
to be effective and that it creates a potential risk of serious
harm to those who experience it. Specifically, the legislature
relied on position statements, articles, and reports published
by the following organizations: the American Psychological
Association, the American Psychiatric Association, the
American School Counselor Association, the American
Academy of Pediatrics, the American Medical Association,
the National Association of Social Workers, the American
Counseling Association, the American Psychoanalytic
Association, the American Academy of Child and Adolescent
Psychiatry, and the Pan American Health Organization.

     In particular, the legislature relied on a report created by
a Task Force of the American Psychological Association.
That report resulted from a systematic review of the scientific
literature on SOCE. Methodological problems with some of
the reviewed studies limited the conclusions that the Task
Force could draw. Nevertheless, the report concluded that
SOCE practitioners have not demonstrated the efficacy of
14                       PICKUP V. BROWN

SOCE and that anecdotal reports of harm raise serious
concerns about the safety of SOCE.

C. Procedural History

    Plaintiffs in Welch include two SOCE practitioners and an
aspiring SOCE practitioner. Plaintiffs in Pickup include
SOCE practitioners, organizations that advocate SOCE,
children undergoing SOCE, and their parents. All sought a
declaratory judgment that SB 1172 is unconstitutional and
asked for injunctive relief to prohibit enforcement of the law.2

    In Welch, Plaintiffs moved for preliminary injunctive
relief, arguing that SB 1172 violates their free speech and
privacy rights. They also argued that the law violates the
religion clauses and is unconstitutionally vague and
overbroad under the First Amendment.

    The Welch court held that SB 1172 is subject to strict
scrutiny because it would restrict the content of speech and
suppress the expression of particular viewpoints. It reasoned
that the fact that the law is a professional regulation does not
change the level of scrutiny. The court granted preliminary
relief because it determined that the state was unlikely to
satisfy strict scrutiny, Plaintiffs would suffer irreparable harm

   2
     In Pickup, Equality California, an advocacy group for gay rights,
sought and received intervenor status to defend SB 1172. Pickup
Plaintiffs argue that the Supreme Court’s recent decision in Hollingsworth
v. Perry, 133 S. Ct. 2652 (2013), means that Equality California does not
have standing to defend the statute. We need not resolve that question,
however, because the State of California undoubtedly has standing to
defend its statute, and “the presence in a suit of even one party with
standing suffices to make a claim justiciable.” Brown v. City of Los
Angeles, 521 F.3d 1238, 1240 n.1 (9th Cir. 2008) (per curiam).
                           PICKUP V. BROWN                                 15

in the absence of an injunction, the balance of the equities
tipped in their favor, and the injunction was in the public
interest. Because the district court granted relief on their free
speech claim, it did not reach Plaintiffs’ other constitutional
challenges.3

    In Pickup, Plaintiffs moved for preliminary injunctive
relief, arguing that SB 1172 violates the First and Fourteenth
Amendments by infringing on SOCE practitioners’ right to
free speech, minors’ right to receive information, and parents’
right to direct the upbringing of their children. They also
argued that SB 1172 is unconstitutionally vague.

    The Pickup court denied Plaintiffs’ motion because it
determined that they were unlikely to prevail on the merits of
any of their claims. It reasoned that, because the plain text of
SB 1172 bars only treatment, but not discussions about
treatment, the law regulates primarily conduct rather than
speech. Applying the rational basis test, the court ruled that

   3
      The Welch Plaintiffs’ response brief contains a single paragraph
asserting that SB 1172 violates the religion clauses of the First
Amendment. That paragraph, which cites neither the record nor any case,
is part of Plaintiffs’ argument that SB 1172 is not narrowly tailored to
achieve a compelling government purpose, as required by the Free Speech
Clause, because it contains no clergy exemption. The religion claim,
however, is not “specifically and distinctly argued,” as ordinarily required
for us to consider an issue on appeal. Thompson v. Runnels, 705 F.3d
1089, 1099–1100 (9th Cir. 2013) (internal quotation marks omitted),
petition for cert. filed, __ U.S.L.W. __ (U.S. June 28, 2013) (No.
13-5127); see also Maldonado v. Morales, 556 F.3d 1037, 1048 n.4 (9th
Cir. 2009) (“Arguments made in passing and inadequately briefed are
waived.”). Moreover, although the Welch Plaintiffs raised the claim in the
district court, the court did not rule on it because it granted relief on their
free speech claim. In these circumstances, we decline to address the
religion claim. The district court may do so in the first instance.
16                    PICKUP V. BROWN

Plaintiffs were unlikely to show a violation of the SOCE
practitioners’ free speech rights or the minors’ right to receive
information. As for vagueness, the court ruled that the text of
the statute is clear enough to put mental health providers on
notice of what is prohibited. Finally, the court ruled that SB
1172 does not implicate parents’ right to control the
upbringing of their children because that right does not
encompass the right to choose a specific mental health
treatment that the state has reasonably deemed harmful to
minors.

                        DISCUSSION

A. Free Speech Rights

   At the outset, we must decide whether the First
Amendment requires heightened scrutiny of SB 1172. As
explained below, we hold that it does not.

   The first step in our analysis is to determine whether SB
1172 is a regulation of conduct or speech. Two of our cases
guide our decision:        National Association for the
Advancement of Psychoanalysis v. California Board of
Psychology, 228 F.3d 1043 (9th Cir. 2000) (“NAAP”), and
Conant v. Walters, 309 F.3d 629 (9th Cir. 2002).

    In NAAP, 228 F.3d at 1053, psychoanalysts who were not
licensed in California brought a First Amendment challenge
to California’s licensing scheme for mental health providers.
The licensing scheme required that persons who provide
psychological services to the public for a fee obtain a license,
which in turn required particular educational and experiential
credentials. Id. at 1047. The plaintiffs alleged that the
licensing scheme violated their First Amendment right to
                     PICKUP V. BROWN                        17

freedom of speech because the license examination tested
only certain psychological theories and required certain
training; plaintiffs had studied and trained under different
psychoanalytic theories. Id. at 1055. We were equivocal
about whether, and to what extent, the licensing scheme in
NAAP implicated any free speech concerns. Id. at 1053 (“We
conclude that, even if a speech interest is implicated,
California’s licensing scheme passes First Amendment
scrutiny.” (emphasis added)); id. at 1056 (“Although some
speech interest may be implicated, California’s content-
neutral mental health licensing scheme is a valid exercise of
its police power . . . .” (emphasis added)). We reasoned that
prohibitions of conduct have “‘never been deemed an
abridgement of freedom of speech . . . merely because the
conduct was in part initiated, evidenced, or carried out by
means of language.’” See id. at 1053 (ellipsis in original)
(quoting Giboney v. Empire Storage & Ice Co., 336 U.S. 490,
502 (1949)). And, importantly, we specifically rejected the
argument that “because psychoanalysis is the ‘talking cure,’
it deserves special First Amendment protection because it is
‘pure speech.’” Id. at 1054. We reasoned: “[T]he key
component of psychoanalysis is the treatment of emotional
suffering and depression, not speech. That psychoanalysts
employ speech to treat their clients does not entitle them, or
their profession, to special First Amendment protection.” Id.
(internal quotation marks and ellipsis omitted).

    Nevertheless, we concluded that the “communication that
occurs during psychoanalysis is entitled to constitutional
protection, but it is not immune from regulation.” Id. But we
neither decided how much protection that communication
should receive nor considered whether the level of protection
might vary depending on the function of the communication.
Given California’s strong interest in regulating mental health,
18                   PICKUP V. BROWN

we held that the licensing scheme at issue in NAAP was a
valid exercise of its police power. Id. at 1054–55.

    We went on to conclude that, even if the licensing scheme
in NAAP regulated speech, it did not trigger strict scrutiny
because it was both content neutral and viewpoint neutral. Id.
at 1055. We reasoned that the licensing laws did not “dictate
what can be said between psychologists and patients during
treatment.” Id. Further, we observed that those laws were
“not adopted because of any disagreement with
psychoanalytical theories” but for “the important purpose of
protecting public health, safety, and welfare.” Id. at 1056
(internal quotation marks omitted). We again concluded that
the laws were a valid exercise of California’s police power.
Id.

    In Conant, 309 F.3d at 633–34, we affirmed a district
court’s order granting a permanent injunction that prevented
the federal government from revoking a doctor’s DEA
registration or initiating an investigation if he or she
recommended medical marijuana. The federal government
had adopted a policy that a doctor’s “recommendation” of
marijuana would lead to revocation of his or her license. Id.
at 632. But the government was “unable to articulate exactly
what speech [the policy] proscribed, describing it only in
terms of speech the patient believes to be a recommendation
of marijuana.” Id. at 639. Nevertheless, the demarcation
between conduct and speech in Conant was clear. The policy
prohibited doctors from prescribing or distributing marijuana,
and neither we nor the parties disputed the government’s
authority to prohibit doctors from treating patients with
marijuana. Id. at 632, 635–36. Further, the parties agreed
that “revocation of a license was not authorized where a
                      PICKUP V. BROWN                        19

doctor merely discussed the pros and cons of marijuana use.”
Id. at 634 (emphasis added).

    We ruled that the policy against merely “recommending”
marijuana was both content- and viewpoint-based. Id. at 637.
It was content-based because it covered only doctor-patient
speech “that include[d] discussions of the medical use of
marijuana,” and it was viewpoint-based because it
“condemn[ed] expression of a particular viewpoint, i.e., that
medical marijuana would likely help a specific patient.” Id.
We held that the policy did not withstand heightened First
Amendment scrutiny because it lacked “the requisite narrow
specificity” and left “doctors and patients no security for free
discussion.” Id. at 639 (internal quotation marks omitted).

    We distill the following relevant principles from NAAP
and Conant: (1) doctor-patient communications about
medical treatment receive substantial First Amendment
protection, but the government has more leeway to regulate
the conduct necessary to administering treatment itself; (2)
psychotherapists are not entitled to special First Amendment
protection merely because the mechanism used to deliver
mental health treatment is the spoken word; and (3)
nevertheless, communication that occurs during
psychotherapy does receive some constitutional protection,
but it is not immune from regulation.

    Because those principles, standing alone, do not tell us
whether or how the First Amendment applies to the
regulation of specific mental health treatments, we must go
on to consider more generally the First Amendment rights of
professionals, such as doctors and mental health providers.
In determining whether SB 1172 is a regulation of speech or
20                   PICKUP V. BROWN

conduct, we find it helpful to view this issue along a
continuum.

    At one end of the continuum, where a professional is
engaged in a public dialogue, First Amendment protection is
at its greatest. Thus, for example, a doctor who publicly
advocates a treatment that the medical establishment
considers outside the mainstream, or even dangerous, is
entitled to robust protection under the First Amendment—just
as any person is—even though the state has the power to
regulate medicine. See Lowe v. SEC, 472 U.S. 181, 232
(1985) (White, J., concurring) (“Where the personal nexus
between professional and client does not exist, and a speaker
does not purport to be exercising judgment on behalf of any
particular individual with whose circumstances he is directly
acquainted, government regulation ceases to function as
legitimate regulation of professional practice with only
incidental impact on speech; it becomes regulation of
speaking or publishing as such, subject to the First
Amendment’s command that ‘Congress shall make no
law . . . abridging the freedom of speech, or of the press.’”);
Robert Post, Informed Consent to Abortion: A First
Amendment Analysis of Compelled Physician Speech,
2007 U. Ill. L. Rev. 939, 949 (2007) (“When a physician
speaks to the public, his opinions cannot be censored and
suppressed, even if they are at odds with preponderant
opinion within the medical establishment.”); cf. Bailey v.
Huggins Diagnostic & Rehab. Ctr., Inc., 952 P.2d 768, 773
(Colo. Ct. App. 1997) (holding that the First Amendment
does not permit a court to hold a dentist liable for statements
published in a book or made during a news program, even
when those statements are contrary to the opinion of the
medical establishment). That principle makes sense because
communicating to the public on matters of public concern lies
                         PICKUP V. BROWN                              21

at the core of First Amendment values. See, e.g., Snyder v.
Phelps, 131 S. Ct. 1207, 1215 (2011) (“Speech on matters of
public concern is at the heart of the First Amendment’s
protection.” (internal quotation markets, brackets, and ellipsis
omitted)). Thus, outside the doctor-patient relationship,
doctors are constitutionally equivalent to soapbox orators and
pamphleteers, and their speech receives robust protection
under the First Amendment.

    At the midpoint of the continuum, within the confines of
a professional relationship, First Amendment protection of a
professional’s speech is somewhat diminished. For example,
in Planned Parenthood of Southeastern Pennsylvania v.
Casey, 505 U.S. 833, 884 (1992), the plurality upheld a
requirement that doctors disclose truthful, nonmisleading
information to patients about certain risks of abortion:

             All that is left of petitioners’ argument is
         an asserted First Amendment right of a
         physician not to provide information about the
         risks of abortion, and childbirth, in a manner
         mandated by the State. To be sure, the
         physician’s First Amendment rights not to
         speak are implicated, but only as part of the
         practice of medicine, subject to reasonable
         licensing and regulation by the State. We see
         no constitutional infirmity in the requirement
         that the physician provide the information
         mandated by the State here.[4]

   4
      Although the plurality opinion garnered only three votes, four
additional justices would have upheld the challenged law in its entirety.
Casey, 505 U.S. at 944 (Rehnquist, C.J., concurring in the judgment in
22                       PICKUP V. BROWN

(Citations omitted; emphasis added.)               Outside the
professional relationship, such a requirement would almost
certainly be considered impermissible compelled speech. Cf.
Wooley v. Maynard, 430 U.S. 705, 717 (1977) (holding that
a state could not require a person to display the state motto on
his or her license plate).

    Moreover, doctors are routinely held liable for giving
negligent medical advice to their patients, without serious
suggestion that the First Amendment protects their right to
give advice that is not consistent with the accepted standard
of care. A doctor “may not counsel a patient to rely on quack
medicine. The First Amendment would not prohibit the
doctor’s loss of license for doing so.” Conant v. McCaffrey,
No. C 97-00139 WHA, 2000 WL 1281174, at *13 (N.D. Cal.
Sept. 7, 2000) (order) (unpublished); see also Shea v. Bd. of
Med. Exam’rs, 146 Cal. Rptr. 653, 662 (Ct. App. 1978) (“The
state’s obligation and power to protect its citizens by
regulation of the professional conduct of its health
practitioners is well settled. . . . [T]he First Amendment . . .
does not insulate the verbal charlatan from responsibility for
his conduct; nor does it impede the State in the proper
exercise of its regulatory functions.” (citations omitted)); cf.
Post, 2007 U. Ill. L. Rev. at 949 (“[W]hen a physician speaks
to a patient in the course of medical treatment, his opinions
are normally regulated on the theory that they are inseparable
from the practice of medicine.”). And a lawyer may be
disciplined for divulging confidences of his client, even
though such disclosure is pure speech. See, e.g., In re
Isaacson, State Bar Court of California, Case No. 08-O-
10684, 2012 WL 6589666, at *4–5 (Dec. 6, 2012)

part and dissenting in part). Thus, there were seven votes to uphold the
disclosure requirement.
                       PICKUP V. BROWN                         23

(unpublished) (noting prior suspension of bar license for
failure to preserve client confidences). Thus, the First
Amendment tolerates a substantial amount of speech
regulation within the professional-client relationship that it
would not tolerate outside of it. And that toleration makes
sense: When professionals, by means of their state-issued
licenses, form relationships with clients, the purpose of those
relationships is to advance the welfare of the clients, rather
than to contribute to public debate. Cf. Lowe, 472 U.S. at 232
(White, J., concurring) (“One who takes the affairs of a client
personally in hand and purports to exercise judgment on
behalf of the client in the light of the client’s individual needs
and circumstances is properly viewed as engaging in the
practice of a profession.”).

     At the other end of the continuum, and where we
conclude that SB 1172 lands, is the regulation of professional
conduct, where the state’s power is great, even though such
regulation may have an incidental effect on speech. See id.
(“Just as offer and acceptance are communications incidental
to the regulable transaction called a contract, the
professional’s speech is incidental to the conduct of the
profession.”). Most, if not all, medical treatment requires
speech, but that fact does not give rise to a First Amendment
claim when the state bans a particular treatment. When a
drug is banned, for example, a doctor who treats patients with
that drug does not have a First Amendment right to speak the
words necessary to provide or administer the banned drug.
Cf. Conant, 309 F.3d at 634–35 (noting the government’s
authority to ban prescription of marijuana). Were it
otherwise, then any prohibition of a particular medical
treatment would raise First Amendment concerns because of
its incidental effect on speech. Such an application of the
First Amendment would restrict unduly the states’ power to
24                      PICKUP V. BROWN

regulate the medical profession and would be inconsistent
with the principle that “it has never been deemed an
abridgement of freedom of speech or press to make a course
of conduct illegal merely because the conduct was in part
initiated, evidenced, or carried out by means of language,
either spoken, written, or printed.” Giboney, 336 U.S. at 502.

    Senate Bill 1172 regulates conduct. It bans a form of
medical treatment for minors; it does nothing to prevent
licensed therapists from discussing the pros and cons of
SOCE with their patients. Senate Bill 1172 merely prohibits
licensed mental health providers from engaging in SOCE
with minors. It is the limited reach of SB 1172 that
distinguishes the present cases from Conant, in which the
government’s policy prohibited speech wholly apart from the
actual provision of treatment. Under its police power,
California has authority to prohibit licensed mental health
providers from administering therapies that the legislature has
deemed harmful and, under Giboney, 336 U.S. at 502, the fact
that speech may be used to carry out those therapies does not
turn the prohibitions of conduct into prohibitions of speech.
In fact, the Welch Plaintiffs concede that the state has the
power to ban aversive types of SOCE. And we reject the
position of the Pickup Plaintiffs—asserted during oral
argument—that even a ban on aversive types of SOCE
requires heightened scrutiny because of the incidental effect
on speech.5 Here, unlike in Conant, 309 F.3d at 639, the law
allows discussions about treatment, recommendations to

  5
   We do not mean to suggest that any Plaintiff here conducts aversive
SOCE therapy. The record shows that Plaintiffs who are licensed mental
health providers practice SOCE only through talk therapy. We mention
aversive techniques merely to highlight the state’s legitimate power to
regulate professional conduct.
                     PICKUP V. BROWN                       25

obtain treatment, and expressions of opinions about SOCE
and homosexuality.

     We further conclude that the First Amendment does not
prevent a state from regulating treatment even when that
treatment is performed through speech alone. As we have
already held in NAAP, talk therapy does not receive special
First Amendment protection merely because it is
administered through speech. 228 F.3d at 1054. That
holding rested on the understanding of talk therapy as “the
treatment of emotional suffering and depression, not speech.”
Id. (internal quotation marks omitted) (first emphasis added).
Thus, under NAAP, to the extent that talk therapy implicates
speech, it stands on the same First Amendment footing as
other forms of medical or mental health treatment. Senate
Bill 1172 is subject to deferential review just as are other
regulations of the practice of medicine.

    Our conclusion is consistent with NAAP’s statement that
“communication that occurs during psychoanalysis is entitled
to constitutional protection, but it is not immune from
regulation.” Id. Certainly, under Conant, content- or
viewpoint-based regulation of communication about
treatment must be closely scrutinized. But a regulation of
only treatment itself—whether physical medicine or mental
health treatment—implicates free speech interests only
incidentally, if at all. To read NAAP otherwise would
contradict its holding that talk therapy is not entitled to
“special First Amendment protection,” and it would, in fact,
make talk therapy virtually “immune from regulation.” Id.

    Nor does NAAP’s discussion of content and viewpoint
discrimination change our conclusion. There, we used both
a belt and suspenders. In addition to holding that the
26                        PICKUP V. BROWN

licensing scheme at issue was a permissible regulation of
conduct, we reasoned that even if California’s licensing
requirements implicated First Amendment interests, the
requirements did not discriminate on the basis of content or
viewpoint. Id. at 1053, 1055–56. But here, SB 1172
regulates only treatment, and nothing in NAAP requires us to
analyze a regulation of treatment in terms of content and
viewpoint discrimination.6

    Because SB 1172 regulates only treatment, while leaving
mental health providers free to discuss and recommend, or
recommend against, SOCE, we conclude that any effect it
may have on free speech interests is merely incidental.
Therefore, we hold that SB 1172 is subject to only rational
basis review and must be upheld if it “bear[s] . . . a rational
relationship to a legitimate state interest.”7 Id. at 1049.

    According to the statute, SB 1172 advances California’s
interest in “protecting the physical and psychological well-
being of minors, including lesbian, gay, bisexual and
transgender youth, and in protecting its minors against
exposure to serious harms caused by sexual orientation
change efforts.” 2012 Cal. Legis. Serv. ch. 835, § 1(n).
Without a doubt, protecting the well-being of minors is a
legitimate state interest. And we need not decide whether

 6
   We acknowledge that Plaintiffs ask us to apply strict scrutiny, but they
have not cited any case in which a court has applied strict scrutiny to the
regulation of a medical or mental health treatment. Nor are we aware of
any.
 7
   The parties dispute whether we are limited to the legislative record in
assessing the constitutionality of SB 1172. We need not resolve that
dispute because, whether or not we restrict our review to the legislative
record, we conclude that the legislature acted rationally.
                        PICKUP V. BROWN                             27

SOCE actually causes “serious harms”; it is enough that it
could “reasonably be conceived to be true by the
governmental decisionmaker.” NAAP, 228 F.3d at 1050
(internal quotation marks omitted).

    The record demonstrates that the legislature acted
rationally when it decided to protect the well-being of minors
by prohibiting mental health providers from using SOCE on
persons under 18.8 The legislature relied on the report of the
Task Force of the American Psychological Association,
which concluded that SOCE has not been demonstrated to be
effective and that there have been anecdotal reports of harm,
including depression, suicidal thoughts or actions, and
substance abuse. The legislature also relied on the opinions
of many other professional organizations. Each of those
organizations opposed the use of SOCE, concluding, among
other things, that homosexuality is not an illness and does not
require treatment (American School Counselor Association),
SOCE therapy can provoke guilt and anxiety (American
Academy of Pediatrics), it may be harmful (National
Association of Social Workers), and it may contribute to an
enduring sense of stigma and self-criticism (American
Psychoanalytic Association). Although the legislature also
had before it some evidence that SOCE is safe and effective,
the overwhelming consensus was that SOCE was harmful and
ineffective. On this record, we have no trouble concluding

  8
    We need not and do not decide whether the legislature would have
acted rationally had it banned SOCE for adults. One could argue that
children under the age of 18 are especially vulnerable with respect to
sexual identity and that their parents’ judgment may be clouded by this
emotionally charged issue as well. The considerations with respect to
adults may be different.
28                        PICKUP V. BROWN

that the legislature acted rationally by relying on that
consensus.

    Plaintiffs argue that the legislature acted irrationally when
it banned SOCE for minors because there is a lack of
scientifically credible proof of harm. But, under rational
basis review, “[w]e ask only whether there are plausible
reasons for [the legislature’s] action, and if there are, our
inquiry is at an end.” Romero-Ochoa v. Holder, 712 F.3d
1328, 1331 (9th Cir. 2013) (internal quotation marks
omitted).

    Therefore, we hold that SB 1172 is rationally related to
the legitimate government interest of protecting the well-
being of minors.9

B. Expressive Association

    We also reject the Pickup Plaintiffs’ argument that SB
1172 implicates their right to freedom of association because
the First Amendment protects their “choices to enter into and
maintain the intimate human relationships between
counselors and clients.”10

 9
   The foregoing discussion relates as well to the Pickup Plaintiffs’ claim
that SB 1172 violates minors’ right to receive information. See Monteiro
v. Tempe Union High Sch. Dist., 158 F.3d 1022, 1027 n.5 (9th Cir. 1998)
(recognizing the “well-established rule that the right to receive
information is an inherent corollary of the rights of free speech and
press”).
     10
     The Pickup Plaintiffs arguably waived their expressive association
argument by not raising it in the district court. But “the rule of waiver is
a discretionary one.” Ruiz v. Affinity Logistics Corp., 667 F.3d 1318, 1322
(9th Cir. 2012) (internal quotation marks omitted). We have discretion to
                         PICKUP V. BROWN                              29

    First, SB 1172 does not prevent mental health providers
and clients from entering into and maintaining therapeutic
relationships. It prohibits only “practices . . . that seek to
change an individual’s sexual orientation.” Cal. Bus. & Prof.
Code § 865(b)(1). Therapists are free, but not obligated, to
provide therapeutic services, as long as they do not “seek to
change sexual orientation.”

    Moreover, the therapist-client relationship is not the type
of relationship that the freedom of association has been held
to protect. The Supreme Court’s decisions “have referred to
constitutionally protected ‘freedom of association’ in two
distinct senses.” Roberts v. U.S. Jaycees, 468 U.S. 609, 617
(1984). The first type of protected association concerns
“intimate human relationships,” which are implicated in
personal decisions about marriage, childbirth, raising
children, cohabiting with relatives, and the like. Id. at
617–19. That type of freedom of association “receives
protection as a fundamental element of personal liberty.” Id.
at 618. The second type protects association “for the purpose
of engaging in those activities protected by the First
Amendment—speech, assembly, petition for the redress of
grievances, and the exercise of religion.” Id. at 618.
Plaintiffs in Pickup claim an infringement of only the first
type of freedom of association.

address an argument that otherwise would be waived “when the issue
presented is purely one of law and either does not depend on the factual
record developed below, or the pertinent record has been fully developed.”
Id. (internal quotation marks omitted). Whether SB 1172 violates the right
to expressive association is such an issue, and we exercise our discretion
to address it.
30                    PICKUP V. BROWN

    Although we have not specifically addressed the
therapist-client relationship in terms of freedom of
association, we have explained why the therapist-client
relationship is not protected by the Due Process Clause of the
Fourteenth Amendment: “The relationship between a client
and psychoanalyst lasts only as long as the client is willing to
pay the fee. Even if analysts and clients meet regularly and
clients reveal secrets and emotional thoughts to their analysts,
these relationships simply do not rise to the level of a
fundamental right.” NAAP, 228 F.3d at 1050 (internal
quotation marks and citation omitted). Because the type of
associational protection that the Pickup Plaintiffs claim is
rooted in “personal liberty,” U.S. Jaycees, 468 U.S. at 618,
and because we have already determined that the therapist-
client relationship does not “implicate the fundamental rights
associated with . . . close-knit relationships,” NAAP, 228 F.3d
at 1050, we conclude that the freedom of association also
does not encompass the therapist-client relationship.

C. Vagueness

     We next hold that SB 1172 is not void for vagueness.

    “It is a basic principle of due process that an enactment is
void for vagueness if its prohibitions are not clearly defined.”
Grayned v. City of Rockford, 408 U.S. 104, 108 (1972).
Nevertheless, “perfect clarity and precise guidance have
never been required even of regulations that restrict
expressive activity.” Ward v. Rock Against Racism, 491 U.S.
781, 794 (1989). “[U]ncertainty at a statute’s margins will
not warrant facial invalidation if it is clear what the statute
proscribes ‘in the vast majority of its intended applications.’”
Cal. Teachers Ass’n v. State Bd. of Educ., 271 F.3d 1141,
1151 (9th Cir. 2001) (quoting Hill v. Colorado, 530 U.S. 703,
                      PICKUP V. BROWN                        31

733 (2000)). “A defendant is deemed to have fair notice of
an offense if a reasonable person of ordinary intelligence
would understand that his or her conduct is prohibited by the
law in question.” United States v. Weitzenhoff, 35 F.3d 1275,
1289 (9th Cir. 1994) (internal quotation marks omitted). But,
“if the statutory prohibition involves conduct of a select
group of persons having specialized knowledge, and the
challenged phraseology is indigenous to the idiom of that
class, the standard is lowered and a court may uphold a
statute which uses words or phrases having a technical or
other special meaning, well enough known to enable those
within its reach to correctly apply them.” Id. (internal
quotation marks omitted).

    Although the Pickup Plaintiffs argue that they cannot
ascertain where the line is between what is prohibited and
what is permitted—for example, they wonder whether the
mere dissemination of information about SOCE would
subject them to discipline—the text of SB 1172 is clear to a
reasonable person. It prohibits “mental health providers”
from engaging in “practices” that “seek to change” a minor
“patient[’s]” sexual orientation. Cal. Bus. & Prof. Code
§§ 865–865.1. A reasonable person would understand the
statute to prohibit only mental health treatment, including
psychotherapy, that aims to alter a minor patient’s sexual
orientation. Although Plaintiffs present various hypothetical
situations to support their vagueness challenge, the Supreme
Court has held that “speculation about possible vagueness in
hypothetical situations not before the Court will not support
a facial attack on a statute when it is surely valid in the vast
majority of its intended applications.” Hill, 530 U.S. at 733
(internal quotation marks omitted).
32                        PICKUP V. BROWN

    Moreover, considering that SB 1172 regulates licensed
mental health providers, who constitute “a select group of
persons having specialized knowledge,” the standard for
clarity is lower. Weitzenhoff, 35 F.3d at 1289. Indeed, it is
hard to understand how therapists who identify themselves as
SOCE practitioners can credibly argue that they do not
understand what the ban on SOCE prohibits.

    Neither is the term “sexual orientation” vague. Its
meaning is clear enough to a reasonable person and should be
even more apparent to mental health providers. In fact,
several provisions in the California Code—though not SB
1172 itself—provide a simple definition: “heterosexuality,
homosexuality, or bisexuality.” Cal. Educ. Code §§ 212.6,
66262.7; Cal. Gov’t Code § 12926®; Cal. Penal Code
§§ 422.56(h), 11410(b)(7). Moreover, courts have repeatedly
rejected vagueness challenges that rest on the term “sexual
orientation.” E.g., United States v. Jenkins, 909 F. Supp. 2d
758, 778–79 (E.D. Ky. 2012); Hyman v. City of Louisville,
132 F. Supp. 2d 528, 546 (W.D. Ky. 2001), vacated on other
grounds, 53 F. App’x 740 (6th Cir. 2002) (unpublished).

D. Overbreadth

      We further hold that SB 1172 is not overbroad.11

 11
    Intervenor Equality California argues that the Pickup Plaintiffs waived
their overbreadth challenge by failing to raise it adequately in the district
court. Although they did not argue overbreadth with specificity, they did
allege it in their complaint and in their memorandum in support of
preliminary injunctive relief. Moreover, whether the statute is overbroad
is a question of law that “does not depend on the factual record developed
below.” Ruiz, 667 F.3d at 1322. Therefore, we exercise our discretion to
address Plaintiffs’ overbreadth challenge.
                      PICKUP V. BROWN                        33

    Overbreadth doctrine permits the facial invalidation of
laws that prohibit “a substantial amount of constitutionally
protected speech.” City of Houston v. Hill, 482 U.S. 451, 466
(1987). “[T]he mere fact that one can conceive of some
impermissible applications of a statute is not sufficient to
render it susceptible to an overbreadth challenge.” Members
of City Council v. Taxpayers for Vincent, 466 U.S. 789, 800
(1984). Rather, “particularly where conduct and not merely
speech is involved, . . . the overbreadth of a statute must not
only be real, but substantial as well, judged in relation to the
statute’s plainly legitimate sweep.” Broadrick v. Oklahoma,
413 U.S. 601, 615 (1973).

    Senate Bill 1172’s plainly legitimate sweep includes the
prohibition of SOCE techniques such as inducing vomiting or
paralysis, administering electric shocks, and performing
castrations. And, as explained above, it also includes SOCE
techniques carried out solely through words. As with any ban
on a particular medical treatment, there may be an incidental
effect on speech. Any incidental effect, however, is small in
comparison with the “plainly legitimate sweep” of the ban.
Broadrick, 413 U.S. at 615.

   Thus, SB 1172 is not overbroad.

E. Parents’ Fundamental Rights

    The Pickup Plaintiffs also argue that SB 1172 infringes on
their fundamental parental right to make important medical
decisions for their children. The state does not dispute that
parents have a fundamental right to raise their children as
they see fit, but argues that Plaintiffs “cannot compel the
State to permit licensed mental health [professionals] to
engage in unsafe practices, and cannot dictate the prevailing
34                    PICKUP V. BROWN

standard of care in California based on their own views.”
Because Plaintiffs argue for an affirmative right to access
SOCE therapy from licensed mental health providers, the
precise question at issue is whether parents’ fundamental
rights include the right to choose for their children a
particular type of provider for a particular medical or mental
health treatment that the state has deemed harmful. See
Washington v. Glucksberg, 521 U.S. 702, 720–21 (1997)
(holding that courts should precisely define purported
substantive due process rights to direct and restrain
exposition of the Due Process Clause).

    Parents have a constitutionally protected right to make
decisions regarding the care, custody, and control of their
children, but that right is “not without limitations.” Fields v.
Palmdale Sch. Dist., 427 F.3d 1197, 1204 (9th Cir. 2005).
States may require school attendance and mandatory school
uniforms, and they may impose curfew laws applicable only
to minors. See id. at 1204–05 (collecting cases demonstrating
the “wide variety of state actions that intrude upon the liberty
interest of parents in controlling the upbringing and education
of their children”). In the health arena, states may require the
compulsory vaccination of children (subject to some
exceptions), see Prince v. Massachusetts, 321 U.S. 158, 166
(1944), and states may intervene when a parent refuses
necessary medical care for a child, see Jehovah’s Witnesses
v. King Cnty. Hosp., 278 F. Supp. 488, 504 (W.D. Wash.
1967) (three-judge panel) (per curiam), aff’d, 390 U.S. 598
(1968) (per curiam). “[A] state is not without constitutional
control over parental discretion in dealing with children when
their physical or mental health is jeopardized.” Parham v.
J.R., 442 U.S. 584, 603 (1979).
                      PICKUP V. BROWN                          35

     We are unaware of any case that specifically addresses
whether a parent’s fundamental rights encompass the right to
choose for a child a particular type of provider for a particular
treatment that the state has deemed harmful, but courts that
have considered whether patients have the right to choose
specific treatments for themselves have concluded that they
do not. For example, we have held that “substantive due
process rights do not extend to the choice of type of treatment
or of a particular health care provider.” NAAP, 228 F.3d at
1050. Thus, we concluded that “there is no fundamental right
to choose a mental health professional with specific training.”
Id. The Seventh Circuit has also held that “a patient does not
have a constitutional right to obtain a particular type of
treatment or to obtain treatment from a particular provider if
the government has reasonably prohibited that type of
treatment or provider.” Mitchell v. Clayton, 995 F.2d 772,
775 (7th Cir. 1993). Moreover, courts have held that there is
no substantive due process right to obtain drugs that the FDA
has not approved, Carnohan v. United States, 616 F.2d 1120,
1122 (9th Cir. 1980) (per curiam), even when those drugs are
sought by terminally ill cancer patients, see Rutherford v.
United States, 616 F.2d 455, 457 (10th Cir. 1980) (“It is
apparent in the context with which we are here concerned that
the decision by the patient whether to have a treatment or not
is a protected right, but his selection of a particular treatment,
or at least a medication, is within the area of governmental
interest in protecting public health.”). Those cases cut against
recognizing the right that Plaintiffs assert; it would be odd if
parents had a substantive due process right to choose specific
treatments for their children—treatments that reasonably have
been deemed harmful by the state—but not for themselves.
All the more anomalous because the Supreme Court has
recognized that the state has greater power over children than
over adults. Prince, 321 U.S. at 170 (stating that “the power
36                   PICKUP V. BROWN

of the state to control the conduct of children reaches beyond
the scope of its authority over adults”).

    Further, our decision in Fields counsels against
recognizing the right that Plaintiffs assert. In that case,
parents of school children argued that a school violated their
parental rights when it administered to students a survey that
contained several questions about sex. Fields, 427 F.3d at
1203. We rejected that argument, holding that, although
parents have the right to inform their children about sex when
and as they choose, they do not have the right to “compel
public schools to follow their own idiosyncratic views as to
what information the schools may dispense.” Id. at 1206.
Similarly, here, to recognize the right Plaintiffs assert would
be to compel the California legislature, in shaping its
regulation of mental health providers, to accept Plaintiffs’
personal views of what therapy is safe and effective for
minors. The aforementioned cases lead us to conclude that
the fundamental rights of parents do not include the right to
choose a specific type of provider for a specific medical or
mental health treatment that the state has reasonably deemed
harmful.

    Therefore, SB 1172 does not infringe on the fundamental
rights of parents.

                       CONCLUSION

    Senate Bill 1172 survives the constitutional challenges
presented here. Accordingly, the order granting preliminary
relief in Welch, No. 13-15023, is REVERSED, and the order
denying preliminary relief in Pickup, No. 12-17681, is
AFFIRMED. We remand both cases for further proceedings
consistent with this opinion.