December 2, 2025 – In mid-November, the U.S. Conference of Catholic Bishops gathered for the second of its twice-yearly “plenary assemblies,” in which the bishops discuss and vote on issues of importance to American Catholics. This was a big one, with the bishops electing the Archbishop of Oklahoma City Paul Coakley as conference president, issuing a major statement opposing the rise of anti-immigration action in the United States and, of course, finalizing new rules to control health care access in large swaths of the country.
The Catholic Church has a lot of rules about which kinds of health care are theologically permissible, all conveniently outlined for Americans in the “Ethical and Religious Directives for Catholic Health Care Services” (ERD). The ERD is its own bible in a way, making sure that Catholic-owned healthcare systems know precisely what limits there are on the medical care they’re allowed to provide their communities. If you have any passing familiarity with the Catholic Church, these probably aren’t surprising. Reproductive care, including access to abortion, voluntary sterilization, fertility treatments, morning-after pills for rape survivors and birth control are heavily restricted or banned. End-of-life care is restricted as well, banning certain life-ending interventions that do not align with the Catholic-specific understanding of “respect for life.”
And of course, unsurprisingly, gender affirming care has entered the conversation, as it continues to stir controversy and be wielded by the Christian nationalist movement as a political cudgel.
Paragraph 29 of the latest edition of the ERD now reads as follows:
“In accord with the mission of Catholic health care, which includes serving those who are vulnerable, Catholic health care services and providers ‘must employ all appropriate resources to mitigate the suffering of those who experience gender incongruence or gender dysphoria’ and to provide for the full range of their healthcare needs, employing only those means that respect the fundamental order of the human body.”
For those unfamiliar with Catholic jargon and doctrine, you might think that this directive is supportive of gender affirming care, with its language recognizing the need to mitigate the suffering caused by gender dysphoria. After all, the gender affirming model has been best-practice medical care for decades now, with a wealth of reputable scientific evidence to back it up. But that final clause there at the very end, and the document it uses as a citation, unfortunately, lead us in the absolute opposite direction.
“Fundamental order of the human body” pops up everywhere in modern Catholic theology, particularly when it comes to gender roles and human sexuality. Pope John Paul II’s infamous series of lectures that would come to be known as the “Theology of the Body” solidified this notion in the post-Vatican II Catholic consciousness. These speeches were a direct reaction to the global rise of feminism, reproductive autonomy and the acceptance of sexual diversity that characterized much of the back half of the 20th century. “Men” and “women” (and by that he meant those assigned male and female at birth, respectively), according to the pope, were created by god to fulfill certain roles. Men were meant to be the leaders and dominant force in the family, working to provide for material needs and providing moral guidance to their wives and children. Women, on the other hand, were created to remain in the home and raise and nurture children, as evidenced by the fact that they are the ones who give birth. These traits are “divinely ordered” under the “Theology of the Body,” and deviation from them is deviation from god’s plan, and thus inherently immoral. Included in this railing against deviation from our “fundamental biological ordering” was homosexuality, leading to the development of referring to gay people as “intrinsically disordered” and in need of a cure.
Less at the forefront of Pope John Paul II’s mind was the existence of trans people, though it was likely somewhere in the ether of his writings at the time. The “Theology of the Body” and the resulting mindset, though, are one of the most likely roots of the favorite phrase of the anti-trans movement — “gender ideology.”
These ideas were also at the core of the 14-page “Doctrinal Note On the Moral Limits to Technological Manipulation of the Human Body,” which was released by the conference of bishops in 2023 in the lead-up to its incorporation into the ERD and provides us with the most direct explanation of the future of gender affirming care in Catholic health systems. The Doctrinal Note was the U.S. bishops’ formal statement banning the gender-affirming model on theological grounds, and essentially was a warning to hospitals, patients, doctors and other care providers under their jurisdiction that the ERD was going to be updated in the near future. An important note here is that the bishops’ subcommittee on healthcare issues does not formally include a single medical provider. The subcommittee does have formal “consultants” from the major Catholic healthcare organizations, but committee members may choose to ignore that expertise. And it appears that they did, in fact, do just that, as the Catholic Health Association — the president and CEO of which is one of those consultants — released a statement opposing the Doctrinal Note shortly following its announcement.
While the Doctrinal Note is not binding, many care providers ceased offering gender affirming care, or at a minimum began to phase it out, with real impacts on real people. In the Freedom From Religion Foundation’s own backyard, a teenager who had gone through the long and arduous process to get approved for breast reduction surgery had his surgery suddenly canceled after SSM Health (better known as St. Mary’s Hospital) made the decision to cease all gender-affirming surgeries amid clerical pressure. (FFRF Co-President Dan Barker and I spoke with his father after the incident. Watch the broadcast here).
Regardless of your personal beliefs, there is a significant chance that if you live in the United States, you receive healthcare through a Catholic system and are thus subject to the whims of the Catholic bishops.
According to MergerWatch, Catholic control of the healthcare system is expanding exponentially. Somewhere around one-in-six acute care hospital beds are controlled by Catholic hospitals, and the 10 largest Catholic healthcare systems alone also run more than 860 urgent care centers, 380 ambulatory surgery centers and 270 physician groups. While the number of non-Catholic acute care hospitals has decreased by more than 13 percent over the past two decades, the number of Catholic hospitals has increased by 50 percent. More recent, though less thorough statistics from the Catholic Health Association show that more than one-in-seven patients in the U.S. are cared for in a Catholic hospital. In Wisconsin, where the Freedom From Religion Foundation is based, a whopping one-third of hospitals are Roman Catholic.
It becomes even more difficult to attempt to avoid Catholic healthcare systems for people in rural areas, as mergers and acquisitions of hospitals are increasing the number of communities where the only option is the Catholic option. Even for people living in places with secular options, it may not be readily apparent without fairly significant research that a healthcare provider is Catholic, thanks to management agreements that allow previously secular medical institutions to retain their original name (or deceitful name changes to camouflage religious ownership, as with “St. Mary’s Hospital” being rebranded as “SSM Health” here in Madison). And none of this even begins to account for the role that health insurance plays in limiting people’s choice of healthcare provider.
Legally speaking, Catholic hospitals have a well-established right to deny this type of care. Statutory protections for institutions and individuals who object to providing certain types of health care on religious or ethical grounds were first introduced in the 1970s through a series of amendments called the “Church Amendments” (ironically, not named as a reference to religious institutions, but for their author, Sen. Frank Church). Created as a response to the Supreme Court’s decision in Roe v. Wade, the Church Amendments permit institutions and individuals to refuse to participate in abortion or sterilization procedures if they conflict with their religious beliefs or moral convictions.
Since then, pressure from conservative religious groups has only further expanded the right to refuse care. Numerous state and federal laws codify these conscience protections, and major medical associations have historically bowed to clerical pressure supporting these protections and making it difficult to argue that religious refusals violate the normal requirement that healthcare providers must adhere to a specific standard of care. There is no telling how many people in the United States have been harmed and will continue to be harmed by the Catholic hierarchy’s arrogance — all while it rakes in around $48 billion in taxpayer dollars each year in the form of Medicare and Medicaid reimbursements. This new addition to the ERD is not about theological freedom, but about the U.S. Roman Catholic Church continuing to profit off of the American people while simultaneously limiting our right to bodily autonomy, regardless of our own personal beliefs.
There are ways to fight this, though, I promise.
Although not feasible for most people, if it is possible for you to no longer spend your money in Catholic healthcare systems, please take that step. Even if it might be a bit more inconvenient, people removing their money from Catholic healthcare systems can make a massive difference in terms of slowing their growth. Similarly, if you’re lucky enough to be in a situation where you have multiple options for health insurance, double-check that your insurance isn’t through a Catholic healthcare system.
Individual choice isn’t the only way to push back, though. You can oppose upcoming hospital mergers by voicing your dissent to state and federal regulatory agencies, as well as to elected officials. You can also discuss with your own healthcare providers what plans they might have should they get caught in the crossfire of a hospital merger or management agreement. It is not uncommon for care providers to adopt a policy of quietly continuing to provide certain types of healthcare regardless of Church teaching.
The most important thing you can do, however, is build relationships with your fellow community members. Discussing highly polarizing issues like religious intrusion in health care can be uncomfortable, but it has never been more necessary. Even if you are the only nonbeliever in your community, you will likely find that many of your neighbors value things like bodily autonomy and access to science-based health care. Having difficult conversations and finding shared values builds stronger communities that, in turn, can be leaned on to coordinate opposition to local mergers, create mutual aid networks to help people access secular health care and fight back against religious organizations that use their immense political and financial resources to dictate everyone else’s health care decisions.
The dominance of Catholic hospitals isn’t going away any time soon. The institution of the Catholic Church is one of the most powerful religious organizations in the world, thanks to centuries of hoarding misbegotten wealth and psychologically torturing believers with the threat of damnation. But that does not mean we should simply roll over and allow the violation of our right to make informed, science-based healthcare decisions to continue.
ABOUT THE AUTHOR
Kat Grant (they/them) is a queer lawyer, activist, and theorist focusing on the intersections of law, queerness, religion, and politics. Originally from rural southern Indiana, Kat earned their B.A. in Political Science in 2019 before continuing on to earn their J.D. in 2022, both from Indiana University- Bloomington. A former Equal Justice Works Fellow for the Freedom From Religion Foundation, Kat has spent their professional life fighting for the separation of church and state and LGBTQIA+ rights. You can find more of Kat’s work on their blog Transing Boundaries.