He needed a gender-affirming procedure. The hospital said no.

As rural hospitals shutter, and faith-based care grows, “religious refusals” are leaving some patients without options.

In the summer of 2016, Evan Minton was preparing for his scheduled hysterectomy at Mercy San Juan Medical Center in Carmichael, California, just outside Sacramento. The procedure, part of his gender-affirming care, should have been routine.

But the day before, the hospital abruptly canceled his surgery; the hospital was Catholic, and a procedure that results in sterilization is a violation of the Ethical and Religious Directives that, with rare exceptions, govern Catholic hospitals. Minton had experienced what’s known as “religious refusal,” a growing — and divisive — phenomenon in which health care is denied on the basis of religious beliefs.

Catholic facilities argue that the directives are protected under religious liberty laws. Minton, who was unavailable for comment, felt he’d been denied care on the basis of his gender identity, making it a civil rights issue, and in September, a court agreed to let him continue a lawsuit against Dignity Health, which operated the hospital where he was denied care. (It later referred him to a Methodist facility in the same chain that performed his surgery.)

Minton’s fight for health care is the latest in a growing list of court battles over religious liberty and civil rights; the Supreme Court just heard a trio of cases about whether firing people on the basis of gender identity or sexual orientation is acceptable, and last year ruled in the Masterpiece Cakeshop case, which revolved around whether a Christian baker could refuse service to a gay couple requesting a wedding cake.

When it comes to health care, the stakes are life and death, an issue that the California court in Minton’s case recognized when identifying the need for “full and equal access to medical treatment.”

“I want it to end with me,” Minton told a local NBC affiliate; he has since received much of the gender-affirming care he needs.

Dignity Health, which has since merged with Catholic Health Initiatives to form CommonSpirit Health, told the Los Angeles Times that its hospitals “do not perform sterilizing procedures such as hysterectomies for any patient regardless of their gender identity, unless there is a serious threat to the life or health of the patient.”

When patients go to the doctor, they expect treatment rooted in the latest medical advancements, not interpretations of the Bible. But as medical facilities continue to close or merge with better-funded institutions, Christian hospitals, which may hew to religious doctrine when making treatment decisions, are becoming a lone source of care for many Americans.

Paired with a presidential administration that is actively working to protect faith-based exemptions to anti-discrimination laws, it’s changing the landscape of health care in America. The Ethical and Religious Directives, for example, severely limit access to reproductive health care, including abortion, contraceptives, sterilization, and in-vitro fertilization (IVF). Care providers may even be barred from offering referrals or discussing issues like contraception. (The US Conference of Catholic Bishops, which develops this guidance, did not respond to a request for comment.)

The implications here are clear for patients like Minton, but the Ethical and Religious Directives also frown on fertility treatment. When former California resident Michelle, 37, and her husband, Josh, 42, learned that something had gone wrong in the early stages of her IVF pregnancy, they were advised to terminate. But when she went to the doctor’s office, the couple alleges, the doctor grumbled about the paperwork needed to get authorization from the Catholic facility for the medically necessary shot of methotrexate, which would have stopped the cells from growing. (Michelle’s then-physician and affiliated hospital did not respond to a request for comment.)

Michelle says the doctor told her, “What did you expect, getting someone pregnant who shouldn’t be?” The couple, who asked that their last names be withheld for privacy reasons, say they felt like an unwelcome burden. They sought treatment elsewhere, but by that time she required general anesthesia and a surgical procedure, which came with increased risks including infection, infertility, and even death. The memory haunts Michelle, preventing her and her husband from “emotionally being able to move forward with our remaining frozen embryo,” she says. They fear a repeat denial of care if something goes wrong with another pregnancy.

Like Evan or Michelle and Josh, patients at Christian hospitals may not even be aware which services will ultimately be denied; at Catholic facilities, the directives provide some guidance, but at Baptist, Adventist, and other religious facilities, no unified set of rules is available for patients to review. “I think they think [religious refusals] happen to certain people going in just for an abortion,” says Ian Smith, a staff attorney at Americans United for Separation of Church and State, underscoring how ignorance of these rules can affect patients who need all manner of care, such as hormone therapy, fertility treatment, gender-affirming care, or tubal ligations.

Catholic entities currently make up three of the top six largest health care chains; 17 percent of the hospital beds in America are in Catholic facilities, which are growing more rapidly than those of other religious sects and most other hospital chains, especially in rural areas. In states such as Alaska, Washington, and Iowa, more than 40 percent of beds are controlled by Catholic facilities and patients who need help may find that Catholic providers are the only option.

For the 14 to 20 percent of Americans who live in the rural US, it is a particularly acute problem. As rural hospitals continue to close — since 2010, 113 rural hospitals have closed, many in states that refused Medicaid expansion — the Catholic health care industry flourishes, snapping up struggling rural facilities in mergers and narrowing access to care. Between 2005 and 2016, there were 380 rural hospital mergers across the United States, some of which were religiously affiliated.

In the case of Dignity, which merged with Catholic Health Initiatives last year, Chad Burns, a communications manager at Dignity Health, told Vox via email that “the religious affiliation of our rural hospitals and the services they offer have not changed as a result of this alignment.”

Other religious hospitals — including Baptist and Adventist — account for 4 percent of the overall hospital market. They, too, may deny care or recommend options that do not match the latest medical practices in accordance with religious beliefs rather than evidence-based medicine.

Sociologist Lori Freeman, who works at the University of California San Francisco, says tracking how often religious refusals occur is notoriously difficult, illustrating how difficult it is for patients to get information needed to make health care choices. Nor is there data on the number of providers who are barred from performing procedures and instead offer referrals. “There’s no paper trail,” she says, with cases only bubbling to the surface when they are “particularly egregious.”

Researcher Lois Uttley of Community Catalyst, a health care advocacy organization, has identified nearly 50 Catholic institutions that are the sole community hospitals: They are at least 35 miles or 45 minutes away from the next hospital. In an emergency, that can be extremely dangerous, especially since some rural areas are extremely remote. Michelle and Josh were able to locate relatively nearby alternate care in Southern California. A pregnant person experiencing a miscarriage in rural Alaska might be looking at hours of travel if a hospital refuses to offer miscarriage care, which researchers say they increasingly do.

Physicians with privileges at these facilities must abide by the directives even if they are not Catholic, and the same extends to secular providers leasing space from Catholic entities. In a 2018 update, the Ethical and Religious Directives suggested it could also apply to hospitals acquired through merger and affiliation, ringing an alarm for advocacy groups.

The legal issues at hand are complex, notes Smith, the lawyer with Americans United for Separation of Church and State. It might seem like an obvious violation for hospitals to accept government money and engage in religious discrimination. But in court, it may be a challenging case because these hospitals are considered private institutions.

But when religious hospitals affiliate with or acquire entities receiving government funds, like public university teaching hospitals or publicly funded community hospitals, the story is slightly different. These issues became sticking points in a proposed collaboration between the University of California, a public entity, and the Catholic Dignity Health chain — the very one that refused to treat Evan Minton — which care providers and communities vigorously and successfully opposed, fearing religious imposition. In 2013, a similar partnership in Texas attracted the attention of Smith’s organization, with local officials altering their original plan to satisfy concerns about spending taxpayer dollars on institutions that were free to deny health care.

The stakes of religious refusal are especially big for people like Michelle. They get a lot more challenging when patients live in isolated rural areas where simply going to another hospital, as she did when she was forced to receive care at a more distant facility, is not possible.

Christina Animashaun/Vox

Freeman, the sociologist, tells the story of a doctor who was reprimanded by a religious hospital for inducing labor in a patient with ruptured amniotic membranes and a severe fetal anomaly. “We live in a rural area,” the doctor said. “Should I tell them to just keep driving for another hour and a half?”

For Freeman, the story illustrated frustrations for care providers: “[Mandates to turn patients away] strike me as something that must be on people’s minds when they work in these remote areas.” In some parts of the US, where “the presence of Catholic health care has become normalized,” patients can waste precious time racing to a hospital that won’t serve them.

“It seems so incomprehensible to me that you can impose on somebody else’s existence in that way,” Josh says of his experience. Many patients find out about discriminatory elements of the health care system when it happens to them, and as Josh notes, it is never just the patient who needs medical treatment who is affected. Their ordeal was traumatic for him, and the loved ones of other patients experiencing religious refusals are similarly affected in a ripple effect that undermines trust in doctors.

Catholic hospitals aren’t the only source of religious refusals. The Trump administration has fought hard to expand the right of religious refusal via rulemaking, including through the creation of the Office of Conscience and Religious Freedom within the Department of Health and Human Services. The agency’s accompanying rule would make it much easier for providers, from front-desk receptionists to surgeons, to refuse patient care, whether or not they are in a religious facility, and has been subject to multiple lawsuits. The expansion of such rulemaking could hit rural communities particularly hard, increasing the risk that patients denied care at one facility may have to travel substantially farther to another, possibly to receive the same treatment.

“If you turn somebody away and they end up dying, or the baby ends up dying because they’re not able to get treatment, what are the ramifications for the hospital?” asks Amy Chen, a senior attorney at the National Health Law Program. The rise in Catholic mergers is making this a more pressing question for pregnant people, people who don’t want to get pregnant, and members of the LGBTQ community who can be caught up in such policies.

Michelle’s experience has forever changed the way she interacts with doctors: Her first question for new care providers is whether they are affiliated with a religious health care entity and if they can offer a whole spectrum of reproductive health services.

And, she notes, if her employer-provided insurance coverage changes, she may not have a choice between the religiously affiliated and secular hospitals in her community. What about the hospital in the next town over where she might seek care if her insurance no longer covered visits to the hospital she uses now?

It’s Catholic.

s.e. smith is a Northern California-based writer and journalist who has appeared in the Guardian, the Nation, Esquire, Rolling Stone, In These Times, and Bitch Magazine.