It’s the all-too-common story of a powerful progressive business interest pushing a deep-red state leftward.
South Dakota has been governed by bicameral Republican supermajorities since 1996. Democrats haven’t carried a statewide race in more than a decade. In a 2018 Gallup survey, the Mount Rushmore State was ranked the third-most conservative in the country, with self-identified “conservative” residents outflanking self-identified liberals by some 31 points.
It is not a state where one would expect to find a major trade conference for transgender medical specialists.
But on January 13, the Sanford Research Center in Sioux Falls is scheduled to host just such an event. The “3rd Annual Midwest Gender Identity Summit,” billed as an effort to “review the needs of transgender patients in healthcare,” is evidence that a variety of factors have converged to make “cherry-red South Dakota the unlikely epicenter of a transgender uprising on the American Great Plains,” as the Washington Post reported in 2020. The summit is co-hosted by Sanford Health, a Sioux Falls–based health-care conglomerate, and the Transformation Project, a local transgender advocacy group.
Both Sanford and the Transformation Project are representative of the larger forces that are working to bring the transgender movement to the deepest-red corners of the United States — a coordinated, well-funded campaign for which South Dakota has become something of a trial run. That campaign’s influence has reached the Republican-dominated state legislature, where dozens of anti-gender-ideology bills have failed over the past decade. “No one thought South Dakota was a state where this could be stopped,” Libby Skarin, the campaign director for the ACLU of South Dakota, boasted in February. “I think the fact that we have consistently stopped these bills has been a source of hope for folks, like if they can do it in South Dakota, we can do it in our state.”
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Numerous sources told NR that Sanford’s affiliates had mobilized behind the scenes, including in Noem’s office, to help kill the women’s-sports bill. (In response to a request for comment for this piece, Noem’s office noted that their contract with the Sanford lobbyist involved in that affair had been terminated.) The health-care group’s business interests were heavily implicated in the bill: On the same day that Noem issued her controversial veto, the company announced a $50 million expansion of Sanford Sports Complex — an athletic facility that stood to lose serious revenue if the NCAA pulled its games from the state in protest, as it had in similar situations in the past.
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At the time, concerns about Sanford’s influence centered on Noem herself. The governor’s close relationship to a company with a record of left-wing cultural activism raised new questions about her own missteps. But that relationship had broader implications, too. What was unfolding in South Dakota was the all-too-common story of a powerful progressive business interest that was pushing a deep-red state leftward — even over the express wishes of its broadly conservative voter base.
To Change a State
While Noem eventually reversed her position on women’s sports, gender ideology’s influence in South Dakota remained. The governor’s office was embroiled in yet another controversy in December when a Daily Signal report revealed that the Department of Health had entered into a $136,000 contract with the Transformation Project for a community- health-worker program. The Transformation Project maintains a specific focus on gender-confused youth, including organizing protests against the recent legislative effort to impose stricter rules governing children’s access to sex-change surgeries and drugs. As Alpha News reported, the group, which did not respond to National Review’s request for comment, also “holds an annual event where participants, including children, ritually ‘burn’ their ‘old name or pronouns.’”
Soon after the report broke, Noem terminated the contract, claiming via her spokesman that it was signed without her “prior knowledge or approval.” Days later, the South Dakota health secretary, Joan Adam, abruptly retired.
Even without taxpayer dollars, left-wing lobbying efforts in South Dakota often benefit from generous out-of-state funding. The Los Angeles–based pop singer Ariana Grande, for example, donated well over $100,000 to the Transformation Project last year as part of her “Protect & Defend Trans Youth Fund” initiative. Another California group, the wayOUT LGBTQ Foundation, dedicated its annual gala in November to raising $145,000 for the South Dakota activist group. At least one of the Transformation Project’s board members, Michaela Seiber, received a two-year Bush Fellowship grant of up to $100,000 “to advance a health equity agenda for LGBTQ people” in South Dakota. Seiber, whose primary job at the time was as a senior researcher at Sanford Health, appeared at the South Dakota legislature to lobby and testify against the proposed ban on medical sex changes for children.
The influence of these well-financed groups in South Dakota — buttressed by Sanford’s own resources, which were valued at $7.5 billion as of 2019 — has frustrated conservative efforts to pass the kinds of anti-gender- ideology measures seen in Republican states such as Florida, Texas, and Arkansas. South Dakotans tend to hold conservative views on the issue: A May 2022 South Dakota State University (SDSU) poll, for example, found that 66 percent of registered voters in the state believed that transgender athletes “should only be allowed to play on sports teams that match their birth gender,” whereas just 17 percent believed that they “should be able to play on sports teams that match their current gender identity.” But conservative lawmakers have struggled to get any number of social-conservative bills, particularly as they pertain to transgender issues, across the finish line.
Bills that have failed to make it out of the legislature include the expansion of conscience rights for medical practitioners (HB 1247); the prohibition on sex-change surgeries and drugs for children (HB 1057); a ban on changing one’s sex on birth certificates (HB 1076); a bill requiring teachers to inform parents when students express feelings of gender dysphoria (SB 88); mandated reporting of the number of human embryos destroyed in medical facilities (HB 1248); a requirement that students use bathrooms and locker rooms that correspond to their sex (HB 1005); and the establishment of the “fundamental” parental right “to make decisions concerning the upbringing, education and care of a child” (HB 1246). As of February 2021, there had also been seven failed attempts “by South Dakota lawmakers to prevent transgender athletes from competing,” the ACLU said in a press release at the time.
Despite the overwhelmingly Republican composition of South Dakota politics, gender ideology has made inroads in almost every area of the state’s governing institutions. Last month, for example, SDSU drew conservative criticism for hosting a “kid-friendly” drag show, an event that multiple local lawmakers argued could be illegal under the state’s prohibition on “show[s] or other presentation[s]” deemed “harmful to minors.” Elsewhere, the Noem-appointed head of the state’s Department of Corrections signed a new “Management of Gender Dysphoria” policy specifying that state-prison inmates could request transfers to facilities that corresponded with their “gender identity” rather than sex — and be provided with sex-change drugs on the taxpayer dime.
But no set of institutions in South Dakota has embraced gender ideology more than the state’s Sanford-dominated business community, which sits well to the left of the state’s political center of gravity. (In November 2020, Sanford replaced its CEO of 24 years after he informed employees that he wouldn’t be wearing a mask around the office, arguing that he had recently recovered from the Covid virus and therefore posed no threat of spreading it.) The state’s Chamber of Commerce chapters, which are closely tied to Sanford, regularly lobby against social- conservative bills, including medical conscience rights, the prohibitions on sex changes for minors, birth-certificate gender changes, transgender locker room use, and bans on men in women’s sports.
On cultural issues such as transgenderism, that influence leaves a marked effect. “We see [Sanford] attack good social conservative ideas all the time,” Norman Woods, the director of the local advocacy group Family Heritage Alliance, told National Review. Social conservatives run into opposition from big business “across the nation,” Woods said. “In Arkansas, their biggest opponent is Walmart. Walmart kills the social- conservative stuff. In other states, you know, it’s something else. So within our movement, we have a joke that every state has their Walmart. And for South Dakota, it’s Sanford.”
Sanford’s Man in Sioux Falls
Numerous Sanford employees are scheduled to speak at the upcoming Midwest Gender Identity conference. Among them is Dr. Keith Hansen, a reproductive endocrinology specialist who is billed as a co-host of the event’s panel on “Providing Gender-Affirming Care.”
Hansen, whose practice is based out of Sanford Fertility & Reproductive Medicine in Sioux Falls, is a case study in how advocates of hard-left social policies can wield significant influence in even the most conservative regions of the country. The doctor, the chairman of the University of South Dakota Sanford School of Medicine’s ob-gyn department, is a regular donor to Noem. (USD’s executive vice president, Michelle Bruhn, is also the chief financial officer and treasurer at Sanford Health.) Hansen also serves on the board of directors for the South Dakota State Medical Association (SDSMA).
Hansen, who did not respond to National Review’s request for comment, describes himself as “an expert on the medical treatment of transgender children.” A 2020 Watertown Public Opinion story on the South Dakota legislature’s proposed ban on “gender-affirming” drugs and surgeries for children, which Hansen testified against, included Hansen worrying that he “could go to jail if he prescribes” puberty blockers to children. The report noted that he had “treated 19 transgender minors” in the prior year — patients that, according to another local report, can be as young as eight.
Hansen often advocates for gender ideology in his capacity as both a Sanford doctor and a medical-school professor. In addition to his upcoming lecture at Sanford’s gender-identity conference, he has delivered numerous lectures at USD on the “endocrine care of transgender individuals,” appeared on South Dakota Public Broadcasting to discuss the “value of gender-affirming care,” and is listed as one of the endocrinologists on the “resources” page of TransAction South Dakota, a local transgender activist group. (Hansen also presented on “providing gender-affirming care” at a recent conference hosted by the group.) In 2019, he submitted a letter in a local court case regarding a 13-year- old child petitioning to change the “gender marker” on her birth certificate, arguing that the child — whom Hansen himself was treating — “has had appropriate clinical treatment for gender transition.”
As an employee of USD, Hansen’s work is overseen by the South Dakota Board of Regents. But the state’s higher-education agency is also staffed by multiple Sanford-linked members. Those include Tony Venhuizen, who worked for Sanford directly for a five-month stint in 2007; Barb Stork, who retired from the board in January and served as chairwoman of the Sanford Health System Board of Trustees; and Tim Rave, who served as Sanford’s vice president of public policy after resigning from his post as South Dakota senate majority leader in 2015. Rave is currently the president and CEO of the South Dakota Association of Healthcare Organizations (SDAHO). His son, Mitchell Rave, is a Sanford lobbyist who has represented the health-care company in advocating against numerous social-conservative bills, including medical conscience rights and the youth sex-change ban. All three were appointed by Noem.
Those alliances often surface in the Board of Regents’ governing decisions. The board sent its general counsel to lobby against HB 1217, and in the process of hiring new USD and Black Hills State University presidents, both of the board’s hand-picked search committees included representatives from Sanford. Amid the controversy over SDSU’s “kid- friendly” drag show, Woods, of the Family Heritage Alliance, penned an open letter urging Noem and her appointees on the board — whom the governor had “the power to hold . . . accountable and fire at will” — to take action, given that the school is overseen by the board. In response, Noem called for Woods to be fired.
The Sanford Caucus
Sanford has publicly joined its allies in lobbying against a number of recent conservative initiatives. In addition to several bills to protect medical conscience rights and the ban on youth sex changes, the health- care company sent Mitchell Rave to help kill HB 1248, a bill requiring medical facilities to report the number of human embryos they destroy. “As the bill progressed through the legislature, representatives of Sanford Health and other opponents kept asking, ‘Why do you want to know?’ — as if the destruction of embryos was something that nobody should care about,” Woods told National Review. “Clearly, they didn’t want the world to know how many embryos were being destroyed in their facilities.”
But even in situations where Sanford lobbyists don’t explicitly oppose such bills, the routine failure of social-conservative legislation in South Dakota is often orchestrated by Sanford-linked lawmakers and operatives working on many fronts.
Outside advocates such as Mitchell Rave and Keith Hansen are joined by a number of current and former Sanford employees in the state legislature. Doug Barthel, who has represented district ten in the state house since 2017, joined the health-care company’s “community relations” team in 2015 and has continued to serve as its “senior community relations” specialist throughout his tenure as a legislator. Sydney Davis, who has represented district 17 in the state house since 2021, currently works as a nurse anesthetist at Sanford; Taylor Rehfeldt, who has represented district 14 in the state house since 2021, worked in a similar position at Sanford from 2016 to 2021. Erin Tobin, who has represented district 21 in the state senate since 2021, works as a nurse practitioner at Avera Health, another major health-care interest in the state that is closely linked to Sanford via various advocacy groups. Tobin previously served as a board member for the Nurse Practitioner Association of South Dakota, which is chaired by a Sanford nurse.
Barthel, Davis, Rehfeldt, and Tobin are all Republicans. But in culture- war fights where Sanford’s interests are at odds with South Dakota’s conservative voter base, the legislators often align with the former. Barthel, for example, has consistently ranked among the lowest-rated Republicans in the state house on the Family Heritage Alliance scorecard, which evaluates legislators primarily on their votes on social issues. In 2022, he voted against HB 1005, the bill mandating that access to single-sex facilities in public schools be determined by one’s sex, and SB 46, the new women’s-sports bill that Noem, having suffered the backlash to her veto of the initiative the previous year, supported. In 2021, he voted against a bill protecting medical conscience rights, the ban on birth-certificate gender changes, mandated human-embryo reporting, and both the initial women’s-sports bill and the legislature’s attempted override of Noem’s veto. In 2020, he voted against the prohibition on youth sex changes, and in 2019, he voted against another effort to restrict participation in high-school sports to biological sex.
Throughout his time in the legislature, Barthel appears to have been actively employed as a paid representative of Sanford’s interests. The base salary of a South Dakota state legislator is just shy of $14,000, meaning that typically the lawmakers require second jobs. “Barthel won’t escape entirely his duties as senior public affairs specialist during his term as a Republican representative in the South Dakota Legislature,” a 2019 Sanford report wrote. “That’s just as well — Sanford Health seems to suit the former Sioux Falls police chief who just marked his third anniversary with the organization.”
Davis, too, is currently employed by Sanford as a certified registered nurse anesthetist. Her record also reflects, at times, the social views of her primary employer. In 2021 — after having received financial backing from Sanford-linked health-care groups in her 2020 election campaign — Davis, like Barthel, voted against the social-conservative bills; she did not vote to override Noem’s women’s-sports veto, although she voted for the initial women’s-sports legislation. Rehfeldt, who has received well over $10,000 from health-care groups over the past two election cycles, voted similarly. Like Davis, she did not vote to override the women’s-sports veto but voted for the original bill. In the most recent legislative session, she sponsored the successful effort to kill a subsequent bill enshrining medical conscience rights while it was still in committee.
Tobin, whose largest career donor is the health-care sector, backed the effort to kill the mandated embryo-reporting legislation while serving as vice chairman of the state senate’s health and human services committee — the legislative body where bills on youth sex changes, birth-certificate gender changes, embryo-reporting, and another bill concerning medical conscience rights all died over the course of the past few years. The Avera nurse has served in the legislature only since 2021, but many of her Sanford-linked colleagues were directly involved in killing various other conservative bills. Tobin’s predecessor as health committee vice chairman, Wayne Steinhauer — another beneficiary of thousands of dollars from Sanford-affiliated health-care groups — was the sponsor of the move to kill HB 1057, the youth sex-change ban, in 2020. The committee chairwoman at the time, Deb Soholt — who backed Steinhauer’s move to kill HB 1057 — was a registered Avera nurse who also counted the health-care sector as her top industry donor. (Steinhauer replaced Soholt as the sitting chairman of the health committee. In September, he was given the award of “state legislator of 2022” at SDAHO’s annual conference.)
Soholt, who in 2020 also voted to kill legislation on medical conscience rights while still in committee, was one of twelve legislators to sue to block a 2016 anti-corruption bill that would have barred lawmakers from being simultaneously employed by businesses that lobbied the legislature; that lawsuit was joined by R. Blake Curd, an orthopedic surgeon and former USD Sanford School of Medicine professor who also sits on the senate health committee. Curd counts the health-care sector as his top career donor, and was honored with SDSMA’s “Friend of Medicine Award” for “serving as an effective advocate for health care and the medical profession” during the organization’s 2022 banquet. He voted to kill the birth-certificate and embryo-reporting bills in the 2021 session, and he appeared before the committee in 2020 — before he served as a member — to lobby for killing the ban on youth sex changes.
Soholt, Steinhauer, Curd, Rehfeldt, and Barthel did not respond to requests for comment. In an emailed statement, Davis wrote that she strives “to make the best possible decisions based on the information we are provided.”
South Dakota’s Health-Care Advocacy Groups
Campaign-finance regulations prohibit corporations such as Sanford from donating directly to candidates. But the company and allied health-care interests like Avera and Monument Health tend to exert their influence through advocacy groups such as SDAHO (the Association of Healthcare Organizations) and SDSMA (the State Medical Association). Nearly half of SDAHO’s board of trustees are Sanford Health executives, including the board’s chairman, Sanford Sioux Falls president Paul Hanson. The SDAHO PAC, which is also chaired by Hanson, counts Sanford employees as four of its twelve members — including both Tim Rave and Mitch Rave — and Sanford is a top sponsor of the annual SDAHO convention. SDSMA, where Dr. Keith Hansen serves as a board member, policy council chairman, and PAC chairman-elect, counts Sanford doctors as its immediate past president and current secretary-treasurer. Sanford is also a sponsor of the annual SDSMA conference.
Both Sanford-backed lobbying groups have served as powerful allies of the Left in South Dakota. In 2021, SDAHO boasted that it “worked to defeat” the bill enshrining medical conscience rights, as well as a proposal to specify that municipal public-health enforcement powers could not “prohibit or interfere with” basic constitutional rights (a measure SDAHO described as “anti-public health legislation”). In 2020, it opposed another effort to protect medical conscience rights, which died in the senate health and human services committee with the help of health-care-aligned legislators such as Deb Soholt. And during the most recent legislative session, SDAHO opposed an abortion ban, the parental- rights bill, legislation permitting designated visitors in nursing facilities, and the extension of unemployment benefits to those who had been fired for being unvaccinated, as well as actively lobbying against yet another failed medical-conscience-rights bill. All of the bills ultimately failed.
SDSMA has invited criticism for its relationships with left-wing health- care interests in the past. In a 2016 affidavit submitted to the South Dakota supreme court, physician and longtime SDSMA member Ryan Novotny alleged that SDSMA “has been largely co-opted by the corporate interests of their board members’ employers whose financial motivations are codified as fiduciary obligations in their employment contracts and which often conflict with patient care.” The group has been on the front lines of lobbying for stricter Covid lockdown measures and closures, and it backed mask requirements for South Dakota schoolchildren as late as August 2021. Its website argues that “an abortion is a personal health and medical decision to be made by a qualified physician and patient,” and it promises “to oppose attempts to infringe upon the physician- patient relationship” in that context. Abortion is effectively illegal in South Dakota owing to a trigger ban passed in 2005; but in the last legislative session, SDSMA successfully lobbied against a ban on chemical abortions and proposed referendum on a constitutional amendment declaring that human life begins at fertilization. And although it was “not able to defeat” a 2021 bill mandating life-saving care for children born during botched abortions, the group boasted that it was “successful in getting the tort claim section removed from the bill and the civil penalty reduced.”
Other bills SDSMA was “involved in” opposing over the course of the past two sessions, per the group’s 2021 and 2022 “Legislative Accomplishments” pages, include two efforts to protect medical conscience rights, vaccine-mandate exemptions “for religious objections and natural immunity,” and the bill to ban birth-certificate gender changes. In 2020, SDSMA sent its chief lobbyist to push against the ban on youth sex changes. Except for the amended born-alive abortion- survivors act, all of the bills listed above failed.
‘This Is South Dakota, Not California’
The faction of the South Dakota legislature backed by the health-care industry has played a significant role in the failure of many of these bills. But the coalition’s ability to squash social-conservative bills is also the result of the systematic attempt to marginalize lawmakers who are at odds with its interests. In the internecine fights within the South Dakota GOP, Sanford and its affiliates have decisively sided with the more liberal wing, in large part through the heavy campaign spending of health-care PACs. In 2018, SDAHO tapped former state legislator Deb Peters to serve as its vice president of communications. Soon after, Peters partnered with Lee Schoenbeck, the president pro tempore of the state senate, to fund primary challenges to the so-called ultra- conservative wing of the state legislature. Among those candidates was Erin Tobin, who received $1,000 from SDAHO’s PAC, $1,000 from SDSMA’s PAC, and $1,000 from Schoenbeck himself in her successful 2020 state- senate run against house majority leader Lee Qualm. Rehfeldt, Davis, and Barthel are also all regular recipients of SDAHO’s financial backing.
These efforts targeted the most conservative faction of the state legislature — what the Dakota Leader described as “South Dakota’s most outspoken lawmakers, who previously led the efforts against vaccine mandates, state closures, CRT, and tax increases.” But they enjoyed the support of many of South Dakota’s most prominent Republican leaders. In 2022, Noem herself backed primary challenges to a number of “far-right members of the party” named on a hit list circulated by Schoenbeck. Noem even openly campaigned with a Schoenbeck- and SDAHO-backed primary challenger to Fred Deutsch, a conservative incumbent in the state house who had butted heads with the governor over her missteps on transgender issues.
In an emailed statement, Noem spokesman Ian Fury rejected “any implication that Governor Noem is overly cozy with SDAHO or SDSMA,” pointing to four bills — including a separate born-alive abortion- survivors act that Noem signed in February 2021 — where the governor was at odds with the health-care lobbying groups. Fury also described “the Governor’s supposed ties to Lee Schoenbeck” as “a laughable implication, at best,” citing a recent public row between the two regarding a grocery-sales tax. In a subsequent email, Fury pivoted to querying whether National Review was “no longer pro-life,” alleging that “that’s the message you send by carrying water” for Florida governor Ron DeSantis, whose record on abortion Fury criticized.
Schoenbeck’s South Dakota Strong PAC, which spent at least $138,000 on attempts to unseat conservative lawmakers, also received numerous donations from Helene Duhamel, the majority whip in the state senate and another regular beneficiary of campaign financing from SDAHO and other health-care PACs. While serving on the health and human services committee, Duhamel, who was appointed to the legislature by Governor Noem in 2019, was one of the backers of the successful efforts to kill the ban on youth sex changes and the bill to protect medical conscience rights. And she backed the in-committee scrapping of the bathroom-use and parental-rights bills while serving as vice chairman of the senate judiciary committee during the last legislative session. Duhamel’s husband, Steve Duffy, also donated to South Dakota Strong while in the middle of a successful bid for the state legislature. Duffy ran on the Republican ticket, despite having run in previous races as a registered Democrat — and donating thousands of dollars to Hillary Clinton in 2007 and 2008.
Critics say these funds were part of a concerted effort to consolidate control of state politics on behalf of more liberal-minded legislators who were friendlier to Sanford and its allies. “Sanford influences public policy in ways most people can’t imagine and that certainly don’t align with the values of ordinary South Dakotans,” Jon Hansen, a Republican representing district 25 in the South Dakota house, told National Review. Because the company “promotes, performs, and profits off of chemically castrating minor children — a practice that most South Dakotans find disgusting and contemptible — they need an army of lobbyists to ‘persuade’ legislators otherwise.”
“This is South Dakota, not California,” Jon Hansen said. “We’re supposed to be protecting our kids from harmful stuff like this.”
Schoenbeck, Peters, Duhamel, SDAHO, SDSMA, and Sanford Health did not respond to requests for comment.