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International Journal of Transgender Health logoLink to International Journal of Transgender Health
. 2025 Oct 8;27(5):2628–2639. doi: 10.1080/26895269.2025.2569725

“I couldn’t practice in a place where my patients couldn’t get the care they need”: A qualitative exploration of residency decision-making among Southern medical students interested in providing gender-affirming care

Sophie Knifton 1,✉, Tecora Turner 1, Chuka Onuh 1, Ashley Gordon 1, Madeline Quasebarth 1, Lee Hasselbacher 1
PMCID: PMC13618158  PMID: 42807907

Abstract

Introduction

Legislative efforts to restrict healthcare access for transgender individuals have increased across the United States recently. Limited research has explored how anti-transgender state legislation impacts where medical students wish to attend residency and practice medicine in the future. We explored factors that influence residency choices among medical students from the Southern United States—a region heavily impacted by anti-transgender legislation.

Methods

We conducted in-depth interviews with Southern medical students who want to provide abortion and/or gender-affirming care and applied to residency during the 2023 application cycle (N = 22). Interviews were conducted virtually between February and June 2024 and audio-recorded, de-identified, transcribed, and coded using Dedoose.

Results

Most participants identified as cisgender women (86.4%) and as either White (40.1%) or Black or African American (36.4%). Participants represented ten Southern states and nine medical specialties. Four major themes emerged from our reflective thematic analysis: (1) Gender-affirming care as essential healthcare and a human right; (2) Challenges identifying gender-affirming care training opportunities in residency; (3) Moral distress about training in states that restrict or ban gender-affirming care; (4) Responsibility to serve and advocate for transgender patients, especially in Southern home communities.

Conclusions

Southern medical students interested in providing gender-affirming care are balancing conflicting priorities between their clinical aspirations, personal responsibilities, and legal and geographical limitations. More transparency regarding gender-affirming care training opportunities in residency can help support medical students make informed decisions.

Keywords: Anti-transgender policy, gender-affirming care, medical education, medical students, Southern United States

Introduction

In recent years, lawmakers in the United States have increasingly introduced and passed legislation that restricts transgender individuals’ access to healthcare, education, public facilities, and legal recognition. In 2023, more bills targeting gender-affirming care—medical, social, and psychological interventions to support individuals’ gender expression—were introduced than the previous five years combined (Trans Legislation Tracker, n.d.a). In addition, 2023 signified the introduction of federal anti-transgender legislation, as multiple bills sought to broaden state-imposed restrictions to the national level (Trans Legislation Tracker, n.d.a). Anti-transgender legislation is particularly prominent in the Southern United States (defined using Census Bureau Region 3), where approximately one-third of American transgender youth and adults reside (Chin et al., 2024; Herman et al., 2022). Of the 22 U.S. states categorized by the Movement Advancement Project as having negative gender identity policy scores, indicating harmful or discriminatory policies targeting transgender individuals, 12 are in the Southern United States (Movement Advancement Project, 2022).

In addition to legal barriers, transgender Southerners face structural and cultural barriers to healthcare access. The Southern United States has higher rates of poverty and fewer social services than other U.S regions, which may make it more difficult for individuals to access affordable and timely healthcare (Blackburn, 2025; Johnson et al., 2020; Smart et al., 2022). The region is also characterized by rurality, conservatism, and evangelicalism–social factors that have been linked with anti-transgender stigma (Abelson, 2016; Campbell et al., 2019; Joudeh et al., 2021; White Hughto et al., 2016). Furthermore, structural racism creates greater barriers to healthcare access and more frequent experiences of discrimination for Black and Latinx transgender individuals compared to White transgender individuals in the Southern United States (James et al., 2016; Johnson et al., 2020; Smart et al., 2022). These barriers contribute to relatively low levels of satisfaction with healthcare access among transgender Southerners. A recent study found that less than one-third of transgender Southerners felt their healthcare needs were being met, and most believed that being in the South makes it harder for LGBTQ individuals to access quality medical care (Johnson et al., 2022).

Another barrier to healthcare access for transgender Southerners is lack of healthcare providers knowledgeable about gender-affirming care (Dubin et al., 2018; Honigberg et al., 2017; Mousavian et al., 2024; Vasudevan et al., 2022; Yip et al., 2024; Zelin et al., 2018). An increasing number of medical specialties have identified a need for gender-affirming care training, including obstetrics and gynecology, endocrinology, urology, surgery, and psychiatry (Juarez et al., 2023; Lee Cruz et al., 2024; Markowitz et al., 2024). However, gender-affirming care curricula is generally limited in medical education, and many medical students report having low knowledge of medical management of transgender and gender-diverse patients (Mousavian et al., 2024; Vasudevan et al., 2022). Beyond the classroom, many medical students deliver medical care to few or no transgender patients during undergraduate training (Honigberg et al., 2017; Vasudevan et al., 2022). Lack of clinical training and experience may affect how comfortable healthcare providers are treating transgender patients, which can negatively impact transgender individuals’ experiences seeking healthcare and deter them from further care (Johnson et al., 2020; Lee Cruz et al., 2024; Zelin et al., 2018). Medical providers who offer gender-affirming care to minors also risk legal consequences in some states, such as medical license discipline, lawsuits, and criminalization (Mallory et al., 2023).

To improve healthcare access for transgender individuals in the Southern United States, it is important to understand future healthcare providers’ interest in learning about and providing gender-affirming care, as well as geographical preferences for residency and beyond. Limited research has explored medical students’ perspectives on legislation restricting gender-affirming care. These studies suggest that some medical students are considering anti-transgender legislation when deciding where to apply for residency, particularly noting concerns about how state and federal restrictions could impact training and career opportunities as well as personal and community safety (Jewell et al., 2025; Kurman et al., 2024). Recent literature has also highlighted the different ways healthcare providers who offer gender-affirming care may experience moral distress—the psychological turmoil experienced by clinicians when their professional ethics conflict with institutional constraints (Gzesh et al., 2024). These studies have emphasized how a healthcare provider’s broader sociopolitical context can influence their feelings of moral distress (Mabel et al., 2022; Shirin et al., 2025). Feelings of moral distress may be heightened for healthcare providers originating from states that restrict gender-affirming care, which could in turn influence where they choose to practice medicine. We interviewed Southern medical students who are interested in providing gender-affirming care, exploring their motivations, their interest in relevant clinical training, and the role of anti-transgender legislation in their residency decision-making.

Materials and methods

Research design

Eligible participants were fourth-year medical students who applied to residency during the 2023 cycle, were interested in providing abortion and/or gender-affirming care, and identified as Southerners. We defined “Southerner” as having resided in a U.S Census Bureau Region 3 (South) state for at least five years prior to their undergraduate/medical education. Eligible states included: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. We excluded those from Delaware and Maryland as those states have minimal restrictions on abortion and gender-affirming care (Movement Advancement Project, 2025). We focused on medical students who resided in Southern states prior to undergraduate/medical education to better understand their motivations to return to their communities of origin during and after residency. Participants did not have to currently reside in the South to be eligible for participation. We did not limit our scope to specific medical specialties, so long as participants were interested in providing either abortion or some aspect of gender-affirming care as part of their clinical practice.

Recruitment

Prospective participants were recruited between February and June 2024. All interviews took place during the residency application process, with participants receiving their Match results in March 2024. Study information was shared via professional networks and medical school mailing lists. Fifty-nine potential participants completed an online screener that asked respondents to self-report demographic information, including their gender, race, ethnicity, medical school status, and state of origin. Participants also indicated if they were interested in providing abortion care, gender-affirming care, or both during the online screener. The research team contacted 37 eligible participants for an interview. Of these participants, ten did not respond after three contact attempts and four did not attend their scheduled interview. We discontinued recruitment when we reached thematic saturation. For this analysis, we also removed one participant who was not interested in providing gender-affirming care.

Data collection

Individual interviews were conducted by TT, SK, and MQ—research staff trained in qualitative methods. Interviews occurred virtually and were audio recorded via Zoom, lasting 45 to 60 min. We used a semi-structured interview guide that explored: specialty and program choice; interest in providing abortion and gender-affirming care; response to the Dobbs decision and anti-transgender legislation; geographic preferences; and Southern identity and interest in returning to one’s community of origin. This analysis focuses on participants’ interest in providing gender-affirming care, response to anti-transgender legislation, and geographic preferences for training and future career. Along with questions about their overall preferences and priorities for residency training, we asked participants questions such as: “Is it important to you to work with a gender diverse patient population during your residency?,” “Did the wave of anti-trans legislation impact your application process?” and “Did you consider residency programs in states with restrictions on providing gender-affirming care?.” Participants received a $30 digital gift card upon completion of the interview. All study activities were approved by the Institutional Review Board at the University of Chicago, IRB number: 23-1544.

Data analysis

After completing interviews, the study team wrote memos to overview participants’ responses and key themes that emerged from their interviews. We then removed all identifiable data from interview transcripts, which were then sent to a third-party transcription service to be professionally transcribed. Following transcription, the research team conducted reflexive thematic analysis with inductive coding (Green & Thorogood, 2018). First, the study team members familiarized themselves with the interview memos and interview transcripts as to better immerse themselves in the data. Second, the study team used emergent themes to create an initial codebook, which was iteratively adjusted and discussed across the team. Study team members actively participated in reflexivity during the coding process and attempted to bracket lived experiences through ongoing candid discussions between team members (Tufford & Newman, 2012). Third, three study team members (SK, CO, MQ) coded the same two transcripts and met to review coding line by line for consistency and concordance, revising the codebook accordingly. After establishing a sufficient level of coding concordance, fourth, the remaining transcripts were coded individually by study team members. The coding team continued to meet regularly to discuss codebook efficacy and further refinement. Lastly, the research team created code summaries that synthesized excerpts for each code and identified overarching themes and subthemes.

Positionality statement

We are a research team associated with an academic medical center in urban Illinois, USA. Our research team is composed of a group of diverse individuals in their professional and personal backgrounds. We are all researchers trained in qualitative health research, but some of us are also early career medical professionals. Our identities include people who identify across the sexuality spectrum, while most of us identify as cisgender. Further, our team makes up a racial and ethnically diverse group, with some of us identifying as first-generation American. Three study members identify as Southerners, allowing further insight into the study population. We acknowledge and integrate our positionality within this research project. Overall, our myriad social identities across gender, ethnicity, sexuality, race, and disability status, contributed to both our research questions and data analysis.

Results

We interviewed 22 fourth-year medical students applying to residency during the 2023 application cycle. Participants self-identified as 86.4% cisgender female, 40.9% White, 36.4% Black or African American, and 22.7% Asian (Table 1). Participants applied to nine medical specialties, with OBGYN applicants making up the highest proportion (Table 1). Participants were originally from 10 Southern states, with the largest number coming from Texas (Figure 1). At the time of their interviews, half of the participants (n = 11) were attending medical school in a Southern state.

Table 1.

Participants’ sociodemographic characteristics (N = 22).

Sociodemographic characteristic Number of participants (%)
Gender  
 Cisgender woman 19 (86.4)
 Cisgender man 3 (13.6)
Race  
 Black or African American 8 (36.4)
 White 9 (40.9)
 Asian 5 (22.7)
Ethnicity  
 Hispanic/Latino 1 (4.5)
 Not Hispanic/Latino 21 (95.5)
Sexual orientation  
 Heterosexual 14 (63.6)
 Gay or Lesbian 2 (9.1)
 Bisexual 5 (22.7)
 Don’t know 1 (4.5)
Relationship status  
 Single 9 (40.9)
 Partnered 6 (27.3)
 Married 7 (31.8)
Intended specialty  
 Anesthesia 1 (4.5)
 Family Medicine 5 (22.7)
 Internal Medicine and Pediatrics 1 (4.5)
 Neurology 1 (4.5)
 OBGYN 10 (45.5)
 Pediatrics 2 (9.1)
 Plastic Surgery 1 (4.5)
 Psychiatry 1 (4.5)
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Figure 1.

Figure 1.

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Participants’ state of origin (N = 22).

Several interrelated themes emerged regarding participants’ reactions to policies that limit access to gender-affirming care and their interest in providing such care. First, participants described a strong motivation to provide gender-affirming care, which they viewed as a human right. Second, they expressed interest in receiving clinical training in gender-affirming care, noting that such training would improve their overall abilities as healthcare providers. However, participants reported that residency programs offered limited, if any, opportunities for gender-affirming care training. Third, participants voiced concerns about training in states that restrict or ban gender-affirming care, though many still applied to programs due to the structure of the residency application process. Finally, participants emphasized their responsibility to serve and advocate for transgender patients, with several hoping to return to the South in the future to care for their home communities.

Gender-affirming care as essential healthcare and a human right

We explored participants’ motivations for providing gender-affirming care and interest in obtaining relevant clinical training during residency. Many participants felt motivated to provide care for transgender patients because they believed that gender-affirming care is not only an essential health service but also a human right. As one participant, an internal medicine applicant from Tennessee, explained: “Recognizing that caring for another human’s life includes all of the things that they value and are important to their livelihood is essential to the practice of medicine.” Similarly, an OBGYN applicant from Florida explained that she viewed gender dysphoria as a “quality of life issue,” and wanted to provide gender-affirming care because she believed that “to live in a body that does not feel like yours, does not feel like home to you, has so many more negative effects … I think if that is someone’s choice and what they want to do, then they should be able to do that with as minimal barriers as possible.”

Most participants reported that receiving gender-affirming care during residency was very important to them, even if they did not plan to pursue a medical specialty directly related to gender-affirming care. An OBGYN applicant from Mississippi explained that it was important for her to learn how to care for transgender patients, even if it is not a primary part of her clinical practice: “I know that I will learn how to have those conversations and provide that counseling for people, even if I am not the person primarily doing bottom surgery for people or reconstructive surgeries or even hormone replacement therapies and things like that.” In addition, every participant reported that it was important for them to work with a gender-diverse patient population during residency. Participants felt that learning how to provide comprehensive care for transgender and gender-diverse patients would improve their overall abilities as a provider. For instance, an OBGYN applicant from Tennessee said: “I think the more exposure you have to diverse peoples of all backgrounds, the stronger you are as a provider.” Similarly, an OBGYN applicant from Texas expressed: “I want to be able to walk into a room and not be surprised.”

Though most participants had not received prior gender-affirming care training, some discussed their experiences observing care to transgender individuals during their undergraduate medical training. For these participants, their experiences motivated their desire to gain additional clinical experience in gender-affirming care. A pediatrics applicant from North Carolina described how she felt after observing a gender-affirming surgery during a urology rotation in medical school: “These people are providing a service that I think is important, and I want to be part of that too.” Similarly, a plastic surgery applicant from Arkansas discussed an impactful experience observing chest reconstruction: “I got to see a lot of follow-ups from top surgeries. I remember one patient, we took their dressings off for the first time, and they were crying with their dad because they were just so happy about how their result was. It was super, super impactful. Patients were very, very happy.”

Challenges identifying gender-affirming care training opportunities in residency

In general, participants perceived that residency programs offer limited, if any, gender-affirming care training. Programs tended to vary in the level of gender-affirming care training they offered, and some participants preferred programs with more robust curricula. A family medicine applicant from Georgia explained that “some programs had very specific training or rotations that you could do to build up your experience, and that was really awesome. And then others, they just kind of had it as part of their regular training in the sense that you may encounter a few patients who would need this kind of care from you.” Some participants felt that current opportunities for gender-affirming care training were inadequate and hoped to receive more comprehensive training in the future. For instance, a family medicine applicant from Virginia, called for more holistic gender-affirming care training, questioning: “What does providing global, general, well-rounded preventative care and chronic disease management look like for folks who just happen to also be gender diverse and maybe also on hormones?”

Several participants found it difficult to identify programs with comprehensive gender-affirming care training. These participants felt it was easier to find programs with fully integrated abortion training and wanted a more systematic way to determine which programs offer gender-affirming care training. One participant, a family medicine applicant from Louisiana, would have liked to see a clearinghouse for programs that offer gender-affirming care similar to the RHEDI (Reproductive Health Education in Family Medicine) programs. RHEDI programs—now part of TEACH (Training in Early Abortion for Comprehensive Healthcare)—are family medicine residency programs that offer comprehensive abortion care training through on opt-out model (“About Teach,” n.d.). To overcome this lack of information, this participant created a spreadsheet organizing programs based on their state’s legislation toward transgender healthcare. She explained: “If the program didn’t say on their website that they provided gender care or mentioned LGBTQ care at all, I didn’t apply to them. Gender care was my main non-negotiable way to narrow down where I applied.”

Some participants inquired about the availability of gender-affirming care training during the residency application process. For example, participants asked faculty about the gender diversity of the patient population their program served and whether faculty provided specific types of gender-affirming care. While faculty directors generally responded positively to these inquiries, many participants noted that programs were still limited in the level of gender-affirming care training opportunities they offered. For instance, an internal medicine applicant from Tennessee explained: “I think in general, people are understanding that [gender-affirming care] is an important subject in medicine that needs more study and needs more resources. Nobody was hostile about it. In general, they’re just kind of dismissive because it’s not something that’s very common in residency programs.”

Moral distress about training in states that restrict or ban gender-affirming care

Many participants felt scared, disheartened, and frustrated about state legislation that restricts access to gender-affirming care. Many also worried about how state legislation would affect their ability to access training and provide care to transgender patients. For instance, a pediatrics applicant from Tennessee discussed her feelings about legislation prohibiting gender-affirming care for minors: “I would be really frustrated if I wanted to provide care to a child and I couldn’t because of all of these limiting factors … I think that would be so draining and frustrating and contribute further to any burnout that’s already going to happen during residency.” Several participants also considered how legislation targets healthcare providers offering gender-affirming care, expressing concerns about the legal consequences they could face for providing care that they perceived as medically necessary. For instance, a pediatrics applicant from North Carolina said: “It is so scary. I don’t even like interpersonal conflict or confrontation. And I’m talking about a state suing me.”

Some participants also worried about how anti-transgender legislation could impact their own access to medical care. Several voiced concerns about living and raising families in areas with legislation restriction transgender rights. While no participants anticipated needing gender-affirming care themselves, a few considered the possibility that their children or partner may need gender-affirming care in the future. For instance, a pediatrics applicant from Tennessee expressed concerns about how the increasing wave of anti-transgender legislation could impact her future family:

[T]hat was something that I considered like my future kids. I didn’t want them to be raised in a state where there were not only these restrictive legislations for gender-affirming care, but who knows what’s to roll out in the future in terms of healthcare … So that was a bigger consideration for me.

Some participants with LGBTQ+ identities had similar concerns about living in states with legislation restricting gender-affirming care. An OBGYN applicant from Texas explained: “I’m not comfortable with my own personal life in [restrictive states] as, again, a woman of reproductive age, as somebody who dates trans and non-binary people sometimes.” Similarly, a family medicine applicant from Louisiana explained that even though she identifies as cisgender, “being able to be in a state where that access is available to everyone makes me feel safer as a woman and as a queer individual anyway.”

Most participants felt that the recent rise in legislation restricting access to gender-affirming care impacted where they applied for residency. For some participants, anti-transgender legislation strongly limited their geographic choices for residency programs. For instance, a pediatrics applicant from Tennessee explained how recent legislation in her home state impacted her comfort applying to programs there: “Tennessee recently rolled out legislation banning gender-affirming care, and that definitely affected my decision—I couldn’t practice in a place where my patients couldn’t get the care they need.” Similarly, a family medicine applicant from Georgia who was interested in providing gender-affirming care said: “My geographic choices were very limited to states where I knew that I could get training in the state and didn’t necessarily have to make extra effort to get the training that I need.”

Some participants only considered residency programs in states they perceived as liberal and had less restrictions on gender-affirming care. Many of these participants expressed a desire to leave the South to avoid restrictive legislation. For instance, an internal medicine applicant from Tennessee explained: “I think incidentally, a lot of the states that support [gender-affirming care] or where patients feel safe enough to ask for that are states that I would prefer to live in. So that kind of conflates the issue.” Other participants based their geographic choices for residency primarily on a state’s abortion legislation, especially those applying into surgical specialties such as OBGYN. Most of these participants thought state attitudes toward abortion usually also reflect those toward gender-affirming care. For instance, an OBGYN applicant from Texas felt “that the states that restricted abortion were kind of passing similar legislation regarding LGBTQ patients. So I feel like by avoiding that, it was like a double whammy. And I was able to avoid both.”

All participants expressed some level of concern about how anti-transgender legislation could impact their access to training, career opportunities, and personal and community safety—still, most participants (n = 18) applied to programs in states with restrictions to gender-affirming care. Many participants felt that although they would prefer to train and reside in nonrestrictive states, they felt limited by the residency application process and wanted to rank many programs in order to prioritize matching. For instance, an internal medicine applicant from Tennessee explained: “I feel like [restrictive states] are states where patients are just less likely to be treated well in general…So those are not states that I particularly want to train in, but I am not removing states from my list because of that.”

Responsibility to serve and advocate for transgender patients in Southern home communities

Many participants expressed a commitment to advocating for transgender patients, both within their clinical practice and beyond. Some participants saw an opportunity to use their privilege as healthcare providers to serve communities in need of culturally responsive and inclusive care. A family medicine applicant from North Carolina explained how his commitment to providing gender-affirming care stems from his desire to advocate for transgender patients: “I think this is a type of care that is marginalized and subordinated … So, I think me being trained in this is one way that I can try and increase access and advocate for this from a standpoint of a certain degree of expertise, having MD behind my name.” While not transgender themselves, these participants were committed to supporting gender-diverse individuals in navigating the healthcare system. An OBGYN applicant from Texas explained: “I will never know what it’s like to be a trans person. I don’t know what they go through but one thing I do know is that if I can provide something that improves someone’s mental health, makes them want to live another day, gives them the feeling of purpose, then that is what I should do.”

Many participants expressed a responsibility to provide care for transgender Southerners, noting concerns about how restrictive legislation adversely impacts transgender communities in the South. For some participants who planned to train out-of-state, this commitment often came with a sense of guilt about leaving their home state. An OBGYN applicant from Tennessee said: “It’s hard to abandon your home state to go somewhere where it’s a little bit easier. Because you know, again, these are people who are frankly faced with an uphill battle for where we thought we were making progress on a lot of these topics that are just constantly being regressing…But I do think it’s not forgotten on me that even as someone who grew up here, my voice still matters.” Similarly, a family medicine applicant from Louisiana explained:

I think as a queer person of color from the South, I care a lot about queer populations in the South and understand that lots of people are not flocking to the South to provide care because of lots of policies and flaws. And so I do feel, frankly, a sense of obligation. And I do anticipate if I don’t return to the South, I will have to grapple with just some guilt and feelings like, “I’m kind of leaving this community that I know needs me and could benefit from the work that I’m able to do there.”

Given the limited opportunities for gender-affirming care training in residency, some participants planned to attend residency in states with more protections for gender-affirming care and return to their home state after obtaining their medical training. An OBGYN applicant from Texas who did not apply for residency programs in states that restrict access to gender-affirming care said:

Our trans patients are getting zero care here [in Texas and other restrictive states]. They’re not being acknowledged. No one’s even listening to them … And I think that’s horrible. So, for me, just being able to go somewhere where I can learn about that, be trained to do that, and then maybe come back or provide resources for those who really, really need it and don’t have access.

Beyond the clinical setting, several participants expressed that they hoped to advocate for transgender rights through policy changes that protect transgender rights and expand access to gender-affirming care. For instance, an OBGYN applicant from Tennessee expressed the belief that physicians should advocate for their patients politically as well as clinically: “So much of your job is impacted by factors outside of the clinic or the operating room and we have a duty to use our voices to just stand up for our patients … So much of what we do can be changed though if we use our voices in other realms.” Similarly, a family medicine applicant from Virginia explained that she felt comfortable training and residing in states that restrict access to gender-affirming care “because that would actually be a great opportunity to do a little bit of grassroots efforts on trying to understand how we can come to some common ground.” She further explained: “I am not trans, and so it’s no skin off my back to use that privilege to say, “This is really important healthcare and I provide it. And I think that the state should continue to protect it.””

Discussion

Our study is among the first to explore medical students’ perspectives on legislation restricting gender-affirming care and its influence on their residency decision-making process (Jewell et al., 2025; Kurman et al., 2024). Further, our study’s focus on medical students from the Southern United States—a region characterized by significant anti-transgender legislation—explored the complex tradeoffs medical students must make between their professional goals and geographical ties. Our results suggest that Southern medical students who are interested in providing gender-affirming care are considering how anti-transgender state legislation shapes their future clinical and professional opportunities. The participants in this study viewed themselves not only as clinicians, but also as advocates committed to providing high-quality and affirming healthcare to transgender and gender-diverse patients. While some planned to leave the Southern United States for greater access to training and ability to provide gender-affirming care, others felt committed to returning to the South after residency.

Participants in our study felt motivated to obtain gender-affirming care training and to serve a gender-diverse patient population because of the belief that such care is a human right and learning such care would improve their overall skills as healthcare providers. Prior research has shown that despite limited training, many health professionals are interested in learning about and providing gender-affirming care (Dubin et al., 2018; Vasudevan et al., 2022; Yip et al., 2024). Participants in our study applied to a diverse range of medical specialties—from surgical specialties like plastic surgery, to mixed specialties like OBGYN and anesthesia, to medical specialties like psychiatry and family medicine. However, all participants were interested in receiving gender-affirming care training during residency, emphasizing the need for training across medical specialties. Some participants in our sample wanted a more structured way to identify programs that offer intensive gender-affirming care training. A standardized gender-affirming care curriculum using a similar opt-out model as used in the RHEDI curriculum (now part of TEACH), which offers opt-out abortion training in family medicine programs, can be developed to ensure that future healthcare providers have the skills they need to confidently serve transgender patients (“About TEACH,” n.d.; Das & Drolet, 2022).

Participants discussed making complicated decisions about where to apply for residency, balancing access to training and healthcare, legal barriers to practice medicine, and the obligation to provide for their community members. Some participants expressed a desire to leave the South and only applied to residency programs in U.S. states that did not restrict access to gender-affirming care. Prior research exploring the impact of anti-transgender legislation on medical students’ residency decision-making found that many participants had specific concerns about how state policy could impact their professional opportunities and personal safety when deciding where to apply for residency (Jewell et al., 2024). Another study found that some American healthcare providers had considered moving to less restrictive states due to professional, legal, and personal concerns (Hughes et al., 2021). Participants in our study expressed similar worries when deciding where to apply for residency, while also grappling with a sense of responsibility to remain in and serve their home communities. Despite having concerns about training in states that restrict or ban gender-affirming care, most still applied to residency programs in these states due to the selective nature of the ranking process. Themes from our study reflect similar studies exploring moral distress among healthcare providers who offer gender-affirming care. Participants described frustration in balancing conflicting priorities regarding their professional aspirations, personal responsibility, and legal and geographical limitations Gzesh et al., 2024; Mabel et al., 2022; Shirin et al., 2025). As anti-transgender legislation continues to gain momentum, regions with restrictive gender-affirming care policies, such as the Southern United States, may face a future shortage of providers trained in gender-affirming care. Given the crucial role providers play in shaping transgender individual’s experiences with and trust in the healthcare system, this has the potential to exacerbate existing health inequities facing gender-diverse communities (Heng et al., 2018; Rosa et al., 2025).

Limitations

Our study focused on medical students who were interested in providing gender-affirming care and/or abortion care as part of their clinical practice. Since we only recruited participants interested in providing abortion and/or gender-affirming care, our results may not be generalizable to all medical students. However, by focusing on medical students already interested in providing gender-affirming care, we can better understand the broader barriers to training. If highly interested students find it difficult to access training, those with less interest—but still open to providing gender-affirming care—are likely to face even greater challenges.

In addition, our interviews took place at different points in time throughout the 2023 residency application process. Our interviews began when applicants were still finalizing their rank order list and concluded after applicants had received their program match. As a result, we were not able to collect data regarding participants’ residency programs for all participants. Further, due to the selective nature of the residency match system, participants are matched via an algorithm and have limited autonomy over the program they choose. However, our exploration allowed us to understand participants’ preferences for residency programs, regardless of the program they are actually matched with.

Further, most (86.4%, n = 19) participants identified as cisgender women. This bias reflects the gender distribution of the medical specialties represented in our sample. Of the top three specialties represented in our sample—OBGYN, family medicine, and pediatrics—all have a greater concentration of female residents (87.2%, 55.0%, 73.6%) (Brotherton & Etzel, 2023). Still, this gender bias may limit the diversity of experiences and perspectives in our findings, particularly those of transgender and gender-diverse medical students who may face unique challenges and considerations when selecting residency programs (Weinand et al., 2023). In addition, participants represented ten Southern states. Despite recruitment efforts targeting students in all eligible states, we were unable to recruit participants from Alabama, Oklahoma, South Carolina, and West Virginia.

Conclusion

The United States has experienced a rapid increase in anti-transgender legislation in the past decade. In 2025, over 200 bills have already been introduced that seek to prohibit or limit access to gender-affirming care, and the number is expected to increase (Trans Legislation Tracker, n.d.b). As a result, medical students who wish to provide gender-affirming care are considering how state legislation impacts their ability to access clinical training and provide care for transgender patients. Those from the Southern United States, a region significantly impacted by anti-transgender legislation, are also balancing their clinical aspirations with proximity to and responsibility for home communities. To support medical students interested in providing gender-affirming care, a more streamlined method to determine which programs offer comprehensive gender-affirming care training could be developed.

Acknowledgements

The authors would like to thank Vanya Manthena for her invaluable assistance with conducting interviews. This work was supported by the Emerging Scholars in Family Planning grant from the Society of Family Planning.

Funding Statement

This study was funded by the Emerging Scholars in Family Planning grant from the Society of Family Planning.

Disclosure statement

The authors declare that they have no conflict of interest.

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research, supporting data is not available.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research, supporting data is not available.

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