"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.

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.