Qualitative Analysis of Program Director Perspectives on Conscientious Objection Policies to Gender-Affirming Care

Emerging reports of objection to gender-affirming care by resident physicians in obstetrics and gynecology (OBGYN), plastic surgery, urology, and pediatric training programs have begun to highlight the rising incidence and ethical complexities of trainee-objection scenarios. This study examines perspective of residency program leadership toward trainee objection to gender-affirming care.

Program directors from accredited U.S. OBGYN, plastic surgery, urology, and pediatric residencies were surveyed about their experience with objections to gender-affirming care in 2023. The survey included an optional, open-ended item to allow for respondent perspectives on conscientious objection to gender-affirming care. Open-ended responses were coded independently and then collaboratively by two authors using the constant comparison method. Subanalyses were performed based on geographic region, objector status, and policy status.

Of the 257 programs' respondents, 62 (24%) completed the open-ended item. Respondents comprised program leadership from 14 OBGYN (23%), 14 plastic surgery (23%), 13 urology (21%), and 21 pediatrics (34%) residencies. Overall, conscientious objection to gender-affirming care was recognized as an important topic. Programmatic attitudes and limitations were modulated by specialty, experience with objection to other types of contentious care, personal values, and state, specialty, and institution-specific regulations.

Our findings underscore the diversity of perspectives and constraints regarding conscientious objection to gender-affirming care. There is an unmet need to balance uniform policy formation with consideration of specialty, existing frameworks of contentious objection practices for other types of care, and geographic location. Particular consideration must be taken for programs encountering prohibitive state-level legislation or institutional policies.