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In this Instagram Live clip, Jeremy Faust, MD, editor-in-chief of 番茄社区app, and Blair Peters, MD, of Oregon Health & Science University (OHSU) in Portland, discuss the recent restrictions on gender-affirming care, and the difficult decisions providers are forced to make as a result. Peters is an assistant professor of surgery in the division of plastic and reconstructive surgery at the OHSU School of Medicine.

Click here to watch Part 1 of this conversation.

The following is a transcript of their remarks:

Faust: One of the things I want to just put out there for people watching is that as of June of 2023, which is when we're recording this, if the number I'm looking at is correct, 20 states now have restrictions on gender-affirming care. Is that right?

Peters: Yeah, it's a moving target because a lot of these pieces of legislation are in various stages. Some are active, others aren't, but the gist is yes, care has been limited in many states across the country, or there are certainly threats of that care falling through imminently.

There are definitely families and people that are moving to other states, if they're resourced enough to do so, just to protect access to care that they've been getting for literally years, if not even a decade in some situations. So yeah, it's a very real thing.

This is no longer a theoretical or something that may be happening; there are people that have lost access to care, whether that's been from the legislation itself, or the threats that that legislation has brought on; shaking a provider or an institution no longer feeling comfortable or whatever it is, all of those things matter because the outcome is the same.

Faust: In these states where the laws are becoming more restrictive, what can people do? I mean, I know that it's like 'Oh, they can just go somewhere else, right?' But that's not so easy, right?

Peters: No. That's been...I struggle sometimes when I've gotten heat before for going to Texas to speak or going to Florida and people [say] 'Why are you supporting [them]?' I'm not supporting a state, but those are some of the most populous states in the country. Do you know how many trans people are in those two states? Thousands and thousands. And most people are not resourced enough or fortunate or privileged enough to just pick up their lives and be able to move to a new state without consequences. That is a huge privilege to be able to do that. I can't just abandon people in those other states.

Ultimately, my experience until pretty recently has been that those of us in these spaces have been very siloed. I think gender-affirming care and gender-affirming medicine has always been viewed as this very niche thing. It's very recently, but you see it at the medical and the residency level, that gender-affirming care is being woven into the fibers of academic medicine. All the younger generations just look at gender-affirming care as just part of medicine; that this is a population of people that we care for, like anybody else. But that's new in terms of being truly integrated at those younger stages of training.

I think because of that, at the upper institutional level, in a lot of ways -- even within my specialty of plastic surgery -- it's only very recently that I think people are really becoming aware that this is happening to many of us that are in these spaces. I think part of that has been starting to be vocal about it, and that isn't anything someone should have to shoulder alone. I think that's really where medicine needs to do a better job -- supporting us; supporting those of us that are in these spaces, and not having just you as an individual gender-affirming provider carrying that burden of all that advocacy work and holding that space, but really, at an institutional level, putting out statements and providing you with protection and resources and making it clear that they not only stand with you, but they stand with trans patients.

Because what has made me the most vulnerable, and others the most vulnerable is, having to speak up as an individual where you do not have even a fraction of the power that an institution or an organization or an association does. So anytime I go to speak at a surgical society or whatever it is, I really push explicit statements in support of gender-affirming care and trans and gender-diverse people, because if you don't have those statements, then it's up to us as individuals to have to speak up, and that's where we get targeted.

Faust: I feel like there's the egress and whatever the opposite of egress is, which is that people who want the care who can't get it locally have to go somewhere else. They, obviously, most of the time probably cannot do that. Then there's the flip side, which is that if you are a surgeon who's trained in this area, why would you go hang a shingle in some state that won't allow you to practice what you are expert in? And so it creates the double-edged problem. Is that starting to happen?

Peters: Oh, for sure. I mean, gender-affirming surgery in particular has always been heavily concentrated on the [U.S.] coasts and there's been a massive paucity in the Midwest and the South, but that's happening to an even greater degree now, I would say.

All of our recent fellows and anyone I know that's training is mostly going to a coastal city where they are more supported and feel safe. Physicians are people too. We're human, and I think sometimes the public overlooks that. But it is a very real thing so it's exacerbating that geographic lack of access, where most of the access is really concentrated on the West coast in the California, Oregon, and Washington area, and then New York on the East coast.

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