What the Physician-Objection Surveys Actually Show

The question and why the number matters

Public argument about clinician participation in gender-dysphoria care often turns on an unstated number. Advocates of conscience protection imply that objecting physicians are numerous, so that compelling them would be both oppressive and impractical. Advocates of universal participation imply that objecting physicians are few, so that accommodating them is a concession to prejudice. A third claim, frequently made in professional settings, is that most physicians simply lack the training for this care, and that their reluctance is a matter of competence rather than conviction.

Each of these claims is empirical. Each could be tested. As of November 1, 2026, none has been tested at the level at which it is usually asserted. What exists is two small studies, of selected populations, with careful authors who stated their limitations. This article sets out exactly what they found, and then what it would take to answer the larger question properly.

The two studies

The Patel study's own summary is precise: "Surveyed physicians (n = 115) had no objection to caring for TGD patients but notable objection to prescribing GAH therapy to adults (23.5%) and minors (33.0%)." Proved B01 The Domalaon study reports: "In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns." Proved B03 Both studies use the term "gender-affirming hormones"; this article uses their terminology when reporting their results.

The Domalaon study adds two findings that matter for the competence question. The share of respondents reporting no relevant training fell from 74% in 2016 to 44% in 2023, and willingness to prescribe was associated with four or more hours of education (odds ratio 2.2). The share able to provide nonjudgmental care rose from 76% to 85%. Proved B04 Its authors concluded that "clinicians unable to provide gender-affirming care should ensure timely referrals." Documented B03

What the reasons actually were

The single study that asked about religion found that it was not the dominant reason for objection. Of the 23.5% who objected to prescribing for adults, 8.7% of all respondents cited any religious reason and 14.8% cited non-religious reasons only. Of the 33.0% who objected to prescribing for minors, 8.7% cited any religious reason and 24.3% non-religious reasons only. Proved B02 Participants could indicate "no objection, objections due to religious reasons, objections due to non-religious reasons, or objections due to both," but the authors acknowledged that "it was not possible to determine the nature of the non-religious objections." Proved B02

The pattern — religious objection constant across age groups, non-religious objection rising sharply for minors — is suggestive. Inference It is consistent with the hypothesis that much of the additional hesitation about minors concerns evidence, consent or development rather than religious conviction. But the study did not ask, and a pattern in 115 respondents at one centre cannot establish it.

In the military sample, the 26% figure combines two groups: 10% who cited ethical concerns only and 16% who cited both ethical concerns and lack of comfort. A further 11% cited lack of comfort only. Proved B04 "Ethical concerns" in that study was not divided into religious and secular reasons. Treating the 26% as a measure of religious objection — or the 23.5% in the other study as a measure of religiously motivated refusal — would misreport both.

What the studies cannot establish

The limits are not technicalities. A single-centre sample reflects that centre's specialties, training culture and patient population. A conference sample reflects who attends conferences. A survey without a reported response rate cannot be weighted for nonresponse. And a survey of attitudes cannot tell us whether patients in a given region can actually obtain care. Inference

The untested premise: do most physicians lack the training?

A claim often heard in clinical settings is that the majority of physicians lack the experience, training and education needed to provide gender-dysphoria care, and that participation should therefore not be compelled. The first half of that claim is plausible for some services and some specialties, but as of November 1, 2026 it is not established by any representative study located for this article. Open

The one study with time-series data points the other way for its own population: by 2023, only 44% of military family physicians surveyed reported having no relevant training — down from 74% in 2016 — so that, on the study's own figures, a majority reported at least some; and 62% reported willingness to prescribe adult hormones independently or with help. Proved B04 That population is not representative of California physicians, and "some training" is not demonstrated competence. But it shows that the premise cannot be assumed. Competence is also task-specific. The Endocrine Society's 2017 guideline states that for adults "the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery" — a description of team expertise, not a statement that every member must possess all of it. Documented B05 Whether most physicians lack the competence for adolescent puberty suppression (a specialist, multidisciplinary service under that guideline) is a different question from whether most primary-care physicians could, with training and consultation, monitor an adult's established hormone therapy. A single "majority" claim cannot answer both.

The honest position is therefore narrower: the training gap is real enough in the available data to justify investment in task-specific education and consultation, and uncertain enough that it should not be asserted as a population fact in law or policy. Inference

How the national number could be measured

A study capable of settling the question would need features that neither existing study possessed. Inference

1. A complete sampling frame. Licensed physicians drawn from licensing records, stratified by specialty, practice setting and region, with weights for nonresponse — not conference attendees or a single institution.
2. Questions by service and population. General care; diagnostic assessment; adult hormone initiation; adult hormone continuation and monitoring; adolescent puberty suppression; adolescent hormones; surgical referral; management of complications — asked separately.
3. Reasons asked separately and non-exclusively. Religious conviction; other moral or ethical conviction; concern about evidence; lack of training or competence; lack of time or resources; institutional policy; legal or regulatory risk; low local demand.
4. Referral behaviour. Whether the clinician would refer, to whom, and whether a referral destination is actually available.
5. Competence measured, not only reported. Knowledge items or vignette-based assessment, so that self-reported preparation can be compared with demonstrated knowledge.
6. Repetition over time. The same instrument repeated, so that policy changes can be related to changes in willingness and availability.
7. A link to access data. Clinician responses paired with patient-side measures — appointment availability, travel and waiting times — so that attitudes can be connected to outcomes.

Such a study would cost far less than the litigation now conducted in its absence. Until it exists, every claim about how many physicians object, why, and with what consequence should be stated with its denominator, its year and its population — or not stated at all.

How the existing figures should be used

The two studies can responsibly support three propositions: that treatment-specific objection exists at meaningful levels in at least two physician populations; that objection to general care was rare in the one study that measured it; and that education is associated with willingness. They cannot support a national figure, a California figure, a claim about religion's share of objection outside one centre, or a claim about competence. Any publication — including this one — that uses them for more should be corrected. Inference

For the legal framework within which these attitudes operate, see Physician competence, religious conscience and equal access; for the access consequences, see When does a patient need an endocrinologist?

Correction history

Sources

Official issuers, statutes, opinions and original studies are preferred; reproductions of primary legal text are identified. Checked 1 November 2026 unless stated. A source that opens is not proof of every neighbouring claim.

1. B01Patel MS, Jones KA, Davisson L, et al. Journal of Appalachian Health 2024;6(1-2):57–69Original research · doi:10.13023/jah.0601.05 · single academic medical centre · data collected 2018 · n=115
2. B02Patel et al. — full text (PMC11617021)Full text used for denominators and question wording · PMID 39640241
3. B03Domalaon KO, Parsons AM, Thornton JA, et al. J Prim Care Community Health 2024;15:21501319241264193Serial cross-sectional study · 2016 and 2023 Uniformed Services Academy of Family Physicians conferences
4. B04Domalaon et al. — full text (PMC11320690)Full text used for response rates and reason categories
5. B05Endocrine Society — guideline resourcesTeam expertise; 2017 guideline

Reviewed and approved for publication by Kanwar Partap Singh Gill, MD. Healthcare Controversies examines disputes about medical care, institutions, money, conscience and law using public records. It is institutional and legal analysis: not patient-specific clinical guidance, not legal advice, and not a finding about any named clinician or organisation beyond what the cited records establish. Survey figures are reported with their denominators and dates; a funding rule, guideline, audit sample or payment incentive is not treated as proof of more than it measures.

Healthcare Controversies · opening investigations

1. 01 · Gender-dysphoria care · California lawCompetence, conscience and equal access
2. 02 · Denominators, reasons, limitsWhat the physician-objection surveys show
3. 03 · Competence by task · accessWhen does a patient need an endocrinologist?
4. 04 · CMS-2451-F · HCAI · litigationThe October 13 federal funding rule and California's response
5. 05 · Fresno · independent-practice economicsHalf a county on Medi-Cal
6. 06 · Fresno · Kings · MaderaCalViva's 2025 access survey
7. 07 · FQHC payment · completion of careBeyond the billable visit
8. 08 · Private equity · MSOs · CPOMClinical independence after SB 351
9. 09 · AI notes, orders and responsibilitySigned but not written

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