Conscientious Objection to Gender-Affirming Surgery in Residency Training

Conscientious objection (CO) in medicine has historically centered on reproductive and end-of-life care, and as a result, the topic has largely escaped the attention of plastic surgeons (Bummett, Petrykowski and Bohler 2025). However, with the growth of gender-affirming surgery (GAS) programs nationwide, CO among surgical trainees has begun to emerge as a growing concern (Arteaga et al. 2025; Morrison et al. 2023). Recent case reports, including institutional experience at the University of Michigan, indicate that resident physicians may request to abstain from participating in GAS, signaling the emergence of CO within plastic surgery education (Eble et al. 2024; Morrison et al. 2023). Yet, in the absence of formal guidance from the American Society of Plastics Surgeons (ASPS), American Council of Educators in Plastic Surgery (ACEPS), or the Accreditation Council for Graduate Medical Education (ACGME), individual programs are left to manage these requests in an ad hoc fashion (Arteaga et al. 2025; Eble et al. 2024; Morrison et al. 2023). This lack of standardization has created uncertainty for residents, applicants, and program leadership alike (Eble et al. 2024). As a result, many program directors acknowledge limited experience managing such cases, express uncertainty about how to respond, and explicitly call for centralized guidance to prepare their programs for future cases (Arteaga et al. 2025).

At present, no public-facing ASPS, ACEPS, or ACGME policy clarifies the rights of residents regarding CO to GAS, nor the responsibilities of programs to accommodate such objections while safeguarding patient access. Institutions that have encountered CO requests have relied on ethics committees and general counsel to improvise responses (Morrison et al. 2023). This vagueness leaves trainees vulnerable to feeling compelled to participate in surgeries that violate their moral or religious values, out of fear of repercussions on evaluations or career advancement. It also exposes programs to inconsistency and potential conflict if coverage or patient care is disrupted. Importantly, as GAS continues to expand, residents from other specialties, such as orthopedic or general surgery residents rotating through plastic surgery services, may face similar uncertainties. Without clear specialty-level leadership, the risk of inconsistency, hidden distress, and service disruption persists.

I propose that plastic surgery leadership develop and publish an official policy on resident CO in the context of GAS. Such a policy would offer multiple benefits:

Catalyze program policies: A national framework would encourage individual residency programs to proactively create and publish their own CO policies, rather than reacting only after conflict arises (Morrison et al. 2023).

This approach parallels precedents in fields such as obstetrics and gynecology, where the American College of Obstetricians and Gynecologists has provided professional society guidance to manage CO to abortion, underscoring the need for our leadership to play a similar role in plastic surgery (American College of Obstetricians and Gynecologists 2014).

The expansion of GAS in academic medical centers makes CO among trainees a foreseeable challenge. Current inaction from leadership fosters uncertainty for residents and risk for patients. Organizations such as the ASPS,ACEPS, and ACGME are uniquely positioned to lead by issuing a clear, balanced policy that respects resident autonomy, protects patient care, and provides baseline consistency across programs. Now is the time for leadership to act.