Danna Ghafir doesn’t want to leave Texas. The 27-year-old was born and raised here, part of a tightly connected Arab American community spread throughout sunny, sprawling Houston. She grew up speaking three languages, crisscrossing the massive city to meet up with friends in neighborhoods that, to Ghafir, felt teeming with life—mosaics of homes and restaurants and schools and museums all on top of one another. They’re one of the reasons she loves Houston: she’s comfortable in the diverse city, where she is never the only woman of color in the room. So, when she decided she wanted to become a doctor, Ghafir picked a medical school in her hometown, with the goal of bringing access and openness around women’s health to her community.

Ghafir grew up not talking about reproductive health. She remembers family friends being afraid to let their daughters get Gardasil—a common vaccine to prevent some types of HPV that can lead to cervical cancer—because they worried it could be an “instigator” for sexual activity. “There was a lot of fear around some really routine procedures,” said Ghafir, “like getting a regular pap smear, for example.” As she got older and learned more, she began to realize how dangerous that education gap could be.

“I want to bring that [education] to the Arab community in a culturally sensitive way that won’t turn people off,” she said. Even while she found her medical-school program lacking in in-depth reproductive health-care education, Ghafir sought out ways to supplement her training through nonprofits such as Medical Students for Choice, which provides additional training for medical students, and attended seminars and lectures in her free time. She had always hoped to stay in Houston for her residency and to eventually practice in the area. That changed this past fall.

In September, the Accreditation Council for Graduate Medical Education—the governing body for medical training throughout the country—updated its requirements for OB-GYN residency programs, doubling down on its abortion training requirement and stating that, in order to qualify as a certified residency program, an institution must offer “clinical experience or access to clinical experience in the provision of abortions.” (The ACGME rejected proposed use of simulation and assessment activities to meet the training requirements.) For programs based in states with harsh abortion restrictions, such as Texas, Arkansas, Louisiana, and Oklahoma, the requirements mean residents will have to leave the state for abortion training—and that students in states with abortion bans must receive “support” from their programs to make this travel possible. Since Texas outlawed nearly all abortions last summer, after the U.S. Supreme Court overturned Roe v. Wade in its Dobbs v. Jackson Women’s Health Organization ruling, Ghafir can’t complete her training without leaving the state. “Abortion care is so important to me; it’s so central to my career plans,” said Ghafir. “But it’s so hard to say I want to leave, because this is the community I want to serve.”

Even though residency programs are expected to offer students the option to travel out of state to meet requirements, Ghafir, and many other Texas medical students, are considering leaving for the full four years. And after that, who knows? “The availability of abortion care and how much it’s protected is a huge factor in where I plan to apply,” said Ghafir. Even if medical residency programs in Texas do offer out-of-state training, not only is leaving the state for an extended period of time to train often a burden—particularly for residents with families—but, for Ghafir, it’s not enough. “I want more than that. I want to be surrounded by physicians who are continually engaged in this care.”

Haley, another 27-year-old medical student whose last name has been withheld to protect her privacy, said her Dallas medical school has “next to no mention of abortion” in its curriculum. Haley, like Ghafir, was born and raised in Texas and always planned to complete her training here. But that’s changed—in part because of her concern with the quality of training, but also because she’s worried about her own access to reproductive health care in Texas. Haley had an abortion years ago in another state, and since the procedure is now illegal in most cases in Texas, she’s worried about her own health-care options should she stay. “It’s become very mentally tiring to be someone who cares about abortion—and to be someone who has had an abortion—in Texas,” Haley said. “I don’t want to abandon the state that I grew up in, and I don’t want to abandon the patients and pregnant people here, but I need to give myself a break, for at least a couple years.” While she still has two years left in medical school, Haley told me she won’t apply for residencies in Texas. 

States with abortion bans saw a 10.5 percent drop in applications for OB-GYN residency programs this year, according to new data from the Association of American Medical Colleges. (Applications across the board dropped this year; in states where abortion remains legal, there was a 5.3 percent drop in applications.) Pamela Merritt, the executive director of Medical Students for Choice, says Texas is a uniquely scary place to be an OB-GYN resident. That’s because of a bill that passed in Texas’s 2021 legislative session, Senate Bill 8, which allows private citizens to sue individuals who help patients obtain abortion care, and the avenues for legal battles SB 8 has opened. This session, Texas Republicans in the statehouse have made repeated efforts to punish companies, independent abortion funds, and employers attempting to help fund out-of-state abortion costs. “If a resident in Texas tells their roommate, ‘Oh, I’m going to New York to do my abortion training this month,’ then can their roommate sue them? We don’t know,” said Merritt. And that uncertainty is causing a chilling effect across the state. “Dobbs may have thrown abortion to the states, but when we’re talking about medical education, Dobbs threw it to each individual residency program,” said Merritt.

While reporting this piece, many of the medical students and residents I spoke to were confused and fearful about what could happen to them if they participated in out-of-state abortion training. Since abortion became illegal in Texas last year, that sentiment has proliferated in the medical field, leaving care providers worried about offering even the limited care they are legally allowed to provide. In early March, five women sued the state after they were denied abortion care despite suffering from dangerous pregnancy complications they say should have qualified them for the state’s limited exception to the abortion ban; they’re seeking clarification on legal exemptions to the ban. “Doctors are afraid of talking about the issue of abortion,” said Elizabeth Sepper, a professor at University of Texas at Austin’s School of Law. “They often wrongly believe they can’t give their patients information or a referral out of state. We’re just seeing the medical profession duck and cover.” But the reality, Sepper says, is that Texas’s laws—as they are now—can’t touch providers in these situations. “SB 8 and criminal bans all stop at the boundaries of the state,” she said, though she conceded that doctors’ fears are not completely unfounded. Indeed, Attorney General Ken Paxton has recently launched an investigation at a hospital in Texas for mentioning gender-affirming care for elementary school–age patients, even though, as Sepper said, “it’s not clear that [he] has any law on his side.” Similarly, last year Governor Greg Abbott ordered state child welfare officials to launch investigations into reports of children receiving gender-affirming care, again, despite the fact that no current laws in Texas expressly prohibit gender-affirming care for minors. (While the Texas Legislature this session passed Senate Bill 14, which would ban gender-affirming care for minors, it would not become law until September.) Sepper believes actions like this have sent a clear message to people working in medicine: keep your heads down.

I reached out to Texas’s 23 OB-GYN residency programs listed by the ACGME to ask how each institution plans to comply with the updated requirements. After multiple attempts, I heard back from only 4, three of which declined comment. The only response came from Dell Medical School, at the University of Texas at Austin, stating: “To comply with Texas state law and national accreditation standards, Dell Med offers its OBGYN residents the opportunity to receive this training in California. Residents may opt out of this training.”

The combination of Texas’s laws and the ACGME’s updated requirements mean that it’s likely other programs will follow Dell’s lead. In Texas, “if you have accreditation for your OB-GYN residency program . . . you have to leave the state; you have to do abortions,” said Merritt. The ACGME enforces its requirements primarily through “routine site visits, faculty and resident surveys,” and annual evaluations, according to an emailed statement from Justin Dreyfuss, the ACGME’s media communications manager. Should it find that programs are not offering residents this training, the programs could lose accreditation. For its part, the ACGME recognizes how difficult it could be for residents to access abortion training in states such as Texas, but it maintained that “clinical experience in performing induced abortions is essential to the evidence-based practice of obstetrics and gynecology.” Texas already struggles with a serious maternal mortality and morbidity crisis, one reason reproductive-health advocates say abortion training remains essential for Texas OB-GYN practitioners. “Doctors here still have to fulfill their obligation to save the life of a mother should her life be at risk—that very often is a far more serious procedure than [procedures used to treat miscarriages]. There really is no substitute for clinical abortion training,” said Merritt.

Since SB 8 passed, medical providers and patients have sought clarification on what exactly is legal. What qualifies as a life-threatening “medical condition” that warrants an abortion? What activities fall under “aiding or abetting” an abortion? But with the current session winding down, there is little by way of clarification coming from the Legislature. David Gonzalez, another professor with the UT-Austin School of Law, wonders if keeping these laws murky isn’t intentional. “We want citizens to comply with rules,” he wrote in a statement. “There’s an entire profession that wants to comply—and is simply asking for clarity.”

The future of OB-GYN residency training is not much clearer for those who have matched in Texas. Dallas native Rachel Williams, a 26-year-old graduate of UT Southwestern, matched into the residency program at Parkland Memorial Hospital, in Dallas. When she was interviewing for her placement with different programs, she received varied information. “Some of them outright told me they are working on training out of state, or trying to have miscarriage care be an option. But some places just wouldn’t talk about it at all,” she said. She’s heard that some programs are planning to send residents to New York or California, while medical school friends have told her they still aren’t sure how their programs plan to offer the training. Even after the extensive, months-long process of interviewing for and selecting a residency, Williams admits she doesn’t have a clear understanding of how things will look; everything has changed so quickly. This spring Williams heard from her residency program that she’ll receive her required abortion training at a miscarriage-management clinic in Dallas. “It’s not the setting I wish it could be in,” she said. For Williams the biggest missing piece is learning to counsel patients; she wants to go into high-risk pregnancy management, and a big part of that work, she says, is talking to women about their options. In medical school, she saw pregnant women whose babies had no chance of survival: scans revealed they would be born without brains or with other devastating fetal anomalies. “A year and a half ago during that counseling is when we would have said that termination is always a possibility because that baby will not live when it’s born. . . . We can’t say that anymore,” said Williams. She told me she’s been instructed to not give patients information about abortions, even out of state, adding she’s concerned she could lose her medical license for sharing information about abortion during her residency.

Residency programs in Texas seem to be scrambling to adapt to the massive change. Medical professionals are still scared, and the Legislature has not clarified the law, which has resulted in delayed and subpar medical care for patients. But one thing is for sure: the state desperately needs OB-GYN doctors. Just this past winter, a new report from the Texas Maternal Mortality and Morbidity Review Committee revealed that the state’s maternal mortality crisis had seen little improvement, even before SB 8 went into effect. Meanwhile Texas medical schools have trained dedicated students like Ghafir, Haley, and Williams, all of whom hope to one day practice in Texas. “The fight is here,” said Ghafir. “It is my intention that after seeking training elsewhere, I would like to come back to Texas and multiply the impact of that training.” But like so much about the current abortion landscape in Texas, whether that will be a possibility remains unclear.