This story was published in partnership with the Center for Public Integrity, a newsroom that investigates inequality.

When Andrea Montañez visited her Orlando-area cardiologist two years ago to treat her abnormally fast heart rate, the receptionists and nurses often misgendered her. 

For a couple of years following her transition, Montañez’s insurance information still listed her deadname and identified her as male. Despite informing the office of her new name and pronouns, clinic staff continued to call her “sir.”

The feeling of being misgendered is “horrible,” said Montañez, who worried about the quality of care she was receiving. 

Over the past two decades, medical schools and residency programs have added diversity, equity and inclusion training — DEI for short — to help counter documented and widespread biases and racism contributing to disparate health outcomes for certain populations, including transgender patients such as Montañez.

However, conservative state legislators have targeted such training over the past three years. Since 2021, Montañez’s home state of Florida along with Georgia, Idaho, Iowa, Mississippi, North Dakota, Oklahoma, South Dakota and Tennessee have passed laws to restrict DEI education in public higher education curricula.

In Florida, medical students on rotation or residents at hospitals tied to a public university may no longer be prepared to provide high-quality care for every patient, said Zinzi Bailey, a social epidemiologist focused on cancer health disparities and a former assistant professor at the University of Miami Miller School of Medicine.

The state’s anti-DEI law, which took effect in July, bans its public universities and colleges from using state or federal funds for DEI programs and restricts general education courses from including “identity politics” or critical race theory in curriculum. Another law passed in 2022, The Stop WOKE Act, which a federal court has since stayed, restricts discussion around certain concepts surrounding race and gender in higher education classrooms. 

The anti-DEI laws are among several pieces of recent legislation restricting Florida doctors’ ability to care for their patients. Last April, Republican Gov. Ron DeSantis signed a law banning abortion after six weeks. In June, a U.S. District Court judge struck down a Florida rule and a statute that prohibited state Medicaid payments for transgender health care, as well as a ban on youths under the age of 18 from receiving gender-affirming care, including hormone therapy and puberty blockers.

Some doctors and scholars fear the new anti-DEI laws could not only stall progress made in providing better care for patients from diverse backgrounds but also make care for those populations worse.

They also worry that it could prompt physicians, medical students and educators to leave, exacerbating Florida’s shortage of doctors.

Fear in the current political climate prompted some Florida practices to pause or shut down their care for trans patients, especially clinics that serve children, said Dr. Michael Haller, a Gainesville, Florida-based pediatric endocrinologist and higher education professor who provides care for trans youths. Planned Parenthood and SPEKTRUM Health are among those taking such actions.

Restrictions requiring physicians rather than nurse practitioners to prescribe gender-affirming hormone treatment for adults and bans on providing such treatment through telehealth appointments have been especially challenging. In a statement provided to the Center for Public Integrity, Planned Parenthood said the organization continues to serve transgender patients seeking gender-affirming care, but is not accepting new ones. 

“These changes have been devastating for our transgender and non-binary communities,” the statement read.

SPEKTRUM has not prescribed any gender-affirming hormone regimens since May. The organization does not have physicians on staff who are legally allowed to prescribe the treatment and have been unable to hire any, Joseph Knoll, CEO of SPEKTRUM Health, said in a statement. 

Gender-affirming care “is in complete chaos in Florida,” Knoll said. “Patients have found a variety of ways to source their medication, most of which do not come with any real monitoring or professional input.” 

There’s always turnover at academic medical centers, Haller said.

But he’s found that recruiting physicians to Florida has been more challenging since it’s unclear what restrictions they would face.

Because of the laws, medical students may no longer learn key lessons about intergenerational trauma, the root causes of disparities or how to think creatively and compassionately about helping address those inequities through health care, said Alison Yager, an attorney and executive director of the Florida Health Justice Project, a health advocacy group. 

While medical schools are trying to find ways to continue providing that training, they don’t fully know yet how the laws will be enforced or what educators must do to avoid running afoul of them. That's the type of atmosphere in which administrators, professors and doctors might decide that it's better to be safe from state authorities than to provide needed training, said Jeremy Young, PEN America’s Freedom to Learn program director. 

Montañez fears that under Florida’s anti-DEI laws, as well as the other anti-transgender legislation, she’ll be misgendered at doctor’s offices more often or, worse, be denied service during medical emergencies. 

Unlike staff at the cardiology office, Montañez’s specialist didn’t misgender her. But after she transitioned, his interactions with her felt more distant, like he didn’t want her there. 

“It’s so hard as a patient to feel trust in these people,” Montañez said. “I don’t want to go back there.”

Her more affirming primary care doctor is now monitoring her heart issues. If she has another emergency and needs to see a specialist again, she’s going to look elsewhere — and hope she finds someone better.

Diagnosing disparities

Bailey, the social epidemiologist, left the University of Miami in September to work as an associate professor at the University of Minnesota School of Public Health. She said Florida’s anti-DEI laws played a role in her departure. 

Her work largely centers around structural racism and touches on critical race theory. And while the anti-DEI laws technically don’t apply to the University of Miami because it’s private, the institution still receives money and support from the state. She was concerned about the willingness of the university to continue supporting her work as well as other initiatives aimed at combating structural racism in health care.

“You can’t talk about disparities without being particularly vocal about structural racism,” Bailey said. 

Within medical schools, DEI is a broadly accepted part of basic training for quality care.

A 2022 Association of American Medical Colleges survey found that 96% of 101 U.S. and Canadian medical schools have undertaken efforts to integrate diversity, inclusion and equity as a key learning outcome. Seventy percent of institutions’ core curriculums require a diversity, inclusion or cultural competency course, and 96% regularly sponsor speakers or events such as town halls or listening groups to encourage dialogue related to DEI. 

But conservative groups claim medical schools are teaching cultural competency and racial bias to push a “woke” agenda — a catchall phrase used to denounce trans and gay rights, critical race theory and discussions about diversity, among other things.

The conservative medical advocacy group Do No Harm has filed several lawsuits and more than 100 U.S. Department of Education Office for Civil Rights complaints aiming to roll back medical school diversity efforts and implicit-bias training requirements. 

Anti-racism within medical education and the health care field is “promoting divisive and discriminatory ideas,” Do No Harm stated on its website. The “radical ideology of ‘anti-racism’ is creating new barriers and bad practices that are endangering the health and well-being of everyone — including the people it claims to help.”

In a statement provided to Public Integrity, Dr. Stanley Goldfarb, chairman of Do No Harm, said: “The answer to health care disparities is health education regarding personal habits that improve outcomes … not implicit bias training. We have been teaching about the need to be sensitive to patients’ individual cultural characteristics and social conditions for many decades before the entire DEI establishment was created.”

Other conservative think tanks, including the Manhattan Institute and the Goldwater Institute, have pushed for the new anti-DEI laws, including Florida’s Stop WOKE Act, claiming that public and private research funding is being redirected from science to political projects. 

Many DEI efforts in medical schools emerged after a landmark 2003 report from a national panel of experts convened by Congress. “Unequal Treatment” showed racial health care disparities are “remarkably consistent” even after adjusting for patient income and other differences. The report warned that bias, stereotyping and prejudice could be playing a contributing role.  

In the 20 years since then, many studies have documented how nurses, doctors and other healthcare professionals are not exempt from implicit biases prevalent in America, said Adrienne Moetanalo, former program coordinator at Ohio State University’s Kirwan Institute for the Study of Race and Ethnicity.  

Anti-DEI laws have an effect on coursework in every academic department on college campuses, argues Young. He’s tracking state legislation. 

Some laws specifically ban teaching students about racial disparities in health care, or cultural competencies that medical professionals need to learn, he said. Even in states where it’s not clear whether the law prohibits those lessons, schools and educators are now afraid to teach them, he added. 

Enforcement can come from states. But so far, Young is seeing these laws primarily take effect through administrative censorship. The order to not talk about certain subjects, he said, comes from the dean of a medical school or a general counsel at a university. 

And some professors are also censoring themselves, deciding they are not willing to risk it, Young said. 

A long history of bias

Biases in health care — and the negative effects that follow — have a long-documented history in the U.S. 

Some research shows that when white and Black patients display similar symptoms, recommendations for clinician treatment can differ, said Moetanalo, who now works as a graduate and professional student wellness coordinator at Ohio State. 

Research has also shown that when clinicians have more implicit anti-Black biases, their appointments with Black patients are often much shorter and they talk more than they listen, Moetanalo said.

That leads to more distrust from Black patients, who may be less likely to follow the recommendations from doctors, Moetanalo said.

A 2020 study of births at Florida hospitals from 1992 to 2015 found that Black newborns had a significantly better chance of surviving when cared for by Black physicians. 

Research also suggests that emergency room medical residents experience so-called “cognitive loads” where their biases are triggered due to the need to make decisions in high-pressure environments, Moetanalo said.

DEI lessons are more than just training sessions to learn buzzwords, said Bailey, the social epidemiologist. It can help healthcare professionals understand the root of health disparities.

Fostering trust between physicians and patients, and the good care that follows, requires cultural understanding. Without the training, “There are going to be some problems,” said Dr. William McDade, chief for diversity, equity and inclusion at the Accreditation Council for Graduate Medical Education, the body that accredits medical residency programs.

Black people have higher cesarean delivery rates, which Jamarah Amani connects to how they are perceived by doctors. Amani, a Florida-based midwife and director of the Southern Birth Justice Network and the National Black Midwives Alliance, sees racist assumptions about patients harming care across the country. 

When she was giving birth to her second child in 2006, Amani said, a nurse questioned whether she was a good mother because she moved around and did squats during her labor, instead of staying in her bed as instructed. 

“I consider that to be abusive, and it definitely had racial overtones and undertones,” Amani said. “It doesn’t always happen to Black people, but it certainly happens disparately to Black people.” 

When Dr. Cheryl Holder moved to Florida in 1987, she learned that the term “hysterical Latin female” was being used in some emergency rooms to describe patients. Holder until recently served as associate dean for diversity, equity, inclusivity and community initiatives at Florida International University’s Herbert Wertheim College of Medicine. 

Diversity education, she said, interrogates racial and gender bias and asks students: How did a woman get labeled that? And how is that helping the patient?

A 2019 study by more than a dozen researchers across the country found that curriculum focused on minority health and disparities increased students’ intention to care for minority patients. 

Even so, physicians often develop negative stereotypes in medical school: Nearly 49% of U.S. medical students reported having been exposed to negative comments about Black patients by attending or resident physicians, according to a 2022 article in the New England Journal of Medicine that summarized multiple studies. Researchers found that those students “demonstrated significantly greater implicit racial bias” in year four than in year one. 

The New England Journal of Medicine article concluded that no interventions for reducing implicit biases showed “enduring effects,” recommending that healthcare organizations prioritize stopping “harmful” behavior instead. 

Other recommendations from disparity experts that go beyond training: increase diversity among health care providers and in leadership and management positions.

‘Having your hands tied’

The lawmakers pushing anti-DEI legislation don’t fully understand the ramifications of those laws and the impact their restrictions will have on patients, said Dr. David Acosta, the Association of American Medical Colleges’ chief diversity and inclusion officer.

Caring for underrepresented communities requires thoughtful and deliberate training that teaches new physicians, nurses, nurse practitioners, social workers and front desk staff to treat people who aren’t like them with respect, said Haller, the Florida-based pediatric endocrinologist and higher education professor.

But the laws have “remarkably diminished the ability to do those things well,” said Haller.

And Holder, who completed a systematic review of the state of gender-affirming care in education in 2023, is particularly nervous about the impact the new laws will have on trans and gender non-conforming patients, who already face high rates of depression, abuse, trauma and suicide.

Holder co-authored a report published in the Annals of Family Medicine in 2023 that found medical students and residents nationwide lack appropriate and sufficient training on how to provide gender-affirming and inclusive care to transgender and gender-diverse patients. 

Holder thinks the Florida laws won’t prevent medical schools and professors from providing that training since physicians must address the needs of all their patients. Still, Holder, also president of Florida Black Doctors, said her group is “very concerned” about the care that patients will receive and whether doctors coming out of medical school will be aware of things they are doing that could harm a patient. 

“Having your hands tied means that it is even more difficult to address the issue,” Holder said. “It’s going to be a huge challenge.”

DEI offices that support medical residents attending public institutions could also be affected by the laws. McDade, with the Accreditation Council for Graduate Medical Education, has spoken to residency program administrators in Florida, Oklahoma, Arkansas and Texas who are concerned about the impact of dismantling and defunding DEI offices. 

The effects could ripple in unexpected ways.

As hormone specialists, endocrinologists such as Haller can support patients receiving gender-affirming care. But as the profession comes under political pressure, Haller fears that Florida's anti-DEI law could also make it even harder for children to find a specialized doctor in the state who can treat diabetes, thyroid disease and delayed puberty, examples of other work that pediatric endocrinologists do.

A 2021 report from the Association of Medical School Pediatric Department Chairs identified a “shortage of trained pediatric endocrinologists” due in part to low pay when compared to other pediatric medical specialties.

“Why would anyone want to go into this field when they are going to get attacked by their own government, and their own institutions are not necessarily going to speak up on behalf of them or their patients?” Haller said. “It's really hurting our ability to recruit the next generation.” 

Some doctors fear other medical specialties in the state could be affected by the anti-DEI laws as well — potentially exacerbating the already dire shortage of doctors there.

Last year, the Florida Safety Net Hospital Alliance and the Florida Hospital Association projected a shortage of nearly 18,000 physicians in the state by 2035 due to its growing, aging population. 

“The continuing attacks on DEI programs, DEI funding or funding diversity offices will have an effect on every aspect of higher education, and medical schools are certainly a big part of that,” said Matthew Boedy, president of the American Association of University Professors’ Georgia conference.

A recent survey of college professors in Georgia, Texas, Florida, and North Carolina found that two-thirds said they would not recommend their states as a desirable place to work for colleagues. Nearly a third were considering leaving their jobs, and some were already interviewing for positions out of state. 

Faculty exodusRestrictions on tenure and academic freedom have college professors eyeing the exits

Nearly 60% of the would-be movers cited their state’s political climate as a reason — and over 40% mentioned issues related to DEI and tenure. The survey was conducted by several state American Association of University Professors conferences and faculty unions in Florida and Texas. 

The survey didn’t specify whether any of the responders were medical school professionals. But medical school doctors are among the respondents who can more easily find employment elsewhere, Boedy said. “If they're willing to leave, I'm sure that is affecting recruitment and retention,” he said. 

It could be too early yet to know exactly how that will play out.

Florida State University’s College of Medicine saw an 8% decrease in full-time faculty between fall 2021 and fall 2023. That includes a 24% decrease in Black faculty members, according to data provided by the college. 

However, that decline was not felt by other public institutes in the state that were also affected by the anti-DEI laws, including the University of Florida College of Medicine and the University of South Florida College of Medicine, which both saw sizable increases in faculty counts — including large increases in Black, Hispanic and female faculty members. 

In a statement provided to Public Integrity, Florida State University said its model differs from other Florida medical schools. Its medical students spend the first two years at the central campus in Tallahassee, then do their clinical rotations at regional campuses across the state. The university employs 3,000 “community physicians” statewide who are considered part-time clerkship faculty and available to teach a rotation in a one-on-one apprenticeship-style approach.  

“Overall, Florida State University has not observed an unusually high number of resignations among faculty or staff …, and our new faculty recruitment and hiring rates continue at the expected levels,” said Amy Farnum-Patronis, director of news and digital communications.

Gaps in Education

Still, a number of doctors are worried. The law could pose an ethical dilemma to providers, said Bailey, the social epidemiologist. Doctors take an oath to “do no harm,” she said, and if they believe that Florida laws will make them act in ways detrimental to the patient population, they may decide to practice in a different state. 

For physicians, the fear does not just center around their ability to practice medicine properly. 

It could affect some doctors’ ability to qualify for grants that require them to describe their community engagement policies and explain what that engagement means for health outcomes and disparities. If a student works at a health system after graduation that is developing health equity initiatives, they’ll have to learn on the job or during their residency, Bailey said.

Still to be determined: how medical schools and residency programs will chart a path forward between the laws restricting DEI and the national standards calling for it. 

All medical schools will still be held to the same accreditation standards, said Acosta, of the Association of American Medical Colleges. Cultural competency education is part of the accreditation standards of the Liaison Committee on Medical Education, which oversees that accreditation.

The Accreditation Council for Graduate Medical Education’s standards includes cultural competency education in its U.S. residency program standards for several specialties, including psychiatry and family medicine.

According to the organization’s accreditation requirements, all residents must demonstrate competence in acknowledging differences and displaying respect for patients of all races, genders, religions, ages, sexual orientations and other backgrounds, McDade said. That includes competency in communicating with diverse populations, such as people who speak different languages.  

The residency program accreditor doesn’t require that training to be part of a residency program’s curriculum, McDade said. Those skills can come from observation, training modules or however a residency program wants to teach it, “as long as they can show they’ve tried to achieve this,” he said. 

And McDade hasn’t yet seen any residency education programs that need to have their accreditation downgraded.

Still, medical schools will have to show liaison committee accreditors how they are addressing those competencies under the new laws, Holder said. And schools know that their students will need such training: Florida law won’t stop patients from discussing gender identity with doctors.

And, Holder asks, if a doctor trained in Florida goes on to practice in another state, will their skills be deficient? “That’s how I know it will be taught. Nobody is going to make their students less marketable,” Holder said. 

But against those practicalities is the specter of how the anti-DEI laws will be enforced. Florida has not yet made that clear.

The state’s anti-DEI law was in force at the start of this school year’s fall semester, but the state’s Board of Governors did not release guidance to higher education institutions about the law until November — leaving medical schools uncertain how to avoid violating it. 

That guidance is vague, in some cases, about what aspects of traditional medical education are not allowed.  

The new guidance exempts classroom instruction. But Young, with PEN America’s Freedom to Learn program, said it’s still unclear whether that exemption applies to medical residency programs or other forms of medical training and whether discussion or programming banned under the law could include abortion rights, cultural competency, gender-affirming care and DEI initiatives. 

Acosta said that medical schools may need to pay attention to their language or processes to ensure they don’t run afoul of the new laws while still trying to accomplish their DEI training objectives. 

Medical school leaders are debating how to do that, contacting their lawyers about what words are safe to use in classrooms, Holder said. 

Despite those efforts, the laws could also be enforced through a chilling effect, Young said. For every professor trying to do the same work under a different name, he said, there could be 10 others who decide that the best thing for their career is to not talk about the issues at all. 

Not giving in

In Florida, employees can be terminated without cause. DeSantis has pushed to remake Florida’s higher educational system in his conservative image. 

Tenured employees in the state university system now have job performance reviews every five years —  a recent measure Florida House Speaker Chris Sprowls said was intended to prevent “indoctrination” and attempts by professors to “smuggle in ideology and politics,” the Tampa Bay Tribune reported. 

In June, Christopher Rufo — a Manhattan Institute senior fellow who was appointed by DeSantis to serve on New College of Florida’s Board of Trustees — posted on social media that the contract of a visiting professor who criticized the institution’s new leadership was not renewed.

That’s not an environment that encourages open discussion, doctors say — in or out of universities. 

After leaving school with hundreds of thousands of dollars in debt, doctors could fear doing work that would help their patients but draw political pressure, Holder said. 

“It’s a hard needle to thread doing what you need to do to take care of patients without putting a target on your back,” Haller agreed. 

Some of Bailey’s former colleagues at the University of Miami, mainly tenured professors, are working to continue providing diversity, equity and inclusion education. But many who do not have tenure protections face an uncertain future about their ability to continue their work identifying and combating health disparities, Bailey said. 

The presidents of the 28 state and community colleges under the Florida College System released a statement in January 2023 that their press office characterized as supporting the governor’s agenda of freeing higher education from “indoctrination” and pledging to remove all “woke” ideology and only present critical race theory or related topics such as intersectionality as one of several theories. 

There are other medical school leaders banding together to advocate for DEI education and figuring out how to continue that training within the law, Acosta said.

“This is about choice, where you want to be and how much of a strong advocate are you for this,” Acosta said. 

Montañez, the Orlando-area resident, fears that if Florida’s medical schools and physicians don’t push back against the anti-DEI laws, she and other transgender patients will encounter more discrimination. 

“Medical school leaders and physicians have to keep strong and keep the profession of medicine out of discrimination and hate,” Montañez said.

Danielle McLean is a journalist working with the Center for Public Integrity, a newsroom that investigates inequality.