Importance: State bans on gender-affirming care for minors may prevent clinicians from providing care they consider medically necessary, generating moral distress. While qualitative studies have explored provider moral distress, quantitative evidence is limited.

Objective: To assess domain-specific moral distress among clinicians caring for transgender and gender-diverse youth and examine differences by state legislation.

Design, setting, and participants: Cross-sectional electronic survey of U.S. clinicians (2024-2025) practicing in states with varying gender-affirming care legislation (shield law, ban, no legislation, unsure). The analytic sample included 443 respondents.

Main outcomes and measures: Eight moral distress domains rated 0-10. Because distributions were non-normal, medians and interquartile ranges were calculated and compared using Kruskal-Wallis tests with Bonferroni-adjusted pairwise comparisons.

Results: Differences across legislation categories were statistically significant for 7 of 8 domains (all P<0.05). Providers in states with bans consistently reported higher distress than those in states with shield laws or no-legislation. Distress related to current legal restrictions was highest in states with bans (median 9 [7-10]) versus shield laws (7 [3-9]) and no-legislation (6 [3-9]; P<0.001). Distress regarding anticipated restrictions (median 8 [6-9]), providing care (8 [4-9]), fear for personal or family safety (6 [4-8]), fear of patients being targeted (8 [6-9]), and patient distress due to restrictions (9 [7-10]) were also elevated in states with bans (all P<0.01). Distress related to caring for out-of-state patients did not differ by legislation (P=0.41).

Conclusions and relevance: Clinicians practicing in states restricting gender-affirming care for minors experience elevated moral distress across legal and patient-centered domains. Restrictive policy environments may constrain clinicians’ moral agency and contribute to workforce attrition.