Access without approval: state-level determinants of peptide availability in sexual medicine.

Background: Despite increasing use of peptides in sexual medicine, interstate differences in access are not fully explained by federal approval status and may instead reflect variation in state-level healthcare delivery structures. Aim: To systematically compare state-level environments affecting access to peptide-based sexual medicine therapies using objective proxy measures and to generate a clinician-friendly framework for identifying geographic disparities. Methods: We conducted a cross-sectional, state-level analysis of all 50 U.S. states and the District of Columbia. Access environments were characterized using three reproducible proxy variables reflecting clinical feasibility of care: (1) telehealth prescribing permissiveness, (2) nurse practitioner (NP) practice authority, and (3) availability of FDA-registered 503B outsourcing facilities normalized by population. Each variable was coded on a standardized scale and averaged to generate a compositive Peptide Access Environment Score (PAES). States were stratified into high-, moderate-, and low-access tiers. Regional differences were evaluated using nonparametric statistical testing and geographic visualization. Outcomes: Primary outcomes included state-level PAES values and access tier classification. Secondary outcomes included regional variation and concordance between telehealth regulation and compounding infrastructure. Results: PAES values ranged from 0.33 to 1.56, demonstrating substantial interstate variability. High-access environments clustered predominantly in the Northeast and West, while low-access states were most frequently observed in the South and parts of the Midwest. Regional differences in PAES were statistically significant (p < .001). Discordance between telehealth prescribing permissiveness and compounding infrastructure was identified, with multiple states permitting telehealth initiation of care despite lacking in-state 503B facilities, and others possessing compounding capacity but maintaining restrictive telehealth regulations. Clinical implications: State-level healthcare delivery policies and infrastructure may meaningfully influence patient access to peptide-based sexual medicine therapies independent of peptide-specific regulatory status. Strengths and limitations: Strengths include a transparent, reproducible methodology using publicly available data and a clinically grounded, multidimensional access framework. Limitations include reliance on proxy measures, exclusion of physician assistant autonomy, and inability to assess within-state socioeconomic or urban-rural heterogeneity. Conclusion: Interstate differences in telemedicine permissiveness, NP practice authority, and compounding infrastructure are associated with significant geographic disparities in access to peptide-based sexual medicine therapies in the United States.