People seeking medication abortions on the U.S. Territory of Guam must first have an in-person consultation with a doctor, a federal appeals court says, even though the nearest physician willing to prescribe the medication is 3,800 miles (6,100 kilometers) — an 8-hour flight — away.

The ruling handed down Tuesday by a unanimous three-judge panel on the 9th U.S. Circuit Court of Appeals could make it even more difficult for pregnant people to access abortions on the remote island where 85% of residents are Catholic and about 1 in 5 live below the poverty line. The last doctor to provide abortions in Guam retired in 2018, leaving people seeking the procedure without local options.

That changed in 2021 when a lower court partially lifted the territory’s in-person consultation requirement and said two Guam-licensed physicians in Hawaii could provide medication abortions via telemedicine to people in Guam. The appellate court panel reversed that ruling Tuesday, saying Guam can enact the laws it thinks are best, even if others find them unwise.

“Guam has legitimate interests in requiring an in-person consultation: the consultation can underscore the medical and moral gravity of an abortion and encourage a robust exchange of information,” wrote Judge Kenneth K. Lee.

Lee was appointed by former President Donald Trump in 2018 along with fellow panel member Judge Daniel P. Collins. The third member of the panel, Judge Carlos T. Bea, was appointed by former President George W. Bush in 2003.

Abortion rights advocates contend having no doctors able to provide abortions on the island creates a significant challenge to people seeking care. The court ruled other doctors there could conduct the in-person consultations even if they do not want to personally perform abortions themselves. It’s not clear if any physicians in Guam are willing to take on that role.

“We are deeply disappointed that the court is permitting medically unnecessary government mandates to once again be enforced,” said Alexa Kolbi-Molinas, the deputy director of the American Civil Liberties Union Reproductive Freedom Project. “Today’s decision imposes unnecessary obstacles on people seeking abortion in Guam, but make no mistake, abortion remains legal in Guam and we will continue to do everything in our power to make sure it stays both legal and accessible.”