Recently on a television show I saw a transgender character go through a very stressful experience at an airport. It was a reminder that a blog post on the travel health needs of this population is long overdue.
So let’s jump into this complex subject. First a note on terminology that is ever evolving and increasingly nuanced. Acronyms vary depending on the advocacy group or organization. These may include terms such as lesbian, gay, transgender, queer, intersex or others; expressed as LGBT, LGBTQ, LGBTI, etc. Transgender is most often defined as an umbrella term that refers to people whose gender identity and/or expression is different from their assigned sex at birth. Gender identity is not the same as sexual orientation, and transgender people may be gay, straight, bisexual, etc. Gender identity is becoming more fluid and now goes well beyond man or woman or girl or boy (e.g. “non-binary” or “genderfluid”). See GLAAD’s list of terminology for additional information.
According to an analysis in 2016 from the Williams Institute, about 1.4 million adults or 0.6% of the U.S. population identify as transgender. This is expected to rise as more people decide to transition and the quality of the research improves. It’s possible you have seen some transgender patients without even being aware of it, as many of these patients are hesitant to confide in health care professionals. While some transgender individuals have legally changed the name assigned at birth, some have not. Be sure and always use the person’s chosen name and update records. Pronoun selection varies so ask what pronouns the patient uses. This is still new territory, so if you make a mistake, simply apologize right away and move forward. Keep in mind that all staff need training around these issues, not just clinicians.
In the last few years, I’ve seen an increase in the number of transgender patients in my own setting so I’ve scrambled to educate myself regarding best practices in this new era where research is still quite limited. Patients can be challenging as they may be at various stages of transition and have different needs. For example, you may encounter a 40 year old male who began transitioning 15 years ago, on testosterone for 13 years, who had “top” surgery to remove the breasts but still needs cervical cancer screening because he has a cervix and uterus. Evidenced-based guidelines for these patients are still evolving. Two terrific learning sources include Fenway Health and The UCSF Center of Excellence For Transgender Health. Here is a short introductory course on patient encounters and some current free CE options.
The following sites are travel specific, and I would strongly urge you to thoroughly familiarize yourself with them. Keep a list handy in your office to share with transgender patients.
The US State Department has some very useful information for the LGBTI community specific to travel, including how to update your name and gender designation on your passport. Also included is information on how to stay safe while traveling, and links to specific country laws and customs which can impact this population. It is especially important that patients be knowledgeable about the latter as there are enormous differences across countries, and violations can carry severe punishments.
Remind these travelers that medication restrictions vary by destination. If there is any question regarding a particular drug, check with the embassy or consulate of the destination country. Many of these patients use injectable hormones, and any needles and syringes they carry while traveling necessitate a letter from the prescribing clinician on official stationery. See Blog #19 Update on the Thorny Issue of Traveling with Medications: It Will Remain Thorny.
Other valuable travel health resources for transgender individuals include:
The National Center for Transgender Equality is a terrific site with the nuts and bolts on how to handle security and your flight, covering such topics as what to expect from body scanners, managing binders and prosthetics, and communicating with TSA officers.
The Equaldex collaborative LGBT knowledge base attempts to crowdsource the current status of LGBT rights around the world. It is very easy to use.
IGTLA, International Gay/Lesbian Travel Association, members are LGBTQ-friendly, tourist related businesses that promote equality and safety for this community.
Transportation Security Administration has a useful section directed towards transgender travelers, describing the screening process and options for advanced imaging technology (AIT) or a pat-down search. Travelers can request to have a private screening with a companion present if desired.
We all understand the enormous benefits of travel, and believe all passengers should be treated with dignity and respect. Let’s do our best to ensure we provide the best possible care to this group as well. It’s time to up our game.
-Julie Richards, Immediate Past President
Thanks to Kelly Holton of CDC for her suggestions.