Rainbow Railroad submitted the below comment in response to the U.S. State Department’s proposed updates that would impact gender-diverse refugees seeking safety.
We, the 120 undersigned immigration and human rights organizations, submit this comment strongly opposing provisions of the Department of State (“DoS”) Notice of Proposed Information Collection, Medical Examination for Visa or Immigration Benefit. The proposed revisions would add several unnecessary, intrusive, and insufficiently justified fields to medical forms that fail to adequately consider the significant harm disclosing this information would have on LGBTQI+ people seeking admission to the United States. These fields include:
- Requiring reporting of surgeries “related to...elective surgeries to attempt to change male traits to female and vice versa”;
- Adding “gender dysphoria” to the parenthetical list of “Psychological/Psychiatric Disorders”;
- Adding HIV as a separately identified laboratory result; and
- Requiring photographs and detailed descriptions of all scars and other bodily markings.
DoS’s stated justification does not establish that the proposed revisions are necessary or practical to determine admission eligibility under § 212(a)(1) of the INA, 8 U.S.C. § 1182(a)(1), or whether refugees have medical conditions affecting the public and requiring treatment under INA § 412(b)(4)(B), 8 U.S.C. § 1522(b)(4)(B). DoS asserts that a medical examination is needed to prevent transmission of communicable disease and to support public-charge analysis; however, DoS fails to explain how the proposed revisions advance the stated purposes. In fact, DoS does not cite any technical or medical data to support the proposed information collection.
Instead, DoS proposes using vague, undefined, and non-clinical terminology, such as the phrase “elective surgeries to attempt to change male traits to female and vice versa.” This language does not identify a recognized procedure, diagnosis, or medical condition, making it unclear what information panel physicians are expected to report and inviting inconsistent application. Moreover, DoS fails to explain how collecting this information is relevant to determining visa or immigrant benefit eligibility under the law. Such procedures do not indicate the presence of a communicable disease of public health significance, nor are they relevant to whether an applicant is likely to become a public charge. Absent a reasoned explanation, DoS has not established that this proposed collection is necessary, nor that it has practical utility. Rather, it appears to be a
fishing expedition to attempt to identify applicants who are members of populations the Trump administration has consistently demonstrated a significant animus against.
Further, adding “gender dysphoria” as a psychological disorder without any explanation of why that diagnosis is relevant to a medical admissibility determination raises concerns that the field is built on outdated or biased clinical premises that pathologize LGBTQI+ identities. Using a diagnosis of “gender dysphoria” as a proxy for identifying transgender, nonbinary, or gender-nonconforming individuals represents a misuse of a medical criterion as grounds for delay or denial of admission to trans individuals, or heightened scrutiny of such individuals during the application process.
The proposed revisions also require photos and descriptions of “scars and markings.” DoS does not provide a clear medical justification or a public charge analysis for this broad and highly invasive requirement to document all scars and markings on an applicant’s body. DoS similarly fails to recognize the severe administrative burden that this would place on panel physicians. Furthermore, DoS does not adequately report how these highly sensitive records will be retained, protected, or shared with other federal agencies, posing significant privacy concerns. Many refugees and other applicants – including those who identify as LGBTQI+ – may bear scars or markings due to a history of torture, trafficking, conflict, violence, and other forms of past persecution. Such a requirement risks re-traumatizing many immigrant survivors and will impose a significant psychological burden on many applicants, for no clearly authorized public policy purpose.
Finally, the proposed addition of HIV status and testing is similarly concerning. HIV has not been a ground of medical inadmissibility for foreign nationals since the decision of the Department of Health and Human Services’ to remove it went into effect in 2010. Significant advancements in access to effective HIV prevention, diagnosis, treatment, and care have transformed HIV into a manageable chronic condition. People living with HIV who achieve and maintain an undetectable viral load through antiretroviral therapy cannot transmit HIV to their sexual partners and often live long, healthy lives.
For many LGBTQI+ people around the world – particularly transgender women, and gay, bisexual, and other men who have sex with men – higher rates of HIV prevalence are a product of criminalization, discrimination, and violence, resulting in unequal access to health care services. Singling out HIV as a distinct reporting category therefore risks reinforcing longstanding stigma against LGBTQI+ communities, while collecting medical information that
DoS has not shown is necessary to determine visa or immigration benefit eligibility under the INA.
Rather than adding the proposed new medical collection data, DoS should ensure that panel physician guidance reflects modern, evidence-based, and inclusive public health practices, and that panel physicians are trained in trauma-informed, culturally competent care. DoS should also expressly prohibit discriminatory screening practices based on race, gender identity, sex characteristics, HIV status, or disability.
Furthermore, the foregoing unnecessary proposed data collection violates the explicit purpose of the Paperwork Reduction Act, which is to “minimize the paperwork burden for individuals… resulting from the collection of information by or for the Federal Government.” 44 U.S.C. § 3501.
The proposed revisions are made in the context of increasingly hostile environments for LGBTQI+ people globally. Today, more than 60 countries criminalize consensual same-sex conduct, while many others use public order, vagrancy, and misdemeanor offenses to harass, arrest, and prosecute transgender people due to their gender identity. State and non-state actors, including family and community members, subject them to physical and sexual violence, extortion, and murder, and widespread discrimination undermines access to essential services, including health care, employment, housing, and education.In situations of humanitarian crises abroad, trans and gender diverse people are often the first people targeted. Research notes that trans and gender diverse people “face multiple, complex and intersecting health inequities including systematic social and economic marginalisation, pathologisation, stigma, discrimination, and violence across their lifespans.”
As a result of the above conditions, many LGBTQI+ persons are, at times, forced to seek protection in the United States precisely because they are targeted on the basis of their sexual orientation or gender identity. Protection systems further frequently fall short, often applying heteronormative frameworks that don’t account for diverse cultural and trauma experiences.9 U.S. immigration medical examinations must not erect barriers that undermine the right to seek safety in the U.S. or violate international obligations under the 1951 Refugee Convention and its 1967 Protocol.
DoS should clarify whether it intends for trans identity to serve as a basis for denial, delay, or heightened scrutiny in the application process. Absent a demonstrated link to a medical condition affecting visa or immigration benefit eligibility, these gaps reveal that the proposed revisions are not a routine clarification for panel physicians, but rather a mechanism to target one’s identity for discriminatory purposes.
For all of these reasons, DoS should withdraw the proposed additions concerning gender dysphoria, gender-affirming surgeries, HIV status, and photographs and descriptions of scars and bodily markings from its proposed rule before submitting the information collection to OMB.
Respectfully submitted,
A New PATH (Parents for Addiction Treatment & Healing)
Advocates for Trans Equality
AIDS Foundation Chicago
Amnesty International USA
Any Positive Change Inc.
APLA Health
ASISTA Immigration Assistance
Association of Nurses in AIDS Care
Astraea Lesbian Foundation for Justice
Autistic Women & Nonbinary Network
Being Alive/People with AIDS Action Coalition
Beyond Survival
Bienestar Human Services
Borderlands Resource Initiative
Caribbean Women's Health Association
Catholics Vote Common Good
Center for Gender & Refugee Studies
CenterLink
Christopher Street Project
Clearinghouse on Women's Issues
Co-Counsel NYC
Coalition to Abolish Slavery and Trafficking
Contigo Immigrant Justice
Council for Global Equality
Create the Pause PLLC
Equality California
Equality Federation
Equality New Mexico
Fair Wisconsin
Feminist Majority Foundation
Fenway Health
Free to Be Youth Project-UJC
Freedom Network USA
Garden State Equality
Gaylesta: The Psychotherapist Association for Gender & Sexual Diversity Gender Justice
Georgia Equality
GLMA
Global Health Council
Granite Pride
Guttmacher Institute
Health Imperatives
Housing Works, Inc.
Human Rights Campaign
Human Rights First
Human Rights Watch
Human Trafficking Legal Center
Humanitarian Outreach for Migrant Emotional Health (H.O.M.E.) Ibis Reproductive Health
Immigrant Defenders Law Center (ImmDef)
Immigrant Legal Resource Center
Immigration Equality
Indivisible Chicago Alliance
Indivisible Marin
InnerVision Resources, LLC
Institute for Justice and Democracy in Haiti
Ipas U.S.
Just Detention International
Lawyers for Good Government
LBGT PA Caucus
League of United Latin American Citizens (LULAC) Los Angeles LGBT Center
MassEquality
Mental Health Provider
Mercy Center
Movement Advancement Project
National Birth Equity Collaborative
National Black Justice Collective
National Harm Reduction Coalition
National Immigrant Justice Center
National LGBTQ Institute on Intimate Partner Violence National LGBTQ Task Force
National LGBTQ+ Bar Association
National Partnership for New Americans
National Women's Law Center
New Disabled South
New Mexico Black Leadership Council
New Mexico Immigrant Law Center
New York Immigration Coalition
NM Comunidades en Accion y de Fe (NM CAFe) Oasis Legal Services
ORAM - Organization for Refuge, Asylum and Migration
OutFront Minnesota
Outright International
PAI
Parable of the Sower Intentional Community Cooperative PFLAG National
Physicians for Reproductive Health
Planned Parenthood Federation of America
Pride Action Tank
Prism Counseling & Advocacy
PROMO Missouri
Rainbow Railroad
Rising Worldwide
Rocky Mountain Equality
San Francisco AIDS Foundation
Sarah Horn LICSW LLC
Sikh American Legal Defense and Education Fund (SALDEF) Silver State Equality
SLO Bangers Syringe Exchange and Overdose Prevention Program Survivor Justice Center
Synergía - Initiatives for Human Rights
The Alliance for Diplomacy and Justice
The Center for HIV Law & Policy (CHLP)
The GLO Center
The Source LGBT Center
The Workers Circle
TransFamily Support Services
Transgender Law Center
Transgender Rights Coalition of New Jersey
U.S. Committee for Refugees and Immigrants (USCRI) UCSF Bixby Center for Global Reproductive Health Vada Counseling
WADEIn NJ
Washington Office on Latin America (WOLA)
Waves Ahead Corp
Whitman-Walker Health
Wisconsin Coalition Against Sexual Assault
Young Center for Immigrant Children's Rights
Yuba Harm Reduction Collective
Sources:
- American Psychiatric Association, A Guide for Working with Transgender and Gender Nonconforming Patients: Gender Dysphoria Diagnosis, https://www.psychiatry.org/psychiatrists/diversity/education/transgender-and-gender-nonconforming-patients/gender -dysphoria-diagnosis (accessed Aug. 7, 2026).
- Human Immunodeficiency Virus (HIV) Infection Removed from CDC List of Communicable Diseases of Public Health Significance, 74 Fed. Reg. 56547, Nov. 2 2009.
- World Health Organization, HIV and AIDS, https://www.who.int/news-room/fact-sheets/detail/hiv-aids (July 27, 2026, accessed Aug. 7, 2026).
- UNAIDS, HIV and stigma and discrimination — Human rights fact sheet series 2024, https://www.unaids.org/en/resources/documents/2024/07-hiv-human-rights-factsheet-stigma-discrmination (Dec. 31, 2024, accessed Aug. 7, 2026).
- Immigration Equality, Country Conditions Materials, https://immigrationequality.org/legal/legal-help/resources/country-conditions-index/ (May 1, 2025, accessed Aug. 7, 2026). See also Human Dignity Trust, https://www.humandignitytrust.org/ (accessed Aug. 7, 2026).
- Nilsson, et al., “Sexual and Gender Minority Refugees and Asylum Seekers: An Arduous Journey” in Violence Against LGBTQ+ Persons: Research, Practice, and Advocacy, (Lund, Burgess, & Johnson eds., 2021).
- Rainbow Railroad, Annual Report 2024: Understanding the State of Global LGBTQI+ Persecution at 22 (June 19, 2025) available at https://www.rainbowrailroad.org/stories/annualreport-2024.
- Hermaszewska, et al, “Lived experiences of transgender forced migrants and their mental health outcomes: systematic review and meta-ethnography,” BJPsych Open, (available at https://doi.org/10.1192/bjo.2022.51 9 See, e.g., LGBTQI+ Refugees and Asylum Seekers: A Review of Research and Data Needs, https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBTQI-Refugee-Review-Jul-2022.pdf, accessed Aug. 7, 2026).