19634 23rd Ave NE Poulsbo, WA 98370 December 24, 2012 Meg L Jones P.O.

Box 40258 Olympia, WA 98504 Re: CR-102-2 I wish to submit comments regarding the proposed rules for WAC 284-43-877 Essential Health Benefits Package Benchmark Parameters, specifically pertaining to 284-43-877(3)(a)(iv). This clause excludes sexual reassignment treatment and surgery, even in those cases where it has been determined to be medically necessary. I believe this exclusion is in violation of RCW 49.60, Washingtons Law Against Discrimination. RCW 49.60.010 outlaws discrimination on the basis of sex and sexual orientation, and 49.60.040(26) defines sex as gender and sexual orientation as including gender expression or identity, and defines gender expression or identity as having or being perceived as having a gender identity, selfimage, appearance, behavior, or expression, whether or not that gender identity, self-image, appearance, behavior, or expression is different from that traditionally associated with the sex assigned to that person at birth. RCW 49.60.01 outlaws discrimination in public accommodation; 49.60.040(2) defines public accommodation as including, but not being limited to, any place, licensed or unlicensed, kept for gain, hire, or reward where charges are made for admission, service, occupancy, or use of any property or facilities, whether conducted . . . for the benefit, use, or accommodation of those seeking health . . . or for the rendering of personal services . . .or where medical service or care is made available . . . The exclusion in 284-43-877(3)(a)(iv) uniquely affects transgender persons. Transgender is an umbrella term for persons whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth. Gender identity refers to a persons internal sense of being male, female, or something else; gender expression refers to the way a person communicates gender identity to others through behavior, clothing, hairstyles, voice, or body characteristics (APA, 2011). Transgender people may experience gender dysphoria, which is a marked incongruence between ones experienced (or) expressed gender and (birth) assigned gender, of at least 6 months duration which is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability (proposed DSM-5, APA, 2011). Gender dysphoria may range from mild to severe.

Transgender people are at high risk for a number of bad outcomes. Anxiety and mood disorders are extremely common. More than half (61%) have been diagnosed with depression (Rotondi, Bauer, Travers, and Travers, Scanlon, and Kaay, 2011) and close to half attempt suicide during their lifetimes (Grant, Mottet, Tanis, Harrison, Herman, and Keisling, 2011; Rotondi, Bauer, Scanlon, Kaay, Travers, and Travers, 2011a, Rotondi, et al., 2011b). Suicide risk appears directly related to a trans persons ability to complete gender transition, with a suicide attempt rate of 27% among those who have not begun to transition, 18% for those who have begun but not completed transition, and 1.1% among who consider their transition complete (Bauer, K, Pyne, Redman, Scanlon, & Travers, 2012). The majority (78%) of trans persons who have transitioned report greater satisfaction at work after transition (Grant, Mottet, et al., 2011). Gender transition is the process by which a transgender person changes gender expression from one typically associated with their gender assigned at birth to an expression consistent with their affirmed gender. Not all gender variant people transition genders, but many do. Transition includes psychotherapy, changing legal documents (including a possible name change), changes in clothing and grooming, electrolysis (for trans women), voice therapy, social coaching, and may or not include medical intervention. Medical intervention includes hormonal treatment and surgeries. Surgeries can include genital reconstruction surgery (GRS) and chest surgery for both trans men and trans women, and facial feminization surgery for trans women. Providers of transition-related health care follow the Standards of Care published by the World Professional Association for Transgender Health (WPATH, 2011). All of these procedures, including psychotherapy, are excluded by 284-43-877(3)(a)(iv). Hormonal treatment is inexpensive, but if it is excluded, trans people often self-treat with hormones obtained on the internet, without medical supervision or lab work. Impatient for changes, they often believe if one dose is good, more must be better, and suffer consequences in the form of blood clots, liver failure, or prolactinomas. These conditions are more expensive to treat. The transgender population is small (0.3%) but not insignificant. The American Medical Association (2008), the American Psychological Association (2008), the American Psychiatric Association (2012) and the World Professional Association for Transgender Health (2008)all have position statements advocating for the availability of transition related medical care when determined to be medically necessary. Please remove 284-43-877(3)(a)(iv), the exclusion of sexual reassignment treatment and surgery, from the proposed rules. Thank you, Jill Davidson, PhD, NCSP 19634 23rd Ave NE Poulsbo, WA 98370 (360) 697-2565

References American Medical Association (2008) H-185.950 Removing Barriers to Care for Transgender Patients. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groupssections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.shtml American Psychiatric Association (2011, May 11). Gender dysphoria in adolescents and adults. Proposed revisions: Diagnostic and statistical manual of mental disorders, Fifth edition (DSM-5). Retrieved August 12, 2012 at http://www.dsm5.org/ProposedRevision. American Psychiatric Association (2012, August 16). News release: APA issues official positions supporting access to care and the rights of transgender and gender variant persons. Arlington, VA: Author. Release No. 12-36. American Psychological Association (2008). Resolution on transgender and gender identity and gender expression non-discrimination. In Anton, Barry S. (2009). Proceedings of the American Psychological Association for the legislative year 2008: Minutes of the annual meeting of the Council of Representatives, February 22-24, 2008, Washington, DC, and August 13 and 17, 2008, Boston, MA, and minutes of the February, June, August, and December 2008 meetings of the Board of Directors. American Psychologist 64, 372-453. doi:10.1037/a0015932 American Psychological Association (2011). Answers to your questions about transgender people, gender identity, and gender expression. Washington, DC: Author. Bauer, G., K, A., Pyne, J ,.Redman, N., Scanlon, K., Travers,R. (March 2012). Improving the health of trans communities: Findings from the TransPulse project. Ottawa, ON: Rainbow Ontario Health Conference. Accessed 08/12/12 from http://transpulseproject.ca/wpcontent/uploads/2012/04/Trans-PULSE.-Rainbow-Health-Ontario-Conference.-Plenary-2012vFINAL.pdf Grant, J. M., Mottet, L., Tanis, J., Harrison, J. Herman, J.L., and Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. Rotondi, K. N., Bauer, G. R ., Scanlon, K., Kaay, M., Travers R., Travers, A. (2011a) Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal of Community Mental Health, 30, 135-155. Rotondi, K. N, Bauer, G. R. , Travers, R., Travers, A., Scanlon K, Kaay, M (2011b). Depression in male-tofemale transgender Ontarians: Results from the Trans PULSE Project. Canadian Journal of Community Mental Health 30, 113-133. World Professional Association for Transgender Health (2008, June 17). WPATH Clarification on medical necessity of treatment, sex reassignment and insurance coverage in the USA. Minneapolis, Author World Professional Association for Transgender Health (2012). Standards of Care for the health of transsexual, transgender, and gender nonconforming people (7th edition). Minneapolis, MN: Author.