Earlier today Ingersoll joined our partners in the Coalition for Inclusive Health Care in Olympia to testify in front of the Health Care Authority of Washington on behalf of more just administrative rules as they relate to accessing gender affirming care for transgender and gender nonconforming Washingtonians on Apple Health. You can check out our testimony here and find our written comments down below. You have until 5:00pm today to submit comments to the Health Care Authority in favor of more just administrative rules that would give more low-income transgender and gender nonconforming Washingtonians access to the life saving health care they need. Check out this note from Gender Justice League for what kind of comments are most helpful and feel free to reach out to us at info@ingersollgendercenter.org! 
 

Dear Rules Coordinator:                            
My name is Karter Booher and I am writing you as the Executive Director of the Ingersoll Gender Center to offer our comments to the proposed changes to administrative rules for Apple Health’s Gender Dysphoria Treatment Program. In addition to our comments below we strongly support the comments submitted by the Coalition for Inclusive Healthcare. 

Ingersoll Gender Center is one of the nations oldest organizations of and by transgender and gender nonconforming people. Ingersoll members have been involved with World Professional Association of Transgender Health since 1984. A large focus of work is healthcare access for transgender and gender nonconforming people. In addition to helping individuals navigate health insurance to access gender affirming care we support a group of almost four hundred health care providers across the state of Washington to learn the best approaches to transgender healthcare from each other and increase the number of trans-competent healthcare providers in Washington. We provide comments with both the transgender and gender nonconforming people we serve and the healthcare providers we work with in mind. 

As an organization we believe that the best approach to gender affirming care is not a ‘one size fits all’ approach. In line with the WPATH standards we support standards of care that act as flexible guidelines that allow transgender people to be seen and treated as whole persons in need of individualized treatment plans. Additionally, most of the healthcare providers that we work to support use an informed consent model that centers the needs of transgender and gender nonconforming people and their relationship with trusted healthcare providers to make the best decisions for the individual seeking treatment. We support the current Apple Health Care rules that use pre surgical requirements that adhere to WPATH standards of care and are deeply concerned by the HCA’s proposed change to require a strict application of requirements. Transgender and gender nonconforming people already navigate numerous barriers in accessing gender affirming care. We believe that a rigid application of requirements will contribute to an erosion of trust in healthcare providers (leading to negative healthcare impacts across the board for transgender and gender nonconforming people) and prevent trans and gender nonconforming people from accessing life saving gender affirming care. 

In particular, we are concerned about the proposed changes that would eliminate flexibility in presurgical requirements, including requirements on “real life experience,” psychological screening, and hormone therapy. The National Center for Transgender Equality surveyed almost 28,000 transgender Americans to create the 2015 U.S Transgender Survey. Almost one quarter of respondents reported being physically attacked while in school (k-12) due to their gender identity. Thirty percent of respondents reported being fired, denied a promotion or facing some other form of mistreatment at work (verbally harassed, physically or sexually assaulted). Additionally this survey found that 29% of respondents were living in poverty (compared to 14% of the average US population) and respondents had an unemployment rate three times higher than the average U.S population. The evidence provided by the 2015 U.S Transgender Survey support the stories of the transgender and gender nonconforming people we serve and paint a more than adequate picture as to why some may feel unsafe in disclosing or “coming out” in every aspect of their lives. We support the flexibility of current HCA rules and believe that a rigid and universal application of ‘real life experience’ standards would not only prevent transgender and gender nonconforming people from accessing gender affirming care but would very likely force transgender and gender nonconforming people to put themselves in unsafe situations in pursuit of adequate healthcare. 

We work in collaboration with mental health providers to ensure that they have the skills, resources and support of peers to provide trans competent care to our communities because we know an overwhelming majority of transgender and gender nonconforming people seek mental health services and they deserve gender affirming and trans competent care. While this is of great import to us we also recognize that not all transgender and gender nonconforming people will seek out mental health support. Requiring a "comprehensive psychosocial evaluation” for all transgender and gender nonconforming people seeking care creates an undo burden and additional barriers to accessing care. Similarly, the strict implementation of the hormone therapy standards set out in WAC 182-531-1675(5)(c) would preclude transgender and gender nonconforming people who, for any number of valid reasons, decide not to pursue hormone replacement therapy from accessing gender affirming healthcare. Once more, we support the flexibility of current HCA rules and believe rigid requirements applied to ‘real life experience’, psychological screening and hormone therapy will have a direct and negative impact on the ability for our communities to access care. 

Additionally, we urge a strong reconsideration of the non covered services listed in Section 6. Many of the services listed in Section 6 are common procedures that transgender and gender nonconforming people pursue to alleviate gender dysphoria in line with WPATH standards of care; in particular, we find it deeply troubling that facial feminization, trachea shave and voice therapy are included in the non covered services listed in Section 6. Ingersoll has helped transgender and gender nonconforming people seeking to alleviate their gender dysphoria access these procedures for decades. We do not believe the exception to the rule process is an adequate alternative as it creates more barriers and undo burden on transgender and gender nonconforming people attempting to access gender affirming care. 

Ingersoll strongly supports the proposed language in revised subsection (2)(b), which would add licensed master’s level clinicians to the list of providers who may make or confirm a diagnosis of gender dysphoria. We know that this change will dramatically increase access to care for transgender and gender nonconforming people. Under the current rules, Ingersoll often acts as an intermediary between individuals and healthcare providers not currently able to make or confirm a diagnosis of gender dysphoria looking for healthcare providers that are currently able to make such a confirmation. This rule change will not only increase access to care but will also allow master’s level clinicians to spend more time supporting their clients and not searching for referrals. Similarly we support the removal of the “centers of excellence” (COE) requirements in WAC 182-531-1675 as we have found the that provision to create more barriers to care for our communities. Both proposed changes will make a substantial positive impact on our work with transgender and gender nonconforming people seeking care and the health care providers working to expand access to gender affirming care. 

Thank you for your consideration of our comments. Ingersoll Gender Center is committed to ensuring all transgender and gender nonconforming Washingtonians have access to trans competent gender affirming healthcare. We welcome any follow up questions or conversations. 


Sincerely, 

Karter Booher, 
Executive Director Ingersoll Gender Center