Opposing Apple Health's Restrictive Rules

June 27th, 2017
Gender Justice League is joining our colleagues in the Coalition for Inclusive Healthcare in opposing rules changes to the Washington Apple Health (Medicaid) Program's coverage for transition-related healthcare (also known as the "Gender Dysphoria program").  In 2015, along with a 30-member coalition of grassroots and national organizations, Gender Justice League successfully petitioned for rule changes to expand coverage under Apple Health to include all medically necessary transition related healthcare.  The program has not been without it's serious challenges such as lack of access to doctors, significant hurdles to getting surgical services approved, and far too few trans and gender diverse people in need of life saving medical care are denied access under the current rules. The Washington Healthcare Authority, the state agency that administer's Washington's medicaid program - Apple Health - has proposed significant new restrictions.

We are urging our members, supporters, and allies to write a brief email to the Healthcare Authority of Washington - or attend a hearing on Tuesday June 27th, 2017 at 10am at the Healthcare Authority of Washington Building to oppose new restrictions imposed by these rules changes.

People can submit comments to arc@hca.wa.gov by 5pm 6/27/2017  -

Subject: Re: WAC 182-531-1675 -- Gender Dysphoria Treatment Program

Dear Healthcare Authority of Washington Apple Health Program,
I am writing to express my serious concerns about proposed rules changes to the Apple Health Gender Dysphoria Program.
My name is [insert name]  and I am a [Apple Health member, therapist, doctor, concerned community member, etc].  I believe
that the proposed rules would make access to live saving medical care for the treatment of gender dysphoria more difficult in
a way that discriminates against transgender people.  The US Trans Survey has found that nearly 40% of Trans and gender diverse people attempt suicide at some point in their life, and numerous studies have shown those numbers are greatly decreased when trans people have access to medically necessary care.  I am urging you to remove all  categorical exclusions to specific medical procedures.

1. I oppose the elimination of flexibility in the Gender Dysphoria Treatment Guidelines which not supported by medical necessity and is contrary to law.
2. I believe you should allow for the flexible application of standards of care based on provider recommendation.
3. I believe you should eliminate the unnecessary  gatekeeping requirements to "Verify the appropriateness of treatment".
4. I believe you should reduce the rigid application of specific gatekeeping requirements.
5. You should remove the "non-covered services list" and consider all services on a case by case basis as recommended by the patients care team.
6. You should also retain language regarding exception to rule process for "non-covered services".
7. I support you removing the "Centers of Excellence" and other unnecessary restrictions that have limited the number of providers offering this type of care under Apple Health.
8. I  support expanding the list of providers who may make or confirm a Gender Dysphoria diagnosis to increase access to care.
9. I support the changes to requirements regarding "Proof of Informed Consent" to allow providers to include a note in a patient's prior authorization letter.
10. I believe that the Healthcare Authority should work with community advocacy organizations to increase its network of providers, and expand the types of covered services to all those deemed medically necessary by a care team.

[Your Name]
[Phone Number]

2017 Pride speaker Jennicet Gutiérrez

Jennicet Gutiérrez is a transgender Latina organizer from México, and she is an organizer of Los Angeles based Familia: Trans Queer Liberation Movement. Jennicet believes in the importance of uplifting and centering the voices of trans women of color in all racial justice work. Jennicet will continue to organize in order to end the deportation, incarceration and criminalization of immigrants and all people of color.

Gender Justice Awards 2016

The 2016 Gender Justice Awards dinner will highlight and showcase the incredible activism and culture creation of trans and allied activists and artists who have made incredible strides for trans, gender queer, non-binary, and gender non-conforming people in the Pacific Northwest. This is the annual fundraiser for Gender Justice League to support our work throughout Washington to build community and fight for the human rights of trans, gender queer, gender non-conforming, and non-binary people.

To nominate someone for an award: https://goo.gl/forms/igkKiSG8xorZKoYT2

This year's Gender Justice Awards will be hosted by Aleksa Manila with special music guest Rae Spoon.

$60.00 for Regular Tickets
$100.00 for VIP
10% Sliding Scale Tickets Available.

Tickets costs are going to (per person cost):
Price of a catered & served union meal ($35.00/plate)
Space Rental ($7.30)
Decorations ($5.00)
Trans & allied Emcee & performers ($9.00)
Equipment rental ($4.00)

We ask attendees to come prepared to make an additional donation if possible, tickets are priced to be as accessible as possible for our community and are intended to simply cover the cost of producing the event. We recognize not everyone who attends can give, at our ticket prices we expect to only "break even" for the event - we work to ensure that catering staff and performers are equitably paid. Additional Gifts will go directly to support Gender Justice League's efforts including Trans Pride Seattle 2017, The Washington SAFE Alliance & Efforts to defeat anti-trans attacks, and our efforts to provide public education & training throughout the state.

Gender Justice League is committed to economic accessibility - 10% of seats (15 tickets) will be reserved for sliding scale attendance, additional tickets will be made available as they are sponsored. Please email danni@genderjusticeleague.org if you are in need of a sliding scale ticket. Attendees can also sponsor one of these tickets to increase the pool of sliding scale tickets. We offer these tickets on a first come, first serve basis with an emphasis on providing sliding scale tickets to youth, people experiencing homelessness, folks who are unemployed, elders, people with disabilities, people of color, and those with children.

GJL strives to make our spaces radically accessible. Melrose Market is wheelchair accessible.
THIS EVENT WILL BE ASL INTERPRETED, please email danni@genderjusticeleague.org to let us know if you will need ASL interpretation.

This is a scent- & smoke-free event; please refrain from using chemical fragrences or products. For more questions check out our event page or email danni@genderjusticeleague.org

VICTORY! SB 6443 Defeated!

Moments ago, the full Senate debated Sen. Ericksen's (R-Ferndale) harmful SB 6443. This bill would have eliminated the Washington State Human Rights Commission's rules, which made the 2006 Anderson-Murray Anti-Discrimination law's requirements clear for employers, businesses, and other places of public accommodation.  This was one of 6 bills in the Washington State Legislature aimed at repealing rules recently passed by the Washington Human Rights Commission clarifying protections for Transgender Washingtonians.

By a vote of 25 to 24, the bill was defeated by proponents of equality who opposed SB 6443.

To every single one of you who contacted your state legislators, attended and/or testified during the hearings, and shared your stories and this work - THANK YOU!
For those of you that reached out to your own clients, constituents and lists and urged them to contact their legislators - THANK YOU!

Elected officials and their legislative aides told us that your efforts made the difference.

If your state Senator is one of the 25 Senators that stood with our community, please take a moment and send them an email thanking them. Those Senators are: Billig, Carlyle, Chase, Cleveland, Conway, Darneille, Fain, Fraser, Frockt, Habib, Hasegawa, Hill, Hobbs, Jayapal, Keiser, Liias, Litzow, McAuliffe, McCoy, Mullet, Nelson, Pedersen, Ranker, Rolfes, Takko. Click here for SB 6443 info.

We appreciate you standing with us to ensure that all of our lives are protected.

Gender Justice League has taken a key role in educating the public, mobilizing our communities, and traveling the state to train hundreds of Transgender people, their family, friends, and allies to educate legislators and the media about the impact of these bills would have on the everyday impact on Transgender people.

Please consider donating to support our continued work to defeat the additional 5 bills still active in our legislature.

In Solidarity,
Gender Justice League


Response to the YMCA of Pierce & Kitsap counties non-discrimination statement of December 15th, 2015

For Immediate Release
December 15th, 2015

In Washington State, and across the country, there is a growing focus on transgender individuals and their rights to access public restrooms and locker rooms. These are places the rest of us usually take for granted. In October, the YMCA of Pierce and Kitsap Counties issued a policy that discriminated against transgender members. Over the past three months, the YMCA has listened to its members and community leaders.

The YMCA has strengthened our communities for years based on policy, practices and programs that build a healthy spirit, mind and body for all. By helping children, adults and families from all walks of life reach their goals and contribute to solutions that improve communities, the Y provides people with endless opportunities to achieve more, and we will continue to support them in those efforts.

Through this process, we have been reminded that true equality is not yet a reality for many in our community. Though we might not always realize it, transgender people are part of our families, workplaces, our neighborhoods, and our places of worship—and they need to be able to use the restroom and locker room, just like everyone else.

The YMCA is an institutional leader in our community and is now a model for transgender inclusion. As community leaders, organizations that support the LGBT community, and faith leaders, we applaud the YMCA of Pierce and Kitsap Counties for their December 15th, 2015 decision to allow all its members, including transgender individuals, use of the restroom and locker room facilities that are consistent with their gender identities. By adopting inclusive policies, places of public accommodation can ensure that all people are welcomed, included, and supported.

The YMCA's Statement

Rev. Ann Adkinson, First United Methodist Church of Tacoma
Pierce County Auditor Julie Anderson
Metro Parks Commissioner Elect Jessie Baines
Rev. Dave Brown, Immanuel Presbyterian
City of Tacoma Councilmember Marty Campbell
WA State Sen. Jeannie Darneille
WA State Rep. Jake Fey
Metro Parks Commissioner Erik Hanberg
U.S. Rep. Denny Heck
City of Tacoma Councilmember Anders Ibsen
WA State Rep. Laurie Jinkins
U.S. Rep. Derek Kilmer
Jeff Klein
City of Tacoma Councilmember Ryan Mello
Kurt Miller
Rev. Tad Monroe
Rev. Jenny Rake-Marona
City of Tacoma Mayor Marilyn Strickland
Pierce County Councilmember Rick Talbert
City of Tacoma Councilmember Robert Thoms
Tacoma School Board Director Catherine Ushka
Tacoma School Board Director Karen Vialle
City of Tacoma Councilmember Lauren Walker
Rev. David Wright, University of Puget Sound Director for Spiritual Life and Civic Engagement

Victory! Apple Health (medicaid) Announces Final Trans Health Coverage - furthest state so far!

Gender Justice League is excited to announce our Frequently Asked Questions document on the Washington Apple Health Plan's Transgender Health Coverage.

The Washington Healthcare Authority announced on Friday July 31st that it has issued it's final rules for expanding coverage for gender transition related health care. The new rules go further than any other state so far, covering additional medically necessary procedures and providing parity of coverage with other medical and mental health conditions.  The new rules also provide a clear and concise policy for appeals of currently "non-covered services" that may be medically necessary on a case by case basis for individual transgender people.

Gender Justice League extends our thanks and congratulations to our many colleagues in the Coalition for Inclusive Healthcare in this victory - with special thanks to Lisa Brodoff of Seattle Unviersity School of Law (whose lawsuit on behalf of a client initiated this process nearly 6 years ago!), Marsha Botzer of Ingersoll Gender Center, David Ward of Legal Voice, Kris Hermans of Pride Foundation, Jenni Wong of the ACLU of Washington, Monisha Harrell of Equal Rights Washington, Tobi Hill-Mayer of Gender Justice League, Gunner Scott of Pride Foundation, Seth Kirby of Oasis Youth Center, Petra Wilson, the many other Coalition members, as well as the dozens of trans people, advocates, medical and mental health providers, parents, and supporters who provided public testimony to the Healthcare Authority.

"This is an astounding victory that took nearly 5 years to achieve," said Danni Askini Gender Justice League's Executive Director "We are so greatful to have been a part of this collaborative advocacy effort and look forward to ensuring a smooth implementation of this new policy.  While we know not all surgical services will be immediately available in Washington State, we are working closely with the Health Care Authority to identify and contract with surgical providers.  This is a huge step forward but we have a great deal of work to do to ensure that all trans and gender non-conforming Washingtonians get the medical and mental health care they need"

The new policy goes into effect August 31st and will cover all medically necessary mental health, medical, and surgical services listed bellow.

Please see our very detailed Frequently Asked Questions document to understand the details of this new and exciting policy.

Additionally you can read the source documentation from the Health Care Authority of Washington (who issues rules on Apple Health) including, The HCAs Answers to Our Testimony, Their Guidance to Physicians, and of course The Final Rule Document.

Bellow are the list of covered services:

Covered Treatments
(if deemed medically necessary for you by Apple Health)

Please note this list is not exhaustive. The following list is a treatments that may be considered medically necessary for some people. It also notes the availability of these treatments in Washington to the best of our knowledge.

Treatment Description or example Is it available in Washington?
Hormone therapy Prescription testosterones, estrogens, progesterone, etc. Yes. You just need a prescription and to go to a pharmacy that takes your health insurance. You will also need to get a diagnosis of gender dysphoria from a licensed mental health provider and a prescription from your primary care doctor or a specialist.
Puberty blockers Suppressants that act as a “pause button” on the body’s release of hormones typically begins at puberty
Hormone blockers Aromatase inhibitors or gonadotropin-releasing hormone (GnRH) analogues used to suppress hormone release (ex. Anti-androgen, androgen blocker)
Mental health treatment Counseling, psychotherapy, substance abuse treatment, family or couples counseling, and crisis intervention treatment. Yes. You just need to find a therapist,
substance abuse treatment center, or crisis intervention center who takes Apple Health. Contact your Managed Care Organization for more details
Preventive screenings Pap tests, prostate exams, mammograms, breast exams Yes. You need to go to a provider who takes Apple Health. Please know they no longer can deny you care that does not correspond with your gender marker in your file.
Laboratory tests Blood tests to assess
hormone levels, electrolytes, cholesterol levels, liver or kidney
Yes, as long as your labs are ordered by a doctor who takes your insurance and sends you to a lab that is covered by your insurance.
Hysterectomy; Salpingo-oophorectomy Removal of the uterus,
cervix, fallopian tubes and ovaries
Many doctors are experienced at these surgeries for non-transgender people but may not have treated trans patients. They should be readily available in Washington, however be careful in selecting your surgeon.
Orchiectomy Removal of testicles Yes, there are providers at University of Washington Urology Department who have performed these surgeries. You will want to verify they are taking your Managed Care Organization.
Mastectomy /
Chest Reconstruction
Removal of the chest or breast tissue for transgender men – Chest Reconstruction or top surgery Chest surgery is available in Washington State – we are working to identify surgeons who will take Apple Health. It is important to note that while currently chest surgery for trans people is labeled under mastectomy, it is a different procedure than a standard mastectomy received for breast cancer and should be done by a surgeon that is familiar with chest reconstruction for trans people.
Breast Reconstruction /
Breast Augmentation
Adding a saline or silicone filled medical device to your chest to reconstruct your chest or breasts to be larger. Breast Reconstruction is readily available in Washington State – we are working to identify providers who are willing to take Apple Health. Several surgical providers such as the Poly Clinic, Swedish Medical Center, and University of Washington Medical Center may be good places to inquire about these services as they generally take Apple Health. These providers will have to sign up with Apple Health first as a COE provider.
Laryngoplasty We believe this means vocal chord surgery – or voice modification surgery We are unsure if this service is available in Washington State – please contact Apple Health’s Transgender Health program for more information.
Abdominoplasty Removing excess skin or fat from the abdomen which may be needed for other surgical procedures such as bottom surgery. Abdominoplasty is readily available in Washington State, however – this procedure is likely only covered when done in combination with another medical procedure. You should check with the surgeon you are working with for bottom surgery to find out more.  Some surgeons may want to do the surgery themselves, and having a separate surgeon in Washington do this surgery may not be helpful.
Belpharoplasty Surgical treatment of the eyelid This surgical procedure is available in Washington State and may be medically necessary as a component of facial feminization surgery. Please consult with your primary care doctor, mental health team, and a surgeon to determine medical necessity.
Colpecotmy; Vaginectomy Surgical removal of the vagina This procedure is typically done in conjunction with other bottom surgeries. It may be available in Washington, we are currently unsure. However, if you plan to have other bottom surgeries you should consult the bottom surgeon first before doing this procedure locally.
Reconstruction and/or
rerouting of the urethra
We aren’t sure when these surgeries will be available in Washington. Right now we do not know of any local doctors who provide these and accept insurance. However, you should contact the Healthcare Authority – covered services should be made available to all patient, Apple Health can coordinate this care.
Phalloplasty Construction or
reconstruction of the penis
Scrotoplasty; Placement of testicular prosthesis The creation of the scrotum; implantation of testicular implants/prosthesis. This procedure is not likely available in Washington State.
Genital electrolysis Electrolysis done in preparation for Vaginoplasty. Most surgeons require patients to undergo genital electrolysis prior to vaginoplasty. This is considered a medically necessary service when done in conjunction with preparation for vaginoplasty – it is important to note that this must be done in a physician’s office to be covered by Apple Health.  This procedure is available in Washington State.
Vaginoplasty, Penectomy, Cliteroplasty, Colovaginoplasty, Labiaplasty ,Genital surgery. Construction or
reconstruction of the vagina, removal of the penis, creation of the labia, and creation of the clitoris.
We aren’t sure when these surgeries will be available in Washington. Right now we do not know of any local doctors who provide these and accept insurance. However, you should contact Apple Health who is working to identify a contract surgeon out of state.


Non-covered Treatments
(only considered on a case-by-case basis under Exception To The Rule)

Please note this list is not exhaustive. The following list is a treatments that may be considered medically necessary for some people but only on a case by case basis through the "Exception to the Rule process"  Please read our FAQ for more information on this process.  Please remember: these are not generally covered – and you must first BE DENIED these services, and then file an appeal including the documentation outlined in the FAQ justifying the medical necessity of these procedures. It also notes the availability of these treatments in Washington to the best of our knowledge.

Treatment Description or example Is it available in Washington?
Brow lift A surgical procedure to shorten the length of the forehead / brow. Yes
Calf implants Prosthetic implants to increase the size/definition of the calf muscle. Possibly, we are unsure.
Cheek/Mylar implants A surgical procedure to place a prosthetic that  increases the size or prominence of the cheeks. Yes.
Chin/nose implants A surgical procedure to place a prosthetic that  increases the size or prominence of the chin or nose. Yes.
Collagen injections Injections of the face to increase prominence or feminize the face. Yes.
Drugs for hair loss or growth Drugs that are specifically used for hair growth. Yes, despite this - we believe that these medications may be covered under testosterone suppression/hormone blockade. Check with your primary care provider.
Facial or trunk electrolysis Removal of body or facial hair by electrolysis. Yes, this is widely available in Washington.
Facial feminization Surgical procedures to feminize the face Yes, there are several Washington plastic surgeons who perform surgeries to feminize the face
Face lift A surgical procedure to ”rejuvenate” the face or reduce the appearance of age Yes, this is widely available in Washington.
Forehead lift A reduction of the forehead to shorten it and bring the hairline downward. Yes, we believe this is available in Washington State.
Hair transplantation Transfer of hair follicles from one part of the scalp to another part. Yes, this is widely available.
Jaw shortening A procedure to shorten the length of the jaw. Yes, there are Maxilliofacial surgeons in Washington performing this procedure.
Lip reduction A surgical procedure to reduce the size or prominence of the lips or reduce the size the surrounding skin. Yes, this procedure is available.
Liposuction The surgical removal of fat by a suction assisted device. This is widely available in Washington
Mastopexy; Also called a ”breast lift” this procedure raises the areola and breast tissue on the chest. Yes, this procedure is widely available in Washington
Neck tightening A surgical procedure to tighten the skin of the neck. Yes, this is available in Washington.
Pectoral implants; The implantation of devices intended to increase the prominence of the pectorals muscles. This procedure is available in Washington
Reduction thyroid chondroplasty; Trachea shave Surgical procedures to reduce the prominence of the Adams Apple / Trachea protrusion. Yes, this procedure is available in Washington
Removal of redundant skin Surgical procedures to reduce excess skin. These surgeries may be available in Washington.
Suction-assisted lipoplasty of the waist A form of Liposuction of the waste Yes, this is available in Washington
Voice modification surgery; Voice Therapy Surgical procedures to change the pitch, tone, or resonance of the voice. We are unsure, these surgeries may be available. Note: Larygoplasty is a covered service – we are currently unclear about this contradiction.

“The agency evaluates a request for any non-covered service listed in (e) of this subsection as an exception to rule under the provisions of WAC 182-501-0160. The justification included in the surgical plan for any of the procedures listed in (e) of this subsection may be recognized by the agency as meeting the documentation requirements of WAC 182-501-0160”

Seattle becomes 3rd City with Gender Neutral Restroom Legislation

Gender Justice League congratulates the Seattle City Council for unanimously passing legislation transmitted to the council by Seattle Mayor Ed Murray. Seattle joins West Hollywood, California and Washington DC in requiring all single stall restrooms to be labeled as gender neutral. This legislation specifically will increase access to safe restrooms and public accomodations for transgender and gender non-conforming residents and visitors in Seattle. The legislation is part of a set of comprehensive recommendations made by the Mayor's Task Force on LGBTQIA Hate Crimes and the Mayor's Action Plan. The policy was also proposed by both the city's LGBTQ Commission and former city council member Sally Clark, we are honored to support their work!

Mayor Murray's office said today: "This legislation will provide for all-gender restroom facilities and amend the Seattle Municipal Code so that single-occupant restrooms will no longer be restricted to a specific sex or gender identity. Single-occupant restrooms in City facilities and all public accommodations (including restaurants, coffee shops, stores, etc.) must have signage that makes it clear that they are not gender exclusive and allow use by any person regardless of sex or gender identity, rather than just “men” or “women.” The Seattle Office of Civil Rights (SOCR) will be responsible for enforcing these changes."  You can read his office's full comments on their website.

Gender Justice League joined the work of the Seattle LGBTQ Commission over the last 3 years in supporting this legislation - you can read our letter of support to the council committee when the legislation was first introduced this spring.  Many LGBTQ organizations joined in the call for this legislation, specifically citing the horrifying statistic that 53% of transgender and gender non-conforming people have faced verbal harassment or disrespect in places of public accommodations, and 8% had reported being physically attacked or assaulted in places of public accommodation.

Gender Justice League has recently partnered with Pike Place Market to change the labeling of their bathrooms (the oldest public bathrooms on the west coast), as well as with local artists and designers to create more gender neutral rest room signage to assist places of public accommodation in following this ordinance.  Gender Justice League looks forward to working with the Seattle Office of Civil Rights and the Seattle LGBTQ Commission in providing guidance and assistance to local area businesses in following these new guidelines.

For more information or press inquiries - please contact our Executive Director - Danni Askini, danni@genderjusticeleague.org

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