Behind this fall’s ballot measure on transgender student athletes, one that’s pushed Washington’s youth sports into a national spotlight, is a web of ambiguous language that many health providers in the state are still trying to untangle.
Some parts of Initiative 638, a hotly debated measure brought by conservative political committee Let’s Go Washington, are clear. The initiative, if passed, would ban trans girls from participating in K-12 interscholastic girls sports. It would not require a new, additional medical appointment. It would apply only to girls, not boys, teams.
Other portions, like how the measure would alter the way health providers give athletic assessments to all girls, are murkier.
According to the first section of I-638, for example, “existing Washington state law and school district policies require students to undergo a routine physical examination prior to participation in interscholastic sports, which includes documentation of the student's sex assigned at birth.”
Some health providers have immediate questions: Which state law? How is a routine physical examination" defined? What "documentation" is the language referring to?
And while the initiative does not explicitly require genital exams for anyone, mixed messaging over how providers would have to verify student information has caused confusion, too.
“This is so clearly written by somebody who does not understand what I’m doing in a sports physical,” said Dr. Glenna Martin, a family physician who works at a Seattle community health center and who opposes the measure.
I-638 supporters say, in practice, the initiative wouldn’t change much for doctors, that it would just add a check box on a medical form. But the measure’s vague writing has left many health experts throughout the state uncertain or misinformed about what they could be required to do when signing off on students' sports eligibility.
Campaigns on either side of I-638 have spent months arguing over what the initiative would or would not do, though much of that back-and-forth isn't represented in the four-sentence description that appears on the ballot.
Many health professionals and expert organizations, including the Washington chapter of the American Academy of Pediatrics, have declined to comment publicly on the measure. In the state voters guide, no medical organizations are listed as supporting I-638.
Some, however, have spoken out in opposition, including the Washington Academy of Family Physicians, the Washington State Nurses Association and the Washington State Psychological Association.
Here’s what several medical providers from around the state say about how they’re interpreting the measure and how they would implement potential changes, should it pass.
How would sports exams for student athletes change?
To Martin, who specializes in family, addiction and abortion medicine, I-638 appears to require providers to confirm girls' assigned sex at birth when analyzing their ability to play school sports, using one of three methods.
Those three methods are, according to the initiative, looking at “reproductive anatomy, genetic makeup, or normal endogenously produced testosterone levels.”
In other words, Martin said, she could give a young patient a pelvic exam, test their genes or test their hormone levels. (She added these tests do not necessarily determine somebody’s sex or gender.)
That does not mean that all providers would be required to give students pelvic exams for them to play sports.
It does seem to mean that providers could give pelvic exams — or a genetic or blood test — if they felt “legally obligated to comply," Martin said. It depends on how individual providers would feel about enforcing a change to patient care based on the outcome of an election, she said.
“At the end of the day, I wouldn’t do it because I think it is completely unethical,” Martin added. “I would probably cross that part off and say, ‘this is not medically indicated.’”
She said she also opposes the measure because, despite being a point often at the heart of debate, there is not consistent research that shows trans girls have an athletic advantage over cis girls.
Let's Go Washington counters that "sex-based athletic categories are necessary," as supporters of the initiative wrote in the state voters guide.
Hallie Herzberg, spokesperson for the political committee, has a different interpretation of the initiative language when it comes to confirmation of assigned sex at birth.
According to Herzberg, providers would be able to confirm their patient’s assigned sex at birth “based on history of treating the patient.”
“In most cases, it would just be a doctor relying on existing medical records to check that box, so we don’t anticipate much of a change,” Herzberg wrote in an email.
She also noted, according to the initiative, providers would not be able to use birth certificates to confirm sex "because they can be changed in Washington state."
Dr. Ken Gass, a retired pediatrician in Bellingham, said that even if the initiative allows providers to check assigned sex at birth with existing medical records, not all children have regular primary care providers who have those records.
Those students often, unfortunately, get sports physicals from providers they’ve never met before, like at an urgent care center or during a mass clinic in a school gym, Gass said.
“Now you’re in a situation where if you’re honest, you’re not going to check a box on a child you do not know,” without having to then turn to a pelvic or genetic exam for confirmation, he said.
As a result, said Gass, who opposes the initiative, he guessed that all students, including cis and trans girls, may be less motivated to join school sports. Or providers may be less likely to offer sports physical exams at all, he said.
“Doctors don’t want to put themselves at risk of signing a paper of someone they don’t know,” Gass said.
What do health providers typically check during sports physicals?
Some providers pushed back against the wording in I-638 about what state policies currently require around school sports.
It is true, as the measure language says, that state law allows school districts or regional interscholastic sports organizations, like the Washington Interscholastic Activities Association, to oversee and manage their own rules for school sports.
It’s true that per WIAA rules, student athletes must receive a sports physical exam from a health provider in order to get certain medical forms signed.
It is not true that those sports physicals typically include official provider confirmation of a student’s assigned sex at birth, according to several Washington primary care and family medicine doctors.
“I’m not usually checking that off,” Martin said.
If I-638 passes, that would change.
Herzberg, of Let's Go Washington, said there is a WIAA form that requires confirmation of assigned sex at birth, pointing to a medical history form on the association’s website.
That document, which does ask about assigned sex at birth and gender identity, goes into a student’s medical file, per WIAA, but it’s signed by students and/or their parents, not their health providers.
"They are official medical forms," Herzberg wrote in an email.
The two WIAA documents that health providers usually sign are a physical exam form and a medical eligibility form. Neither asks for confirmation of assigned sex at birth.
Dr. Eloi Hoopman, a family physician in Pierce County, said the topic can come up, but “we just take (students') word for it." She doesn't do pelvic exams or other testing to confirm kids’ assigned sex at birth for sports physicals, she said.
According to Let’s Go Washington, the initiative would allow providers to sign off on sports physical forms, using patient information they gather in annual well-child visits.
Most children in the U.S. receive annual well exams, but not all do, according to the Centers for Disease Control and Prevention.
Hoopman has said it's misleading for proponents of I-638 to conflate the two types of exams, and called the measure "poorly written."
Now, how provider roles could change when caring for student athletes is up to voters.
A "yes" vote on the initiative bans trans girls from girls K-12 sports. A "no vote rejects the proposed ban, and maintains Washington's existing policies that allow students to compete on teams aligned with their gender identity.
Ballots must be returned to official election drop boxes by 8 p.m. Tuesday. The U.S. Postal Service recommends mailing your ballot at least one week before Election Day, so at this point, drop boxes are a better option.
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