SEATTLE — For most Washington public school students, a sports physical is a brief ritual — a stethoscope pressed to the chest, a few questions about injuries, a vision test and a physician's signature clearing them for the first practice.

A recently certified state initiative could turn that routine screening into something far more invasive and subjective.

Initiative IL26-638, expected to appear statewide on the November ballot, would require students who want to compete in girls sports to provide documentation from a health care provider to verify their biological sex." It is an effort to keep transgender girls from competing.

Supporters say the measure is necessary to protect fairness and safety in girls athletics. Pediatricians say it would transform their role from doing a medical safety check into making an eligibility determination — with unresolved questions about cost, privacy and implementation.

Under current policy, the Washington Interscholastic Activities Association allows students to "participate in athletics consistent with their gender identity." Its handbook requires schools to provide transgender and gender-diverse students equal opportunities to compete and to maintain a discrimination-free environment.

"From our association standpoint, we continue to follow state law and what's required of state law around gender identity and participation in school athletics," said Justin Kesterson, the association's assistant executive director.

The initiative's supporters want to go around the association. Backed by Brian Heywood, a conservative hedge fund manager and founder of group Let's Go Washington, the initiative wants medical providers to determine a child's gender based on “reproductive anatomy, genetic makeup, or normal endogenously produced testosterone levels.” It does not mandate a specific test, leaving the method to a provider’s discretion.

These tests can include blood tests, examination of a child's genitals or genetic analysis. Some athletics governing bodies already have mandated tests, which have shown limits in reliability. For instance, cisgender and intersex elite athletes have been barred from competition for natural testosterone levels above the standard set for women.

Heywood has said numerous times the proposal would not change how sports physicals are conducted, arguing that in “99.9% of cases,” sex is already confirmed through medical history and routine examination.

"This is not creating any new thing for anybody at all," Heywood said. "This is already required, it has been for 50-plus years for boys and girls."

Physicians dispute that characterization.

Under current standards of care, sports physicals focus on identifying conditions that could endanger a student during competition — cardiac abnormalities, concussion history, asthma and orthopedic risk. They do not include blood testing, hormone panels, genetic analysis or internal pelvic exams for healthy adolescents, pediatricians said.

"It is not required or part of my practice to do a hernia exam, unless there are concerns that are specifically brought up around that," said Dr. Glenna Martin, a Washington board-certified pediatrician. "That's not even on the form for most of the physicals I've done."

The state athletics association does not mandate a single physical form. It posts the American Academy of Pediatrics preparticipation evaluation online for schools and families to use but leaves final documentation decisions to providers who may use a different form.

As a medical student, Martin volunteered at large-scale physical events for students without regular providers. “There wasn’t any capacity to do blood draws, and we were definitely never doing genital exams,” she said.

Dr. Lelah Rave, executive director of the Washington chapter of the American Academy of Pediatrics, said neither blood tests nor pelvic exams are included in sports physicals under current standards of care.

"They would certainly not do a blood test, and a pelvic exam is never conducted as part of a sports physical," Rave said.

The initiative allows verification through hormone testing or genetic analysis — evaluations that typically require lab work and, in some cases, specialist interpretation. It does not set testosterone thresholds, define documentation standards or explain how cases involving intersex traits, delayed puberty or natural hormonal variation would be handled.

"If you're doing blood tests, who pays for those?" Rave said. "Are we now going to have a financial bar to enter into sports participation? And if you get the blood test, who interprets it?"

Access to care varies statewide. About 18% of Washington children lack consistent access to medical care, according to the Data Resource Center for Child and Adolescent Health. For some adolescents, a sports physical may be their only health care visit in a year.

Joe Mizrahi, a Seattle School Board member and parent, said additional appointments or lab work could deter participation, particularly for families already navigating transportation, insurance or cost barriers.

“School athletics are about engagement and belonging, not elite competition,” Mizrahi said. “If families have to navigate extra appointments, extra costs or unclear requirements, that’s a barrier.”

Supporters say those concerns are overstated.

"It's up to the doctor how to determine the child's biological sex," said Hallie Herzberg, director of communications for Let's Go Washington. "Often, none of those things would be needed because of the existing relationship or other procedures that a doctor has to do during a sports physical."

State Sen. Judy Warnick, a Republican who supports the initiative, said her primary concern is injury risk if “girls compete against biological males" in reference to transgender girls. She said she would ultimately like to see a third competitive category for transgender athletes, though she acknowledged building such a system would take time.

Pediatricians say the biology is often less straightforward than political rhetoric suggests.

Dr. Erica Li, a Washington pediatrician aligned with Heywood, said adolescent exams may include a brief external inspection to monitor puberty.

“That’s to track growth and development, not to assign eligibility,” Li said.

Li said the debate should focus strictly on whether a child's gender matches the one assigned by a doctor at birth, not on the gender a child identifies as. To her, the initiative is intended to restore what she calls "sex-based rights — ones defined by the sex assigned by a doctor at birth.

Doctors routinely encounter delayed puberty, hormonal variation and intersex traits — medically recognized differences in sex development in which anatomy, hormones and genetics do not align neatly, according to Li.

For some physicians, the broader concern is precedent.

“The difficulty is that you now have essentially the government directing what medical evaluation is required for participation,” Rave said. “That changes the relationship between physician and patient.”

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