83 FR 31711 - Exclusion of Gender Alterations From the Medical Benefits Package

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 83, Issue 131 (July 9, 2018)

Page Range		31711-31712
FR Document		2018-14629

On May 9, 2016, the Department of Veterans Affairs (VA) received a Petition for Rulemaking petitioning VA to amend its medical regulations by removing a provision that excludes ``gender alterations'' from its medical benefits package. The effect of the amendment sought by the petitioners would be to authorize gender alteration surgery as part of VA care when medically necessary. VA seeks comments on the petition to assist in determining whether to amend the medical benefits package and eliminate the exclusion of gender alteration from VA's medical benefits package.

Federal Register, Volume 83 Issue 131 (Monday, July 9, 2018)

[Federal Register Volume 83, Number 131 (Monday, July 9, 2018)]
[Proposed Rules]
[Pages 31711-31712]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2018-14629]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17


Exclusion of Gender Alterations From the Medical Benefits Package

AGENCY: Department of Veterans Affairs.

ACTION: Petition for Rulemaking and request for comments.

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SUMMARY: On May 9, 2016, the Department of Veterans Affairs (VA) 
received a Petition for Rulemaking petitioning VA to amend its medical 
regulations by removing a provision that excludes ``gender 
alterations'' from its medical benefits package. The effect of the 
amendment sought by the petitioners would be to authorize gender 
alteration surgery as part of VA care when medically necessary. VA 
seeks comments on the petition to assist in determining whether to 
amend the medical benefits package and eliminate the exclusion of 
gender alteration from VA's medical benefits package.

DATES: Comments must be received/submitted on or before September 7, 
2018.

ADDRESSES: Written comments may be submitted through http://www.regulations.gov; or by mail or hand delivery to Director, Office of 
Regulation Policy and Management (00REG), Department of Veterans 
Affairs, 810 Vermont Ave. NW, Room 1063B, Washington, DC 20420; or by 
fax to (202) 273-9026. Comments should indicate that they are submitted 
in response to ``Notice of Petition for Rulemaking and request for 
comments--Exclusion of Gender Alterations from the Medical Benefits 
Package.'' Copies of comments received will be available for public 
inspection in the Office of Regulation Policy and Management, Room 
1063B, between the hours of 8:00 a.m. and 4:30 p.m., Monday through 
Friday (except holidays). Please call (202) 461-4902 for an 
appointment. (This is not a toll-free number.) During the comment 
period, comments may

[[Page 31712]]

also be viewed online through the Federal Docket Management System 
(FDMS) at http://www.regulations.gov.

FOR FURTHER INFORMATION CONTACT: Michael Shores, Director, Office of 
Regulation Policy and Management, Office of the Secretary, Department 
of Veterans Affairs, 810 Vermont Avenue NW, Washington DC, 20420; (202) 
461-4921.

SUPPLEMENTARY INFORMATION: Section 1710 of title 38 United States Code 
(U.S.C.) requires VA to ``furnish hospital care and medical services 
which the Secretary determines to be needed'' for eligible veterans. In 
1999, VA promulgated 38 CFR 17.38, establishing the Department's 
medical benefits package for veterans enrolled in VA's health care 
system. 64 FR 54207 (Oct. 6, 1999). The regulation describes the types 
of medical care and services available for such veterans. Care referred 
to in the medical benefits package is provided to individuals only if 
it is determined by appropriate healthcare professionals that the care 
is needed to promote, preserve, or restore the health of the individual 
and is in accord with generally accepted standards of medical practice. 
38 CFR 17.38(b). Paragraph (c) of that section provides a list of 
medical services the medical benefits package does not include. 
Paragraph (c)(4) explicitly excludes ``gender alterations'' from the 
medical benefits package.
    On May 9, 2016, VA received a Petition for Rulemaking petitioning 
VA to amend its medical regulations by removing the exclusion of 
``gender alterations'' from its medical benefits package. The petition 
asks VA to remove 38 CFR 17.38(c)(4), allowing VA to provide gender 
alteration surgeries.
    As part of its ongoing consideration of the petition, VA now seeks 
public comment on the petition and on whether ``gender alterations'' 
should be included in the medical benefits package. On February 22, 
2018, the Department of Defense issued a report that considered the 
efficacy of gender alteration surgery as treatment for gender 
dysphoria. That report noted considerable scientific uncertainty and 
overall lack of high quality scientific evidence demonstrating the 
extent to which transition-related treatments such as sex reassignment 
surgery remedy the multifaceted mental health problems associated with 
gender dysphoria.
    Commenters are specifically invited to address the following 
questions:
    What evidence is available about the safety and effectiveness of 
gender alterations for the treatment of gender dysphoria and how 
reliable is that evidence?
    Given the challenge of the high rates of Veteran suicide, what does 
the evidence, including peer-reviewed evidence, suggest about the 
impact of gender alterations on the rates of suicide and suicide 
ideation among those suffering from gender dysphoria?
    Given that any addition to the medical benefits package will have 
an associated cost and burden on existing specialists, especially 
urological and vascular surgeons and other highly trained specialists 
who are already in shorty supply nationwide, what is the potential 
impact of adding ``gender alterations'' on Veterans' access to care, 
particularly for Veterans facing life-threatening medical conditions 
waiting to see surgical specialists?
    We are providing a 60-day period from the date of publication of 
this Federal Register Notice for the public to submit comments on this 
subject. VA will consider the comments received, and then determine 
whether to propose a regulatory change in response to the Petition for 
Rulemaking. VA will announce any action it takes in the Federal 
Register.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Jacquelyn 
Hayes-Byrd, Acting Chief of Staff, Department of Veterans Affairs, 
approved this document on June 19, 2018, for publication.

Michael Shores,
Director, Office of Regulation Policy & Management, Office of the 
Secretary, Department of Veterans Affairs.
[FR Doc. 2018-14629 Filed 7-6-18; 8:45 am]
 BILLING CODE 8320-01-P

Federal Register / Vol. 83, No. 131 / Monday, July 9, 2018 / Proposed Rules 31711

mine dust consist of interstitial and response to this RFI, respirable coal and mine worker exposure. Congress
obstructive pulmonary diseases (79 FR mine dust sampling data, and directed MSHA to provide assistance
24819). Interstitial lung diseases, like compliance rates for controlling and necessary data to NAS for its study,
coal workers’ pneumoconiosis (CWP) exposure to coal mine dust. which the Agency has done and
and silicosis, have a significant latency continues to do when requested. MSHA
III. Engineering Controls and Best
period between exposure and disease. will evaluate the results of the NAS
Practices
The health effects from exposure to study after the report is final.
respirable coal mine dust may not be As mentioned, since the Dust rule’s
publication and implementation, MSHA David G. Zatezalo,
realized for a decade or more until the
disease becomes clinically apparent. In has continually evaluated respirable Assistant Secretary of Labor for Mine Safety
dust controls and best practices for and Health.
addition, the chronic effects of
interstitial lung diseases, such as CWP compliance with the rule’s [FR Doc. 2018–14536 Filed 7–6–18; 8:45 am]
and silicosis, may progress or worsen requirements. The Agency has met with BILLING CODE 4520–43–P
even after miners are no longer exposed mine operators and miners to provide
to respirable coal mine dust. Thus, mine-specific compliance and technical
miners’ exposure to respirable coal mine assistance. MSHA also held a MSHA/ DEPARTMENT OF VETERANS
dust before final implementation of the NIOSH-sponsored meeting on AFFAIRS
Dust rule on August 1, 2016, may engineering controls and best practices
continue to contribute to the on December 6, 2016. Technical 38 CFR Part 17
development of lung diseases in coal assistance materials and other materials
miners. New miners hired after August from the meeting are available on Exclusion of Gender Alterations From
1, 2016, are the only cohort of coal MSHA’s website at https:// the Medical Benefits Package
miners who are unaffected by exposures www.msha.gov. AGENCY: Department of Veterans Affairs.
that occurred before full MSHA intends to continue its
ACTION: Petition for Rulemaking and
implementation of the Dust rule. consultations and will continue to offer
request for comments.
In the preamble to the Dust rule, technical assistance on best practices for
MSHA stated its intent to take the lead controlling coal mine dust and quartz SUMMARY: On May 9, 2016, the
in conducting a retrospective study exposures. MSHA is interested in the Department of Veterans Affairs (VA)
beginning February 1, 2017 (79 FR engineering controls and best practices received a Petition for Rulemaking
24867), with an unspecified completion that mine operators find most effective petitioning VA to amend its medical
date. Since the Dust rule went into to achieve and maintain the required regulations by removing a provision that
effect, MSHA has analyzed more than respirable coal mine dust and quartz excludes ‘‘gender alterations’’ from its
250,000 respirable dust samples taken levels—particularly those practices that medical benefits package. The effect of
by mine operators who use the CPDM can be replicated throughout coal mines the amendment sought by the
and by MSHA inspectors who use the nationwide to achieve similar results. petitioners would be to authorize gender
gravimetric sampler. MSHA’s analysis alteration surgery as part of VA care
IV. Data Request
shows that more than 99 percent of the when medically necessary. VA seeks
samples were in compliance with the The purpose of this RFI is to solicit comments on the petition to assist in
MSHA respirable coal mine dust comments, data, and information from determining whether to amend the
standards. industry, labor, NIOSH, and other medical benefits package and eliminate
The sample data allow MSHA to stakeholders to assist MSHA in the exclusion of gender alteration from
evaluate the effectiveness of dust developing the framework for a study to VA’s medical benefits package.
controls in mines and whether the rule assess the health effects of the Dust rule.
DATES: Comments must be received/
results in reduced levels of respirable Commenters should be specific about
submitted on or before September 7,
coal dust. However, due to the latency any recommendations they offer,
2018.
between exposure and disease, MSHA including detailed rationales and
likely will not be able to evaluate fully supporting documentation. ADDRESSES: Written comments may be
the health effects of the rule for a decade submitted through http://
V. National Academy of Sciences Study www.regulations.gov; or by mail or hand
or more.
While the Agency continues to MSHA notes that in the Explanatory delivery to Director, Office of Regulation
evaluate the respirable dust samples, Statement to the 2016 Consolidated Policy and Management (00REG),
MSHA also is seeking comments, data, Appropriations Act (Pub. L. 114–113), Department of Veterans Affairs, 810
and information from stakeholders to Congress directed NIOSH to charter a Vermont Ave. NW, Room 1063B,
assist the Agency in developing a National Academy of Sciences (NAS) Washington, DC 20420; or by fax to
framework to assess the health effects of study to examine and describe: Current (202) 273–9026. Comments should
the Dust rule and its impact on the monitoring and sampling protocols and indicate that they are submitted in
health protections provided to coal requirements to understand miners’ response to ‘‘Notice of Petition for
miners going forward. With respect to occupational exposure to respirable coal Rulemaking and request for comments—
suggested elements for a framework, mine dust in the United States and other Exclusion of Gender Alterations from
commenters should be specific and industrialized countries; coal mine dust the Medical Benefits Package.’’ Copies
include detailed rationales and composition and application of comments received will be available
sradovich on DSK3GMQ082PROD with PROPOSALS

supporting documentation, if any. procedures, including the impact of new for public inspection in the Office of
Throughout the comment period, MSHA rock dust mixtures and regulatory Regulation Policy and Management,
will continue to consult with interested requirements; monitoring and sampling Room 1063B, between the hours of 8:00
parties and the Department of Health technologies, along with sampling a.m. and 4:30 p.m., Monday through
and Human Services’ National Institute protocols and frequency; and the Friday (except holidays). Please call
for Occupational Safety and Health efficacy of those technologies and (202) 461–4902 for an appointment.
(NIOSH), as it collects and evaluates all protocols in aiding decisions regarding (This is not a toll-free number.) During
available information, comments in the control of respirable coal mine dust the comment period, comments may

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31712 Federal Register / Vol. 83, No. 131 / Monday, July 9, 2018 / Proposed Rules

also be viewed online through the dysphoria and how reliable is that DATES: Submit comments on or before
Federal Docket Management System evidence? August 8, 2018.
(FDMS) at http://www.regulations.gov. Given the challenge of the high rates ADDRESSES: Mail or deliver written
FOR FURTHER INFORMATION CONTACT:
of Veteran suicide, what does the comments to the manager, Product
Michael Shores, Director, Office of evidence, including peer-reviewed Classification, U.S. Postal Service, 475
Regulation Policy and Management, evidence, suggest about the impact of L’Enfant Plaza SW, Room 4446,
Office of the Secretary, Department of gender alterations on the rates of suicide Washington, DC 20260–5015. If sending
Veterans Affairs, 810 Vermont Avenue and suicide ideation among those comments by email, include the name
NW, Washington DC, 20420; (202) 461– suffering from gender dysphoria? and address of the commenter and send
Given that any addition to the to ProductClassification@usps.gov with
4921.
medical benefits package will have an a subject line of ‘‘New Standards for
SUPPLEMENTARY INFORMATION: Section associated cost and burden on existing Liquids’’. Faxed comments are not
1710 of title 38 United States Code specialists, especially urological and accepted. You may inspect and
(U.S.C.) requires VA to ‘‘furnish hospital vascular surgeons and other highly photocopy all written comments, by
care and medical services which the trained specialists who are already in appointment only, at USPS
Secretary determines to be needed’’ for shorty supply nationwide, what is the Headquarters Library, 475 L’Enfant
eligible veterans. In 1999, VA potential impact of adding ‘‘gender Plaza SW, 11th Floor North,
promulgated 38 CFR 17.38, establishing alterations’’ on Veterans’ access to care, Washington, DC 20260. These records
the Department’s medical benefits particularly for Veterans facing life- are available for review Monday through
package for veterans enrolled in VA’s threatening medical conditions waiting Friday, 9 a.m.–4 p.m., by calling 202–
health care system. 64 FR 54207 (Oct. 6, to see surgical specialists? 268–2906.
1999). The regulation describes the We are providing a 60-day period
FOR FURTHER INFORMATION CONTACT:
types of medical care and services from the date of publication of this
available for such veterans. Care Direct questions to Wm. Kevin Gunther
Federal Register Notice for the public to
referred to in the medical benefits at wkgunther@uspis.gov or phone at
submit comments on this subject. VA
package is provided to individuals only (202) 268–7208, or Michelle Lassiter at
will consider the comments received,
if it is determined by appropriate michelle.d.lassiter@usps.gov or phone at
and then determine whether to propose
healthcare professionals that the care is (202) 268–2914.
a regulatory change in response to the
needed to promote, preserve, or restore Petition for Rulemaking. VA will SUPPLEMENTARY INFORMATION: The Postal
the health of the individual and is in announce any action it takes in the Service and United States Postal
accord with generally accepted Federal Register. Inspection Service (USPIS) have
standards of medical practice. 38 CFR observed an increased frequency of
17.38(b). Paragraph (c) of that section Signing Authority incidents involving containers of liquids
provides a list of medical services the The Secretary of Veterans Affairs, or rupturing while in Postal Service
medical benefits package does not designee, approved this document and networks. A typical result of these
include. Paragraph (c)(4) explicitly authorized the undersigned to sign and incidents is damage to surrounding
excludes ‘‘gender alterations’’ from the submit the document to the Office of the mailpieces and to Postal Service
medical benefits package. Federal Register for publication equipment.
electronically as an official document of When responding to incidents
On May 9, 2016, VA received a
the Department of Veterans Affairs. involving liquid spills, Postal Service
Petition for Rulemaking petitioning VA
Jacquelyn Hayes-Byrd, Acting Chief of employees frequently note that
to amend its medical regulations by
Staff, Department of Veterans Affairs, mailpieces containing liquids are often
removing the exclusion of ‘‘gender
approved this document on June 19, not marked on the outer mailing
alterations’’ from its medical benefits
2018, for publication. container as required by DMM 601.3.4.
package. The petition asks VA to
Many of these leaking mailpieces
remove 38 CFR 17.38(c)(4), allowing VA Michael Shores, contain plastic primary receptacles.
to provide gender alteration surgeries. Director, Office of Regulation Policy & Mailers often do not consider plastic
As part of its ongoing consideration of Management, Office of the Secretary, primary receptacles to be breakable, and
the petition, VA now seeks public Department of Veterans Affairs. therefore do not cushion these primary
comment on the petition and on [FR Doc. 2018–14629 Filed 7–6–18; 8:45 am] receptacles with absorbent material or
whether ‘‘gender alterations’’ should be BILLING CODE 8320–01–P include secondary containers, as
included in the medical benefits specified by DMM 601.3.4.
package. On February 22, 2018, the The Postal Service and USPIS have
Department of Defense issued a report POSTAL SERVICE also observed that spills of non-
that considered the efficacy of gender hazardous materials in relatively small
alteration surgery as treatment for 39 CFR Part 111 quantities can result in damage to
gender dysphoria. That report noted surrounding mailpieces and cause
considerable scientific uncertainty and New Mailing Standards for Mailpieces temporary equipment shutdowns. This
overall lack of high quality scientific Containing Liquids is especially true with viscous or oily
evidence demonstrating the extent to substances, such as oils and lotions.
AGENCY: Postal ServiceTM.
which transition-related treatments such These materials are often mailed by
sradovich on DSK3GMQ082PROD with PROPOSALS

as sex reassignment surgery remedy the ACTION: Proposed rule.
First-Class Package Service®. When
multifaceted mental health problems SUMMARY: The Postal Service is ruptured, they will frequently leak onto
associated with gender dysphoria. proposing to revise Mailing Standards other lightweight mailpieces containing
Commenters are specifically invited of the United States Postal Service, photographs and documents.
to address the following questions: Domestic Mail Manual (DMM) section This proposed revision would require
What evidence is available about the 601.3.4 to provide for more rigorous mailers of all liquids in nonmetal
safety and effectiveness of gender packaging requirements for mailpieces containers, regardless of volume, to
alterations for the treatment of gender containing liquids. provide triple packaging, including

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Document Created: 2018-07-07 00:42:32
Document Modified: 2018-07-07 00:42:32

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Proposed Rules
Action		Petition for Rulemaking and request for comments.
Dates		Comments must be received/submitted on or before September 7, 2018.
Contact		Michael Shores, Director, Office of Regulation Policy and Management, Office of the Secretary, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington DC, 20420; (202) 461-4921.
FR Citation		83 FR 31711