Starting at the end of January, people born in Washington will have a new option when designating their sex on their birth certificates.

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People born in Washington will now have a third choice — X — when defining their sex on a birth certificate.

Anyone born here can change the designation on their birth record from male or female to a single mark of “X,” a nonbinary designation, starting Jan. 27.

The steps are simple, can be done multiple times, and there is no fee. A person completes the request, signs it, has it notarized and submits it to the Department of Health.

“The most important thing is that we are trying to reflect that norms are changing and provide people with options that match their living experience,” said Christie Spice, DOH state registrar and director of Center for Health Statistics. “This is an opportunity to reduce risk of harassment and promote health equity.”

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Washington will be the second state in the U.S. to give an option other than male or female, following Oregon. California’s law will take effect Sept. 1.

The health department defines X as a “gender that is not exclusively male or female, including, but not limited to, intersex, agender, amalgagender, androgynous, bigender, demigender, female-to-male, genderfluid, genderqueer, male-to-female, neutrois, nonbinary, pangender, third sex, transgender, transsexual, Two Spirit, and unspecified.”

For minors, only an adult or legal guardian may apply for the change on the birth certificate. It also requires a statement from the minor’s licensed health care provider that says the request to change sex designation on the birth certificate is consistent with the minor’s identity.

A birth certificate can be a critical document, sometimes used to obtain a license, passport or public benefits; establish proof of citizenship; or even get a job, Spice added.

Through a rule-making process that included public comment and changes to the Washington Administrative Code, DOH will implement the new policy.

Spice said no group drove the change, but the department received more than 1,000 comments, with the majority in favor of it.

Danni Askini, executive director of Seattle-based Gender Justice League, said, “it’s a critical step to eliminate social and legal barriers for nonbinary people that undermine the health, safety and equality of people because of their gender.”

The Family Policy Institute, based in Lynnwood, opposed it.

“We are concerned for one practical reason — the integrity of state records and people being able to change a state record based on their desired expression and intent on any given day,” said Chris Plante, policy director.

He said a birth certificate should “reflect the biological reality,” and is concerned other official documents that reference a sex will change, too.

For the past decade, a person could change a certificate from female to male or from male to female.

Spice said she doesn’t know how many people will take advantage of the change, but said there has been an increase in changes from one sex designation to another with 100 in 2015 and 276 last year.

When asked if other state agencies, such as Department of Licensing and Department of Social and Health Services, will follow suit or be affected by the change, Spice didn’t know.

Christine Anthony, spokesperson for Department of Licensing, said the agency is in the early stages of researching how it would change driver’s licenses, saying it’s unclear if it would be a rule-making process or need legislative approval.

“We want to accommodate people who prefer that on their driver’s license,” she added.