The “Sex-check” and Genetic Determinism in Genetic Testing

The “Sex-check” and Genetic Determinism in Genetic Testing

by and | May 9, 2022 | Genetics and Society

Genetic testing offers an opportunity for individuals to learn more about their risk of developing certain diseases and their genealogy.  Both direct to consumer (genetic tests you can order online, such as 23andMe or Ancestry.com) and clinical genetic testing are becoming much more accessible and popular as genetic testing technology advances. As of 2019, more than 2.6 million people had purchased direct to consumer genetic tests in the United States (Regaldo 2019). As genetic technology advances, our understanding of the ethical, legal, and social implications of genetic technology has not kept pace (Phillips et al. 2018; Schaper and Schicktanz 2018), particularly in regard to one process of quality control – the “sex check”.

The sex check is common practice in clinical genetics, direct-to-consumer genetic testing, and genetic research (Mathias et al. 2016; Coleman et al. 2016; Hunter-Zinck et al. 2020; Turner et al. 2011). It involves comparing an individual’s sex chromosomes against their sex or gender. Sometimes, the only information that is available in a clinical or research setting may be either their sex or gender, and it may not be clear which is reported. Although sex and gender are often used interchangeably in genetic research and by genetic scientists, they capture different constructs.

Sex refers to an individual’s sexual chromosome composition or their biological sex characteristics while gender refers to an individual’s internal sense of their gender, whether it be male, female, both, or neither (TSER n.d.). Running the sex check during quality control in genetic testing checks that individuals with a sex or gender that may not be self-reported but is listed as Female have XX chromosomes and individuals with sex or gender that may not be self-reported but is listed as Male have XY chromosomes.

The purpose of this check is to make sure that the sample being processed belongs to the correct individual. Individuals whose sex chromosomes do not match their reported sex or gender are followed up with to ensure the correct sample is being processed for the right person (in the case of clinical or DTC genetic testing) or are removed from a dataset (in a research setting). The utility of this measure is limited; as pointed out by Warmerdam et al. (2021), it does nothing to differentiate sample mix ups between two individuals with the same sex chromosomes. It is only applicable to sample of individuals which contains multiple sexes, and for a sample which contains half people with XX chromosomes and half people with XY chromosomes, it is only 50% effective (Warmerdam et al. 2021). Standard, primary sample quality control procedures in genetic testing include identifying individuals with poor DNA quality, with high variation across autosomal chromosomes, mismatched sex information, removing duplicated or related samples, and running analysis stratified by continental ancestry (Mills, Barban, and Tropf 2020). Additionally, clinical genetic testing, and typically research, involves signing an informed consent at the time that the sample for genetic testing is collected.

Ample procedures are already in place to ensure that the correct sample is matched to the right person. The argument to include the sex-check in genetic testing is weak at best and at its worst it has the effect of either singling transgender individuals or excluding transgender people from genetic research altogether.

Excluding transgender people from genetic research or singling them out in clinical practice directly contributes to the stigma and discrimination that transgender folks experience within the American healthcare system (Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities 2011). Multiple studies have found that transgender individuals do not seek out healthcare services due to previous negative experiences and medical distrust, resulting in decreased healthcare access and worse health outcomes within the transgender community (Barnes, Morris, and Austin 2020; Kosenko et al. 2013; Rolle et al. 2021).

The sex check inherently “others” transgender individuals not only by reminding them of something they may already feel insecure about , but also by perpetuating the idea that biological sex determines gender, a concept tied to genetic determinism (McKeague and Terry 2019). Genetic determinism refers to the belief that our genetic makeup is the sole factor in determining our individual characteristics (Sarraf and Woodley of Menie, Michael A. 2019). This concept has historically been weaponized against the transgender community, particularly in public policy.

An example of the implications of genetic determinism for transgender people and how this ideology results in exclusion of trans individuals lies in the growing national conversation on transgender athletes and whether they should be allowed to participate in competitive sports. Controversial “sex verification,” including molecular tests to identify sex chromosomes, were introduced to determine eligibility for athletes to compete in gendered sporting events in the 1960s (Tucker and Collins 2010). Today, transgender athletes are permitted to compete in the category that is consistent with their gender identity given that they follow certain protocols, such as hormone level monitoring. However, there is still debate as to whether a performance advantage exists for trans women, leading some to argue for reintroduction of genetic testing in this arena. Lia Thomas is the most recent trans athlete to be under public scrutiny for competing in women’s sports (Ghorayshi 2022). This is a reiteration of the same genetic determinism that trans athletes and trans people more broadly have faced for years. Cisgender people see trans people as a threat in sports because of their perceived, unfair advantage due to their biological makeup.

Efforts are being made to move away from genetic determinism (particularly in the clinical space) to be more inclusive of transgender patients, but they often do not go far enough to protect trans people who are receiving clinical care. For example, genetic counselors are currently adapting their practices to be more welcoming and inclusive of folks with varying gender identities. Some of these efforts include use of intake forms that ask for pronouns and gender identity, creation of new pedigree nomenclature that affirms trans and non-binary individuals’ gender identities, and implementation of gender-inclusive language when describing genetics concepts (Barnes, Morris, and Austin 2020; Rolle et al. 2021; Sheehan et al. 2020). Still, an abundance of research describes the negative experiences of trans patients undergoing genetic counseling or genetic testing in a clinical setting. Experiences in a healthcare setting induce anticipatory anxiety for trans people, and it is the responsibility of clinicians to create safety and clarity (Barnes, Morris, and Austin 2020; Rolle et al. 2021).

Clinicians need to clearly communicate with trans patients how and when information about their sex and gender will be used in genetic testing (Barnes, Morris, and Austin 2020). Additionally, it is necessary to take additional steps that validate individuals’ gender identities and to use inclusive language throughout the process of genetic counseling and genetic testing (Barnes, Morris, and Austin 2020; Rolle et al. 2021).

Genetic testing companies are taking steps to be more inclusive by creating “best practices” for processing genetic tests for their transgender clients. For example, Color Genomics has integrated questions about gender identity and sex assigned at birth into their health history intake, as well as a disclaimer that gendered information within a genetic test report may not reflect their identity (Mar et al. 2020). Direct-to-consumer genetic testing company 23andMe allows for customers to self-report their “profile sex” with which they identify, and advise that during sample processing if “genetic sex” does not match selected profile sex they will notify the customer, who can validate that the difference was expected (23andMe n.d.). Other genetic testing companies also notify or call patients when this occurs to ask them to confirm their sex assigned at birth. This process of validating the difference between profile sex and chromosomal sex, in practice, singles out trans people by creating an incredibly uncomfortable experience and presenting an additional barrier to care.

Another concern in the process of genetic testing lies in the return of results. Genetic testing reports that make suggestions for preventative care are inherently gendered. For example, a positive result for a BRCA1 mutation may state that women with a mutation should receive regular mammograms without considering that not all individuals with breasts may identify as women. For both 23andMe and Color Genomics, the test report that is returned to consumers still contains gendered information, such as labels like “maternal” or “paternal”, no matter how the customer or their relatives identify.  Altogether, the consequence of the practices of these genetic testing companies are only somewhat successful in preventing negative experiences or interactions with their transgender clients.

To make genetic testing more approachable and more inclusive to individuals whose gender identities don’t match their sex chromosomes, we need to carefully consider how the sex check is being used and exactly how necessary it is. Given all of this information, we make the following recommendations:

First, we call for genetic testing companies and genetic researchers to think carefully about the necessity of the sex-check, and to implement alternative quality control procedures when appropriate. While alternative methods compare other phenotypic characteristics with a sample’s genotype, new methods which rely on the generation of polygenic risk scores have been shown to be more effective in identifying sample mix ups (Warmerdam et al. 2021).

When necessary, researchers and genetic testing companies should utilize and collect information on both sex assigned at birth and gender identity to ensure that individuals whose chromosomes do not match their reported sex are not singled out in the genetic testing process.

Additionally, we suggest updating language in the genetic testing process to be more inclusive, such as changes to pedigree nomenclature and avoidance of gendered language such as “maternal” or “paternal”. Moving forward, it is our responsibility as genetics professionals to address the historical exclusion and discrimination of trans people within the fields of clinical and research genetics and to ensure that an individual’s genetic makeup will not be weaponized against them.

References

Barnes, Heather, Emily Morris, and Jehannine Austin. 2020. “Trans-Inclusive Genetic Counseling Services: Recommendations from Members of the Transgender and Non-Binary Community.” Journal of Genetic Counseling 29 (3): 423–34.

Coleman, Jonathan R. I., Jack Euesden, Hamel Patel, Amos A. Folarin, Stephen Newhouse, and Gerome Breen. 2016. “Quality Control, Imputation and Analysis of Genome-Wide Genotyping Data from the Illumina HumanCoreExome Microarray.” Briefings in Functional Genomics 15 (4): 298–304.

De Sloover D. Servais L. Zhou A. & Topper S., Mar L. Rieger K. Helm Stamp M. Musselman-Brown A. . 2020. “Designing for Inclusivity in Population Genomics.” Color Genetics. 2020. https://www.color.com/wp-content/uploads/2020/05/2020_ACMG_Poster_Gender_final.pdf.

Ghorayshi, A. 2022. “Trans Swimmer Revives an Old Debate in Elite Sports: What Defines a Woman?” The New York Times, 2022.

Hunter-Zinck, Haley, Yunling Shi, Man Li, Bryan R. Gorman, Sun-Gou Ji, Ning Sun, Teresa Webster, et al. 2020. “Genotyping Array Design and Data Quality Control in the Million Veteran Program.” American Journal of Human Genetics 106 (4): 535–48.

“I’m Transgender. Will This Impact My DNA Test Kit Experience?” n.d. 23andMe. Accessed February 20, 2022. https://customercare.23andme.com/hc/en-us/articles/115015843628-I-m-Transgender-Will-This-Impact-My-DNA-Test-Kit-Experience-.

Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US).

Kosenko, Kami, Lance Rintamaki, Stephanie Raney, and Kathleen Maness. 2013. “Transgender Patient Perceptions of Stigma in Health Care Contexts.” Medical Care 51 (9): 819–22.

Mathias, Patrick C., Emily H. Turner, Sheena M. Scroggins, Stephen J. Salipante, Noah G. Hoffman, Colin C. Pritchard, and Brian H. Shirts. 2016. “Applying Ancestry and Sex Computation as a Quality Control Tool in Targeted Next-Generation Sequencing.” American Journal of Clinical Pathology 145 (3): 308–15.

McKeague, Madelyn, and Sharon F. Terry. 2019. “Let’s Talk about Sex: Understanding Gender beyond Genetics.” Genetic Testing and Molecular Biomarkers 23 (9): 599–600.

Mills, Melinda C., Nicola Barban, and Felix C. Tropf. 2020. An Introduction to Statistical Genetic Data Analysis an Introduction to Statistical Genetic Data Analysis. The MIT Press. London, England: MIT Press.

Phillips, Kathryn A., Patricia A. Deverka, Gillian W. Hooker, and Michael P. Douglas. 2018. “Genetic Test Availability and Spending: Where Are We Now? Where Are We Going?” Health Affairs (Project Hope) 37 (5): 710–16.

Regaldo, A. 2019. “More than 26 Million People Have Taken an At-Home Ancestry Test.” MIT Technology Review, 2019.

Rolle, Lathel, Kimberly Zayhowski, Diane Koeller, Dee Chiluiza, and Nikkola Carmichael. 2021. “Transgender Patients’ Perspectives on Their Cancer Genetic Counseling Experiences.” Journal of Genetic Counseling, December. https://doi.org/10.1002/jgc4.1544.

Sarraf, Matthew A., and Woodley of Menie, Michael A. 2019. “Genetic Determinism.” In Encyclopedia of Evolutionary Psychological Science, edited by Todd K. Shackelford and Viviana A. Weekes-Shackelford, 1–14. Cham: Springer International Publishing.

Schaper, Manuel, and Silke Schicktanz. 2018. “Medicine, Market and Communication: Ethical Considerations in Regard to Persuasive Communication in Direct-to-Consumer Genetic Testing Services.” BMC Medical Ethics 19 (1). https://doi.org/10.1186/s12910-018-0292-3.

Sheehan, Elizabeth, Robin L. Bennett, Miles Harris, and Gayun Chan-Smutko. 2020. “Assessing Transgender and Gender Non-Conforming Pedigree Nomenclature in Current Genetic Counselors’ Practice: The Case for Geometric Inclusivity.” Journal of Genetic Counseling 29 (6): 1114–25.

Trans Student Educational Resources. n.d. “The Gender Unicorn.” Transforming Education. Accessed April 27, 2022. https://transstudent.org/gender/.

Tucker, Ross, and Malcolm Collins. 2010. “The Science of Sex Verification and Athletic Performance.” International Journal of Sports Physiology and Performance 5 (2): 127–39.

Turner, Stephen, Loren L. Armstrong, Yuki Bradford, Christopher S. Carlson, Dana C. Crawford, Andrew T. Crenshaw, Mariza de Andrade, et al. 2011. “Quality Control Procedures for Genome-Wide Association Studies.” Current Protocols in Human Genetics / Editorial Board, Jonathan L. Haines … [et Al.] Chapter 1 (January): Unit1.19.

Warmerdam, Robert, Pauline Lanting, Lifelines Cohort Study, Patrick Deelen, and Lude Franke. 2021. “Idéfix: Identifying Accidental Sample Mix-Ups in Biobanks Using Polygenic Scores.” Bioinformatics (Oxford, England) 38 (4): 1059–66.

The Genetic Information Nondiscrimination Act Allows for Too Much Discrimination

The Genetic Information Nondiscrimination Act Allows for Too Much Discrimination

by | Mar 23, 2021 | Genetics and Society

In recent years direct-to-consumer (DTC) genetic tests have become so accessible, becoming something of a cultural phenomenon. As of 2021 there are more than 77,000 different types of genetic tests being performed around the world for more than 10,000 different conditions with more than 300 labs performing these tests in the U.S alone [1]. By 2019, 26 million Americans had taken part in DTC genetic testing, through companies such as FamilyTree DNA, Ancestry.com, and 23andMe [2].

Today, using these tests, I could find out that I carry a mutation in the BRCA1 gene. The presence of this mutation means that I would have more than a five-fold increase in my lifetime risk for breast cancer and more than a thirty-six fold increase in my lifetime risk for ovarian cancer [3]. The good news is that equipped with the knowledge of this mutation, I could take life-saving preventive measures to mitigate that cancer risk [4]. The bad news is that in some states a variety of companies can now use this genetic information to legally discriminate against me if I were to apply for some type of economic benefit, such as a mortgage or life insurance. These companies can request my genetic test result and use the result to deny my application altogether, to justify setting different terms of agreement, or deny my application if I refuse to give them the information.

The only federal law that prohibits discrimination on the basis of one’s genetics prior to the manifestation of a disease or disorder is the 2008 Genetic Information Nondiscrimination Act (GINA) [5]. One of the intentions of GINA is to allow Americans to take advantage of personalized medicine, like testing for the BRCA1 genetic mutation, without fear of discrimination [6]. GINA defines “genetic information” as an individual’s genetic tests, the genetic tests of family members, and the manifestation of disease in family members [5]. GINA provides significant protections against genetic discrimination in employment and health insurance settings. Title I of GINA prohibits health insurers from using genetic information to determine an individual’s eligibility or coverage, underwriting, or premium-setting decisions [5]. Title I also prohibits health insurers from requesting or requiring individuals or their family members to undergo genetic testing or provide genetic information [5]. These protections extend to private insurers, Medicare, Medicaid, Federal Employees Health Benefits, and the Veterans Health Administration [7-8]. Title II of GINA prohibits employers from using genetic information in employment decisions and requiring or requesting genetic information from applicants or employees [5].

While the protections GINA provides are important, they don’t go far enough. It is unlikely that at the time of GINA’s passage in 2008 the government anticipated the DTC genetic testing boom. GINA does not provide protections in a wide variety of important scenarios. For instance, GINA does not ban genetic discrimination in any other realms outside of employment and health insurance. This leaves out different types of insurance coverage, including long term care, disability, and life insurance [9-10], as well as applications for housing, education, or mortgage lending [10]. It is legal in some states for a mortgage lender to request genetic information from an applicant to estimate if they will be healthy long enough to pay off their loan. The mortgage lender can then use this information to decide if they are going to deny a loan application altogether, set higher interest rates, or set shorter loan terms for those with genetic information that suggests they are genetically predisposed to being unhealthy. These companies have the right to deny your application based on your test results or if you don’t provide them with the genetic information they want.

Furthermore, GINA only protects those who have not yet manifested a disease, even though the distinction between an asymptomatic individual and an individual that has manifested a disease is frequently ambiguous [11]. Those who have already manifested a genetic condition must rely on other laws, like the Americans with Disabilities Act (ADA), for legal protection [7]. GINA also does not apply to everyone. GINA does not apply to employers with fewer than 15 employees and only applies to the military in part [5]. GINA protects military members from discrimination in the military’s TRICARE health insurance program. However, one must be a member of the military to enroll in TRICARE and the GINA does not prohibit the military from using genetic information to make employment decisions [8]. However, military policies are in place that mirror GINA in many ways [9]. Interestingly, the Department of Defense (DoD) has officially advised all military members to refrain from direct-to-consumer genetic testing [12], which is counterintuitive to one of the previously mentioned underlying purposes of GINA, to encourage people to take advantage of genetic testing without fear of discrimination [6].

Some states have recognized these shortcomings and have enacted state level legislation to provide additional protections within their borders, but the protections they offer vary widely in scope from state to state [8]. In 2011, California enacted Cal-GINA, one of the most inclusive genetic nondiscrimination state statutes [8,13]. Cal-GINA expanded protections against genetic discrimination in housing, employment, education, public accommodations, health insurance coverage, life insurance coverage, mortgage lending, elections and to employers with 5 or more employees [13]. Cal-GINA amended the Unruh Civil Rights Act to make genetic information a protected class [14] outlawing genetic discrimination in “all business establishments of every kind whatsoever” [15]. Cal-GINA also allows for individuals to seek unlimited damages, which the federal GINA caps at $50,000-$300,000 dependent upon the size of the defendant [16]. In contrast, Maryland passed one of the least inclusive genetic nondiscrimination state statutes in 2008. Maryland House Bill 29 stated that if a long-term care insurance company can provide evidence that the genetic test result would be useful to them financially, they can request and use it to determine insurance eligibility and premiums [17]. Moreover, this bill did not provide protections for either life or disability insurance.

According to a 2012 analysis, 13 states had restricted the use of genetic information in life insurance, 14 states had restricted it’s use in disability insurance, and 11 states had restricted it’s use in long-term care insurance [18]. Only a handful of states had laws that regulated all three types of insurance [18]. Ultimately, this patchwork of legislation is confusing and contributes to American’s fears and concerns surrounding genetic testing and discrimination. The interstate variability in genetic nondiscrimination laws makes it difficult for consumers of genetic testing to navigate and are insufficient to deal with the widespread use of genetic testing, including both clinical and DTC genetic testing, across all 50 states.

GINA needs to be expanded at the federal level to provide consistent nationwide protections to Americans. With so many ways in which genetic information can be misused, federal genetic nondiscrimination legislation must be broad [14]. Therefore, GINA should be expanded at the federal level to mimic Cal-GINA by extending genetic discrimination protections to housing, employment, education, public accommodations, health insurance coverage, life insurance coverage, mortgage lending, elections, employers with 5 or more employees [12] and in “all business establishments of every kind whatsoever” [15]. This would truly provide comprehensive protection from genetic discrimination to all Americans.

The longer GINA remains unchanged more Americans will face genetic discrimination. This may contribute to Americans forgoing genetic testing, both DTC and medically recommended, out of fear that they will later face genetic discrimination as a result. Additionally, Americans may forgo participating in genetics research for the same fearful reasons, ironically leading to stagnation in this field of science, and ultimately slowing progress towards the cures and treatments of the genetic diseases we are discriminating against.

My ask is simple: do some more research yourself and start informing your friends, family, and colleagues about this issue. Then, request that your representatives get familiar with this issue so they can advocate for the expansion of GINA at the federal level to mimic Cal-GINA to widely prohibit genetic discrimination throughout the U.S. Here are some resources to help you get started.

References

[1] Rubinstein, W. S., Maglott, D. R., Lee, J. M., Kattman, B. L., Malheiro, A. J., Ovetsky, M., … Ostell, J. M. (2012). The NIH genetic testing registry: a new, centralized database of genetic tests to enable access to comprehensive information and improve transparency. Nucleic Acids Research, 41(D1), D925–D935. https://doi.org/10.1093/nar/gks1173

[2] Regalado, A. (2020, June 19). More than 26 million people have taken an at-home ancestry test. Retrieved December 13, 2020, from https://www.technologyreview.com/2019/02/11/103446/more-than-26-million-people-have-taken-an-at-home-ancestry-test/

[3] Kuchenbaecker, K. B., Hopper, J. L., Barnes, D. R., Phillips, K.-A., Mooij, T. M., Roos-Blom, M.-J., … Olsson, H. (2017). Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA, 317(23), 2402. https://doi.org/10.1001/jama.2017.7112

[4] Kotsopoulos, J. (2018). BRCA Mutations and Breast Cancer Prevention. Cancers, 10(12), 524. https://doi.org/10.3390/cancers10120524

[5] Genetic Information Nondiscrimination Act of 2008. (n.d.). Retrieved November 21, 2020, from https://www.congress.gov/bill/110th-congress/house-bill/493/text

[6] Suter, S. M. (2018). GINA at 10 years: the battle over ‘genetic information’ continues in court. Journal of Law and the Biosciences, 5(3), 495–526. https://doi.org/10.1093/jlb/lsz002

[7] Congressional Research Service. (2015, August). The Genetic Information Nondiscrimination Act of 2008 (GINA)(RL34584). Retrieved from https://crsreports.congress.gov/product/pdf/RL/RL34584

[8] National Human Genome Research Institute. (2020a, August 3). Genome Statute and Legislation Database. Retrieved November 20, 2020, from https://www.genome.gov/about-genomics/policy-issues/Genome-Statute-Legislation-Database

[9] Baruch, S., & Hudson, K. (2008). Civilian and Military Genetics: Nondiscrimination Policy in a Post-GINA World. The American Journal of Human Genetics, 83(4), 435–444. https://doi.org/10.1016/j.ajhg.2008.09.003

[10] Zhang, S. (2017, March 13). The Loopholes in GINA, the Law Prohibiting Genetic Discrimination. The Atlantic. Retrieved from https://www.theatlantic.com

[11] Areheart, B. A., & Roberts, J. L. (2019). GINA, Big Data, and the Future of Employee Privacy. Yale Law Journal, 128(3), 710–790. Retrieved from https://advance-lexis-com.offcampus.lib.washington.edu/api/document?collection=analytical-materials&id=urn:contentItem:5VCK-7150-02BN-10RB-00000-00&context=1516831.

[12] Department of Defense. (2019, December). Direct-to-Consumer Genetic Testing Advisory for Military Members. Retrieved from https://www.scribd.com/document/440727436/DOD-memo-on-DNA-testing#from_embed

[13] Senate Bill No. 559, Chapter 261. (2011, September 6). Retrieved November 21, 2020 from https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120SB559

[14] Prince, A. E. R. (2013). Comprehensive Protection of Genetic Information : One Size Privacy or Property Models May Not Fit All. Brooklyn Law Review, 79, 175. Retrieved from https://advance-lexis-com.offcampus.lib.washington.edu/api/document?collection=analytical-materials&id=urn:contentItem:5BSP-GBB0-00CV-M0N8-00000-00&context=1516831.

[15] Unruh Civil Rights Act. (1959). Retrieved from https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV§ionNum=51

[16] Rothstein, M. A., & Rothstein, L. (2017). FEATURE, THE USE OF GENETIC INFORMATION IN REAL PROPERTY TRANSACTIONS, 31 Probate & Property 13. Retrieved January 10, 2021, from https://advance-lexis-com.offcampus.lib.washington.edu/document?crid=39b943d7-95ff-4fd4-9b62-f69306140616&pddocfullpath=%2Fshared%2Fdocument%2Fanalytical-materials%2Furn%3AcontentItem%3A5P09-Y730-00DB-537M-00000-00&pdsourcegroupingtype=&pdcontentcomponentid=155878&pdmfid=1516831&pdisurlapi=true#

[17] House Bill 29. (2008, May 22). Retrieved November 23, 2020, from http://mgaleg.maryland.gov/mgawebsite/search/legislation?target=/2008rs/billfile/hb0029.htm

[18] Beyond GINA, States Build Patchwork of Protections. (2012, August 22). Retrieved November 23, 2020, from https://www.genomeweb.com/archive/beyond-gina-states-build-patchwork-protections#.X7w0vy9h0_V

[19] National Human Genome Research Institute. (2020b, September 16). Genetic Discrimination. Retrieved November 22, 2020, from https://www.genome.gov/about-genomics/policy-issues/Genetic-Discrimination