[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 1595 Introduced in Senate (IS)]

<DOC>






118th CONGRESS
  1st Session
                                S. 1595

To prohibit taxpayer-funded gender transition procedures, and for other 
                               purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                              May 15, 2023

 Mr. Marshall (for himself, Mrs. Blackburn, Mr. Braun, Mr. Cramer, Mr. 
Daines, Mrs. Hyde-Smith, Mr. Lee, Mr. Mullin, Mr. Risch, Mr. Rubio, Mr. 
 Wicker, and Mr. Hawley) introduced the following bill; which was read 
             twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To prohibit taxpayer-funded gender transition procedures, and for other 
                               purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``End Taxpayer 
Funding of Gender Experimentation Act of 2023''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
   TITLE I--PROHIBITING FEDERALLY FUNDED GENDER TRANSITION PROCEDURES

Sec. 101. Prohibiting taxpayer-funded gender transition procedures.
Sec. 102. Amendment to table of chapters.
          TITLE II--APPLICATION UNDER THE AFFORDABLE CARE ACT

Sec. 201. Clarifying application of prohibition to premium credits and 
                            cost-sharing reductions under ACA.

   TITLE I--PROHIBITING FEDERALLY FUNDED GENDER TRANSITION PROCEDURES

SEC. 101. PROHIBITING TAXPAYER-FUNDED GENDER TRANSITION PROCEDURES.

    Title 1, United States Code, is amended by adding at the end the 
following new chapter:

 ``CHAPTER 4--PROHIBITING TAXPAYER-FUNDED GENDER TRANSITION PROCEDURES

``Sec.
``301. Prohibition on funding for gender transition procedures.
``302. Prohibition on funding for health benefits plans that cover 
                            gender transition procedures.
``303. Limitation on Federal facilities and employees.
``304. Construction relating to separate coverage.
``305. Construction relating to the use of non-Federal funds for health 
                            coverage.
``306. Construction relating to complications arising from gender 
                            transition procedures.
``307. Definitions.
``Sec. 301. Prohibition on funding for gender transition procedures
    ``No funds authorized or appropriated by Federal law, and none of 
the funds in any trust fund to which funds are authorized or 
appropriated by Federal law, shall be expended for any gender 
transition procedures.
``Sec. 302. Prohibition on funding for health benefits plans that cover 
              gender transition procedures
    ``No funds authorized or appropriated by Federal law, and none of 
the funds in any trust fund to which funds are authorized or 
appropriated by Federal law, shall be expended for health benefits 
coverage that includes coverage of gender transition procedures.
``Sec. 303. Limitation on Federal facilities and employees
    ``No health care service furnished--
            ``(1) by or in a health care facility owned or operated by 
        the Federal Government; or
            ``(2) by any physician or other individual employed by the 
        Federal Government to provide health care services within the 
        scope of the physician's or individual's employment,
may include gender transition procedures.
``Sec. 304. Construction relating to separate coverage
    ``Nothing in this chapter shall be construed as prohibiting any 
individual, entity, or State or locality from purchasing separate 
coverage for gender transition procedures or health benefits coverage 
that includes gender transition procedures so long as such coverage is 
paid for entirely using only funds not authorized or appropriated by 
Federal law and such coverage shall not be purchased using matching 
funds required for a federally subsidized program, including a State's 
or locality's contribution of Medicaid matching funds.
``Sec. 305. Construction relating to the use of non-Federal funds for 
              health coverage
    ``Nothing in this chapter shall be construed as restricting the 
ability of any non-Federal health benefits coverage provider from 
offering coverage for gender transition procedures, or the ability of a 
State or locality to contract separately with such a provider for such 
coverage, so long as only funds not authorized or appropriated by 
Federal law are used and such coverage shall not be purchased using 
matching funds required for a federally subsidized program, including a 
State's or locality's contribution of Medicaid matching funds.
``Sec. 306. Construction relating to complications arising from gender 
              transition procedures
    ``Nothing in this chapter shall be construed to apply to the 
treatment of any infection, injury, disease, or disorder that has been 
caused by or exacerbated by the performance of a gender transition 
procedure.
``Sec. 307. Definitions
    ``For purposes of this chapter:
            ``(1) Biological sex.--The term `biological sex' means the 
        biological indication of male or female in the context of 
        reproductive potential or capacity, such as sex chromosomes, 
        naturally occurring sex hormones, gonads, and non-ambiguous 
        internal and external genitalia present at birth, without 
        regard to an individual's psychological, chosen, or subjective 
        experience of gender.
            ``(2) Cross-sex hormones.--The term `cross-sex hormones' 
        means--
                    ``(A) testosterone or other androgens given to 
                biological females at doses that are profoundly larger 
                or more potent than would normally occur naturally in 
                healthy biological females; and
                    ``(B) estrogen given to biological males at doses 
                that are profoundly larger or more potent than would 
                normally occur naturally in healthy biological males.
            ``(3) Gender.--The term `gender' means the psychological, 
        behavioral, social, and cultural aspects of being male or 
        female.
            ``(4) Gender transition.--The term `gender transition' 
        means the process in which an individual goes from identifying 
        with and living as a gender that corresponds to his or her 
        biological sex to identifying with and living as a gender 
        different from his or her biological sex, and may involve 
        social, legal, or physical changes.
            ``(5) Gender transition procedure.--
                    ``(A) In general.--The term `gender transition 
                procedure' means any medical or surgical service that 
                seeks--
                            ``(i) to alter or remove physical or 
                        anatomical characteristics or features that are 
                        typical for the individual's biological sex; or
                            ``(ii) to instill or create physiological 
                        or anatomical characteristics that resemble a 
                        sex different from the individual's birth sex.
                    ``(B) Inclusions.--For purposes of subparagraph 
                (A), the term `medical or surgical service' includes--
                            ``(i) physician's services;
                            ``(ii) inpatient and outpatient hospital 
                        services;
                            ``(iii) prescribed drugs relating to gender 
                        transition;
                            ``(iv) a medical service that provides--
                                    ``(I) puberty-blocking drugs;
                                    ``(II) cross-sex hormones; or
                                    ``(III) other mechanisms to promote 
                                the development of feminizing or 
                                masculinizing features (in the opposite 
                                sex); and
                            ``(v) gender transition surgery.
                    ``(C) Exclusions.--The term `gender transition 
                procedure' does not include--
                            ``(i) services to individuals born with a 
                        medically verifiable disorder of sex 
                        development, including an individual with 
                        external biological sex characteristics that 
                        are irresolvably ambiguous, such as an 
                        individual born with 46 XX chromosomes with 
                        virilization, an individual born with 46 XY 
                        chromosomes with undervirilization, or an 
                        individual born having both ovarian and 
                        testicular tissue;
                            ``(ii) services provided when a physician 
                        has otherwise diagnosed a disorder of sexual 
                        development in which the physician has 
                        determined through genetic or biochemical 
                        testing that the individual does not have 
                        normal sex chromosome structure, sex steroid 
                        hormone production, or sex steroid hormone 
                        action for a biological male or biological 
                        female; or
                            ``(iii) the treatment of any infection, 
                        injury, disease, or disorder that has been 
                        caused by or exacerbated by the performance of 
                        gender transition procedures, whether or not 
                        the gender transition procedure was performed 
                        in accordance with State and Federal law or 
                        whether or not funding for the gender 
                        transition procedure is permissible under this 
                        chapter.
            ``(6) Gender transition surgery.--
                    ``(A) In general.--The term `gender transition 
                surgery' means any medical or surgical service that 
                seeks to surgically alter or remove healthy physical or 
                anatomical characteristics or features that are typical 
                for the individual's biological sex in order to instill 
                or create physiological or anatomical characteristics 
                that resemble a sex different from the individual's 
                birth sex.
                    ``(B) Inclusions.--The term `gender transition 
                surgery' includes genital gender transition surgery and 
                non-genital gender transition surgery.
                    ``(C) Exclusions.--The term `gender transition 
                surgery' does not include any procedure undertaken 
                because the individual suffers from a physical 
                disorder, physical injury, or physical illness that 
                would, as certified by a physician, place the 
                individual in imminent danger of death or impairment of 
                major bodily function unless the procedure is 
                performed, unless such procedure is performed for the 
                purpose of a gender transition or for the alleviation 
                of psychological or mental distress.
            ``(7) Genital gender transition surgery.--The term `genital 
        gender transition surgery' means a surgical procedure performed 
        for the purpose of assisting an individual with a gender 
        transition, including--
                    ``(A) for biologically male patients, a penectomy, 
                orchiectomy, vaginoplasty, clitoroplasty, and 
                vulvoplasty; and
                    ``(B) for biologically female patients, a 
                hysterectomy/ovariectomy, reconstruction of the fixed 
                part of the urethra with or without a metoidioplasty or 
                a phalloplasty, vaginectomy, scrotoplasty, and 
                implantation of erection or testicular prostheses.
            ``(8) Non-genital gender transition surgery.--The term 
        `non-genital gender transition surgery' means a surgical 
        procedure performed for the purpose of assisting an individual 
        with a gender transition, including--
                    ``(A) for biologically male patients, augmentation 
                mammoplasty, facial feminization surgery, liposuction, 
                lipofilling, voice surgery, thyroid cartilage 
                reduction, gluteal augmentation (implants/lipofilling), 
                hair reconstruction, and various aesthetic procedures; 
                and
                    ``(B) for biologically female patients, 
                subcutaneous mastectomy, voice surgery, liposuction, 
                lipofilling, pectoral implants, and various aesthetic 
                procedures.
            ``(9) Puberty-blocking drugs.--The term `puberty-blocking 
        drugs' means--
                    ``(A) Gonadotropin-releasing hormone (GnRH) 
                analogues or other synthetic drugs used in biological 
                males to stop luteinizing hormone secretion and 
                therefore testosterone secretion; and
                    ``(B) synthetic drugs used in biological females 
                that stop the production of estrogen and progesterone, 
                when used to delay or suppress pubertal development in 
                children for the purpose of assisting an individual 
                with a gender transition.''.

SEC. 102. AMENDMENT TO TABLE OF CHAPTERS.

    The table of chapters for title 1, United States Code, is amended 
by adding at the end the following new item:

``4.  Prohibiting taxpayer-funded gender transition              301''.
                            procedures.

          TITLE II--APPLICATION UNDER THE AFFORDABLE CARE ACT

SEC. 201. CLARIFYING APPLICATION OF PROHIBITION TO PREMIUM CREDITS AND 
              COST-SHARING REDUCTIONS UNDER ACA.

    (a) In General.--
            (1) Disallowance of refundable credit and cost-sharing 
        reductions for coverage under qualified health plan which 
        provides coverage for gender procedures.--
                    (A) In general.--Subparagraph (A) of section 
                36B(c)(3) of the Internal Revenue Code of 1986 is 
                amended by inserting before the period at the end the 
                following: ``or any health plan that includes coverage 
                for gender transition procedures (other than any 
                procedure described in section 306 of title 1, United 
                States Code)''.
                    (B) Option to purchase or offer separate coverage 
                or plan.--Paragraph (3) of section 36B(c) of such Code 
                is amended by adding at the end the following new 
                subparagraph:
                    ``(C) Separate coverage or plan for gender 
                transition procedures allowed.--
                            ``(i) Option to purchase separate coverage 
                        or plan.--Nothing in subparagraph (A) shall be 
                        construed as prohibiting any individual from 
                        purchasing separate coverage for gender 
                        transition procedures described in such 
                        subparagraph, or a health plan that includes 
                        such gender transition procedures, so long as 
                        no credit is allowed under this section with 
                        respect to the premiums for such coverage or 
                        plan.
                            ``(ii) Option to offer coverage or plan.--
                        Nothing in subparagraph (A) shall restrict any 
                        non-Federal health insurance issuer offering a 
                        health plan from offering separate coverage for 
                        gender transition procedures described in such 
                        subparagraph, or a plan that includes such 
                        gender transition procedures, so long as 
                        premiums for such separate coverage or plan are 
                        not paid for with any amount attributable to 
                        the credit allowed under this section (or the 
                        amount of any advance payment of the credit 
                        under section 1412 of the Patient Protection 
                        and Affordable Care Act).''.
            (2) Disallowance of small employer health insurance expense 
        credit for plan which includes coverage for gender transition 
        procedures.--Subsection (h) of section 45R of the Internal 
        Revenue Code of 1986 is amended--
                    (A) by striking ``Any term'' and inserting the 
                following:
            ``(1) In general.--Any term''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(2) Exclusion of health plans including coverage for 
        gender transition procedures.--
                    ``(A) In general.--The term `qualified health plan' 
                does not include any health plan that includes coverage 
                for gender transition procedures (other than any 
                procedure described in section 306 of title 1, United 
                States Code).
                    ``(B) Separate coverage or plan for gender 
                transition procedures allowed.--
                            ``(i) Option to purchase separate coverage 
                        or plan.--Nothing in subparagraph (A) shall be 
                        construed as prohibiting any employer from 
                        purchasing for its employees separate coverage 
                        for gender transition procedures described in 
                        such subparagraph, or a health plan that 
                        includes such gender transition procedures, so 
                        long as no credit is allowed under this section 
                        with respect to the employer contributions for 
                        such coverage or plan.
                            ``(ii) Option to offer coverage or plan.--
                        Nothing in subparagraph (A) shall restrict any 
                        non-Federal health insurance issuer offering a 
                        health plan from offering separate coverage for 
                        gender transition procedures described in such 
                        subparagraph, or a plan that includes such 
                        gender transition procedures, so long as such 
                        separate coverage or plan is not paid for with 
                        any employer contribution eligible for the 
                        credit allowed under this section.''.
    (b) Application to Multi-State Plans.--Section 1334(a) of Public 
Law 111-148 (42 U.S.C. 18054(a)) is amended by adding at the end the 
following new paragraph:
            ``(7) Coverage consistent with federal policy regarding 
        gender transition procedures.--In entering into contracts under 
        this subsection, the Director shall ensure that no multi-State 
        qualified health plan offered in an Exchange provides health 
        benefits coverage for which the expenditure of Federal funds is 
        prohibited under chapter 4 of title 1, United States Code.''.
    (c) Effective Date.--The amendments made by subsection (a) shall 
apply to taxable years ending after the date that is 1 year after the 
date of enactment of this Act, but only with respect to plan years 
beginning after such date, and the amendment made by subsection (b) 
shall apply to plan years beginning after such date.
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