[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 2357 Introduced in Senate (IS)]

<DOC>






118th CONGRESS
  1st Session
                                S. 2357

   To amend chapter 110 of title 18, United States Code, to prohibit 
        gender-affirming care on minors, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             July 18, 2023

   Mr. Vance introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
   To amend chapter 110 of title 18, United States Code, to prohibit 
        gender-affirming care on minors, 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.

    This Act may be cited as the ``Protect Children's Innocence Act''.

          TITLE I--GENDER-AFFIRMING CARE ON MINORS PROHIBITED

SEC. 101. GENDER-AFFIRMING CARE ON MINORS PROHIBITED.

    Chapter 110 of title 18, United States Code, is amended--
            (1) by adding at the end the following:
``Sec. 2260B. Gender-affirming care on minors
    ``(a) Definitions.--In this section:
            ``(1) Biological sex.--The term `biological sex' means the 
        indication of male or female sex by reproductive potential or 
        capacity, sex chromosomes, naturally occurring sex hormones, 
        gonads, or internal or external genitalia present at birth.
            ``(2) Gender-affirming care.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), the term `gender-affirming care' 
                means, with respect to an individual, any of the 
                following:
                            ``(i) Performing any surgery for the 
                        purpose of changing the body of the individual 
                        to correspond to a sex that differs from the 
                        individual's biological sex, including--
                                    ``(I) castration;
                                    ``(II) orchiectomy;
                                    ``(III) scrotoplasty;
                                    ``(IV) vasectomy;
                                    ``(V) hysterectomy;
                                    ``(VI) oophorectomy;
                                    ``(VII) ovariectomy;
                                    ``(VIII) metoidioplasty;
                                    ``(IX) penectomy;
                                    ``(X) phalloplasty;
                                    ``(XI) vaginoplasty;
                                    ``(XII) vaginectomy;
                                    ``(XIII) vulvoplasty;
                                    ``(XIV) reduction 
                                thyrochondroplasty;
                                    ``(XV) chondrolaryngoplasty; and
                                    ``(XVI) mastectomy.
                            ``(ii) Any plastic surgery that feminizes 
                        or masculinizes the facial features of the 
                        individual for the purposes described in clause 
                        (i).
                            ``(iii) Any placement of chest implants in 
                        the individual to create feminine breasts for 
                        the purposes described in clause (i).
                            ``(iv) Any placement of fat or artificial 
                        implants in the gluteal region of the 
                        individual for the purposes described in clause 
                        (i).
                            ``(v) Administering, supplying, 
                        prescribing, dispensing, distributing, or 
                        otherwise conveying to the individual 
                        medications for the purposes described in 
                        clause (i), including--
                                    ``(I) gonadotropin-releasing 
                                hormone (commonly known as `GnRH') 
                                analogues or other puberty-blocking 
                                drugs to stop or delay normal puberty;
                                    ``(II) testosterone or other 
                                androgens to a biological female at 
                                doses that are supraphysiologic to the 
                                female sex; and
                                    ``(III) estrogen to a biological 
                                male at doses that are supraphysiologic 
                                to the male sex.
                    ``(B) Exception.--Subparagraph (A) shall not apply 
                to conduct with respect to the following individuals:
                            ``(i) An individual with both ovarian and 
                        testicular tissue.
                            ``(ii) An individual who does not have 
                        normal sex chromosome structure, sex steroid 
                        hormone production, or sex steroid hormone 
                        action, as determined by a physician through 
                        genetic or biochemical testing.
                            ``(iii) An individual experiencing 
                        infection, disease, injury, or disorder caused 
                        or exacerbated by previous gender transition 
                        procedures.
                            ``(iv) An individual suffering 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 a major bodily 
                        function unless a procedure described in that 
                        subparagraph is performed.
            ``(3) Minor.--The term `minor' means any individual under 
        the age of 18 years.
    ``(b) Prohibition on Performing Gender-affirming Care on Minors.--
            ``(1) Offense.--It shall be unlawful, in any circumstance 
        described in subsection (e), to knowingly perform any gender-
        affirming care on a minor.
            ``(2) Penalty.--Any person who violates paragraph (1) shall 
        be fined under this title, imprisoned for not more than 12 
        years, or both.
    ``(c) Prohibition on Prosecution of Person on Whom Intervention Is 
Performed.--A person on whom gender-affirming care is performed may not 
be arrested or prosecuted for an offense under subsection (b).
    ``(d) Civil Action.--A person on whom gender-affirming care is 
performed in violation of subsection (b) may bring a civil action in an 
appropriate district court of the United States for appropriate relief, 
including compensatory and punitive damages, against each person who 
performed the gender-affirming care.
    ``(e) Circumstances Described.--The circumstances referred to in 
subsection (b) are that--
            ``(1) the defendant or victim traveled in interstate or 
        foreign commerce, or traveled using a means, channel, facility, 
        or instrumentality of interstate or foreign commerce, in 
        furtherance of or in connection with the conduct described in 
        that subsection;
            ``(2) the defendant used a means, channel, facility, or 
        instrumentality of interstate or foreign commerce in 
        furtherance of or in connection with the conduct described in 
        that subsection;
            ``(3) any payment of any kind was made, directly or 
        indirectly, in furtherance of or in connection with the conduct 
        described in that subsection using any means, channel, 
        facility, or instrumentality of interstate or foreign commerce 
        or in or affecting interstate or foreign commerce;
            ``(4) the defendant transmitted in interstate or foreign 
        commerce any communication relating to or in furtherance of the 
        conduct described in that subsection--
                    ``(A) using any means, channel, facility, or 
                instrumentality of interstate or foreign commerce; or
                    ``(B) in or affecting interstate or foreign 
                commerce by any means or in any manner, including by 
                computer, mail, wire, or electromagnetic transmission;
            ``(5) any instrument, item, substance, or other object that 
        has traveled in interstate or foreign commerce was used to 
        perform the conduct described in that subsection;
            ``(6) the conduct described in that subsection occurred 
        in--
                    ``(A) the special maritime and territorial 
                jurisdiction of the United States; or
                    ``(B) a territory or possession of the United 
                States; or
            ``(7) the conduct described in that subsection otherwise 
        occurred in or affected interstate or foreign commerce.
    ``(f) Rule of Construction.--Nothing in this section shall be 
construed as prohibiting provision of the medical services described in 
subsection (a)(2)(A) to address legitimate health issues, such as any 
male or female reproductive cancers, apart from changing the body of an 
individual to correspond to a sex that differs from the individual's 
biological sex.''; and
            (2) in the table of sections, by adding at the end the 
        following:

``2260B. Gender-affirming care on minors.''.

      TITLE II--PROHIBITING FEDERALLY FUNDED GENDER-AFFIRMING CARE

SEC. 201. PROHIBITING TAXPAYER-FUNDED GENDER-AFFIRMING CARE.

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

     ``CHAPTER 4--PROHIBITING TAXPAYER-FUNDED GENDER-AFFIRMING CARE

``301. Prohibition on funding for gender-affirming care.
``302. Prohibition on funding for health benefits plans that cover 
                            gender-affirming care.
``303. Limitation on Federal facilities and employees, Federal land and 
                            territories, and Tribal territories.
``304. Effect on separate coverage.
``305. Effect on use of non-Federal funds for health coverage.
``306. Application to complications arising from gender-affirming care.
``307. Application to individuals born with medically verifiable 
                            disorder of sex development.
``308. Gender-affirming care defined.
``309. Effect of chapter.
``Sec. 301. Prohibition on funding for gender-affirming care
    ``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, including funds provided under titles 
XVIII, XIX, and XXI of the Social Security Act, shall be expended for 
any gender-affirming care.
``Sec. 302. Prohibition on funding for health benefits plans that cover 
              gender-affirming care
    ``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-affirming care.
``Sec. 303. Limitation on Federal facilities and employees, Federal 
              land and territories, and Tribal territories
    ``Gender-affirming care may not be included in any health care 
service furnished by--
            ``(1) a health care facility owned or operated by the 
        Federal Government;
            ``(2) a health care facility operated on Federal land, in a 
        territory, or in a Tribal territory; or
            ``(3) any physician or other individual providing health 
        care services within the scope of the physician's or 
        individual's employment who is--
                    ``(A) employed by the Federal Government; or
                    ``(B) employed by a health care facility operated 
                on Federal land, in a territory, or in a Tribal 
                territory.
``Sec. 304. Effect on separate coverage
    ``Nothing in this chapter prohibits any individual, entity, or 
State or locality from purchasing separate coverage for gender-
affirming care or health benefits coverage that includes gender-
affirming care, on the condition that such coverage--
            ``(1) is paid for entirely using funds--
                    ``(A) not authorized or appropriated by Federal 
                law; or
                    ``(B) not received from Federal programs, 
                platforms, or infrastructure;
            ``(2) does not cover any practice that would be subject to 
        penalty under section 2260B of title 18; and
            ``(3) is not purchased using matching funds required for a 
        federally subsidized program, including a State's or locality's 
        contribution of Medicaid matching funds.
``Sec. 305. Effect on use of non-Federal funds for health coverage
    ``Nothing in this chapter restricts the ability of any non-Federal 
health benefits coverage provider from offering coverage for gender-
affirming care, or the ability of a State or locality to contract 
separately with such a provider for such coverage, on the condition 
that such coverage--
            ``(1) is paid for entirely using funds--
                    ``(A) not authorized or appropriated by Federal 
                law; or
                    ``(B) not received from Federal programs, 
                platforms, or infrastructure;
            ``(2) does not cover any practice that would be subject to 
        penalty under section 2260B of title 18; and
            ``(3) is not purchased using matching funds required for a 
        federally subsidized program, including a State's or locality's 
        contribution of Medicaid matching funds.
``Sec. 306. Application to complications arising from gender-affirming 
              care
    ``Nothing in this chapter applies to the treatment of any 
infection, injury, disease, or disorder that has been caused or 
exacerbated by the performance of a gender-affirming care, regardless 
of whether--
            ``(1) the gender-affirming care was performed in accordance 
        with Federal or State law; or
            ``(2) funding for the gender-affirming care is permissible 
        under section 307.
``Sec. 307. Application to individuals born with medically verifiable 
              disorder of sex development
    ``The prohibitions and limitations described in sections 301, 302, 
and 303 shall not apply to conduct with respect to an individual 
described in section 2260B(a)(2)(B) of title 18.
``Sec. 308. Gender-affirming care defined
    ``For purposes of this chapter, the term `gender-affirming care' 
has the meaning given such term in section 2260B of title 18.
``Sec. 309. Effect of chapter
    ``Nothing in this chapter prohibits the provision of the medical 
services described in section 2260B(a)(2)(B) of title 18, to address 
any male or female reproductive cancers (other than medical services to 
change the body of an individual to correspond to a sex that differs 
from the individual's biological sex).''.

SEC. 202. AMENDMENT TO TABLE OF CHAPTERS.

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

``4. Prohibiting taxpayer-funded gender-affirming care......     301''.

          TITLE III--APPLICATION UNDER THE AFFORDABLE CARE ACT

SEC. 301. 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-affirming care.--
                    (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-affirming care (other than any gender-
                affirming care or treatment described in section 306 or 
                307 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-
                affirming care 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-
                        affirming care described in such subparagraph, 
                        or a health plan that includes such gender-
                        affirming care, so long as no credit is allowed 
                        under this section with respect to the premiums 
                        for such coverage or plan and such coverage or 
                        plan does not cover any practice that would be 
                        subject to penalty under section 2260B of title 
                        18, United States Code.
                            ``(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-affirming care described in such 
                        subparagraph, or a plan that includes such 
                        gender-affirming care, 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) and such coverage or plan does not 
                        cover any practice that would be subject to 
                        penalty under section 2260B of title 18, United 
                        States Code.''.
            (2) Disallowance of small employer health insurance expense 
        credit for plan which includes coverage for gender-affirming 
        care.--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-affirming care.--
                    ``(A) In general.--The term `qualified health plan' 
                does not include any health plan that includes coverage 
                for gender-affirming care (other than any gender-
                affirming care or treatment described in section 306 or 
                307 of title 1, United States Code).
                    ``(B) Separate coverage or plan for gender-
                affirming care 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-affirming care described in such 
                        subparagraph, or a health plan that includes 
                        such gender-affirming care, so long as no 
                        credit is allowed under this section with 
                        respect to the employer contributions for such 
                        coverage or plan and such coverage does not 
                        cover any practice that would be subject to 
                        penalty under section 2260B of title 18, United 
                        States Code.
                            ``(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-affirming care described in such 
                        subparagraph, or a plan that includes such 
                        gender-affirming care, so long as such separate 
                        coverage or plan is not paid for with any 
                        employer contribution eligible for the credit 
                        allowed under this section and such coverage or 
                        plan does not cover any practice that would be 
                        subject to penalty under section 2260B of title 
                        18, United States Code.''.
    (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:
            ``(8) Coverage consistent with federal policy regarding 
        gender-affirming care.--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 one 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.

                    TITLE IV--ADDITIONAL PROVISIONS

SEC. 401. PROHIBITION ON INSTITUTIONS OF HIGHER EDUCATION AND 
              ACCREDITING AGENCIES OR ASSOCIATIONS.

    (a) Prohibition on Institutions of Higher Education.--Section 
487(a) of the Higher Education Act of 1965 (20 U.S.C. 1094(a)) is 
amended by adding at the end the following:
            ``(30) The institution will not offer instruction in 
        gender-affirming care (as defined in section 2260B of title 18, 
        United States Code).''.
    (b) Prohibition on Accrediting Agencies or Associations.--Section 
496(a) of the Higher Education Act of 1965 (20 U.S.C. 1099b(a)) is 
amended--
            (1) by striking ``and'' at the end of paragraph (7);
            (2) by striking the period at the end of paragraph (8) and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(9) such agency or association does not accredit any 
        institution that offers instruction in gender-affirming care 
        (as defined in section 2260B of title 18, United States 
        Code).''.

SEC. 402. IMMIGRATION CONSEQUENCES WITH RESPECT TO PROVIDING GENDER-
              AFFIRMING CARE.

    (a) Definition of Gender-Affirming Care.--Section 101(a) of the 
Immigration and Nationality Act (8 U.S.C. 1101(a)) is amended by adding 
at the end the following:
            ``(53) The term `gender-affirming care' shall have the 
        meaning given such term in section 2260B of title 18, United 
        States Code.''.
    (b) Classes of Aliens Ineligible for Visas or Admission.--Section 
212(a)(1)(A) of the Immigration and Nationality Act (8 U.S.C. 
1182(a)(1)(A)) is amended--
            (1) in clause (iii)(II), by striking ``or'' at the end;
            (2) in clause (iv), by striking the comma at the end and 
        inserting ``, or''; and
            (3) by inserting after clause (iv) the following:
                            ``(v) who is determined to have performed 
                        gender-affirming care on a child that has not 
                        attained the age of 18 years old,''.
    (c) Classes of Deportable Aliens.--Section 237(a) of the 
Immigration and Nationality Act (8 U.S.C. 1227(a)) is amended by adding 
at the end the following:
            ``(8) Gender-affirming care.--Any alien who has performed 
        gender-affirming care on a child who has not attained the age 
        of 18 years old is deportable.''.
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