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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10426 Introduced in House (IH)]

<DOC>

118th CONGRESS
  2d Session
                               H. R. 10426

   To amend part E of title IV of the Social Security Act to require 
 States to prohibit genital surgery on foster children with variations 
in sex characteristics who are under six years of age as a condition of 
                   receiving grants under such part.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           December 16, 2024

Ms. Garcia of Texas (for herself, Mr. Pocan, Mr. Takano, Mr. Torres of 
New York, Ms. Bonamici, Ms. Chu, Mr. Frost, Mr. Garcia of Illinois, Mr. 
Green of Texas, Ms. Jacobs, Ms. Jayapal, Ms. Lee of California, Ms. Lee 
  of Pennsylvania, Mrs. Lee Carter, Ms. McClellan, Mr. McGovern, Mrs. 
 McIver, Ms. Pingree, Ms. Pressley, Mr. Quigley, Mrs. Ramirez, and Ms. 
    Tlaib) introduced the following bill; which was referred to the 
                      Committee on Ways and Means

_______________________________________________________________________

                                 A BILL

 
   To amend part E of title IV of the Social Security Act to require 
 States to prohibit genital surgery on foster children with variations 
in sex characteristics who are under six years of age as a condition of 
                   receiving grants under such part.

    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 Intersex Children Act''.

SEC. 2. PREAMBLE.

    (a) The Congress opposes all forms of prejudice, bias, and 
discrimination, and affirms its commitment to the dignity and autonomy 
of all people, including those born with variations in their physical 
sex characteristics. The Congress especially notes the importance of 
protecting children within the guardianship of the foster care system.
    (b) ``Variations in physical sex characteristics'' is an umbrella 
term used to describe a wide range of natural bodily variations in 
traits including genitals, gonads, hormone function, and chromosomal 
patterns, and may be referred to as ``difference of sex development'' 
or ``intersex''.
    (c) People born with variations in their physical sex 
characteristics are a part of the fabric of the Nation's diversity and 
are equally entitled to dignity and bodily autonomy.
    (d) People born with variations in their physical sex 
characteristics are regularly subjected in infancy, without their 
consent, to surgeries to change the appearance or function of those 
variations, even though performing such surgeries may result in lasting 
harm and therefore does not serve the child's best interests.
    (e) Not all persons with variations in their physical sex 
characteristics will need or desire the surgeries that may be 
recommended or performed on them in infancy. People born with 
variations in their physical sex characteristics should be free to 
choose whether to undergo surgeries that impact not only their bodily 
autonomy but also their reproductive and sexual health.
    (f) The Congress recognizes that leading pediatric hospitals have 
begun to institute partial bans on these surgeries on patients with 
variations in their physical sex characteristics who are too young to 
participate in a meaningful discussion of the implications of these 
surgeries, and therefore cannot meaningfully assent or consent to them, 
but the prohibition on non-consensual surgical procedures on pediatric 
patients with differences in sex characteristics should not be 
construed to apply to, regulate, or prohibit surgical procedures 
provided to transgender patients, with the consent of the patients, by 
skilled and knowledgeable surgeons.
    (g) Therefore, the Congress calls upon the States to hold health 
professionals responsible for safeguarding the bodily autonomy of 
people born with variations in their physical sex characteristics and 
ensuring patient-centered care that conforms with best practices in the 
medical profession by ending the practice of performing specified 
surgeries on such children when they are under the age of six and the 
surgery is not required to address an immediate risk to life, as 
provided.

SEC. 3. FINDINGS.

    The Congress finds the following:
            (1) Individuals with variations in their physical sex 
        characteristics may present with differences in genital 
        anatomy, internal reproductive structures, chromosomes, or 
        hormonal variations. An estimated 1.7 percent of babies are 
        born with genetic, physiological, or anatomical variations that 
        can cause their physical sex characteristics to not conform to 
        the expectations for a typical male or female baby. The vast 
        majority of babies born with these variations do not require 
        surgical intervention related to their physical sex 
        characteristics immediately, if at all.
            (2) Beginning in the 1950s physicians in the United States 
        began performing irreversible and involuntary surgeries (often 
        referred to as genital-normalizing surgeries) on infants with 
        variations in their physical sex characteristics without 
        medical justification.
            (3) According to available public records, at least about 
        80 percent of these irreversible surgeries occur on infants 
        under the age of 2, with even higher figures reported in 
        published medical studies. A literature review of genital 
        surgery conducted on children with variations in their physical 
        sex characteristics published in the Journal of Steroid 
        Biochemistry and Molecular Biology found that between 2005 and 
        2012 the average age of patients was 11.2 months old and the 
        median age was 9.9 months at initial surgery.
            (4) These surgeries, which include unnecessary infant 
        vaginoplasties, clitoral reductions and recessions, and removal 
        of gonadal tissues, are often performed before a child can even 
        speak or stand, meaning the individual is excluded from the 
        decision whether to undergo these irreversible procedures.
            (5) There is evidence that these surgeries cause severe 
        psychological and physiological harm when performed without the 
        informed consent of the individual. These harms may include 
        scarring, chronic pain, urinary incontinence, loss of sexual 
        sensation and function, sterilization, depression, post-
        traumatic stress disorder, suicidality, and surgical 
        enforcement of incorrect gender assignment.
            (6) Three former United States Surgeons General who served 
        in both Republican and Democratic Administrations, Dr. Joycelyn 
        Elders, Dr. David Satcher, and Dr. Richard Carmona, issued a 
        statement calling for a moratorium on medically unnecessary 
        surgeries on intersex children too young to participate in the 
        decision, noting that, ``Cosmetic genitoplasty should be 
        deferred until children are old enough to voice their own view 
        about whether to undergo the surgery. Those whose oath or 
        conscience says `do no harm' should heed the simple fact that, 
        to date, research does not support the practice of cosmetic 
        infant genitoplasty.''.
            (7) A number of domestic and international human rights 
        organizations have conducted thorough inquiries into genital 
        surgeries on infants with variations in their physical sex 
        characteristics and have concluded that performing these 
        procedures, inextricably without the consent of the infants, is 
        cruel and catastrophic, as follows:
                    (A) The United Nations Special Rapporteur on 
                Torture and Other Cruel, Inhuman or Degrading Treatment 
                or Punishment explained in 2013, ``children who are 
                born with atypical sex characteristics are often 
                subject to irreversible sex assignment, involuntary 
                sterilization, involuntary genital normalizing surgery, 
                [or] performed without their informed consent . . . `in 
                an attempt to fix their sex,' leaving them with 
                permanent, irreversible infertility and causing severe 
                mental suffering.''.
                    (B) The United Nations High Commissioner for Human 
                Rights explained in 2015 that non-consensual 
                ``medically unnecessary surgeries and other invasive 
                treatment of intersex babies and children . . . are 
                rarely discussed and even more rarely investigated or 
                prosecuted. . . . The result is impunity for the 
                perpetrators; lack of remedy for victims; and a gap 
                between legislation and the lived realities of intersex 
                people.''.
                    (C) The World Health Organization explained in 
                2015, that children with variations in their physical 
                sex characteristics have been ``subjected to medically 
                unnecessary, often irreversible, interventions that may 
                have lifelong consequences for their physical and 
                mental health, including irreversible termination of 
                all or some of their reproductive and sexual capacity. 
                . . . Human rights bodies and ethical and health 
                professional organizations have recommended that free 
                and informed consent should be ensured in medical 
                interventions for people with intersex conditions, 
                including full information, orally and in writing, on 
                the suggested treatment, its justification and 
                alternatives.''.
                    (D) Physicians for Human Rights has ``call[ed] for 
                an end to all medically unnecessary surgical procedures 
                on intersex children before they are able to give 
                meaningful consent to such surgeries.''.
                    (E) Human Rights Watch concluded that these 
                surgeries, when performed without consent, are ``often 
                catastrophic, the supposed benefits are largely 
                unproven, and there are generally no urgent health 
                considerations at stake. Procedures that could be 
                delayed until intersex children are old enough to 
                decide whether they want them are instead performed on 
                infants who then have to live with the consequences for 
                a lifetime.''.
            (8) In 2005, the San Francisco Human Rights Commission 
        performed an investigation into this topic and issued an in-
        depth report, recommending that ```normalizing' interventions 
        should not occur in infancy or childhood. Any procedures that 
        are not medically necessary should not be performed unless the 
        patient gives their legal consent.''.
            (9) Intersex advocacy groups led by individuals with 
        variations in their physical sex characteristics themselves 
        advocate for the postponing or banning of these surgeries. 
        Those subjected to surgery to alter their variations in sex 
        characteristics at a young age express despair over the fact 
        that they were unable to make these decisions for themselves, 
        publishing about their experiences in major news outlets: ``I 
        know firsthand the devastating impact [these non-consensual 
        surgeries] can have, not just on our bodies but on our souls. 
        We are erased before we can even tell our doctors who we are. 
        Every human rights organization that has considered the 
        practice has condemned it, some even to the point of 
        recognizing it as akin to torture.''.
            (10) The United States Department of State has acknowledged 
        Intersex Awareness Day under the Obama, Trump, and Biden 
        Administrations by recognizing the harm of these surgeries. In 
        2017, the Department released a statement recognizing that ``at 
        a young age, intersex persons routinely face forced medical 
        surgeries without free or informed consent. These interventions 
        jeopardize their physical integrity and ability to live 
        freely.''.
            (11) Physicians who have participated in these surgeries 
        have also expressed remorse that their training did not 
        properly prepare them to respect the bodily autonomy of people 
        born with variations in their physical sex characteristics. As 
        a Stanford-educated urologist explains: ``I know intersex women 
        who have never experienced orgasm because clitoral surgery 
        destroyed their sensation; men who underwent a dozen penile 
        surgeries before they even hit puberty; people who had . . . 
        vaginas created that scarred and led to a lifetime of pain 
        during intercourse . . . the psychological damage caused by 
        [non-consensual] intervention is just as staggering, as 
        evidenced by generations of intersex adults dealing with post-
        traumatic stress disorder, problems with intimacy and severe 
        depression. Some were even surgically assigned a gender at 
        birth, only to grow up identifying with [a different] 
        gender.''.
            (12) When the life of an infant born with variations in 
        their physical sex characteristics is threatened and medical 
        attention cannot be safely deferred, therapeutic treatment 
        options should remain available to children, families, and 
        medical professionals to ensure that the imminent risk to life 
        is addressed. In such cases, where surgical intervention cannot 
        be deferred and the infant lacks agency to advance the infant's 
        own interests, clinical ethicists may be consulted or included 
        in decision-making to serve as a proxy for the interests of the 
        infant and to ensure that the infant's long-term well-being is 
        a primary consideration in decision-making.
            (13) The United States should serve as a model of competent 
        and ethical medical care and has a compelling interest in 
        protecting the physical and psychological well-being of 
        children, including those born with variations in their 
        physical sex characteristics.

SEC. 4. STATES REQUIRED TO PROHIBIT SPECIFIED SURGERIES ON FOSTER 
              CHILDREN WITH VARIATIONS IN SEX CHARACTERISTICS WHO ARE 
              UNDER 6 YEARS OF AGE, AS A CONDITION OF PARTICIPATION IN 
              THE FEDERAL FOSTER CARE AND ADOPTION ASSISTANCE PROGRAM.

    (a) State Plan Requirement.--Section 471 of the Social Security Act 
(42 U.S.C. 671) is amended--
            (1) in subsection (a)--
                    (A) by striking ``and'' at the end of paragraph 
                (36);
                    (B) by striking the period at the end of paragraph 
                (37) and inserting ``; and''; and
                    (C) by adding at the end, the following:
            ``(38) provides that the State shall have in effect the 
        laws and procedures described in subsection (f), which shall 
        specify appropriate penalties and enforcement mechanisms 
        described in subsection (f)(3) to ensure compliance with the 
        laws and procedures.''; and
            (2) by adding at the end the following:
    ``(f) State Laws and Procedures To Prohibit Genital Surgery on 
Foster Children Born With Variations in Their Physical Sex 
Characteristics Who Are Under 6 Years of Age.--
            ``(1) In general.--The laws and procedures described in 
        this subsection are laws and procedures which prohibit a 
        physician who is licensed to provide medical care under State 
        law from performing any of the following surgical procedures on 
        a foster child who has not attained 6 years of age and who is 
        an individual born with variations in their physical sex 
        characteristics, unless the surgical procedure is to address an 
        immediate risk to life:
                    ``(A) Clitoroplasty, clitoral reduction, or 
                clitoral recession, including corporal-sparing 
                procedures.
                    ``(B) Gonadectomy.
                    ``(C) Vaginoplasty, urogenital sinus mobilization, 
                or vaginal exteriorization.
                    ``(D) Phallectomy, penectomy, or phalloplasty.
            ``(2) Definitions.--In paragraph (1):
                    ``(A) Individual born with variations in their 
                physical sex characteristics.--The term `individual 
                born with variations in their physical sex 
                characteristics' means an individual born with physical 
                traits, including genitals, gonads, hormone function, 
                or chromosomal patterns, that vary from stereotypical 
                notions regarding the development, appearance, or 
                function of sex characteristics.
                    ``(B) Surgical procedure to address an immediate 
                risk to life.--The term `surgical procedure to address 
                an immediate risk to life' means a surgical procedure--
                            ``(i) to remove tissue that is malignant;
                            ``(ii) to create an opening to allow urine 
                        or feces to exit the body where an opening is 
                        underdeveloped or not present;
                            ``(iii) to reposition internal organs that 
                        formed outside of the body;
                            ``(iv) that is required to treat 
                        complications of a previous surgery and cannot 
                        be delayed without increasing physical health 
                        risks to the patient; or
                            ``(v) that is necessary to preserve life in 
                        the event of a medical emergency.
            ``(3) Enforcement.--
                    ``(A) In general.--The relevant licensing entity of 
                the State shall consider a violation of a State law or 
                procedure described in paragraph (1) to be 
                unprofessional conduct, and shall discipline any 
                violator of such a law or procedure accordingly.
                    ``(B) Concurrent authority.--The relevant 
                department of health or regulatory body of a State 
                shall have concurrent authority to initiate proceedings 
                to address violations of a State law or procedure 
                described in paragraph (1).
            ``(4) Rule of interpretation.--This subsection shall not be 
        interpreted to require a State to impose liability on a 
        hospital at which a violation of a State law or procedure 
        described in paragraph (1) occurs.''.
    (b) Effective Date.--
            (1) In general.--The amendments made by subsection (a) 
        shall take effect on the 1st day of the 1st calendar quarter 
        that begins 1 year or more after the date of the enactment of 
        this Act, and shall apply to payments under part E of title IV 
        of the Social Security Act for calendar quarters beginning on 
        or after such date.
            (2) Delay permitted if state legislation required.--If the 
        Secretary of Health and Human Services determines that State 
        legislation (other than legislation appropriating funds) is 
        required in order for a State plan developed pursuant to part E 
        of title IV of the Social Security Act to meet the additional 
        requirements imposed by the amendments made by subsection (a), 
        the plan shall not be regarded as failing to meet any of the 
        additional requirements before the 1st day of the 1st calendar 
        quarter beginning after the 1st regular session of the State 
        legislature that begins 1 year or more after the date of the 
        enactment of this Act. For purposes of the preceding sentence, 
        if the State has a 2-year legislative session, each year of the 
        session is deemed to be a separate regular session of the State 
        legislature.
                                 <all>
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