I 

118TH CONGRESS 

1ST SESSION H. R. 1399 

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

IN THE HOUSE OF REPRESENTATIVES 

MARCH 7, 2023 

Ms. GREENE of Georgia (for herself, Mrs. MILLER of Illinois, Mr. GOSAR, Mr. 

GOODEN of Texas, Mr. GROTHMAN, Mr. DUNCAN, Mrs. LUNA, Mrs. 

HARSHBARGER, Mr. NORMAN, Mr. NEHLS, Mr. GOOD of Virginia, Mr. 

HERN, Mr. ROSENDALE, Mr. BABIN, Mr. LAMBORN, Mr. HIGGINS of 

Louisiana, Mr. STEUBE, Ms. HAGEMAN, Mrs. LESKO, and Mr. BIGGS) 

introduced the following bill; which was referred to the Committee on the 

Judiciary, and in addition to the Committees on Ways and Means, Energy and Commerce, and Education and the Workforce, for a period to 

be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee 

concerned 

A BILL 

To amend chapter 110 of title 18, United States Code, 

to prohibit gender-affirming care on minors, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Protect Children’s In5 nocence Act’’. 


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1 TITLE I—GENDER-AFFIRMING 

2 CARE ON MINORS PROHIBITED 

3 SEC. 101. GENDER-AFFIRMING CARE ON MINORS PROHIB4 ITED. 

5 Chapter 110 of title 18, United States Code, is 

6 amended— 

7 (1) by adding at the end the following: 

8 ‘‘§ 2260B. Gender-affirming care on minors 

9 ‘‘(a) IN GENERAL.—Whoever, in any circumstance 

10 described in subsection (e), knowingly performs any gen11 der-affirming care on a minor is guilty of a class C felony. 

12 ‘‘(b) PROHIBITION ON PROSECUTION OF PERSON ON

13 WHOM INTERVENTION IS PERFORMED.—No person on 

14 whom the gender-affirming care under subsection (a) is 

15 performed may be arrested or prosecuted for an offense 

16 under this section. 

17 ‘‘(c) CIVIL ACTION.—A person on whom gender-af18 firming care is performed under this section may bring 

19 a civil action for appropriate relief, including compen20 satory and punitive damages, against each person who 

21 performed the gender-affirming care. 

22 ‘‘(d) DEFINITIONS.—In this section: 

23 ‘‘(1) GENDER-AFFIRMING CARE.— 

24 ‘‘(A) IN GENERAL.—For purposes of this 

25 chapter, except as provided in subparagraph 


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1 (B), the term ‘gender-affirming care’ means, 

2 with respect to an individual, any of the fol3 lowing: 

4 ‘‘(i) Performing any surgery for the 

5 purpose of changing the body of such indi6 vidual to correspond to a sex that differs 

7 from their biological sex, including— 

8 ‘‘(I) castration; 

9 ‘‘(II) orchiectomy; 

10 ‘‘(III) scrotoplasty; 

11 ‘‘(IV) vasectomy; 

12 ‘‘(V) hysterectomy; 

13 ‘‘(VI) oophorectomy; 

14 ‘‘(VII) ovariectomy; 

15 ‘‘(VIII) metoidioplasty; 

16 ‘‘(IX) penectomy; 

17 ‘‘(X) phalloplasty; 

18 ‘‘(XI) vaginoplasty; 

19 ‘‘(XII) vaginectomy; 

20 ‘‘(XIII) vulvoplasty; 

21 ‘‘(XIV) reduction 

22 thyrochondroplasty; 

23 ‘‘(XV) chondrolaryngoplasty; and 

24 ‘‘(XVI) mastectomy. 


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1 ‘‘(ii) Any plastic surgery that femi2 nizes or masculinizes the facial features for 

3 the purposes described in clause (i). 

4 ‘‘(iii) Any placement of chest implants 

5 to create feminine breasts for the purposes 

6 described in clause (i). 

7 ‘‘(iv) Any placement of fat or artificial 

8 implants in the gluteal region for the pur9 poses described in clause (i). 

10 ‘‘(v) Administering, supplying, pre11 scribing, dispensing, distributing, or other12 wise conveying to an individual medications 

13 for the purposes described in clause (i), in14 cluding— 

15 ‘‘(I) gonadotropin-releasing hor16 mone (GnRH) analogues or other pu17 berty-blocking drugs to stop or delay 

18 normal puberty; 

19 ‘‘(II) testosterone or other 

20 androgens to biological females at 

21 doses that are supraphysiologic to the 

22 female sex; and 

23 ‘‘(III) estrogen to biological 

24 males at doses that are 

25 supraphysiologic to the male sex. 


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1 ‘‘(B) EXCEPTION.—Subparagraph (A) 

2 shall not apply to the following individuals: 

3 ‘‘(i) An individual with both ovarian 

4 and testicular tissue. 

5 ‘‘(ii) An individual with respect to 

6 whom a physician has determined through 

7 genetic or biochemical testing that the in8 dividual does not have normal sex chro9 mosome structure, sex steroid hormone 

10 production, or sex steroid hormone action. 

11 ‘‘(iii) An individual experiencing infec12 tion, disease, injury, or disorder caused or 

13 exacerbated by previous gender transition 

14 procedures. 

15 ‘‘(iv) An individual suffering from a 

16 physical disorder, physical injury, or phys17 ical illness that would, as certified by a 

18 physician, place the individual in imminent 

19 danger of death or impairment of a major 

20 bodily function unless the procedure is per21 formed. 

22 ‘‘(2) BIOLOGICAL SEX.—The term ‘biological 

23 sex’ means the indication of male or female sex by 

24 reproductive potential or capacity, sex chromosomes, 


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1 naturally occurring sex hormones, gonads, or inter2 nal or external genitalia present at birth. 

3 ‘‘(3) MINOR.—The term ‘minor’ means any per4 son under the age of eighteen years. 

5 ‘‘(e) CIRCUMSTANCES DESCRIBED.—For purposes of 

6 subsection (a), the circumstances described in this sub7 section are that— 

8 ‘‘(1) the defendant or victim traveled in inter9 state or foreign commerce, or traveled using a 

10 means, channel, facility, or instrumentality of inter11 state or foreign commerce, in furtherance of or in 

12 connection with the conduct described in subsection 

13 (a); 

14 ‘‘(2) the defendant used a means, channel, fa15 cility, or instrumentality of interstate or foreign 

16 commerce in furtherance of or in connection with 

17 the conduct described in subsection (a); 

18 ‘‘(3) any payment of any kind was made, di19 rectly or indirectly, in furtherance of or in connec20 tion with the conduct described in subsection (a) 

21 using any means, channel, facility, or instrumen22 tality of interstate or foreign commerce or in or af23 fecting interstate or foreign commerce; 

24 ‘‘(4) the defendant transmitted in interstate or 

25 foreign commerce any communication relating to or 


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1 in furtherance of the conduct described in subsection 

2 (a) using any means, channel, facility, or instrumen3 tality of interstate or foreign commerce or in or af4 fecting interstate or foreign commerce by any means 

5 or in manner, including by computer, mail, wire, or 

6 electromagnetic transmission; 

7 ‘‘(5) any instrument, item, substance, or other 

8 object that has traveled in interstate or foreign com9 merce was used to perform the conduct described in 

10 subsection (a); 

11 ‘‘(6) the conduct described in subsection (a) oc12 curred within the special maritime and territorial ju13 risdiction of the United States, or any territory or 

14 possession of the United States; or 

15 ‘‘(7) the conduct described in subsection (a) 

16 otherwise occurred in or affected interstate or for17 eign commerce. 

18 ‘‘(f) RULE OF CONSTRUCTION.—Nothing in this sec19 tion shall be construed as prohibiting provision of the med20 ical services described in subsection (d)(1)(A) to address 

21 legitimate health issues, such as any male or female repro22 ductive cancers, apart from changing the body to cor23 respond to a sex that differs from one’s biological sex.’’; 

24 and 


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1 (2) by amending the table of sections for such 

2 chapter by adding at the end the following: 

‘‘2260B. Gender-affirming care on minors.’’. 

3 TITLE II—PROHIBITING FEDER4 ALLY FUNDED GENDER-AF5 FIRMING CARE 

6 SEC. 201. PROHIBITING TAXPAYER-FUNDED GENDER-AF7 FIRMING CARE. 

8 Title 1, United States Code, is amended by adding 

9 at the end the following new chapter: 

10 ‘‘CHAPTER 4—PROHIBITING TAXPAYER11 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 lands and territories, and Tribal territories. 

‘‘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-affirming care. 

‘‘307. Treatment of individuals born with medically verifiable disorder of sex development. 

‘‘308. Gender-affirming care defined. 

‘‘309. Rule of construction. 

12 ‘‘§ 301. Prohibition on funding for gender-affirming 

13 care 

14 ‘‘No funds authorized or appropriated by Federal 

15 law, and none of the funds in any trust fund to which 

16 funds are authorized or appropriated by Federal law, in17 cluding funds provided under titles XVIII, XIX, and XXI 

18 of the Social Security Act, shall be expended for any gen19 der-affirming care. 


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1 ‘‘§ 302. Prohibition on funding for health benefits 

2 plans that cover gender-affirming care 

3 ‘‘No funds authorized or appropriated by Federal 

4 law, and none of the funds in any trust fund to which 

5 funds are authorized or appropriated by Federal law, shall 

6 be expended for health benefits coverage that includes cov7 erage of gender-affirming care. 

8 ‘‘§ 303. Limitation on Federal facilities and employ9 ees, Federal lands and territories, and 

10 Tribal territories 

11 ‘‘No health care service furnished— 

12 ‘‘(1) by or in a health care facility owned or op13 erated by the Federal Government, Federal land or 

14 territory, or a Tribal territory; or 

15 ‘‘(2) by any physician or other individual em16 ployed by the Federal Government, Federal land or 

17 territory, or a Tribal territory to provide health care 

18 services within the scope of the physician’s or indi19 vidual’s employment, 

20 may include gender-affirming care. 

21 ‘‘§ 304. Construction relating to separate coverage 

22 ‘‘Nothing in this chapter shall be construed as pro23 hibiting any individual, entity, or State or locality from 

24 purchasing separate coverage for gender-affirming care or 

25 health benefits coverage that includes gender-affirming 

26 care so long as such coverage is paid for entirely using 


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1 only funds not authorized or appropriated by Federal law, 

2 federal programs, platforms, or infrastructure, such cov3 erage does not cover any practice that would be subject 

4 to penalty under section 2260B of title 18, United States 

5 Code, and such coverage shall not be purchased using 

6 matching funds required for a federally subsidized pro7 gram, including a State’s or locality’s contribution of Med8 icaid matching funds. 

9 ‘‘§ 305. Construction relating to the use of non-Fed10 eral funds for health coverage 

11 ‘‘Nothing in this chapter shall be construed as re12 stricting the ability of any non-Federal health benefits cov13 erage provider from offering coverage for gender-affirming 

14 care, or the ability of a State or locality to contract sepa15 rately with such a provider for such coverage, so long as 

16 only funds not authorized or appropriated by Federal law 

17 are used, such coverage does not cover any practice that 

18 would be subject to penalty under section 2260B of title 

19 18, United States Code, and such coverage shall not be 

20 purchased using matching funds required for a federally 

21 subsidized program, including a State’s or locality’s con22 tribution of Medicaid matching funds. 


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1 ‘‘§ 306. Construction relating to complications arising 

2 from gender-affirming care 

3 ‘‘Nothing in this chapter shall be construed to apply 

4 to the treatment of any infection, injury, disease, or dis5 order that has been caused by or exacerbated by the per6 formance of a gender-affirming care. This rule of con7 struction shall be applicable without regard to whether the 

8 gender-affirming care was performed in accord with Fed9 eral or State law, and without regard to whether funding 

10 for the gender-affirming care is permissible under section 

11 307. 

12 ‘‘§ 307. Treatment of individuals born with medically 

13 verifiable disorder of sex development 

14 ‘‘The limitations established in sections 301, 302, 

15 and 303 shall not apply with respect to an individual de16 scribed in section 2260B(d)(1)(B) of title 18, United 

17 States Code. 

18 ‘‘§ 308. Gender-affirming care defined 

19 ‘‘For purposes of this chapter, the term ‘gender-af20 firming care’ has the meaning given such term in section 

21 2260B(d)(1) of title 18, United States Code. 

22 ‘‘§ 309. Rule of construction 

23 ‘‘Nothing in this chapter shall be construed as pro24 hibiting provision of the medical services described in sec25 tion 2260B(d)(1)(A) of title 18, United States Code, to 

26 address any male or female reproductive cancers, apart 


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1 from changing the body to correspond to a sex that differs 

2 from one’s biological sex.’’. 

3 SEC. 202. AMENDMENT TO TABLE OF CHAPTERS. 

4 The table of chapters for title 1, United States Code, 

5 is amended by adding at the end the following new item: 

‘‘4. Prohibiting taxpayer-funded gender-affirming care ... 301’’. 

6 TITLE III—APPLICATION UNDER 

7 THE AFFORDABLE CARE ACT 

8 SEC. 301. CLARIFYING APPLICATION OF PROHIBITION TO 

9 PREMIUM CREDITS AND COST-SHARING RE10 DUCTIONS UNDER ACA. 

11 (a) IN GENERAL.— 

12 (1) DISALLOWANCE OF REFUNDABLE CREDIT

13 AND COST-SHARING REDUCTIONS FOR COVERAGE

14 UNDER QUALIFIED HEALTH PLAN WHICH PROVIDES

15 COVERAGE FOR GENDER-AFFIRMING CARE.— 

16 (A) IN GENERAL.—Subparagraph (A) of 

17 section 36B(c)(3) of the Internal Revenue Code 

18 of 1986 is amended by inserting before the pe19 riod at the end the following: ‘‘or any health 

20 plan that includes coverage for gender-affirming 

21 care (other than any gender-affirming care or 

22 treatment described in section 306 or 307 of 

23 title 1, United States Code)’’. 

24 (B) OPTION TO PURCHASE OR OFFER SEP25 ARATE COVERAGE OR PLAN.—Paragraph (3) of 


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1 section 36B(c) of such Code is amended by 

2 adding at the end the following new subpara3 graph: 

4 ‘‘(C) SEPARATE COVERAGE OR PLAN FOR

5 GENDER-AFFIRMING CARE ALLOWED.— 

6 ‘‘(i) OPTION TO PURCHASE SEPARATE

7 COVERAGE OR PLAN.—Nothing in subpara8 graph (A) shall be construed as prohibiting 

9 any individual from purchasing separate 

10 coverage for gender-affirming care de11 scribed in such subparagraph, or a health 

12 plan that includes such gender-affirming 

13 care, so long as no credit is allowed under 

14 this section with respect to the premiums 

15 for such coverage or plan and such cov16 erage or plan does not cover any practice 

17 that would be subject to penalty under sec18 tion 2260B of title 18, United States 

19 Code. 

20 ‘‘(ii) OPTION TO OFFER COVERAGE OR

21 PLAN.—Nothing in subparagraph (A) shall 

22 restrict any non-Federal health insurance 

23 issuer offering a health plan from offering 

24 separate coverage for gender-affirming 

25 care described in such subparagraph, or a 


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1 plan that includes such gender-affirming 

2 care, so long as premiums for such sepa3 rate coverage or plan are not paid for with 

4 any amount attributable to the credit al5 lowed under this section (or the amount of 

6 any advance payment of the credit under 

7 section 1412 of the Patient Protection and 

8 Affordable Care Act) and such coverage or 

9 plan does not cover any practice that 

10 would be subject to penalty under section 

11 2260B of title 18, United States Code.’’. 

12 (2) DISALLOWANCE OF SMALL EMPLOYER

13 HEALTH INSURANCE EXPENSE CREDIT FOR PLAN

14 WHICH INCLUDES COVERAGE FOR GENDER-AFFIRM15 ING CARE.—Subsection (h) of section 45R of the In16 ternal Revenue Code of 1986 is amended— 

17 (A) by striking ‘‘Any term’’ and inserting 

18 the following: 

19 ‘‘(1) IN GENERAL.—Any term’’; and 

20 (B) by adding at the end the following new 

21 paragraph: 

22 ‘‘(2) EXCLUSION OF HEALTH PLANS INCLUDING

23 COVERAGE FOR GENDER-AFFIRMING CARE.— 

24 ‘‘(A) IN GENERAL.—The term ‘qualified 

25 health plan’ does not include any health plan 


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1 that includes coverage for gender-affirming care 

2 (other than any gender-affirming care or treat3 ment described in section 306 or 307 of title 1, 

4 United States Code). 

5 ‘‘(B) SEPARATE COVERAGE OR PLAN FOR

6 GENDER-AFFIRMING CARE ALLOWED.— 

7 ‘‘(i) OPTION TO PURCHASE SEPARATE

8 COVERAGE OR PLAN.—Nothing in subpara9 graph (A) shall be construed as prohibiting 

10 any employer from purchasing for its em11 ployees separate coverage for gender-af12 firming care described in such subpara13 graph, or a health plan that includes such 

14 gender-affirming care, so long as no credit 

15 is allowed under this section with respect 

16 to the employer contributions for such cov17 erage or plan and such coverage does not 

18 cover any practice that would be subject to 

19 penalty under section 2260B of title 18, 

20 United States Code. 

21 ‘‘(ii) OPTION TO OFFER COVERAGE OR

22 PLAN.—Nothing in subparagraph (A) shall 

23 restrict any non-Federal health insurance 

24 issuer offering a health plan from offering 

25 separate coverage for gender-affirming 


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1 care described in such subparagraph, or a 

2 plan that includes such gender-affirming 

3 care, so long as such separate coverage or 

4 plan is not paid for with any employer con5 tribution eligible for the credit allowed 

6 under this section and such coverage or 

7 plan does not cover any practice that 

8 would be subject to penalty under section 

9 2260B of title 18, United States Code.’’. 

10 (b) APPLICATION TO MULTI-STATE PLANS.—Section 

11 1334(a) of Public Law 111–148 (42 U.S.C. 18054(a)) is 

12 amended by adding at the end the following new para13 graph: 

14 ‘‘(8) COVERAGE CONSISTENT WITH FEDERAL

15 POLICY REGARDING GENDER-AFFIRMING CARE.—In 

16 entering into contracts under this subsection, the 

17 Director shall ensure that no multi-State qualified 

18 health plan offered in an Exchange provides health 

19 benefits coverage for which the expenditure of Fed20 eral funds is prohibited under chapter 4 of title 1, 

21 United States Code.’’. 

22 (c) EFFECTIVE DATE.—The amendments made by 

23 subsection (a) shall apply to taxable years ending after 

24 the date that is one year after the date of enactment of 

25 this Act, but only with respect to plan years beginning 


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1 after such date, and the amendment made by subsection 

2 (b) shall apply to plan years beginning after such date. 

3 TITLE IV—ADDITIONAL 

4 PROVISIONS 

5 SEC. 401. PROHIBITION ON INSTITUTIONS OF HIGHER EDU6 CATION AND ACCREDITING AGENCIES OR AS7 SOCIATIONS. 

8 (a) PROHIBITION ON INSTITUTIONS OF HIGHER

9 EDUCATION.—Section 487(a) of the Higher Education 

10 Act of 1965 (20 U.S.C. 1094(a)) is amended by adding 

11 at the end the following: 

12 ‘‘(30) The institution will not offer instruction 

13 in gender-affirming care (as defined in section 

14 2260B(d) of title 18, United States Code).’’. 

15 (b) PROHIBITION ON ACCREDITING AGENCIES OR AS16 SOCIATIONS.—Section 496(a) of the Higher Education 

17 Act of 1965 (20 U.S.C. 1099b(a)) is amended— 

18 (1) by striking ‘‘and’’ at the end of paragraph 

19 (7); 

20 (2) by striking the period at the end of para21 graph (8) and inserting ‘‘; and’’; and 

22 (3) by adding at the end the following: 

23 ‘‘(9) such agency or association does not ac24 credit any institution that offers instruction in genVerDate Sep 11 2014 00:00 May 02, 2023 Jkt 039200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\H1399.IH H1399

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1 der-affirming care (as defined in section 2260B(d) 

2 of title 18, United States Code).’’. 

3 SEC. 402. IMMIGRATION CONSEQUENCES WITH RESPECT 

4 TO PROVIDING GENDER-AFFIRMING CARE. 

5 (a) DEFINITIONS.—Section 101(a) of the Immigra6 tion and Nationality Act (8 U.S.C. 1101(a)) is amended 

7 by adding at the end the following: 

8 ‘‘(53) The term ‘gender-affirming care’ shall 

9 have the meaning given such term in section 

10 2260B(d) of title 18, United States Code.’’. 

11 (b) CLASSES OF ALIENS INELIGIBLE FOR VISAS OR

12 ADMISSION.—Section 212(a)(1)(A) of the Immigration 

13 and Nationality Act (8 U.S.C. 1182(a)(1)(A)) is amend14 ed— 

15 (1) in clause (iii)(II), strike ‘‘or’’ at the end; 

16 (2) in clause (iv), strike the comma at the end 

17 and insert ‘‘, or’’; and 

18 (3) by adding at the end the following: 

19 ‘‘(v) who is determined to have per20 formed gender-affirming care on a child 

21 that has not attained the age of 18 years 

22 old,’’. 

23 (c) CLASSES OF DEPORTABLE ALIENS.—Section 

24 237(a) of the Immigration and Nationality Act (8 U.S.C. 

25 1227(a)) is amended by adding at the end the following: 


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1 ‘‘(8) GENDER-AFFIRMING CARE.—Any alien 

2 who has performed gender-affirming care on a child 

3 that has not attained the age of 18 years old is de4 portable.’’. 

Æ 


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