II 118th CONGRESS 1st Session S. 1595 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.

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. I Prohibiting federally funded gender transition procedures 101. Prohibiting taxpayer-funded gender transition procedures Title 1, United States Code, is amended by adding at the end the following new 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. 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. 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. 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. 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. 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. 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. 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. . 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 procedures 301 . II Application under the Affordable Care Act 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.