I 118th CONGRESS 1st Session H. R. 3329 IN THE HOUSE OF REPRESENTATIVES May 15, 2023 Mr. LaMalfa (for himself, Mrs. Boebert , Mr. Lamborn , Mr. Gosar , Mr. Banks , Mr. Duncan , Mr. Babin , Mr. Rouzer , Mr. Barr , Mr. Rosendale , Mr. Weber of Texas , Mr. Brecheen , Mr. Norman , Mrs. Miller of Illinois , Mr. Grothman , Mr. Wilson of South Carolina , Mr. Mills , Mr. Burlison , Mr. Smith of New Jersey , Mr. Aderholt , Mrs. McClain , Mrs. Lesko , Mrs. Harshbarger , Mr. Nehls , Mr. Kelly of Mississippi , Mr. Ogles , Mr. Fallon , Mr. LaTurner , Mr. Davidson , Mr. Gaetz , Ms. Tenney , Mr. Allen , Mr. Roy , and Mr. Mooney ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committees on the Judiciary , and Ways and Means , 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 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 are 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 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, State, or locality from purchasing separate coverage for gender transition procedures or health benefits coverage that include gender transition procedures so long as such coverage is paid for entirely with 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 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 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 naturally occur in healthy biological females; or (B) estrogen given to biological males at doses that are profoundly larger or more potent than would naturally occur 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 a person 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, including physician’s services, inpatient and outpatient hospital services, or prescribed drugs related to gender transition, that seek to alter or remove physical or anatomical characteristics or features that are typical for an individual’s biological sex, or to instill or create physiological or anatomical characteristics that resemble a sex different from an individual’s birth sex, including, without limitation, medical services that provide puberty-blocking drugs, cross-sex hormones, or other mechanisms to promote the development of feminizing or masculinizing features (in the opposite sex), or genital gender transition surgery or nongenital gender transition surgery performed for the purpose of assisting an individual with a gender transition. (B) Exceptions The term gender transition procedure does not include— (i) services to those born with a medically-verifiable disorder of sex development, including a person with external biological sex characteristics that are irresolvably ambiguous, such as those born with 46 XX chromosomes with virilization, 46 XY chromosomes with undervirilization, or having both ovarian and testicular tissue; or services provided when a physician has otherwise diagnosed a disorder of sexual development, in which such physician has determined through genetic or biochemical testing that the person does not have normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action for a biological male or biological female; or (ii) the treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of a gender transition procedure, whether or not such procedure was performed in accordance with State or Federal law, or whether funding for such procedure was 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 an individual’s biological sex in order to instill or create physiological or anatomical characteristics that resemble a sex different from an individual’s birth sex, including, without limitation, genital gender reassignment surgery or non-genital gender reassignment surgery performed for the purpose of assisting an individual with a gender transition. (B) Exception 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 surgery is performed. (7) Genital gender transition surgery The term genital gender transition surgery includes surgical procedures such as penectomy, orchiectomy, vaginoplasty, clitoroplasty, or vulvoplasty for biologically male patients, or hysterectomy/ovariectomy, reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty, vaginectomy, scrotoplasty, or implantation of erection or testicular prostheses for biologically female patients when performed for the purpose of assisting an individual with a gender transition. (8) Non-genital gender transition surgery The term non-genital gender transition surgery means surgical procedures including augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants or lipofilling), hair reconstruction, or other aesthetic procedures for biologically male patients or subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants, or other aesthetic procedures for biologically female patients, when performed for the purpose of assisting an individual with a gender transition. (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; (B) synthetic drugs used in biological females that stop the production of estrogen; and (C) 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 transition procedures (A) In general Section 36B(c)(3)(A) 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 or 307 of title 1, United States Code) . (B) Option to purchase or offer separate coverage or plan Section 36B(c)(3) 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 a procedure described in section 306 or 307 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 the Patient Protection and Affordable Care Act ( 42 U.S.C. 18054(a) ) is amended by adding at the end the following new paragraph: (8) 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 (1) Effective date with respect to premium credits and cost sharing reductions The amendments made by subsection (a) shall apply to taxable years 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. (2) Effective date for application to multi-State plans The amendment made by subsection (b) shall apply to plan years beginning on the date that is one year after the date of enactment of this Act.