II 118th CONGRESS 1st Session S. 435 IN THE SENATE OF THE UNITED STATES February 15, 2023 Mr. Rubio (for himself, Mrs. Blackburn , Mr. Budd , Mr. Tuberville , and Mr. Braun ) introduced the following bill; which was read twice and referred to the Committee on Armed Services A BILL To provide requirements related to the eligibility of individuals who identify as transgender from serving in the Armed Forces.

1. Short title This Act may be cited as the Ensuring Military Readiness Act of 2023 . 2. Limitations on military service by individuals who identify as transgender Not later than 90 days after the date of the enactment of this Act, the Secretary of Defense shall prescribe regulations regarding service of individuals who identify as transgender as follows: (1) Persons who identify as transgender with a history of diagnosis of gender dysphoria are disqualified from military service except under the following limited circumstances: (A) Individuals may serve in the Armed Forces if they have been stable for 36 consecutive months in their biological sex prior to accession. (B) Members of the Armed Forces diagnosed with gender dysphoria after entering into service may be retained if they do not undergo gender transition procedures and remain deployable within applicable retention standards for their biological sex. (C) Members of the Armed Forces serving as of the date of the enactment of this Act who have been diagnosed with gender dysphoria may continue to serve only in their biological sex, irrespective of any changes previously made to their gender marker in the Defense Enrollment Eligibility Reporting System (DEERS), and receive medically necessary treatment for gender dysphoria. Such treatment may not include gender transition procedures. (2) Persons who identify as transgender who seek or have undergone gender transition are disqualified from military service. (3) Persons who identify as transgender without a history or diagnosis of gender dysphoria, who are otherwise qualified for service and meet all physical and mental requirements, may serve in the Armed Forces in their biological sex. 3. Revised regulations regarding gender markings Not later than 90 days after the date of the enactment of this Act, the Secretary of Defense shall prescribe regulations updating the Defense Enrollment Eligibility Reporting System (DEERS) to require the gender markers for members of the Armed Forces to match their biological sex, irrespective of any previous changes allowed. 4. Definitions In this Act: (1) Cross-sex hormones The term cross-sex hormones means 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, or estrogen given to biological males at doses that are profoundly larger or more potent than would normally occur naturally in healthy biological males. (2) Gender The term gender means the psychological, behavioral, social, and cultural aspects of being male or female. (3) Gender dysphoria The term gender dysphoria means a marked incongruence between one’s experienced or expressed gender and biological sex. (4) Gender transition The term gender transition means the process by 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 procedures The term gender transition procedures — (A) means— (i) any medical or surgical intervention, including physician's services, inpatient and outpatient hospital services, or prescribed drugs related to gender transition, that seeks to alter or remove physical or anatomical characteristics or features that are typical for the individual’s biological sex or to instill or create physiological or anatomical characteristics that resemble a sex different from the individual’s birth sex, including 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); and (ii) genital or non-genital gender transition surgery performed for the purpose of assisting an individual with a gender transition; and (B) 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; (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 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 (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. (6) Gender transition surgery 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, including genital or non-genital gender reassignment surgery performed for the purpose of assisting an individual with a gender transition. (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 — (A) includes, when performed for the purpose of assisting an individual with a gender transition— (i) surgical procedures such as augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants or lipofilling), hair reconstruction, or various aesthetic procedures for biologically male patients; or (ii) subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants or various aesthetic procedures for biologically female patients; and (B) 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, unless the procedure is for the purpose of a gender transition. (9) Puberty-blocking drugs The term puberty-blocking drugs means, when used to delay or suppress pubertal development in children for the purpose of assisting an individual with a gender transition— (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. (10) Sex; birth sex; biological sex The terms sex , birth sex, and biological sex refer to the biological indication of male and 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.