S1551-119

1. Short title This Act may be cited as the No Subsidies for Gender Transition Procedures Act.

2. Denial of medical expense tax deduction Subsection (d) of section 213 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph: The term medical care does not include any gender transition procedure. For purposes of this paragraph— The term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition, including— the provision of gonadotropin-releasing hormone agonists or other puberty-suppression drugs or puberty-blocking drugs to stop or delay normally-timed puberty in an individual who does not identify as his or her sex, the provision of testosterone, estrogen, progesterone, or other androgen blockers to an individual at doses which are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex, with the intent to align an individual's physical appearance with an identity that differs from his or her sex, surgical procedures that attempt to transform an individual's physical appearance to align with an identity that differs from his or her sex or that attempt to alter or remove an individual's sexual organs to minimize or destroy their natural biological functions, castration, vasectomy, penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, mastectomy, hysterectomy, oophorectomy, ovariectomy, reconstruction of the fixed part of the urethra with or without metoidioplasty or phalloplasty, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, implantation of erection or testicular prostheses, reduction thyrochondroplasty, chondrolaryngoplasty, tubal ligation, sterilization, augmentation mammoplasty, placement of chest implants to create feminine breasts, placement of fat or artificial implants in the gluteal region, liposuction, lipofilling, voice surgery, hair reconstruction, pectoral implants, any plastic, cosmetic, or aesthetic surgery which feminizes or masculinizes the facial or other physiological features of an individual, and any removal of any otherwise healthy or non-diseased body part or tissue. The term gender transition procedure does not include, when furnished to an individual by a health care provider with the consent of such individual (or, if applicable, such individual’s parents or legal guardian)— services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics which 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, services relating to any other physician-diagnosed disorder of sexual development with respect to 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 healthy male or female of the same age, the treatment of any infection, injury, disease, or disorder caused or exacerbated by the performance of gender transition procedures, without regard to whether the gender transition procedure was performed in accordance with State and Federal law or whether the gender transition procedure is treated as medical care under this section, any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) which 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 to alleviate said physical disorder, physical injury, or physical illness, procedures to restore or reconstruct the body of the individual in order to correspond to the individual's sex after one or more previous gender transition procedures, which may include the removal of a pseudo phallus or breast augmentation, puberty suppression or puberty-blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty, or male circumcision. The term gender transition means the process by which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting as a self-proclaimed identity which does not correspond with or is different from his or her sex, and may be accompanied by social, legal, or physical changes. The term sex, when referring to an individual’s sex, means either male or female, as biologically determined. The term female, when used to refer to a natural person, means a person belonging, at conception, to the sex characterized by a reproductive system with the biological function of producing eggs (ova). The term male, when used to refer to a natural person, means a person belonging, at conception, to the biological sex characterized by a reproductive system with the biological function of producing sperm. The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act. (12) Expenses relating to gender transition (A) In general The term medical care does not include any gender transition procedure. (B) Definitions For purposes of this paragraph— (i) Gender transition procedure (I) In general The term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition, including— (aa) the provision of gonadotropin-releasing hormone agonists or other puberty-suppression drugs or puberty-blocking drugs to stop or delay normally-timed puberty in an individual who does not identify as his or her sex, (bb) the provision of testosterone, estrogen, progesterone, or other androgen blockers to an individual at doses which are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex, with the intent to align an individual's physical appearance with an identity that differs from his or her sex, (cc) surgical procedures that attempt to transform an individual's physical appearance to align with an identity that differs from his or her sex or that attempt to alter or remove an individual's sexual organs to minimize or destroy their natural biological functions, (dd) castration, vasectomy, penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, mastectomy, hysterectomy, oophorectomy, ovariectomy, reconstruction of the fixed part of the urethra with or without metoidioplasty or phalloplasty, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, implantation of erection or testicular prostheses, reduction thyrochondroplasty, chondrolaryngoplasty, tubal ligation, sterilization, augmentation mammoplasty, placement of chest implants to create feminine breasts, placement of fat or artificial implants in the gluteal region, liposuction, lipofilling, voice surgery, hair reconstruction, pectoral implants, any plastic, cosmetic, or aesthetic surgery which feminizes or masculinizes the facial or other physiological features of an individual, and any removal of any otherwise healthy or non-diseased body part or tissue. (II) Exclusions The term gender transition procedure does not include, when furnished to an individual by a health care provider with the consent of such individual (or, if applicable, such individual’s parents or legal guardian)— (aa) services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics which 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, (bb) services relating to any other physician-diagnosed disorder of sexual development with respect to 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 healthy male or female of the same age, (cc) the treatment of any infection, injury, disease, or disorder caused or exacerbated by the performance of gender transition procedures, without regard to whether the gender transition procedure was performed in accordance with State and Federal law or whether the gender transition procedure is treated as medical care under this section, (dd) any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) which 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 to alleviate said physical disorder, physical injury, or physical illness, (ee) procedures to restore or reconstruct the body of the individual in order to correspond to the individual's sex after one or more previous gender transition procedures, which may include the removal of a pseudo phallus or breast augmentation, (ff) puberty suppression or puberty-blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty, or (gg) male circumcision. (ii) Gender transition The term gender transition means the process by which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting as a self-proclaimed identity which does not correspond with or is different from his or her sex, and may be accompanied by social, legal, or physical changes. (iii) Sex The term sex, when referring to an individual’s sex, means either male or female, as biologically determined. (iv) Female The term female, when used to refer to a natural person, means a person belonging, at conception, to the sex characterized by a reproductive system with the biological function of producing eggs (ova). (v) Male The term male, when used to refer to a natural person, means a person belonging, at conception, to the biological sex characterized by a reproductive system with the biological function of producing sperm. .

3. Prohibiting Federal medicaid funding for gender transition procedures Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) is amended— in paragraph (26), by striking ; or and inserting a semicolon; in paragraph (27), by striking the period at the end and inserting ; or; by inserting after paragraph (27) the following new paragraph: with respect to any amounts expended for any specified gender transition procedure (as defined in section 1905(kk)) to an individual enrolled in a State plan under this title (or a waiver of such plan), including any amounts expended for the administration of a State program that furnishes any such procedure. in the flush left matter at the end, by striking and (18), and inserting (18), and (28). Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection: For purposes of section 1903(i)(28), except as provided in paragraph (2), the term specified gender transition procedure means, with respect to an individual, any hormonal or surgical intervention for the purpose of gender transition, including— the provision of gonadotropin-releasing hormone agonists or other puberty suppression drugs or puberty-blocking drugs to stop or delay normally timed puberty in an individual who does not identify as his or her sex; the provision of testosterone, estrogen, progesterone, or other androgen blockers to an individual at doses which are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex, with the intent to align an individual’s physical appearance with an identity that differs from his or her sex; surgical procedures that attempt to transform an individual’s physical appearance to align with an identity that differs from his or her sex or that attempt to alter or remove an individual’s sexual organs to minimize or destroy their natural biological functions; or castration, vasectomy, penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, mastectomy, hysterectomy, oophorectomy, ovariectomy, reconstruction of the fixed part of the urethra with or without metoidioplasty or phalloplasty, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, implantation of erection or testicular prostheses, reduction thyrochondroplasty, chondrolaryngoplasty, tubal ligation, sterilization, augmentation mammoplasty, placement of chest implants to create feminine breasts, placement of fat or artificial implants in the gluteal region, liposuction, lipofilling, voice surgery, hair reconstruction, pectoral implants, any plastic, cosmetic, or aesthetic surgery which feminizes or masculinizes the facial or other physiological features of an individual, and any removal of any otherwise healthy or non-diseased body part or tissue. The term specified gender transition procedure shall not include, when furnished to an individual by a health care provider with the consent of such individual (or, if applicable, the parents or legal guardian of such individual)— services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics which 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; services relating to any other physician-diagnosed disorder of sexual development with respect to 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 healthy male or female of the same age; the treatment of any infection, injury, disease, or disorder caused or exacerbated by the performance of gender transition procedures, without regard to whether the gender transition procedure was performed in accordance with State and Federal law or whether the gender transition procedure is treated as medical care under this section; any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) which 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 to alleviate said physical disorder, physical injury, or physical illness; any procedure to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after 1 or more previous gender transition procedures, which may include the removal of a pseudo phallus or breast augmentation; puberty suppression or puberty-blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty; or male circumcision. For purposes of this subsection: The term gender transition means the process by which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting as a self-proclaimed identity which does not correspond with or is different from his or her sex, and may be accompanied by social, legal, or physical changes. The term sex, when referring to an individual’s sex, means either male or female, as biologically determined, including as described in subparagraphs (C) and (D). The term female, when used to refer to a natural person, means an individual belonging, at conception, to the sex characterized by a reproductive system with the biological function of producing eggs (ova). The term male, when used to refer to a natural person, means an individual belonging, at conception, to the biological sex characterized by a reproductive system with the biological function of producing sperm. The amendments made by this section shall apply to services furnished on or after the date of the enactment of this Act. (28) with respect to any amounts expended for any specified gender transition procedure (as defined in section 1905(kk)) to an individual enrolled in a State plan under this title (or a waiver of such plan), including any amounts expended for the administration of a State program that furnishes any such procedure. ; and (kk) Prohibiting Federal medicaid funding for specified gender transition procedures (1) Specified gender transition procedures defined For purposes of section 1903(i)(28), except as provided in paragraph (2), the term specified gender transition procedure means, with respect to an individual, any hormonal or surgical intervention for the purpose of gender transition, including— (A) the provision of gonadotropin-releasing hormone agonists or other puberty suppression drugs or puberty-blocking drugs to stop or delay normally timed puberty in an individual who does not identify as his or her sex; (B) the provision of testosterone, estrogen, progesterone, or other androgen blockers to an individual at doses which are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex, with the intent to align an individual’s physical appearance with an identity that differs from his or her sex; (C) surgical procedures that attempt to transform an individual’s physical appearance to align with an identity that differs from his or her sex or that attempt to alter or remove an individual’s sexual organs to minimize or destroy their natural biological functions; or (D) castration, vasectomy, penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, mastectomy, hysterectomy, oophorectomy, ovariectomy, reconstruction of the fixed part of the urethra with or without metoidioplasty or phalloplasty, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, implantation of erection or testicular prostheses, reduction thyrochondroplasty, chondrolaryngoplasty, tubal ligation, sterilization, augmentation mammoplasty, placement of chest implants to create feminine breasts, placement of fat or artificial implants in the gluteal region, liposuction, lipofilling, voice surgery, hair reconstruction, pectoral implants, any plastic, cosmetic, or aesthetic surgery which feminizes or masculinizes the facial or other physiological features of an individual, and any removal of any otherwise healthy or non-diseased body part or tissue. (2) Exclusions The term specified gender transition procedure shall not include, when furnished to an individual by a health care provider with the consent of such individual (or, if applicable, the parents or legal guardian of such individual)— (A) services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics which 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; (B) services relating to any other physician-diagnosed disorder of sexual development with respect to 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 healthy male or female of the same age; (C) the treatment of any infection, injury, disease, or disorder caused or exacerbated by the performance of gender transition procedures, without regard to whether the gender transition procedure was performed in accordance with State and Federal law or whether the gender transition procedure is treated as medical care under this section; (D) any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) which 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 to alleviate said physical disorder, physical injury, or physical illness; (E) any procedure to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after 1 or more previous gender transition procedures, which may include the removal of a pseudo phallus or breast augmentation; (F) puberty suppression or puberty-blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty; or (G) male circumcision. (3) Additional definitions For purposes of this subsection: (A) Gender transition The term gender transition means the process by which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting as a self-proclaimed identity which does not correspond with or is different from his or her sex, and may be accompanied by social, legal, or physical changes. (B) Sex The term sex, when referring to an individual’s sex, means either male or female, as biologically determined, including as described in subparagraphs (C) and (D). (C) Female The term female, when used to refer to a natural person, means an individual belonging, at conception, to the sex characterized by a reproductive system with the biological function of producing eggs (ova). (D) Male The term male, when used to refer to a natural person, means an individual belonging, at conception, to the biological sex characterized by a reproductive system with the biological function of producing sperm. .

4. Prohibiting Federal children’s health insurance program funding for gender transition procedures on minors Section 2105(c) of the Social Security Act (42 U.S.C. 1397ee(c)) is amended by adding at the end the following new paragraph: Payment shall not be made to a State under this section for any amount expended under the State plan to pay for specified gender transition procedures (as defined in section 1905(kk)) or to assist in the purchase, in whole or in part, of health benefit coverage that includes coverage of any such procedure. Section 2107(e)(1)(N) of the Social Security Act (42 U.S.C. 1397gg(e)(1)(N)) is amended by striking and (17) and inserting (17), and (28). The amendments made by this section shall apply to services furnished on or after the date of the enactment of this Act. (13) Limitation on payment for specified gender transition procedures for minors Payment shall not be made to a State under this section for any amount expended under the State plan to pay for specified gender transition procedures (as defined in section 1905(kk)) or to assist in the purchase, in whole or in part, of health benefit coverage that includes coverage of any such procedure. .

5. Prohibiting Federal medicare funding for gender transition procedures Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— in paragraph (24), by striking or at the end; in paragraph (25), by striking the period at the end and inserting ; or; and by inserting after paragraph (25) the following new paragraph: which are specified gender transition procedures (as defined in section 1905(kk)). The amendments made by subsection (a) shall apply to items and services furnished on or after the date of the enactment of this Act. (26) which are specified gender transition procedures (as defined in section 1905(kk)). .

6. Exclusion of gender transition procedures from essential health benefits Section 1302(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(b)(2)) is amended— in the paragraph heading, by striking Limitation and inserting Limitations; by redesignating subparagraph (B) as subparagraph (C); by inserting after subparagraph (A) the following: In defining the essential health benefits under paragraph (1), or in revising essential health benefits under paragraph (4)(H), the Secretary shall not include the category of gender transition procedures (as defined in section 213(d)(12)(B) of the Internal Revenue Code of 1986) or any items or services covered within such a category. in subparagraph (C) (as so redesignated), by striking paragraph (2) and inserting subparagraph (A). (B) Exclusions In defining the essential health benefits under paragraph (1), or in revising essential health benefits under paragraph (4)(H), the Secretary shall not include the category of gender transition procedures (as defined in section 213(d)(12)(B) of the Internal Revenue Code of 1986) or any items or services covered within such a category. ; and