,,ii #aahth ,,congress #ast ,session ,s4 #bceg ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,july #ah1 #bjbc,mr4 ,vance introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend chapter #aaj of title #ah1 ,united ,states ,code1 to prohibit gender-affirming care on minors1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,protect ,children's ,innocence ,act4 ,i ,gender-affirming care on minors prohibited #aja4 ,gender-affirming care on minors prohibited ,chapter #aaj of title #ah1 ,united ,states ,code1 is amended-- 7#a7 by adding at the end the following3 #bbfj;,b4 ,gender-affirming care on minors 7a7 ,definitions ,in this section3 7#a7 ,biological sex ,the term biological sex means the indication of male or female sex by reproductive potential or capacity1 sex chromosomes1 naturally occurring sex hormones1 gonads1 or internal or external genitalia present at birth4 7#b7 ,gender-affirming care 7,a7 ,in general ,except as provided in subparagraph 7,b71 the term gender-affirming care means1 with respect to an individual1 any of the following3 7i7 ,performing any surgery for the purpose of changing the body of the individual to correspond to a sex that differs from the individual's biological sex1 including-- 7,i7 castration2 7,,ii7 orchiectomy2 7,,iii7 scrotoplasty2 7,,iv7 vasectomy2 7,v7 hysterectomy2 7,,vi7 oophorectomy2 7,,vii7 ovariectomy2 7,,viii7 metoidioplasty2 7,,ix7 penectomy2 7,x7 phalloplasty2 7,,xi7 vaginoplasty2 7,,xii7 vaginectomy2 7,,xiii7 vulvoplasty2 7,,xiv7 reduction thyrochondroplasty2 7,,xv7 chondrolaryngoplasty2 and 7,,xvi7 mastectomy4 7ii7 ,any plastic surgery that feminizes or masculinizes the facial features of the individual for the purposes described in clause 7i74 7iii7 ,any placement of chest implants in the individual to create feminine breasts for the purposes described in clause 7i74 7iv7 ,any placement of fat or artificial implants in the gluteal region of the individual for the purposes described in clause 7i74 7v7 ,administering1 supplying1 prescribing1 dispensing1 distributing1 or otherwise conveying to the individual medications for the purposes described in clause 7i71 including-- 7,i7 gonadotropin-releasing hormone 7commonly known as ,gn,r,h7 analogues or other puberty-blocking drugs to stop or delay normal puberty2 7,,ii7 testosterone or other androgens to a biological female at doses that are supraphysiologic to the female sex2 and 7,,iii7 estrogen to a biological male at doses that are supraphysiologic to the male sex4 7,b7 ,exception ,subparagraph 7,a7 shall not apply to conduct with respect to the following individuals3 7i7 ,an individual with both ovarian and testicular tissue4 7ii7 ,an individual who does not have normal sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action1 as determined by a physician through genetic or biochemical testing4 7iii7 ,an individual experiencing infection1 disease1 injury1 or disorder caused or exacerbated by previous gender transition procedures4 7iv7 ,an individual suffering from a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of a major bodily function unless a procedure described in that subparagraph is performed4 7#c7 ,minor ,the term minor means any individual under the age of #ah years4 7b7 ,prohibition on performing gender-affirming care on minors 7#a7 ,offense ,it shall be unlawful1 in any circumstance described in subsection 7e71 to knowingly perform any gender-affirming care on a minor4 7#b7 ,penalty ,any person who violates paragraph 7#a7 shall be fined under this title1 imprisoned for not more than #ab years1 or both4 7c7 ,prohibition on prosecution of person on whom intervention is performed ,a person on whom gender-affirming care is performed may not be arrested or prosecuted for an offense under subsection 7b74 7d7 ,civil action ,a person on whom gender-affirming care is performed in violation of subsection 7b7 may bring a civil action in an appropriate district court of the ,united ,states for appropriate relief1 including compensatory and punitive damages1 against each person who performed the gender-affirming care4 7e7 ,circumstances described ,the circumstances referred to in subsection 7b7 are that-- 7#a7 the defendant or victim traveled in interstate or foreign commerce1 or traveled using a means1 channel1 facility1 or instrumentality of interstate or foreign commerce1 in furtherance of or in connection with the conduct described in that subsection2 7#b7 the defendant used a means1 channel1 facility1 or instrumentality of interstate or foreign commerce in furtherance of or in connection with the conduct described in that subsection2 7#c7 any payment of any kind was made1 directly or indirectly1 in furtherance of or in connection with the conduct described in that subsection using any means1 channel1 facility1 or instrumentality of interstate or foreign commerce or in or affecting interstate or foreign commerce2 7#d7 the defendant transmitted in interstate or foreign commerce any communication relating to or in furtherance of the conduct described in that subsection-- 7,a7 using any means1 channel1 facility1 or instrumentality of interstate or foreign commerce2 or 7,b7 in or affecting interstate or foreign commerce by any means or in any manner1 including by computer1 mail1 wire1 or electromagnetic transmission2 7#e7 any instrument1 item1 substance1 or other object that has traveled in interstate or foreign commerce was used to perform the conduct described in that subsection2 7#f7 the conduct described in that subsection occurred in-- 7,a7 the special maritime and territorial jurisdiction of the ,united ,states2 or 7,b7 a territory or possession of the ,united ,states2 or 7#g7 the conduct described in that subsection otherwise occurred in or affected interstate or foreign commerce4 7f7 ,rule of construction ,nothing in this section shall be construed as prohibiting provision of the medical services described in subsection 7a77#b77;,a7 to address legitimate health issues1 such as any male or female reproductive cancers1 apart from changing the body of an individual to correspond to a sex that differs from the individual's biological sex4 2 and 7#b7 in the table of sections1 by adding at the end the following3 #bbfj;,b4 ,gender-affirming care on minors4 4 ,,ii ,prohibiting federally funded gender-affirming care #bja4 ,prohibiting taxpayer-funded gender-affirming care ,title #a1 ,united ,states ,code1 is amended by adding at the end the following3 #d ,prohibiting taxpayer-funded gender-affirming care #cja4 ,prohibition on funding for gender-affirming care4 #cjb4 ,prohibition on funding for health benefits plans that cover gender-affirming care4 #cjc4 ,limitation on ,federal facilities and employees1 ,federal land and territories1 and ,tribal territories4 #cjd4 ,effect on separate coverage4 #cje4 ,effect on use of non-,federal funds for health coverage4 #cjf4 ,application to complications arising from gender-affirming care4 #cjg4 ,application to individuals born with medically verifiable disorder of sex development4 #cjh4 ,gender-affirming care defined4 #cji4 ,effect of chapter4 #cja4 ,prohibition on funding for gender-affirming care ,no funds authorized or appropriated by ,federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by ,federal law1 including funds provided under titles ,,xviii1 ,,xix1 and ,,xxi of the ,social ,security ,act1 shall be expended for any gender-affirming care4 #cjb4 ,prohibition on funding for health benefits plans that cover gender-affirming care ,no funds authorized or appropriated by ,federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by ,federal law1 shall be expended for health benefits coverage that includes coverage of gender-affirming care4 #cjc4 ,limitation on ,federal facilities and employees1 ,federal land and territories1 and ,tribal territories ,gender-affirming care may not be included in any health care service furnished by-- 7#a7 a health care facility owned or operated by the ,federal ,government2 7#b7 a health care facility operated on ,federal land1 in a territory1 or in a ,tribal territory2 or 7#c7 any physician or other individual providing health care services within the scope of the physician's or individual's employment who is-- 7,a7 employed by the ,federal ,government2 or 7,b7 employed by a health care facility operated on ,federal land1 in a territory1 or in a ,tribal territory4 #cjd4 ,effect on separate coverage ,nothing in this chapter prohibits any individual1 entity1 or ,state or locality from purchasing separate coverage for gender-affirming care or health benefits coverage that includes gender-affirming care1 on the condition that such coverage-- 7#a7 is paid for entirely using funds-- 7,a7 not authorized or appropriated by ,federal law2 or 7,b7 not received from ,federal programs1 platforms1 or infrastructure2 7#b7 does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah2 and 7#c7 is not purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cje4 ,effect on use of non-,federal funds for health coverage ,nothing in this chapter restricts the ability of any non-,federal health benefits coverage provider from offering coverage for gender-affirming care1 or the ability of a ,state or locality to contract separately with such a provider for such coverage1 on the condition that such coverage-- 7#a7 is paid for entirely using funds-- 7,a7 not authorized or appropriated by ,federal law2 or 7,b7 not received from ,federal programs1 platforms1 or infrastructure2 7#b7 does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah2 and 7#c7 is not purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cjf4 ,application to complications arising from gender-affirming care ,nothing in this chapter applies to the treatment of any infection1 injury1 disease1 or disorder that has been caused or exacerbated by the performance of a gender-affirming care1 regardless of whether-- 7#a7 the gender-affirming care was performed in accordance with ,federal or ,state law2 or 7#b7 funding for the gender-affirming care is permissible under section #cjg4 #cjg4 ,application to individuals born with medically verifiable disorder of sex development ,the prohibitions and limitations described in sections #cja1 #cjb1 and #cjc shall not apply to conduct with respect to an individual described in section #bbfj;,b7a77#b77;,b7 of title #ah4 #cjh4 ,gender-affirming care defined ,for purposes of this chapter1 the term gender-affirming care has the meaning given such term in section #bbfj;,b of title #ah4 #cji4 ,effect of chapter ,nothing in this chapter prohibits the provision of the medical services described in section #bbfj;,b7a77#b77;,b7 of title #ah1 to address any male or female reproductive cancers 7other than medical services to change the body of an individual to correspond to a sex that differs from the individual's biological sex74 4 #bjb4 ,amendment to table of chapters ,the table of chapters for title #a1 ,united ,states ,code1 is amended by adding at the end the following3 #d4,prohibiting taxpayer-funded gender-affirming care#cja 4 ,,iii ,application under the ,affordable ,care ,act #cja4 ,clarifying application of prohibition to premium credits and cost-sharing reductions under ,,aca 7a7 ,in general 7#a7 ,disallowance of refundable credit and cost-sharing reductions for coverage under qualified health plan which provides coverage for gender-affirming care 7,a7 ,in general ,subparagraph 7,a7 of section #cf;,b7c77#c7 of the ,internal ,revenue ,code of #aihf is amended by inserting before the period at the end the following3 or any health plan that includes coverage for gender-affirming care 7other than any gender-affirming care or treatment described in section #cjf or #cjg of title #a1 ,united ,states ,code74 7,b7 ,option to purchase or offer separate coverage or plan ,paragraph 7#c7 of section #cf;,b7c7 of such ,code is amended by adding at the end the following new subparagraph3 7,c7 ,separate coverage or plan for gender-affirming care allowed 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any individual from purchasing separate coverage for gender-affirming care described in such subparagraph1 or a health plan that includes such gender-affirming care1 so long as no credit is allowed under this section with respect to the premiums for such coverage or plan and such coverage or plan does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah1 ,united ,states ,code4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any non-,federal health insurance issuer offering a health plan from offering separate coverage for gender-affirming care described in such subparagraph1 or a plan that includes such gender-affirming care1 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 7or the amount of any advance payment of the credit under section #adab of the ,patient ,protection and ,affordable ,care ,act7 and such coverage or plan does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah1 ,united ,states ,code4 4 7#b7 ,disallowance of small employer health insurance expense credit for plan which includes coverage for gender-affirming care ,subsection 7h7 of section #de,r of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 by striking ,any term and inserting the following3 7#a7 ,in general ,any term 2 and 7,b7 by adding at the end the following new paragraph3 7#b7 ,exclusion of health plans including coverage for gender-affirming care 7,a7 ,in general ,the term qualified health plan does not include any health plan that includes coverage for gender-affirming care 7other than any gender-affirming care or treatment described in section #cjf or #cjg of title #a1 ,united ,states ,code74 7,b7 ,separate coverage or plan for gender-affirming care allowed 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any employer from purchasing for its employees separate coverage for gender-affirming care described in such subparagraph1 or a health plan that includes such gender-affirming care1 so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan and such coverage does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah1 ,united ,states ,code4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any non-,federal health insurance issuer offering a health plan from offering separate coverage for gender-affirming care described in such subparagraph1 or a plan that includes such gender-affirming care1 so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section and such coverage or plan does not cover any practice that would be subject to penalty under section #bbfj;,b of title #ah1 ,united ,states ,code4 4 7b7 ,application to multi-,state plans ,section #accd7;a7 of ,public ,law #aaa-adh 7#db ,u4,s4,c4 #ahjed7;a77 is amended by adding at the end the following3 7#h7 ,coverage consistent with ,federal policy regarding gender-affirming care ,in entering into contracts under this subsection1 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 #d of title #a1 ,united ,states ,code4 4 7c7 ,effective date ,the amendments made by subsection 7a7 shall apply to taxable years ending after the date that is one year after the date of enactment of this ,act1 but only with respect to plan years beginning after such date1 and the amendment made by subsection 7b7 shall apply to plan years beginning after such date4 ,,iv ,additional ,provisions #dja4 ,prohibition on institutions of higher education and accrediting agencies or associations 7a7 ,prohibition on institutions of higher education ,section #dhg7;a7 of the ,higher ,education ,act of #aife 7#bj ,u4,s4,c4 #ajid7;a77 is amended by adding at the end the following3 7#cj7 ,the institution will not offer instruction in gender-affirming care 7as defined in section #bbfj;,b of title #ah1 ,united ,states ,code74 4 7b7 ,prohibition on accrediting agencies or associations ,section #dif7;a7 of the ,higher ,education ,act of #aife 7#bj ,u4,s4,c4 #ajii;b7a77 is amended-- 7#a7 by striking and at the end of paragraph 7#g72 7#b7 by striking the period at the end of paragraph 7#h7 and inserting 2 and2 and 7#c7 by adding at the end the following3 7#i7 such agency or association does not accredit any institution that offers instruction in gender-affirming care 7as defined in section #bbfj;,b of title #ah1 ,united ,states ,code74 4 #djb4 ,immigration consequences with respect to providing gender-affirming care 7a7 ,definition of gender-,affirming care ,section #aja7;a7 of the ,immigration and ,nationality ,act 7#h ,u4,s4,c4 #aaja7;a77 is amended by adding at the end the following3 7#ec7 ,the term gender-affirming care shall have the meaning given such term in section #bbfj;,b of title #ah1 ,united ,states ,code4 4 7b7 ,classes of aliens ineligible for visas or admission ,section #bab7;a77#a77;,a7 of the ,immigration and ,nationality ,act 7#h ,u4,s4,c4 #aahb7;a77#a77;,a77 is amended-- 7#a7 in clause 7iii77,,ii71 by striking or at the end2 7#b7 in clause 7iv71 by striking the comma at the end and inserting 1 or2 and 7#c7 by inserting after clause 7iv7 the following3 7v7 who is determined to have performed gender-affirming care on a child that has not attained the age of #ah years old1 4 7c7 ,classes of deportable aliens ,section #bcg7;a7 of the ,immigration and ,nationality ,act 7#h ,u4,s4,c4 #abbg7;a77 is amended by adding at the end the following3 7#h7 ,gender-affirming care ,any alien who has performed gender-affirming care on a child who has not attained the age of #ah years old is deportable4 4