HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 1639 Gender and Biological Sex
SPONSOR(S): Insurance & Banking Subcommittee, Select Committee on Health Innovation, Bankson, Black
and others
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 10 Y, 5 N, As CS Lloyd Calamas
2) Insurance & Banking Subcommittee 12 Y, 6 N, As CS Fortenberry Lloyd
3) Infrastructure Strategies Committee 15 Y, 9 N Hinshelwood Harrington
SUMMARY ANALYSIS
Gender dysphoria is a behavioral health disorder diagnosable by a health care practitioner in which a person
experiences incongruence between one’s experienced or expressed gender and birth sex, and meets age-
specific diagnostic sub-criteria. Treatment for gender dysphoria has evolved from a behavioral health approach
focused on helping patients become comfortable with their biological sex, to an affirmation-focused approach
potentially involving puberty blocking medication for minors and potentially cross-hormone medication and
surgical interventions. Current law prohibits these services for minors, and requires informed consent for adults.
Health insurers and health maintenance organizations (HMOs) are regulated by the Office of Insurance
Regulation and the Agency for Health Care Administration, respectively. Current law does not regulate
insurance coverage of sex-reassignment prescriptions or procedures.
CS/CS/HB 1639 requires any health insurer or health maintenance organization coverage policy delivered in
the state after January 1, 2025, which covers sex-reassignment prescriptions or procedures, to also provide
coverage for treatment to de-transition from such prescriptions or procedures, for an appropriate additional
premium. In addition, insurers and HMOs that offer policies with coverage for sex-reassignment prescriptions
or procedures must also offer a policy that does not provide that coverage. The bill also forbids all health
insurers and HMOs from prohibiting coverage of mental health or therapeutic services to treat a person’s
perception that his or her sex is inconsistent with the person’s sex at birth by affirming the insured’s sex at
birth.
Current law requires driver licenses and identification cards issued by the Department of Highway Safety and
Motor Vehicles (DHSMV) to include the licensee’s gender, among other information; however, current law does
not define “gender” or outline procedures relating to the identification of a person’s gender. CS/CS/HB 1639
requires a driver license or identification card to state the applicant’s sex at birth, rather than gender.
The bill has an insignificant negative fiscal impact on the DHSMV and no fiscal impact on local government.
The bill may have an indeterminate, negative fiscal impact on health insurers and HMOs, depending on their
current coverage options and offerings.
The bill has an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
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 FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Gender Dysphoria
Transgender and gender nonconforming are general terms for individuals whose gender identity, role,
or expression differ from their biological sex at birth.1
Gender dysphoria refers to the significant discomfort or distress felt as a result of the gender
incongruency.2 Gender dysphoria is a behavioral health disorder diagnosable by a health care
practitioner. The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders
(DSM) classification of gender dysphoria denote a “marked incongruence between one’s
experienced/expressed gender and assigned3 gender, of at least six months’ duration” and
manifestation of sub-criteria that differs based on age.4
Treatment
Treatment of gender dysphoria has evolved. Traditionally, gender identity issues were treated as a
mental illness, with treatment primarily provided through psychotherapy to help patients become
comfortable with their sex at birth.5
In the late 1990’s, treatment began shifting to an “affirmative care model” after physicians in the
Netherlands published a report on positive psychological outcomes for a transgender adolescent
treated with hormones.6 Those physicians suppressed puberty in the early stages followed by cross-
sex hormone therapy starting at age 16. This treatment model became known as the “Dutch Protocol”.
The “Dutch Protocol”, as well as the re-categorization of gender identity issues in the DSM, created a
profound shift in the medically accepted treatment for gender issues. In 2013, the authors of the DSM
replaced the term “gender identity disorder” with “gender dysphoria in children” and “gender dysphoria
in adolescence and adults” to diagnose and treat the distress individuals felt by the incongruency
between their gender identities and their bodies.7 The medical community stopped classifying gender
identity issues as a mental illness. The “Dutch Protocol” was subsequently incorporated into the widely
adopted standards of care for the treatment of transgender patients. 8
The treatment goal now focuses on affirming the patient’s gender identity rather than affirming the
gender of the patient’s sex at birth. Treatment for gender dysphoria now primarily addresses the
1 Coleman, E., Radix, A.E., Bouman, W.P., Brown, G.R., de Vries, A.L.C., et al, (2022), Standards of Care for the Health of
Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23(S1), S1-S260.
2 Id.
3
The DSM uses “assigned” to refer to the delivery physician’s assessment and notation of the child’s biological sex, usually based on
external genitalia. See American Psychiatric Association, Gender Dysphoria, available at, https://www.psychiatry.org/patients -
families/gender-dysphoria (last visited Feb. 20, 2024).
4 American Psychiatric Association, (2013), Diagnostic and Statistical Manual of Mental Disorders (5 th ed.), Arlington, VA: American
Psychiatric Publishing.
5 See Diagnostic and statistical manual of mental disorders. 3 rd ed. Washington, DC: American Psychiatric Publishing; 1980; Diagnostic
and statistical manual of mental disorders. 4 th ed. Washington, DC; American Psychiatric Publishing; 1994.
6 Cohen-Kettenis P.T., van Goozen S.H., (1998), Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent, Eur
Child Adolsc. Psychiatry, 7(4):246-8.
7 The American Psychiatric Association stated that “it is important to note that gender nonconformity is not itself a mental disorder”.
Supra note 4.
8 Supra note 2; Hembree, W., Cohen-Kettenis, P., et al, (2017), Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent
Persons: An Endocrine Society Clinical Practice Guideline, Journal of Clinical Endocrinology & Metab olism , 102(11):2896-3903.
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 incongruency with psychotherapy and medical interventions that align the body with the mind, rather
than the mind with the body. This treatment may include:9
 Psychotherapy to address the negative impact of gender dysphoria and mental health, which
includes social transitioning to affirm an individual’s felt gender identity, role, and expression.
 Puberty blockers to suppress the release of testosterone or estrogen and stop the onset of
secondary sex characteristics.
 Cross-sex hormone therapy to feminize or masculinize the body.
 Sex reassignment surgery to change primary and/or secondary sex characteristics (e.g.,
breasts/chest, external and/or internal genitalia, facial features, and body contouring).
Concerns with Treatment
Clinicians and academics have raised concerns with the appropriateness of medical interventions for
minors based on the lack of rigorous scientific research on the issue. Various issues bring the value of
gender treatment research into question, specifically: many lack randomized control trials, use small
sample sizes, and have a medium to high risk of bias due to recruitment design. 10 From the perspective
of some clinicians, there are no studies that sufficiently evaluate the long-term impact of medical
treatments, so the long-term effects on physical developments, fertility, sexual function and brain
development is unknown.11
Limited research suggests access to puberty blockers and gender-affirming hormones may improve
mental health outcomes, including reduced anxiety, depression, self-harm, and suicidality, in the short-
term.12 On the other hand, other research found a higher rate of suicide attempts and suicide
completion in the short term, and much higher rates of suicide compared to the general population
beginning 10 years post-transition.13
Researchers are just beginning to understand the unintended physical effects of transgender treatment.
Puberty is a time of complex chemical changes that direct the development of many bodily functions.
Taking puberty blockers at that time can prevent that development, with the possibility of significant
future harms as an adult. For example, recent studies document the effect of puberty-blocking
medications on bone development, causing severe lack of density, which may be irreversible.14 The
long-term effect of puberty blockers and cross-sex hormone treatment on sexual function in adulthood
requires further research. One literature review noted both positive and negative effects, but also noted
that there is no valid tool to accurately measure sexual health outcomes. 15 Similarly, researchers are
beginning to express concerns about the impact on the brain, including permanent alterations to
neurodevelopment. 16
9 Supra note 3.
10 See Hruz, P., (2019), Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria, The Linacre Quarterly 87:1,
34-42.; Abbruzzese, E., Levine, S., Mason, J., (2023), The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical
evaluation of the Dutch Studies – and research that has followed, Journal of Sex & Martial Therapy DOI:
10.1080/0092623X.2022.2150346.
11 Supra note 9.
12 See Allen, L. R., Watson, L. B., Egan, A. M., Moser, C. N., (2019), Well-being and suicidality among transgender youth after gender-
affirming hormones, Clinical Practice in Pediatric Psychology, 7(3), 302.
13 Dhejne C., Lichtenstein, P., Boman M., Johansson A., Långström N., Landén, M., (2011), Long -term follow-up of transsexual persons
undergoing sex reassignment surgery: cohort study in Sweden, PLoS One, vol. 6, issue 2.
14 See, e.g., Joseph T, Ting J, Butler G. The effect of GnRH analogue treatment on bone mineral density in young adolescents wit h
gender dysphoria: Findings from a large national cohort. J Pediatr Endocrinol Metab . 2019; 10: 1077– 1081; Lee J., et al, (2020), Low
bone mineral density in early pubertal transgender/gender diverse youth: findings from the trans youth care study, J Endocr Soc. Sep 1;
4(9): bvaa065. In 2022, the Endocrine Society took the position that more research is needed in this area to properly address bone
health in young patients. Endocrine Society, “Longer treatment with puberty-delaying medication in transgender youth leads to lower
bone mineral density”, June 12, 2022, available at https://admin.endocrine.org/news-and-advocacy/news-room/2022/longer-treatment-
with-puberty-delaying-medication-leads-to-lower-bone-mineral-density (last visited Feb. 20, 2024).
15 Mattawanon N., Charoenkwan K., Tangpricha V., (2021), Sexual dysfunction in transgender people: a systematic review, Urol Clin N
Am 48 (2021) 437–460. See, Shirazi TN, Self H, Dawood K, et al., Pubertal timing predicts adult psychosexuality: Evidence from
typically developing adults and adults with isolated GnRH deficiency, Psychoneuroendocrinology. 2020; 104733:104733;
16 See, e.g.,Chen D, Strang JF, Kolbuck VD, et al. Consensus parameter: Research methodologies to evaluate neurodevelopmental
effects of pubertal suppression in transgender youth. Transgender Health. 2020; 4: 246– 257.
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 Regulation of Sex-Reassignment Prescriptions and Procedures in Florida
Current law regulates sex-reassignment prescriptions and procedures as a matter of practitioner
licensure. These prescriptions and procedures include: 17
 Puberty blockers prescribed to stop or delay normal puberty in order to affirm a person’s
perception of his or her sex if that perception is inconsistent with the person’s sex; 18
 Hormones or hormone antagonists prescribed to affirm a person’s perception of his or her sex if
that perception is inconsistent with the person’s sex; and
 Medical procedures to affirm a person’s perception of his or her sex if that perception is
inconsistent the person’s sex.
Current law prohibits sex-reassignment prescriptions and procedures for patients under age 18, with
exceptions for minors actively receiving this treatment at the time the law was enacted in 2023. For
adults, physicians must obtain specified informed consent on a form adopted by the Boards of Medicine
and Osteopathic Medicine.19
Regulation of Insurers and Health Maintenance Organizations
The Office of Insurance Regulation (OIR) licenses and regulates the activities of insurers, health
maintenance organizations (HMOs), and other risk bearing entities in Florida.20 The Agency for Health
Care Administration (AHCA) regulates the quality of care by HMOs under part III of ch. 641, F.S. Before
receiving a certificate of authority from the OIR, an HMO must receive a Health Care Provider
Certificate from AHCA.21
All persons who transact insurance in this state must comply with the Florida Insurance Code (Code).22
The OIR has the authority to collect, propose, publish, and disseminate any information relating to the
subject matter of the Code,23 and may investigate any matter relating to insurance.24
A health insurance mandate is a legal requirement that an insurance company or health plan cover
specific benefits, or services by particular health care providers, or specific patient groups. A contingent
coverage mandate requires coverage of a service, condition, or provider’s care only if coverage is
provided for a certain other service, condition, or provider’s care. In general, coverage mandates
increase the cost of health coverage in varying amounts depending on the cost of the mandated care
and the amount of patient utilization of that care.
Mandated offerings, on the other hand, do not mandate that certain benefits be provided. Rather, a
mandated offering law requires that insurers offer an option for coverage for a particular benefit or
specific patient groups, which may require an additional premium and which the consumer is free to
accept or reject.
Current Florida law requires every person or organization seeking consideration of a legislative
proposal which would mandate a health coverage or the offering of a health coverage by an insurer, to
submit to the Agency for Health Care Administration and the legislative committees having jurisdiction,
a report that assesses the social and financial impacts of the proposed coverage.25 To the extent
information is available, the report should address:
17 S. 456.08, F.S.
18 Under current law, a person’s sex is indicated by a person ’s sex chromosomes, naturally occurring sex hormones, and internal and
external genitalia present at birth. S. 456.001(8), F.S.
19 S. 456.52, F.S.
20 S. 20.121(3)(a), F.S.
21 S. 641.21(1)(1), F.S.
22 S. 624.11, F.S. The Code is comprised of chs. 624-632, 634-636, 641, 642, 648, and 651, F.S. S. 624.01, F.S.
23 S. 624.307(4), F.S.
24 S. 624.307(3), F.S.
25 S. 624.215, F.S.
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  The extent to which the treatment or service is generally used by a significant portion of the
population.
 The extent to which insurance coverage is generally available; or, if not generally available,
results in persons avoiding necessary health care treatment.
 The extent to which lack of coverage results in unreasonable financial hardship.
 The level of public demand for the treatment or service.
 The level of public demand for insurance coverage of the treatment or service.
 The level of interest of collective bargaining agents in negotiating for the inclusion of this
coverage in group contracts.
 The extent to which coverage will increase or decrease the cost of the treatment or service.
 The extent to which coverage will increase the appropriate uses of the treatment or service.
 The extent to which the treatment or service will be a substitute for a more expensive treatment
or service.
 The extent to which the coverage will increase or decrease the administrative expense