Women’s health is under attack—here, there, and everywhere.
Domestically, we see Trump’s pick of a Supreme Court nominee, Neil Gorsuch, who he suspects might vote to overturn Roe v. Wade (and who will not affirm his support for its holding, which provides women a right to terminate a pregnancy before a certain point without undue burden from the government). We see Congress’s unrelenting threats to cut off all government support for Planned Parenthood, one of the most effective and trusted providers of family planning in the United States—a move that will reduce or eliminate access to reproductive health care (including all preventative services) for more than a million women, the vast majority of whom are low-income and live in areas underserved by the medical profession. We see Congress’s threats to forbid the most commonly used method for second-trimester abortion and even suggestions that private insurance could be banned from covering abortion. We also see Congress’s fumbling attempts to repeal the Affordable Care Act, including the provision that bans sex discrimination in the provision of health insurance and the extremely important one that requires insurance companies to fund reproductive health care (not including abortions) at zero cost to patients. All women will be affected by these developments.
Outside of the United States, the attack on women’s health care is even more devastating. The day after millions of women marched across the country to protest Trump and his thoughtless and malevolent governance, he issued an executive order reinstating something referred to as the global gag rule.
This rule, also known as the Mexico City policy, was first devised by Ronald Reagan’s administration. First enforced in 1984 at the United Nations International Conference on Population, the policy had the effect of globalizing barriers to women’s health care. In its first iteration, the global gag rule banned foreign non-governmental organizations (NGOs) who received U.S. international family planning assistance from offering abortion services—even if those particular services were funded with non-U.S. money. Even before the global gag rule was first instituted, a federal law called the Foreign Assistance Act prohibited the use of U.S. funds to pay “for the performance of abortion as a method of family planning.” This provision, known as the “Helms Amendment,” was passed in 1973. But Reagan did not believe it went far enough to sever the connection between the United States and abortion.
The global gag rule was thus designed to expand on existing federal law. In addition to prohibiting family planning support to foreign NGOs that provided abortion services, it also prohibited aid recipients from providing any information about abortion to patients or clients, providing referrals to other providers who perform safe (and legal) abortions, and advocating for the legalization of abortion in their country. (Governmental organizations have always been exempt from these restrictions, even if they receive U.S. aid, for diplomatic reasons.)
The global gag rule is a political football. When Bill Clinton took office in 1993, he withdrew the executive order that imposed the rule. When George W. Bush took office from him in 2001, he reinstated it. And, predictably, Barack Obama reversed it in 2009. It was not a surprise when Trump reinstated the rule during his first week in office. However, his executive order not only resurrects the barriers to women’s health care that had been imposed by prior Republican administrations, but also vastly expands the rule to cover more than ten times as much funding.
In the new order, Trump specifically reinstates the Mexico City policy. The content of the order was a subject of a slowly unfolding mystery, as Trump did not initially release the actual order despite referring to its existence. The broad and unprecedented language was first, perhaps accidentally, revealed by an anti-abortion activist who posted a picture on Twitter of a screenshot of the actual order. (This is how governance seems to work in the Trump Administration.) When the order was released, it was not accompanied or followed by any guidance on the proper interpretation or application of this new and wide-ranging policy. And, like other orders from this administration, it seems to have been drafted and finalized without input from any agencies with relevant expertise. According to news reports, neither USAID nor the State Department, both deeply affected by the order, knew anything about it. The order was not accompanied by a press release, and the White House phone line was shut down that day. (Now, at least, the order is on the White House website, occupying space freed up by the many things Trump deleted, such as any reference to the judicial branch of government.) The picture-gone-viral of Trump’s signing an order imposing vast restrictions on women’s health across the globe says it all: He looks sternly at the page, while being gazed at by eight white men. (There is apparently one woman at the end of the row who has been cropped out of most pictures of this moment, but she was only a press aide, and certainly not someone who had input into the policy.)
Putting aside the sketchy rollout of the order, and the absurdity of women’s absence from the policy-making table, we should focus on the problems it resurrects—and creates. Even the basic gag rule causes significant and well-documented harms. But Trump didn’t stop there. In a second paragraph, the order provides as follows:
I direct the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies.
What does this mean? The traditional policy applied only to foreign NGOs who received U.S. aid for family planning. But Trump’s order, through this additional provision, governs money that the United States provides for any global health assistance. In practical terms, this increases the scope of the gag rule from $575 million (amount of family planning assistance given to other countries in 2016) to an estimated $9.5 billion. This is a devastating and bizarre expansion that occurs during an era in which thirty countries across the globe have acted to liberalize abortion laws and to safeguard women’s health.
Moreover, when the United States launched President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, George W. Bush exempted funds in that program from the gag rule. This was based on the understanding that organizations providing prevention, care, or treatment to people with HIV/AIDS could not function under the gag rule’s restrictions. Trump’s order, in contrast, provides no such exception.
The global gag rule was deliberately designed to reduce abortion worldwide, by targeting all the activities that might indirectly promote or facilitate abortion. But the available research does not support this claim. Because the global gag rule has been withdrawn and reinstated so many times, researchers are able to study its effects against a control. The first study on the effect of the gag rule showed that the policy might actually have increased the number of abortions. Another study of the gag rule’s effect in Ghana found that because of the reduced access to contraceptive services, the rate of unintended pregnancy increased, as did the abortion rate, among rural and poor populations. And neither of these facts should be taken lightly. Across the globe, 830 women die each day from pregnancy and childbirth complications. (And this is not just a global phenomenon; Texas has the highest maternal mortality rate in the developed world, which doubled in just the last three years.) And while abortion is an incredibly safe procedure when legal, it can be very unsafe when illegal and secreted. According to a recent New Yorker article, seven million women in the developing world are treated every year for attempting to end a pregnancy unsafely—and 68,000 of them die.
The global gag rule is also touted as promoting women’s health. But it does nothing of the kind. There is a consensus that the lack of safe abortion services increases risk for women. The harmful effects of Trump’s expanded gag rule, moreover, go far beyond abortion. Many foreign NGOs decided to forego all U.S. aid after the first introduction of the gag rule in 1984 in order to preserve their integrity and to adequately serve their patients, who needed complete and accurate information alongside comprehensive healthcare. The result was that these health providers often had to cut staff and services because of the loss of funding, causing thousands of women to lose access to family planning and reproductive health services. And the NGOs that had served them were often the only provider in the area, especially in low-income and rural areas. The outreach efforts to underserved populations are the most expensive work these organizations do and thus the most vulnerable when resources are diminished. The gag rule thus puts providers in an impossible situation—they can forego funding, which will cause them to serve fewer patients and provide fewer services, or they can accept funding and deny their patients information and services they desperately need.
Eight countries have promised to increase funding to fill the huge gap created by the newly expanded global gag rule. But those countries have nowhere near the wealth or funding capacity of the United States. The United States is the largest funder of global health initiatives worldwide, and women across the globe will suffer from this decision.
When Trump says he is putting “America First,” (a troubling reference for many reasons), he includes only men in that promise.
This column benefited from the work and insights of Heather D. Boonstra, Director of Public Policy at the Guttmacher Institute, a leading research and policy organization committed to advancing sexual and reproductive health and rights in the United States and globally.