The first week of Trump’s second presidency was head-spinning, and not in a good way. His first batch of executive orders was largely about unleashing harm—in even more reckless and nihilistic ways than in his first administration. For sexual and reproductive health across the globe, this means trouble.
One of his first actions was to reinstate the so-called global gag rule, which prevents organizations abroad from even mentioning abortion to patients if they receive any U.S. foreign aid. As this column will explain, this policy goes far beyond the version followed by other Republican presidents and will combine with Trump’s attacks on HIV/AIDS funding to cause serious harm abroad.
The History of the “Global Gag” Rule
Ronald Reagan is responsible for the first global gag rule, also known as the Mexico City policy. It was rolled out in 1984 at the United Nations International Conference on Population and had the effect of globalizing barriers to women’s health care. In 1973, Congress enacted the Foreign Assistance Act, which contained a provision known as the Helms Amendment that prohibited the use of U.S. funds to pay “for the performance of abortion as a method of family planning.” (This was the same year that the Supreme Court recognized a constitutional right to seek an abortion until a certain point in pregnancy in the Roe v. Wade decision—which was in place until the Supreme Court overturned it in 2022.) In Reagan’s view, however, the 1973 prohibition on funding abortion in foreign countries did not go far enough to sever the connection between the United States and abortion. Thus, Reagan devised the new rule to impose further restrictions on recipients of family planning funds from the U.S.
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. 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 was an executive add-on to existing federal law. It cut a wide swath and had harmful effects, some intended, some unintended. Family planning NGOs that also provide abortion care lost their funding; some then had to close or reduce service levels because of the lack of funding. NGOs that continued to accept were barred even from providing information about abortion to their patients or making referrals to other providers. Funded organizations were also banned from advocating for the legalization or expansion of access to abortion in their countries. The United States is the largest funder of global health initiatives worldwide, and women across the globe suffer both when the global gag rule is in place—and later because of funding and service cuts that are not easily restored when it is revoked.
In the four decades since the global gag rule was first introduced, it has become standard for Democratic presidents to withdraw it and Republican presidents to reinstate it. The first version was in place through the Reagan and Bush administrations and then withdrawn by Bill Clinton in 1993. When George W. Bush took office in 2001, he reinstated it; Barack Obama withdrew it in 2009. It was thus not a surprise when Trump reinstated the rule during the first week of his first administration in 2017. It was a surprise, however, that he added a few sentences that had the effect of expanding the rule to cover about ten times as much funding. Rather than restricting the activities only of NGOs that receive family planning funds, the Trump version of the rule applied to “global health assistance furnished by all departments or agencies.” The expanded policy came with no instructions or explanation. Like much of what Trump did in his first administration, the policy was drafted and finalized without input from any agencies with relevant expertise.
Trump’s expansion of the rule was breathtakingly broad. 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 increased 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.
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, provided no such exception.
Biden repealed the global gag rule, as expected. And, quietly on a Friday night, Trump reinstated it for a second time. It again applies to all recipients of U.S. aid, regardless of the type. And it again does not exempt PEPFAR funding.
The Harmful Effects of the Global Gag Rule—Especially Trump’s Expanded Version
The global gag rule was deliberately designed to reduce abortion worldwide, by targeting all the activities that might indirectly promote or facilitate abortion. But it doesn’t seem to have this effect. 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; the United States has the highest maternal mortality rate in the developed world, and in many states it is increasing even as it falls globally.) And while abortion is an incredibly safe procedure when legal, it can be very unsafe when illegal and done in secret. According to a 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 forgo 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 forgo 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.
A new study by the Guttmacher Institute found that Trump’s gag rule had a variety of deleterious effects in Uganda and Ethiopia. In Uganda, the gag rule stalled progress in increasing contraceptive use and reducing the rate of unintended pregnancy. Uganda has highly restrictive abortion laws, so the rule mostly affected other aspects of women’s healthcare. Researchers found that reproductive health outcomes differed depending on whether the area was served by NGOs who were affected by the rule. In Ethiopia, the impact was even more negative. The country had made significant gains in reproductive health over the preceding 20 years, including a reduction in maternal mortality. The gains can be largely attributed to the liberalization of the country’s abortion law in 2005. But researchers found that it was “highly susceptible to the impact of the gag rule because it relies heavily on foreign donors—the United States, in particular—for family planning and reproductive health services.” Two large NGOs in the country refused to follow Trump’s expanded gag rule, which caused them to lose U.S. funding. This loss was significant enough that “reproductive health services throughout the entire country faltered.”
As noted by the Kaiser Family Foundation, the available research makes clear that the global gag policy has a variety of consequences: “increases in abortion rates and reductions in contraceptive prevalence (among other health outcomes); disruption and gaps in services; reduction in service integration; over-implementation and chilling effects; confusion about the policy; loss of civil society/NGO coordination and partnerships; and increased administrative burden.”
Yet, despite all this evidence of harm, here we go again.
Conclusion
It has only been a week since Trump took office for the second time, but he has been issuing executive orders that will cause immediate and lasting harm to public health. In addition to reinstating the global gag rule, Trump imposed a “pause” on all foreign assistance, including disbursements under PEPFAR, which supplies most of the treatment for HIV in Africa and which has served over 25 million people since its inception. The pause could last as long as 180 days, which is long enough to fuel the rise of drug-resistant HIV and cause infection rates to rise. Trump also removed webpages from Whitehouse.gov that provided information about how to access reproductive healthcare. He reaffirmed the Hyde Amendment, which restricts the use of federal funding for abortion in the U.S. He announced that his Justice Department will “deprioritize” prosecutions under the Freedom of Access to Clinic Entrances (FACE) Act, which was enacted in 1994 due to increased violence directed at abortion providers and patients.
It is impossible to overstate the harm that will come from Trump’s reckless, ill-informed, and mean-spirited actions on reproductive health. The cruelty is the point.
