The 'frightening' long-term impact of the global gag rule

Members of the international development community are on the edge of their seats as they await the results of this year’s U.S. presidential election, which is expected to be a rematch between current President Joe Biden and his predecessor, Donald Trump. Sexual and reproductive health rights advocates fear that an even more expanded version of the global gag rule — which bans U.S. health funding to foreign NGOs if they use their own non-US funds for abortion-related activities — could be put in place if Trump is victorious. In addition to the loss of funding and services, advocates fear the long-term repercussions of the rule at a time when sexual and reproductive health rights are experiencing greater pushback globally. “We know that women die, and women suffer long term health consequences because of this loss of funding. But the piece that's really hard to quantify and to document and is really insidious is the way [the global gag rule] just sort of chips away at norms, and what's acceptable and what's not,” said Sarah Shaw, associate director of advocacy at MSI Reproductive Choices, an international NGO providing contraceptives and abortion services in 37 countries. The global gag rule has been a staple policy for Republican presidents for the last four decades since it was first introduced by Ronald Reagan. But Trump, who is vying for a second term despite facing a slew of criminal charges, expanded the scope of the policy during his term in office to apply to all U.S. global health assistance. He also extended the policy to cover subgrantees of U.S. aid recipients. If he wins in November, there is little doubt among advocates that he would reinstate the rule. They fear he may even expand it to include all U.S. development assistance, and block funding to multilateral organizations such as the United Nations Population Fund. This would have huge implications for other organizations, and not just those working in global health. These proposals are part of Project 2025, a policy agenda put together by conservatives for the next Republican president. While packaged as a set of recommendations, the paper is known to be backed by conservative funders. It was published by The Heritage Foundation, a conservative think-tank based in Washington, D.C. whose former employees were part of the Trump administration. MSI Reproductive Choices estimates that 8 million women lost access to sexual and reproductive services when they lost funding from USAID under Trump’s expanded global gag rule. This resulted in 6 million unintended pregnancies, 1.8 million unsafe abortions, and 20,000 maternal deaths. “[The global gag rule] basically sends a message that, hey, it's alright, to prevent women from choosing abortions, and it's alright to treat those women and those people that provide those services not very well,” Shaw said. A recent UNFPA report on the state of the world’s population highlighted that there’s been zero reduction in maternal mortality since 2016, and in several countries it’s even rising. In addition, nearly half of all women are not able to exercise their sexual and reproductive health and rights. While Biden reversed the global gag rule as one of his first policy moves when he won the presidency in 2021, advocates have seen an increase in U.S.-based anti-choice groups setting up offices in places like Uganda, a country where many rights are already legally curtailed, including abortion, and Ethiopia, where abortion is allowed under a 2005 law which is now under threat of being overturned as anti-choice groups spread misinformation, mobilize public criticism of abortion, and appeal to politicians to revisit the law, Shaw said. "We've really seen that the global gag rule has really contributed to an enabling environment for these [anti-choice] groups to start mobilizing against reproductive health and reproductive rights. So that's, that's quite frightening," Shaw said. Advocates have been calling on the U.S. Congress to permanently repeal the global gag rule for decades, but to no avail. Trump’s expanded policy Uganda is heavily reliant on U.S. foreign assistance for family planning programs — the U.S. Agency for International Development is the largest donor to its family planning budget — and it was hit hard by the global gag rule’s implementation during Trump’s four-year term. It affected not just abortion services but also other sexual and reproductive health programs as affected NGOs that deliver more than half of the family planning services in the country complied with the rule, according to a recent report by the Guttmacher Institute that aimed to capture the impact of the expanded policy in Uganda and Ethiopia. Two major NGOs that refused to comply lost funding, and had to scale back their programs. Some districts saw a decline in community health workers providing contraceptive education and counseling, while the number of women seeking post-abortion care from complications brought about by unsafe abortion increased. “What we're seeing there is greater stress placed on women's lives because they're having to risk their life and their health going through this unsafe service. But then we're also seeing greater pressure put on the health system, because post-abortion care is a lot more expensive to provide than a first trimester abortion or contraception,” Shaw said. Use of long-active contraceptives, such as implants and intrauterine devices, which saw an increase in uptake over the years in the country, also plateaued. This left women with little choice but to revert to short-term contraceptive use like injectables or pills, or not use any method at all, Shaw said. “Obviously, the side effects of that is increasing unintended pregnancies,” she added. Ethiopia is another country heavily reliant on U.S. foreign assistance that was hard hit by the policy. While the Ethiopian government and several NGOs tried to maintain abortion services through public health facilities, declines were seen in other reproductive health services. Researchers found depleted stocks of contraceptives, and declines in services providing post-abortion care, even though the global gag rule doesn’t ban it, according to the Guttmacher Institute report. Long-term impacts The rule’s adverse effects on sexual and reproductive health rights remain long after it was rescinded. In the case of the global gag rule under Trump, guidance on the policy reversal under Biden took a while to reach all implementers. The 2022 overturning of Roe v. Wade, which revoked women’s constitutional right to abortion in the U.S., added to the confusion. Many grassroots implementers didn’t understand that Roe v. Wade only applies within the U.S. and does not affect U.S. foreign assistance. They thought it was the global gag rule “coming back under a different name,” and it created additional confusion “in a space that was already confused,” Shaw said. But the longer-term consequences of the global gag rule might be harder to roll back. There’s been an increase in anti-abortion and anti-human rights activities in places like Uganda and Ethiopia, spearheaded by U.S.-based anti-choice groups, according to Shaw. This includes groups like Family Watch International, an NGO accused of promoting anti-LGBTQ+ stance in several African countries and is known for opposing abortion and comprehensive sexuality education, which teaches young people about contraception, consent, and access to sexual and reproductive health services. The NGO now has an office in the Ethiopian capital Addis Ababa, and according to Shaw, played a role in the blocking of comprehensive sexuality education for young people in the country. According to Shaw, the Ethiopian Ministry of Education is "very conservative," and didn't quite agree with the proposals put forward by UNESCO for the curriculum. However, she said “there is no doubt that the work of Family Watch International was a significant contributor.” Through a campaign called “Stop CSE,” the group “embarked on a largescale online misinformation campaign that weaponised comprehensive sexuality education in Ethiopia and is now threatening to overturn the abortion law with devastating consequences for the health and rights of women and girls,” she said. The organization has been campaigning against comprehensive sexuality education in schools in the country, with its Africa director, Ethiopian surgeon Seyoum Antonios, at the forefront of that messaging. In a written response to Devex, Family Watch International Director of Communications Lynn Allred said they oppose CSE as they find that many such programs, particularly in Africa, sexualize young children, and she dismissed that they are spreading misinformation. “I'm not sure how publicizing direct quotes from CSE manuals can be characterized as ‘misinformation,’ but that is all CSE advocates can do once it is clear what they are promoting to children,” Allred wrote. She said many CSE out-of-school manuals for African countries “teach 10-year-olds about masturbation, anal and oral sex. bestiality, sexual pleasure with urine and feces, sex with corpses, among other things,” and referenced a CSE for out-of-school young people in Zimbabwe facilitators’ manual, developed by the Zimbabwean Ministry of Health and Child Care together with UNFPA and other organizations, containing such. The 293-page manual mentioned those terms once as part of a definition of terms to explain sexual orientation. However, it noted it is only to raise participants’ awareness of such behaviors and “does not encourage or facilitate experimentation.” The note stated that these behaviors are not accepted in all cultures, and that homosexuality and exhibitionism are considered criminal acts in Zimbabwe. The CSE program that was to be implemented in Ethiopia contained what the organization perceives as “harmful” elements, and that’s why they oppose it, according to a written response from Antonios. He added that they oppose the abortion law in Ethiopia “because it has the broad health of the mother exception which has been used globally to justify abortion at any time for any reason, even late-term abortion and partial-birth abortion, which we deem as similar to infanticide.” Ethiopian law provides specific provisions when abortion is allowed. That includes in case of rape, incest, or fetal impairment. Women can also terminate their pregnancy if their life is in danger, if they have physical or mental disabilities, or if they are a minor and “physically or mentally unprepared for childbirth,” according to the Guttmacher Institute. Ethiopia has been a model example in the region in establishing access to abortion and contraception. Its abortion law helped lead to a drop in maternal mortality rates in the country, as women no longer had to seek unsafe abortion services. But now the country is at risk of “undoing great work” as anti-choice groups strengthen their presence and advocacy in the country, Shaw said. Even if Biden wins the upcoming election, advocates expect the pushback on sexual and reproductive health rights to continue. “There will still be a lot of pushback, I think, on women's rights, because these organizations they're becoming entrenched, they're building their own ecosystems, their own architecture at country level. And they're gaining a lot of support and a lot of traction at the moment,” Shaw said. Update, May 20, 2024: This story has been updated to reflect comments made by Family Watch International’s Africa director, Seyoum Antonios, and provide additional reporting on Ethiopia’s abortion law.