Today, Donald Trump reinstated an anti-abortion policy known as the global gag rule.

This follows a day-one executive order that instituted a 90-day pause on all U.S. foreign aid—a portfolio currently totalling $68 billion —and subsequent guidance from Secretary of State Marco Rubio that stopped spending on nearly all existing foreign aid grants for the same time period.

Also known as the Mexico City Policy, the global gag rule was first introduced in 1984. It bans foreign non-governmental organizations (NGOs) that receive U.S. family planning funds from engaging in abortion counseling, referrals, or advocacy. This was an expansion of the Helms Amendment, which had barred U.S. international aid funds from being used to pay for any abortion care since 1973.

From Ronald Reagan on, each Republican president has imposed the global gag rule via executive order, and each Democrat has rescinded it. (The Helms Amendment, by contrast, has remained in effect continuously.)

However, in his first term, Donald Trump went further than any president before him. In an unprecedented expansion, Trump extended the global gag rule in 2017 to apply to all U.S. global health assistance, rather than just family planning programs. This affected organizations working on projects as diverse as clean water, HIV/AIDS treatment and prevention, nutrition, and infectious diseases.

In 2019, Department of State guidance expanded the gag rule yet again, announcing that it would also apply to all sub-grantees of NGOs receiving U.S. aid funds, even if those sub-grantees didn’t receive a dime of U.S. money.

It was unclear exactly which version of the gag rule Trump restored on Friday evening. Previously, MSI Reproductive Choices—one of the world’s largest providers of reproductive health services—estimated that such restrictions on U.S. funds could harm as many as one in three women of reproductive age around the world.

And if Trump’s administration follows the recommendations laid out in Project 2025, he’ll do even more. In addition to the expanded gag rule, Project 2025 calls for “deep cuts” to some aid programs, fewer grants to “expensive, inefficient, and corrupt U.N. agencies, global NGOs, and contractors,” more partnerships with faith-based organizations, and broad limits on speech about sexual and reproductive health and rights.

The U.S. government is the world’s single-biggest funder of global health initiatives. When it comes to sexual and reproductive health, the gag rule and other proposed measures could set back critical objectives like safe abortion care, contraceptive self-determination and access, maternal and infant health, and HIV and AIDS eradication back decades or more.

Trump likely to follow his own blueprint

The U.S. provided 32 percent of the world’s health funding as of 2022, according to KFF. It was also the top donor to several leading multinational health funds and United Nations programs, including the Global Fund to Fight AIDS, the United Nations Population Fund (UNFPA), and the World Health Organization (WHO).

Under Biden, U.S. global health funding hovered around $12 billion annually—though in 2021 that spiked to $21 billion thanks to emergency supplemental funding for COVID-19. Soon, this funding could be substantially cut, and due to the gag rule, some of it could also go unused.

According to the U.S. Government Accountability Office, during Trump’s first term, his expanded gag rule applied to about $12 billion in planned international aid funds from May 2017 through the end of 2018. As a result, NGOs that refused to comply with the rule declined about $153 million in U.S. aid.

Trump also withheld funds from the WHO in 2020, a move he re-initiated on the very first day of his second term. He also withheld funds from UNFPA, another decision he is expected to repeat. In the case of UNFPA, his administration’s justification was the 1985 Kemp-Kasten Amendment, which bans federal funds from going to any organization that, in a president’s opinion, “supports or participates in the management of a program of coercive abortion or involuntary sterilization.” Past Republican administrations have used this tactic as well, usually citing UNFPA’s programs in China.

Even the status quo under Democratic administrations—the Helms Amendment’s ban on direct funding for abortion—holds back global reproductive health. A 2021 Guttmacher Institute analysis estimated that ending the Helms Amendment would result in 19 million fewer unsafe abortions, 17,000 fewer maternal deaths, and 12 million fewer women who need medical treatment for abortion-related complications annually across the globe.

A rise in unsafe abortions and pregnancy-related deaths

In December, staff from MSI Reproductive Choices told Rewire News Group they were already bracing to lose U.S. funding.

In addition to philosophical opposition to the gag rule, MSI can’t agree to those terms because it provides abortion services, MSI Associate Director of Advocacy Sarah Shaw said. When the gag rule is not in place, NGOs that provide abortions can receive U.S. aid funding as long as that funding doesn’t go directly to abortion care. With the gag rule in place, any association with abortion care is essentially disqualifying.

MSI says that it lost out on $120 million in total funding during Trump’s first term. That money could have been used “to serve an estimated 8 million women with family planning, preventing 6 million unintended pregnancies, 1.8 million unsafe abortions, and 20,000 maternal deaths.” Immediately, MSI expects to lose $14 million in already-committed U.S. aid—and that’s just the start.

The International Planned Parenthood Federation (IPPF), another major global reproductive health provider, says it stands to lose out on $60 million. Project 2025 directly calls out both MSI and IPPF as “pro-abortion NGOs,” alongside a false claim that the Biden administration has given them “abortion subsidies.”

“We’re going to start to see projects that are reliant on U.S. funding start to close out,” Shaw said. “We will start to see a reduction in service provision within those countries if they’re not able to find alternative funding.”

Abortion-providing organizations are also likely to become isolated, as other NGOs and even governments fear jeopardizing their relationships with the U.S.

“More broadly, we’re going to see a wider chilling around our partnerships and around how we engage within governance and decision making in the health system,” she continued. “Our teams will start to find that they’re not invited to meetings… particularly those partners that are receiving USAID [U.S. Agency for International Development] funding, they’ll start to distance themselves.”

This will affect the provision of services not related to abortion, Shaw said, because in many communities, MSI and its partners are the only local reproductive health providers.

“Particularly for adolescents and more marginalized and underserved women, it’s going to be harder to access contraceptive services,” she said.

A growing international anti-rights movement

During the first Trump administration, many European governments stepped in to fill some of the funding gaps left by his policies. That may not happen this time around.

“Last time, European governments were in a very different place,” said Beth Schlachter, MSI’s senior director of U.S. external relations, who previously spent 15 years in the State Department. “This populist wave is not exclusively hitting the United States.”

And the global anti-sexual and reproductive rights movement has been gaining steam, thanks in part to former Trump officials who could be poised to re-enter government. For example, Valerie Huber, who held multiple roles in the previousTrump administration, is a well-known figure in the international anti-abortion movement and has continued to spread abstinence-only, anti-comprehensive sexual health and education programs around the world.

Huber was one of the chief architects of the Geneva Consensus Declaration, a joint statement originally composed by the U.S., Brazil, Egypt, Hungary, Indonesia, and Uganda, and eventually co-sponsored by a total of 34 nations—a number Huber has said she’d like to double. The Geneva Consensus signatories agreed that “there is no international right to abortion” and promised to “support the role of the family as foundational to society,” among other claims.

Through her nonprofit Institute for Women’s Health—part of the Project 2025 Advisory Board—Huber established an initiative called Protego to implement the principles of the Geneva Consensus Declaration around the world.

In Zambia—one of the countries where Protego operates—”we’ve seen attempts to roll back reproductive health education,” Shaw said. “Not even comprehensive sexuality education, because that’s long gone, but we’ve seen attempts to restrict access to education for adolescents.”

Shaw added that there has also been an effort to remove the word “rights” from “SRHR,” which stands for “sexual and reproductive health and rights,” a commonly used acronym among governments and NGOs.

“This is hugely problematic because we know that it will affect implementation,” she said. “As soon as you take the word ‘rights’ out of SRHR, you lose the universality of it … SRHR for who? SRHR for married women? What about adolescents?”

Schlachter noted that many of these anti-rights policies grew out of the Commission on Unalienable Rights, a project of Trump-appointed former Secretary of State Mike Pompeo. The Commission’s report essentially elevated the right to religious liberty and private property over human rights, including sexual and reproductive rights and LGBTQ+ rights.

Unprecedented limits on speech

Another harbinger of new restrictions is the first Trump administration’s “domestic gag rule,” which applied a global gag rule-style policy to funds from Title X, the federal family planning program. Title X funds can’t be used for abortion care due to the Hyde Amendment, but Title X providers had been able to provide abortion information and referrals—until 2019.

According to the Guttmacher Institute, an estimated 981 clinics were forced to leave the Title X network until the Biden administration reversed Trump’s policy in late 2021, reducing the entire network’s capacity by at least 46 percent, or 1.6 million patients.

Internationally, U.S.-based organizations have not previously been subject to a gag rule. They can’t use federal funds for abortion, but there are no limits on their speech.

“Just the threat that they could try to apply the global gag rule to U.S.-based organizations has led to self-censoring” among many U.S. NGOs, Schlachter said.

And Trump may not stop at restricting the speech of NGOs: He will almost certainly change the way the U.S. government itself communicates about sexual and reproductive health.

Among Project 2025’s recommendations, for instance, are that the next presidential administration should remove all references to terms including “‘gender,’ ‘gender equality,’ ‘gender equity,’ ‘gender diverse individuals,’ ‘gender aware,’ ‘gender sensitive,’ etc.,” from materials produced by USAID. “It should also remove references to ‘abortion,’ ‘reproductive health,’ and ‘sexual and reproductive rights’ and controversial sexual education materials,” the plan continues.

As an abortion-providing organization, MSI has chosen to speak out even though it means losing U.S. funding and partnerships.

“Other organizations are already declining to step forward and are behaving in a cautious way, so that we’re looking at a completely different landscape for the global reproductive health sector,” Schlachter said. “In the past, we’ve seen at least a continuity of U.S-.based organizations being able to speak out and to form partnerships with others.”

As in the case of all other abortion bans, this chilling effect may be the most damaging consequence of all.

“There’s going to be a massive shift in how all of us work together,” Schachter said. “And then when we put that on top of the accelerated efforts of anti-choice and anti-rights groups that have been funding this accelerated opposition, this is gas on the flames.”