This story was originally published by The New Humanitarian.

Chaos, confusion, and more ethical dilemmas: Humanitarians are still trying to understand the impacts of a sweeping expansion to the so-called “global gag rule” on US funding.

The Trump administration expanded the on-again, off-again anti-abortion care directive known as the Mexico City policy to include nearly all foreign assistance, including humanitarian funding sent through UN agencies and international and local aid groups.

The rules – announced on 23 January and published last week – also slap vague bans on programmes related to diversity and equity, and gender identity.

The gag rule’s impacts are clear: more backstreet abortions, more unwanted pregnancies, and higher school dropout rates for girls, among them. Harsher rules will extend more harm to trans people and others in the LGBTQI+ community, and to racialised communities and others already on the margins in emergencies, aid groups warn.

For humanitarians, the move injects more chaos into emergency responses: Will they over-comply and over-interpret the rules – cutting more than they need to and undermining others that provide reproductive care or protective services for marginalised groups? Will they choose between US funding and other donors – making them even more dependent on one volatile government? Several aid officials have said that their organisations were still weighing the implications – especially with $2 billion in recently announced US funding in the backdrop.

But the risks are inevitable, say reproductive health advocates, who have hard-won lessons from previous gags.

“There’s a lot of stigma, there’s a lot of chilling,” said Sarah Shaw, associate director of advocacy at MSI Reproductive Choices, an organisation providing abortion and contraception services globally. “Organisations that used to refer women to us for services will stop doing that. So those women will have nowhere to go.”

MSI is among the non-profits who have refused to sign on to all versions of the global gag rule. Shaw and Beth Schlachter, MSI’s senior director of US external relations, explained what humanitarians can expect from the expanded global gag rule. They warned of “chaotic” disaster response scenarios, spoke of the “chilling” effect on over-complying with vague rules, and offered advice on what humanitarian groups who choose to sign should prioritise.

Q: In previous iterations, humanitarians have stayed on the sidelines because they felt they didn’t need to get involved. How would you describe the reaction from humanitarian organisations in the past, compared to what everyone’s facing now?

Beth Schlachter: I think everyone stays away from this if they don’t have to be involved. So, no shame on the humanitarians, but it’s one of those “you’re not going to stand up for it unless you have to”, because life is hard enough with the work that you do and you don’t have time or resources for it, and so then when it does hit you, you’re like, “Oh damn, look at that.”

Sarah Shaw: I would agree with that. It’s no criticism on other sectors, but why would you engage in this toxic fight that you will never win unless you have to?

Can you talk about the impacts you’ve seen?

Shaw: As an abortion provider, we’ve been impacted by every iteration of this, and this is probably my fourth global gag rule I think in my life.

So based on past experience, you know what the impacts of this are. It means that a lot of organisations have to choose. They have to choose between their abortion programming or their US funding. And to be honest, for most organisations, they will choose their US funding because it will probably be a much bigger part of the organisation’s ability to survive.

For MSI, because we are an abortion provider, we will always choose our abortion provision. So we’ve always had to relinquish our US funding. This time round, we didn’t have as much because we learned our lesson under Trump One. We diversified our funding base, and so [for] Trump Two we were less reliant.

But our Zimbabwe programme were incredibly reliant and, for them, it was probably nearly half of their funding for family planning work. They had 10 outreach teams – these are mobile teams that will go at regular intervals to visit communities to provide family planning services. And these are communities that won’t have access to any other provider…

We didn’t have time to fundraise to fill the gap or to negotiate with other partners to pick up some of the work. So for those communities, it’s disastrous and it’s a breach of trust as well. For a lot of women, accessing contraception is a big leap of faith, because there will be community stigma, there will be opposition in the family.

And then, for the people that convinced them to do it and told them that it was a good thing, to just not show up is really damaging. So as a result of that, we’re going to see more unintended pregnancies, more unsafe abortions, more girls dropping out of school. I mean, this is what’s so nonsensical about it. They claim it’s to reduce abortion, but all it does is reduce access to family planning, which increases the need for abortion.

Can you talk about the risk of over-compliance: organisations that over-interpret the rules?

Shaw: [The global gag rule is] incredibly complicated and badly communicated. And this time around, it’s just off-the-scale complicated, to be quite honest. Even the abortion part alone is way more complex than it’s ever been, and then you’re factoring in the other aspects as well. This causes a lot of confusion.

So generally, the safe place to be is to over-interpret, over-implement. I totally understand why organisations do that, because it’s either that or risk collapse which is not an option. But the result of that is there’s a lot of stigma, there’s a lot of chilling. We will have organisations that used to refer women to us for services will stop doing that. So those women will have nowhere to go.

Our teams have reported being excluded from critical policy conversations and technical working groups; have their access to data limited; commodities as well.

I remember last time around in one country – and I’m not going to name them because it’s not fair – but we were a sub[-grantee] on another INGO’s project and our role in the project was to deliver family planning services. And that sub came up – the day after the global gag rule was announced – with a truck and started taking all the USA-branded contraceptives out of our pharmacy, saying “Oh you can’t use this because of the global gag rule,” which isn’t true, because we got them from the national government. It’s just this over-interpretation; this chilling.

We know that in times of crisis that the rates of rape and sexual violence escalate against women, children, against men. So if you have organisations who don’t know what they can or cannot provide when it comes to abortion without potentially violating their agreement with the US then are they going to be able to meet the needs of people who are in an immediate crisis?

Schlachter: So you imagine the complexity of that, and now, if you report on humanitarian situations, you know how challenging it is to operate. If the largest providers of assistance in any particular situation, the ones who are on the ground, have not signed the global gag rule, or this doesn’t apply to them, then they may not be able to work with those other entities there who do. And it causes fracture about who can provide services and which services then could be provided…

We know that in times of crisis that the rates of rape and sexual violence escalate against women, children, against men. So if you have organisations who don’t know what they can or cannot provide when it comes to abortion without potentially violating their agreement with the US – and potentially losing tens of millions of dollars or hundreds of million dollars – then are they going to be able to meet the needs of people who are in an immediate crisis?

It introduces more complexity, more chaos in the situation that’s already chaotic and just creates a situation where fewer people are going to have access to resources.

The new version of the global gag rule includes all multilateral aid, including through UN agencies.

Schlachter: We know that even though the US isn’t funding UNFPA [the UN’s sexual and reproductive health agency], the partners who work with UNFPA would be affected because [the rule covers] all multilateral assistance. And so that gets complex as well because UNFPA is the cluster lead for the minimum initial service package for reproductive health in crisis settings and for [sexual and gender-based violence] in crisis settings. So, again, it creates [a] fracture of who can work with whom and who’s providing what resources to others.

We don’t yet know how humanitarians are going to deal with this because they’ve never had to deal with it before.

If UNFPA is not under [the global gag rule], but other UN partners are, then can UNFPA work with other UN entities in the time of a crisis? We don’t yet know. So it’s just creating unnecessary chaos. They’re just trying to stigmatise abortion and deny services to women and girls. So we don’t yet know how humanitarians are going to deal with this because they’ve never had to deal with it before.

Can you expand on other examples of the over-compliance risk?

Shaw: Supply chains are a big risk. Over the years, our supply chains have become incredibly integrated. I think this time round, because it’s so complicated, folks are going to try a lot harder to try and firewall between abortion-related commodities, and contraception commodities, or reproductive health commodities. So definitely a big risk is that countries will just stop procuring abortion commodities or stop distributing them because they won’t want to distribute them in the same vehicles with the same driver that’s on a US government project payroll. I think that’s a big risk.

Similarly, with who receives these commodities – particularly in countries where there’s scarcity and maybe where the government is less concerned about reproductive health and maybe the government has given indications that they are ideologically aligned with the Christian nationalist agenda of the current US administration – there’s a risk that they will start to deprioritise certain implementing partners because they will maybe be seen not to be aligned with their agenda.

Schlachter: Sarah, as you’re talking, I was thinking of one way this could really cause a problem as well, particularly in natural disasters or when people are displaced and health workers are displaced along with everybody else.

If the global gag is applied through government sites and services, the folks who are healthcare workers themselves in addition to the commodities. And then humanitarian entities come in and try to work with them – as you would in any humanitarian situation – then you have a challenge of who’s gagged by what and who can work with whom. Why would you even be talking about that? There’s an earthquake. There’s somebody who’s been raped. You need to help the people, not check their credentials on the global gag. Can I even be a partner with you or not?

Shaw: Exactly.

Schlachter: So, how is that going to play out? I hope people just help people, as they would, and figure it out later.

Shaw: It’s just putting an incredibly complicated administrative layer in a situation that is not able to deal with administration. You just need to do services when you’re in a humanitarian crisis, and the risk is – and the chilling is – that providers will just refuse to do anything that is not deemed safe.

By that, I mean providing services for certain communities – like the LGBTQI community or trans people – or providing reproductive health services. There’s a risk even [with] post-abortion care: Post-abortion care is permitted, but it’s still going to come with that stigma.

So there’s a real risk that people will just get turned away because providers will refuse to provide because they’ll be frightened. They don’t want to lose their jobs; they don’t want to lose their license.

For those organisations that choose to sign the global gag rule, what advice do you have?

Shaw: Really take care to develop very clear communications and guidance – for their partners on the ground, but also their sub-grantees as well – on what this means and where the red lines are. Because often the communications around this are very poor. They’re not in local language, or it will take the US government a year, two years to get around to doing the French and Lusophone translations, let alone African local languages. And in all that time there’s just all this confusion and chilling growing.

Also: Really focus on what they can do. By fixating on what we can’t do, we just frighten people, so just really emphasise what they can do and continue to do… For example, be very clear that, yes, you can’t refer for abortion, but if a woman comes and says that she’s had an unsafe abortion and she needs treatment, you can and must treat her. Because the risk is that there will just be a complete carte blanche: “No, we’re not doing anything like that.”

So, you know, looking at the things they can do. [The rules] very clearly say abortion as a method of family planning is not permitted. So that means if a woman’s life is at risk or she’s had an unsafe abortion, then you can provide a service. So, really focus on that. Because a lot of the time people think it’s just a carte-blanche ban on abortion and it’s not. Similarly, you know, for rape survivors. If a woman comes and says she’s been raped, well they are permitted to provide her a service. And I think that nuance, that’s what gets lost. The further down you get, the more that nuance is lost.

The New Humanitarian puts quality, independent journalism at the service of the millions of people affected by humanitarian crises around the world. Find out more at www.thenewhumanitarian.org.