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January 01, 2008

The Exportation of Ideology: Reproductive Health and Rights in U.S. Foreign Policy

by Suzanne Petroni and Patty Skuster

For over forty years, the United States has been a leader in the international development arena, particularly in regard to family planning assistance. While this era began with two decades of remarkable unity and bipartisanship, the management and implementation of foreign assistance programs related to sexual and reproductive health have moved over time from being evidence-based to ideologically driven, at the expense of women’s health and human rights. Through restrictions and funding conditionalities, the United States has ensured that these foreign aid programs and policies reflect the ideology of the Religious Right, instead of effectively providing services and enabling organizations to promote women’s human rights. In so doing, it has weakened considerably its moral authority with respect to the rest of the world.

The Early Years of U.S. International Family Planning Assistance

Beginning in the 1960s, both the White House and Congress strongly and consistently supported family planning programs as a means to curb global population growth, improve the quality of life of people around the world, advance U.S. security interests, and, in later years, promote environmental concerns. By the mid-1970s, the United States was the world’s leader in this area, contributing $110 million annually for U.S. Agency for International Development (USAID) and United Nations (UN) family planning programs.

But opposition to abortion by the Catholic Church and the far right soon began to politicize family planning assistance programs. The 1973 Supreme Court decision of Roe v. Wade, 410 U.S. 113, galvanized opponents of abortion access. Women in the Global South would be the first target of what would become numerous funding restrictions that hinder the ability of women to access reproductive health care, both inside and outside the United States. Only months following Roe, then-Sen. Jesse Helms (R-NC) led a successful effort to prohibit U.S. foreign aid funds for the provision of abortion, and three years later, Rep. Henry Hyde (R-IL) promoted passage of a law that similarly required limiting the use of domestic funds.

The United States in Retreat

The election of Ronald Reagan in 1980 augured a significant and lasting shift in how the U.S. government approached the issue of international family planning. Beginning with the election of Reagan, members of the “New Right,” composed of evangelical Christians and free-market thinkers who decried governmental interference in favor of individual decision-making, were allowed an unprecedented role in formulating U.S. policy around sexuality-related issues. Government-supported family planning—whether at home or abroad—signaled to the New Right intrusion into matters of the family, and was thus anathema to them.

A major turning point for the field came at the Mexico City International Population Conference in 1984, with a stunning reversal of U.S. international population policies by the Reagan Administration—abetted by leaders of the Christian Coalition and other New Right groups. Rejecting a stance that had endured for nearly two decades, the U.S. delegation proclaimed that population was “a neutral phenomenon” in regard to development. U.S. representatives further declared a new policy of denying funding to any foreign non-governmental organization (NGO) that provided, lobbied, or counseled on abortion, even with its own funding. (This policy was to become known as the Mexico City Policy, and later, the Global Gag Rule by its opponents.) Citing concerns about China’s one-child policy, and again disingenuously making a connection between abortion and family planning in U.S. funding, the delegation further announced that it would require the United Nations Population Fund (UNFPA) to prove that it did not support abortion or coercive family planning programs there.

George H.W. Bush maintained Reagan’s restrictive policies upon assuming the presidency in 1989. Reversing his earlier support for UNFPA, Bush vetoed the 1990 Foreign Operations bill because of an earmark for that agency, just one of several vetoes and veto threats during his administration over international family planning. Bush’s apostasy is widely held to have stemmed from a desire to maintain the support of the Religious Right, which President Reagan had so effectively cultivated, and which was now a central and powerful constituency of the Republican Party.

The 1980s saw increasing opposition not only from the Religious Right and economic conservatives, but also from feminists. Feminists and women’s health advocates from around the world had become increasingly concerned that family planning programs were too strongly guided by demographic goals and gave inadequate regard for the health and rights of women. Building on the alliances and networks forged through the UN Decade for Women (1976–1985), women’s groups began to advocate more vociferously for family planning within a context of greater attention to women’s empowerment and reproductive health and rights. While these arguments gained no traction under presidents Reagan and Bush, they did become both sharper and more refined during this time, and they would earn the ear of the next president.

A Changed Paradigm

Indeed, it was partly due to promises made to women’s groups during the 1992 campaign that President William J. Clinton restored the United States’ leading position in the international population arena, but within a new paradigm. In his first official act as president, Clinton overturned the Mexico City Policy. He then resumed funding to UNFPA, citing the agency’s critical and lifesaving work around the world.

A key element of the revived leadership of the United States was its role in formulating a new framework for the population field at the 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt. A decade after the Mexico City conference, the United States had come full circle. Not only did the U.S. delegation agree with the need to achieve a sustainable global population, so too did it give credence and support to the voices of those concerned first and foremost with women’s health and rights. In the end, the United States helped to forge a consensus at Cairo that reflected the successful advocacy of women’s groups from around the world. Stabilizing global population remained an essential goal, but women’s health and rights were placed squarely at the center of global priorities.

However, the Religious Right was now governing the agenda of the Republican Party and, beginning with the 1994 republican congressional sweep, the new Congress pressed persistently over the next six years for budget cuts and new restrictions on family planning assistance. The relentless debates between Congress and the Clinton White House contributed to several funding delays, complicated metering of appropriations, government shutdowns, vetoes and, eventually, significant funding cuts for international family planning.

The Religious Right Consolidates its Gains Under Bush

The Religious Right has obtained unprecedented access to the George W. Bush administration, and issues related to sexuality, including both domestic and international family planning, have been manifestly at the core of their crusade. The administration has peopled delegations to international conferences with representatives of the Religious Right who aim to roll back long-standing agreements and long-agreed language regarding reproductive health and who threaten to cut assistance to countries that refuse to support the U.S. position. The administration has withdrawn funding from groups providing basic, yet literally lifesaving reproductive health care. (The Reproductive Health for Refugees Consortium, for example, lost $1 million in U.S. funding for its work to prevent gender-based violence and to provide emergency obstetric care, HIV/AIDS prevention services, and emergency contraception in refugee settings.) It has proceeded to withhold over $200 million in congressionally appropriated funds to UNFPA. Population assistance through USAID has declined, and if left to the White House, such programs would receive a sharp 29 percent decrease in the coming year.

HIV/AIDS Prevention Efforts Suffer...

Through funding conditionalities, the Bush administration now mandates that recipients of U.S. foreign assistance adopt programming and policies that maintain the ideology of the Religious Right. In 2003 the President’s Emergency Plan for AIDS Relief (PEPFAR) was established––a five-year, $15 billion initiative to fight HIV/AIDS in fifteen of the most affected countries. Through PEPFAR, the administration has compelled the promotion of abstinence-until-marriage policies for young people in the developing world, disregarding conclusive evidence that young married women in the developing world are now the most vulnerable population to HIV/AIDS infection.

Recipients of federal funds working to combat HIV/AIDS must also adopt an organization-wide policy explicitly opposing prostitution. Failure to endorse the anti-prostitution pledge means health workers striving to stop the spread of HIV/AIDS could lose funding and be forced to abandon their lifesaving programs.

In Alliance for Open Society International, Inc. et al. v. United States Agency for International Development, et al., 05 Civ. 8209, the U.S. District Court for the Southern District of New York found that the anti-prostitution pledge violated the First Amendment for U.S.–based recipients of such funds. The government subsequently conceded that, as written, the anti-prostitution pledge violated the free speech rights of its grantees and issued guidelines to permit grantees to engage in free speech utilizing private funds. The new government guidelines require grantees to form privately funded affiliates that could operate free of the pledge requirement, which would create a financially prohibitive separation between the two entities. Remanded by the Second Circuit on the constitutional and statutory claims as pertaining to the guidelines, the case is now pending at the district court.

...and So Do Women's Rights

In a stunning example of just how far U.S. foreign aid policy can go to limit human rights, on his first day in office, George W. Bush reinstated the Global Gag Rule. Continuing to press the link between family planning assistance and abortion, Bush claimed that the policy was necessary in order to prevent taxpayer funds from being “used to pay for abortions,” something that had already been prohibited for some twenty-eight years. Citing the ban’s inconsistency with freedom of speech and U.S. foreign policy goals, in 2001, the American Bar Association adopted a resolution opposing the Global Gag Rule.

The Global Gag Rule requires foreign NGOs that receive USAID funds to agree that they will not provide abortion, refer clients to abortion providers, or lobby to make their national abortion law less restrictive—even with their own, non–U.S. funds. Organizations that have refused to sign the policy have lost significant portions of their budgets, forcing them to lay off staff and close clinics, which are often the only providers of health care services in developing countries. The Global Gag Rule not only restricts organizations’ abilities to provide effective, evidence-based reproductive health care services, but, with its ban on lobbying, impedes reform that would further countries’ compliance with human rights standards. (For more information, see

Several UN treaty-monitoring committees have identified the human rights implications of unsafe abortion and the need for governments to review their restrictive abortion laws. The committee overseeing the Convention on the Elimination of All Forms of Discrimination against Women issued General Recommendation 24 (to aid States Parties in their interpretation of the convention), which states, “When possible, legislation criminalizing abortion should be amended, in order to withdraw punitive measures imposed on women who undergo abortion.” The Human Rights Committee issued General Comment 28 on Article 3 of the International Covenant on Civil and Political Rights, on the equal rights of men and women, calling upon States Parties, “when reporting on the right to life protected by article 6,” to inform the committee of “any measures taken by the State to help women prevent unwanted pregnancies, and to ensure that they do not have to undergo life-threatening clandestine abortions.” The Committee on the Rights of the Child has recommended that States Parties take steps to reduce maternal morbidity and mortality from unsafe abortion and implement programs that provide access to safe abortion services.

Approximately 67,000 women die from unsafe abortion worldwide each year, and complications from unsafe abortion hospitalize 5 million more. Studies have confirmed that restrictive abortion laws correlate to high rates of unsafe abortion. In some countries, the most effective way to decrease maternal mortality is by liberalizing restrictive abortion laws.

Curtailing the Human Rights of Women in the Global South

Under the Global Gag Rule, USAID-funded organizations are unable to participate in national movements to reform abortion laws, and organizations working on abortion law reform are denied the support of USAID. USAID effectively hobbles national movements to reform the abortion law, the gains of which would further governments’ compliance with human rights standards. Two examples, from Nigeria and Ethiopia, illustrate the problems.

In Nigeria, women’s groups, medical providers, and reproductive health professionals are engaged in a burgeoning movement toward reforming Nigeria’s restrictive abortion law. Faced with the second-highest rate of maternal death in the world, advocates in Nigeria have identified abortion law reform as an important avenue to save women’s lives. Party to the Optional Protocol on the Rights of Women in Africa to the African Charter on Human and People’s Rights, Nigeria has committed to “authorize … abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the unborn child.” Along with forwarding Nigeria’s compliance with international human rights treaties, liberalization of the abortion law in Nigeria will fulfill a part of its obligations under the Protocol on the Rights of Women in Africa.

The Global Gag Rule, however, is at odds with the work of these advocates. The policy dictates that USAID can choose implementing partners based only on their support for the current restrictive abortion law, not on the basis of who can best provide the services. Organizations are denied USAID funding because of their support for access to safe abortion. Organizations that do receive USAID funding are unable to voice their support for changing the law, which is a major contributing factor in the deaths and injuries of women in Nigeria.

As the Global Gag Rule was being implemented over the past few years, women’s health and rights advocates in Ethiopia were working to liberalize the Ethiopian abortion law to include several provisions that improve access to safe abortion services. Injuries resulting from unsafe, clandestine abortions caused as many as half of Ethiopia’s maternal deaths, and Ethiopian lawyers, women’s rights activists, doctors, and other health professionals were working to inform the public and the Ethiopian parliament that the restrictive abortion law was contributing to the crisis. Silent in the debate were a large number of reproductive health providers and organizations, though they were aware of the death and suffering from unsafe abortion and the need for legal reform.

Opponents of safe abortion access, however, unrestrained by USAID policies, were heavily involved in the law reform process and lobbied the Ethiopian Parliament. Strong opposition in the last phase of deliberations may have contributed to adoption of a more restrictive law than sought by supporters of law reform. While the law passed by the Ethiopian Parliament in 2004 significantly expanded the indications for legal abortion, abortion in many cases remains a crime punishable by prison for the woman and the provider.

Though both houses of Congress proposed measures to weaken the Global Gag Rule during the appropriations process for fiscal year 2008, ideologically driven policy prevailed. Under the threat of veto from President Bush, Congress ultimately removed any language on the Global Gag Rule, leaving the policy in place.


As the end result of a process that began over two decades ago, U.S. assistance—and the health and rights of women in the Global South—have become the ultimate victims of the ideological hijacking of U.S. policies. As Esther Kaplan writes in With God on Their Side, Bush has “happily ceded huge swaths of his domestic and international policy” to the Christian Right. These religious traditionalists aim to shape American public policy and the programs and policies of non-governmental recipients of U.S. funding so as to mirror their own values. This reflection is not one in which the facts regarding either reproductive health or human rights matter to policymakers. Rather it is one in which the promotion of women’s human rights is curtailed and public health evidence is denied.

PEPFAR Focus Countries

The fifteen focus countries are among the world’s most severely affected nations. Collectively, they are home to approximately half of the world’s estimated 33 million HIV-positive people and to almost 8 million children orphaned or made vulnerable by HIV/AIDS.

  • Botswana
  • Cote d’Ivoire
  • Ethiopia
  • Guyana
  • Haiti
  • Kenya
  • Mozambique
  • Namibia
  • Nigeria
  • Rwanda
  • South Africa
  • Tanzania
  • Uganda
  • Vietnam
  • Zambia



Suzanne Petroni manages the reproductive health program of a private foundation in Washington, D.C. Patty Skuster works in the Policy unit of Ipas, an international reproductive health and rights organization. She is vice chair of the ABA’s Section of Individual Rights and Responsibilities’ Health Rights and Bioethics Committee.