Merely Lying Dormant Under the Obama Administration, the Global Gag Rule Needs to Be Put to Rest for Good -Noël Hatley

As the global population increases and health in third world countries declines, people are in dire need of family planning assistance. With the increasing numbers of children that women have, comes the increasing chances of maternal mortality and infant mortality. The United States’ Mexico City Policy, a policy that limits international organizations from performing or giving information on abortions, tries to eradicate abortion. Instead of helping reduce the number of abortions, it has actually caused the number of maternal deaths due to unsafe abortions to increase. Even with substantial historical evidence of governments trying to restrict people’s actions, such as in prostitution and the prohibition of alcohol, the actions do not cease, and yet the U.S. government still tries to restrict abortions (6, 9, 17, 31, 36). Even though the Mexico City Policy has been around for only three decades it is a part of a larger debate, the debate on abortion and family planning that is unlikely to resolve in the near future, and the policies of family planning will shift as the political and social views shift over time. Within a few weeks of the inauguration of Barack Obama the policy was rescinded, however only temporarily. Eventually, the political powers will shift with the election of a new president and congressional members, which could bring the Mexico City policy back on the table.
In 1973, before the Mexico City Policy was in place, the United States Supreme Court legalized abortion from the ruling in the case Roe v. Wade. At the same time, Congress passed the legislation containing Helms Amendment, which meant U.S. moneys could not be used overseas to fund abortion services. The conflicting views of the U.S. government remain for the entirety of this debate (31, 38). It was not until 1984 that President Reagan introduced the Mexico City Policy at the International Conference on Population. It was his belief that no organization should be funded if they provide information, counseling, referrals and services for abortion. Reagan did not want to fund Non-Governmental Organizations and governments that would spend U.S. money and other funders’ money on anything to do with abortion (38). Since people are not allowed to even discuss abortion or give out information, the Global Gag Rule nickname came into place.
The Global Gag Rule not only increases the rate of maternal mortality, it forces NGOs and clinics to choose between adherence to these policies and restriction of their free speech or risk the loss of financial aid. Since USAID can decide to rescind all funding to NGOs, the NGOs take excessive precautions to make sure they do not violate any of the rules of the policy. Ironically, the U.S. Supreme Court’s decision Rust v. Sullivan in 1991 ruled that governmental restriction of an organization’s legal activities is a violation of that organization’s right to free speech (27). According to the study done by Julia Ernst and Tzili Mor of The Center for Reproductive Rights, one of the largest NGOs located in Ethiopia lost its U.S. family planning assistance for refusing to follow the gag rule policy, forcing them to end vital community-based contraceptive distribution programs (17). Not only were these organizations providing abortion services, they were also providing contraceptives. By hurting the organizations providing abortion information, the gag rule hurt programs for contraception and ultimately undermined women’s abilities to control their lives and bodies from unwanted pregnancies and STDs (17). With prohibited speech and prohibited abortions women are subjected to unsafe abortions, fear, and stigma.
Throughout the years the policy has been apart of a political tug-of-war: rescinded and reinstated with each change in political power. It is time the policy was laid to rest, for good. Introduced to the House of Representatives in 2007, the Global Democracy Act seeks to create a permanent, legislative barrier to attempts to reinstate the detrimental policy (25). With the end to this policy in sight, I will attempt to explain using social science theories why the Global Gag Rule caused more harm than good and why it is ineffectual. I will also explain better, more efficient ways to reduce abortions without banning them and infringing on free speech.

Argument 1: Policy Makers Assume Women Follow the Health Belief Model When Making Abortion Decisions

The first critical miscalculation policy makers made was assuming women would stop having abortions if they were not funded and banned. The only way that would take place is if women seeking abortions followed the Health Belief Model when decision-making. The Health Belief Model is based on the idea that people’s decisions are a rational, cost-benefit analysis (35). People weigh the perceived benefits and the perceived barriers and based on the conclusion act accordingly. Once the analysis is complete, people act. In the scenario that policy makers believe will undoubtedly play out, a woman debating on having an abortion will follow these rational steps: compare the benefits of having an abortion to the costs. Proponents of the gag rule believe that either the lack of availability of safe abortion practices or the illegality of abortions will be the deciding factor and ultimately deter women from having abortions (9, 17, 31, 38). The facts state otherwise: In 2007 alone, while the gag rule was in practice, out of the 42 million abortions performed, 20 million women worldwide risked their lives and health to undergo unsafe abortions (24).
The health belief model is not only insufficient in mapping women’s actions regarding abortion, it assumes that “human behavior is determined by an objective, logical thought process” (35). Firstly, becoming pregnant is not done after careful consideration of one’s costs and benefits. It has been estimated that 40% of all pregnancies around the world are unintended (39). An estimated 51 million unintended pregnancies occur in developing countries every year because of lack of contraception and another 25 million occur because of incorrect use and misperceptions of contraception, say otherwise (1). Additionally, pregnancy and abortion are processes not so simple as for one to weigh the health benefits and health barriers before decisions are made. Pregnancy, especially in developing countries, can be surrounded by a range of emotions including happiness, pride, shame, and guilt and can be met with a multitude of societal forces and factors including stigma, socio-economic status, and social support systems (24). The process of abortion, like that of pregnancy, is not cut and dry when weighing the pros and cons. Just because a safe abortion is illegal, nor available, does nothing to deter women from seeking alternative, more harmful abortions or self-inducing abortions (24, 39).
If, for example, one were to act extremely rational, as the policy makers assume, and map out the perceived benefits one would begin by identifying one’s perceived susceptibility and one’s perceived security. In the case of abortion, the perceived susceptibility would include anything that makes one feel susceptible to the negative consequences of having a child. Negative consequences may include a multitude of effects ranging from banishment by one’s social group (because of a pregnancy out of wedlock, for example) to a lack of independence because of the unintentional thrust into motherhood. The perceived severity is indicative of the chances of the negative consequences happening because of having a child. Both of these steps in the model include so many differing factors, that the model quickly becomes too complicated for a simple mental cost-benefit analysis, and we did not even completely identify one’s perceived benefits nor begin to indentify one’s perceived barriers. The model is only useful if health factors were to satisfy the perceived benefits and barriers, but abortion is much more convoluted, including social, emotional, economic and political factors (35). For such a complicated action, the health belief model falls short in representing a woman’s thought processes and actions.

Argument 2: Restricting actions and speech motivates people to rebel against confining policies

Another important effect that policy makers and governments in general overlook when enforcing freedom-restricting policies is psychological reactance. Psychological Reactance theory states that people will rebel against policies, and direct orders when personal freedoms are restricted. According to Brehm, psychological reactance is defined as a motivational state directed toward the reestablishment of the threatened or eliminated freedom, which should manifest itself as an increased desire or an actual attempt to engage in the relevant behavior (5). In order for reactance to occur, one must be aware that the particular freedom exists and one must have the ability to exercise that freedom (20). In the case of reproduction, control of one’s reproduction abilities is a decision of “when” and with reliable contraception and availability of abortion allows women to be in greater control of the timing of motherhood and offspring. Eliminating resources of contraception, including abortion, through funding cutbacks and bans, infringes upon the control one has over their reproductive abilities. In the absence of contraception and safe abortions, women are forced to resort to unsafe and self-induced abortions (17, 36). When faced with restrictive policies, the freedom-threatening influence attempts can backfire, in that pressure toward change created may induce a person to do just the opposite (8). In the case of the gag rule, women resort to harmful and drastic solutions.
In an article about the psychological analysis of drug prohibition, it was found that restrictions on drugs and people’s freedom of usage drives people to overcome that restriction and reclaim the freedom that was once theirs (30). The same holds true with the availability of abortion and other contraceptives, because the loss of reproductive freedom is ultimately the loss of control over one’s body.

Argument 3: Abortion stigma

As defined by Hessini and others, abortion stigma is a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood (24). The global gag rule stigmatizes in two ways: first it marginalizes abortion services by physically isolating them from other health services and second it seeks to silence and obstruct abortion advocacy. Not only does the global gag rule enforce this stigma it creates and fortifies a stigma cycle. Known as the prevalence paradox, the cycle is a social construction of deviance despite the high incidence of abortion. Under the global gag rule and other anti-abortion laws, women underreport and intentionally misclassify abortion behavior for fear of retribution. Because of such underreporting, abortion is thought to be uncommon and a social norm is perpetuated that abortion is deviant. From such a norm, women who have abortions face discrimination causing women to fear stigmatization for engaging in abortion behavior, which causes women to continue underreporting (22, 24, 26). This vicious cycle, only perpetuated by the global gag rule, does not end abortion rather it marginalizes women and causes rifts in societies. Labeling abortion-seeking behavior as deviant, forces women to terminate pregnancies on their own or follow through with the unwanted pregnancy. In Zambia, one-third of schoolgirls and two-thirds of women studied reported attempting an abortion alone, often using caustic substances (24).
Stigmatizing abortion services and labeling abortion-seeking behavior as deviant, has forced women into secrecy. Secrecy does assist women in avoiding certain disapproval and social conflict, however it only hinders women in the process of healing and coping (22). In trying to eliminate abortion and save unborn fetuses, the policy makers of the U.S. have only hurt the women around the world in more ways than necessary. Not only are women around the world plagued by societal stigmas of abortion, internalized abortion stigma causes women to feel shame and guilt when abortions are sought out. Since the mid 1980s, organizations against abortion have used shame and guilt to their advantage (24). Such organizations seek to position shame as a natural and necessary response of the procedure and not as a consequence of societal scorn and marginalization of women.

Alternative approach to reduce the need for and incidence of abortions

The high number of abortions worldwide indicating the staggering number of unplanned pregnancies points to a failure in family planning and contraception availability. The global gag rule eliminates funding to international organizations that provide abortion services and information. What the policy fails in recognizing is that most if not all of the organizations that are cut from U.S. aid are the same organizations that provide family planning assistance, contraception, reproductive counseling and psychological support (17). For the Family Guidance Association of Ethiopia, the first and largest non-profit organization in Ethiopia to provide family planning services, the cut in U.S. funding was detrimental. Over 35% of their funding disappeared over night and technical assistance, including training for staff, was completely terminated. The organization was forced to drastically cut back on its distribution of supplies and vital services (32).
In order to reduce the incidence of abortions, we need to make abortions less necessary, however still available. I propose the United States fund all family planning organizations, regardless of the availability of abortion services. Organizations providing abortion services, information and referrals should also provide alternative information. Women seeking abortions should not be turned away or condemned by staff members. Contraceptive methods such as male and female condoms as well as education on the correct usage should be made readily available to the population served. The United States should focus its funding on organizations that provide access to emergency contraception, programs curtailing domestic violence and sexual abuse, comprehensive sexual education programs that include medically accurate information about abstinence and contraception, and also programs that work to provide public funding for family services. Such programs are already out there and only need a bit of funding to be successful. Instead of limiting the services available to women, U.S. policy should work to make available as much support and services possible, to ensure adequate and available options.

Defense 1: Better family planning services

If the United States were to fund organizations providing comprehensive family planning services, the need for abortions would be reduced. As seen in a study in Bangladesh, abortion rates were significantly lower in an area introduced to an intervention containing better family planning services than an area without the intervention. Better family services were characterized as having more choice, greater accessibility, and higher quality of care. Prior to the study intervention, both areas had similar rates of abortion (11). In the United States, it has been shown that an increase in the use of contraceptives and the introduction of other contraceptives available, led to the reduction of unintended pregnancies and the reduction of abortions, based on surveillance data (40). An increase in better family planning services internationally would help lead to a reduction in the rates of unintended pregnancy and abortion.

Defense 2: Education

One of the best ways to reduce unintended pregnancies and by extension, abortions, is to increase education. Funding organizations and programs that effectively educate the populations served ensure that people are made aware of their options. Education should be part of better family services, so that people have access. Educational resources should include quality data that is relevant to the specific population. Even education and additional contraceptive methods given after abortions help to reduce the occurrence of abortions in the future, as was seen in a study in Zimbabwe. Many women worldwide who have had unsafe abortions lack access to contraceptive services. As a result, many have subsequent unplanned pregnancies and some have more unsafe abortions. The results of the study suggest that post-abortion family planning services reduce the incidence of repeat abortions (7). Not only should the U.S. and other countries fund sex education in organizations, but also in schools. According to Kirby and others school-based sex and contraceptive education in developing countries have reported reduced risky behavior, especially programs that included peer-led education (28). Education is empowering, as it places control back into a woman’s hands.

Defense 3: Reactance theory revisited

Using reactance theory in a positive manner helps to restore lost freedoms and one’s sense of control over reproduction. According to Deatrick and others, the use of restoration postscripts to restore freedom shows positive outcomes of change (12). In order to reduce the incidence of abortion, we do not need to make it illegal, just increase efforts into education and other forms of contraception. By restoring the lost freedom of choice through the returned funding of abortion and also restoring women’s choice in contraceptives, increases one’s overall sense of freedom. The key is to increase the availability of options in family planning, options gained from education, and including options for when a woman is pregnant. The idea is to place the control of a woman’s body and control of her own reproduction in her own hands, where it belongs.

Conclusion

The policy known by some as the Mexico City Policy and by others as the Global Gag Rule has made a profound impact on the way NGOs and governments around the world deal with family planning. The ongoing debate on whether to fund organizations that perform and address abortion as a means of family planning has governments around the world split and there seems to be no compromise in sight, just a battle between the two sides of the debate. Even though the Obama administration has repealed the policy, nothing stands in the way of the next administration bringing it back into use. If the Global Democracy Act is passed, it will put an end to the gag rule for good. Flawed from the start, the gag rule relied too heavily on stigmatization, control, and the belief that the decision to have an abortion is based on health effects. The ongoing struggle in the abortion issue should not hinder women when it comes to contraception. In the end the U.S. should focus more on funding organizations and programs that work to educate, provide family planning assistance, contraception, counseling, and abortion services in order to give women the best possible support in reproductive health.

References

1. Åhman, E., Henshaw, S., Sedgh, G., Shah, I. H., and Singh, S. Induced abortion: estimated rates and trends worldwide. Lancet 2007; 370:1338-1345.
2. Åhman, E., and Shah, I. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. Journal of Obstetrics and Gynecology Canada 2009; 31(12):1149-1158.
3. Bahamondes, L., Bahamondes, M. V., Fernandez-Funes, J., Palena, C., and Schenk, V. High rate of unintended pregnancy among pregnant women in a maternity hospital in Cordoba, Argentina: a pilot study. Reproductive Health 2009; 6(11).
4. Bankole, A., Drescher, J., Henshaw, S. K., Sedgh, G., and Singh, S. Legal abortion worldwide: incidence and recent trends. International Family Planning Perspectives 2007; 33(3):106-116.
5. Brehm, J. W. A theory of psychology reactance. NewYork: Academic Press, 1966.
6. Bush, George W. United States. President. The White House. Memorandum of March 28, 2001 on the Restoration of the Mexico City Policy. .
7. Chipato, T., Farr, S. L., Johnson, B. R., and Ndhlovu, S. Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception. Studies in family planning 2002; 33(2):195-202.
8. Clee, M. A., and Wicklund, R. A. Consumer behavior and psychological reactance. The Journal of Consumer Research 1980; 6(4):389-405.
9. Cohen, Susan A. Global gag rule revisited: HIV/AIDS initiative out, family planning still in (issues and implications). The Guttmacher Report on Public Policy, 2003.
10. Condelli, L. Social and attitudinal determinants of contraceptive choice: using the health belief model. The Journal of Sex Research 1986; 22(4):278-491.
11. DaVanzo, J., Rahman, M., and Razzaque, A. Do better family planning services reduce abortion in Bangladesh? Lancet 2001; 358:1051-1056.
12. Deatrick, L. M., Lane, L. T., Miller, C. H., Potts, K. A., and Young, A. M. Psychological reactance and promotional health messages: the effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research 2007; 33:219-240.
13. Dillard, J. P., and Shen, L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72(2):144-168.
14. Dixon-Mueller, Ruth. Population Policy and Women's Rights. London: Praeger, 1993.
15. Edwards, S. M., Lee, J. H., and Li, H. Forced exposure and psychological reactance: antecedents and consequences of the perceived intrusiveness of pop-up ads. Journal of Advertising 2002; 31(3):83-95.
16. Epstein, Susan B., Connie Veillette. State, Foreign Operations, and Related Programs: FY2008 Appropriations. Congressional Research Service. Washington D.C.: Library of Congress.
17. Ernst, Julia, and Tzili Mor. Breaking the Silence: the Global Gag Rule's Impact on Unsafe Abortion. The Center for Reproductive Rights. New York: The Center for Reproductive Rights, 2003.
18. Family Planning Methods and Practice: Africa. Centers for Disease Control 1984.
19. Fascell, Dante B. United States. Cong. House. International Cooperation Act of 1991. 102nd Cong., 1st sess. HR 2508.
20. Förg, M., Frey, D., Heinemann, F., Jonas, E., and Traut-Mattausch, E. How should politicians justify reforms to avoid psychological reactance, negative attitudes, and financial dishonesty? Journal of Psychology 2008; 216(4):218-225.
21. Gipson, J. D., Hindin, M. J., and Koenig, M. A. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in Family Planning 2008; 39(1):18-38.
22. Gramzow, R. H., and Major, B. Abortion as stigma: cognitive and emotional implications of concealment. Journal of Personality and Social Psychology 1999; 77(4):735-745.
23. Guttmacher Institute. Costs and benefits of family planning, 2009.
24. Hessina, L., Kumara, A., and Mitchell, E. M. H. Conceptualizing abortion stigma, Culture, Health & Sexuality 2009; 1-15.
25. House of Representatives. Global Democracy Promotion Act. (H. R. 619, A Bill). Washington, DC, 2007.
26. Kleinman, A., Keusch, G. T., and Wilentz, J. Stigma and global health: developing a research agenda. Lancet 2006; 367:525-527.
27. Knudsen, Lara M. Reproductive Rights in a Global Context. Vanderbilt University, 2006.
28. Laris B. A., Kirby D., and Obasi A. The effectiveness of sex education and HIV education interventions in schools in developing countries. World Health Organ Tech Rep Service 2006; 938(103):317-41.
29. Luker, K. Taking Chances: Abortion and the decision not to contracept. University of California Press, 1976.
30. MacCoun, R. J. Drugs and the law: a psychological analysis of drug prohibition. Psychological Bulletin 1993; 113(3):497-512.
31. Nowels, L., and Veillette, C. International Population Assistance and Family Planning Programs: Issues for Congress. Congressional Research Service. Washington D.C.: Library of Congress, 2006.
32. Population Action International. Impact of the global gag rule in Ethiopia. Global Gag Rule Impact Project, 2005.
33. Rohlinger, D. A. Framing the abortion debate: organizational resources, media strategies, and movement-countermovement dynamics. The Sociological Quarterly 2002; 43(4):479-507.
34. Severity and cost of unsafe abortion complications. International Family Planning Perspectives 2008; 34(1).
35. Salazar, M. K. Comparison of four behavioral theories: a literature review. AAOHN Journal 1991; 39(3):171-178.
36. The Center for Reproductive Rights. Breaking the silence: the global gag rule’s impact on unsafe abortion, 2003.
37. Thomas, L. W. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11(4):246-252.
38. United States. Policy Statement of the United States of America At the United Nations International Conference on Population, 1984.
39. Unsafe Abortion: Global Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2003. World Health Organization, 2007.
40. Westoff, C. F. Contraceptive paths toward the reduction of unintended pregnancy. Family Planning Perspectives 1988; 21(1):4-13.