Global Gagging: Free Speech, Justice and Women’s Health

Amie Newman

Is the twenty-three year long game of tug-o-war, while women's health and democratic justice hang in the balance, almost over?

Since 1984, the global health community has been embroiled in one of the biggest volleys for free speech and constitutional fairness – but you may not think of it as such.

The Global Gag Rule (aka "The Mexico City Policy," so-named because of the location of a conference where the policy was originally announced) is at the center of a political game that has seemingly no end. The stakes have always been extremely high – not only do women's health and rights around the world depend partially on the crucial financial resources from the U.S. government, but free speech and a commitment to democratic ideals are alternately squashed or encouraged by this policy, depending on which U.S. presidential administration we're dealing with.

The Global Gag Rule was originally put in place by President Reagan, by executive order, to deny funding to international family planning organizations unless they agreed to specific curtailments as set by the United States on the medical services and information they provided to their patients. That is, health centers that operate in developing nations to help women and men plan their families and avoid unintended pregnancies, were told that they would not be allowed to provide abortions (regardless of whether or not it is legal in their country to do so), refer to abortion services, discuss abortion as an option, or even so much as hang a poster that mentions abortion without potentially being denied funds for the provision of health services that have nothing to do with abortion. In addition, if a reproductive health organization provides abortions anywhere in the world – or advocates for safe, legal abortion anywhere in the world – and also runs separate family planning clinics, which do not provide abortions their funding can be cut off.

According to Planned Parenthood:

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"Overseas family planning agencies thus have to choose between accepting U.S. money, which is often their main source of support, or offering their clients comprehensive – and potentially life-saving – reproductive health services and information."

In 1993, when President Clinton moved into the White House the ball was thrown back to him and he did what one would expect – he rescinded the order and restored funding to the international family planning NGOs through USAID (United States Agency for International Development). By Clinton's reckoning, the "excessively broad anti-abortion conditions" as set by the Mexico City Policy were a ruse. The Foreign Assistance Act of 1961 already prohibits international agencies from using federal funds to pay for abortion provision or lobbying. The point of Reagan's order was to flaunt his ruthless politics – he was sucking the wind out of the reproductive rights community's sails by dictating what they could – and could not – support.

President Bush reinstated the order on his very first day in office as what can only be called a symbolic gift to his anti-choice supporters who not only worked hard to get him elected but who had been tirelessly working to preserve the policy by attempting (unsuccessfully) to enact it into law. When Bush restored the policy there was, of course, an outcry from reproductive rights activists who reasoned simply that denying funds for family planning agencies around the world thus denying birth control and contraceptive counseling to those who need them, under the auspices of an anti-abortion political stance, would in fact lead to an increase in unintended pregnancy and thus abortion rates. From the Senate Democrat's 1997 Joint Resolution:

"Giving funds to private foreign organizations that perform abortions with the requirement that they use those funds on pregnancy prevention programs is going to reduce the number of abortions that are performed. Years of experience in Latin America, in Eastern Europe, and countries in other areas confirms this fact. It does not matter if the groups dispensing contraceptives perform abortions or not–all that matters is that pregnancies are prevented, which results in fewer abortions being performed."

The evidence is mounting about how the global gag rule is limiting access to contraceptive services for some of the world's poorest citizens.

And now there is yet more proof that anti-choice forces, led by President Bush, are not merely against abortion but are full-stop opposed to contraception as well.

The ball is in play once again. In June of this year, Representative Nita Lowey (D-NY) led the charge in the House of Representatives to "partially" repeal the Global Gag Rule. While Lowey's amendment does not entirely lift the global gag rule, it provides for "free" contraception to be provided to the international NGOs who have been denied funds through the rule so that, at the very least, women and men would have access to a means of family planning. They correctly argued that broader access to contraceptives will help reduce the need for abortion.

Yet even this has invoked the ire of anti-choicers. Speaking out against Lowey's amendment, Colin Mason, of the extremely conservative Population Research Institute, said, "Contraception always leads to abortion, of course, so Lowey's argument is false on its face."

On September 6th, buoyed by the success in the House, the Senate voted to fully repeal the Global Gag Rule through an amendment introduced by Senators Barbara Boxer (D-CA) and Olympia Snowe (R-ME) attached to a State Department foreign aid bill. Boxer relied on language she has used in years past when attempting to overturn the global gag rule. In 2003, interpreting the rule as a clear infringement on free speech, Boxer said:

"I cannot understand for the life of me how we can in good faith, as the leading democracy in the world…how we could put a Global Gag Rule on those organizations, when in this country you couldn't even consider it for two seconds because it would be completely unconstitutional."

Indeed, it is hard to imagine how such a harmful and restrictive policy such as this, a policy that has never been enacted into law simply because it has never had the congressional support to do so, has been able to survive. For fifteen non-consecutive years, women in some of the most poverty stricken segments of our world have been denied access to full reproductive health care because of the restrictions borne of this order. So the reproductive rights advocacy community is speaking out once again. But, as straight forward as this issue might seem, there are differing thoughts on how to approach it.

President Bush has already said he would veto both the House and Senate versions. So why was a House version, one that barely scratches the surface of this policy's detrimental effects, floated in the first place? Some reproductive health advocates have stood in support of the amendment as a simple measure that, with Bush's promise to veto, would highlight Bush's obvious anti-contraception stance and force him to explain how he could possibly be opposed to contraception abroad unless he was also opposed to it here in the states.

But, according to others in the reproductive health community, there was and is clearly plenty of support for a full repeal of the global gag rule. A compromise such as the contraceptive amendment passed by the House only served to muddy the waters with confusion and to weaken a strong position. They say the contraceptive amendment will have little impact on the larger issue of free speech and ensuring that family planning agencies are allowed to use their funds the way they see fit in order to best help women and families.

Many say a full repeal of the Global Gag Rule is the first and best place to begin if we are to hold firm to the principles behind the push to repeal. There has always been an outcry against this policy because it crushes the very democratic ideals this country is supposed stand for; because it imposes a double-standard, allowing family planning organizations in this country access to funding while denying it to international agencies which do the same thing; and most significantly because it devastates women's lives by denying them basic reproductive health care. Finally, a compromise such as the House amendment has the potential to sacrifice bargaining power. I can hear parents' advice to their young adult children ringing in my ear: you never start with your mid-tier offer, you start with what you want in the best of all possible circumstances leaving you room to dicker.

Regardless of Bush's threats to veto both the House contraception amendment and the Senate's full repeal, reproductive rights supporters across the board are urging us not to give up.

And despite the debate that rages within the reproductive health advocacy community pitting Lowey's "free contraception" amendment against the full-scale repeal set forth by Senator Boxer, there seems to be a desire, publicly, to continue forcing the issue – to see the global gag rule overturned completely.

Population Connection warns us, "The Boxer Amendment is a tremendous step forward, but there is still a long way to go…"

It is unlikely that there will be any significant movement in either the House or the Senate on this issue over the next several weeks. For now, the reproductive health advocacy community needs to convince itself that an abiding loyalty to our deepest-held values and a sense of trust in our progressive political and social ideals form a strong foundation for any political strategy. This is an issue that reaches beyond, though fully encompasses, reproductive health and rights. To ensure that women's health and lives, and a democratic commitment to free speech are not subject to the tides of presidential administrations, most advocates say it is crucial that we continue to prioritize a full repeal of the Global Gag Rule.

For more information on the Global Gag Rule, check out last week's episode of RealityCast, our weekly podcast with Amanda Marcotte.

News Abortion

Pennsylvania’s TRAP Law Could Be the Next to Go Down

Teddy Wilson

The Democrats' bill would repeal language from a measure that targets abortion clinics, forcing them to meet the standards of ambulatory surgical facilities.

A Pennsylvania lawmaker on Wednesday introduced a bill that would repeal a state law requiring abortion clinics to meet the standards of ambulatory surgical facilities (ASF). The bill comes in response to the U.S. Supreme Court’s ruling striking down a similar provision in Texas’ anti-choice omnibus law known as HB 2.

A similar so-called targeted regulation of abortion providers (TRAP) law was passed in Pennsylvania in 2011 with bipartisan majorities in both the house and state senate, and was signed into law by former Gov. Tom Corbett (R).

SB 1350, sponsored by Sen. Daylin Leach (D-Montgomery) would repeal language from Act 122 that requires abortion clinics to meet ASF regulations. The text of the bill has not yet been posted on the state’s legislative website.

The bill is co-sponsored by state Sens. Art Haywood (D-Philadelphia), Larry Farnese (D-Philadelphia), and Judy Schwank (D-Berks).

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Leach said in a statement that there has been a “nationwide attack on patients and their doctors,” but that the Supreme Court’s ruling upholds the constitutionally protected right to terminate a pregnancy.

“Abortion is a legal, Constitutionally-protected right that should be available to all women,” Leach said. “Every member of the Pennsylvania General Assembly swore an oath to support, obey and defend the Constitution of the United States, so we must act swiftly to repeal this unconstitutional requirement.”

TRAP laws, which single out abortion clinics and providers and subject them to regulations that are more stringent than those applied to medical clinics, have been passed in several states in recent years.

However, the Supreme Court’s ruling in Whole Woman’s Health v. Hellerstedt that struck down two of the provisions in HB 2 has already had ramifications on similar laws passed in other states with GOP-held legislatures.

The Supreme Court blocked similar anti-choice laws in Wisconsin and Mississippi, and Alabama’s attorney general announced he would drop an appeal to a legal challenge of a similar law.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”


“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.