For four decades, the Mexico City Policy—commonly known as the Global Gag Rule—has been a political ping pong. Republican presidents impose it; Democratic presidents rescind it. The policy blocks U.S. funding to foreign organizations that provide or promote abortion, even if those activities are funded by separate, non-U.S. government sources. Until now, its scope was always limited to reproductive health programs.
On Jan. 27, the Trump administration published three final rules that represent the broadest overt application of ideological conditions on U.S. foreign aid in history, together called the Promoting Human Flourishing in Foreign Assistance policy. This policy conditions about $40 billion dollars in non-military aid—global health programs, humanitarian assistance, refugee services, development funding—on compliance with the administration’s positions on abortion, “gender ideology,” and diversity, equity, and inclusion (DEI) programming.
The expanded policy is categorically different from previous iterations of the Mexico City Policy in both scope and ambition. It has taken the Gag Rule model and applied it across nearly all core domains of U.S. foreign assistance, exporting the United States’ culture war over gender identity and DEI through the machinery of U.S. foreign aid. While this article focuses on how the new policy will affect LGBTQI+ populations in particular—communities explicitly targeted by the gender ideology rule and likely to bear significant consequences from all three—the operational problems that the rules create will compromise the effectiveness of U.S. foreign assistance and undermine American strategic interests more broadly.
How the New Rules Expand the Global Gag Rule
The policy includes three components. The Protecting Life in Foreign Assistance rule expands the traditional Mexico City Policy’s abortion restrictions beyond family planning programs to virtually all foreign assistance. For the first time, it also prohibits U.S. NGOs from providing abortion services abroad with any funds.
The Combating Gender Ideology in Foreign Assistance rule is the most sweeping in its reach. It explicitly defines transgender identities as an ideology to be “combated” and prohibits a broad range of activities affecting transgender, nonbinary, and intersex individuals: providing gender-affirming care, using pronouns that correspond with a person’s gender identity, operating facilities that counsel on gender transition, and lobbying foreign governments for legal gender recognition. The rules adopt the definitions of sex and gender identity from Executive Order 14168, “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government,” that President Donald Trump signed in January 2025.
The Combating Discriminatory Equity Ideology in Foreign Assistance rule restricts DEI programming more broadly, targeting what it calls “discriminatory equity ideology” with reference to race, color, religion, sex, and national origin. Whether its restrictions extend to programming serving cisgender lesbian, gay, and bisexual populations is less clear from its operative text. However, the rule’s preamble cites prior USAID work on “LGBTQI+” inclusion as a problem to eliminate, and its vague terms may have a chilling effect on such programming.
Across the three rules, foreign NGOs and international organizations face the most restrictive terms. They must agree not to engage in prohibited activities across their entire operations, with funds from any source, while receiving any U.S. foreign assistance. For example, an organization receiving U.S. funding for tuberculosis treatment that also operates gender-affirming healthcare programs with European funding must abandon the latter entirely or forfeit U.S. funds. U.S.-based NGOs face a different but still onerous standard: physical and financial separation between U.S. government-funded and prohibited activities, including separate facilities, personnel, health records, accounts, and signage.
The compliance mechanisms impose a substantial burden. Organizations must flow restrictions down to all subgrantees, creating liability throughout funding chains. The government retains authority to conduct unannounced inspections of facilities, records, and personnel, and to make “independent inquiries in the community” about compliance. Violations can result in funding termination, debarment, and requirements to refund amounts already spent on prohibited activities.
The rules were issued without the standard notice-and-comment process. The administration’s own regulatory analysis in each rule estimates $16 million in one-time familiarization costs and $114 million in annual compliance costs across 2,500 implementing organizations. A waiver provision exists for “national security or foreign policy purposes,” but with no criteria, process, or timeline for obtaining one, leaving organizations unable to plan around potential exceptions.
Targeted Harms and Collateral Damage
The Combatting Gender Ideology rule most directly targets transgender, nonbinary, and intersex people. But the consequences extend far beyond those populations and into the core effectiveness of programs that have nothing to do with gender identity debates. This matters because gender identity restrictions cannot be neatly siloed.
PEPFAR, launched under President George W. Bush and credited with saving an estimated 26 million lives, works precisely because it targets HIV prevention and treatment to populations at highest risk: gay and bisexual men, transgender women, sex workers, people who inject drugs, and their partners. In 2023, PEPFAR provided preventive services to more than 2.4 million key population members, including nearly 800,000 gay and bisexual men and more than 85,000 transgender people. That same year, nearly 150,000 gay and bisexual men and 12,000 transgender people were initiated on pre-exposure prophylaxis. An analysis in The Lancet HIV estimates that withdrawing targeted support from these populations could result in thousands of additional infections annually. If organizations cannot acknowledge gender identity in intake forms or clinical records, differentiate outreach to reach transgender populations, or provide culturally competent care, they cannot conduct the targeted work that effective HIV prevention requires.
Humanitarian response will also slow. LGBTQI+ refugees face compounding risks at every stage of displacement. In transit countries, they routinely experience harassment, physical violence, and discrimination; even where services nominally exist, homophobia and transphobia among providers frequently block access to health care, mental health support, and legal aid. Transgender refugees face additional, acute barriers: difficulty obtaining gender-affirming medication, lack of appropriate medical care, and identity documents that do not reflect their gender identity, creating constant exposure to scrutiny and risk.
The new rules will directly constrain organizations working with these populations. Providers will be restricted from affirming clients’ gender identities, making appropriate referrals, or advocating for their protection with host governments. Most concretely, the rules bar “lobbying or encouraging a foreign government to provide legal status or protections based on gender identity,” prohibiting advocacy for transgender refugees in some host countries where their identities may even be criminalized. The cumulative effect is likely to drive LGBTQI+ refugees further underground, compounding the invisibility that already makes them targets for exploitation and violence.
Because these rules require foreign NGOs and international organizations receiving any U.S. foreign assistance to observe these prohibitions across all of their activities, an organization receiving U.S. support for girls’ education or small-business development would thus be barred from advocating for legal gender recognition, or running public information campaigns on transgender rights, even where those activities are entirely funded by other donors.
This could include multilateral entities like the United Nations and other U.N. agencies that receive funding through U.S. voluntary contributions and direct funding. For example, it is unclear whether emergency support programs and legal aid for transgender people facing violence or arrest, as currently delivered by UNDP and UNAIDS, would lead to the loss of U.S. funds. Under the Mexico City Policy, the U.N. Population Fund (UNFPA) repeatedly lost U.S. funding under Republican administrations, but those restrictions were limited to reproductive health. The current rules extend ideological conditions across non-military foreign assistance, meaning U.N. entities receiving U.S. support for development, humanitarian, or governance work now face compliance obligations with no precedent in prior policy cycles.
The DEI rule’s effect on broader LGBTQI+ programming is harder to assess with precision, given the vagueness of its prohibitions, but the compliance risk it creates is likely to produce similar restrictions in practice. Indeed, research on previous iterations of the Mexico City Policy offers a preview of what could happen. One study found that organizations routinely “over-implemented” restrictions, curtailing services well beyond what was legally required to avoid any compliance risk. The policy created confusion, fragmented civil society partnerships, and disrupted services far beyond abortion care, including HIV programs with no connection to reproductive health. These new rules are broader, cover more funding, and impose more onerous compliance requirements. The chilling effects will likely be correspondingly greater and fall hardest on the most vulnerable populations.
The Strategic Costs
These restrictions do not operate in a vacuum. At the 2024 Forum on China-Africa Cooperation, President Xi Jinping announced $50 billion in African development commitments over three years, explicitly positioned as partnership without ideological conditions. The contrast with U.S. restrictions is not lost on partner governments evaluating their options.
The downstream effects on the implementing partner ecosystem are harder to predict. Some donors (e.g. EU, UK) have signaled commitments to inclusive programming, and may partially absorb organizations unwilling to operate under U.S. restrictions. But whether alternative funding will materialize at sufficient scale, and on a timeline that prevents organizational disruption, remains uncertain. Many implementing partners lack the flexibility to simply redirect their funding relationships, and some may have no viable alternative but to comply or cease operations.
The rules are also part of a broader international agenda. Both the abortion rule and the gender ideology rule state explicitly that they are “necessary to secure the foreign policy goals of the United States” as articulated in the Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, a political statement the United States first championed in 2020 and rejoined in 2025. Understood by both supporters and critics primarily as a vehicle for contesting abortion rights internationally, the Declaration also reaffirms “the family as the natural and fundamental group unit of society.” Such language has a documented history of use in multilateral settings to resist recognition of same-sex families and LGBTQI+ rights. Its original co-sponsors include Egypt, Hungary, Indonesia, and Uganda, and the sovereignty arguments it enshrines have been routinely deployed in U.N. spaces to block protections based on sexual orientation and gender identity by framing them as “ideological impositions.”
The stakes further extend to issues of governance. Research by the Williams Institute at UCLA, where we both work (and co-authored by one of us), has documented a strong association between attacks on LGBTQI+ people and democratic backsliding: countries that protect LGBTQI+ rights tend to have stronger democratic institutions, and the erosion of those protections often accompanies broader erosion of rule of law and human rights norms. Foreign assistance has long been one instrument through which the United States supports democratic governance abroad. Rules that undermine the wellbeing and inclusion of LGBTQI+ populations do not merely abandon a vulnerable group—they accelerate conditions that global democracy programming is simultaneously trying to reverse.
What Should Happen Now
Congress, implementing organizations, and donors have a range of tools to address the effects of this expanded policy.
First, Congress retains appropriations and oversight authority over these rules, which were issued without public input under claimed exemptions from standard notice-and-comment rulemaking. Legislators concerned about the foreign assistance effectiveness should use that authority to demand data on waiver requests and denials, compliance enforcement actions, and measurable impacts on program outcomes; hold oversight hearings that examine the evidentiary basis for these changes and scrutinize the administration’s failure to quantify key implementation costs; and use the State/Foreign Operations appropriations process to require independent evaluation of health and development outcomes under the new restrictions. Congress should also press the administration to make public the promised guidance on waiver criteria—which had not been issued at the time these rules took effect—and to report on how waivers are being applied in practice across sectors.
Second, organizations with the capacity to do so should systemically document real-world effects the foundation for any future course correction. The most valuable evidence from previous policy cycles came from organizations that tracked service disruptions, partnership fragmentation, and health outcomes in real time. Organizations should establish baseline metrics now—particularly for LGBTQI+ populations—and processes for tracking changes. Donors should allow reprogramming for community-led monitoring of these impacts.
Third, implementing organizations should build relationships with alternative donors. Service disruption happens faster than funding replacement. When organizations previously declined U.S. funding, gaps emerged immediately; alternative funding took longer to materialize. Organizations serving LGBTQI+ and other key populations and potential donors should initiate conversations now, map support, and plan urgent responses.
Finally, groups should coordinate to maintain coverage. Some organizations will decline U.S. funding. Others will accept restrictions. Uncoordinated decisions create coverage gaps. Organizations should look collectively to ensure access to services, whether through referral networks, strengthening local organizations outside U.S. funding streams, or strategic division of programming across funding profiles. Development donors should prioritize core funding for community-led networks, groups, and service providers to engage in critical coordination efforts.
The administration frames these rules as promoting “human flourishing,” but the evidence points in a different direction: reduced effectiveness in HIV prevention, slower humanitarian response, fragmented implementing partnerships, and diminished American influence abroad. These rules reject decades of evidence about what makes foreign assistance effective and instead impose real costs on vulnerable populations and American strategic interests alike.
– Ari Shaw and Laurel Sprague, Published courtesy of Just Security.
