WASHINGTON — The Trump administration’s expansion of the so-called Mexico City policy restricting reproductive care around the world, to now cover gender ideology and diversity efforts, will impact billions of dollars in foreign aid not previously covered, according to health experts.

The State Department on Jan. 23 announced that the policy, reinstated when President Donald Trump took office, would be expanded beyond abortion restrictions and would apply to a wider scope of organizations than during previous administrations.

Known as the Mexico City policy for the location where President Ronald Reagan announced it in 1984, and referred to by critics as the global gag rule, the policy required foreign nongovernmental organizations to certify that they wouldn’t perform or refer for abortions before accepting U.S. dollars. The newly expanded rule requires foreign partners to agree not to promote “gender ideology” or diversity, equity and inclusion activities as well.

And it expands coverage to all nonmilitary foreign aid, not just NGOs, potentially impacting nearly $40 billion spanning 160 countries, according to an analysis by KFF.

The restrictions on gender ideology-related assistance encompass gender-affirming care and legal protections based on gender identity while defining sex as a person’s “immutable biological classification as either male or female.”

“The U.S. is saying ... everything has to be biological determinism or you cannot receive U.S. funds,” said Beirne Roose-Snyder, a senior policy fellow at the Council for Global Equality. “So it’s certainly not just a health care issue. It’s going to have huge impacts on who can access gender-based violence care and who can access food.”

If, for example, a foreign organization providing water, food or education receives U.S. funds but has education materials that fall under the administration’s definition of “gender ideology,” it couldn’t accept U.S. funds.

Several countries to which the U.S. provides foreign assistance have separate laws and requirements surrounding gender and sex education. To maintain their funding, organizations in those countries won’t be able to follow their countries’ nondiscrimination laws around gender if they conflict with the Trump administration’s rules, according to health advocates examining the impact.

The changes are consistent with policies laid out in the conservative framework known as Project 2025, which called on the next Republican administration to apply the policy “to all foreign assistance.” The Project 2025 authors had bemoaned the first Trump administration’s application of it for overlooking loopholes that allowed international organizations to perform and promote abortions after receiving funding from the U.S. Agency for International Development.

Targeting gender-affirming care and limiting gender to two sexes has been a main focus of the Trump administration’s first year, with the White House issuing an executive order soon after inauguration to limit access to care for transgender youth and the Department of Health and Human Services issuing proposals to fully restrict pediatric gender-affirming care. The expanded Mexico City policy marks the first time the Trump administration has tried to promote this policy on a global scale.

The extent of the impact is unclear, but it could be significant in the context of HIV/AIDS services, said Jen Kates, senior vice president and director of the Global and Public Health Policy Program at KFF. U.S. funding has not historically supported gender-affirming care, but the new restrictions go beyond the care provision and impacts what organizations can say or where they can refer patients.

The rule will make it very difficult for transgender people to access antiretrovirals and pre-exposure prophylaxis drugs because they may not be able to see their usual providers or can’t disclose their gender to a new provider, Roose-Snyder said.

Additionally, the vague definition of gender ideology could have a chilling effect on services offered to LGBTQ populations.

“If something is very vague in a rule or a little vague in the rule, an organization often will say, ‘Well, I’m just going to stop doing X, Y and Z because I’m too worried that that’s going to conflict with the rule itself,’” Kates said.

The rule is slated to go into effect Feb. 26.

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