What the Domestic Gag Rule Means for Title X Providers

An examination room is seen at a women's reproductive health center in South Florida, May 2015.

From cuts to teen pregnancy prevention funding to attempts to restrict a woman’s constitutional right to access an abortion, women’s reproductive health is under relentless attack from anti-choice policymakers and the Trump-Pence administration. As this barrage of attacks continues, the fate of a vital safety net hangs in the balance: the federal Title X family planning program.

Almost 4,000 Title X health centers serve more than 4 million low-income women and men every year and provide important family planning and related preventive health services such as birth control, sexually transmitted infection (STI) testing, and cancer screenings. Enacted by the Nixon administration in 1970 after garnering broad bipartisan support, Title X has since saved taxpayers billions of dollars and reduced the country’s rate of unintended pregnancies, unplanned births, and abortions. The program is especially important to young women, women of color, and immigrant women, all of whom typically face systemic barriers to accessing care.

Restrictions to Title X threaten patients and providers; therefore, it is crucial to lift up the voices of those who will be most affected and to understand what undermining a successful evidence-based program and limiting women’s access to lifesaving health care would actually mean. The author spoke with four Title X grantees across the country—in Pennsylvania, Arizona, Texas, and Nevada—about the real-world risks of sabotaging this federal program. Their thoughts and experiences are included throughout this column.

The domestic gag rule: A blow to women’s health

On June 1, 2018, the U.S. Department of Health and Human Services (HHS) issued a domestic gag rule prohibiting Title X grantees from providing a full range of pregnancy-related options, including abortion care. It would do this by, for example, forcing providers to lie to their patients; fundamentally reshaping the network to include anti-choice entities such as fake women’s health centers, also known as crisis pregnancy centers (CPCs); and undermining the integrity of the patient-provider relationship.

Patricia Fonzi, president and CEO of the Family Health Council of Central Pennsylvania, and Santaisha Garcia, the Title X program director at the council, could not be more passionate about the work they do as a Title X grantee. Both are deeply disappointed by HHS’ proposed rule—especially considering they represent the state from which HHS Secretary Alex Azar hails. Fonzi underscores the urgency of fighting the proposed rule based on the proven success of comprehensive family planning:

Family planning is the foundation. It’s one of the top 10 public health achievements of the last 100 years, up there with the polio vaccine and penicillin. If you talked to my colleagues, they would say that things are getting introduced that undermine the very nature of their work.

Undermining the quality and scope of care

One of the most troubling aspects of the proposed rule is its prohibition of abortion referrals. The proposed rule claims, “Referrals for abortion are, by definition, directive” and therefore abortion referrals are inconsistent with current Title X statute. According to the proposed rule, only if a patient has already decided she wants abortion care is a physician allowed to furnish her with a list of providers, some but not all of whom may provide abortion. As a result, it becomes incumbent upon the patient to determine which of these referrals offers the service she is requesting.

The proposed rule would also eliminate the guarantee of unbiased information and comprehensive options counseling for pregnant women seeking care from Title X providers. Even if a woman or young person explicitly requests information about abortion, the provider can refuse that request.

Kami Geoffray, CEO of the Women’s Health and Family Planning Association of Texas (WHFPT), knows all too well what barriers to care can mean for women. As the sole Title X grantee in the state of Texas, WHFPT works with a large and diverse network of providers across the state and has had to overcome a multitude of restrictions enacted by a Republican-controlled state legislature in order to serve its 200,000 clients each year.

Geoffray believes that providing a confusing and potentially misleading list to women who need abortion services is just another attempt to erect a barrier to accessing care that ultimately harms women.

Our clients are low-income, deal with transportation issues, have unstable housing. Many don’t have access to the internet in their home, and many have language barriers. And now you have added one more thing [to block their care]. That does a disservice to the quality of care that our providers strive to offer.

Redirecting funds to anti-choice organizations

The proposed rule also emphasizes the need for additional types of family planning methods and services, with particular attention focused on natural family planning providers.

Many current providers understand this move for what it is: an attempt to extend the reach of single-method natural family planning providers that do not or will not offer comprehensive care and whose method has been found to be comparatively ineffective. Brenda Thomas, CEO of the Arizona Family Health Partnership—which serves 40,000 clients throughout Arizona every year—explains that her organization and many like it already offer clients wraparound care that includes natural family planning as an option.

We meet the client where they are. If they want to practice natural family planning, the provider would of course be willing to do that. But when you have an entity that provides only one type of service, that means clients aren’t getting comprehensive care.

Thomas points out that access to complete care is critical for both women who wish to terminate a pregnancy as well as those who wish to continue the pregnancy—making single-method providers’ entry into the Title X network potentially dangerous.

This is also part of HHS’ strategy to redirect federal funding to anti-choice organizations such as CPCs. Margaret Holloway, an advanced practice registered nurse at Carson City Health and Human Services in Nevada, has seen firsthand the impact of CPCs on her patient population, half of whom are Hispanic.

Crisis pregnancy centers are powerful in our community. We see women after they’ve visited … and they come back with horrible stories. It would be wrong if crisis pregnancy centers ended up getting Title X money, because they are not open to the reality of what women, including women of faith, need.

Breaching patient-provider confidentiality

The proposed rule would also require providers to encourage family participation—such as by involving the parents or guardians—for young people seeking family planning services and to document the specific actions taken by providers to encourage such participation. It would also task providers with collecting information about teenagers, such as their age and the age of their sexual partners, for their medical records.

The impact this could have on teen clients worries many providers. As Garcia explains, it is possible that young people will no longer feel they can receive safe, confidential care at their Title X clinic and instead may forgo care, putting them at risk of unintended pregnancies and STIs. Providers may see “fewer adolescents once word gets out that questions would be asked about sexual partners,” Garcia says. “Adolescents come because they know they can get services without being interrogated or questioned.” Fonzi adds, “You risk violating that covenant relationship of trust. This is an intentional move by the administration to erode patient-provider trust.”

Conclusion

The Title X program has successfully delivered reliable and medically accurate family planning care to millions of women across the country for almost 50 years. It has also empowered young people to seek reproductive health care during an important time in their lives, based on the premise that such care will be confidential and safe. The Trump-Pence administration’s domestic gag rule will reverse decades of progress, imperiling the health of these women and threatening the network of providers that strives to serve them. In the fights that loom ahead, collective action can be taken by submitting public comments, hosting rallies, engaging with elected officials, and speaking truth to power. The American people cannot afford to cede any more ground when it comes to reproductive health and rights—women’s lives depend on it.

Osub Ahmed is a policy analyst for the Women’s Initiative at the Center for American Progress.

Author’s note: The interviews and quotes throughout this column have been edited for clarity. They were conducted by the author on the following dates: Patricia Fonzi and Santaisha Garcia, June 22, 2018; Brenda Thomas, June 22, 2018; Margaret Holloway, June 29, 2018; and Kami Geoffray, July 6, 2018.