Some 60 years ago, American legislators set out to tackle a problem that was driving employment and education rates down, driving health care and welfare costs up and making American family life significantly less stable: Many American women, and particularly poor women and teenagers, were having more children than they wanted or could afford. Close to half of births were to women who had not intended to get pregnant.
Decreasing the unintended pregnancy rate was a bipartisan wish. In 1969, President Richard Nixon recognized that “unwanted or untimely childbearing is one of several forces which are driving many families into poverty.” A year later, Congress passed Title X: the first federal program entirely dedicated to family planning and reproductive health care.
It would go on to become one of the most successful federal programs of the last century, with one study finding it prevented some 20 million unintended pregnancies in just 20 of its 50 years by providing women with free and low-cost birth control. It has significantly reduced child poverty. In 1957, nearly one in 10 teenage girls gave birth. Today, the rate is closer to one in 100. For every dollar spent on family planning funds, the government saves $7 in Medicaid costs.
But President Trump seems intent on killing Title X. This month, the Department of Health and Human Services quietly issued new funding guidelines that have effectively subverted the program’s entire purpose. Instead of getting highly effective contraception methods to the country’s poorest women so that they may decide if and when to have children, Title X under Mr. Trump seems aimed at getting more women pregnant, whether they want to be or not. And it appears to cater to three influential parts of the Trump coalition: The anti-abortion movement; the MAHA, or Make America Healthy Again, movement; and pronatalists who want to see birthrates rise at nearly any cost.
More than half of patients at Title X clinics use modern contraceptive methods to prevent pregnancy. But the word “contraception” comes up just once in the Title X funding document, and only in a section on “reducing overmedicalization in health care.” Instead, in a change pulled directly from Project 2025, H.H.S. tells Title X clinics to emphasize “fertility-awareness-based methods,” a broad category that includes things like tracking your periods or your body temperature to estimate which days you might be fertile. These methods can be helpful for getting pregnant, but are generally far less so for preventing pregnancy. Fertility awareness methods have typical-use failure rates between 12 and 24 percent in the first year, according to the American College of Obstetricians and Gynecologists. The intrauterine device, by contrast, has a failure rate of less than 1 percent.
The health department seems to want to shift taxpayer dollars away from reliable contraception and toward counseling men on erectile dysfunction, testosterone levels and sperm motility, each of which merits three mentions in the new guidance, while IUDs and birth control pills earn none. The document is a mishmash of Make America Healthy Again talking points on lifestyle changes, conservative bromides on marriage before babies and pronatalist nods to fertility.
Some of the guidance sounds sensible on its face. H.H.S. cribs from MAHA when it says it will focus on chronic disease in order to promote “healthy pregnancies and family formation.” But contraception use is a significant part of how women ensure they have healthy pregnancies and form the families they desire, and it’s also a common treatment for chronic diseases, including endometriosis and polycystic ovarian syndrome. Yet it doesn’t come up in the section spelling out the department’s top Title X spending priorities. What does? Addressing “exposure to harmful chemical and environmental toxins,” low sperm count, and pornography use.
The new Title X guidance also includes many mentions of infertility. It’s true that men and women desire more support in having wanted pregnancies, but H.H.S.’s prescription, which includes “sleep” and counseling on “marriage prior to childbearing,” is unsatisfying. On the campaign trail, Mr. Trump declared himself the “father” of in vitro fertilization, yet I.V.F. is absent from his administration’s family planning funding goals.
The good news is that, at least for now, Title X funds are still required to go to clinics that provide or refer out for a range of modern contraceptive options. The bad news is that this is only because of a Biden-era rule that the administration has already signaled it might try to rescind. The threat to the program is all the more concerning because, according to the most recent data available, it still hasn’t fully recovered from draconian regulations put in place during Mr. Trump’s first term, which led to an exodus of clinics and cut the number of patients served by half.
An H.H.S. employee told Politico that the new guidance was catering to the anti-abortion wing of the G.O.P. There’s a terrible irony here — by reducing unintended pregnancy, Title X has prevented more than 9 million abortions — but it’s not surprising: Most of the major “pro-life” groups in the United States either oppose contraception or stay mum on the topic. The old anti-abortion movement strategy was to attack contraception as immoral, though few Americans share that view. The new tactic is more MAHA-coded, and with a pronatalist twist: Sow fear that modern contraceptives are unnatural, and push holistic alternatives instead; generate alarm about declining birthrates and blame the dip on working women (in reality, it largely comes from fewer teen pregnancies).
Women who are able to plan their pregnancies wind up in better physical and psychological health, birth healthier infants, make more money, are less likely to get divorced, are less likely to rely on public assistance and invest more in their children, who, in turn, do better educationally and behaviorally. Modern contraception is nothing short of a medical miracle — one that has saved the lives of millions of women and babies worldwide.
Not satisfied with the end of legal abortion in America, the anti-abortion movement seems poised to end the era of affordable contraception. The result isn’t just the end of Title X as we knew it. It’s the demise of a long-held bipartisan consensus that a woman’s ability to shape her own future, even if she was poor, was worth something — and certainly worth the government’s investment.
Jill Filipovic is a journalist, a lawyer and an author who writes at jill.substack.com.
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