Throughout the U.S. debate on international family planning assistance—at times the most controversial foreign aid issue considered by Congress—the cornerstone of U.S. policy has remained a commitment to funding international family planning programs based on principles of voluntarism and informed choice that give participants access to information and services on a broad range of family planning methods. At present, the U.S. Agency for International Development (USAID) maintains family planning projects in nearly 40 developing countries that include counseling and services, training of health workers, contraceptive commodities and distribution, financial management, policy dialogue, data collection, monitoring and evaluation, public education and marketing, and biomedical and contraceptive research and development. USAID applies a broad reproductive health approach to its family planning programs, increasingly integrating it with other interventions in maternal and child health, the enhancement of the status of women, and HIV treatment and prevention. In addition to these bilateral activities, the United States has supported multilateral family planning efforts through annual contributions to the U.N. Population Fund (UNFPA). Family planning assistance has become a source of substantial contention among U.S. policymakers, centering on two key issues: setting appropriate and effective funding levels for family planning assistance, and the use of federal funds to perform or promote abortions abroad and how to address possible coercion in some national family planning programs, especially in China. Arguably, the most bitter controversies in U.S. family planning policy have erupted over abortion—in particular, the degree to which legal abortions and coercive programs occur in other countries' family planning programs, the extent to which U.S. funds should be granted to or withheld from such countries and organizations that administer these programs, and the effect that withholding U.S. funds might have on global population growth and access to voluntary family planning services in developing nations. These issues stem from the contentious domestic debate over U.S. domestic abortion policy that has continued since the Supreme Court's 1973 Roe v. Wade decision holding that the Constitution protects a woman's decision whether to terminate her pregnancy. In every Congress since 1973, abortion opponents have introduced constitutional amendments or legislation that would prohibit abortions supported with U.S. foreign assistance funds. As an alternative, Congress has attached numerous provisions to annual appropriation measures banning the use of federal funds for performing legal abortions. Much of this debate has focused on domestic spending bills, especially restrictions on abortions under the Medicaid program in the Labor/Health and Human Services appropriation legislation. However, the controversy spilled over into U.S. foreign aid policy when Congress approved an amendment to the Foreign Assistance Act of 1961 in late 1973 introduced by then-Senator Jesse Helms (§104(f)). The provision, widely referred to as the "Helms amendment," prohibits the use of foreign development assistance to (1) pay for the performance of abortions or involuntary sterilizations, (2) motivate or coerce any person to practice abortions, or (3) coerce or provide persons with any financial incentive to undergo sterilizations. Since 1981, Congress has enacted the Helms amendment, as well as other family planning and abortion-related restrictions, in annual Foreign Operations appropriation bills. In the mid-1980s, debate over international abortion restrictions reached the executive branch. In 1984, at the second International Conference on Population held in Mexico City, Mexico, President Reagan issued what has become known as the "Mexico City policy," which required foreign non-governmental organizations (NGOs) receiving USAID family planning assistance to certify that they would not perform or actively promote abortion as a method of family planning, even if such activities were undertaken with non-U.S. funds. In the intervening years, the Mexico City policy has been rescinded and reissued by various Administrations. Most recently, it was rescinded by President Barack Obama in January 2009. In 1985, Congress adopted the "Kemp-Kasten" amendment due to the concerns of President Reagan and some Members of Congress that the U.N. Population Fund's (UNFPA's) program in China engaged in or provided funding for abortion or coercive family planning programs. Kemp-Kasten prohibits U.S. assistance to organizations that, as determined by the President, support or participate in the management of coercive family planning programs. Demonstrating the politicized nature of the international family planning debate, presidential determinations regarding the Mexico City Policy and UNFPA's activities in China have generally been divided along party lines. Presidents Reagan, George Bush, and George W. Bush prohibited U.S. contributions to UNFPA and supported the Mexico City Policy, while Presidents Clinton and Obama have supported U.S. funding of UNFPA and overturned the Mexico City Policy. For the past several decades, both congressional actions and administration directives have restricted U.S. population assistance in various ways. Such restrictions are found in provisions in the Foreign Assistance Act of 1961, as well as executive regulations and appropriation provisions prohibiting indirect support for coercive family planning (specifically in China) and abortion activities related to the work of international and foreign NGOs. This section addresses two key actions that were initiated in the mid-1980s and have remained particularly controversial in the U.S. family planning debate: the Mexico City policy involving funding for foreign non-governmental organizations, and "Kemp-Kasten" restrictions on funding for the U.N. Population Fund (UNFPA) because of its activities in China. In 1984, the Reagan Administration announced that it would restrict U.S. population aid by terminating USAID support for any foreign NGOs (but not national governments) that were involved in voluntary abortion activities, even if such activities were undertaken with non-U.S. funds. U.S. officials presented the revised policy at the 2 nd U.N. International Conference on Population in Mexico City in 1984. Thereafter, it become known as the "Mexico City policy." During the George H. W. Bush Administration, efforts were made in Congress to overturn the Mexico City policy and rely on existing congressional restrictions in the Foreign Assistance Act of 1961 banning direct U.S. funding of abortions and coerced sterilizations. Provisions adopted by the House and/or Senate that would have reversed the policy, however, were removed from legislation under threat of a presidential veto. Critics charge that the Mexico City policy is a violation of free speech and the rights of women to choose to have an abortion in countries where it is legal. They contend that the policy undermines family planning and maternal health care services offered in developing nations and may actually contribute to the rise in the number of abortions performed, including some that are unsafe and illegal. They further emphasize that family planning organizations may cut back on services because they are unsure of the full implications of the restrictions and do not want to risk USAID funding. Opponents also believe that the conditions of the Mexico City policy undermine relations between the U.S. government and foreign NGOs and multilateral groups, creating a situation in which the United States challenges their right to determine how to spend their own money and imposes a so-called gag order on their ability to promote changes to abortion laws and regulations in developing nations. The latter, these critics note, would be unconstitutional if applied to American groups working in the United States. President Clinton, in a January 22, 1993, memo to USAID, lifted restrictions imposed by the Reagan and Bush Administrations on grants to family planning foreign NGOs—in effect ending the Mexico City policy. The memo noted that the policy had extended beyond restrictions in the Foreign Assistance Act and was not mandated by law. In his remarks, President Clinton explained that this step would "reverse a policy that has seriously undermined much needed efforts to promote safe and effective family planning programs abroad, and will allow us to once again provide leadership in helping to stabilize world population." On January 22, 2001, President George W. Bush revoked the Clinton Administration memorandum and restored in full the terms of the Mexico City restrictions. As was the case during the 1980s and early 1990s when the Mexico City policy was in place, foreign NGOs, as a condition for receipt of U.S. family planning assistance, would need to certify that they would not perform or actively promote abortions as a method of family planning in other countries. President Bush, in announcing the policy change, noted that American taxpayer funds should not be used to pay for abortions or to advocate or actively promote abortion. Supporters of the certification requirement argue that even though permanent law bans USAID funds from being used to perform abortions, money is fungible; organizations receiving American-taxpayer funding can use USAID resources for family planning activities while diverting money raised from other sources to perform abortions or lobby to change abortion laws and regulations. The certification process, they contend, stops the fungibility "loophole." On January 23, 2009, President Barack Obama issued a presidential memorandum to the Secretary of State and USAID Administrator revoking the Mexico City policy and Bush Administration conditions on voluntary population planning provided by the State Department. The memorandum stated These excessively broad conditions on grants and assistance awards are unwarranted. Moreover, they have undermined efforts to promote safe and effective voluntary family planning programs in foreign nations. President Obama also directed the Secretary of State and USAID Administrator to waive the conditions set forth in these policies and to notify current grantees as soon as possible. He further directed the State Department and USAID to cease imposing such conditions on any future grants. At the 1984 Mexico City Conference, the Reagan Administration instituted a new policy relating to UNFPA. The Administration required that the organization provide "concrete assurances that [it] is not engaged in, or does not provide funding for, abortion or coercive family planning programs." It was particularly concerned with UNFPA's activities in China, where, according to Administration officials, there was evidence of coercive family planning practices.