On Monday morning, Donald Trump, surrounded by a group of smiling white men, signed an executive order banning foreign nongovernmental organizations that receive certain kinds of American aid from counseling health clients about abortion or advocating for abortion law liberalization. Supporters of international reproductive rights were disappointed but not surprised. Ronald Reagan first issued the so-called Mexico City policy in 1984, stripping U.S. family planning funds from groups involved with abortion, and ever since, every Republican president has reinstated it. By Monday’s end, however, people who work on global reproductive health and rights were reeling. Trump, it eventually emerged, hadn’t simply revived the so-called global gag rule. Quietly, with so little publicity that activists weren’t aware until someone saw the new language in a tweeted image, Trump had massively expanded the rule. Suzanne Ehlers, president and CEO of the global reproductive health organization PAI, says it’s the global gag rule “on steroids.”

In the past, the global gag rule meant that foreign NGOs must disavow any involvement with abortion in order to receive U.S. family planning funding. Trump’s version of the global gag rule expands the policy to all global health funding. According to Ehlers, the new rule means that rather than impacting $600 million in U.S. foreign aid, the global gag rule will affect $9.5 billion. Organizations working on AIDS, malaria, or maternal and child health will have to make sure that none of their programs involves so much as an abortion referral. Geeta Rao Gupta, a senior fellow at the United Nations Foundation who previously served as deputy executive director of UNICEF, gives the example of HIV/AIDS clinics that get U.S. funding to provide antiretrovirals: “If they’re giving advice to women on what to do if they’re pregnant and HIV positive, giving them all the options that exist, they cannot now receive money from the U.S.”

George W. Bush specifically exempted the President’s Emergency Plan for AIDS Relief, or PEPFAR, from the global gag rule because it was widely understood that the program couldn’t meet its prevention and treatment targets otherwise. Scott Evertz, who served as director of the White House Office of National AIDS Policy under George W. Bush, tells me, “It would have been impossible to treat HIV/AIDS in the developing world as the emergency that PEPFAR said it was if the global gag rule were to be applied to the thousands of organizations with which those of us involved in PEPFAR would be working.” Evertz offers the example of a standalone health clinic in the slums of Nairobi, Kenya. Would the U.S. have to certify that it never referred any of its patients to an abortion provider before enlisting it in the fight against AIDS? “The notion of applying the global gag rule to them would have made it impossible to implement the program,” he says.

Ann Starrs, president of the Guttmacher Institute, says her staff feared social conservatives on the Trump team might push to broaden the global gag rule. Others, however, are stunned at the move. “It wasn’t unexpected that they would reinstate the global gag rule, but the dramatic expansion of the scope of it is truly shocking,” says Gupta. Some in international reproductive and sexual health circles are speculating that the new policy is Trump’s way of lashing out at the millions of women who marched against him on Saturday. “I would not necessarily be surprised if it were a reaction to the women’s marches,” Evertz says. “Although applying the global gag rule to PEPFAR’s programs ill affects millions of men as well,” since HIV/AIDS programs that treat entire communities could face defunding.

It took all day Monday for the scope of the policy to become clear because of the new administration’s opacity. Initially, when Trump signed the executive order, the White House didn’t release its exact wording. Reproductive health advocates called colleagues in the State Department and USAID, but no one seemed to know anything. “I had a staff person who tried to call the White House yesterday and was told that the White House telephone lines are down and they aren’t taking calls,” says Debra Hauser, president of Advocates for Youth, a group that champions sex education and sexual health services for young people. “Normally there’s a press release. You can look it up. That was not the case yesterday. Nothing.” Finally, at around 5 p.m., someone in the reproductive health field noticed a tweet by an anti-abortion activist that appeared to include a screenshot of the new language. “That is how we started to realize that it was an expansion and not just a reinstatement,” says Hauser. (The order has since been posted on the White House website.)

It remains to be seen how many organizations submit to the new rules. Gupta thinks that some will forgo funding: “Just knowing the organizations we work with, whose mission is overall health, I can’t imagine they would accept a foreign government’s requirement that is so broad,” she says. “That’s the anxiety in the community—that all of our partners are going to be decimated through this, and this work we have all put in to reducing illness, death, and disease over the past two or three decades is going to be undone.”