Although overshadowed by other issues in the health-care debate, a controversial abstinence-only approach to sex education that recently saw its federal support severed is getting a new lease on life—a five-year lease worth $250 million, to be precise—under the final legislative package signed by President Barack Obama.
At the same time, the health-care law also provides $375 million over five years to promote more-comprehensive approaches to sex education that touch on both abstinence and the use of contraceptives to prevent pregnancy and sexually transmitted diseases. The emphasis in the program is on funding efforts that are “evidence-based,” “medically accurate,” and “age-appropriate,” the law says.
That funding stream, called the Personal Responsibility Education program, appears to dovetail with a new teenage-pregnancy-prevention initiative championed by the Obama administration and financed at nearly $115 million in fiscal 2011.
Critics of the federal abstinence-only program expressed dismay that it was restored in the health-care legislation. The program, which the administration did not support, had expired last June after operating for more than a decade.
The new health-care law contains two provisions related to sex education. One reinstates a $250 million program of state grants for abstinence-only education. The other creates the $375 million Personal Responsibility Education program, which funds comprehensive sex education.
State Abstinence Education Program
To be eligible for federal aid, a program must:
• Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity.
• Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children.
• Teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems.
• Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity.
• Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.
• Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society.
• Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances.
• Teach the importance of attaining self-sufficiency before engaging in sexual activity.
Personal Responsibility Education Program
To be eligible, a program must:
• Replicate evidence-based effective programs or substantially incorporate elements of effective programs that have been proven on the basis of rigorous scientific research to change behavior, which means delaying sexual activity, increasing condom or contraceptive use for sexually active youths, or reducing pregnancy among youths.
• Be medically accurate and complete.
• Include activities to educate youths who are sexually active regarding responsible sexual behavior with respect to both abstinence and the use of contraception.
• Place substantial emphasis on both abstinence and contraception for the prevention of pregnancy among youths and sexually transmitted infections.
• Provide age-appropriate information and activities.
• Offer information and carry out activities in the cultural context that is most appropriate for individuals in the particular population group to which they are directed.
SOURCES: Patient Protection and Affordable Care Act; Personal Responsibility and Work Opportunity Reconciliation Act of 2006
“Advocates for science-based, evidence-based sex education were stunned to learn that some Democrats had kept in the health-care-reform measure a reauthorization of the Title V abstinence-only-until-marriage program,” said James C. Wagoner, the president of Advocates for Youth, a Washington-based nonprofit focused on adolescent sexual health. “Everybody assumed it would be removed.”
GOP Initiative
The program was added to the health-care legislation through an amendment pushed by Republican Sen. Orrin Hatch of Utah during consideration in the Senate Finance Committee. In the end, no Republicans in Congress supported the health-care legislation.
The abstinence program, which provides grants to states, was first established in 1996 under welfare-reform legislation signed by President Bill Clinton. It is contained in Title V of the Social Security Act.
Valerie J. Huber, the executive director of the Washington-based National Abstinence Education Association, which represents organizations that provide such education, praised its inclusion in the final health-care package.
“Obviously, this is a health issue, so it makes perfect sense for it to be in a health bill,” she said. “We were delighted for the bipartisan support for Title V abstinence education funding.”
She added: “It shows that this continues to be an approach that has merit, and the growing body of research in support of it only strengthens the need for this to continue.”
At the same time, Ms. Huber expressed disappointment that the law allocates significantly more money for the Personal Responsibility Education program.
“There is not equitable funding,” she said. “If you look at a public-health model, there is always priority given to the risk-avoidance method.”
State Matching Funds
The decision to reinstate the federal abstinence-only program comes after the release in February of a high-profile study showing promising results for a particular abstinence-based approach. The study from researchers at the University of Pennsylvania concluded that an abstinence program taught to African-American middle schoolers was more effective than other kinds of interventions in delaying sexual activity. It was described by one co-author as the first randomized, controlled study ever to demonstrate the effectiveness of an abstinence-only intervention. (“Study Finds Abstinence Program Effective,” Feb. 10, 2010.)
Some proponents of abstinence-only education had been using the Penn study to argue for reinstating the Title V federal funding. But critics say the program it examined would not even have been eligible for that aid, in part because it did not stress remaining chaste until marriage.
The federal abstinence-only program includes eight main points that local programs must adhere to to get funding, such as teaching “abstinence from sexual activity outside marriage as the expected standard for all school-age children” and teaching that “sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.”
“It really is a very rigid, abstinence-until-marriage program,” said Heather D. Boonstra, a senior public-policy associate at the Guttmacher Institute, a New York City-based nonprofit that promotes sexual and reproductive health through research and policy analysis.
Even though the abstinence program will have $50 million to distribute annually over the next five years, some of that money may never be spent. Before the program expired in 2009, 22 states had declined to participate, said Ms. Boonstra. When a state declined the money, she noted, that share simply returned to the U.S. treasury.
Several issues help explain why states declined, she said. Some state officials have openly said they oppose the strict requirements for an abstinence-only approach, according to Ms. Boonstra. There’s also a financial matter. Unlike the Personal Responsibility Education program, the abstinence one requires matching state dollars, equivalent to 75 percent of its grant.
“That’s one question looking ahead: What will states decide to do, having these fiscal budget crises,” she said, “whether they decide, given the lack of evidence, if this is a waste of their taxpayer dollars.”
She notes that the Title V program was the subject of a detailed, independent evaluation, and the findings were not promising. The congressionally mandated study by Mathematica Policy Research, issued in 2007, found no statistically significant beneficial impact on the sexual behavior of participating young people. For instance, the participants were no more likely to abstain from sex or to avoid unprotected intercourse. (In November, Mathematica won a federal contract to conduct an eight-year, random-assignment study of the effectiveness of sex education programs, including abstinence-based ones.)
That same month, a panel of independent experts appointed by the federal Centers for Disease Control and Prevention found that comprehensive sex education programs that teach the use of contraceptives help reduce risky sexual behavior and decrease the spread of sexually transmitted diseases. The panel said there was not enough evidence to determine the effectiveness of programs that solely promote abstinence as a means of birth control and protection against disease. The task force reviewed 83 separate sex education studies—including 21 abstinence-only programs—conducted between 1980 and 2007. (“Comprehensive Sex Ed. Programs Effective, Panel Finds,” Nov. 18, 2009.)
Despite the restoration of the $250 million state grants program for abstinence education in the health-care law, other abstinence-only funding was zeroed out in the fiscal 2010 budget for the Department of Health and Human Services, including the $113 million Community-Based Abstinence Education Program. The money was essentially redirected to the Obama administration’s teenage-pregnancy-prevention initiative.
Looking ahead, Ms. Boonstra said a key question is how the administration will flesh out some of the core ideas driving grant decisions with the Personal Responsibility Education program and the separate teenage-pregnancy-prevention initiative in the fiscal 2010 budget.
“What do we mean by evidence-based? What is medically accurate and age appropriate? And when is it appropriate to shift our messages from delay [sex] to contraceptives?” she said. “They’ll have to provide some direction for programs on the ground.”
