Twenty-six years ago, teenage pregnancy was distressingly high: 1 in 16 U.S. girls ages 15 to 19 gave birth that year. Today, the rate has reached a historic low of 1 in 49 girls. Over the last decade alone, teen births have dropped by more than half.
But now, health experts worry that the Trump administration will reverse these improvements by promoting abstinence-only programs, cutting off funding for research to prevent teen pregnancy and appointing officials who oppose federal support for birth control.
The axing of the federal Teen Pregnancy Prevention Program, which awarded grants to 81 research institutions and organizations, was first reported by Reveal from The Center for Investigative Reporting.
The science is persuasive: Programs that rely entirely on convincing teens to abstain from sex are ineffective, waste money and are dangerous to their health, while programs that also incorporate education about contraceptives have contributed to dramatic drops in pregnancies.
“Problems arise when there are policies that allow only discussion of abstinence to the exclusion of everything else,” said Dr. Mary A. Ott, an expert in teen pregnancy prevention and associate professor of pediatrics at Indiana University. “Policies that withhold or provide inaccurate information on sex, contraception and STDs (sexually transmitted diseases) are dangerous and inherently unethical.”
A move to transform sex education
In the California farm town of Clovis, Michelle Leiva returned home from her public middle school with strange – and inaccurate – information from her sex education class in 2011.
“You can get HIV from toothbrushes and earrings, and from French kissing,” Michelle told her older sister. She showed worksheets with incorrect information on the effectiveness of condoms and other birth control. She said students were given abstinence pledge cards to sign and watched a video with the message, “If you’re not a virgin, you’re just like a dirty shoe.”
The abstinence-only program, called Teen Choices, is no longer taught at the school after a yearslong battle by Clovis parents and the American Civil Liberties Union. The superior court judge who ruled in favor of the ACLU in 2015 wrote that teenage pregnancies take such a toll on health and the economy that “access to medically, and socially appropriate sexual education, is an important public right.”
Yet a focus on abstinence remains widespread in schools, according to a 2015 report by the U.S. Centers for Disease Control and Prevention. Half of U.S. middle schools taught students abstinence as the most effective way to avoid pregnancy and sexually transmitted diseases, while 27 percent taught about the efficacy of condoms and 10 percent included information on how to use them.
Abstinence-only programs often contain false or distorted information, according to numerous reports, including one from 2004 by the House Committee on Government Reform. Such programs also don’t seem to work. Teens who took part in abstinence programs were just as likely to have sex as those who did not, and they had their first sexual encounter at about the same age, just under 15, according to a 2007 study ordered by Congress.
Schools that teach prevention topics for HIV, pregnancy and STDs as part of required instruction
|Middle schools (%)||High schools (%)|
|Abstinence as most effective method to avoid pregnancy, HIV and other STDs||49.6||76.3|
|Condom efficacy (i.e., how well condoms work and do not work)||26.7||65.7|
|How to correctly use a condom||10.4||35.3|
|Contraception efficacy (i.e., how well contraception works and does not work)||25.5||61.4|
|How to find valid information or services related to pregnancy or pregnancy testing||28.2||63.9|
|How to prevent pregnancy||38.4||72.2|
|How to obtain condoms||17||50.3|
|How to obtain contraception||17.6||52.7|
|Methods of contraception||22.6||60.8|
|Risks associated with teen pregnancy||36.8||69.4|
|Importance of using contraception consistently and correctly||23.2||58.9|
|Source: 2014 School Health Policies and Practices Study, U.S. Centers for Disease Control and Prevention|
The Society for Adolescent Health and Medicine, an association of medical professionals, recently released a position paper stressing that abstinence-only programs do not delay the start of sexual intercourse or change sexually risky behaviors. The group calls for halting federal funding of abstinence-only programs in schools and advocates for programs that offer comprehensive, medically accurate sex education backed by scientific evidence.
“In comprehensive programs, we can find the pattern that teenagers are more likely to delay (sex) and more likely to use condoms. In abstinence-only, we don’t see that pattern,” said Dr. John Santelli, a professor of population and family health and pediatrics at Columbia University.
Yet the Trump administration is taking steps toward reviving programs that teach only abstinence and defunding projects that focus on comprehensive sex education, which includes contraceptives.
In July, Health and Human Services Secretary Tom Price eliminated $213.6 million in funding for the Teen Pregnancy Prevention Program. The five-year grants for sex education research and classes, awarded by the Obama administration to provide services to 1.2 million adolescents, were cut short two years early.
The decision eliminates funding midway through the development of scientifically validated ways to help teens avoid pregnancies. Researchers were tailoring programs to teens of different regions and ethnicities and incorporating modern media and communication methods.
In addition, the House appropriations bill has eliminated funding for fiscal year 2018. Instead, the House allocated $20 million for grants that implement “exclusively education in sexual risk avoidance (meaning voluntarily refraining from nonmarital sexual activity).” The Senate Appropriations Committee has not yet acted.
In a letter to Price, a coalition of 28 large health departments, including Baltimore, Boston, Detroit, Chicago and Los Angeles County, warned that ending the funding “will negatively affect the lives of young people” and result in “fewer trained professionals and reduced community partnerships.”
Birth control opponents in powerful positions
Several top officials appointed to the U.S. Department of Health and Human Services have backgrounds of opposing federal funding for birth control or promoting abstinence-only education.
Price, a physician and former Georgia congressman, has opposed Affordable Care Act provisions requiring employers and insurers to provide free birth control services. He argued that it’s unnecessary and called it “a trampling of religious freedom and religious liberty in this country.”
Price hired Valerie Huber as a high-ranking official in the department. Huber attacked the Teen Pregnancy Prevention Program in an April opinion piece, saying it was “a colossal waste of tax dollars” and “worse than that, most teens are not helped, and too many are harmed.” In June, she was appointed to chief of staff for the yet-unnamed assistant secretary for health, and a month later, the program was eliminated.
Huber declined to be interviewed for this story. But last month, she told a radio audience in Columbus, Ohio: “We’re hopeful Congress will eliminate the Teen Pregnancy Prevention Program. If they choose not to, we have every intention to improve this program so more young people are helped as a result. The program as designed and promoted simply isn’t working.”
Huber previously was president and CEO of Ascend, formerly the National Abstinence Education Association. For 15 years, she represented the movement that pushed for removing information on teen contraception from education programs. She criticized the Obama administration’s move toward comprehensive sex education and last year lobbied for increasing federal money for abstinence-only programs.
In a 2014 paper on the history of sex education in the United States, Huber and a conservative psychology professor, Michael Firmin, linked “a growing subculture of hippies, drugs and free love” in the 1960s and ’70s with birth control pills, sex education and government funding.
Huber told the Associated Press in January that comprehensive sex education “normalizes teen sex, and puts the emphasis on reducing the risk, rather than eliminating it.”
At least four other newly appointed officials have opposed contraceptive funding in the past:
- Teresa Wagner Manning, the Health and Human Services Department’s deputy assistant secretary for population affairs, was an analyst at the antiabortion Family Research Council and a lobbyist for the National Right to Life Committee. In a 2003 radio interview, she said, “Of course, contraception doesn’t work. Its efficacy is very low.” Studies, however, show that birth control pills are 99 percent effective.
- Charmaine Yoest, former president and CEO of Americans United for Life, which lobbies for restrictions on abortion and birth control, was named assistant secretary of public affairs in the department.
- Katy Talento, now a White House aide on domestic policy, has been challenged for writing unfounded statements about health hazards of contraceptives, including that birth control pills cause miscarriage and infertility. In a 2015 opinion piece, she accused the “entire medical profession” of agreeing to “regularly break another healthy human function” by prescribing hormonal birth control, which she calls “dangerous, carcinogenic chemicals.”
- Matthew Bowman, now a top lawyer at the health department, worked for a Christian legal advocacy group, Alliance Defending Freedom. He opposed the Affordable Care Act contraceptives requirement and argued successfully before the Supreme Court that it should not apply to groups with religious and moral objections.
Vice President Mike Pence, an evangelical Christian, also opposes the Affordable Care Act’s requirement for contraceptive services. As Indiana’s governor, he chose an abstinence-until-marriage Pennsylvania company, Real Alternatives, to receive a $3.5 million grant in 2015. The company doesn’t provide medical information on birth control to teens in its public school programs.
Watching these changes under the Trump administration, “I feel like my life’s work is being unraveled,” said Claire Brindis, a University of California, San Francisco pediatrics professor.
Brindis, who has specialized in teen health for 43 years, served on a National Academy of Medicine committee that recommended free birth control and yearly reproductive health checkups in the Affordable Care Act. She said 55 million women benefited nationwide in 2016.
“With the new administration, there has been a major transformation shifting a whole movement based on intervention supported by scientific evidence to one that is going to waste precious taxpayer dollars on programs that have been shown not to be effective or realistic,” she said.
“By the time adolescents graduate from high school, half are sexually active. As a society, we cannot afford to bury our heads in the sand.”
What prevents teen pregnancies?
In the past decade, U.S. teen births have dropped rapidly, from 444,899 in 2007 to 209,480 in 2016. But evidence suggests that programs that rely only on persuading teens to abstain from sex are not playing a significant role in this decline.
“It looks like the recent declines in adolescent birth rates are entirely the result of better contraceptive use,” said Santelli, the Columbia University professor. “There hasn’t been a change in sexual activity. Kids are just being more careful.”
About 86 percent of the reduction in teen pregnancies between 1995 and 2002 was due to contraception, and 14 percent was due to delay in initiation of sex, according to Santelli and co-authors at the Guttmacher Institute in New York.
In additional research, they found that between 1995 and 2012, sexually active young women’s use of birth control increased from 66 percent to 86 percent. Much of the credit, they say, belongs to expanded insurance coverage.
CDC researchers who examined 89 programs in a 2012 study concluded that comprehensive sex education had favorable effects on abstinence, number of partners, frequency of activity and use of condoms and birth control pills. Yet the findings from the abstinence education interventions were inconclusive.
Also, in Great Britain, abstinence-only programs were ineffective in changing sexual behavior, according to university scientists who examined trials of school sex education programs.
In U.S. states with comprehensive sex education, teen birth rates have fallen. California cut its teen birth rate by discarding abstinence-only programs in favor of teaching sex education and contraception. In Texas, which largely relies on promoting abstinence, the teen birth rate was 82 percent higher than California’s in 2015.
“The states that stress abstinence-only have the highest teen pregnancy and birth rates; the more you emphasize abstinence, the higher the rates,” said Kathrin Stanger-Hall, a University of Georgia biology professor who with geneticist David Hall examined data from 48 states in 2011. “And this is true even after accounting for median household income, education level and ethnicity.”
Despite improvements, the U.S. teen birth rate remains much higher than the rates in other industrialized nations. In 2011, 34 per 1,000 U.S. teens were pregnant compared with 13 per 1,000 in Canada and 5 per 1,000 in Germany.
And the U.S. rates are at least twice as high for Latino and black teens as they are for white teens, according to the National Health Statistics Reports. States with higher proportions of white teens tend to be wealthier and emphasize abstinence less, while poorer, more diverse states tend to emphasize abstinence, according to University of Georgia researchers.
“We’re turning the clock back. We have to do better,” Brindis said. “The leadership in the administration says you’re giving teens a double message, that if you teach them about sex, they’ll do it. My argument is that young people can handle receiving a complex message.
“To my mind, knowledge is not dangerous. By not giving knowledge, we can place them at a supreme disadvantage.”
Correction on Nov 7, 2017:
Correction: An earlier version of this story misstated Michelle Leiva's grade level for her sex education class. She was in middle school at the time.