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Federal Funding for More Comprehensive Approaches

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An Explanation of Federal Funding for
More Comprehensive Approaches to Sex Education
 
Prior to Fiscal Year 2010, the federal government did not dedicate funding for comprehensive sex education despite the fact that overwhelming evidence has shown such programs to be effective and there is broad support for these programs from medical and public health organizations as well as the majority of Americans, including parents. While federal funding had previously supported teen pregnancy prevention, HIV-prevention, or STD-prevention activities—such as those funded through the Centers for Disease Control and Prevention (CDC)—it had never dedicated funding specifically to comprehensive sex education programs. As a result, many young people have not received all of the information they needed to make healthy life choices, have healthy relationships, delay sexual activity if they chose to do so, and protect themselves from unintended pregnancy, HIV, and other STDs when they do become sexually active.   
 
In 2006, after more than a decade of decline, the nation’s teen pregnancy rate rose 3 percent.[1] This is not surprising given that, teens were receiving less information about contraception in schools and their use of contraceptive methods was declining.[2] Moreover, while they make up only one-quarter of the sexually active population, young people ages 15–24 account for roughly half of the approximately 19 million new cases of STDs each year.[3] And, those aged 13–24 account for one-sixth of new HIV infections, the largest share of any age group. In fact, it is estimated that one young person every hour is infected with HIV in the United States. [4]  
 
COMPREHENSIVE SEXUALITY EDUCATION
Comprehensive sex education aims to reduce these negative health outcomes while giving young people the information they need to make healthy life decisions. It provides age-appropriate and medically accurate information, stressing the value of abstinence and delaying sexual initiation while also preparing young people for making healthy and safe decisions when they choose to become sexually active. These programs also teach about healthy relationships and communication skills, encourage family communication about sexuality between parents and their children, and give young people the skills to make responsible decisions about sexuality, including how to avoid unwanted verbal, physical, and sexual advances and the potential impact of alcohol and drugs on decision-making. Equally important, these programs do not teach or promote religion and do not discriminate against lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth.
 
Research Supports Comprehensive Programs
There is strong evidence that more comprehensive approaches help young people both withstand the pressure to have sex too soon and learn the skills to build healthy, responsible, and mutually protective relationships when they do become sexually active.[5] Contrary to fears of some adults, sex education programs that teach about both and contraception do not increase sexual behavior or lead young people to engage in sex at an earlier age. In fact, a more comprehensive approach to sex education has been shown to help teens delay sexual initiation, reduce the frequency of sexual intercourse, and have fewer sexual partners. Thus, more comprehensive approaches to sex education have actually been proven to do a better job of helping young people remain abstinent than have abstinence-only-until-marriage programs.
 
Research has also shown that teens exposed to these programs are more likely to use condoms and other contraceptive methods when they do become sexually active.[6] This has lifelong implications as studies have shown that young people who practiced contraception consistently in their first sexual relationship were more likely to continue doing so than those who used no method or who used a method inconsistently.[7] Furthermore, the National Survey of Family Growth recently found that teen females are almost twice as likely to have a birth before reaching age 20 if they did not use a contraceptive method at their first sex.[8] 
 
In addition to this research, the CDC’s Task Force on Community Preventive Services recently reviewed Comprehensive Risk Reduction programs, group-based programs “delivered to adolescents to promote behaviors that prevent or reduce the risk of pregnancy, HIV,” and other STDs, and found sufficient evidence to both recommend their use and conclude that such interventions can have a beneficial effect on public health.[9]The recommendation is based on evidence of effectiveness in reducing a number of self-reported risk behaviors, including engagement in any sexual activity, frequency of sexual activity, number of partners, and frequency of unprotected sexual activity; as well as increasing the self-reported use of protection against pregnancy and STDs and reducing the incidence of self-reported or clinically-documented STDs.[10]
 
Experts and Parents Support Comprehensive Programs
Major medical and public health organization in the United States also raised serious ethical concerns about U.S. support for abstinence-only-until-marriage programs and came to the conclusion that such programs are neither effective nor best for young people. Instead, noting the evidence of what works, leading public health and medical professional organizations— including the American Medical Association, the American Nurses Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Public Health Association, the Institute of Medicine, and the Society of Adolescent Medicine—expressed support for a comprehensive approach to educating young people about sex and issued significant statements articulating this support.[11]  These organizations all stress the need for sexuality education that includes messages about abstinence and provides young people with information about contraception for the prevention of unintended pregnancy, HIV/AIDS, and other STDs. Moreover, they emphasize the need for federal funding to support such approaches. As the American Medical Association noted, “federal funding of comprehensive sex education programs that stress the importance of abstinence in preventing unwanted teenage pregnancy and sexually transmitted infections, and also teach about contraceptive choices and safer sex [is imperative].”[12] 
 
The vast majority of parents also want the federal government to fund programs that are medically accurate, age-appropriate, and educate youth about both abstinence and contraception. Nationwide polls show that eight out of ten voters want young people to receive a comprehensive approach to sex education that includes teaching about both abstinence and contraception.[13] Furthermore, according to the results of a 2005–2006 nationally representative survey of U.S. adults, published in the Archives of Pediatrics and Adolescent Medicine, there is far greater support for comprehensive sex education than for the abstinence-only approach, regardless of respondents’ political leanings and frequency of attendance at religious services. Overall, 82 percent of those polled supported a comprehensive approach, and 68 percent favored instruction on how to use a condom; only 36 percent supported abstinence-only programs.[14]
 
THE FEDERAL GOVERNMENT CHANGES COURSE
The election of President Barack Obama brought with it a significant shift in how the federal government addresses sex education as well as a shift in resources. Prior to his inauguration, the then President-Elect acknowledged that “[w]e must engage in honest, open dialogue and reach out to those most at risk.”[15]  He went on to say, “My administration will educate people about HIV/AIDS…and work with Congress to enact an extensive program of prevention, including access to comprehensive age-appropriate sex education for all school age children.”[16]
 
As Senator, President Obama was also a co-sponsor of the Responsible Education about Life (REAL) Act, which would have established a $50 million dedicated federal funding stream to provide federal grants to states for the purpose of conducting comprehensive sexuality education programs. The REAL Act has been introduced in every Congress since 2005 by Senator Frank Lautenberg (D-NJ) and Representative Barbara Lee (D-CA) and serves as an important tool to garner congressional and public support for comprehensive sex education.
 
The federal government finally began heeding the evidence and the urgings of the nation’s leading medical and public health organizations and dedicated funding for more comprehensive approaches to sex education. For Fiscal Year 2010, President Obama and Congress not only eliminated funding for existing abstinence-only-until-marriage programs, including the Community-Based Abstinence Education grant program and the abstinence-only funding granted pursuant to the Adolescent Family Life Act, but also provided funding for two new sex education initiatives to support both evidence-based programs and innovative approaches to prevent unintended teen pregnancy and STDs, including HIV.[17]
                                                                                                
The President’s Teen Pregnancy Prevention Initiative
In December 2009, President Barack Obama signed the Consolidated Appropriations Act of 2010, which included $114.5 million for the President’s Teen Pregnancy Prevention Initiative (TPPI). This created the first federal funding stream that could be utilized for more comprehensive approaches to sex education.
 
Of the $114.5 million appropriated through this discretionary funding stream, $110 million will go toward “competitive contracts and grants to public and private entities to fund medically accurate and age appropriate programs that reduce teen pregnancy.”[18] At least $75 million will be available for “replicating programs that have been proven effective through rigorous evaluation to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors.”[19] In addition, at least $25 million must be available for “research and demonstration grants to develop, replicate, refine, and test additional models and innovative strategies for preventing teenage pregnancy.”[20] The remaining $4.5 million is provided for program evaluation, including longitudinal evaluations, of teenage pregnancy prevention approaches. Upon passage of the funding, Congress indicated that it intended for “a wide range of evidence-based programs to be eligible for the $75 million available for evidence-based programs.”[21]  Legislators also affirmed that “programs funded under this initiative will stress the value of abstinence and provide age-appropriate information to youth that is scientifically and medically accurate.”[22]
 
These funds will fall under the purview of the newly established Office of Adolescent Health (OAH) within the Office of the Secretary of Health and Human Services (HHS), which will work in cooperation with the Administration for Children, Youth and Families (ACF), the Centers for Disease Control and Prevention (CDC), and other relevant HHS agencies on implementing the initiative.
 
The Office of Adolescent Health was created as part of the Preventive Health Amendments of 1992 (P.L. 102-531), however, Fiscal Year 2010 marks the first time that OAH has been given any funding. In 1992, OAH was charged with coordinating all activities within HHS that related to adolescent “disease prevention, health promotion, preventive health services, and health information and education,” including program design, support, and evaluation, trend monitoring, adolescent health research projects, and training for health providers who work with adolescents.[23] OAH was also designed to carry out demonstration projects to improve adolescent health. Without funding, however, the office was never established.
 
On April 1, 2010, OAH released the Funding Opportunity Announcement (FOA) for Tier 1 of the TPPI funding, $75 million to be awarded to organizations intending to replicate evidence-based programs proven effective after rigorous evaluation. Grants will be awarded in amounts ranging from $400,000 to $4 million, with the largest grants intended for programs to be “implemented in multiple sites in a targeted geographic area.”[24] Projects are expected to target individuals 19 years of age and under (at the time of initial enrollment in the program) and the FOA specifically includes pre-teens as a possible target population. The grants allow applicants to replicate programs from a list of teen pregnancy prevention or youth development programs with proven effectiveness, as determined by Mathematica Policy Research, Inc. In order to compile the list of effective programs, Mathematica reviewed over 190 program evaluations and research articles and identified 28 programs that met its strict criteria.[25] While the programs must be proven effective in “reduc[ing] teenage pregnancy, behavioral risks underlying teenage pregnancy, or other associated risk factors” in order to qualify for TPPI funding, most of the programs selected were designed as HIV- or STD-prevention programs, while several are broad youth development programs.[26] Of the 28 programs selected, 23 include sexuality education as one component.
 
On April 8, 2010, OAH released the FOA for the Tier 2 funding for innovative approaches and promising models. This funding includes $25 million in TPPI funding and $10 million from the Personal Responsibility Education Program (PREP), which was a component of health care legislation and is administered by ACF. Tier 2 funding will be awarded to programs that intend to “develop, replicate, refine, and test additional models and innovative strategies for preventing teenage pregnancy.”[27] Grant amounts will range from $400,000 to $1 million. 
 
For both Tier 1 and Tier 2 funding, a wide range of applicants are eligible, including non-profit organizations, for-profit organizations, universities, hospitals, community-based organizations, faith-based organizations, American Indian/Alaskan Native tribal governments or organizations, and state and local governments, including school districts and departments of education and health.
 
The final FOA for the President’s TPPI was released on May 10, 2010. This Tier 3 funding provides $5 million for programs that will “create and evaluate sustainable, multi-component community-wide initiatives to prevent teen pregnancy and related risk behaviors among youth in communities with the greatest rates of teen pregnancy and births.” [28] Grants, which will be administered by the CDC, in coordination to OAH, will be awarded in amounts ranging from $500,000 to $1 million for projects that will: employ one of the 28 programs approved for Tier 1 funding, connect young people with community-based health care and family planning services, and educate community members about evidence-based teen pregnancy prevention programs and community services. Grants for all tiers of funding will be awarded by September 30, 2010. 
 
While pleased with the creation of a discretionary funding stream that will allow funding for more comprehensive approaches to sex education, advocates for comprehensive sex education are disappointed that the funding focused the funding solely on teen pregnancy prevention, and did not explicitly address the equally important health issues of STDs, including HIV, or require discussion of both abstinence and contraception, as so many advocates were urging them to do. While the underlying risk factors leading to unintended pregnancy can be addressed, they believe the Obama administration and Congress missed an opportunity to provide true, comprehensive sex education that promotes healthy behaviors and relationships for all young people, including LGBTQ youth. Given that over half of young people have had sexual intercourse by the age of 18 and are at risk of both unintended pregnancy and STDs, including HIV, in order to strategically and systemically provide young people with all the information and services they need to make responsible decisions about their sexual health, the President’s TPPI must be broadened to focus on implementing efficient and effective comprehensive sexuality education programs, insofar as they address the delay of sexual initiation and the use of condoms and other forms of contraception for the prevention of unintended pregnancy, HIV, and other STDs.
 
For Fiscal Year 2010, the first year of funding for the program, the President’s Teen Pregnancy Prevention Initiative received $114.5 million. The President requested an increase of $19.2 million in his Fiscal Year 2011 budget request, for a total of $133.7 million.
 
Personal Responsibility Education Program
Following months of negotiations and partisan bickering, President Obama signed health care reform legislation, the Patient Protection and Affordable Care Act (P.L. 111-148), into law on March 23, 2010. Among its many provisions, the legislation created the Personal Responsibility Education Program (PREP), which will provide individual states with grants for comprehensive sex education programs that provide young people with complete, medically accurate, and age-appropriate sex education in order to help them reduce their risk of unintended pregnancy, HIV/AIDS, and other STDs. Programs funded by PREP would also foster development of life skills so that young people can make responsible decisions and lead safe and healthy lives. The program was offered as an amendment to the Senate health care reform legislation (Service Membership Home Ownership Tax Act of 2009) by Senator Max Baucus (D-MT). The amendment passed in the Finance Committee 14–9 with bipartisan support. 
 
The program totals $75 million per year in mandatory funding for the period 2010–2014 and will be administered by the Administration for Children, Youth and Families (ACF) in the U.S. Department of Health and Human Services (HHS). Just over $55 million of the program is dedicated to state grants. Each state will be allocated a minimum of $250,000. If a state does not submit an application for Fiscal Years 2010 or 2011, it will become ineligible to apply for funding, and the Secretary of HHS will be able to award three-year grants to community-based and faith-based organizations and local entities in that state using the allotted funds for Fiscal Years 2012–2014.
 
Under PREP, states will be required to fund programs that include a core sex education component that teaches youth about “both abstinence and contraception for the prevention of pregnancy and [STDs], including HIV/AIDS.”[29] In addition, PREP-funded programs will need to address at least three of the “adulthood preparation subjects” enumerated in the bill: healthy relationships, such as positive self-esteem and relationship dynamics, friendships, dating, romantic involvement, marriage, and family interactions; adolescent development, such as the promoting healthy attitudes and values regarding growth and development, body image, and racial and ethnic diversity; financial literacy; educational and career success, for employment preparation, job seeking, independent living, financial self-sufficiency, and workplace productivity; and, healthy life skills, such as goal-setting, decision-making, negotiation, communication and interpersonal skills, and stress management. PREP-funded programs are required to address the needs of both youth who choose not be sexually active and those that are currently sexually active by placing “substantial emphasis” on both abstinence and contraception for the prevention of pregnancy and STDs, and including information to educate youth who are sexually active “regarding responsible sexual behavior with respect to both abstinence and the use of contraception.”[30]
 
Funded programs will be required to 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, including delaying sexual activity, increasing condom or contraceptive use for sexually active youth, or reducing pregnancy among youth.”[31] Programs will also be required to be “medically accurate and complete,” provide age-appropriate information and activities, and be carried out in “the cultural context that is most appropriate for individuals in the particular population group to which they are directed.”[32]
 
Drafters of the legislation were careful to define key terms in the legislation, with the hope that programs funded under this legislation would not fall prey to the same misinformation and misuse of taxpayer dollars as federally funded abstinence-only-until-marriage programs. The legislative language defines the term “age-appropriate” as including “topics, messages, and teaching methods suitable to particular ages or age groups of children and adolescents, based on developing cognitive, emotional, and behavioral capacity typical for the age or age group.”[33] The term “medically accurate and complete” is defined as including only information that is “verified or supported by the weight of research conducted in compliance with accepted scientific methods” and is published in peer-reviewed journals, where applicable, or contains information that “leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete.”[34] Furthermore, “youth” is defined as those between the ages of 10 and 20 years old, ensuringthat those most in need of comprehensive information about sex and the prevention of unintended pregnancy, HIV, and STDs will be reached.
 
In addition to the funding for state grants, PREP also includes three other funded sections. The first is approximately $3.5 million which will be reserved for awarding grants to “Indian tribes and tribal organizations” so that the specific prevention needs of Native American and Indian communities can be addressed. There is also $10 million included to award grants for innovative youth pregnancy prevention strategies and to target services to high-risk, vulnerable, and culturally under-represented youth populations, including youth in foster care, homeless youth, youth with HIV/AIDS, pregnant women who are under 21 years of age and their partners, mothers who are under 21 years of age and their partners, and youth residing in areas with high birth rates for young parents. Because the President’s Teen Pregnancy Prevention Initiative (TPPI) also included funding for innovative approaches and promising models, ACF and OAH joined together to issue a joint Funding Opportunity Announcement (FOA) for this funding. The FOA includes $25 million from TPPI in addition to the $10 million in PREP funding.
 
Finally, approximately $6.5 million will be reserved for research, training, and technical assistance. This includes the dissemination of research and information regarding effective and promising practices; providing consultation and resources on a broad array of teen pregnancy prevention strategies, including abstinence and contraception; and developing resources and materials to support the activities of recipients of grants and other state, tribal, and community organizations working to reduce teen pregnancy. This funding will be either provided directly or through a competitive grants process and requires the Secretary of HHS to collaborate with a variety of entities that have expertise in the prevention of pregnancy and STDs, including HIV, developing healthy relationships, ensuring financial literacy, and other topics addressed in the personal responsibility education program. The Secretary of HHS will evaluate funded programs carried out by the states, and any organization or entity awarded a grant must agree to participate in a rigorous federal evaluation.
 
At the time of this writing, ACF, which is tasked with administering the program, had just released the Funding Opportunity Announcement for the state grant funds for PREP and it is, of yet, unclear how many states will apply for the funding. There is a two-part application process for PREP funds—abbreviated applications are due August 30, 2010 and completed state plans must be submitted by February 1, 2011 for Fiscal Year 2010 funding. Final approval of federal funding allocated to the states will take place by June 6, 2011 for Fiscal Year 2010 awardees.


[1]  Joyce A. Martin, et. al, “Births: Final Data for 2006,” National Vital Statistics Reports, vol. 57, number 7 (Hyattsville, MD: Centers for Disease Control and Prevention, 7 January 2009), accessed 5 March 2010, <http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf>, Table B.
[2] Ibid.
[3] Hillard Weinstock et al., “Sexually transmitted diseases among American youth: incidence and prevalence estimates,” 2000, Perspectives on Sexual and Reproductive Health, 2004, 36(1):6–10.
[4] HIV/AIDS Surveillance Report, 2006, (Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2008); 18:11.
[5] Douglas Kirby, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases, (Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2007); Kirby D, et al. “Sex and HIV Education Programs: Their Impact on Sexual Behaviors of Young People Throughout the World,” Journal of Adolescent Health, 2007 (40):206–217.
[6] M.A. Schuster, et al., “Impact of a high school condom availability program on sexual attitudes and behaviors,” Family Planning Perspectives, 1998, 30(2):67-72 & 88J; Mauldon J and K. Luker “The effects of contraceptive education on method use at first intercourse,” Family Planning Perspectives, 1996, 28:19-24 & 41.
[7] Jennifer Manlove, et al., “Contraceptive use and consistency in U.S. teenagers’ most recent sexual relationships,” Perspectives on Sexual and Reproductive Health, 2004, 36(6):265-275.
[8] JC Abma, et al, “Teenagers in the United States: Sexual Contraceptive Use, and Childbearing, National Survey of Family Growth,” National Center for Health Statistics, Vital Health Stat 23 (30), 2010.
[9] “Prevention of HIV/AIDS, other STIs and Pregnancy: Comprehensive Risk Reduction Interventions,” Community Guide Branch, Centers for Disease Control and Prevention, (9 March 2010), accessed 7 June 2010, <http://www.thecommunityguide.org/hiv/RRriskreduction.html>.
[10] Ibid.
[11] See “In Good Company: Who Supports Comprehensive Sexuality Education?” SIECUS, (October 2007), accessed 7 June 2010, <http://www.siecus.org/_data/global/images/In%20Good%20Company-SIECUS-%2010.07.pdf>.
[12]Policy Statement, H-170.968 Sexuality Education, Abstinence, and Distribution of Condoms in Schools, American Medical Association, accessed 04 January 2007,
[13] Peter D. Hart Research Associates, Inc., “Memorandum: Application of Research Findings,” (Washington, DC: Planned Parenthood Federation of America and National Women’s Law Center, 12 July 2007), accessed 8 June 2010, <http://www.nwlc.org/pdf/7-12-07interestedpartiesmemo.pdf>, 3.
[14] Amy Bleakley, et al., “Public Opinion on Sex Education in US Schools,” Archives of Pediatric & Adolescent Medicine 160, (November 2006):1154.
[15] “President-elect Obama commemorates 20th Annual World AIDS Day,” The Office of the President-Elect, 1 December 2008, accessed 2 June 2010, <http://change.gov/newsroom/entry/president_elect_obama_commemorates_20th_annual_world_aids_day/>.
[16] Ibid.
[17] Congress also allowed the third funding stream, the Title V abstinence-only-until-marriage program, to expire on June 30, 2009. Unfortunately, in March of 2010 it was resurrected as part of the Patient Protection and Affordable Care Act.  
[18] Consolidated Appropriations Act, 2010, Pub. L. No. 111–117, 123 Stat. 3253, accessed 8 June 2010, <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ117.111.pdf>. 
[19] Ibid.
[20] Ibid.
[21] U.S. Congress, Departments of Transportation and Housing and Urban Development, and Related Agencies Appropriations Act, 2010 (111 H. Rpt. 366), accessed 8 June 2010, <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_reports&docid=f:hr366.111.pdf>, 1043. 
[22] Ibid.
[23] Preventive Health Amendments of 1992, Pub. L. No. 102–515, accessed 8 June 2010.
[24] U.S. Department of Human Services, Office of Adolescent Health, “Teenage Pregnancy Prevention: Replication of Evidence-based Programs,” Funding Opportunity Announcement and Application Instructions released 1 April 2010, accessed 8 June 2010, <https://www.grantsolutions.gov/gs/servlet/document.DownloadPdfPublicServlet?document_id=142579>, 9. 
[25] See “Overview of the Teen Pregnancy Prevention Research Evidence Review,” U.S. Department of Human Services, Office of Adolescent Health, accessed 8 June 2010, <http://www.hhs.gov/ophs/oah/prevention/research/index.html>.
[26] “Teenage Pregnancy Prevention: Replication of Evidence-based Programs,” 3. 
[27] U.S. Department of Human Services, Office of Adolescent Health, “Teenage Pregnancy Prevention (TPP): Research and Demonstration Programs and Personal Responsibility Education Program (PREP),” Funding Opportunity Announcement and Application Instructions released 8 April 2010, accessed 8 June 2010, <https://www.grantsolutions.gov/gs/servlet/document.DownloadPdfPublicServlet?document_id=142823>, 4. 
[28] U.S. Department of Health and Human Services, Office of Adolescent Health and Centers for Disease Control and Prevention, “Teenage Pregnancy Prevention: Integrating Services, Programs, and Strategies through Community-wide Initiatives,” Funding Opportunity Announcement and Application Instructions released 10 May 2010, accessed 8 June 2010,<http://www.grants.gov/search/downloadAtt.do;jsessionid=qyM5MTnh5JvL1SLxTQXBG2QbNB66W7wMkwhQCpGn
[29] Patient Protection and Affordable Care Act, Pub. L. No. 111–148.                
[30] Ibid.
[31] Ibid.
[32] Ibid.
[33] Ibid. 
[34] Ibid.

 

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