Sex Education and Legislation: SIECUS Community Action Kit Bruce Trigg, MD New Mexico Department of Health CityMatch September 21, 2008

Former Surgeon General Richard Carmona said Bush administration political appointees censored his speeches and kept him from speaking out publicly about certain issues, including the science of embryonic stem cell research, contraceptives and including the science of embryonic stem cell research, contraceptives and his misgivings about the administration's embrace of "abstinence-only" sex education. Reuters 7/10/07

“Abstinence from sexual intercourse represents a healthy choice for teenagers, as teenagers face considerable risk to their reproductive health from unintended pregnancies and STI’s including HIV.” - Society for Adolescent Medicine

Critiques of Abstinence-Only Programs Scientific accuracy Withholding of life-saving information Failure to delay initiation of sexual intercourse Promotion of gender stereotypes Insensitivity and unresponsiveness to sexually active and nonheterosexual youths Harm to comprehensive sexuality education and other public health programs Damage to US foreign aid programs Inconsistency with ethical imperatives of medicine and public health John S. Santelli, American Journal of Public Health Oct. 2008, vol 98, No. 10

Since 1982 more than $1.5 billion has been spent on abstinence- only-until-marriage programs in the U.S.

President’s FY2009 Budget Requests Increases CBAE by $27.7 million Total Abstinence funding - $204 million Level funding for Title X Family Planning CDC budget has cuts for HIV/AIDS and STD prevention

8-Point Definition of Abstinence-Only- Education Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity Teaches abstinence from sexual activity outside of marriage as the expected standard for all school-age children Teaches abstinence from sexual activity outside of marriage as the expected standard for all school-age children Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted infections, and other associated health problems Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted infections, and other associated health problems Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity Section 510(b) of Title V of the Social Security Act, P.L

8-Point Definition of Abstinence Only Education 8-Point Definition of Abstinence Only Education Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical side effects Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical side effects Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances Teaches the importance of attaining self-sufficiency before engaging in sexual activity Teaches the importance of attaining self-sufficiency before engaging in sexual activity Section 510(b) of Title V of the Social Security Act, P.L

FY 2006 CBAE Funding Requirements “Does not promote or encourage the use or combining of any contraceptives in order to make sex ‘safer.’ ” “Does not promote or encourage the use or combining of any contraceptives in order to make sex ‘safer.’ ”

“Poking Holes” in Condoms Federal guidelines for Abstinence- Only programs prohibits discussion of condoms except in reference to their failure rates

Ever Had Sexual Intercourse, 2005 YRBS Total Male Female 9 th 10 th 11 th 12 th Grade By The End of High School, the Majority of Students Will Have Had Sexual Intercourse

Percentage of Women Who Have Sexual Intercourse Before Age 20 Sources: Darroch et al., 2001; Graaf et al., 2005; Mosher et al., 2005

Teenage Pregnancy Industrialized Countries

European Teens Have Lower Rates of Unintended Pregnancy Initiate sex at comparable ages Sensible sex ed: teens receive clear and unambiguous prevention messages Social expectation that childbearing will be delayed until adulthood Much more likely to use contraceptives

Source: U.S. Census Bureau, Annual Social and Economic Supplement: 2003 Current Population Survey, Current Population Reports, Series P20-553, "America's Families and Living Arrangements: 2003" and earlier reports

Premarital Sex is Nearly Universal in US – and has been for decades “Trends in Premarital Sex in the US, ” Lawrence B. Finer. Jan/Feb, 2007 Public Health Reports based on National Survey of Family Growth “Trends in Premarital Sex in the US, ” Lawrence B. Finer. Jan/Feb, 2007 Public Health Reports based on National Survey of Family Growth By age 44, 99% of respondents had sex, and 95% had premarital sex By age 44, 99% of respondents had sex, and 95% had premarital sex Even among those who abstained until age 20 or older, 81% had premarital sex by age 44 Even among those who abstained until age 20 or older, 81% had premarital sex by age 44 Among women born in 1940s- nearly 90% had sex before marriage Among women born in 1940s- nearly 90% had sex before marriage

The Content of Federally Funded Abstinence-Only Education Programs Prepared for Representative Henry A. Waxman

The Content of Federally Funded Abstinence-Only Programs “Waxman Report” 80% of curricula contain false, misleading or distorted information including: False information about effectiveness of contraception False information about the risks of abortion Blur religion and science Treat gender stereotypes as scientific fact Contain other scientific errors

False Information About Contraception “Is birth control” the answer? Consider this fact: Most unintended pregnancies (53%) occurred among women who were using birth control. Game Plan, page 27.

They ignored the denominators! 40 million women use contraception & only 3 million do not   3 million unintended pregnancies in US in (NCHS) Half were among women using contraception 1.5 million / 40 million = 4% The other half were among women not using contraception million / 3 million = 50% Correct conclusion: women who didn’t use contraception were 12 times more likely to get pregnant than those who did!

Government-Funded Evaluation Reports Mathematica Policy Inc. was authorized by Congress in 1997 to conduct an evaluation of abstinence-only education programs First Report Released in 2005 An implementation and process analysis Second Report Released in April 2006 Rigorous, experimentally based impact evaluation to estimate effects of program

2007 Final Evaluation Report Evaluated the behavioral impact of 4 abstinence-only programs Evaluated the behavioral impact of 4 abstinence-only programs My Choice, My Future! in Powhatan County, Virginia; My Choice, My Future! in Powhatan County, Virginia; ReCapturing the Vision in Miami, Florida; ReCapturing the Vision in Miami, Florida; Teens in Control in Clarksdale, Mississippi; and Teens in Control in Clarksdale, Mississippi; and Families United to Prevent Teen Pregnancy in Milwaukee, Wisconsin Families United to Prevent Teen Pregnancy in Milwaukee, Wisconsin

Methodology and Results Followed 2,000 children from elementary or middle school into high school randomized to either a program or control group Followed 2,000 children from elementary or middle school into high school randomized to either a program or control group Self-reported results indicated that programs: Self-reported results indicated that programs: Had no impact on sexual initiation rates, age at first intercourse (14.9 years for both groups) or numbers of partners Had no impact on sexual initiation rates, age at first intercourse (14.9 years for both groups) or numbers of partners Had no impact on pregnancies, births or STDs Had no impact on pregnancies, births or STDs Had no impact on use of condoms and birth control Had no impact on use of condoms and birth control

Estimated Impacts on Report Number of Partners

Estimated Impacts on Birth Control Use, Last 12 months

Estimated Impacts of Unprotected Sex and First Intercourse Trenholm C, Devaney B, Forston K, Quay L, Wheeler J, Clark M. “Impacts of Four Title V, Section 510 Abstinence Education Programs,” Mathematica Research Group, 2007.“Impacts of Four Title V, Section 510 Abstinence Education Programs,”

Estimated Impacts on Unprotected Sex, Last 12 months

“Many study youth reported being unsure about whether condoms prevent STDs.” “Overall, program group youth were less likely than control group youth to perceive condoms as effective at preventing STDs.” - Mathematica Study

Public Health Goals Prevention of STDs Prevention of HIV infections Prevention of unintended pregnancies

Sexually transmitted diseases Recent CDC study (3/08) showed that one in four adolescent girls, ages 15 to 19, have one or more STIs chlamydia, herpes, HPV, or trichomoniasis All of these STDs may be asymptomatic – especially in females

Teen birth rate rises for first time in 14 years Between 2005 and 2006, the birth rate for teenagers years rose 3 percent, 40.5 to 41.9 live births per 1,000 females years of age 5% increase for non-Hispanic black teens 2% increase for Hispanic teens 3% increase for non-Hispanic white teens 4% increase for AI/AN teens “Births: Preliminary Data for 2006” NVSR Vol. 56, No. 7. (PHS)

CDC estimates 56,300 new HIV infections in % were in African-Americans

HIV Vaccine Not On Horizon No further towards developing a vaccine after more than 20 years of research Professor David Baltimore, president of the American Association for the Advancement of Science (AAAS), said there was little hope among scientists.

Position Statement on Condoms and HIV Prevention Issued by WHO, UNAIDS, and UNFPA July 2004 Issued by WHO, UNAIDS, and UNFPA July 2004 “The male latex condom is the single most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections.” “The male latex condom is the single most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections.”

Adolescent Condom Use at Last Intercourse, 2005 YRBS

Comprehensive Sex Education Programs Work Douglas Kirby, ETR Associates 2006 review of 77 well-designed studies comprehensive sexuality education programs 2006 review of 77 well-designed studies comprehensive sexuality education programs Delay in initiation – 22 of 49 = 45% Delay in initiation – 22 of 49 = 45% Reduce the number of partners: 20/32 = 63% Reduce the number of partners: 20/32 = 63% Improve condom use: 26/51 = 51% Improve condom use: 26/51 = 51% Review of 6 well-designed studies of abstinence-only curricula Review of 6 well-designed studies of abstinence-only curricula Delay in initiation – 0 of 3 = 0% Delay in initiation – 0 of 3 = 0%

US Adults Favor A Balanced Approach to Sex Education 82% support programs teaching both abstinence and other methods of preventing pregnancy and STDs 82% support programs teaching both abstinence and other methods of preventing pregnancy and STDs 68% support for teaching proper condom use 68% support for teaching proper condom use Abstinence-only had lowest support (36%), highest opposition (about 50%) among 3 options Abstinence-only had lowest support (36%), highest opposition (about 50%) among 3 options Majority support for abstinence-plus and condom instruction among conservatives, liberals, and moderates - although level of support varied significantly Majority support for abstinence-plus and condom instruction among conservatives, liberals, and moderates - although level of support varied significantly Amy Bleakley, et al. Public Opinion on Sex Education in US Schools. Arch Pediatr Adolesc Med. 2006;160:

National Organizations that Support Comprehensive Sexuality Education American Academy of Pediatrics American Academy of Family Practice American Association of School Administrators American College of Obstetricians and Gynecologists American Medical Association American Medical Women's Association American Nurses Association American Psychiatric Association American Psychological Association American Public Health Association American School Health Association National Medical Association National Education Association Society for Adolescent Medicine

Religious Institute on Sexual Morality, Justice, and Healing AN OPEN LETTER TO RELIGIOUS LEADERS ABOUT SEX EDUCATION “As religious leaders, we call on policy makers, school officials, and educators to provide comprehensive sexuality education that honors truth telling and the diversity of religious and moral values represented in the community.”

25 states currently, or plan to, reject federal abstinence funding “The Bush administration’s Abstinence-Only program is an example of a failed national health care policy directive.” Richard Davies New York Health Dept. Commissioner

What can be done? Advocate for evidence-based Comprehensive Sexuality Education in schools Support funding earmarked for CSE Support efforts for medical accuracy in sex education Provide expertise to school boards and State Education Departments in reviewing sex ed curricula Provide data and discuss concerns with public health and political leaders

Nomoremoney.org Members include: American Public Health Association NASTAD, ASHA, NCSD

There is no credible scientific evidence in support of Abstinence-Only sex education policies and a growing body of strong evidence that these policies are ineffective and potentially harmful.

Rather than being driven by science and public health, these policies reflect political agendas in Congress and the moral and ideological opinions a minority of the American public.

The erosion of sexuality education and undermining of other important public health efforts, nationally and internationally, also raises serious human rights issues.

Efforts continue to convince Congress to eliminate or to decrease funding for Abstinence-Only programs, or to loosen the restrictions on the use of the monies. This will likely be an important issue for the new Congress in 2009.

“Our lives begin to end the day we become silent about things that matter.” Martin Luther King