1. What have we learned from 25 years of federally funded abstinence-only-until- marriage programs? Bruce Trigg, MD New Mexico Department of Health National STD Conference March 11, 2008

3. 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

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

6. 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

7. 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. 104-193

8. 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. 104-193

9. Tightening the Rules Adolescent Family Life Act programs are required to comply with ALL Section 510 requirements Adolescent Family Life Act programs are required to comply with ALL Section 510 requirements CBAE (or SPRANS) program more rigid: to create “pure” or “authentic” abstinence-only programs CBAE (or SPRANS) program more rigid: to create “pure” or “authentic” abstinence-only programs Must teach all 8 components of the federal definition Must teach all 8 components of the federal definition Must target 12-18 year olds Must target 12-18 year olds Cannot provide information on contraception or safer- sex practices, even with non-federal funds Cannot provide information on contraception or safer- sex practices, even with non-federal funds

10. FY 2006 CBAE Funding Requirements Assert: “Teen sexual abstinence improves preparation for stable marriage.” Require: “Teaches the potential psychological effects (e.g., depression and suicide) associated with adolescent sexual activity.” Must teach: “that teens who are sexually active are also more likely to engage in other risk behaviors such as: smoking, alcohol abuse, drug abuse, violence, and crime.”

11. 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.’ ”

12. 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

13. 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

14. Premarital Sex is Nearly Universal in US – and has been for decades “Trends in Premarital Sex in the US, 1954- 2003.” Lawrence B. Finer. Jan/Feb, 2007 Public Health Reports based on National Survey of Family Growth “Trends in Premarital Sex in the US, 1954- 2003.” 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

15. Virginity Pledges

16. Virginity Pledge Data Pledgers: Delayed onset of intercourse for up to 18 months (not until marriage) 1/3 less likely to use contraception at eventual intercourse – no significant impact on pregnancy rates Had same STI rates as non-pledgers 88% had intercourse before marriage Source: Bearman P, Bruckner H. Promising the Future: Virginity Pledges and the Transition to First Intercourse. American Journal of Sociology 2001;106(4), 859-912.

17. Follow-Up Virginity Pledge Data Pledgers vs. Non-pledgers: Condom Use Pledgers vs. Non-pledgers: Condom Use Less likely to use condoms at most recent intercourse Less likely to use condoms at most recent intercourse Pledgers vs. Non-pledgers: STI Rates Pledgers vs. Non-pledgers: STI Rates No difference but were less aware of STI status No difference but were less aware of STI status Pledgers vs. Non-pledgers: Oral and Anal Sex Pledgers vs. Non-pledgers: Oral and Anal Sex More likely to have oral/anal sex but not vaginal sex More likely to have oral/anal sex but not vaginal sex Bruckner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health 2005;36:271– 8.

18. 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

19. 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

20. 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 Same rates of condom and birth control use as control group Same rates of condom and birth control use as control group

21. Estimated Impacts on Report Number of Partners

22. Estimated Impacts on Birth Control Use, Last 12 months

23. 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,”

24. Estimated Impacts on Unprotected Sex, Last 12 months

25. “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.”

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

27. Adolescents and STIs/HIV 18.9 million new cases of STIs per year 18.9 million new cases of STIs per year Half of these in young adults under 25 years Half of these in young adults under 25 years Half of 40,000 new HIV infections, under 25 Half of 40,000 new HIV infections, under 25

28. Teen birth rate rises for first time in 14 years Between 2005 and 2006, the birth rate for teenagers 15-19 years rose 3 percent, 40.5 to 41.9 live births per 1,000 females 15- 19 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) 2008- 1120

30. 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.

31. 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.”

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

33. Adolescent Condom Use at Last Intercourse, 2005 YRBS

35. Medical Institute For Sexual Health Austin, TX

36. MISH on Condom Effectiveness If you are worried about STIs, condoms just reduce your risk; they don't eliminate it. And about 1 of every 5 teen couples using condoms for birth control get pregnant within a year.[1] So even if you use a condom every time you have sex, you're still at risk for STIs and pregnancy. http://www.medinstitute.org/content.php?nam e=FactsAboutCondoms

37. In 2004 MISH received a $250,000 “earmark” from the CDC to develop a curriculum for medical students

38. General Accountability Office (GAO) Gary Kepplinger General Counsel of GAO sends letter to Michael O. Leavitt, Secretary of Health and Human Services informing him that the Public Health Service Act requires that medically accurate information on condom effectiveness be used in schools. Gary Kepplinger General Counsel of GAO sends letter to Michael O. Leavitt, Secretary of Health and Human Services informing him that the Public Health Service Act requires that medically accurate information on condom effectiveness be used in schools. October 18, 2006 October 18, 2006

39. Beyond the “ABCs”: Kirby’s Nine behaviors to prevent STDs/HIV 1. Delay/abstain from sex 2. Decrease frequency of sex 3. Reduce number of sexual partners 4. Avoid concurrent partners or partners with concurrent partners 5. Increase time gap between sexual partners 6. Use a condom correctly and consistently 7. Be tested and treated for STDs 8. Be vaccinated 9. Be circumcised

40. 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%

41. 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;160:1151-1156

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

43. 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.”

44. 17 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

46. PEPFAR Congress mandates at least 1/3 of US funds for AIDS prevention be devoted to sexual abstinence and fidelity programs. Congress mandates at least 1/3 of US funds for AIDS prevention be devoted to sexual abstinence and fidelity programs.

47. Global Consequences of U.S. Abstinence Policies o GAO report based on interviews with US officials in 15 countries concluded: “…is hampering their ability to implement key elements of the widely accepted model of HIV/AIDS prevention – the ABC approach.” “…is hampering their ability to implement key elements of the widely accepted model of HIV/AIDS prevention – the ABC approach.” “U.S. Focus on Abstinence Weakens AIDS Fight” - New York Times 4/5/06

49. Compromise on PEPAR Reauthorization 2/27/08 House Committee on Foreign Affairs votes to renew PEPFAR Authorized $50 billion over next 5 years Compromise replaces requirement that 1/3 of all prevention funding go to abstinence education with requirement for “evidence-based” prevention strategies Requires report to Congress if “A and B” falls below 50% of prevention spending in a country

50. Why STD Control Workers Should Be Concerned Inaccurate information on STDs Discourage use of condoms Impact STD screening Abstinence programs compete with STD programs for limited funding Stigmatize sexually active teens and those with STDs Marginalize children from single parent families, gays and lesbians May exacerbate health disparities Negative impact on US and international public health

51. What can be done? Advocate for evidence-based Comprehensive Sexuality Education in schools Support funding earmarked for CSE 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

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