Commentary Sexual Health

A Collision of Culture and Nature: How Our Fear of Teen Sexuality Leaves Teens More Vulnerable

M. Joycelyn Elders

Efforts in the United States to address adolescent sex have been directed toward preventing teenage sex as opposed to preventing its adverse consequences.  These efforts probably have been unsuccessful in stemming sexual activity because teenagers have a hormonal imperative to explore their sexuality. 

Dr. Elders is well-known for and has been widely honored for her work. Just last week, however, she received another honor: The Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, established the Joycelyn Elders Chair in Sexual Health Education. The Chair is the first of its kind in the nation to focus on sexuality education. We congratulate Dr. Elders and the University of Minnesota.

Efforts in the United States (unlike those in other developed countries) to address adolescent sex have been directed toward preventing teenage sex as opposed to understanding helping teens prevent adverse consequences of sexual activity.  These efforts have been largely unsuccessful in stemming sexual activity because teenagers have a hormonal imperative to explore their sexuality. They do not “catch” sexuality from their friends, music, dance, or health education; rather, teens have a perfectly natural biological drive that says, WOW! to them soon after the advent of puberty.  Always has been and always will be this way. It cannot be avoided or evaded, because it is basic human biology.  

When children experience puberty, natural intensification of sexual feelings soon follows. While many adults cringe at simply seeing the words “adolescent” and “sexuality” paired together, the adolescent hormonal imperative proceeds with its relentless takeover of youthful thinking—and, often, action.

We need to make sure that when that moment comes, they know how to be safe.

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Head-On Collision of Culture and Nature

Our children too often become casualties of the head-on collision of culture and nature because we are afraid to give them information about their bodies and sex.  Meanwhile, they are learning inappropriate behavior from other adolescents and the media.  In 1994, for World AIDS Day, I spoke at the United Nations and suggested the ABCD of AIDs prevention should include Abstinence, Be faithful, latex Condoms, and Do other things such as masturbation. Masturbation is natural, does not cause hair to grow on your hands, cause you to go blind, or to go crazy, and you know that you are having sex with someone that you love.  Yet we refuse to teach teens about masturbation, confusing innocence and ignorance, and putting our children’s health at risk.

Nearly half of all 15- to 18-year-olds have engaged in sexual activity before finishing high school, and more than 70 percent are sexually active by the age of 20.  The consequences of adolescents having unprotected sex are devastating.

In the United States, we have difficulty accepting the fact that adolescents and young adults engage in sex before marriage, despite our high rates of adolescent pregnancy and sexually transmitted infection (STI).1 The median age of onset of puberty is 11.6 years, the mean age of initiation of sexual intercourse is 17 years, and the mean age of first marriage is 26 years. 2, 3

A major nationally representative survey found that 95 percent of adult respondents, aged 18–44 years, reported that they had had sex before marriage.  Eighty-one percent of those who abstained from sex until age 20 or older also had premarital sex.4  Abstinence-until-marriage is neither the cultural norm nor a functioning value.  Yet, we seem to expect today’s adolescents to resist their natural sexuality by abstaining from sex until marriage—something that the vast majority of Americans have not done since at least the 1940s and perhaps have never done.4

If more Americans understood the developmental process that occurs during puberty, then adolescent behavior would not be such an anathema.  As a country, we need to recognize fully the costly consequences of unprotected adolescent sex that occur because of limited access to contraceptive services, supplies, and sex education. 

Adolescents are at risk for unintended pregnancies and sexually-transmitted infections (STIs).  Consider the US statistics:

  • Nationwide, 46.8 percent of high school students have had sexual intercourse; this figure has remained relatively constant for at least a decade.1
  • Each year in the United States, almost 850,000 teens become pregnant,
  • About 9.1 million STIs (5,000 of which are HIV) are experienced by young people under age 25, and
  • More than 1 billion acts of unprotected sex among single adults take place.
  • All this devastation occurs while Americans aged 15–34 use condoms in only about 25 percent of sexual encounters. 5–8

On an individual level, preventable health-risk behaviors among sexually-active adolescents can expose them to lifelong consequences about which they are ill-informed. On a national level, the result of withheld information and distribution of misinformation is America’s sexual dysfunction (which, again, can be measured by rates of unintended pregnancy and STIs that are higher than those of virtually every other Western country). This dysfunction threatens public health, disrupts family life, and generally imposes a high societal cost through poverty—and the misery that poverty invariably brings.

We can do better.  We have the most advanced health care in the world, low-cost ways to prevent unintended pregnancy and STIs, and a wealth of information based on sound public health science that can help young people make responsible life decisions regarding their sexual health.  What is missing?  Two things:  universal access to health care and the presence and nature of sexuality education in schools.  If we are serious about protecting the health and well being of adolescents, we must decide whether we want to continue to fight natural human biology by attempting to eliminate sex before marriage or to encourage safe sex.

A Different Approach

The best contraceptive in the world is a good education.  It is important to have a population that is well-educated and informed about sex, sexuality, and sexual health concerns, through age-appropriate, scientifically based universal sexual education across the lifespan.

Comprehensive sexuality education for adolescents does not increase promiscuity, hasten sexual initiation, or increase rates of sexual activity.  It does reduce the number of partners and increases the likelihood of contraceptive use at initiation of sex. 5,13

These facts are borne out by the experience of European countries that send the message of “safe sex or no sex” (instead of just “no sex”). Countries like Denmark, the Netherlands and Sweden do not experience the same devastation of their adolescent populations as does the United States.  Teen pregnancy rates are much higher in the United States than in many other developed countries—twice as high as in England and Wales or Canada and eight times as high as in the Netherlands or Japan. 9

In 1999, the Guttmacher Institute published the first international comparison of adolescent sexuality documenting major differences between the United States and Western Europe. The study showed that, although American and European teenagers initiated sex at about the same age, European teens had longer relationships and fewer sexual partners, were much more likely to use contraceptives, and had startlingly lower rates of pregnancy, births, abortions, and STIs.  Societal responses to the reality of adolescent sexuality differed as well.  In Europe, teenagers received comprehensive sex education and had ready access to confidential contraceptive services, even as they were given the clear message that they should not get pregnant before they were ready to become parents.10

This study helped to refocus the debate in the United States, spurred the development of teen pregnancy-prevention programs across the country, and prompted the enactment of new laws in 21 states ensuring access for minors to confidential contraceptive services and the growth of comprehensive school-based sex-education programs.11

An overwhelming majority of U.S. parents, teachers, and adults agree that children should be given comprehensive, age-appropriate health-care information–including information on sexuality and contraceptives–to protect their health and well-being.  It appears that the most widely-held American value and moral imperative is that our valued and vulnerable children should be healthy and grow up sexually healthy.

What Young People Should Learn and Know

Sex education should be taught in our schools from kindergarten through high school, because that is where most children are educated in the United States. School-based sex-education course material should be age appropriate.

In kindergarten, children could learn that their private parts are private with few exceptions (the doctor or nurse while a parent is present).  No one has the right to touch them even if they are children.  A child needs to know that it is all right to touch himself or herself in private, because private parts are not dirty or forbidden to oneself. 

Beginning in the first grade, children can be taught the parts of their bodies and their functions.  Children could be taught about what they can expect as they grow and develop.  Perhaps most of all, children need to know that it is normal for their bodies to change and what to expect next.

Before children enter puberty, (usually between eight and 12 years of age) they need to know:

  • that they are normal
  • what menses is and what to expect
  • the nature of feelings their hormones will cause
  • the difference between sexual feelings and love
  • that they will require self-esteem and information to make good choices
  • that it is normal to masturbate or touch oneself in private

Just teaching them to say no is not enough information to give to our children to keep them safe.  Teens need to realize the plethora of sexual choices they will be making as they progress through the teen years.  They need to recognize that having sex is a big choice to be considered seriously and slowly rather than quickly in the backseat of a car under the influence of raging hormones.  Sometimes teens may not recognize their actions as choices unless these are pointed out and enumerated. 

If a teen decides to engage in sex with a loving partner, s/he will want to make a visit to the doctor or nurse to secure information about contraceptives suitable for his/her situation and perhaps a prescription.  If the prospective partner has had sex previously, s/he will want to be tested for possible sexually transmitted infections so as not to infect the new partner.  Teens need to know that they can get contraceptives if they think they might need them.  They need to know all of the contraceptive options, how to use them, their effectiveness, and what can happen when having unprotected sex even one time. So, as children, adolescents, and teens mature, the education changes and becomes more detailed to include all aspects of sexual contact, anal, oral, vaginal, homosexual encounters, and always self-esteem evaluations.

Teens need to know the consequences of unprotected sex in terms of disease, unintended pregnancy, and exploitation.  At the same time, they need to know how to go about having a healthy sexual relationship with mutual respect and love.  All teens need to know that healthy sexual activity is mutually respectful activity.  Sex is for more than procreation once or twice in life; sex is also for a lifetime of pleasure.  They need to know the specifics of how to derive pleasure from sexual relationships while maintaining self-esteem for both persons involved and always respect for oneself and one’s partner. Teens need to know how to achieve an orgasm.

Strategies to Create Sexually Healthier Communities
Our valued adolescents are dependent on adults to help them across the often-challenging developmental bridge to adulthood.  We want them to be healthy and happy persons who will develop into well-educated adults, able to define and direct their futures, be motivated, and have hope.14

To attain this goal, we must have strategies to create sexually healthier communities through effective public policy.  We must have age-appropriate, science-based comprehensive health education in schools from kindergarten to twelfth grades and parent-education programs to teach partner-shared sexual responsibility.

Before patients reach puberty, health-care providers should give counseling concerning the changes the youth can anticipate.  They should encourage abstinence while providing age-appropriate counseling to reduce risky sexual behaviors.  Moreover, health care providers must develop policies for all office procedures to ensure privacy and confidentiality of adolescents.

Adolescents must have access to health care to keep themselves healthy.  They must have access to contraceptives, be knowledgeable about their availability and use, and understand their mechanism of action as well as their side effects.  We have both a moral and ethical responsibility to protect all adolescents in our community.

Just recently, the Supreme Court made a ruling that children 18 years of age and younger had a right to purchase or rent violent video games.  I wonder if the same court would rule that children under 18 also have the right to view, rent or purchase sexually explicit videos.  Does our U.S. culture view violence as more acceptable than even respectful sexual activity?

A sexually healthy society must be our new goal for the twenty-first century.  To get there, we must have sex education for our valued and vulnerable children, beginning in kindergarten and continuing through high school.


1.  Eaton, D.K. et al. Youth risk behavior surveillance—United States, 2005 MMWR Surveill Summ 55, 1–108 (2006).

2.  Irwin, H.E. Jr., Shafer, M.A. & Moscichi, A.B. (assoc. eds.). The adolescent patient. In Rudolph’s Pediatrics 21st edn. (eds. Rudolph, C.D., Rudolph, A.M., Lister, G. & Siegel, N.J.) 223–275 (McGraw-Hill, New York, 2003).

3.  Alan Guttmacher Institute. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men (AGI, New York, 2002).

4. Finer, L. Trends in premarital sex in the United States, 1954–2003. Public Health Rep. 122, 73–78 (2007).

5.  American Academy of Pediatrics Committee on Adolescence; Blythe, M.J. & Diaz, A. Contraception and adolescents. Pediatrics 120, 1135–1148 (2007).

6. Weinstock, H., Berman, S. & Cates, W. Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect. Sex. Reprod. Health 36, 6–10 (2004).

7. CDC. HIV/AIDS surveillance report, 2006. 18 (US Department of Health and Human Services, Atlanta, 2008).

8. Holmes, K.K. & Levine, W.M. Effectiveness of condoms in preventing sexually transmitted infections. Bull. World Health Organ. 82, 454–426 (2004).

9. Darroch, J.E. et al. Teenage sexual and reproductive behavior in developed countries: can more progress be made? Occasional Report, No. 3 (Alan Guttmacher Institute, New York, 2001).

10. Berne, L. & Huberman, B. European approaches to adolescent sexual behavior & responsibility: Executive Summary and Call to Action (Advocates for Youth, Washington, DC, 1999).

11. Santelli, J., Sandfort, T. & Orr, M. Transnational comparisons of adolescent contraceptive use: what can we learn from these comparisons? Arch. Pediatr. Adolesc. Med. 162, 92–94 (2008).

12. Haffner, D.W. & Wagoner, J. Vast majority of Americans support sexuality education, SIECUS Report 27, 22–23 (August/September 1999).

13. Santelli, J., Ott, M.A., Lyon, M., Rogers, J., Summers, D. & Schleifer, R. Abstinence and abstinence-only education: a review of U.S. policies and programs. J. Adolesc. Health 38, 72–81 (2006).

14. Elders, M.J. Clinical Pharmacology & Therapeutics (2008); 84, 6, 741–745 doi:10.1038/clpt.2008.178

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”


“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.