Commentary Sexual Health

We’ve Been Here Before: Congress Quietly Increases Funding for Abstinence-Only Programs

Nicole Cushman, Debra Hauser & Monica Rodriguez

The bipartisan $200 billion Medicare “doc fix” and health program funding bill includes a two-year extension of the Title V Sec. 510 program, which funds the implementation of ineffective and stigmatizing abstinence-only-until-marriage programs.

Last week, Congress overwhelmingly passed a bipartisan $200 billion Medicare “doc fix” and health program funding bill. The bill did not pass without its fair share of controversy. But one of its provisions seemed to have escaped public scrutiny: a two-year extension of the Title V Sec. 510 program that funds the implementation of ineffective and stigmatizing abstinence-only-until-marriage (AOUM) programs. The bill also increases funding toward the grants by $25 million annually. What is more, a new provision in the bill requires unused Title V AOUM funds to be made available to states implementing programs that adhere to strict, eight-point—and harmful—definitions of abstinence education; such funds previously would have been returned to the general treasury.

Encouragingly, the bill also included a two-year extension of the Personal Responsibility Education Program (PREP), which funds adolescent sexual health initiatives across the country that include information on a broad range of topics, such as abstinence, birth control, HIV, other STIs, healthy relationships, and life skills. The creation of PREP in 2010 represented a positive step in a new direction for the federal government, after years of funding failed abstinence education programs. However, the extension of PREP does not negate the damage done by continued investments—and now an expansion—of ineffective and damaging AOUM programs. In fact, given the existing funding and the fact that the Title V AOUM program requires states to match federal dollars spent this move could translate to more than $130 million per year in public money wasted on AOUM programs.

Decades of research demonstrate that AOUM programs fail to achieve their stated goal of promoting abstinence among young people. What is more, with no requirement for AOUM programs to provide information on condoms and contraception, these initiatives withhold life-saving information about sexuality-related topics—including HIV—thus failing to equip young people with the information and skills they need to ensure healthy decision making throughout their lives. By contrast, more comprehensive approaches to sex ed that include information about condoms and contraception in addition to abstinence have a proven track record of helping young people to delay having sex, and increasing use of condoms and contraception among those who do become sexually active.

Make no mistake: This legislation continues decades of efforts to divert limited federal resources into programs that have been proven to be ineffective and to denigrate, and ostracize youth who are already sexually active; who are engaged in same-sex relationships; and who are survivors of sexual abuse or assault. Last week’s vote leaves those of us who have advocated for years for comprehensive sex education with a sense of déjà vu. Indeed, we have been making many of the same arguments about the unethical nature of AOUM programs for years.

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However, what sets today’s debates apart from those of the ‘80s, ‘90s and ‘00s is something more subtle and sinister than the blatant imposition of moralizing, stigmatizing views on our young people. Recently, proponents of AOUM programs have quietly appropriated sexual health terms such as “medically accurate,” “age-appropriate,” “evidence-based,” and “personal responsibility.” They have repackaged language of old bills and talking points using more scientific terminology. This co-optation of language is particularly egregious and shocking, given the long history of empirical evidence that has proven AOUM programs to be ineffective, from the government’s own meta-analysis in 2007 to the more recent findings of the Community Preventive Services Task Force and additional studies.

Since 1982, more than $1.7 billion in federal money has been spent on programs that are damaging to young people and fail to provide opportunities to learn vital information and skills that they need. In the past, a collective outcry from young people, parents, educators, and medical and public health professionals has been successful in reducing spending on AOUM programs. Now, in 2015, Congress has passed the first-ever increase in the 18-year-old Title V program. We’ve been here before, and we won’t stand for the perpetuation of these damaging programs. Our young people deserve better.

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.

Commentary Sexual Health

Don’t Forget the Boys: Pregnancy and STI Prevention Efforts Must Include Young Men Too

Martha Kempner

Though boys and young men are often an afterthought in discussions about reproductive and sexual health, two recent studies make the case that they are in need of such knowledge and that it may predict when and how they will parent.

It’s easy to understand why so many programs and resources to prevent teen pregnancy and sexually transmitted infections (STIs) focus on cisgender young women: They are the ones who tend to get pregnant.

But we cannot forget that young boys and men also feel the consequences of early parenthood or an STI.

I was recently reminded of the need to include boys in sexual education (and our tendency not to) by two recent studies, both published in the Journal of Adolescent Health. The first examined young men’s knowledge about emergency contraception. The second study found that early fatherhood as well as nonresident fatherhood (fathers who do not live with their children) can be predicted by asking about attitudes toward pregnancy, contraception, and risky sexual behavior. Taken together, the new research sends a powerful message about the cost of missed opportunities to educate boys.

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The first study was conducted at an adolescent medicine clinic in Aurora, Colorado. Young men ages 13 to 24 who visited the clinic between August and October 2014 were given a computerized survey about their sexual behavior, their attitudes toward pregnancy, and their knowledge of contraception. Most of the young men who took the survey (75 percent) had already been sexually active, and 84 percent felt it was important to prevent pregnancy. About two-thirds reported having spoken to a health-care provider about birth control other than condoms, and about three-quarters of sexually active respondents said they had spoken to their partner about birth control as well.

Yet, only 42 percent said that they knew anything about emergency contraception (EC), the only method of birth control that can be taken after intercourse. Though not meant to serve as long-term method of contraception, it can be very effective at preventing pregnancy if taken within five days of unprotected sex. Advance knowledge of EC can help ensure that young people understand the importance of using the method as soon as possible and know where to find it.

Still, the researchers were positive about the results. Study co-author Dr. Paritosh Kaul, an associate professor of pediatrics at the University of Colorado School of Medicine, told Kaiser Health News that he was “pleasantly surprised” by the proportion of boys and young men who had heard about EC: “That’s two-fifths of the boys, and … we don’t talk to boys about emergency contraception that often. The boys are listening, and health-care providers need to talk to the boys.”

Even though I tend to be a glass half-empty kind of person, I like Dr. Kaul’s optimistic take on the study results. If health-care providers are broadly neglecting to talk to young men about EC, yet about 40 percent of the young men in this first study knew about it anyway, imagine how many might know if we made a concerted effort.

The study itself was too small to be generalizable (only 93 young men participated), but it had some other interesting findings. Young men who knew about EC were more likely to have discussed contraception with both their health-care providers and their partners. While this may be an indication of where they learned about EC in the first place, it also suggests that conversations about one aspect of sexual health can spur additional ones. This can only serve to make young people (both young men and their partners) better informed and better prepared.

Which brings us to our next study, in which researchers found that better-informed young men were less likely to become teen or nonresident fathers.

For this study, the research team wanted to determine whether young men’s knowledge and attitudes about sexual health during adolescence could predict their future role as a father. To do so, they used data from the National Longitudinal Study of Adolescent Health (known as Add Health), which followed a nationally representative sample of young people for more than 20 years from adolescence into adulthood.

The researchers looked at data from 10,253 young men who had completed surveys about risky sexual behavior, attitudes toward pregnancy, and birth control self-efficacy in the first waves of Add Health, which began in 1994. The surveys asked young men to respond to statements such as: “If you had sexual intercourse, your friends would respect you more;” “It wouldn’t be all that bad if you got someone pregnant at this time in your life;” and “Using birth control interferes with sexual enjoyment.”

Researchers then looked at 2008 and 2009 data to see if these young men had become fathers, at what age this had occurred, and whether they were living with their children. Finally, they analyzed the data to determine if young men’s attitudes and beliefs during adolescence could have predicted their fatherhood status later in life.

After controlling for demographic variables, they found that young men who were less concerned about having risky sex during adolescence were 30 percent more likely to become nonresident fathers. Similarly, young men who felt it wouldn’t be so bad if they got a young woman pregnant had a 20 percent greater chance of becoming a nonresident father. In contrast, those young men who better understood how birth control works and how effective it can be were 28 percent less likely to become a nonresident father.9:45]

Though not all nonresident fathers’ children are the result of unplanned pregnancies, the risky sexual behavior scale has the most obvious connection to fatherhood in general—if you’re not averse to sexual risk, you may be more likely to cause an unintended pregnancy.

The other two findings, however, suggest that this risk doesn’t start with behavior. It starts with the attitudes and knowledge that shape that behavior. For example, the results of the birth control self-efficacy scale suggest that young people who think they are capable of preventing pregnancy with contraception are ultimately less likely to be involved in an unintended pregnancy.

This seems like good news to me. It shows that young men are primed for interventions such as a formal sexuality education program or, as the previous study suggested, talks with a health-care provider.

Such programs and discussion are much needed; comprehensive sexual education, when it’s available at all, often focuses on pregnancy and STI prevention for young women, who are frequently seen as bearing the burden of risky teen sexual behavior. To be fair, teen pregnancy prevention programs have always suffered for inadequate funding, not to mention decades of political battles that sent much of this funding to ineffective abstinence-only-until-marriage programs. Researchers and organizations have been forced to limit their scope, which means that very few evidence-based pregnancy prevention interventions have been developed specifically for young men.

Acknowledging this deficit, the Centers for Disease Control and Prevention and the Office of Adolescent Health have recently begun funding organizations to design or research interventions for young men ages 15 to 24. They supported three five-year projects, including a Texas program that will help young men in juvenile justice facilities reflect on how gender norms influence intimate relationships, gender-based violence, substance abuse, STIs, and teen pregnancy.

The availability of this funding and the programs it is supporting are a great start. I hope this funding will solidify interest in targeting young men for prevention and provide insight into how best to do so—because we really can’t afford to forget about the boys.