Order Code RS20873 Updated March 1, 2007 Reducing Teen Pregnancy: Adolescent Family Life and Abstinence Education Programs Carmen Solomon-Fears Specialist in Social Legislation Domestic Social Policy Division Summary In 2005, 47% of students in grades 9-12 reported that they had experienced sexual intercourse; about 20% of female teens who have had sexual intercourse become pregnant each year. In recognition of the often negative, long-term consequences associated with teenage pregnancy, Congress has provided funding for the prevention of teenage and out-of-wedlock pregnancies. This report discusses three programs that exclusively attempt to reduce teenage pregnancy. The Adolescent Family Life (AFL) demonstration program was enacted in 1981 as Title XX of the Public Health Service Act, and the Abstinence Education program was enacted in 1996 as part of the welfare reform legislation. Also, since FY2001, additional funding for community-based abstinence education programs has been included in annual Department of Health and Human Services (HHS) appropriations. This report will be updated periodically. Introduction Since 1991, teen pregnancy, abortion, and birth rates have all fallen considerably. In 2002 (latest available data), the overall pregnancy rate for teenagers was 75.4 per 1,000 females aged 15-19, down 35% from the 1991 level of 115.3. The 2002 teen pregnancy rate is the lowest recorded since 1973, when this series was initiated.1 However, it still is higher than the teen pregnancy rates of most industrialized nations. According to a recent report on children and youth, in 2005, 34% of ninth graders reported that they had experienced sexual intercourse. The corresponding statistics for older teens were 43% for tenth graders, 51% for eleventh graders, and 63% for twelfth graders.2 About 20% of female teens who have had sexual intercourse become pregnant each year. 1 The Alan Guttmacher Institute, U.S. Teenage Pregnancy Statistics: National and State Trends and Trends by Race and Ethnicity, updated September 2006, p. 5. 2 Centers for Disease Control and Prevention, MMWR, vol. 55, no. SS-05, Youth Risk Behavior Surveillance:United States, 2005, June 9, 2006, available at [http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss5505a1.htm]. CRS-2 For many years, there have been divergent views with regard to sex and young people. Many argue that sexual activity in and of itself is wrong if the persons are not married. Others agree that it is better for teenagers to abstain from sex but are primarily concerned about the negative consequences of sexual activity, namely unintended pregnancy and sexually transmitted diseases (STDs). These two viewpoints are reflected in two pregnancy prevention approaches. The Adolescent Family Life (AFL) program encompasses both views and provides funding for both prevention programs and programs that provide medical and social services to pregnant or parenting teens. The Abstinence Education program centers on the abstinence-only message and only funds programs that adhere solely to bolstering that message. (For information on Title X, which serves a much broader clientele than teens and pre-teens, see CRS Report RL33644, The Title X Family Planning Program, by Angela Napili.) The Adolescent Family Life Program The AFL demonstration program was enacted in 1981 as Title XX of the Public Health Service Act (P.L. 97-35). It is administered by the Office of Adolescent Pregnancy Programs, Department of Health and Human Services (HHS). From 1981 until 1996, the AFL program was the only federal program that focused directly on the issues of adolescent sexuality, pregnancy, and parenting.3 Program Purpose. The AFL program was designed to promote — family involvement in the delivery of services, adolescent premarital sexual abstinence, adoption as an alternative to early parenting, parenting and child development education, and comprehensive health, education, and social services geared to help the mother have a healthy baby and improve subsequent life prospects for both mother and child. Allowable Projects. The AFL program authorizes grants for three types of demonstrations: (1) projects provide “care” services only (i.e., health, education, and social services to pregnant adolescents, adolescent parents, their infant, families, and male partners); (2) projects which provide “prevention” services only (i.e., services to promote abstinence from premarital sexual relations for pre-teens, teens, and their families); and (3) projects which provide a combination of care and prevention services. Any public or private nonprofit organization or agency is eligible to apply for a demonstration grant. AFL projects can be funded for up to five years. Currently, the AFL program is supporting 100 demonstration projects across the country. (See [http://opa.osophs. dhhs.gov/titlexx/oapp.html].) AFL care projects are required to provide comprehensive health, education, and social services (including life and career planning, job training, safe housing, decisionmaking and social skills), either directly or through partnerships with other community agencies, and to evaluate new approaches for implementing these services. AFL care projects are based within a variety of settings such as universities, hospitals, schools, 3 The predecessor of the AFL program was the Adolescent Pregnancy program, which was enacted in 1978 (P.L. 95-626). The Adolescent Pregnancy program was designed to alleviate the negative consequences of pregnancy for the adolescent parent and her child (i.e., the care component of the AFL program). The Adolescent Pregnancy program was consolidated into the Maternal and Child Health Block Grant when the AFL program was enacted. CRS-3 public health departments, or community agencies. Many provide home visiting services and all have partnerships with diverse community agencies. Currently, 42 care projects are being funded. Since 1997, all AFL prevention projects that have been funded have been abstinence-only projects that were required to conform to the definition of abstinence education as defined in P.L. 104-193. Most of these projects try to reach students between the ages of 9 to 14 in public schools, community settings or family households; all involve significant interaction with parents to strengthen the abstinence message. Currently, 58 abstinence-only projects are being funded; 14 of the projects started in FY2005.4 Evaluations and Research. Each demonstration project is required to include an internal evaluation component designed to test hypotheses specific to that project’s service delivery model. The grantee contracts with an independent evaluator, usually one affiliated with a college or university in the grantee’s state. The AFL program also authorizes funding of research grants dealing with various aspects of adolescent sexuality, pregnancy, and parenting. Research projects have examined factors that influence teenage sexual, contraceptive and fertility behaviors, the nature and effectiveness of care services for pregnant and parenting teens and why adoption is a little-used alternative among pregnant teenagers. Since 1982, the AFL program has funded 68 research projects. Adolescent Family Life Program (appropriations in millions of dollars) FY Approp. FY Approp. FY Approp. FY Approp. 1982 1983 1984 1985 1986 1987 1988 1989 $11.080 13.518 14.918 14.716 14.689 14.000 9.626 9.529 1990 1991 1992 1993 1994 1995 1996 1997 $9.421 7.789 7.789 7.598 6.250 6.698 7.698 14.209 1998 1999 2000 2001 2002 2003 2004 2005 $16.709 17.700 19.327 24.377 28.900 30.922 30.720 30.742 2006 2007 $30.742 30.742 Abstinence Education 1996 Welfare Reform. P.L. 104-193, the 1996 welfare reform law, provided $250 million in federal funds specifically for the abstinence education program ($50 million per year for five years, FY1998-FY2002). Funds must be requested by states when they solicit Title V Maternal and Child Health (MCH) block grant funds and must be used exclusively for teaching abstinence. To receive federal funds, a state must match every $4 in federal funds with $3 in state funds.5 This means that funding for abstinence 4 Abstinence-only education funding under the AFL program amounted to $9 million in FY2001, $10 million in each of the fiscal years FY2002-FY2004, and $13 million in each of the fiscal years FY2005-FY2007. 5 States use a variety of methods to meet the federal matching requirement, such as state funds, private or foundation funds, matching funds from community-based grantees, and in-kind (continued...) CRS-4 education must total at least $87.5 What Is Abstinence? million annually. Although the Title It is becoming clear that parents, teachers, and V abstinence-only education block teenagers are not in agreement on what constitutes grant has not yet been reauthorized. abstinence. Teens are more likely than adults to For the long term, several bills have believe that behaviors that cannot result in continued funding for the block pregnancy constitute abstinence. Because pregnancy prevention together with avoidance of grant. The latest extension is STDs are dual goals of the abstinence education contained in P.L. 109-432 (the Tax program, some observers contend that it is time for Relief and Health Care Act of 2006), programs to explicitly define what constitutes which continues funding for the sexual activity. Others contend that specifying abstinence-only block grant through behaviors other than sexual intercourse violates a June 30, 2007. P.L. 105-33, enacted child’s innocence and may provide ideas for in 1997, included funding for a experimentation. scientific evaluation of the Source: Lisa Remez, “Oral Sex among Adolescents: Is abstinence education programs. It Sex or Is It Abstinence?” Family Planning Mathematica Policy Research won Perspectives (Alan Guttmacher Institute), 32(6), the contract for the evaluation. (See Nov-Dec. 2000, pp. 298-304. First-Year Impacts of Four Title V, Section 510 Abstinence Education Programs, June 2005 [http://aspe.hhs.gov/hsp/05/abstinence/].) To ensure that the abstinence-only message is not diluted, the law (P.L. 104-193, Section 510 of the Social Security Act) stipulated that the term “abstinence education” means an educational or motivational program that (1) has as its exclusive purpose, teaching the social, psychological, and health gains of abstaining from sexual activity; (2) teaches abstinence from sexual activity outside of marriage as the expected standard for all school-age children; (3) teaches that abstinence is the only certain way to avoid out-of-wedlock pregnancy, STDs, and associated health problems; (4) teaches that a mutually faithful monogamous relationship within marriage is the expected standard of human sexual activity; (5) teaches that sexual activity outside of marriage is likely to have harmful psychological and physical effects; (6) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (7) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (8) teaches the importance of attaining self-sufficiency before engaging in sex. In FY2006, every state except California, Connecticut, Maine, and New Mexico (and several territories) sponsored an abstinence education program. These programs launch media campaigns to influence attitudes and behavior, develop abstinence education curricula, revamp sexual education classes, and implement other activities focused on abstinence education. State funding is based on the proportion of low-income children in the state as compared to the national total. In FY2006, federal abstinence education funding ranged from $66,633 in Vermont to $4,777,916 in Texas. Appropriations History. P.L. 106-246 appropriated $20 million for FY2001 to HHS under the Special Projects of Regional and National Significance (SPRANS) 5 (...continued) services (e.g., volunteer staffing, public service announcements, etc.). CRS-5 program for abstinence-only education for adolescents aged 12 through 18. P.L. 106-554 provided $30 million for FY2002 for the SPRANS abstinence education program; P.L. 107-116 increased SPRANS program funding from $30 million to $40 million for FY2002. The SPRANS program funding was increased by P.L. 108-7 to $55 million for FY2003, and by P.L. 108-199 to $70 million for FY2004. P.L. 108-447 increased funding for the SPRANS program, now called the Community-Based Abstinence Education (CBAE) program, to $100 million for FY2005. P.L. 109-149 increased funding for CBAE to $109 million for FY2006 (post-rescission). P.L. 110-5 maintained funding for CBAE at $109 million for FY2007. Issues Comparable Funding for Abstinence Education. President Bush has indicated his support for abstinence education. As governor of Texas, he stated: “For children to realize their dreams, they must learn the value of abstinence. We must send them the message that of the many decisions they will make in their lives, choosing to avoid early sex is one of the most important. We must stress that abstinence isn’t just about saying no to sex; it’s about saying yes to a happier, healthier future.”6 The proposal he supported during his presidential campaign would have provided at least as much funding for abstinence education as was provided for teen contraception services under the Medicaid, family planning (Title X), and AFL programs, namely about $135 million annually.7 As many as 27 other federal programs have a teen contraception component, but expenditures solely for this component could not be isolated.8 For FY2007, abstinence education funding totaled $177 million: $50 million for the abstinence block grant to states; $13 million for the AFL abstinence education projects; $109 million for the CBAE program (up to $10 million of which may be used for a national abstinence education campaign); and $4.5 million for an evaluation of the program.9 Abstinence-Only Versus Comprehensive Sexuality Education. According to a 1997 survey, among the 69% of public school districts that had a district-wide policy to teach sex education, 14% had a comprehensive policy that treated abstinence as one option for adolescents in a broader sexuality education program; 51% taught abstinence as the preferred option for teenagers, but also permitted discussion about contraception as an effective means of protecting against unintended pregnancy and disease (an abstinence-plus policy); and 35% taught abstinence as the only option outside of marriage, 6 Campaign literature from georgebush.com, accessed by author on Nov. 22, 2000. 7 Some family planning experts caution that the spending data may be misleading because it includes much more than contraception services. They contend that family planning programs include a vast array of medical services beyond the prescription of a contraceptive method, including pap smears, breast exams, screening for STDs, and one-on-one counseling of teens. 8 The MCH and Title XX social services block grants are among the HHS programs that provide contraceptive services to teens (GAO/HEHS-99-4, Teen Pregnancy: State and Federal Efforts to Implement Prevention Programs and Measure Their Effectiveness, Nov. 1998). Also, Temporary Assistance for Needy Families (TANF) funds can be used for such services for teens. 9 Abstinence funding amounted to $79 million in FY2001, $100 million in FY2002, $115 million in FY2003, $135 million in FY2004, $168 million in FY2005, and $177 million in FY2006. CRS-6 with discussion of contraception prohibited entirely or permitted only to emphasize its shortcomings (abstinence-only policy).10 Advocates of the abstinence education approach argue that teenagers need to hear a single, unambiguous message that sex outside of marriage is wrong and harmful to their physical and emotional health. They contend that youth can and should be empowered to say no to sex. They argue that supporting both abstinence and birth control is hypocritical and undermines the strength of an abstinence-only message. They also cite research that indicates that teens who take virginity pledges to refrain from sex until marriage appear to delay having sex longer than those teens who do not make such a commitment. (The study found that teens who publicly promise to postpone sex until marriage refrain from intercourse for about a year and a half longer than teens who did not make such a pledge.)11 They argue that abstinence is the most effective means of preventing unwanted pregnancy and sexually transmitted diseases (including HIV/AIDS). Advocates of the more comprehensive approach to sex education argue that today’s youth need information and decision-making skills to make realistic, practical decisions about whether to engage in sexual activities. They contend that such an approach allows young people to make informed decisions regarding abstinence, gives them the information they need to set relationship limits and to resist peer pressure, and also provides them with information on the use of contraceptives and the prevention of sexually transmitted diseases.12 They maintain that abstinence-only messages provide no protection against the risks of pregnancy and disease for those who are sexually active. They point out that teens who break their virginity pledges were less likely to use contraception the first time than teens who had never made such a promise. There is no consensus on the effectiveness of the abstinence-only education and comprehensive sexuality education approaches. According to a 1997 report: At least four factors limit the conclusions that can be drawn from the many studies reviewed. First, the studies conducted to date are simply too few to evaluate each of the different approaches, let alone the various combinations of approaches. Second, many of these studies are limited by methodological problems or constraints. Third, these studies have often produced inconsistent results. And, fourth, there are very few replications of even the most promising programs that assess their impact in other types of communities and with other groups of youths.13 10 David J. Landry, Lisa Kaeser, and Cory L. Richards, “Abstinence Promotion and the Provision of Information about Contraception in Public School Districts Sexuality Education Policies,” Family Planning Perspectives (Alan Guttmacher Institute), 31(6), November-December 1999, pp. 280-286. 11 Peter S. Bearman and Hannah Bruckner, “Promising the Future: Virginity Pledges as They Affect the Transition to First Intercourse,” American Journal of Sociology, January 2001. 12 Some contend that the abstinence-only approach leads to a substitution of other risky behaviors such as oral sex. They cite recent data that indicates that about 25% of virgin teens (15-19) have engaged in oral sex. Source: Child Trends Data Bank. New Indicator on Oral Sex. Sept. 15, 2005. [http://www.childtrendsdatabank.org/whatsNew.cfm] 13 Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, May 2001, Commissioned by the National Campaign to Prevent Teen Pregnancy.