Family Planning: Title X of the Public Health Service Act

This report discusses Title X of the Public Health Service Act provides support for family planning clinics, research related to family planning and population, training of family planning personnel, and development and dissemination of family planning information.

CONTENTS SUMMARY ISSUE DEFINITION BACKGROUND AND ANALYSIS Major Feasures of Title X Program Description Family Planning Clinics Training Research Information and Education Current Legislative and Regulatory Activities Reauthorization Appropriations Regulations Major Issues Effectiveness of Title X Abortion Adolescents Teenage Pregnancy Parental Notification and Consent School-Based Health Clinics Contraceptive Research and Development Adopt ion LEG1 SLATION CONGRESSIONAL HEARINGS, REPORTS, AND DOCUMENTS CHRONOLOGY FOR ADDITIONAL READING 03-24-88 FAMlLY PLANNING: TITLE X OF THE PUBLIC HEALTH SERVICE ACT T i t l e X of t h e P u b l i c H e a l t h S e r v i c e Act p r o v i d e s s u p p o r t f o r f a m i l y p l a n n i n g c l i n i c s , r e s e a r c h r e l a t e d t o f a m i l y p l a n n i n g and p o p u l a t i o n , t r a i n i n g of f a m i l y p l a n n i n g p e r s o n n e l , and development and d i s s e m i n a t i o n of f a m i l y p l a n n i n g i n f o r m a t i o n . C o n g r e s s i o n a l i n t e r e s t i n t h e T i t l e X program f o c u s e s on t h r e e a c t i v i t i e s : t h e r e a u t h o r i z a t i o n p r o c e s s , t h e a p p r o p r i a t i o n s p r o c e s s , and a c t i v i t i e s concerning recently published regulations. T i t l e X h a s n o t f o r m a l l y been r e a u t h o r i z e d s i n c e t h e end of FY85. I n s t e a d , t h e program h a s been funded t h r o u g h a p p r o p r i a t i o n s by a s e r i e s of continuing resolutions. Two b i l l s t o r e a u t h o r i z e T i t l e X t h r o u g h FY91 S . 1366 was o r d e r e d t o be r e p o r t e d f a v o r a b l y , a s h a v e been i n t r o d u c e d . amended, by t h e S e n a t e Committee on Labor and Human R e s o u r c e s on Nov. 1 2 , 1987. H.R. 3769 was i n t r o d u c e d and r e f e r r e d t o t h e House Cornnittee on Energy and Commerce on Dec. 1 5 , 1987. The FY88 a p p r o p r i a t i o n f o r T i t l e X i s $139.7 m i l l i o n . been f u n d e d t h r o u g h o u t FY88 by c o n t i n u i n g r e s o l u t i o n s . T i t l e X has On S e p t . 1, 1987, t h e A d m i n i s t r a t i o n p u b l i s h e d p r o p o s e d r u l e s i n t h e F e d e r a l R e g i s t e r ( 5 2 F.R. 33209) t o amend t h e r e g u l a t i o n s g o v e r n i n g t h e u s e o f T i t l e X f u n d s , i n c l u d i n g amendments t o p r o h i b i t T i t l e X c l i n i c s from p r o v i d i n g c o u n s e l i n g and r e f e r r a l s f o r a b o r t i o n s e r v i c e s . The P u b l i c H e a l t h S e r v i c e r e c e i v e d a b o u t 75,000 comments on t h e p r o p o s e d r u l e . On Feb. 2 , 1988, t h e A d m i n i s t r a t i o n p u b l i s h e d f i n a l r u l e s i n t h e F e d e r a l R e g i s t e r ( 5 3 FR 2 9 2 1 ) . The r u l e s w i l l be e f f e c t i v e Mar. 3 , 1 9 8 8 , e x c e p t f o r o n e p r o v i s i o n which w i l l be e f f e c t i v e Apr. 2 , 1988. A number o f S t a t e g o v e r n m e n t s and p r i v a t e o r g a n i z a t i o n s have t a k e n c o u r t a c t i o n t o p r e v e n t t h e r u l e s from g o i n g i n t o e f f e c t . The d e b a t e s over T i t l e X r e a u t h o r i z a t i o n , a p p r o p r i a t i o n s , and r e g u l a t i o n s h a v e prompted Congress t o c o n s i d e r a number o f c o n t r o v e r s i a l issues. Many r e s e a r c h e r s have c l o s e l y examined T i t l e X t o d e t e r m i n e w h e t h e r and t o what d e g r e e t h e program i s an e f f e c t i v e one. There has been a g r e a t d e a l of d i s c u s s i o n o v e r t h e r o l e t h e program h a s o r s h o u l d h a v e w i t h r e s p e c t t o a b o r t i o n c o u n s e l i n g and r e f e r r a l s and r e l a t e d activities. The i s s u e s o f t e e n a g e p r e g n a n c y , p a r e n t a l n o t i f i c a t i o n a n d c o n s e n t , and s c h o o l - b a s e d h e a l t h c l i n i c s h a v e f o c u s e d a t t e n t i o n on t h e p r o v i s i o n of family planning services t o adolescents. There i s disagreement over t h e d e s i r e d l e v e l of T i t l e X support f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t . Proposals t o c r e a t e a l a r g e r r o l e f o r T i t l e X c l i n i c s i n a d o p t i o n placement have a l s o g e n e r a t e d c o n t r o v e r s y . ISSUE DEFINITION T i t l e X of t h e P u b l i c H e a l t h S e r v i c e Act i s a n i m p o r t a n t s o u r c e of Federal funding f o r family planning services. The program n o t o n l y f u n d s f a m i l y p l a n n i n g c l i n i c s , b u t a l s o r e s e a r c h , t r a i n i n g , and i n f o r m a t i o n and e d u c a t i o n a c t i v i t i e s . C o n g r e s s h a s a number o f o p p o r t u n i t i e s t o d e t e r m i n e t h e c o m p o s i t i o n o f t h e T i t l e X program and t h e l e v e l o f s u p p o r t i t w i l l r e c e i v e o v e r t h e n e x t few y e a r s . L i k e l y avenues f o r c o n g r e s s i o n a l a c t i o n i n c l u d e t h e r e a u t h o r i z a t i o n p r o c e s s , t h e ' a p p r o p r i a t i o n s p r o c e s s , and Controversial a c e i v i t i e s c o n c e r n i n g r e c e n t l y proposed r e g u l a t i o n s . issues s u r r o u n d i n g t h e T i t l e X program i n c l u d e t h e p r o g r a m ' s e f f e c t i v e n e s s ; t h e program's r o l e with r e s p e c t t o a b o r t i o n c o u n s e l i n g , referral and r e l a t e d a c t i v i t i e s ; a v a r i e t y of i s s u e s concerning a d o l e s c e n t s ( t e e n a g e p r e g n a n c y , p a r e n t a l n o t i f i c a t i o n and c o n s e n t , and school-based h e a l t h c l i n i c s ) ; t h e l e v e l of s u p p o r t f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t ; and t h e r o l e o f f a m i l y p l a n n i n g c l i n i c s i n adoption placement. BACKGROUND AND ANALYSIS h j o r Features of T i t l e X Program D e s c r i p t i o n T i t l e X of t h e P u b l i c H e a l t h S e r v i c e Act p r o v i d e s s u p p o r t f o r f a m i l y p l a n n i n g c l i n i c s , r e s e a r c h r e l a t e d t o f a m i l y p l a n n i n g and p o p u l a t i o n , t r a i n i n g o f f a m i l y p l a n n i n g p e r s o n n e l , and development and d i s s e m i n a t i o n of f a m i l y p l a n n i n g i n f o r m a t i o n . The a g e n c y w i t h i n t h e Department of H e a l t h and Human S e r v i c e s r e s p o n s i b l e f o r a d m i n i s t e r i n g t h e T i t l e X f a m i l y p l a n n i n g program i s t h e O f f i c e of Family Planning, That o f f i c e i s under t h e a u s p i c e s o f t h e O f f i c e of P o p u l a t i o n A f f a i r s w i t h i n t h e P u b l i c H e a l t h S e r v i c e . The a u t h o r i t y f o r r e v i e w i n g , a w a r d i n g , and m o n i t o r i n g t h e f a m i l y p l a n n i n g s e r v i c e g r a n t s h a s been d e l e g a t e d t o t h e P u b l i c H e a l t h S e r v i c e r e g i o n a l offices. The g r a n t and c o n t r a c t a c t i v i t i e s r e l a t e d t o r e s e a r c h , t r a i n i n g , and i n f o r m a t i o n and e d u c a t i o n a r e a d m i n i s t e r e d d i r e c t l y by t h e O f f i c e of Family P l a n n i n g . The Family P l a n n i n g S e r v i c e s and P o p u l a t i o n R e s e a r c h Act of 1970 In (P.L. 91-572) e s t a b l i s h e d T i t l e X o f t h e P u b l i c H e a l t h S e r v i c e Act. FY87, t h e T i t l e X program s p e n t $142.5 m i l l i o n f o r f a m i l y p l a n n i n g and r e l a t e d a c t i v i t i e s . The FY88 a p p r o p r i a t i o n f o r T i t l e X i s $139.7 m i l l i o n . Family P l a n n i n g C l i n i c s Most T i t l e X d o l l a r s s u p p o r t p r o j e c t g r a n t s f o r s e r v i c e s i n f a m i l y planning c l i n i c s . I n FY87, $136.0 m i l l i o n funded 89 g r a n t e e s who p r o v i d e d s e r v i c e s a t a p p r o x i m a t e l y 3,900 c l i n i c s i t e s . I n 3 1 S t a t e s o r t e r r i t o r i e s , t h e g r a n t e e s were S t a t e o r t e r r i t o r i a l h e a l t h d e p a r t m e n t s . I n 11 o t h e r S t a t e s , t h e S t a t e a g e n c y was one of s e v e r a l g r a n t e e s . No s p e c i f i c S t a t e m a t c h i n g r e q u i r e m e n t s e x i s t f o r t h e s e g r a n t s ; however, r e g u l a t i o n s s p e c i f y t h a t no f a m i l y p l a n n i n g c l i n i c p r o j e c t g r a n t may be f u l l y s u p p o r t e d by T i t l e X funds. P a r t i c i p a t i n g c l i n i c s a r e r e q u i r e d t o o f f e r a broad r a n g e of a c c e p t a b l e and e f f e c t i v e f a m i l y p l a n n i n g methods and s e r v i c e s t o a l l persons d e s i r i n g such s e r v i c e s . These s e r v i c e s i n c l u d e n a t u r a l f a m i l y planning methods, n o n d i r e c t i v e counseling s e r v i c e s , p h y s i c a l examinations ( i n c l u d i n g c a n c e r d e t e c t i o n and l a b o r a t o r y t e s t s ) , i n f e r t i l i t y s e r v i c e s , s e r v i c e s f o r a d o l e s c e n t s , pregnancy t e s t s , c o n t r a c e p t i v e s u p p l i e s , p e r i o d i c f o l l o w - u p e x a m i n a t i o n s , r e f e r r a l t o and f r o m o t h e r s o c i a l and m e d i c a l s e r v i c e a g e n c i e s , and a n c i l l a r y s e r v i c e s . C l i n i c s a r e r e q u i r e d t o encourage, t o t h e extent practicable, family p a r t i c i p a t i o n . The T i t l e X s t a t u t e p r o h i b i t s t h e u s e o f any T i t l e X f u n d s i n A l l family programs where a b o r t i o n i s a method of f a m i l y p l a n n i n g . p l a n n i n g s e r v i c e s must b e v o l u n t a r y and must n o t b e a p r e r e q u i s i t e f o r t h e r e c e i p t o f a n y o t h e r s e r v i c e s ( e . g . , t h e Aid t o F a m i l i e s w i t h Dependent C h i l d r e n program may n o t r e q u i r e a n i n d i v i d u a l t o u s e f a m i l y p l a n n i n g services in order to receive its benefits). T i t l e X law r e q u i r e s t h a t p r i o r i t y f o r t h e p r o v i s i o n o f c l i n i c s e r v i c e s be g i v e n t o c l i e n t s from l o w i n c o m e f a m i l i e s . C l i n i c s must p r o v i d e s e r v i c e s f r e e of c h a r g e ( e x c e p t t o t h e e x t e n t t h a t M e d i c a i d o r o t h e r h e a l t h i n s u r e r s c o v e r t h e s e s e r v i c e s ) t o c l i e n t s whose incomes do n o t e x c e e d 100% o f t h e F e d e r a l p o v e r t y g u i d e l i n e s ( $ 9 , 3 0 0 f o r a f a m i l y o f t h r e e i n 1987). A s l i d i n g payment s c a l e must be o f f e r e d f o r t h o s e whose incomes a r e between 100% and 250% of t h e p o v e r t y l e v e l . The O f f i c e o f Family P l a n n i n g e s t i m a t e s t h a t T i t l e X f a m i l y p l a n n i n g c l i n i c s s e r v e d 4 . 3 m i l l i o n i n d i v i d u a l s i n FY87. Of t h e s e , i t i s e s t i m a t e d t h a t o v e r 85% were 1ow-income women and a p p r o x i m a t e 1 y one-t h i r d were adolescents. Training T i t l e X p r o v i d e s f u n d i n g f o r t r a i n i n g n u r s e p r a c t i t i o n e r s and o t h e r c l i n i c personnel t o c a r r y out family planning services. General t r a i n i n g a c t i v i t i e s c o n s i s t of o n e g r a n t f o r e a c h o f t h e n a t i o n ' s t e n r e g i o n s on s u c h t o p i c s a s f a m i l y i n v o l v e m e n t , program management, c l i n i c management, c o u n s e l i n g and c l i e n t e d u c a t i o n , i n f e r t i l i t y , and n a t u r a l f a m i l y p l a n n i n g . A s p e c i f i c program, composed o f f i v e g r a n t s , e x i s t s t o t r a i n n u r s e practitioners. I n FY87, $3.7 m i l l i o n funded g e n e r a l t r a i n i n g f o r 1 4 , 0 0 0 p e r s o n n e l i n a d d i t i o n t o t r a i n i n g f o r 140 n u r s e p r a c t i t i o n e r s , a c c o r d i n g t o O f f i c e of F a m i l y P l a n n i n g e s t i m a t e s . Research T i t l e X a u t h o r i z e s r e s e a r c h a c t i v i t i e s i n t h e biomedical, c o n t r a c e p t i v e d e v e l o p m e n t , b e h a v i o r a l , and program i m p l e m e n t a t i o n f i e l d s r e l a t e d t o f a m i l y p l a n n i n g and p o p u l a t i o n . The O f f i c e o f F a m i l y P l a n n i n g a w a r d s g r a n t s and c o n t r a c t s f o r r e s e a r c h t o h e l p f a m i l y p l a n n i n g p r o v i d e r s d e l i v e r t h e i r s e r v i c e s more e f f e c t i v e l y and e f f i c i e n t l y . The N a t i o n a l I n s t i t u t e o f C h i l d H e a l t h and Human Development, o n e o f t h e N a t i o n a l I n s t i t u t e s o f H e a l t h , i s a l s o a u t h o r i z e d t o award g r a n t s and c o n t r a c t s f o r T i t l e X research. Such r e s e a r c h i n c l u d e s b i o m e d i c a l r e s e a r c h on t h e p r o b l e m s of human f e r t i l i t y and i n f e r t i l i t y , development o f s a f e and e f f e c t i v e methods f o r f e r t i l i t y r e g u l a t i o n , e v a l u a t i o n o f t h e b e n e f i t s and r i s k s of c u r r e n t c o n t r a c e p t i v e methods, and demographic and b e h a v i o r a l s c i e n c e s r e s e a r c h on t h e c a u s e s and c o n s e q u e n c e s o f p o p u l a t i o n s t r u c t u r e and c h a n g e . Informat i o n and Education T i t l e X provides funds t o public o r p r i v a t e organizations f o r t h e d e v e l o p m e n t and d i s s e m i n a t i o n o f f a m i l y p l a n n i n g and p o p u l a t i o n g r o w t h i n f o r m a t i o n and e d u c a t i o n a l m a t e r i a l s . Activities include the operation of t h e N a t i o n a l C l e a r i n g h o u s e f o r Family P l a n n i n g I n f o r m a t i o n ( f u n d e d a t a b o u t $257,000 i n FY87), and t h e development of m a t e r i a l s t o h e l p p a r e n t s communicate w i t h t h e i r c h i l d r e n and a s s i s t i n making r e s p o n s i b l e c h o i c e s c o n c e r n i n g s e x u a l i t y , p r e g n a n c y , and p a r e n t h o o d . C u r r e n t L e g i s l a t i v e and Regulatory A c t i v i t i e s C o n g r e s s i o n a l i n t e r e s t i n t h e T i t l e X program c u r r e n t l y f o c u s e s on t h r e e a c t i v i t i e s : t h e reauthorization process, t h e appropriations process, and a c t i v i t i e s c o n c e r n i n g r e c e n t l y proposed r e g u l a t i o n s . I s s u e s comnon t o e a c h of t h e s e a r e d i s c u s s e d i n t h e "Major I s s u e s " s e c t i o n . Reauthorization C o n g r e s s h a s n o t o f f i c i a l l y r e a u t h o r i z e d T i t l e X s i n c e i t p a s s e d P.L. 98-512, which e x t e n d e d t h e p r o g r a m ' s f u n d i n g t h r o u g h t h e end o f FY85. S i n c e t h e n , C o n g r e s s h a s n o t been a b l e t o r e a c h c o n s e n s u s on a number of c o n t r o v e r s i a l i s s u e s through t h e r e a u t h o r i z a t i o n process. Instead, C o n g r e s s h a s e x t e n d e d f u n d i n g f o r t h e program t h r o u g h t h e a p p r o p r i a t i o n s p r o c e s s by a s e r i e s of c o n t i n u i n g r e s o l u t i o n s . The P r e s i d e n t ' s FY88 Budget p r o p o s e d t h a t t h e f u n c t i o n s o f t h e T i t l e X program be t r a n s f e r r e d t o a Family P l a n n i n g Block G r a n t , u n d e r which t h e F e d e r a l Government would p r o v i d e f u n d s t o S t a t e s and t e r r i t o r i e s f o r family planning a c t i v i t i e s . L e g i s l a t i o n would be r e q u i r e d t o e n a c t t h i s p r o p o s a l ; no s u c h l e g i s l a t i o n h a s been i n t r o d u c e d i n t h e 1 0 0 t h C o n g r e s s . Two b i l l s -- S. 1366 and H.R. r e a u t h o r i z e T i t l e X t h r o u g h FY91. 3769 -- have been introduced to On J u n e 1 6 , 1987, S e n a t o r Kennedy, Chairman of t h e S e n a t e Committee on Labor and Human R e s o u r c e s , i n t r o d u c e d S. 1366. S. 1366 would a u t h o r i z e f u n d i n g f o r f a m i l y p l a n n i n g c l i n i c g r a n t s and c o n t r a c t s a t $155.5 m i l l i o n f o r FY88, $163.0 m i l l i o n f o r FY89, $171.0 m i l l i o n f o r FY90, and $179.5 m i l l i o n f o r FY91. The b i l l would a l s o r e v i s e T i t l e X t o (1) r e p e a l e x i s t i n g p r o v i s i o n s which a l l o w t h e S e c r e t a r y , a t t h e r e q u e s t of a T i t l e X g r a n t r e c i p i e n t , t o r e d u c e t h e amount of t h e g r a n t by t h e v a l u e of s u p p l i e s o r equipment ( e . g . , t h o s e p u r c h a s e d i n b u l k ) f u r n i s h e d by t h e S e c r e t a r y ; ( 2 ) a u t h o r i z e f u n d i n g f o r t e c h n i c a l a s s i s t a n c e and p e r s o n n e l t r a i n i n g ( a t $4.3 m i l l i o n f o r FY88, $4.5 m i l l i o n f o r FY89, $4.7 m i l l i o n f o r FY90, and $5.0 m i l l i o n f o r FY91); ( 3 ) r e p e a l e x i s t i n g f o r m u l a g r a n t provisions; ( 4 ) a u t h o r i z e r e s e a r c h i n c o n t r a c e p t i v e d e v e l o p m e n t and e v a l u a t i o n ( a t $10 m i l l i o n f o r FY88 and s u c h sums a s may be n e c e s s a r y f o r FY89, FY90, and FY91) and t o improve c l i n i c a l management and d i r e c t i n f o r m a t i o n and d e l i v e r y of s e r v i c e s ; ( 5 ) a u t h o r i z e community-based e d u c a t i o n programs ( a t $10 m i l l i o n f o r FY88 and s u c h sums a s may be n e c e s s a r y f o r FY89, FY90, and FY9l); and ( 6 ) r e q u i r e d a t a c o l l e c t i o n . H e a r i n g s on S. 1366 were h e l d on J u l y 30, 1987. The b i l l was o r d e r e d t o be r e p o r t e d f a v o r a b l y by t h e S e n a t e C o m n i t t e e on Labor and Human R e s o u r c e s , a s amended, on Nov. 1 2 , 1987. On Dec. 1 5 , 1987, R e p r e s e n t a t i v e Waxman, Chairman o f t h e House C o m m i t t e e on Energy and Commerce Subcommittee on H e a l t h and t h e E n v i r o n m e n t , i n t r o d u c e d H.R. 3769. The b i l l would r e a u t h o r i z e f u n d i n g f o r f a m i l y p l a n n i n g c l i n i c g r a n t s and c o n t r a c t s a t $148.3 m i l l i o n f o r FY89, $156.2 m i l l i o n f o r FY90, and $164.2 m i l l i o n f o r FY91. The b i l l would a l s o r e v i s e T i t l e X t o ( 1 ) r e p e a l e x i s t i n g p r o v i s i o n s which a l l o w t h e S e c r e t a r y , a t t h e r e q u e s t of a T i t l e X g r a n t r e c i p i e n t , t o r e d u c e t h e amount o f t h e g r a n t by t h e v a l u e of s u p p l i e s o r e q u i p m e n t ; ( 2 ) r e p e a l e x i s t i n g formula g r a n t p r o v i s i o n s ; ( 3 ) a u t h o r i z e funding f o r t e c h n i c a l a s s i s t a n c e and p e r s o n n e l t r a i n i n g ( a t $4.7 m i l l i o n f o r FY89, $4.9 m i l l i o n and $5.1 m i l l i o n f o r FY91); (4) authorize research in f o r FY90, c o n t r a c e p t i v e development and e v a l u a t i o n ( a t s u c h sums as may b e n e c e s s a r y ) and t o improve c l i n i c a l management and d i r e c t d e l i v e r y o f s e r v i c e s ; ( 5 ) a u t h o r i z e i n f o r m a t i o n and e d u c a t i o n programs ( a t s u c h sums a s may be n e c e s s a r y ) ; and r e q u i r e d a t a c o l l e c t i o n . The b i l l was r e f e r r e d t o t h e House Committee on Energy and Commerce. Appropriations The FY88 a p p r o p r i a t i o n f o r T i t l e X i s $139.7 m i l l i o n . T i t l e X has been funded t h r o u g h o u t FY88 by a s e r i e s o f c o n t i n u i n g r e s o l u t i o n s . P.L. 100-120 ( s i g n e d S e p t . 3 0 , 1 9 8 7 ) f u n d e d T i t l e X from O c t . 1 , 1987, u n t i l Nov. 1 0 , 1987. P.L. 100-162 ( s i g n e d Nov. 1 0 , 1 9 8 7 ) e x t e n d e d f u n d i n g t h r o u g h Dec. 1 6 , 1987. P.L. 100-193 ( s i g n e d Dec. 1 6 , 1 9 8 7 ) e x t e n d e d f u n d i n g t h r o u g h Dec. 1 8 , 1987. P.L. 100-197 ( s i g n e d Dec. 2 0 , 1 9 8 7 ) e x t e n d e d f u n d i n g t h r o u g h Dec. 2 1 , 1987. P.L. 100-202 ( s i g n e d Dec. 22, 1 9 8 7 ) e x t e n d s f u n d i n g t h r o u g h t h e r e m a i n d e r of FY88. On S e p t . 18, 1 9 8 7 , t h e S e n a t e C o m m i t t e e on A p p r o p r i a t i o n s Subcommittee on L a b o r , H e a l t h and Human S e r v i c e s , E d u c a t i o n , and R e l a t e d 3058 ( ~ a t c h e r ) which would h a v e A g e n c i e s i n c l u d e d an amendment t o H.R. r e q u i r e d T i t l e X f u n d s t o be s p e n t i n a c c o r d a n c e w i t h r e g u l a t i o n s a n d g u i d e l i n e s i n e f f e c t a s of Aug. 3 1 , 1987. The s u b c o m n i t t e e ' s l a n g u a g e was a p p r o v e d by t h e f u l l S e n a t e A p p r o p r i a t i o n s C o m n i t t e e on Oct. 1, 1987, a n d I f t h a t l a n g u a g e had b e e n a p p r o v e d on t h e S e n a t e f l o o r on O c t . 1 4 , 1987. by t h e C o n f e r e n c e Committee on H.R. 3058, i t would h a v e p r e v e n t e d r e g u l a t i o n s p r o p o s e d by t h e A d m i n i s t r a t i o n ( s e e t h e f o l l o w i n g s e c t i o n ) from g o i n g i n t o e f f e c t ; however, t h a t l a n g u a g e was n o t a c c e p t e d . H.R. 3058 was t h e n i n c o r p o r a t e d i n t o P.L. 100-202, t h e c o n t i n u i n g r e s o l u t i o n which f u n d s t h e T i t l e X program t h r o u g h S e p t . 3 0 , 1988. Regulations On S e p t . 1, 1987, t h e A d m i n i s t r a t i o n p u b l i s h e d p r o p o s e d r u l e s i n t h e F e d e r a l R e g i s t e r ( 5 2 F.R. 33209) t o amend t h e r e g u l a t i o n s g o v e r n i n g t h e Under t h e s e proposed r u l e s , T i t l e X c l i n i c s would use of T i t l e X funds. be ( 1 ) p r o h i b i t e d from p r o v i d i n g c o u n s e l i n g and r e f e r r a l s f o r a b o r t i o n s e r v i c e s o r f o r any o t h e r p r e g n a n c y - r e l a t e d s e r v i c e s , i n c l u d i n g a d o p t i o n o r p r e n a t a l c a r e ; ( 2 ) r e q u i r e d t o keep t h e i r f a c i l i t i e s p h y s i c a l l y a n d f i n a n c i a l l y s e p a r a t e from t h o s e where a b o r t i o n s o r r e l a t e d s e r v i c e s a r e p r o v i d e d ; and ( 3 ) p r o h i b i t e d from t a k i n g any a c t i o n ( i n c l u d i n g l o b b y i n g , paying dues t o o r g a n i z a t i o n s , l e g a l a c t i o n , o r developing o r d i s s e m i n a t i n g m a t e r i a l s ) which " e n c o u r a g e s , p r o m o t e s , o r a d v o c a t e s " a b o r t i o n . The comment p e r i o d on t h e p r o p o s e d r u l e s ended Nov. 2 , 1987. During t h a t period, t h e Pub1 i c H e a l t h S e r v i c e r e c e i v e d a b o u t 75,000 comments, i n c l u d i n g comments from Members of C o n g r e s s . C r i t i c s of t h e p r o p o s e d r u l e s u n s u c c e s s f u l l y t r i e d t o o b t a i n a p p r o p r i a t i o n s l a n g u a g e which would have b l o c k e d them from g o i n g i n t o e f f e c t ( s e e t h e p r e c e d i n g s e c t i o n ) . On Feb. 2 , 1988, t h e A d m i n i s t r a t i o n p u b l i s h e d f i n a l r u l e s i n t h e F e d e r a l R e g i s t e r ( 5 3 FR 2921) which c o n t a i n e d r e s p o n s e s t o t h e p u b l i c comments. F o r e x a m p l e , o n e r e s p o n s e s p e c i f i e d t h a t t h e p r o h i b i t i o n s on c o u n s e l i n g and r e f e r r a l f o r pregnancy c a r e would n o t a p p l y i f a T i t l e X c l i n i c r e f e r r e d a woman w i t h pregnancy c o m p l i c a t i o n s t o a n emergency medical f a c i l i t y . The r u l e s w i l l b e e f f e c t i v e Mar. 3 , 1988, e x c e p t f o r t h e p r o v i s i o n r e q u i r i n g p h y s i c a l and f i n a n c i a l s e p a r a t i o n which w i l l be e f f e c t i v e Apr. 2 , 1988. A number of o r g a n i z a t i o n s h a v e t a k e n c o u r t a c t i o n t o p r e v e n t t h e r u l e s from g o i n g i n t o e f f e c t . Those f i l i n g l a w s u i t s i n c l u d e S t a t e governments i n M a s s a c h u s e t t s and N e w York, and p r i v a t e o r g a n i z a t i o n s s u c h a s t h e N a t i o n a l Family P l a n n i n g and R e p r o d u c t i v e H e a l t h A s s o c i a t i o n , t h e P l a n n e d P a r e n t h o o d F e d e r a t i o n of America, and t h e American P u b l i c H e a l t h A s s o c i a t i o n . Major I s s u e s and The debates over T i t l e X reauthorization, appropriations, r e g u l a t i o n s h a v e prompted Congress t o c o n s i d e r a number o f c o n t r o v e r s i a l issues. T h e s e i s s u e s i n c l u d e t h e e f f e c t i v e n e s s of t h e T i t l e X program, t h e d e b a t e over a b o r t i o n , a v a r i e t y of i s s u e s concerning a d o l e s c e n t s ( t e e n a g e p r e g n a n c y , p a r e n t a l n o t i f i c a t i o n and c o n s e n t , and s c h o o l - b a s e d h e a l t h c l i n i c s ) , t h e l e v e l o f s u p p o r t f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t , and t h e r o l e of f a m i l y p l a n n i n g c l i n i c s i n a d o p t i o n placement. E f f e c t i v e n e s s of T i t l e X The T i t l e X program i s d e s i g n e d t o p r o v i d e F e d e r a l s u p p o r t f o r f a m i l y planning services. T h e r e i s d e b a t e o v e r w h e t h e r t h e c u r r e n t program i s providing these services effectively. Underlying t h i s d e b a t e i s d i s a g r e e m e n t o v e r which a p p r o a c h e s t o p r e v e n t i n g p r e g n a n c y a r e most effective. T i t l e X a d v o c a t e s b e l i e v e t h e program e f f e c t i v e l y prevents u n i n t e n d e d p r e g n a n c i e s and r e d u c e s t h e i n c i d e n c e of a b o r t i o n . These a d v o c a t e s , i n c l u d i n g r e p r e s e n t a t i v e s of m e d i c a l s p e c i a l t y g r o u p s , s a y t h a t t h e , t y p e s o f f a m i l y p l a n n i n g s e r v i c e s p r o v i d e d by T i t l e X a r e c o r r e l a t e d w i t h improved m a t e r n a l and i n f a n t h e a l t h i n d i c a t o r s ( p a r t i c u l a r l y r e d u c e d low b i r t h w e i g h t and i n f a n t m o r t a l i t y ) . They e m p h a s i z e t h a t t h e T i t l e X program i s w e l l - d e s i g n e d t o t a r g e t l o w i n c o m e women and t e e n a g e r s , g r o u p s a t h i g h r i s k f o r p o o r p r e g n a n c y outcomes. They a l s o d i s c u s s t h e i m p o r t a n c e of t h e o t h e r p r e v e n t i v e h e a l t h m e a s u r e s o f f e r e d a t T i t l e X c l i n i c s , such a s s c r e e n i n g f o r c e r v i c a l c a n c e r and sexually transmitted diseases. While t h e s e a d v o c a t e s m a i n t a i n t h a t t h e T i t l e X program i s a n e f f e c t i v e o n e , t h e y i n s i s t t h a t i t c o u l d b e more e f f e c t i v e with increased funding l e v e l s . They a r g u e t h a t i n c r e a s e s a r e n e c e s s a r y t o r e s t o r e s e r v i c e s which were c u r t a i l e d i n t h e e a r l y 1 9 8 0 s a n d t o provide additional reproductive health services t o additional c l i e n t s . C r i t i c s of t h e program a r e c o n c e r n e d t h a t f a m i l y p l a n n i n g programs promote t h e u s e of c o n t r a c e p t i v e s e r v i c e s , w i t h o u t s u f f i c i e n t a t t e n t i o n t o d i s c l o s i n g t h e p o t e n t i a l h e a l t h h a z a r d s of u s i n g c e r t a i n c o n t r a c e p t i v e t h e r i s k s t o c e r t a i n women smokers who u s e t h e b i r t h methods ( e . g . , control p i l l ) . C r i t i c s o f t h e program q u e s t i o n i t s e f f e c t i v e n e s s a t r e d u c i n g t h e r a t e of unintended pregnancies, p a r t i c u l a r l y t o t e e n a g e r s . Some of t h e s e c r i t i c s b e l i e v e t h a t i t i s n o t a p p r o p r i a t e t o p r o v i d e c o n t r a c e p t i v e s e r v i c e s t o t e e n a g e r s because they b e l i e v e t h a t t e e n a g e r s a r e l e s s l i k e l y t o use contraceptives responsibly. They a r g u e t h a t r e d u c e d t e e n a g e b i r t h r a t e s may i n s t e a d be a t t r i b u t a b l e t o a n i n c r e a s e d i n c i d e n c e of a b o r t i o n . These c r i t i c s b e l i e v e t h a t a r e d u c e d ' t e e n a g e p r e g n a n c y r a t e c o u l d b e a c h i e v e d i f f a m i l y p l a n n i n g programs p l a c e d g r e a t e r e m p h a s i s on e f f o r t s t o p r e v e n t t e e n s from becoming s e x u a l l y a c t i v e , r a t h e r t h a n on e f f o r t s t o d e c r e a s e t h e p e r c e n t a g e o f s e x u a l l y a c t i v e t e e n a g e r s who become p r e g n a n t . Abortion S i n c e t h e e n a c t m e n t o f t h e program, u s e o f T i t l e X f u n d s f o r a b o r t i o n a s a method o f f a m i l y p l a n n i n g h a s been p r o h i b i t e d by s t a t u t e a n d regulation. T i t l e X guidelines require c l i n i c s t o provide nondirective c o u n s e l i n g ( i . e . , c o u n s e l i n g which d o e s n o t f a v o r one o p t i o n o v e r a n o t h e r ) t o women who r e q u e s t i n f o r m a t i o n on o p t i o n s f o r t h e management o f t h e i r unintended pregnancy. These o p t i o n s i n c l u d e p r e n a t a l c a r e and d e l i v e r y ; i n f a n t c a r e , f o s t e r c a r e , o r a d o p t i o n ; and a b o r t i o n . Title X clinics are a l s o r e q u i r e d , upon r e q u e s t , t o p r o v i d e r e f e r r a l s f o r t h e s e women. S u p p o r t e r s o f c u r r e n t p o l i c y s a y t h a t T i t l e X p r o v i d e r s h a v e been s c r u p u l o u s i n t h e i r a d h e r e n c e t o t h e law and r e g u l a t i o n s r e g a r d i n g abortion. They a r g u e i n f a v o r of c l i n i c p e r s o n n e l b e i n g a b l e t o c o n t i n u e t o o f f e r n o n d i r e c t i v e c o u n s e l i n g and r e f e r r a l s on o p t i o n s f o r u n i n t e n d e d pregnancy, b e l i e v i n g t h a t t h e s e a c t i v i t i e s a r e important t o m a i n t a i n i n g m e d i c a l s t a n d a r d s and t h e p a t i e n t ' s r i g h t s t o informed c o n s e n t . C r i t i c s of c u r r e n t p o l i c y e x p r e s s t h e i r b e l i e f t h a t t h e r e i s n o t a c l e a r enough s e p a r a t i o n between T i t l e X c l i n i c s and a b o r t i o n - r e l a t e d activities. I n p a r t i c u l a r , they b e l i e v e t h a t r e s t r i c t i o n s on t h e 11 c o - s i t i n g " of T i t l e X c l i n i c s w i t h f r e e - s t a n d i n g a b o r t i o n c l i n i c s a r e n o t b e i n g a d m i n i s t e r e d s t r i c t l y enough ( i . e . , they a r e concerned about t h e e x i s t e n c e of f a m i l y p l a n n i n g and a b o r t i o n c l i n i c s which a r e l o c a t e d a d j a c e n t t o o n e a n o t h e r o r which s h a r e c e r t a i n f a c i l i t i e s , p a r t i c u l a r l y t h o s e owned o r o p e r a t e d by t h e same o r g a n i z a t i o n ) . They would l i k e t o s e e ' t i g h t e r r e s t r i c t i o n s on T i t l e X p a r t i c i p a t i o n by o r g a n i z a t i o n s which They oppose c u r r e n t g u i d e l i n e s perform a b o r t i o n s w i t h non-Title X funds. t h a t r e q u i r e T i t l e X c l i n i c p e r s o n n e l t o o f f e r n o n d i r e c t i v e c o u n s e l i n g on and r e f e r r a l s f o r a b o r t i o n . I n r e s p o n s e t o t h e c o n c e r n s of t h e s e c r i t i c s , t h e A d m i n i s t r a t i o n p u b l i s h e d p r o p o s e d r u l e s on S e p t . 1 , 1987 ( 5 2 FR 33209) and f i n a l r u l e s on Feb. 2 , 1988 (53 FR 2 9 2 1 ) i n t h e F e d e r a l R e g i s t e r which would amend T i t l e X regulations. The r u l e s would p r o h i b i t T i t l e X f u n d i n g f o r c l i n i c s which p r o v i d e c o u n s e l i n g and r e f e r r a l s f o r a b o r t i o n ; r e q u i r e g r e a t e r p h y s i c a l and f i n a n c i a l s e p a r a t i o n between c l i n i c s w i t h T i t l e X f u n d i n g and t h o s e which p r o v i d e a b o r t i o n s ; and r e s t r i c t o t h e r a c t i v i t i e s , s u c h a s p a y i n g d u e s t o an o r g a n i z a t i o n which " e n c o u r a g e s , promotes, o r advocates" a b o r t i o n ( t h e s e a c t i v i t i e s c o u l d be i n t e r p r e t e d t o i n c l u d e t h e c u r r e n t a c t i v i t i e s o f s u c h p r i v a t e o r g a n i z a t i o n s a s Planned P a r e n t h o o d ) . Those o p p o s i n g t h e proposed r u l e s a r g u e t h a t t h e y a r e c o n t r a r y t o a n e s t a b l i s h e d r e c o r d o f l e g i s l a t i v e i n t e n t and c o u r t d e c i s i o n s i n s u p p o r t of c o u n s e l i n g and r e f e r r a l s on a b o r t i o n . They b e l i e v e t h e p r o p o s e d r e g u l a t i o n s a r e unnecessary because T i t l e X c l i n i c s c u r r e n t l y do n o t promote a b o r t i o n . On m e d i c a l g r o u n d s , o p p o n e n t s b e l i e v e t h a t t h e p r o v i s i o n s which p r o h i b i t f a m i l y planning p r o v i d e r s from o f f e r i n g i n f o r m a t i o n on o p t i o n s f o r u n i n t e n d e d p r e g n a n c i e s would d i s r e g a r d e t h i c a l and l e g a l s t a n d a r d s o f m e d i c a l c a r e and would i n t e r f e r e w i t h a p a t i e n t ' s c o n t i n u i t y o f c a r e . They a l s o b e l i e v e t h a t t h e p r o v i s i o n s on p h y s i c a l and f i n a n c i a l s e p a r a t i o n would r e q u i r e T i t l e X c l i n i c s t o c h o o s e between a c c e p t i n g government r e s t r i c t i o n s o r f o r e g o i n g F e d e r a l s u p p o r t . Adolescents T e e n a g e P r e g n a n c y . I n r e c e n t y e a r s , g r e a t e r a t t e n t i o n h a s f o c u s e d on i n c r e a s e s i n t e e n a g e p r e g n a n c y r a t e s . Concern h a s been e x p r e s s e d o v e r t h e c o n s e q u e n c e s of t e e n a g e c h i l d b e a r i n g ( p a r t i c u l a r l y t o u n m a r r i e d and y o u n g e r a d o l e s c e n t s ) and o v e r t h e i n c i d e n c e of t e e n a g e a b o r t i o n s . The A d o l e s c e n t F a m i l y L i f e program, funded u n d e r T i t l e XX of t h e P u b l i c H e a l t h S e r v i c e Act, i s p r i m a r i l y intended t o h e l p prevent o r d e l a y sexual a c t i v i t y by t e e n a g e r s . While T i t l e X g u i d e l i n e s s t a t e t h a t a b s t i n e n c e i s a v a l i d and r e s p o n s i b l e o p t i o n and s h o u l d be d i s c u s s e d , T i t l e X f a m i l y p l a n n i n g c l i n i c s a r e a l s o r e q u i r e d t o o f f e r a b r o a d r a n g e of a c c e p t a b l e and e f f e c t i v e f a m i l y p l a n n i n g methods and s e r v i c e s ( i n c l u d i n g c o n t r a c e p t i v e s e r v i c e s ) t o a d o l e s c e n t s seeking such s e r v i c e s . The Off i c e of Family P l a n n i n g e s t i m a t e s t h a t a p p r o x i m a t e l y o n e - t h i r d o f a l l c l i e n t s s e r v e d a t T i t l e X c l i n i c s i n FY87 were a d o l e s c e n t s . Some s u p p o r t t h e a v a i l a b i l i t y and u s e of c o n t r a c e p t i v e s by t e e n a g e r s a s o n e o f t h e most e f f e c t i v e ways t o r e d u c e u n i n t e n d e d p r e g n a n c y and t h e i n c i d e n c e of a b o r t i o n . They deny t h a t a c c e s s t o c o n t r a c e p t i v e s e n c o u r a g e s s e x u a l a c t i v i t y among t e e n a g e r s ; i n s t e a d t h e y b e l i e v e i t i s a p r a g m a t i c r e s p o n s e t o minimize t h e r i s k f o r t h o s e t e e n a g e r s who e l e c t t o b e s e x u a l l y active. They a l s o s e e a n i m p o r t a n t r o l e f o r T i t l e X i n e d u c a t i o n a n d outreach f o r teenagers. O t h e r s d i s a g r e e t h a t i n c r e a s i n g c o n t r a c e p t i v e s e r v i c e s and i n f o r m a t i o n t o t e e n a g e r s h a s been d e m o n s t r a t e d t o be e f f e c t i v e a t r e d u c i n g t e e n a g e p r e g n a n c y and a b o r t i o n r a t e s . They would p r e f e r a g r e a t e r e m p h a s i s t o be p l a c e d on e f f o r t s t o p r e v e n t t e e n s f r o m becoming s e x u a l l y a c t i v e , r a t h e r t h a n on e f f o r t s t o d e c r e a s e t h e p e r c e n t a g e o f s e x u a l l y a c t i v e t e e n a g e r s who become p r e g n a n t . P a r e n t a l N o t i f i c a t i o n and C o n s e n t . T i t l e X law r e q u i r e s f a m i l y planning c l i n i c s t o encourage, t o t h e extent practical, family participation. I n 1983, t h e Department of H e a l t h and Human S e r v i c e s i s s u e d r e g u l a t i o n s t o implement t h i s p r o v i s i o n by r e q u i r i n g T i t l e X c l i n i c s t o n o t i f y p a r e n t s of unemancipated m i n o r s when p r e s c r i p t i o n d r u g s o r d e v i c e s a r e provided t o t h e s e a d o l e s c e n t s . C r i t i c s of t h e r e g u l a t i o n m a i n t a i n e d t h a t t h e Department e x c e e d e d i t s s t a t u t o r y a u t h o r i t y and c o n t r a v e n e d c o n g r e s s i o n a l i n t e n t by m a n d a t i n g , r a t h e r than simply encouraging, p a r e n t a l involvement. T h e s e c r i t i c s s o u g h t and o b t a i n e d a j u d i c i a l remedy, p r e v e n t i n g t h e r e g u l a t i o n s from t a k i n g e f f e c t . Those who s u p p o r t p a r e n t a l n o t i f i c a t i o n o r c o n s e n t r e q u i r e m e n t s c o n t e n d t h a t f a m i l y p l a n n i n g c l i n i c s c u r r e n t l y do n o t p l a c e enough e m p h a s i s on t h e need f o r f a m i l y i n v o l v e m e n t . They b e l i e v e t h a t s u c h r e q u i r e m e n t s would e n c o u r a g e p a r e n t s and t e e n s t o c o m n u n i c a t e b e t t e r a b o u t t h e a p p r o p r i a t e use of c o n t r a c e p t i v e s . Some p r e d i c t t h e g r e a t e r c o m u n i c a t i o n which t h e y b e l i e v e would r e s u l t c o u l d e n c o u r a g e t e e n a g e r s t o a b s t a i n from s e x u a l a c t i v i t y . They d i s p u t e c l a i m s t h a t p a r e n t a l n o t i f i c a t i o n o r c o n s e n t would r e s u l t i n i n c r e a s e d p r e g n a n c i e s t o t e e n s , s a y i n g i n s t e a d t h a t t h e i n c r e a s e d f a m i l y p a r t i c i p a t i o n as a r e s u l t of p a r e n t a l n o t i f i c a t i o n o r c o n s e n t would a l l o w T i t l e X c l i n i c s t o more e f f e c t i v e l y c o n t r i b u t e t o a reduced teenage pregnancy r a t e . Those opposed t o r e q u i r e d p a r e n t a l n o t i f i c a t i o n o r c o n s e n t f o r T i t l e X s e r v i c e s s a y t h e y a g r e e w i t h t h e v a l u e of encouraging family i n v o l v e m e n t , b u t do n o t b e l i e v e t h a t m a n d a t i n g s u c h i n v o l v e m e n t w i l l promote u s e f u l f a m i l y p a r t i c i p a t i o n ( i . e . , t h e y a r e c o n c e r n e d t h a t i n some c a s e s i t may s u b j e c t t h e t e e n a g e r t o f a m i l y f r i c t i o n o r a b u s i v e b e h a v i o r ) . They s t a t e t h e r e i s no e v i d e n c e t h a t p a r e n t a l n o t i f i c a t i o n o r c o n s e n t r e q u i r e m e n t s w i l l s i g n i f i c a n t l y r e d u c e t h e number o f s e x u a l l y a c t i v e a d o l e s c e n t s o r a s s i s t them i n making r e s p o n s i b l e d e c i s i o n s ; i n s t e a d , t h e o p p o n e n t s a r g u e , t h e r e q u i r e m e n t s may compel t e e n a g e r s who d o n o t w i s h t o i n v o l v e t h e i r p a r e n t s t o f o r e g o c o n t r a c e p t i o n o r t o u s e less e f f e c t i v e o v e r - t h e - c o u n t e r methods. School-Based Health Clinics. Concern o v e r a d o l e s c e n t s w i t h o u t a d e q u a t e a c c e s s t o h e a l t h c a r e s e r v i c e s h a s g e n e r a t e d an i n c r e a s i n g number of s c h o o l - b a s e d h e a l t h c l i n i c s i n t h e p a s t few y e a r s . These c l i n i c s g e n e r a l l y p r o v i d e a v a r i e t y of h e a l t h c a r e s e r v i c e s , i n many c a s e s including family planning services. According t o t h e O f f i c e o f Family P l a n n i n g , T i t l e X f u n d i n g s u p p o r t s Few, i f a n y a t a l l , o f t h e s e c l i n i c s (most F e d e r a l Government s u p p o r t comes f r o m t h e M a t e r n a l and C h i l d H e a l t h S e r v i c e s Block G r a n t and Medicaid programs; o t h e r f u n d i n g h a s been a v a i l a b l e f r o m f o u n d a t i o n s , p r i v a t e f u n d s , and f e e s ) . The two b i l l s t o r e a u t h o r i z e t h e T i t l e X program, S. 1366 ( ~ e n n e d ~and ) H.R. 3769 (Waxman), c o n t a i n p r o v i s i o n s which c o u l d f u n d i n f o r m a t i o n and e d u c a t i o n programs i n t h e community. T h e r e i s d i s a g r e e m e n t o v e r w h e t h e r o r t o what e x t e n t t h e s e new f u n d s would be u s e d t o i n c r e a s e T i t l e X s u p p o r t f o r s c h o o l - b a s e d health clinics. Some of t h o s e opposed t o s c h o o l - b a s e d h e a l t h c l i n i c s s a y t h e y a r e c o n c e r n e d t h a t new f u n d s f o r community-based i n f o r m a t i o n and e d u c a t i o n programs proposed i n t h e c u r r e n t r e a u t h o r i z a t i o n b i l l s would b e u s e d t o i n c r e a s e T i t l e X s u p p o r t f o r s c h o o l - b a s e d h e a l t h c l i n i c s which p r o v i d e family planning services. Acceptance of T i t l e X funding, t h e y m a i n t a i n , would r e q u i r e t h e s e c l i n i c s t o p r o v i d e a b o r t i o n c o u n s e l i n g and r e f e r r a l s . T h o s e opposed t o s c h o o l - b a s e d h e a l t h c l i n i c s which p r o v i d e f a m i l y p l a n n i n g s e r v i c e s b e l i e v e t h a t t h e y h a v e n o t been d e m o n s t r a t e d t o be e f f e c t i v e a t r e d u c i n g t h e a d o l e s c e n t pregnancy r a t e . They a r g u e t h a t i t i s u n c l e a r w h e t h e r c o n t r a c e p t i v e s e r v i c e s a r e b e i n g s o u g h t by t h o s e a l r e a d y s e x u a l l y a c t i v e o r t h o s e c o n t e m p l a t i n g t h e i n i t i a t i o n o f s e x u a l a c t i v i t y b e c a u s e of t h e a v a i l a b i l i t y of contraception. Opponents of s u c h c l i n i c s a l s o b e l i e v e t h a t t h e p r o v i s i o n o f c o n t r a c e p t i v e s by s c h o o l s s e n d s t h e wrong message t o c h i l d r e n and may, i n f a c t , condone t h e i r u s e . They a r g u e t h a t t h e p a r e n t a l c o n s e n t p o l i c i e s of some s c h o o l - b a s e d h e a l t h c l i n i c s ( e . g . , r e q u i r i n g b l a n k e t c o n s e n t forms u n r e l a t e d t o a n y s p e c i f i c c l i n i c v i s i t o r s e r v i c e ) a s w e l l a s t h e i r c o n f i d e n t i a l i t y p r o c e d u r e s may undermine p a r e n t a l a u t h o r i t y and r e s p o n s i b i l i t y . S u p p o r t e r s of t h e r e a u t h o r i z a t i o n b i l l s p o i n t o u t t h a t T i t l e X c u r r e n t l y p r o v i d e s v i r t u a l l y no f u n d i n g t o s c h o o l - b a s e d h e a l t h c l i n i c s , and s a y t h e y do n o t e x p e c t p r o v i s i o n s i n t h e r e a u t h o r i z a t i o n b i l l s on community-based i n f o r m a t i o n and e d u c a t i o n programs t o s i g n i f i c a n t l y i n c r e a s e t h e l e v e l of funding f o r school-based h e a l t h c l i n i c s , Without r e g a r d t o t h e d e b a t e o v e r r e a u t h o r i z a t i o n , s u p p o r t e r s of s c h o o l - b a s e d h e a l t h c l i n i c s which p r o v i d e f a m i l y p l a n n i n g s e r v i c e s b e l i e v e t h a t t h e i r a c c e s s i b i l i t y makes them p a r t i c u l a r l y e f f e c t i v e . The s u p p o r t e r s s a y t h a t t e e n a g e r s a r e more l i k e l y t o s e e k o u t t h e s e r v i c e s o f s c h o o l - b a s e d h e a l t h c l i n i c s b e c a u s e t h e y a r e c o n v e n i e n t ( u s u a l l y l o c a t e d on t h e s c h o o l g r o u n d s ) , a f f o r d a b l e , c o n f i d e n t i a l , and s t a f f e d w i t h h e a l t h p r o f e s s i o n a l s who have e x p e r i e n c e w i t h t h e s p e c i a l n e e d s o f a d o l e s c e n t s . They f a v o r t h e p r o v i s i o n of r e p r o d u c t i v e h e a l t h care services i n such c l i n i c s , p a r t i c u l a r l y i n r e s p o n s e t o t h e c o n c e r n o v e r t h e r a t e of t e e n a g e p r e g n a n c y a n d t h e s p r e a d o f s e x u a l l y t r a n s m i t t e d d i s e a s e s , i n c l u d i n g AIDS. S u p p o r t e r s emphasize t h a t school-based h e a l t h c l i n i c s do n o t o n l y p r o v i d e f a m i l y p l a n n i n g s e r v i c e s , b u t a l s o o f f e r o t h e r c o m p r e h e n s i v e p h y s i c a l and m e n t a l h e a l t h c a r e s e r v i c e s and r e f e r r a l s . C o n t r a c e p t i v e R e s e a r c h and Development T i t l e X s u p p o r t s family planning r e s e a r c h i n t h e biomedical, c o n t r a c e p t i v e d e v e l o p m e n t , b e h a v i o r a l , and program i m p l e m e n t a t i o n f i e l d s . The O f f i c e of F a m i l y P l a n n i n g awards g r a n t s and c o n t r a c t s f o r r e s e a r c h t o h e l p f a m i l y p l a n n i n g p r o v i d e r s d e l i v e r t h e i r s e r v i c e s more e f f e c t i v e l y and e f f i c i e n t l y . The N a t i o n a l I n s t i t u t e o f C h i l d H e a l t h and Human Development (NICHD), o n e o f t h e N a t i o n a l I n s t i t u t e s of H e a l t h , i s a l s o a u t h o r i z e d t o award g r a n t s and c o n t r a c t s f o r T i t l e X r e s e a r c h . S. 1366 would a u t h o r i z e new f u n d s f o r NICHD programs f o r t h e development and e v a l u a t i o n of c o n t r a c e p t i v e s and f o r t h e improvement o f c l i n i c a l management and d i r e c t d e l i v e r y of f a m i l y p l a n n i n g s e r v i c e s . There i s d e b a t e over whether t h e s u p p o r t f o r s u c h r e s e a r c h n e e d s t o be i n c r e a s e d and o v e r how s u c h a d d e d f u n d i n g would a f f e c t t h e s t a t u s o f r e s e a r c h on t h e a n t i p r o g e s t e r o n e d r u g RU-486, a d r u g whose p o t e n t i a l u s e s i n c l u d e u s e a s a c o n t r a c e p t i v e o r a b o r t i f a c i e n t ( i . e . , a d r u g which c a n c a u s e an a b o r t i o n ) . Those opposed t o i n c r e a s e d f u n d i n g l e v e l s f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t s a y t h e y a r e c o n c e r n e d t h a t some o f t h e new f u n d i n g w i l l n o t b e l i m i t e d t o r e s e a r c h on d r u g s and d e v i c e s which p r e v e n t p r e g n a n c y , b u t i n s t e a d may be u s e d f o r r e s e a r c h on a b o r t i f a c i e n t s . In particular, t h e y w o r r y t h a t some o f t h e money may go toward r e s e a r c h i n g RU-486, n o t i n i t s p o t e n t i a l c a p a c i t y as a c o n t r a c e p t i v e , b u t a s a n a b o r t i f a c i e n t . They a l s o b e l i e v e t h a t c u r r e n t f u n d i n g l e v e l s f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t a r e a d e q u a t e and e x p r e s s t h e p o s s i b i l i t y t h a t a s l o w e r p a c e of c o n t r a c e p t i v e development may a c t u a l l y b e d e s i r a b l e i n h e l p i n g t o p r e v e n t p o t e n t i a l damage t o women and t h e i r c h i l d r e n , s u c h a s t h e d a n g e r s posed i n t h e p a s t by t h a l i d o m i d e and d i e t h y l s t i l b e s t r o l (DES). T h o s e i n s u p p o r t of i n c r e a s e d f u n d i n g f o r c o n t r a c e p t i v e r e s e a r c h and d e v e l o p m e n t b e l i e v e s u c h f u n d i n g i s n e c e s s a r y t o f i n d and make a v a i l a b l e new s a f e and e f f e c t i v e c o n t r a c e p t i v e s . They s a y t h e y a r e c o n c e r n e d t h a t c o n t r a c e p t i v e o p t i o n s a r e becoming i n c r e a s i n g l y l i m i t e d (e.g., r e s t r i c t i o n s on t h e a v a i l a b i l i t y of i n t r a u t e r i n e d e v i c e s (IUDs) t o U.S. women) and a r e c o n c e r n e d a b o u t t h e l e n g t h o f t h e r e g u l a t o r y a p p r o v a l p r o c e s s and t h e expenses incurred i n o b t a i n i n g product liability insurance. S u p p o r t e r s ' s t a t e t h a t t h e l a n g u a g e on a b o r t i o n i n T i t l e X law, which p r o h i b i t s t h e u s e of f a m i l y p l a n n i n g f u n d s i n programs where a b o r t i o n i s a method o f f a m i l y p l a n n i n g , a l r e a d y p r o h i b i t s N I C H D from doing a b o r t i f a c i e n t research. They a r g u e t h a t l i m i t i n g b i o m e d i c a l r e s e a r c h on RU-486 and o t h e r a n t i p r o g e s t e r o n e d r u g s would b e u n w i s e b e c a u s e s u c h r e s e a r c h i s i n i t s e a r l y p h a s e s and may e v e n t u a l l y d e m o n s t r a t e s i g n i f i c a n t b e n e f i t s r e s u l t i n g from RU-486 i n t h e areas o f r e p r o d u c t i v e h e a l t h c a r e s e r v i c e s ( e . g . , c o n t r a c e p t i o n ) and o t h e r h e a l t h c a r e s e r v i c e s (e.g., b r e a s t cancer t r e a t m e n t ) . Adoption T i t l e X c l i n i c s a r e required t o o f f e r nondirective counseling and, upon r e q u e s t , r e f e r r a l s t o women r e q u e s t i n g i n f o r m a t i o n on o p t i o n s f o r t h e management o f a n u n i n t e n d e d p r e g n a n c y , i n c l u d i n g a d o p t i o n . The c l i n i c s a r e a l s o r e q u i r e d t o p r o v i d e a b r o a d r a n g e of a c c e p t a b l e and e f f e c t i v e f a m i l y p l a n n i n g methods and s e r v i c e s , i n c l u d i n g i n f e r t i l i t y s e r v i c e s . A l t h o u g h a d o p t i o n may be o n e o f t h e o p t i o n s a v a i l a b l e t o b o t h p r e g n a n t women and i n f e r t i l e c o u p l e s , t h e law d o e s n o t s p e c i f y t h a t T i t l e X s e r v i c e s may i n c l u d e a d o p t i o n placement s e r v i c e s . There i s c u r r e n t l y d i s c u s s i o n over t h e r o l e T i t l e X c l i n i c s should have w i t h r e s p e c t t o a d o p t i o n placement s e r v i c e s . Legislative proposals t o give T i t l e X c l i n i c s t h e option t o o f f e r a d o p t i o n p l a c e m e n t s e r v i c e s have been o f f e r e d i n t h e 1 0 0 t h C o n g r e s s . Those i n s u p p o r t of t h e s e p r o p o s a l s b e l i e v e t h a t a l a r g e r r o l e f o r T i t l e X c l i n i c s i n a d o p t i o n s e r v i c e s would e m p h a s i z e t h e i m p o r t a n c e o f p l a n n i n g f a m i l i e s t h r o u g h a d o p t i o n , b o t h by m o t h e r s f a c i n g an u n i n t e n d e d p r e g n a n c y and c o u p l e s u n a b l e t o o t h e r w i s e e s t a b l i s h a f a m i l y . They a r g u e t h a t some t e e n a g e r s may be c u r r e n t l y d i s c o u r a g e d from c h o o s i n g t o make a d o p t i o n p l a n s b e c a u s e t h e n e c e s s a r y s e r v i c e s a r e n o t w e l l i n t e g r a t e d . They s t r e s s t h a t t h e p r o p o s a l s would n o t o b l i g e a n y T i t l e X c l i n i c t o p r o v i d e a d o p t i o n s e r v i c e s , b u t would o n l y g i v e them t h e o p t i o n t o do s o . They s a y t h a t because T i t l e X c l i n i c s a r e r e q u i r e d t o o f f e r a broad range o f f a m i l y p l a n n i n g s e r v i c e s , t h e s e p r o p o s a l s would n o t a l l o w T i t l e X f u n d s t o s u b s i d i z e p r o j e c t s which o n l y p r o v i d e a d o p t i o n s e r v i c e s . l'hose opposed t o T i t l e X c l i n i c s p r o v i d i n g a d o p t i o n p l a c e m e n t s e r v i c e s argue t h a t family planning p r a c t i t i o n e r s a r e not g e n e r a l l y t r a i n e d o r e x p e r i e n c e d i n f u r n i s h i n g s u c h s e r v i c e s ( i n c l u d i n g home s t u d i e s and f o l l o w - u p c o u n s e l i n g ) . Opponents a r g u e t h a t f u n d i n g f o r a d o p t i o n s e r v i c e s would d i v e r t T i t l e X f u n d i n g away from t h e i r p r i m a r y p u r p o s e o f p r o v i d i n g c o n t r a c e p t i v e s e r v i c e s and i n f o r m a t i o n t o low-income women. They a l s o p o i n t o u t t h a t w h i l e f a m i l y p l a n n i n g s e r v i c e s a r e n e c e s s a r i l y o r i e n t e d t o a d u l t s , a d o p t i o n a g e n c i e s a r e t r a d i t i o n a l l y o r i e n t e d toward t h e n e e d s of t h e c h i l d . LEGISLATION 100-202, B.J.Res. 395 j o i n t r e s o l u t i o n making co n u i n g a p p r o p r i a t i o n s f o r FY88. E x t e n d s f u n d i n g f o r t h e F e d e r a l Government's a c t i v i t i e s ( i n c l u d i n g T i t l e X), a t t h e f u n d i n g l e v e l s of t h e p r e v i o u s f i s c a l y e a r , f r o m Nov. 2 2 , 1 9 8 7 , u n t i l S e p t . 30, 1988. S i g n e d i n t o law Dec. 2 2 , 1987. P.L. A 100-197, B.J.Res. 431 j o i n t r e s o l u t i o n making c o n t i n u i n g a p p r o p r i a t i o n s f o r FY88. E x t e n d s f u n d i n g f o r t h e F e d e r a l Government's a c t i v i t i e s ( i n c l u d i n g T i t l e X), a t t h e f u n d i n g l e v e l s o f t h e p r e v i o u s f i s c a l y e a r , from Dec. 1 9 , 1 9 8 7 , u n t i l Dec. 2 1 , 1987. Signed i n t o law Dec. 19, 1987. P.L. A P , L . 100-193, X.J.Res. 425 j o i n t r e s o l u t i o n making c o n t i n u i n g a p p r o p r i a t i o n s f o r FY88. Extends funding f o r t h e Federal ~ o v e r n m e n t ' sa c t i v i t i e s ( i n c l u d i n g T i t l e X), a t t h e f u n d i n g l e v e l s of t h e p r e v i o u s f i s c a l y e a r , f r o m Dec. 1 7 , 1987, u n t i l Dec. 1 8 , 1987. S i g n e d i n t o law Dec. 1 6 , 1987. A 100-162, B.J.Res. 394 j o i n t r e s o l u t i o n making c o n t i n u i n g a p p r o p r i a t i o n s f o r FY88. Extends funding f o r t h e Federal ~ o v e r n m e n t ' sa c t i v i t i e s ( i n c l u d i n g T i t l e X ) , a t t h e f u n d i n g l e v e l s o f t h e p r e v i o u s f i s c a l y e a r , from Nov. 11, 1987, u n t i l Dec. 1 6 , 1987. S i g n e d i n t o law Nov. 10, 1987. P.L. A 100-120, B.J.Res. 362 j o i n t r e s o l u t i o n making c o n t i n u i n g a p p r o p r i a t i o n s f o r FY88. Extended f u n d i n g f o r t h e F e d e r a l ~ o v e r n m e n t ' s a c t i v i t i e s ( i n c l u d i n g T i t l e X ) , a t t h e f u n d i n g l e v e l s of t h e p r e v i o u s f i s c a l y e a r , from O c t . 1, 1 9 8 7 , u n t i l Nov. 1 0 , 1987. S i g n e d i n t o law S e p t . 3 0 , 1987. P.L. A H.R. 1279 ( B l i l e y ) / s . 271 ( ~ u m p h r e y ) Allows T i t l e X f a m i l y planning p r o j e c t s t o o f f e r adopt i o n s e r v i c e s . R e q u i r e s s u c h s e r v i c e s t o be n o n d i s c r i m i n a t o r y a s t o r a c e , c o l o r , H.R. 1279 i n t r o d u c e d Feb, 26, 1987; religion, or national origin. r e f e r r e d t o Committee on Energy and Commerce Subcommittee on H e a l t h and t h e Environment. S. 271 i n t r o d u c e d J a n . 6 , 1987; r e a d t w i c e and r e f e r r e d t o Committee o n Labor and Human R e s o u r c e s . H.R. 1729 ( H Y ~ ~ ) / s 1242 . (~umphre~) P r o h i b i t s T i t l e X f u n d s from p r e s i d e n t ' s P r o - L i f e B i l l of 1987. b e i n g awarded by g r a n t o r c o n t r a c t ( e x c e p t a g r a n t o r c o n t r a c t d i r e c t l y a d m i n i s t e r e d by a S t a t e o r i t s p o l i t i c a l s u b d i v i s i o n ) t o a n y o r g a n i z a t i o n p r o v i d i n g a b o r t i o n s o r a b o r t i o n r e f e r r a l s , u n l e s s t h e l i f e of t h e mother would be e n d a n g e r e d by c o n t i n u i n g t h e pregnancy. P r o h i b i t s t h e u s e of F e d e r a l f u n d s f o r a b o r t i o n s , e x c e p t when c o n t i n u i n g t h e p r e g n a n c y would endanger t h e mother's l i f e . H.R. 1729 i n t r o d u c e d Mar. 1 9 , 1987; r e f e r r e d t o Committee on Energy and Commerce Subcommittee o n H e a l t h a n d t h e Environment. S. 1242 i n t r o d u c e d May 20, 1987; r e a d t w i c e and r e f e r r e d t o Committee on Labor and Human R e s o u r c e s . H.R. 3769 axma man) F a m i l y P l a n n i n g Amendments Act of 1987. Authorizes T i t l e X family p l a n n i n g c l i n i c s e r v i c e s a t $148.3 m i l l i o n f o r FY89, $156.2 m i l l i o n f o r FY90, and $164.2 m i l l i o n f o r FY91. Removes p r o v i s i o n s i n T i t l e X s t a t u t e which c u r r e n t l y a l l o w t h e S e c r e t a r y , a t t h e r e q u e s t of a T i t l e X g r a n t r e c i p i e n t , t o r e d u c e t h e amount o f t h e g r a n t by t h e v a l u e o f s u p p l i e s o r e q u i p m e n t f u r n i s h e d by t h e S e c r e t a r y . Repeals e x i s t i n g formula g r a n t provisions. A u t h o r i z e s g r a n t s and c o n t r a c t s f o r t e c h n i c a l a s s i s t a n c e a n d p e r s o n n e l t r a i n i n g a t $4.7 m i l l i o n f o r FY89, $4.9 m i l l i o n f o r FY90, a n d $5.1 m i l l i o n f o r FY91. A u t h o r i z e s r e s e a r c h g r a n t s and c o n t r a c t s f o r t h e d e v e l o p m e n t and e v a l u a t i o n o f c o n t r a c e p t i v e s and f o r t h e improvement o f c l i n i c a l management and d i r e c t d e l i v e r y of f a m i l y p l a n n i n g s e r v i c e s a t s u c h sums a s may be n e c e s s a r y . Authorizes g r a n t s o r c o n t r a c t s f o r i n f o r m a t i o n and e d u c a t i o n programs a t s u c h sums a s may be n e c e s s a r y . R e q u i r e s t h e s e c r e t a r y t o c o l l e c t s p e c i f i e d d a t a a n n u a l l y and p r o v i d e s f o r i t s a v a i l a b i l i t y t o C o n g r e s s and t h e p u b l i c . I n t r o d u c e d Dec. 1 5 , 1987; r e f e r r e d t o Cornnittee on Energy and Comnerce. S. 1366 (Kennedy) F a m i l y P l a n n i n g Amendments of 1987. Authorizes T i t l e X family p l a n n i n g c l i n i c s e r v i c e s a t $155.5 m i l l i o n f o r FY88, $163.0 m i l l i o n f o r FY89, $171.0 m i l l i o n f o r FY90, and $179.5 m i l l i o n f o r FY91. Removes p r o v i s i o n s i n T i t l e X s t a t u t e which c u r r e n t l y a l l o w t h e S e c r e t a r y , a t t h e r e q u e s t of a T i t l e X g r a n t r e c i p i e n t , t o r e d u c e t h e amount o f t h e g r a n t by t h e v a l u e o f s u p p l i e s o r equipment f u r n i s h e d by t h e S e c r e t a r y . A u t h o r i z e s g r a n t s and c o n t r a c t s f o r t e c h n i c a l a s s i s t a n c e and p e r s o n n e l t r a i n i n g a t $4.3 m i l l i o n f o r FY88, $4.5 m i l l i o n f o r FY89, $4.7 m i l l i o n f o r FY90, and $5.0 m i l l i o n f o r FY9l. Repeals e x i s t i n g formula g r a n t p r o v i s i o n s . A u t h o r i z e s r e s e a r c h g r a n t s and c o n t r a c t s f o r t h e d e v e l o p m e n t and e v a l u a t i o n of c o n t r a c e p t i v e s and f o r t h e improvement o f c l i n i c a l management and d i r e c t d e l i v e r y of f a m i l y p l a n n i n g s e r v i c e s a t $10 m i l l i o n f o r FY88 and s u c h sums a s may be n e c e s s a r y f o r FY89, FY90, and FY91. A u t h o r i z e s g r a n t s o r c o n t r a c t s f o r comnunity-based i n f o r m a t i o n and e d u c a t i o n programs a t $10 m i l l i o n f o r FY88 and s u c h sums a s may be n e c e s s a r y f o r FY89, FY90, and FY91. Requires t h e Secretary t o c o l l e c t s p e c i f i e d d a t a a n n u a l l y and p r o v i d e s f o r i t s a v a i l a b i l i t y t o C o n g r e s s and the public. I n t r o d u c e d J u n e 1 6 , 1987; r e a d t w i c e and r e f e r r e d t o C o r n i t t e e on Labor and Human R e s o u r c e s . H e a r i n g s h e l d J u l y 3 0 , 1987. O r d e r e d t o be r e p o r t e d f a v o r a b l y , a s amended, Nov. 1 2 , 1987. CONGRESSIONAL HEARINGS, REPORTS, AND DOCUMENTS U.S. Congress. Senate. Committee on Labor and Human R e s o u r c e s . F a m i l y P l a n n i n g Amendments of 1987. Hearings, 100th Congress, s e s s i o n . J u l y 3 0 , 1987. [ u n p u b l i s h e d ] The 1st CHRONOLOGY 02/02/88 --- Administration published f i n a l r u l e s i n the Federal Register ( 5 3 FR 2921) t o amend t h e r e g u l a t i o n s g o v e r n i n g t h e u s e o f T i t l e X funds. 12/22/87 --- H.J.Res. 395, which e x t e n d s f u n d i n g f o r T i t l e X u n t i l S e p t . .30, 1988, s i g n e d i n t o law a s P.L. 100-202. 12/20/87 --- H.J.Res. 431, which e x t e n d e d f u n d i n g f o r T i t l e X u n t i l Dec. 2 1 , 1987, s i g n e d i n t o law a s P.L. 100-197. 12/16/87 --- 11/12/87 --- H.J.Res. 4 2 5 , which e x t e n d e d f u n d i n g f o r T i t l e X u n t i l Dec. 1 8 , 1987, s i g n e d i n t o law a s P.L. 100-193. S . 1366, a b i l l t o r e a u t h o r i z e T i t l e X , r e p o r t e d f a v o r a b l y by t h e S e n a t e C o m n i t t e e on Labor and Human R e s o u r c e s , a s amended . 11/10/87 --- 09/30/87 --- 09/01/87 --- 07/30/87 --- H.J.Res. 3 9 4 , which e x t e n d e d f u n d i n g f o r T i t l e X u n t i l Dec. 1 6 , 1987, s i g n e d i n t o law a s P.L. 100-162. H.J.Res. 362, which e x t e n d e d f u n d i n g f o r T i t l e X u n t i l Nov. 1 0 , 1987, s i g n e d i n t o law a s P.L. 100-120. A d m i n i s t r a t i o n published proposed r u l e s i n t h e F e d e r a l R e g i s t e r ( 5 2 F.R. 33209) t o amend t h e r e g u l a t i o n s g o v e r n i n g t h e use of T i t l e X funds. H e a r i n g s h e l d on S. 1366, a b i l l t o r e a u t h o r i z e T i t l e X . FOR ADDITIONAL READ1NG U.S. L i b r a r y of C o n g r e s s . Congressional Research S e r v i c e . Legal 1729, t h e P r e s i d e n t ' s P r o - L i f e B i l l o f 1987, by a n a l y s i s of H . R . ( W a s h i n g t o n ] J u n e 1 6 , 1987. C h a r l e s V. Dale. CRS R e p o r t 87-862 A ----- L e g a l a n a l y s i s of t h e Department o f H e a l t h and Human S e r v i c e s ' p r o p o s e d r e g u l a t i o n s t o amend c u r r e n t r e g u l a t i o n s g o v e r n i n g t h e u s e of Federal funds f o r family planning s e r v i c e s under T i t l e X of t h e [Washington] Oct. 19, P u b l i c H e a l t h S e r v i c e A c t , by Karen J . Lewis. 1987. CRS R e p o r t 87-840 A ----- Teenage pregnancy: i s s u e s and l e g i s l a t i o n [ b y ] S h a r o n S t e p h a n and R u t h E l l e n Wasem. [ W a s h i n g t o n ] 1986. (Updated r e g u l a r l y ) CRS I s s u e B r i e f 86128