A feature article published on Rewire this morning, June 29th, 2009, explores the links between sexual violence and coercion and patterns of contraceptive use, unintended pregnancy, and sexually transmitted infections in teens.  The article cites the work of Elizabeth Miller, M.D., Ph.D.,
an assistant professor of pediatrics at the University of California,
Davis, whose work with colleagues at the Harvard School of Public Health shows that intimate partner violence plays a critical but largely overlooked role in high rates of adverse sexual and reproductive health outcomes among teens.

Rates of unintended pregnancy among teens have been on the upswing the past few years.  "We also have an epidemic of sexually
transmitted diseases among youth and every hour at least one young person
acquires HIV in our country," wrote Bill Smith, Vice President of Public Policy at the Sexuality Information and Education Council of the United States and James Wagoner, President of Advocates For Youth, in a recent feature article for Rewire.

After years of funding abstinence-only-until marriage programs, there is virtually unanimous agreement among researchers and advocates about doing far more to
address teen sexuality, prevent unintended pregnancy and sexually
transmitted infections, and prevent the violence and coercion by intimate
partners among youth that contribute to these problems. The complexities and synergies between the factors that result in adverse sexual and reproductive health outcomes among teens must be addressed as they are experienced by real people in their everyday lives–comprehensively.  Most experts agree that the solutions lie in sophisticated and integrated approaches to sexuality and reproductive health education and service delivery in schools and communities. 

According to Miller, for example, a critical place to start addressing
these links, is within sex education programs.  Today, she says:

Most schools are
barely doing sex ed and basic health. It doesn’t make sense to talk about substance
abuse use this week and pregnancy next week and STDs the following week
and then healthy relationships the week after that. We need
to be talking about how they’re all linked together.

Her
vision: stop "siloing" the issues that affect teen sexual health and
relationships.

During the campaign, then-candidate Obama appeared to agree.  And after the election, a great deal of hope was placed in the Obama Administration’s promise to create comprehensive, evidence-based approaches to these problems.

It then comes as something of a surprise that a coalition of over 175 state and national organizations representing advocates, service providers and researchers concerned with comprehensive sex ed now finds itself pressing the White House and Congress to get rid of these silos and is pushing back against what they see as the limited scope of the Obama Administration’s new Teen Pregnancy Prevention Initiative.  The approach taken by the Administration is even more puzzling when placed in a global context: Recognizing the problems with silo-ed approaches to global health, for example, the Administration has proposed a far more integrated approach to global health programs than in the past.

As Congress turns to appropriations for Fiscal Year 2010, the coalition– which includes local groups such as the AIDS Taskforce of Greater Cleveland and Chicago Women’s AIDS Project; state groups such as the Minnesota AIDS Project, Pennsylvania NOW, and the South Carolina Coalition for Healthy Families; and national groups such as the Black Women’s Health Imperative and United Church of Christ among many others–is working strenuously to ensure that both the Administration and Congress commit to a broader program than originally called for in the President’s budget.

In his first budget request to Congress, President Obama recommended elimination of the abstinence-only programs of
the past, replacing these with a new Teen Pregnancy Prevention
Initiative.  As Rewire  reported earlier, the budget request abolished both Title V and the Community-Based Abstinence Education Program (CBAE),
which provided large pots of money to community-based organizations for
now-discredited abstinence-only-until-marriage programs. Getting rid of
these programs and replacing them with evidence-based initiatives represented a
major victory for public health and human rights, as did the elimination of the narrow “8-point”
definition that has long governed abstinence-only program funding. 

In place of abstinence-only programs, the President’s budget recommended that roughly $170 million be spent on a new Teen Pregnancy
Prevention initiative.  If enacted by Congress as recommended by the White House, $110 million of that total would be used to
support "community-based and faith-based efforts to reduce teen
pregnancy using evidence-based and promising models."  An additional $50
million in funding would be granted to the states for programming, and
the rest to research, evaluation, and management.

The majority of groups in the public health and sexual and
reproductive health advocacy communities applauded the elimination of
abstinence-only programs, but were deeply disappointed at the narrow scope of the new initiative, in part, they argued because the programs eligible for funding would address only one outcome (unintended pregnancy), deny funding to programs addressing a wider range of outcomes, and ignore the needs of gay, lesbian and transgender youth, among other concerns.  In fact, they argue, the proposed approach only repeats past mistakes and the vague direction given by the Administration leaves the program vulnerable to changes in the balance of power in Congress. 

A letter sent to the White House and Congress by the informal coalition of groups stated:

We are encouraged by the significant step forward that the
President’s Fiscal Year 2010 budget represents in supporting
evidence-based interventions.  After $1.5 billion of wasteful spending
on ineffective abstinence-only-until-marriage programs, we have an
opportunity to craft a program that addresses the root issues that help
teens make responsible decisions and keep them safe and healthy.  And
with that opportunity comes the responsibility to take a holistic
approach that includes both disease and teen pregnancy prevention
programs.

Now, however, is the time, according to the letter, to take a more comprehensive approach to empowering, informing and training all young people to make healthy decisions and to act responsibly about their relationships and their sexual health.

As currently written, states a memo sent by members of the Coalition to the Office of Management and Budget (OMB),

the President’s initiative could be interpreted to limit eligible programs to those with the primary intention of preventing teen pregnancy.   If not expanded, the language may be interpreted to preclude other evidence-based prevention programs that were originally designed to reduce rates of sexually transmitted infection, including HIV/AIDS, but that also have been shown to have a positive impact on the behaviors associated with teen pregnancy prevention. 

The narrow focus of the President’s teen pregnancy initiative caught the advocacy community by surprise in part because the informal coalition of groups, which had been meeting for months, drafted consensus language and recommendations and submitted these to the White House well in advance of the release of the budget.  Given the open-door policy of the White House in working with the communities in question, the broad-base of the coalition, the consensus achieved, and the signals given by key Administration officials, members of the coalition assumed that the case had been made for the replacement of narrow abstinence-only programs with broader, evidence-based approaches that would address teen health wholistically.

In fact, said Smith of SIECUS, the confusion was amplified by assurances from White House officials after release of the budget that "they never intended for this program to be so narrowly conceived." 

But, according to another coalition member speaking on condition of anonymity, White House officials, representatives of the Department of Health and Human Services (HHS), and representatives of OMB appeared to be operating under different assumptions and communicating different messages, definitions and descriptions of the initiative to Congress, the community, and the press regarding the scope of the new program, how it would be administered, and what outcomes it would seek to achieve.  Efforts to gain clarity on the program for this article from public affairs staff at the White House, HHS and OMB were unsuccessful.

Only one organization, the National Campaign to Prevent Teen and Unplanned Pregnancy, has come out publicly supporting the intiative in its current form.  The Campaign, which did not participate in earlier coalition efforts to create consensus, and was not a signatory to the broader community letter, circulated a brief in reaction to the coalition’s efforts to broaden the initiative warning that "discussions about this bold proposal must not become so testy that policymakers who already face a whole host of pressing challenges turn away from this area entirely."  Members of the larger coalition speaking off the record for this article expressed deep frustration at what they saw as the effort of one organization to hinder efforts of a broad-based coalition to achieve urgently needed changes in approaches to teen health for which many have been working for more than a decade.  A request for further comment by the Campaign on these issues and to understand the organization’s objection to a broader focus was declined. 

Smith, Wagoner and others are deeply concerned about the limited scope of the current initiative in light of the challenges faced in promoting better sexual and reproductive health outcomes among teens and young adults, and because there is currently no coordinated plan to create a consistent effort to reach teens through school-based programs, the one place where the greatest level of consistency in program design and effort can be achieved through reaching the greatest number of teens.

These concerns are heightened by several considerations.  One is timing. The coalition of groups has asked the White House Domestic Policy Council to provide clarity on the scope of the program and their commitment to broadening it.  Participants in recent meetings on this issue indicated that they were "definitely heard by the Administration staff, but were told that a response is not forthcoming immediately."  Smith says that "until the White House makes clear its intentions to broaden the program, the message to Congress is one of a narrow approach, which leaves us in a precarious position as we go into appropriations."

Another concern is that some critical public health initiatives are already short of funds, and because of the narrow scope of the new initiative,  programs considered critical to improving teen health outcomes will have greater constraints if they are not eligible for funding under the proposed teen initiative.

Given the spread of HIV and other sexually transmitted infections among
adolescents, notes Donna Crews, Director of Government Affairs at the AIDS Action
Council, "An effort created within a ‘teen pregnancy silo’ is too
narrow" to address this critical areas of public health. 

Crews cites the flatlining of funding for HIV prevention and
surveillance by the Centers for Disease Control as one part of the
broader problem. Between Fiscal Years (FY) 2006 and 2007, for example, funding
for HIV prevention and surveillance rose from $651 million to nearly
$696 million.  In FY 2008, however, that funding fell to $692
million and was flatlined in FY 2009, at a time when HIV infections are
rising among certain populations, including among youth.

These
funding constraints would be compounded if HIV and STI prevention are
left out of the new initiative.  Moreover, separate streams of funding are part of the problem to begin with so the solution sought is to have an integrated program, not increases in various silos for school-based efforts per se. 

A memo prepared by SIECUS and
Advocates for Youth notes that at least 10 evidence-based interventions
currently being advanced by the Centers for Disease Control and others could not be funded under
the proposed structure because they are not teen
pregnancy prevention programs per se, but rather HIV/AIDS prevention
initiatives that result in the "same salutary behavioral outcomes that
reduce risk behaviors and that contribute to teen pregnancy and
acquisition of STIs, including HIV," according to Smith.

Examples of programs that would not be eligible include:

Becoming a Responsible Teen: A program that combines HIV/AIDS education with behavioral skills training, including assertion, refusal, self-management, problem solving, risk recognition, and correct condom use. Teens learn to clarify their own values about sexual decisions and to practice skills to reduce sexual risk-taking.  Outcomes include delayed initiation of sex; reduced frequency of sex; reduced number of partners; and increased use of condoms.

¡Cuidate!: This HIV risk reduction curriculum was culturally adapted from Be Proud! Be Responsible! It incorporates salient aspects of Latino culture, especially the importance of family and gender role expectations. It presents both abstinence and condom use as culturally acceptable and effective ways to prevent STIs, including HIV. Outcomes include   reduced frequency of sex; reduced number of partners; reduced incidence of unprotected sex; and increased use of condoms.

HIV Risk Reduction for African American and Latina Adolescent Women, a skills-based HIV and STI risk reduction intervention designed for use in an adolescent medicine clinic that also provides young clients with confidential and free family planning services. The program teaches young women skills necessary to use condoms and addresses personal vulnerability and the heightened HIV risk facing young, inner-city Latinas and African American women. Outcomes include reduced number of partners; reduced incidence of unprotected sex; reduced incidence of STIs.

Crews and others agree that it is urgent to create comprehensive approaches to education and prevention among teens, in school and at the community level, because the money allocated for the program can be used more effectively to achieve several positive outcomes simultaneously, a concern greatly amplified by the current crisis in health care costs nationwide.

In their letter, the coalition is urging the Administration and Congress, to support the following:

1) Inclusive language that supports HIV/AIDS and other sexually transmitted infection programs in addition to teen pregnancy prevention.  

"Young people in this country need access to complete and comprehensive information that helps them make responsible and informed decisions," states the letter. "The current FY10 budget proposal focuses solely on preventing teen pregnancy and must be expanded to include the prevention of sexually transmitted infections. While teen pregnancy prevention is certainly important, it must not create an artificial barrier to investment in other critical interventions such as those that focus on HIV/AIDS education and prevention, healthy relationships, and comprehensive sex education.  By supporting overarching language that is inclusive of additional approaches, we can make sure that comprehensive programs are brought to scale that meet the diverse needs all young people in all communities, including lesbian, gay, bisexual, transgender, and questioning youth whose needs fall wholly outside of the narrow teen pregnancy prevention framework."

2) Specific and strategic investment in schools and school-based programs as a compliment to already stated support for community-based programs.

The letter states that "President Obama’s FY10 budget recognizes the need to support evidence-based intervention programs by working with community-based and faith-based organizations. These important institutions are critical for reaching young people, but must work alongside schools and school-based programs. Over the past several years, significant policy shifts and evidence-based programming in schools have created a unique and unprecedented opportunity to support a systemic change by assisting schools in institutionalizing comprehensive programs aimed at helping improve adolescent sexual behaviors.  The current language excludes important public entities, such as schools, from accessing funds under the new initiative.  Prioritizing schools in the new initiative can help ensure smart and multi-faceted investments toward a sustainable legacy to improve the health of our nation." 

3) Diversified investments among multiple existing government agencies that can work in communities as well as schools, particularly at the Centers for Disease Control and Prevention.

"The Administration’s current language maintains all of the funding at the Administration for Children and Families (ACF) within the Department of Health and Human Services," says the letter.  "Ensuring funding for evidence-based interventions through the CDC will allow for a greater diversification of the new initiative’s funding and can ensure that scarce resources are invested in federal agencies that have the capacity to successfully bring evidence-based interventions to scale immediately.  For example, the CDC’s Division of Reproductive Health and the Division of Adolescent School Health have proven track records in sex education programming for youth that is firmly rooted in public health practice.  Therefore, while ACF certainly should have a role in the new initiative to work with faith and community-based organizations, it must not come at the exclusion of the CDC’s proven prevention efforts that can help ensure success of the new initiative."

SIECUS, Advocates for Youth, and members of the coalition report that they are working collegially with the White House and Congress to urge this expansion in language and to hold the White House and Congress accountable for the investment in comprehensive sex education that is needed and for which the President has stated support.

"The three items we advance here," states the coalition letter, "and [which we] urge you to support, will move us closer to the type of change
that is needed in our nation’s approach to achieving a healthier and
safer generation of young people."