Several years ago, David Wiley, a professor of health education at Texas State University, was discussing human papillomavirus in one of his classes. The virus, known as HPV, is the most common sexually-transmitted disease. Often it is harmless and infected individuals aren’t even aware they have it. But it can also cause cancer, including of the cervix.
Wiley was discussing all of this with his students — the different types of HPV, the connection between HPV and cervical cancer, and its prevalence; “you know, just an intro, lower-level course,” he recently recalled — when a male student raised his hand with an earnest question: What was his risk of contracting cervical cancer?
“And I don’t know what’s sadder,” Wiley told The Intercept, “that he asked that question or that really nobody in the classroom even laughed because they didn’t know either.”
The question wasn’t terribly surprising to Wiley, who has been teaching and researching health education — including sex education — for nearly four decades. Many of the students who’ve come through his classes over the years have been woefully uninformed about the workings of their own bodies, he says. But Wiley doesn’t blame the students — after all, “if you never teach people math, how are they going to learn calculus? So, that’s part of our problem: You get exactly what you pay for.”
And in Texas — along with a majority of other states — when it comes to sex education, that means sinking millions into programs that preach to students the virtues of abstinence until marriage while foregoing actual education on sexuality and reproductive health, including the use of contraceptives (aside from emphasizing their failure rates), the prevention of STDs, and the importance of consent.
The federal government began funding so-called Abstinence-Only Until Marriage programs in 1981 as a way to encourage “chastity” and “self-discipline.” Since then, the feds have poured more than $2 billion into this strategy — commonly known as “ab-only” — without any proven positive effects, like delaying sexual activity or avoiding unintended pregnancy. In recent years, that funding had been in decline, in part because research — and practical experiences like Wiley’s — shows that the programs do not work. But in an ironic twist, they’re now making a comeback. Trump, an alleged serial adulterer who has bragged about sexually assaulting women and has been accused of such behavior close to two dozen times, has asked that abstinence funding be increased. And in the budget deal he signed last month, he got his wish, enough to bring total spending on abstinence up to $100 million for 2018.
Texas was an eager adopter of the abstinence-only approach, which expanded in 1996 and continued rapid growth during the George W. Bush administration, and has spent more than any other state on ab-only programs. Yet the state has also consistently had among the highest rates of teen pregnancy — it’s currently fifth in the nation; Arkansas is No. 1 — and maintains a stranglehold on the top spot for the number of repeat births to teens (at 24 percent).
Under Obama, funding for ab-only programs decreased as new emphasis was placed on using science to develop evidence-based sexuality and reproductive education strategies. But the Trump administration is trying to reverse course. Along with the return to Bush-era funding levels to push the ab-only message, Trump has appointed anti-abortion, anti-birth control, and pro-ab-only advocates to positions within the Department of Health and Human Services and has yanked funding for a successful evidence-based teen pregnancy prevention strategy.
Chitra Panjabi, president and CEO of the Sexuality Information and Education Council of the United States, said in a press release that it was “unacceptable” that Congress would go along with this and elect “to waste millions on this failed approach to sex ed that is not only ineffective, but also actively harms young people.”
A Cycle of Ignorance
At the time that Wiley was confronted with a male student’s concern about developing cervical cancer, he was also deep into research on sex education in Texas public schools that would result in a groundbreaking report issued in 2009 by the Texas Freedom Network Education Fund, titled “Just Say Don’t Know.”
The research was ambitious: The team sent open records requests to each of the state’s more than 1,000 school districts asking for materials related to sex ed, including curricula and student handouts. They received documents from more than 96 percent of districts. What they learned was illuminating.
More than 94 percent of districts were teaching only lessons in abstinence; just under 4 percent were providing any instruction in “responsible pregnancy and STD prevention,” including the use of contraceptives. And roughly 2 percent of districts were ignoring sex ed altogether, even though it was part of a state health education requirement. Religious justifications played a part in some of the district’s explanations for why they weren’t teaching sex ed, while others were simply dismissive. One superintendent emailed Wiley and his colleagues to explain that in his small district most of the kids “live on a farm or have animals they feed and care for,” the school official wrote. “They get a pretty good sex education from their animals.”
Perhaps more troubling were the abstinence-only curricula that the schools were using. They reflected a staunchly heteronormative worldview, and thus completely dismissed the needs of LGBTQ students. They downplayed the importance of contraceptives and in particular the effectiveness of condoms in preventing the spread of disease. They were heavy on the use of fear and shame as a teaching strategy — suggesting those who’ve engaged in sex are “unclean” — and rife with problematic, if not dangerous, gender stereotypes. “Girls, taking into consideration that guys are more easily sexually turned on by sight, you need to think long and hard about the way you dress and the way you come on to guys,” reads one curriculum that was used in multiple school districts. “A girl who shows a lot of skin and dresses seductively fits into one of three categories: 1.) She’s pretty ignorant when it comes to guys, and she has no clue what she’s doing. 2.) She’s teasing her boyfriend, which is extremely cruel to the poor guy! 3.) She’s giving her boyfriend an open invitation saying, ‘Here I am. Come take me.’”
Unsurprisingly, all the problems the Texas researchers found in the state’s ab-only programs are found in classrooms across the country. “These programs that are solely focused on promoting abstinence until marriage can be very harmful, particularly for young people who are already marginalized,” says Jesse Boyer, senior policy manager at the Guttmacher Institute. “There’s a lot of research and attention, rightfully so, … around the impacts of these programs on LGBTQ people and, particularly in this last year, at the height of the Me Too awareness and sexual violence, thinking through [what] the message of being ‘unclean’ if you have engaged in sex before marriage might mean for a survivor of sexual assault.”
Ultimately, Wiley’s 2009 report didn’t prompt much improvement in Texas. That same year state lawmakers eliminated the state’s health education requirement.
In a follow-up report that looked at the 2015-16 school year, Wiley and his team found that the percentage of school districts teaching abstinence-only had decreased from 94 to 58 percent, but the number of districts teaching nothing at all had skyrocketed from just over 2 percent to nearly 22 percent. “So, it’s this revolving cycle of ignorance,” says Wiley.
While the goal of abstinence programs is to convince adolescents to refrain from all sexual activity until marriage, it makes little practical sense — and they’re entirely ineffective in prompting sexual abstinence. By the time they’re seniors in high school, roughly 60 percent of adolescents have engaged in sexual activity, says SIECUS CEO Panjabi. Yet, abstinence programs shame sexually active adolescents, completely ignoring the fact that the majority of teens need practical sexual health information — including the importance of contraception and pregnancy and STD prevention. Research shows that adolescents subjected to ab-only programs are less likely to use contraception when they do have sex. Other research shows that girls who break a pledge to abstain from sex have a higher risk of getting pregnant and of developing HPV. “These studies suggest that user failure with abstinence is high,” reads a September 2017 article in the Journal of Adolescent Health. “Thus, although theoretically completely effective in preventing pregnancy, in actual practice the efficacy of [ab-only] interventions may approach zero.”
Given the clear failure of these programs, it’s perhaps unsurprising that ab-only advocates in recent years have made a concerted effort to rebrand their efforts — forsaking the title “abstinence education” in favor of “sexual-risk avoidance” programs, language co-opted from the public health community.
Among the biggest proponents of ab-only programs — and their rebranding — is Valerie Huber, a Trump appointee to HHS. Huber started her career promoting ab-only programs in her son’s school before moving on to manage the ab-only program at the Ohio Department of Health. She became the president of the National Abstinence Education Association in 2007. (The advocacy organization has also rebranded itself. It’s now known as Ascend.) Huber acknowledges that the term “sexual-risk avoidance” was taken from public health, but insists it was appropriately chosen. “I bristle at the terminology ‘abstinence only,’ because our programs are so holistic,” she told Focus on the Family’s magazine “Citizen,” and address “a whole battery of different topics that surround a young person’s decision whether to have sex or not.”
“Our critics like to pigeonhole this as a religious issue,” she said, “but the truth is that this has value for every student regardless of faith or moral framework — or lack thereof.”
Huber’s protestations aside, sexuality education experts say the new ab-only programs are the same as the old ones. “Let’s first point out why they’re trying to rebrand,” says Panjabi. “They’re trying to rebrand because ‘abstinence-only’ has become a dirty term. There’s no support for abstinence-only programs.” Polling shows that parents “overwhelmingly” want their kids to be getting sex education in the classroom — education that talks about the “value” of abstinence, she says, “but in conjunction with understanding condoms, … contraception, and now, increasingly, wanting young people to know about consent” — none of which the ab-only programs actually do, no matter what they’re called.
The name change simply hasn’t “changed the content,” says Boyer. “They claim that they cover contraception in a comprehensive way. They claim they cover healthy relationships in a comprehensive way, but unfortunately, when the ultimate goal of providing the information is to promote abstinence as the only and best course of behavior, there is no way that can be provided in a noncoercive, complete way.”
Also concerning to Boyer is that the language of sexual-risk avoidance has crept into funding announcement for the Title X program — the only funding stream dedicated to family planning — and over which Huber has significant influence. Breaking with recommendations of the Centers for Disease Control and Prevention, which say quality family planning programs should provide “comprehensive” information on pregnancy and STD prevention to patients, Trump’s HHS is urging that abstinence be stressed. (The Trump administration’s vision for Title X would also have providers push natural family planning as viable birth control.)
Preventing Teen Pregnancy Prevention
In all, Boyer says that the administration’s strategy — from the provision of sexuality education to the provision of family planning services — is being driven by ideology and not science or data. “The motivation behind supporting abstinence-only programs is an ideological agenda to co-opt … evidence-based and public-health approaches to try to sell the programs that we know can harm young people,” she said. “And I think that’s really the baseline of it all.”
Last fall the administration demonstrated as much in announcing it was going to yank funding for an ongoing evidence-based program known as the Teen Pregnancy Prevention Program. The TPP Program was created in 2010 as part of the negotiations around passage of the Affordable Care Act. At the same time, lawmakers created the Personal Responsibility Education Program, which still wasn’t comprehensive sexuality education, but in addition to promoting abstinence it required education on contraceptives as well as other life lessons, including discussion of things like healthy relationships. Both the TPP Program and PREP program had broad bipartisan support.
What was so groundbreaking about each program was that they were evidence-based programs. Researchers would study how states implemented PREP and collect performance data. The TPP Program funded grantees not only to implement programs proven “through rigorous evaluation” to reduce the incidence of teen pregnancy, but also to conduct rigorous evaluations of “new and innovative approaches” that aimed to reduce teen pregnancy. The TPP Program was to be funded in five-year study cycles.
“Both programs were incredibly unique, it’s kind of embarrassing to say, because it was one of the first times there was an evidence requirement,” says Boyer, “that we’re going to use evidence and science to direct where these resources go, which was absolutely a ginormous deal.”
And things were going well, particularly in the testing of new strategies under the TPP. Although teen pregnancy has been on a decline for years, the numbers plummeted after creation of the PREP and TPP Program — declining 41 percent between 2010 and 2016, more than twice the decline seen in any other six-year period. While advocates and experts don’t claim the reduction is totally a result of the new evidence-based programs, they believe they have played a role. In January, the CDC said as much, noting that the “innovations in federal resources” for teen pregnancy prevention may have contributed to the steep decline.
The Trump administration was apparently unimpressed. In award letters that went out last year, HHS summarily informed TPP Program grantees that the program would end this summer, on June 30, instead of in 2020 — a move reportedly guided in part by Huber. “One of the really good things about the [TPP Program] is that it is providing a real understanding, evidence-based, of what does work with those very specific outcomes … such as reducing unintended pregnancy,” says Panjabi. “So why would we shorten a grant period and prevent clear evaluations from happening?”
According to the administration, the TPP Program wasn’t working because a number of the strategies being studied failed to change teen behavior. But Panjabi says this is misleading at best: Rigorous evaluation of public health programs is designed to weed out what doesn’t work and to find the best strategies — that is, after all, the point of scientific study. And with the TPP Program, she said, four of the 10 programs that were repeatedly evaluated over time did have a positive impact. “One of the things I think is really important to remember is that when you’re sort of looking at this in line with other public health evaluations, that’s actually a pretty good percentage,” she said. “So again, it’s a misunderstanding of how data and analysis and science are used to inform our approaches. That’s something that we should all be concerned about.”
Although the Trump administration’s goal was to completely defund the TPP Program, it lost that bid when lawmakers put money into the new budget to keep it going. Meanwhile, a number of groups involved in the TPP Program — including Planned Parenthood — have sued the administration in federal court, claiming that defunding the project mid-cycle violates the Administrative Procedures Act. Cutting off the funding would harm the 1.2 million adolescents being served by the program nationwide, and would “deprive” them of the “high-quality information and education that have demonstrated effectiveness in helping young people make healthy decisions about their health and their futures,” reads one lawsuit filed on behalf of several Planned Parenthood affiliates whose participation in the TPP Program is serving some 40,000 young people. The lawsuits, filed last month, are pending.
For all the years that professor David Wiley has spent teaching and researching health education, he isn’t surprised that the state of sex education in the U.S. isn’t better. And in Texas, he’s not sure it ever will be. He notes that while research shows that ab-only programs are ineffective at changing adolescent behavior — that is, delaying sexual initiation or providing essential information on reproductive health — research shows that what does work is to “normalize” the topic by having direct and comprehensive discussions with young people. “Actually, the sooner you talk to kids about sex and birth control, the more information you give them, the more likely they are to wait longer before having sex, and once they do they’re much more likely to use birth control,” he says. “So, what we’re doing is exactly the opposite of what science shows.”