For the past four months, advocates for comprehensive sexuality education have been waiting with great anticipation for President Obama’s 2010 budget. After eight years of funding of disproven abstinence-only programs, the recent upturn in the teen pregnancy rate, stalled efforts to reduce the incidence of HIV and other sexually transmitted infections, and “educational” strategies that ranged from the ridiculous (abstinence clowns) to the dangerous (the withholding of accurate information to teens at risk), it was long past time to fund programs that work.

The budget, released yesterday, puts us on the road to evidence-based public health policy.  It does not, unfortunately, really advance the journey towards comprehensive sex education, and is therefore a missed opportunity.  Instead, it is now up to advocates, Congress, and the agencies that administer sex education programs to drive the process needed to get us to our destination.

The President’s budget would eliminate the abstinence-only programs of the past and replace them with a new Teen Pregnancy Prevention Initiative. The budget abolishes both Title V and the Community-Based Abstinence Education Program (CBAE), which provided large pots of money to community-based organizations for now-discredited programs. Title V, for example, which is administered by the Department of Health and Human Services (HHS) Administration for Children and Families (ACF), requires that states, in order to receive funding, adhere to certain requirements, including barring teachers from discussing contraception and requiring them to say that sex within marriage is "the expected standard of sexual activity."  Getting rid of this program and replacing it with evidence-based programs represents a major victory, as does the elimination of the narrow “8-point” definition that has long governed abstinence-only program funding.  (It is important to note that the President’s budget is hortatory; it advises on the President’s goals and objectives, but final decisions on what actually happens with all of this will rest with Congress so much work has yet to be done.)

The budget includes roughly $170 million for the new Teen Pregnancy Prevention initiative. Of that total, $110 million 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.

Funding for community and faith-based initiatives is split into two streams of which $75 million is slated for programs that:

"replicate the elements of one or more teenage pregnancy prevention programs that have been proven through rigorous evaluation to delay sexual activity, increase contraceptive use (without increasing sexual activity), or reduce teenage pregnancy."

An additional $25 million dollars is made available for:

"research and demonstration grants to develop, replicate, refine, and test additional models and innovative strategies for preventing, teen pregnancy; and of which any remaining amounts shall be available to fund other teen pregnancy prevention activities."

The public health advocacy community applauded these changes, but with important caveats.

“Eliminating CBAE and Title V is a big deal,” said James Wagoner, President of Advocates for Youth.  “After a decade of failed abstinence-only programs, this is a huge step forward. President Obama deserves praise for returning evidence- and science-based approaches to public health policy by eliminating these programs.” Ron Johnson, Deputy Director of AIDS Action Council, agreed, saying, “We are very pleased with the redirection of funds away from abstinence-only toward broader approaches.”

Still, all those interviewed expressed concern that the framework set forth by the Administration for programs is too narrow, and that ambiguous language in the budget leaves open the possibility of continued support for abstinence-only programs.

For example, there is an epidemic of sexually transmitted diseases among youth in the United States and approximately 24 new HIV infections among youth every day. Yet, “instead of focusing on providing comprehensive sexuality education aimed at achieving a wide range of outcomes…the President’s budget focuses on reducing teen pregnancy as the critical outcome for federal funding,” said Joseph DiNorcia, President of the Sexuality Information and Education Council of the United States (SIECUS).  He states that:

"The exact language in the President’s budget for this new initiative remains narrowly focused on the silo of preventing teen pregnancy and fails to embrace programs that also help young people avoid acquiring a sexually transmitted disease, including HIV/AIDS. This myopic approach does not represent the current state of the research or the desire of the American people for the federal government to invest in comprehensive sex education. We need a broader approach to help adolescents make good, healthy, and responsible decisions."

Wagoner agrees, adding that;

"While the narrower pregnancy prevention framework is science-based, as currently defined it would exclude some programs to reduce HIV and other sexually transmitted infections among youth, and does not immediately or holistically address the needs of youth, particularly in communities of color or among LGBT youth."

Moreover, he continued,

"It represents a big missed opportunity both in failing to fund comprehensive sex education and failing to clarify that programs should take the holistic, positive, and affirming approach to sexual health offered by proven comprehensive programs, and that goes well beyond the current narrow focus."

Well-designed comprehensive programs use age-appropriate tools to  develop better negotiation skills, tackle gender stereotypes, support mutuality, communication, and consensuality in healthy relationships and both address and prevent sexual coercion and violence, especially among intimate partners.  The goals are healthier sexual and reproductive choices throughout a person’s life-cycle and not just the absence of disease or pregnancy. Advocates will work through the appropriations process to strengthen language supporting such an approach.

The budget also leaves gaps that may prove to be highly problematic. It provides dedicated funding to “community- and faith-based organizations,” for example, but none for schools. This amounts to a “shotgun” approach to funding, according to Wagoner, because spreading money and programming among many organizations means reaching only those youth who attend such programs, and does not provide the more universal, concentrated and systematic approaches that would come through promoting school-based comprehensive sexual health education with consistent well-designed curricula.

“After a decade of denial and misinformation and $1.5 billion spent on failed programs,” says Wagoner, “we have to target schools because that is where the kids are.” He continues:

"It is not that pregnancy prevention is not important and there is no objection to funding going to community-based organizations and state agencies to do this work. But without strong signals and support from the White House, many school districts will continue ab-only policies. Putting all $170 million into one strategy alone is deeply misguided and a portion of these funds should be allocated to help those school districts that choose to create new programs get some of these funds."

The vagueness of the language also leaves the “back-door” open for continued funding of failed abstinence-only programs, depending on which agencies administer the funds, and what guidelines they write for funding. Lack of clarity in the language directing spending of the $25 million in community grants allocated to “innovative strategies” could be used by specific agencies to support abstinence-only-until-marriage programs.  It also is not yet clear which faith-based organizations will be able to receive funding given the emphasis on evidence-based programs, which further raises concerns about the share of the money pegged for "innovative" approaches.  Can faith-based programs opposed to providing accurate information on safer sex, contraception and HIV and other infections be able to claim "innovations" in abstinence-only efforts, or in programs that omit discussion of sexual diversity, stigma, and discrimination?  This remains to be seen.

As with every law and policy, the devil is in the details of funding guidelines and the internal politics of the agencies that administer funds. Under Title V, the Administration for Children and Families (ACF) was responsible for writing guidelines for and funding abstinence-only programs, and is still staffed with holdovers from the Bush Administration. It is possible that ACF would be tasked with administering a large portion of the new funding, in which case some fear that without much greater clarity from the Administration and Congress in support of comprehensive programs for all funding streams, there may be a tendency within ACF to take the easy route and continue funding ideologically- driven programs.

“The track record of some of these agencies on ab-only is really bad,” said Wagoner, “ and it would take some real leadership and a stated commitment to public health within these agencies to ensure we do not return to the days when politics and ideology undermined public health and science. We’d like to see these resources go through the public health divisions within HHS and CDC instead.”

Going forward, notes AIDS Action Council’s Johnson:

"we intend to join others in the community to make sure that actual implementing guidelines include HIV and STD prevention as key outcomes.  We also want to make sure the focus on teen pregnancy does not exclude the kind of comprehensive sex education needed for LGBT youth."

Most agree that the budget is a product of a political compromise wrought from trying to find ways to keep public health, science and conservative faith-based organizations in the same room in the current effort to find a “middle ground” on most things sex-related.

But, as Wagoner says:

“sex education is about public health and the human right to accurate information needed both to exercise rights and safeguard individual and national health. You cannot compromise this. When individual rights and public health get mediated through a political desire to ‘reduce the need for abortion’ or appease a specific community’s political demands, it is public health that suffers.”

Now the focus turns to Congress, particularly the Democratic leadership.

“To get us further toward our destination,” says Wagoner, “we are going to have to do three things:”

• Work with the Democratic leadership–Speaker Pelosi and Congressman Obey–to eliminate failed abstinence-only programs as the budget process moves into appropriations;
• Ensure that abstinence-only programs don’t get funded through the backdoor;
• And broaden the focus of the Obama effort to include comprehensive sex education through targeted funding for schools, as well as providing a push to local school districts to broaden their curricula to include what works.

"This is the only way," says Wagoner, "to provide redress for a decade of denial and disinformation which is the legacy of the abstinence-only debacle."