The debate over sexuality education and teenage pregnancy prevention has been extremely divisive for many years, and it promises only to heat up in the coming months in the context of the presidential campaign. Texas Gov. George Bush, who locked up the Republican nomination in March, has long made abstinence promotion a prominent feature of his campaign rhetoric. Gov. Bush has promised that, if elected president, he would "elevate abstinence education from an afterthought to an urgent priority" by dramatically increasing funding for federal abstinence-only programs.

On the congressional front, Rep. Ernest Istook (R-OK), a long-standing opponent of the Title X family planning program, secured a major down payment on this effort during last year's annual appropriations cycle and has already pledged to come back this year for more. Yet the drive to boost funding for abstinence-only education programs—already up significantly since 1996—continues despite a dearth of evidence that these programs are effective in delaying sexual activity. Instead, the evidence strongly supports the effectiveness of more comprehensive efforts and the important role of contraceptive use in reducing teenage pregnancy rates.

Federal Funding for Abstinence

Gov. Bush promises that his administration would spend at least as much each year on promoting abstinence education as it does on providing contraceptive services to teenagers. However, quantifying the exact amount being spent in each area is not easy.

Currently, there are two federal programs that provide funding specifically for abstinence-only education. One is the 1981 Adolescent Family Life Act (AFLA), sponsored by Title X opponents and promoted as a "family-centered" approach to teenage pregnancy prevention that would "promote chastity and self-discipline" to teenagers rather than provide them with contraceptive services. AFLA has been dogged by controversy from the beginning, and, until recently, its funding has been low. In its early years, it was attacked from the left and was subjected to a protracted lawsuit alleging numerous constitutional violations. Subsequent reforms instituted by the Clinton administration to ensure that AFLA funding did not promote religious dogma or provide medically inaccurate information only alienated conservatives, who charged that the administration had watered down the original abstinence-only thrust of the program ("Whatever Happened to the Adolescent Family Life Act?" April 1998).

In 1996, conservative policymakers and activists were successful in including, with virtually no debate, a provision in the massive welfare reform bill that resulted in a major infusion of dollars into abstinence-only education. Unlike AFLA, which targets premarital sex, the new program funds education efforts that must have as their "exclusive purpose" censuring all sex outside of marriage, at any age; the provision of any information about contraception beyond failure rates is prohibited. To qualify for funding, education programs under the welfare provision must adhere to a strict eight-point definition of "abstinence education."

Together, these two programs provide significant funding—notwithstanding the protestations of those who claim that funding for abstinence remains woefully low. The welfare law entitles states to $50 million in federal funds annually; because states must spend $3 for every $4 they receive, the total amount spent pursuant to this one program alone is almost $90 million annually. Due to Rep. Istook's efforts, a 1999 appropriation bill doubled funding for the AFLA program to $40 million (some of which, however, will not become available until October 1), requiring most of those funds to be spent on abstinence-only education under the strict welfare-program definition ("Congress in 1999: Actions on Major Reproductive Health—Related Issues," December 1999).

In addition to this dedicated federal funding, funds available to the states under other health or social welfare programs also may be used for abstinence education or counseling; such programs include the maternal and child health (MCH) block grant and the social services block grant, as well as the Title X program. In fact, more than half of agencies that receive Title X funding run programs at one or more clinic sites designed to encourage adolescents to postpone sexual activity. Finally, abstinence promotion is strongly supported by state and local governments, and it is now required by the overwhelming majority of local school districts that have a policy to teach sexuality education (see box).

Assessing the Impact

Clearly, then, there is a substantial amount of federal and other public support for abstinence education—and for abstinence-only education. Yet, the fact remains that, to date, there is a stunning lack of evidence of the effectiveness of this approach. While AFLA was enacted as a temporary "demonstration" program specifically to test and evaluate various program interventions, two decades and millions of dollars later there is no conclusive evidence that abstinence-only education works. In the most complete analysis of AFLA evaluations to date, a team of university researchers concluded in a 1996 report that "the quality of AFLA evaluations funded by the federal government vary from barely adequate to completely inadequate." Indeed, the researchers report that they "are aware of no methodologically sound studies that demonstrate the effectiveness" of abstinence-only curricula.

Other evaluations of abstinence-only programs arrived at a similar conclusion. A 1997 report commissioned by the National Campaign to Prevent Teen Pregnancy, while noting that methodological limitations due to the poor quality of the evaluations could have obscured program impact, nonetheless concluded that published studies of abstinence-only programs yielded no evidence that such programs delayed the onset of sexual activity. In contrast, the review concluded that more comprehensive sexuality education programs—those which included discussion of contraception—did not hasten sexual activity as their critics claim but, instead, helped teenagers to delay sexual activity. When teenagers who received more comprehensive education did become sexually active, the report found, they had fewer partners and were more likely than their peers who did not receive such messages to use contraceptives.

Finally, an article published in the Journal of the American Medical Association in 1998, which reported the results of the first-ever randomized controlled trial comparing an abstinence-only program with a "safer-sex" initiative designed to reduce the risk for HIV infection through condom use and a control group that received health education unrelated to sexual behavior, found similar results. After one year, the abstinence group reported similar levels of sexual activity as the safer-sex group and the control group. For teenagers who were already sexually active at the inception of the program, there was less sexual activity reported among the safer-sex group than among the abstinence or control groups. Those in the safer-sex group also reported less frequent unprotected sex than did the abstinence and control groups, suggesting that abstinence-only efforts may discourage effective contraceptive use and thus put individuals at greater risk of unintended pregnancy or sexually transmitted diseases (STDs) when they do become sexually active.

Funding for Contraception

If it is difficult to quantify exactly how much the federal government spends on abstinence education, it is even harder to measure how much is being spent on contraceptive services to teenagers. Both the U.S. General Accounting Office and Advocates for Youth, an advocacy organization dedicated to promoting adolescent reproductive and sexual health, have estimated the amount spent on contraceptive services to teenagers under Title X and Medicaid—the two major sources of federal funding for family planning—to be almost $130 million annually.

Family planning experts caution that such calculations are at best imprecise and that comparisons between funding for abstinence education and contraceptive services can be misleading. Jacqueline Darroch, senior vice president and vice president for research at The Alan Guttmacher Institute (AGI), notes that "these estimates were arrived at simply by taking the proportion of clients served by the programs who were teens and applying that percentage to the overall funding level. That assumes all clients receive the same services, while certain populations—particularly teens—may be more expensive to serve than others, because they require more intensive counseling and may be at high risk for STDs, for example. And, to be fair," says Darroch, "it needs to be acknowledged that these estimates do not take into account funding for contraceptive services under other federal programs, such as the MCH or social services block grants."

Judith DeSarno, president and CEO of the National Family Planning and Reproductive Health Association, meanwhile, argues that "spending in these two areas is simply not comparable on a number of fronts." DeSarno notes, "Family planning involves providing a broad package of medical services beyond just the prescription of a contraceptive method, including pap smears, breast exams, and screening and treatment for STDs. It also involves in-depth, one-on-one counseling. This is a far more expensive endeavor than talking to adolescents, often in a classroom or other group setting, about abstinence."

What is clear, however, is that publicly funded family planning has a significant effect on teenage pregnancy. Each year, subsidized family planning services prevent an estimated 386,000 teenagers from becoming pregnant. Without these services, the number of births to teenagers would increase by one-quarter, and the number of abortions to teenagers would rise by nearly two-thirds. Moreover, while abstinence advocates claim credit for recent declines in teenage pregnancy, an AGI analysis of available data suggests otherwise. In fact, this analysis found that approximately one-quarter of the decline in teenage pregnancy between 1988 and 1995 is due to increased abstinence; about three-quarters of the decline is due to improved contraceptive use among sexually active teenagers.

The Road Ahead

Gov. Bush, as have so many abstinence proponents before him, claims that "the contraceptive message sends a contradictory message [that] tends to undermine the message of abstinence." The evidence, however, suggests that the reverse is true: Teenagers who receive messages that support postponing sexual activity but also include accurate information about contraception are more likely to delay sexual initiation than those who just receive abstinence-only messages, and they are better prepared to avoid unintended pregnancy and disease when they eventually do have intercourse. The drive to increase federal funding for abstinence-only education is also out of step with the beliefs of most Americans, who overwhelmingly favor—by a margin of more than four to one—broader sex education programs over those that teach abstinence as the only option.

Nonetheless, the effort to further increase funding for abstinence-only education is likely to gather steam as the presidential and congressional campaigns heat up. Key conservative members of Congress are already working toward this goal, and even many progressive politicians have trouble distinguishing between abstinence education, which virtually no one opposes, and abstinence-only efforts.

After ensuring last year that an additional $20 million for abstinence-only education will be set aside for release on October 1, Rep. Istook and his colleagues are already working for an additional $30 million in the context of the upcoming appropriation cycle. Their goal is to raise the annual federal funding level alone for abstinence-only education beyond the $100 million mark. Whether this effort will be successful, and whether it will be accompanied by a corresponding increase in federal funding for family planning services, remains to be seen.