This analysis was originally published on Health Affairs Blog.
In April, the Trump administration released two Teen Pregnancy Prevention Program (TPPP) funding opportunity announcements (FOAs) that would fundamentally shift the program from one grounded in evidence to one emphasizing abstinence-only when it comes to the sexual and reproductive health and rights of young people.
The TPPP was created with bipartisan support in 2010 to fund both evidence-based programs and innovative approaches to reducing pregnancy among adolescents and supporting their sexual health. Grant recipients have implemented and evaluated a wide range of interventions, including youth development, child and parent communication, abstinence-based programs, HIV prevention programs and sex education.
Although the administration avoids the term "abstinence" entirely—instead using the rebranded label of "sexual risk avoidance"—the administration cannot mask its goal of promoting abstinence outside of marriage as the only choice for young people. In the process, these FOAs abandon evidence; ignore the rights of young people to information and education that reflect and respect their experiences and needs; and manipulate research and data in an attempt to legitimize its abstinence-only approach.
Abandoning Evidence
The creation of TPPP represented an important shift from ideology to evidence in programs to address adolescent sexual health. In 2010, Congress drastically reduced spending on abstinence-only-until-marriage programs, heeding overwhelming scientific evidence that these programs were not only ineffective at their singular goal, but harmful to young people. Instead, Congress established TPPP to support a wide range of programs that are age-appropriate, medically accurate and based on evidence. Still, dedicated funding continued to flow toward abstinence-only programs, with two such programs, a state-based "sexual risk avoidance education" grant program and a similarly named competitive grant program currently funded at a combined total of $100 million this year alone.
Yet social conservatives have always opposed TPPP. Consequently, President Trump’s first two budget proposals recommended eliminating TPPP, and the administration ended some grants immediately and shortened the rest from five to three years—leading to ongoing legal actions. Congress ultimately rebuffed the administration’s proposal to eliminate TPPP and maintained funding for it in fiscal year (FY) 2018.
Under the new FOAs, future TPPP recipients will be expected to implement abstinence-only priorities, including emphasizing that "teen sex is a risk behavior" promoting avoidance of— i.e. abstinence from—this behavior and "skills to help those youth already engaged in sexual risk to return toward risk-free choices in the future." Furthermore, the FOAs neglect to provide applicants with evidence-based guidance in selecting replicable program models proven effective through rigorous evaluation.
Specifically, the FOAs ignore the body of research developed over the past eight years of investments in programs to prevent adolescent pregnancy and HIV and other STIs, including lessons learned and information about programs proven effective in changing adolescent sexual behaviors.
Notably in these FOAs, grantees are no longer directed to model their programs on ones that HHS has already determined to be effective based on the evidence—a list that has grown from 28 programs to 48 programs as a result of investment in programs like TPPP. Instead, applicants are supposed to choose a program based on a program selection "tool." One of the two tools that applicants may use is centered on the single goal of promoting abstinence until marriage. The other option seems to allow for a broader approach, but its inclusion appears to be a smokescreen, because in practice, a broader approach would conflict with the abstinence-only implementation priorities required by the administration’s new FOAs.
The program selection guidance—or lack thereof—is not the only indication that the administration is turning its back on science. The administration altered the definitions of key terms such as "medical accuracy" and "age appropriate" in the TPPP FOAs to enable abstinence-only programs to withhold or misrepresent information. For example, the definition of "age appropriate" was amended in a way that allows program implementers and facilitators to withhold information based on their subjective beliefs about what is appropriate for a particular age group.
Ignoring The Rights, Needs And Experiences Of Young People
While evidence clearly shows that increased and improved use of contraception is driving the declining rate of pregnancy among 15–19 year olds in the United States, the administration makes no reference in the FOAs to the role that access to health services plays in preventing pregnancy among adolescents. The current round of TPPP projects are required to establish and maintain linkages and referrals for youth-friendly health care services, and to disseminate information about these services to young people and their families. By contrast, future recipients under these FOAs will not have to address the specific needs of young people in accessing sexual and reproductive health services.
Despite more than 70% of adolescent pregnancies occurring among 18–19 year olds, the administration fails to highlight programs meeting the needs of these older adolescents. Recipients of TPPP funding would be required to promote returning to abstinence as the only acceptable message—as opposed to providing truly age-appropriate information. Not only does this deny the lived reality of young people, the majority of whom have had sex by the end of high school, it also ignores their needs as they age, with nine in 10 people having sex by their mid-20s.
Disregarding the research on LGBTQ young people’s need for inclusive sex education, the administration reverses prior requirements regarding LGBTQ inclusivity. The administration also removes prior requirements that grant recipients ensure a safe and supportive environment for youth and their families, as well as policies prohibiting discrimination and harassment based on race, sexual orientation, gender, gender identity and expression, religion, and national origin. Instead, the administration asserts that non-discrimination requirements may only apply "in some cases," leaving LGBTQ young people even more marginalized and vulnerable to harassment and stigmatization under future TPPP projects.
Ultimately, with these FOAs, the administration fails to prioritize the actual needs of young people. Prior TPPP projects were required to implement or develop programs intended to reduce existing disparities and meet the needs of marginalized populations, such as young people of color, youth in foster care, young parents and LGBTQ young people. While TPPP programs will be required to select target "participants and communities most at risk," no specific adolescent populations—or proven effective program models serving these young people—are discussed. The Trump FOAs in no way acknowledge the unique and individualized needs of young people who cannot be served by a one-size-fits-all abstinence-only approach to sexual health.
Manipulating Research And Data
Decades of research show that abstinence-only programs are not only ineffective at their own goal and harmful to young people, but also that programs including topics beyond abstinence better equip young people with the information and skills to make their own healthy sexual decisions. The administration ignores this large body of evidence and instead offers up a selective interpretation and misrepresentation of data and research in the TPPP FOAs.
For instance, to make the case for an abstinence-only approach, the FOAs emphasize recent trends around young people delaying sex and the number of young people who have never had sex. Notably absent, however, is recognition that the trend toward sexual delay is among younger adolescents who are still just as likely as in the past to have had sex before finishing high school. Additionally, the vast majority of the decline of younger adolescents having sex occurred between 2013 and 2015, a timeframe in which the federal government was putting a larger emphasis on evidence-based programs over abstinence-only approaches.
Finally, the administration distorts the findings of a leading credible source to support its reimagining of the program, while failing to acknowledge that the same report explicitly recommends against implementing abstinence-only programs. In fact, the report finds that comprehensive sexuality education is the approach that is likely to "ensure that all adolescents and young adults’ rights to essential health information are met."
Looking To The Future
There are key decision points still to come in the months ahead that may determine how successful the Trump administration will be in converting TPPP into a third dedicated federal funding stream for abstinence-only programs. According to the FOAs, as many as 345 grants could be awarded for two-year abstinence-only projects by the end of September 2018.
It is critical that the progress made since 2010—with the creation of TPPP and prioritizing the role of evidence in support of programs to help prevent unintended pregnancy, HIV and other STIs among adolescents—not be reversed for the sake of an abstinence-only agenda. Beyond that, advocates will continue to push for improvements that strengthen TPPP, as well as fight for policies that go further to meet the needs and experiences of all young people through comprehensive sex education.