This analysis was originally published on Health Affairs Blog.
On February 23, the Trump administration released its long-overdue funding opportunity announcement (FOA) for Title X family planning services grants. This year’s FOA release is noteworthy not only for its months-long delay, but also for how it signals the administration’s interest in fundamentally altering the Title X program in the name of its own socially conservative agenda—particularly when it comes to contraceptive and related care.
Title X is the sole federal program dedicated to family planning services, with a focus on helping disadvantaged individuals affordably obtain the care they need and want. According to the Office of Population Affairs (OPA), which administers Title X, the program supports about 4,000 safety-net family planning sites that collectively served four million women, men and adolescents in 2016 alone. In recent years, OPA has also worked with the Centers for Disease Control and Prevention to establish Quality Family Planning Guidelines, evidence-informed clinical recommendations that set the standard of care for family planning services—standards to which Title X-supported providers have previously been held.
Now, however, the Trump administration is using the FOA to push long-standing socially conservative priorities. It opens the door to undercutting the intent and impact of Title X in four overarching ways: reshaping its provider network; promoting natural family planning over other contraceptive methods; pushing abstinence-only messaging to adolescents; and interfering with individuals’ ability obtain confidential care.
Reshaping The Title X Provider Network
The FOA stacks the deck against providers that focus on reproductive health care, instead favoring providers that offer family planning services in the broader context of primary care, such as federally qualified health centers (FQHCs). The FOA does not provide a reason or cite evidence for why such a shift is needed. However, this preference tracks with a favorite but flawed political talking point of social conservatives, who suggest FQHCs are ubiquitous and readily able to meet the need for publicly funded family planning.
Funneling scarce Title X dollars to primary care providers would inevitably come at the expense of reproductive health-focused sites, in turn jeopardizing the program’s ability to meet women’s needs. Title X relies on a diverse network of family planning providers, 72 percent of which focus on reproductive health care.
Among family planning providers, reproductive health-focused providers are more likely than primary care providers to implement protocols that help women choose and start using whatever methods of contraception will work best for them. This includes offering a full range of contraceptive method options (74 percent versus 48 percent of sites, respectively), and helping women to obtain those methods at the same time as their initial visit; this is particularly true for long-acting reversible contraceptive methods and birth control pills.
Moreover, many women actively choose reproductive health-focused providers for their contraceptive care, even when there is a primary care-focused site available. Top reasons women cite for this decision include feeling respected by staff, being able to obtain confidential services, and feeling that staff are well-versed in women’s health.
And although FQHC sites in particular are an increasingly important part of the Title X network, it is unrealistic to expect them to quickly develop the capacity to serve significantly more contraceptive clients, both because they are already struggling to meet the demand for care and because they cannot specialize in reproductive health.
Promoting Natural Family Planning Over All Other Contraceptive Options
In keeping with priorities articulated in a Trump administration memo leaked last year, the FOA repeatedly emphasizes the need to offer fertility awareness methods (FAMs)—implying that currently, such methods are not sufficiently available to Title X clients. In fact, FAMs have always been part of the broad range of contraceptive methods supported by the program, and are explicitly mentioned in the Title X statute and regulations. And although the FOA repeatedly mentions FAMs, it does not acknowledge the importance of ensuring women have a true choice of contraceptive methods. Nor does it mention to the standard of client-centered, comprehensive contraceptive care as detailed in the Quality Family Planning Guidelines—a sharp departure from last year’s funding announcement, which emphasized these guidelines throughout.
Additionally, the FOA explicitly promotes the inclusion of sites that "have developed expertise in one family planning approach or method" of contraception. Sites that offer only a single contraceptive method have always been permitted as part of a larger Title X project as long as the project overall makes a broad range of methods available to clients. However, the FOA’s explicit invitation to single-method sites and its emphasis on FAMs seem to open the door to ideologically motivated entities, such as antiabortion counseling centers, whose approach would actively undermine the Title X tenets of ensuring women’s contraceptive choices are voluntary and free from coercion.
In fact, FAMs instruction and supplies are widely available among Title X-supported sites: more than nine in 10 (93 percent) offer FAMs instruction and supplies. Notably, reproductive health-focused sites are more likely than those offering family planning in the context of broader primary care to offer FAMs (91 percent versus 75% percent). And the trend has been toward making FAMs more available, not less: From 2003 to 2015, the proportion of all Title X family planning centers offering FAMs counseling or supplies increased significantly, from 61 percent to 93 percent.
Moreover, even though FAMs are widely available at Title X sites, Title X clients (like U.S. contraceptive users generally) do not commonly choose them; less than 0.5 percent of Title X clients chose to rely on these methods in 2016. This low prevalence may relate to patient preferences. For example, a 2012 study on contraceptive features preferred by women at high risk of unintended pregnancy found that FAMs are tied with withdrawal for having the fewest features women find important in a birth control method.
Once again reflecting a well-known preoccupation of the administration—particularly of the Trump-appointed head of OPA, Valerie Huber—the FOA urges providers to communicate abstinence-only-until-marriage messages to adolescents. It promotes this messaging using language such as "avoiding sexual risk" and "returning to a sexually risk-free status." This language is now common among abstinence-only proponents, as part of an attempt to rebrand their agenda.
All of this again flies in the face of the federal Quality Family Planning guidelines that advise that adolescents be given "comprehensive information…about how to prevent pregnancy" and sexually transmitted infections (STIs), including—but not limited to—information on abstinence.
In contrast, no matter the label, abstinence-only approaches withhold crucial, potentially life-saving information on sexual health, and are not even effective in achieving their goal of keeping young people from engaging in sexual activity. Research has shown that adolescents receiving these messages were less likely to use contraception or condoms when they did have sex for the first time, compared with adolescents not in these programs or who received more complete sexual health education. These approaches also perpetuate harmful stigma around sex, sexual health and sexuality, among other harms.
Obstacles To Obtaining Confidential Reproductive Health Care
The FOA appears to promote family participation over the right to confidential care in individuals’ family planning decision-making. Unlike the previous FOA, this year’s sets a Title X program priority of encouraging minors to involve parents or guardians. Also new this year, the FOA goes so far as to explicitly promote the involvement of spouses. It does not once mention confidentiality—a hallmark of Title X.
Title X has long encouraged family participation as appropriate, especially for adolescents. Title X statute states: "To the extent practicable, entities which receive grants or contracts under this subsection shall encourage family participation." At the same time, Title X regulations and guidelines strongly affirm adolescents’ right to confidential care. For example, per a 2014 program policy notice, Title X providers "may not require written consent of parents or guardians for the provision of services to minors. Nor can Title X project staff notify a parent or guardian before or after a minor has requested and/or received Title X family planning services."
Without the guarantee of confidentiality, many adolescents would likely not seek family planning care. Rather, many would continue to engage in sexual activity, but some would end up at greater risk for an unintended pregnancy or STIs.
The FOA also calls on providers to "subject" any Title X client under the age of 18 who has an STI or is pregnant to "preliminary screening to rule out victimization." Title X grantees have long been required to adhere to federal and state notification and reporting requirements, but requiring providers to screen adolescent clients in this way is a step beyond—one that stigmatizes adolescents who are sexually active and could discourage them from seeking care they need.
Socially conservative policy makers have pushed variations of this strategy before. Rather than advancing adolescent health and well-being, such approaches only serve to politicize reporting requirements and legal protections for young people in an attempt to restrict adolescents’ access to confidential sexual and reproductive health care.
Only The Beginning
Although this funding announcement signals the Trump administration’s intent to reshape the Title X program to fit its own ideology, it is just the start of this year’s grant process. The extent to which this will practically impact the family planning safety net and the millions of people who rely on it for care will only be understood in the months ahead, as Title X grants are awarded and projects’ provider networks and scope of services take shape.
And, beyond the potential harm of the FOA, the administration is likely to continue its campaign against people’s reproductive health and rights—including by moving to revamp the regulations that govern Title X.