The Trump administration’s recent funding opportunity announcement for Title X family planning services grants seeks to advance a number of long-standing socially conservative priorities. Among them is an emphasis on harmful abstinence-only-until-marriage messages—especially (but not only) directed at adolescents—that promote abstinence as an “optimal health outcome” for Title X clients. This marks a stark shift from the evidence-informed and patient-centered approach to clinical family planning care previously advanced by the Office of Population Affairs (OPA), which administers Title X, and is deeply concerning given that extensive evidence demonstrates abstinence-only approaches can cause considerable harm to young people.
The funding announcement also calls for Title X clinics to have “a meaningful emphasis on education and counseling that communicates the social science research and practical application” of abstinence and marriage. The Trump administration identifies a small set of studies in a series of frequently asked questions (FAQ) as the social science evidence base for its abstinence-only approach, and relies on them to describe how providers should counsel Title X clients on abstinence. The administration’s responses misrepresent the body of available evidence by ignoring limitations identified by the authors of the research themselves and obfuscating the studies’ fundamental conclusions.
First, to support its assertion that having sex for the first time earlier versus later in life is associated with higher numbers of sexual partners, STIs and adolescent pregnancies, the Trump administration points to a 2015 systematic review of 65 studies. This review examined studies “on the associations between early first sexual intercourse and later sexual/reproductive outcomes,” with the intent of informing policymaking intended to delay sexual activity.
Given that it is being cited to advance major shifts in the Title X program, it is problematic that the Trump administration disregards the review authors’ conclusion: “Given the limitations and issues with current understandings of the associations between early first sexual intercourse and later sexual and reproductive outcomes…it is hard to make confident evidence-based predictions and recommendations for public policy.” This is in part because the review actually found mixed results among studies, with “some” showing an increased risk of pregnancy among adolescents who had sex early and “mixed” results for risk of STIs. The authors further warned that their findings should be “interpreted with caution,” because individual studies employed different definitions of “early first sexual intercourse” and “data have been poorly or incorrectly analyzed.” The authors also highlighted the bias of previous research in “ignoring the possibility that early initiators may experience positive sexual or reproductive outcomes.”
Second, the Trump administration takes components of well-regarded recommendations for providing sexual and reproductive health care for adolescents out of context, and flatly ignores the overall conclusions, which focus on providing comprehensive, unbiased services for adolescents.
Seeking validation for its abstinence-only counseling approach, the administration cites a technical report from the American Academy of Pediatrics (AAP). In reality, the AAP’s “Contraception for Adolescents” report centers on how clinicians can best provide contraceptive counseling and method options to young patients. It identifies counseling on abstinence as “an important component of sexual health care” for adolescents, but in the context of patient-centered adolescent health care and more holistic counseling on sexual decision making and contraceptive care. The administration also ignores the report’s conclusion that many adolescents do not adhere to being abstinent all of the time, and that “existing data suggest that the effectiveness of abstinence for pregnancy and STI prevention over extended periods of time is likely low.”
Similarly, under the guise of instruction for providers, the Trump administration points to an article in the Journal of Adolescent Health that details clinical best practices for counseling adolescents on abstinence. The administration advances a directive approach, asserting that providers “[share] the risks that may be associated with certain choices and introduce risk-free alternatives.” In contrast, the article’s authors advise a “motivational interviewing” approach widely utilized by health care providers, which focuses on enabling adolescents to identify and invest in their own behavioral change. In addition, while the administration continues to advance confusing, coded language like “sexually risk-free,” the cited article makes clear that clinicians must use concrete, specific definitions and ask detailed questions about sexual behaviors to “minimize the confusion and complex social meanings attached to sexual abstinence.”
Finally, the Trump administration seeks to support supposed links “between early sexual initiation and decreased educational attainment, economic status, and adult monogamy.” The handful of studies cited to support this assertion are weak. For example, the administration cites one paper that is not only unavailable, but also seems to examine the impact of sexual initiation after age 18 among adults 20–40 years ago, which likely does not reflect the experiences of today’s young people. And the administration elevates other work that has not previously garnered much—if any—attention from the research community, having been cited very little in peer-reviewed literature.
A patient-centered approach
Decades’ worth of evidence—including from some of the very research the administration misrepresents in its FAQ—has shown that the sexual and reproductive health needs of adolescents are best served by medically accurate and complete information and by comprehensive sexual and reproductive health services. This holistic approach includes, but is certainly not limited to, counseling on abstinence.
For instance, national Quality Family Planning (QFP) guidelines, established by OPA and the Centers for Disease Control and Prevention in 2014 and updated as recently as December 2017, provide evidence-informed clinical recommendations that adolescents should be given comprehensive counseling on preventing pregnancy that includes information on abstinence, contraception and STI prevention. For adolescents who indicate being sexually active, QFP guidelines demonstrate how providers should help their patients choose and use the methods of contraception that will work best for them. QFP guidelines undergo rigorous review, and reinforce recommendations of nationally recognized professional medical organizations such as AAP, the American College of Obstetricians and Gynecologists (ACOG), and the Society for Adolescent Health and Medicine (SAHM).
These same professional medical associations flatly reject the administration’s abstinence-only approach. In a position paper on abstinence-only policies and programs, SAHM notes that “providing ‘abstinence only’ or ‘abstinence until marriage’ messages as a sole option for teenagers is flawed from scientific and medical ethics viewpoints,” urging that such approaches be “abandoned.” Clinical recommendations from SAHM, AAP and ACOG all advise that providers foster open communication and that they offer counseling on abstinence in the context of comprehensive information on contraception and sexual health. Moreover, the administration broadly ignores ample evidence that risks associated with adolescents’ sexual activity are influenced by broader systemic and policy factors, including economic resources, gender-based expectations, and access to comprehensive sexual health information and contraceptive care.
It is particularly concerning that the Trump administration is pressing its abstinence-only approach within the nation’s publicly funded family planning program for all Title X clients, not just adolescents. Public policies promoting abstinence until marriage have long sought to influence the sexual behaviors of unmarried women specifically, many of whom are sexually active and in need of comprehensive sexual and reproductive health information and care. And, just as pushing this ideology in educational settings disproportionately harms young people of color and other marginalized youth, expanding it to the Title X setting will disproportionately impact marginalized communities: two-thirds of Title X clients live at or below the federal poverty level, and more than half identify as people of color.
This influence is not accidental, but rather an intentional component of the Trump administration’s broader, coercive agenda to restrict people’s sexual and reproductive health and rights—particularly those who obtain publicly funded services. Policymakers should not be in the business of forcing providers to parrot misinformed ideological messages in public health programs and clinical family planning settings. Instead, policies and funding should rely on high-quality research and reputable findings that demonstrate the need for comprehensive, patient-centered care that respects each individual’s sexual and reproductive health, rights and dignity.
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