June 12, 2018 Kim Krisberg 1Comment

Earlier this month, another judge rebuked the Trump administration’s attempts to terminate teen pregnancy prevention grants, ruling the decision unlawful and ordering federal health officials to reinstate the five-year grant agreements. Youth health advocates are cautiously relieved, but they also say the shift away from evidence-based sexual health education is well underway.

“The bigger story here is that this was another attempt to chip away at access to sexual and reproductive health care for young people — it was setting the stage to deny people the information, education and access they need to lead healthy lives,” Chitra Panjabi, president and CEO of the Sexuality Information and Education Council of the United States (SIECUS), told me. “We’re shocked when things like this happen, but we weren’t really surprised.”

About a year ago, the U.S. Department of Health and Human Services notified more than 80 grantees of its Teen Pregnancy Prevention Program (TPPP) — without warning or explanation — that their grants were being terminated, effectively cutting off funding three years into a five-year grant cycle. The announcement was especially troublesome because it meant grantees would be cut off right at the evaluation stage, meaning money would dry up right as they were learning what worked and what didn’t to reduce the risk of teen pregnancy, the vast majority of which are unintended. TPPP, administered via the HHS Office of Adolescent Health, was created in 2009 to support evidence-based and innovative approaches to reducing America’s teen pregnancy rate, which is among the highest in the industrialized world.

The most recent court ruling, issued June 1 by the U.S. District Court for the District of Columbia, was one of five that have all come down on the side of grantees. In April, judges ruled in favor of a group of Planned Parenthood affiliates and youth health nonprofits, followed shortly by rulings in favor of the city of Baltimore and King County, Washington, where local health departments had been in the middle of their TPPP grant cycles. The June decision sided with 62 additional TPPP grantees, with the court ordering HHS to accept and process the grantees’ noncompeting continuation applications for TPPP funds (such applications are a typical grant requirement). In all the cases, judges agreed that HHS broke the rules governing grant terminations, making the agency’s decision to end the grants unlawful.

Sean Sherman, an attorney with Public Citizen Litigation Group that represented the 62 TPPP grantees, said HHS, in fact, conceded that it didn’t comply with its own rules, but argued that it shouldn’t matter because the agency wasn’t terminating the grants — it was shortening the grants. The courts disagreed. Now, nearly all of the more than 80 current TPPP grantees can submit their applications for funding continuation with the hope that HHS acts before funds run out at the end of the month. Sherman noted that the Trump administration has tried to end TPPP two years in a row via budget proposals that called for zeroing out the program’s funding. So far, Congress has rejected the idea and appropriated the promised funds.

But it’s still not entirely clear what HHS will do in terms of granting the actual TPPP monies. SIECUS warns that while the court decisions vacate the unlawful termination of TPPP grants, grantees are not automatically entitled to continued funding. And in April, HHS issued two new Funding Opportunity Announcements related to the $101 million in TPPP funds that Congress appropriated in March, shifting the program’s emphasis toward abstinence-only education and away from the Obama-era emphasis on comprehensive sexual health education.

In particular, the new HHS funding announcement favors programs that teach teens to simply avoid sex altogether. Earlier this month, Multnomah County, Oregon, filed suit against HHS, arguing the new funding criteria violate Congress’ intent when it created TPPP in 2009. The lawsuit states: “The new criteria…violate the terms of the statute by shifting funds away from ‘replicating programs that have been proven effective through rigorous evaluation.’ Instead, the new FOA allows prospective grantees to choose any program, without any requirement that it have undergone any evaluation, let alone have been proven effective. The most important criterion is now adherence to an abstinence-only message that Congress consciously chose not to mandate in creating the TPP Program.”

“This funding,” Sherman told me, “first and foremost, should go to the existing grantees.”

Local health departments celebrate TPPP wins

When Congress authorized TPPP in 2009, it was with the expressed intent of building an evidence base on how to effectively prevent teen pregnancy across different communities. Terminating grants midway into their cycles, as HHS attempted to do, would have meant losing the very data that TPPP was designed to capture.

“This ruling is such a relief, as we are so close to the finish line for completing this study and building an evidence base for sex education nationwide,” said Patty Hayes, director of Public Health — Seattle & King County, in a news release. “Our goal with FLASH is to improve the quality of what happens in classrooms across the nation and to protect our most vulnerable youth.”

In King County, Washington, which won its lawsuit against HHS in May, losing TPPP funds would gut efforts to evaluate FLASH, a sexual health curriculum used in every school district in King County, which includes Seattle, and in schools in the Midwest and South. The evaluation is designed to confirm whether FLASH increases the number of students who delay sex and whether it increases condom and birth control use among teens already sexually active. According to county officials, the evaluation data is critical, as “local school districts face pressure to use unproven and harmful ideological-based sexual health programs, and they need the availability of a curriculum that is not only based on science but also has evidence that it works.”

Across the country, Baltimore won its lawsuit against HHS in April, with the judge describing the actions of HHS as “unlawful, arbitrary and capricious.” In a news release on the ruling, Baltimore City Health Commissioner Leana Wen said the grant termination would have impacted 20,000 local students who now have access to evidence-based sexual health education, including a Youth Advisory Council that uses peer-to-peer education to reach vulnerable teens with health information. Between 2000 and 2016, with the help of such prevention programs, Baltimore’s teen pregnancy rate has fallen 61 percent, according to city health officials.

“I am hopeful that the value of science and evidence will continue to be recognized, and I look forward to continuing to fulfill our responsibility of protecting the health and ensuring the well-being of our youth,” Wen said.

In addition to cutting off thousands of Baltimore students from direct sexual health education, HHS’ decision could have also impacted the effort’s long-term sustainability, said Gabe Auteri, chief policy and engagement officer at the Baltimore City Health Department. Auteri told me the program’s viability beyond the five-year grant cycle depends on having enough trained teachers and staff to truly embed the evidence-based curriculum throughout the school district — a process that would stop short if grant funding ended two years early.

“These aren’t easy topics to discuss so it’s really important that we train and build out a strong, evidence-based curriculum so conversations can be meaningful, productive and beneficial to students,” he said.

HHS distorts findings on TPPP projects, manipulates abstinence research

Beyond providing no reasonable or legal justification for ending the TPPP grants, it also appears the Trump administration is intentionally misleading Americans on the program’s results.

Among the reasons HHS gave for terminating TPPP grants and that the Trump administration gave for zeroing out TPPP’s budget is that the program is proven ineffective and is a “waste of taxpayer money.” Such claims are still posted on the HHS site under the heading “Teen Pregnancy Prevention Program Facts: False Claims vs. The Facts” — read it here. However, youth health advocates disagree with the agency’s characterization, as do HHS’ own staff.

Internal emails from HHS staff, made public as part of a FOIA request by Democracy Forward, show Evelyn Kappeler, director of HHS’ Office of Adolescent Health (OAH), attempted to correct misinformation about TPPP outcomes that HHS had given to reporters. In particular, Kappeler questioned reports attributed to HHS that an evaluation of the first round of TPPP grants found that only four of 37 programs showed lasting positive impacts, while most other TPPP programs had no impact or were harmful to young people.

In her email, Kappeler writes that “we’re not clear where some of the statements in this quote are coming from,” adding that “Cohort 1 data identified 12 TPP program models with demonstrated positive behavioral impacts at varying time points post program delivery. Nine of these program models demonstrated positive behavioral impacts 6+ months after intervention delivery, some demonstrating fairly prolonged impacts.” She went on to write: “The field considers the evidence from the TPP Cohort 1 evaluations to be very strong.”

Indeed, in a study published in 2016 in the American Journal of Public Health, HHS researchers synthesized the impact of TPPP’s 2010-2015 grantees, concluding: “In 2010 through 2015, the OAH TPP Program provided an additional 41 rigorous, independent studies that yielded eight new TPP programs with evidence of effectiveness, identified additional settings and populations where four evidence-based programs are effective, and contributed further data on 10 previously identified evidence-based TPP programs. The number of evaluations demonstrating statistically significant positive impacts on behavioral outcomes represents a larger proportion than found in large evaluation efforts from other fields.”

Panjabi, president and CEO at SIECUS, said HHS’ misrepresentation of TPPP results is just another case of the administration sidelining facts and evidence.

“This administration is doubling down on the idea that data and facts don’t matter, that they’ll interpret them as they see fit,” she told me.

Panjabi said it’s critical to remember that the measure of whether TPPP is working isn’t only reflected in behavior change among young people — which is notoriously difficult to impact — but in its ability to build an evidence base about what works and, just as importantly, about what doesn’t work. Unfortunately, Panjabi said recent actions at HHS suggest a shift toward unproven abstinence-only education, such as Trump’s appointment of long-time pro-abstinence advocate Valerie Huber to oversee funding decisions for the Title X family planning program and the weakening of evidence-based standards in its funding announcements.

For instance, in its April funding announcement on the availability of TPPP funds, certain applicants would have to follow one of two abstinence-based approaches, despite evidence showing such strategies don’t work to protect all youth. In a study published just last year in the Journal of Adolescent Health, researchers found that abstinence-only-until-marriage programs “have little demonstrated efficacy in helping adolescents to delay intercourse, while prompting health-endangering gender stereotypes and marginalizing sexual minority youth.” In fact, the researchers wrote that because such abstinence programs often withhold information from young people, they “threaten fundamental human rights to health, information and life.” (SIECUS has complied an extensive list of abstinence-only education research here and Jesseca Boyer at the Guttmacher Institute wrote about how HHS is manipulating research to make the case for abstinence funding here.)

Also in contrast to the new abstinence push is the simple reality that nearly half of high school-age students have had sex.

“This (abstinence-only) approach doesn’t recognize the true reality of young people’s lived experiences,” Panjabi told me.

Susan Wood, director of the Jacobs Institute of Women’s Health at George Washington University, served as a lead evaluator for a TPPP-funded after-school program known as “Be Yourself/Sé Tú Mismo,” one of the many efforts evaluated during TPPP’s 2010-2015 cycle. She said while some TPPP-funded projects might struggle to produce large effects, it certainly doesn’t mean researchers aren’t learning valuable lessons in the process.

“This is hard work — it’s hard to change behavior,” Wood told me. “But investing in promising programs and finding new ones that work (to prevent teen pregnancy) are all part and parcel of how you keep moving forward.”

Learn more about what works to prevent teen pregnancy at www.siecus.org.

One thought on “Judges rule against HHS for unlawfully ending teen pregnancy prevention grants, but shift to abstinence still underway

  1. The blog post titled, “Judges rule against HHS for unlawfully ending teen pregnancy prevention grants, but shift to abstinence still underway” by Kim Krisberg was recently posted on June 12, 20181. She lays out the key components of, and the cascade effects resulting from the recent ruling of the Teen Pregnancy Prevention Program (TPPP). She also speaks on what events might take place moving forward. TPPP is a national program that works towards ending teen pregnancy across the US2. More importantly, they aim to use evidence-based programs to make this change occur2. The Teen Pregnancy Prevention Program administers funding, in five-year cycles2, out to grantees through the Human and Health Services (HHS). The Trump administration has continuously tried to shut down TPPP for two years now1. Krisberg noted that while courts have ruled in favor of TPPP grantees, the initial ruling to terminate their funding was still in effect, causing a major halt to progress in their research1. This means there are more than 80 TPPP grantees that are stuck having to submit applications for funding continuation in hopes if it getting approved before funds run out within their five-year funding cycle1.
    This brings us to the next problem: how will the HHS grant the TPPP monies? As Krisberg’s blog noted, the HPP just issued two new FOA’s that will shift TPPP’s programs from comprehensive and evidence-based sexual health education to abstinence only sexual health education1. This is a huge problem in regards to many things related to public health. Evidence-based sexual health programs help to prevent many things including risky sexual behaviors in teens, unintended pregnancies, STI’s, general knowledge about puberty and human reproduction as well as numerous other beneficial components of sexual health5. By slashing these programs and focusing on abstinence only, evidence has shown a major decline in the progress of all these topics and many others occurs.
    For the purposes of this paper, I am focusing on the educational aspect of teen pregnancy, but I am sure you can deduce the many other issues linked to teen pregnancy and why fixing one problem is only one piece of a much bigger puzzle. In the US alone, teen (15-19) pregnancies account for 5.3 percent of all births in 20163. While the birth rate of 20.33 is significantly lower compared to past years, this trend could be significantly lower if we had gotten to the place of using comprehensive sexual health education in schools sooner. I am a true believer of the effects consumerism has on human health. By definition, consumerism places skepticism on third-parties and emphasizes autonomy4. While I can appreciate the autonomous independence and choice-granting way of life this ideal gives us, it places more emphasis on not swaying the consumer’s opinion and decision one way or another. But I argue that we need to be swayed when it comes to important issues such as controlling teen pregnancy. Of course, we need to be objective and ethical in doing this, but I firmly believe that if more information was given to decision makers in situations like this, we would be better off. This form of swaying is not unethical when it is backed by evidence. If consumers’ decisions are informed, if they are backed with evidence from reputable resources, then we have more people making changes, giving support, and voting for topics with an informed opinion.
    Having the HHS stick their hands into how funding gets distributed hinders the informed consent part of decision making out of the equation for not only schools but also children. If the HHS does not require schools to administer comprehensive sexual health education, we will be left with schools that prefer abstinence-only programs and the others who prefer comprehensive education. But when you take that funding away and only give it to those who comply with your ruling that abstinence-only is the route to take when teaching sexual health education, there is no choice allowed. This tactic should be unlawful and I am very curious to see what will happen moving forward.
    What I propose the HHS should do with TPPP funding is using an insurance-esque outline and rank interventions, programs, incentives, etc. for sexual health education, backed by prior and on-going science-backed evidence, based on their cost-effectiveness. For example, if studies are showing that comprehensive sexual health education for teens is most affective at lowering the prevalence of teen pregnancy, they should give bigger stipends to schools that use this approach. This is because of all the cascading price effects having a child has on a mother and family could be avoided if we start at the root of the issue, which is lack of comprehensive education. That way, if a school decides to go against what scientifically works, they still get funding for sexual health education, but it is less than what would actually work at fixing the problem that plagues teens. This also means emphasizing cost-effectiveness higher than other factors. If certain sexual health education programs do not effectively educate and protect teens, then we should not give them nearly as much (if any) funding as programs that have been proven to work.
    I am aware, however, of the fact that this approach brings up cultural preferences. I do want to note that we should also be sensitive to the differing cultures within the school system. By this I mean, there are differing ethnic composed schools, differing religion composed schools and so on. If we were to put the emphasis on effectiveness this would control for these differences. With adequate research and knowledge on what works best for each school and/or school district we can better accommodate their needs. With an effectiveness-prioritized sexual health education program, we could see that each differing school would get what they need to lower the prevalence of teen pregnancy lower, which should also be what schools want. Not to mention, this would make for overall healthier and educated sexually active and non-active teens.

    1. Krisberg K. Judges rule against HHS for unlawfully ending teen pregnancy prevention grants, but shift to abstinence still underway. The Pump Handle. June 2018. http://www.thepumphandle.org/2018/06/12/judges-rule-against-hhs-for-unlawfully- ending-teen-pregnancy-prevention-grants-but-shift-to-abstinence-underway/#.W- I8xBNKgnV. Accessed November 6, 2018.
    2. Office of Adolescent Health. Teen Pregnancy Prevention Program. HHS.gov. https://www.hhs.gov/ash/oah/adolescent-development/reproductive-health-and-teen- pregnancy/teen-pregnancy-and-childbearing/teen-pregnancy-prevention- program/index.html. Published May 4, 2016. Accessed November 7, 2018.
    3. Office of Adolescent Health. Trends in Teen Pregnancy and Childbearing. HHS.gov. https://www.hhs.gov/ash/oah/adolescent-development/reproductive-health-and-teen- pregnancy/teen-pregnancy-and-childbearing/trends/index.html. Published June 2, 2016. Accessed November 7, 2018.
    4. SOCIAL INSURANCE IN EMERGING NATIONS Key Takeaways . PB HLTH 200J Section Lecture.
    5. Welcome to the Teen Pregnancy Prevention Evidence Review. Teen Pregnancy Prevention Evidence Review. https://tppevidencereview.aspe.hhs.gov/. Accessed November 7, 2018.

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