Just Say No!

During an interview before a live audience in the KLRU studio in 2010, Evan Smith, editor of the Texas Tribune, put his chin in his hand and asked Gov. Rick Perry: "Governor, why does Texas continue with abstinence education programs when they don't seem to be working? In fact, we have the third-highest teen pregnancy rate in the country, among all the states."

"Abstinence works," Perry replied, his arms folded and resting on the table be-tween them.

Smith tried again – the point of the question, he said, was that abstinence education, by the stats, doesn't exactly seem to be working. It does work, Perry replied; it's the "best form ... to teach our children," he said.

"Can you give me a statistic suggesting it works?" Smith asked.

"I'm sorry, I'm just going to tell you ... from my own personal life, abstinence works," said Perry, increasingly agitated. "If the point is ... we're going to stand up here and say, 'Y'all go have sex and have the whatever is going on ... and here's the ways to have safe sex' – I'm sorry; call me old-fashioned if you want, but that's not what I'm going to stand up in front of the people in the state of Texas and say, 'That's the way we need to go, and forget about abstinence.'"

Of course, neither Smith nor anyone else was asking the governor to "forget about abstinence," but the truth, say advocates for adolescent health, including doctors and educators, is that teaching "abstinence only" has not worked to reduce the high rates of teen pregnancy and births in Texas despite the tens of millions in funding the state has thrown at it during the last decade. According to the University of Texas Prevention Research Center in Houston, a teen gets pregnant somewhere in Texas every 10 minutes, and teen pregnancy costs the state more than $1.2 billion per year – a figure which includes not only health care costs but also child welfare and criminal justice costs, as well as loss of revenue as a result of lower educational attainment of teen parents. The Texas teen pregnancy rank has dipped slightly – from the third-place spot Smith referenced to No. 5 – but the teen birth rate and repeat teen birth rate stand solidly at third highest and second highest in the country, respectively. And while it might be tempting to believe that the slide to No. 5 for teen pregnancies means that the Texas system – teaching abstinence-only sex education, banning broad distribution of contraceptives, and requiring, except in limited circumstances, that teens have parental permission to access birth control and other reproductive health services – is actually working, it's just not so. The state's drop to No. 5 isn't because the Texas teen pregnancy rate has decreased; it's because the rates in other states have actually increased even more dramatically than Texas'.

Indeed, consider the statistics on teen birthrates – that is, the number of babies born per 1,000 teens: Texas had the highest rate in the country in 2005, with a birthrate of 61.6; in 2007, that dropped to third highest, even though the rate increased to 64.2 per 1,000. Since then, the state has stayed in third place but nonetheless posts a rate of 63.4 per 1,000. In other words, there's been no real progress in combating the state's persistently large number of children having babies.

Advocates say that a major reason is an absence of meaningful leadership by Perry and other state officials. "We have willfully ignored the issue, and we have the sad statistics to show for it," says Sarah Wheat, interim co-CEO of Planned Parenthood of the Texas Capital Region, a long-term resource for sex education in Austin. Under the leadership of Govs. George W. Bush and Perry, the modus operandi has been "to ignore the issue and to support an agenda that doesn't work," Wheat said. "This idea of 'just don't talk about it' doesn't work – it doesn't matter which century you grew up in."

Guard Your Purity

Whether it works or not – that's how we like to do things in Texas. The move to abstinence-only sex education began in the mid-1990s during the Clinton administration, when federal lawmakers authorized millions in funds to be spent supporting a sex education curriculum stressing that teens should simply abstain from any sexual activity either until they're adults or married – and preferably both. That approach was embraced by Bush, who led Texas through a change in law that encouraged public schools to abandon comprehensive sex education curricula in favor of abstinence-only education. When Bush subsequently ran for president, he pledged to expand the pot of abstinence-only sex-education funding, and once elected, he delivered. Perry in turn embraced Bush's approach – and its large pot of taxpayer funds – with the tacit support of his backers in Texas' powerful pro-life movement. As a result, by 2009, 94% of Texas public schools were teaching abstinence as the only certain way to avoid pregnancy and sexually transmitted infections, as Texas State University professor David Wiley and assistant professor Kelly Wilson reported that year in a study for the Texas Freedom Network. The saturation of abstinence education across the state is not particularly surprising when you consider that Texas – including not only state agencies but also community-based grantees – has been one of the largest recipients of the roughly $1.5 billion in federal funds doled out during the last decade to support this form of sex education. In 2009 alone, Texas received more than $10 million to fund abstinence-only education, according to the Sexuality Information and Education Council of the United States. Since 2008, the Texas Department of State Health Services has taken in $23.3 million in abstinence education funds.

But just because something costs a lot doesn't mean it's worth it. Wiley and Wilson found that the curricula used in the nearly 1,000 Texas school districts included in their study varied wildly in content and quality. Forty percent contained misinformation about condoms, including in one the false assertion that HIV passes through latex; curriculum used by Austin LifeGuard, an arm of the local crisis pregnancy center Austin LifeCare, teaches incorrectly that there is "virtually no evidence" that condoms reduce the risk of human papillomavirus infection, which is linked to cervical and throat cancers. Given the quality of the information being taught, it's no wonder that 42% of the nearly 1 million Texas adolescents that researchers know are sexually active do not use condoms. Despite the generally dismal performance of the state's abstinence-only education, lawmakers, including Perry, continue to insist it is the best way to keep teens smart and safe. "Are we, on the amount of money that we're spending, getting a return on that that is appropriate?" he asked Smith during their sit-down last year, and then answered himself: "I believe that these are some dollars that are well spent."

Conservative lawmakers and advocates wholeheartedly agree. Although a host of bills have been filed during recent sessions that would require sex education to be comprehensive and medically accurate, those measures have been repeatedly rejected by the Republican-dominated Legislature, often without even a committee hearing. When Democratic lawmakers tried in 2009 to attach a medically accurate sex-education provision to a bill on the House floor, Perry's allies rallied to kill the measure. In mid May 2009, the Plano-based Free Market Foundation (now the Liberty Institute) sent out a "TRULY URGENT" email alert to supporters, warning that the medically accurate sex-education provision was a ruse by Planned Parenthood and the Texas Freedom Network to "steal your children's sexual purity from them." The measure quickly failed, and the Texas abstinence-only train rolled on.

Or at least it did so until later that year, when the Obama administration eliminated most abstinence-only funding in favor of grants to support evidence-based age-appropriate sex-education programs across the country; according to the SIECUS, none of the abstinence programs taught in public schools had actually been evaluated by researchers for their effectiveness in delaying sexual initiation. In their first year, the newly created Teen Pregnancy Prevention Initiative and the Personal Responsibility Education Program grants were funded with $155 million. Both grants require teaching evidence-based programs that include both abstinence and accurate and comprehensive information about contraception and sexually transmitted diseases. In the first round of funding, announced in September 2010, Texas received $7.6 million – less than was taken in during any single year for abstinence-only funding.

Indeed, according to a recent memo from TFN, Perry's disdain for comprehensive sex education may be to blame. According to TFN, since 2010 at least two state agencies have "halted efforts to apply for millions" in PREP funding "following discussions" with Perry's office. In August 2010, the Department of State Health Services pulled an application for $4.4 million in funding after Health and Human Services Executive Commissioner Tom Suehs declined to pursue the money; the Governor's Office "was part of that discussion," the Tribune reported. And then, in April, a similar deal was canceled. This time, Texas Attorney General Greg Abbott's office was preparing an application when at the last minute it, too, was pulled. According to emails obtained by TFN, several agencies – including the A.G.'s Child Support Division, DSHS, and the Texas Higher Education Coordinating Board, with assistance from nonprofit National Campaign To Prevent Teen and Unplanned Pregnancy – were involved in the bid, which would "focus ... on prevention of repeat teen pregnancies" in the state's "big 7 counties for teen births," Michael Hayes, deputy for family initiatives in the Child Support Division, wrote on April 12. This is, of course, not a minor issue – according to the nonprofit Child Trends, for example, the city of Dallas has the third-highest percentage of repeat teen births in the country, at 26%; overall, 23% of teen births in Texas are repeats.

Representatives of each agency continued to correspond over the next few days while awaiting the outcome of a scheduled meeting to discuss the grant application with Perry's office. Although Hayes wrote on April 14 that he was eager to "get those funds obligated to Texas asap" – a sentiment that was apparently shared by other stakeholders – the application remained in limbo for several days. Some of the agency reps emailed to ask the outcome of the meeting with the Governor's Office. "I've still not heard how our meeting went with Gov's office – will let you know as soon as I hear," Hayes wrote to colleagues on April 17.

On April 21, Hayes sent a series of emails to stakeholders to share the bad news: "[U]nfortunately a decision was made this morning to pull the plug on the application," he wrote in one communication. "[W]e are just a bit miffed," he wrote in another. As for what exactly happened, Hayes never explained in any of the emails the A.G.'s Office provided to TFN. When asked about the decision to end the process, A.G.'s Office spokesman Jerry Strickland said the application was pulled because of "strings" attached to the funding (a term regularly applied by Perry himself to any federal funding), and that after applying "due diligence," it was decided that it would be "too cumbersome" to fulfill the grant requirements. Moreover, he said, the overarching issue was that the education requirements of PREP appeared to "go beyond what the Texas Legislature" has authorized for sex education – that is, beyond an abstinence-centered approach to include "evidence-based teen pregnancy prevention strategies," according to the federal PREP requirements, as well as incorporation of other "adult responsibility topics" such as maintaining healthy relationships and improving communication with parents. Strickland said he'd reviewed the documents associated with the situation and sees nothing that would implicate Perry's office in influencing the decision to walk away from the application process.

TFN Executive Director Kathy Miller isn't convinced. "Look, Texas has been a poster child for failed abstinence-only sex education," she said. "A fiscally conservative leader might be expected to at least stop promoting a policy that's been such an expensive failure. But apparently not Rick Perry. He has repeatedly chosen to follow the will of the right-wing base of the Republican Party, especially as the party continued to shift further [to the right]. It doesn't matter that a majority of parents want more than abstinence taught in our schools, and it doesn't matter what our kids really need to be healthy and responsible. What matters to Rick Perry is winning Republican primaries, and to him that means following his base rather than trying to lead it."

Ignorance, Not Bliss

Unfortunately, it appears that abstinence-only education in Texas has been successful in at least one regard: making teens less knowledgeable about basic health, sexuality, and their own bodies. Dr. Celia Neavel, director of the Center for Adolescent Health at Austin's People's Community Clinic, sees a lot of teens – some pregnant, who are served through the clinic's obstetrics program, and some she's trying to keep from getting pregnant. Over the last year, 681 teens have been served through the clinic's Center for Adolescent Health, and 181 have accessed the clinic's prenatal services. Over the last decade, says Neavel, she's been concerned with the decline in her adolescent clients' knowledge of basic health issues. Teens come in who "know nothing about their bodies," she says; she's seen teens pregnant and "not even aware of their own anatomy" and others who are simply ignorant of the "basic, how do things work." Some teens, she says, say "nobody talked to me at all" about sex. "We've seen more of that since the beginning of abstinence-only education," she says. "There's a sense [that] people ... are not as empowered about their bodies."

Of course, personal empowerment is not among Texas' goals in educating teens about their bodies and sexual health. Some – including those with Texas Right to Life, the organizational home to some of the staunchest Perry supporters in the state – simply equate abstinence-plus education (through which attention is also given to comprehensive education on reproduction and contraception) with their favorite whipping-post, Planned Parenthood. In a June 21 post to the group's website, Doug McGee, TRL's development associate, wrote that PP is now "attempting to increase their presence in public schools to promote their pro-abortion agenda to students." The nearly 100-year-old nonprofit, McGee wrote, pushes a curriculum that "promotes sexual promiscuity and exploration of alternative lifestyles" and posts on its website links to information "that cast[s] sexual behavior and expression in a positive light." The message students are getting is "that sexual expression is healthy and normal" and, of course, that should they become pregnant as a result "and need an abortion" then PP "will be there to assist them." This is all part of a foul agenda to "corrupt the impressionable minds of the country's youth," McGee wrote.

While McGee's ideologically charged accusations might strain belief, there is no doubt that the political disdain of Planned Parenthood by TRL and others in Texas – and with more intensity in recent months by those in Washington, D.C. – has been successful in framing the issue and driving policy. This year, with the help of TRL, conservative lawmakers, with Perry's blessing, stripped two-thirds of the entire budget to provide basic health care services, including reproductive and family-planning care, for hundreds of thousands of low-income and uninsured women in the state. TRL claims this as a success that took money from the "abortion industry" – that is, Planned Parenthood, in fact a major Texas provider of women's health care. The reality, of course, is that none of this federal pass-through money pays for abortion care. But it does pay for cancer screenings, birth control, and screening for and treating sexually transmitted infections. Slashing this budget – leaving just under $38 million out of a roughly $110 million biennial budget – is likely to have a negative impact on thousands of Texas teens, pregnant or not. The People's Community Clinic, for example, has lost all of its public funding, and administrators are having to figure out how to maintain services without breaking the bank. "The people who cut that funding don't realize how much that money is used for health care," says Neavel. "The bottom line is that our patients don't terminate [their pregnancies]. We do [obstetrical] care. The crisis pregnancy centers are all up in arms about abortion, but they're not taking care of these teens – we are." Moreover, the loss of funding, particularly of Title X funding, the 40-year-old pot of money exclusively for family planning and related services, means that the clinic is also cut from group pricing for pharmaceuticals, including birth control. That's particularly daunting for clinicians who are trying to keep teens from getting pregnant, especially those who have already given birth. With that group, say clinic officials, long-lasting birth control methods are the surest preventative, but they're no longer affordable. For example, with the support of Title X, the cost to People's Community Clinic for a 25-count box of Depo-Provera (a three-month injectable contraceptive) was $42; without that funding, the cost of that same box is now $1,007.

Moreover, last month congressional Republicans released their draft Labor, Health and Human Services, and Education budget, slashing funding for the new abstinence-plus Teen Pregnancy Prevention Initiative grants by $85 million – leaving just $20 million for the year, while simultaneously reviving the shelved abstinence-only education grants, funded with an equal pot of $20 million. The draft budget would also completely eliminate Title X funding, which is the only federal funding that provides adolescents confidential access to basic reproductive health care and birth control. "This is why this is one of the most successful programs and why they want to eliminate it," says Planned Parenthood's Wheat.

A Public Health Issue

The absence of strong and reasoned leadership from the state is certainly a major factor in the state's high rates of teen pregnancies and births – Texas, with roughly 8% of the U.S. population, now accounts for 12% of teen births nationwide, says Texas State's Wiley, who is also chair of the nearly 3-year-old Texas Campaign to Prevent Teen Pregnancy. That said, the leadership vacuum has also opened an opportunity for researchers and advocates to address and earn support for a new approach at the local level – city by city, school district by school district. That's exactly what the folks with the University of Texas Prevention Research Center are now doing. The UTPRC, an arm of UT's School of Public Health, was created in 1986 as a prevention research partner with the Centers for Disease Control. While the group originally focused its efforts more broadly, encompassing research on various elements of adolescent health – including nutrition and mental health – the collective of researchers, led by Director Susan Tortolero, a professor of behavioral science, health promotion, and epidemiology and vice chair of the Texas Campaign, now focuses its efforts exclusively on adolescent sexual health. The researchers have created their own evidence-based sex education program that does, in fact, work – not only to delay sexual initiation but also, among teens who are already sexually active, to increase the use of contraceptives and reduce the number of teens' sexual partners. The program has been adopted in 10 Harris County school districts; Austin ISD is also incorporating the program through a federal grant partnership between Planned Parenthood (at the high school level) and LifeWorks (in middle schools).

At present, UTPRC is focusing much of its energies at the local level, addressing the School Health Advisory Councils – which include parents, educators, students, and other community members – organized in each Texas school district and tasked with coordinating and implementing health education in schools. It is at this level, says Kimberly Johnson, UTPRC project director, that decisions are made – and parents are educated. Johnson says the UTPRC team presents data to SHACs to help debunk myths about sex education and to provide serious data demonstrating how broad the problem is. "We really want people to understand what 'works' means" when it comes to sex education programs. Providing research and data, for example, is the first step, she says. "We're in urban, suburban, and rural districts; some are very conservative," she says. "They all have different needs, and they're all on board because of the data."

The SHACs weren't always so engaged – in fact, in their 2009 report, Wiley and Wilson found that many SHACs across the state had not met in years. That same year, Sen. Jane Nelson, R-Flower Mound, sponsored legislation that beefed up SHAC meeting and reporting requirements. That has, in turn, led to more scrutiny (at least in some districts) of the actual content of sex education curricula. The Austin SHAC, for example, ended the district's relationship with Austin LifeGuard – which teaches, among other things, a cheesy lesson called "I Heart Pants," which admonished that STDs and pregnancy can be prevented simply by "wearing pants" (i.e., a condescending call for abstinence only).

These small, independent efforts are encouraging, but there is no doubt that – if there is to be any sustained and effective statewide action to reduce the number of adolescent pregnancies and births – over the long term and without other major resources, the state must be more directly and adequately involved. "Apparently people like the status quo, because they keep electing the same people. The current power structure is not going to address this as a public health issue at the state level," Wiley says. "We need to talk about contraception [and] use evidence-based policies in schools, instead of [basing policy] on morality, politics, and public opinion." (It's worth noting, however, that opinion polls consistently reflect majorities in favor of comprehensive sex education.)

Speaking to a group of more than 300 who came to the Capitol last week to attend the Texas Campaign's second statewide conference, UTPRC's Tortolero said the job ahead is to reframe the debate and enlist everyone in the process of charting a new course toward better public health and quality sex education. "Texas," she told the group, "has been focusing on just one piece of the puzzle" by harping exclusively on a just-say-no brand of sex education. The reality, however, is that a holistic approach is needed. And, certainly, it can be done – just consider the example of California, says colleague Johnson. With similar demographics and population size, Texas and California in 1990 had very similar teen birthrates, with Texas at 75 per 1,000 and California with 71. By 2008, however, California's rate had dropped dramatically, to just 38 per 1,000 – below the national average – while Texas' rate had declined only to 63. The difference, says Johnson, is plain: California embraced the use of evidence-based, abstinence-plus education (in fact, the UTPRC program is now in use in Los Angeles); eased access to contraceptives; and rallied parents to get involved in their children's sex education. Research shows that Texas parents are overwhelmingly on board – despite political rhetoric to the contrary, 90% of parents in Texas support teaching comprehensive sex education.

The difference, of course, is that California had support in Sacramento – getting Texas officials on board will be necessary in order to move Texas forward. "Just hoping and wishing that high school kids won't engage in sex isn't working," says Wiley. This is a "public health issue, and not a social issue," Johnson agrees. Getting state officials – from Perry's office all the way down the chain – to heed the research, to mandate the teaching of evidence-based sex education, and to open access to contraceptives is key to reducing the problem. "It may be a long road for Texas," Johnson says, "but I'm not saying it's not possible."