Twice a week, a few dozen high school students shuffle into Ashley Cunningham’s sexual health education class. And while they’re seated in front of her, Cunningham, a community health educator with the Baltimore City Health Department, wants this space to feel like home.
She plays mellow ’90s Hip-Hop and R&B music — think: Mos Def — to make the teens more comfortable. Rather than lecture, she said she asks them to do things like write down their life goals. They often list wanting to graduate from high school and college, owning a home, running a business. Sex is about more than just sex. The choices her students make about their own sexual health — about condoms, contraception, or abstinence — can make a huge difference in how close they can get to reaching those goals.
“We see these kids more than their parents do sometimes, and they need to get the right information,” she said in a phone interview.
Cunningham’s classes are funded by the federal Teen Pregnancy Prevention Program, which was established in 2010 by the Obama administration to help reduce the number of teen pregnancies. The initiative gives funding to individual communities and schools, encouraging them to develop and test their own ideas to target teen pregnancy.
In recent years, the program and other efforts started before Obama took office have started to pay off, research shows. Birth rates among teens aged 15 to 19 dropped by half between 2007 and 2017, according to the Centers for Disease Control and Prevention.
But under the Trump administration the program has faced mounting uncertainty. Last year, the Trump administration notified organizations that receive funding through the program that the funding would end on June 30.
The issue resurfaced this week when an earlier House spending bill did not include funding for the program, though it set aside $25 million for abstinence education.
A revised version of the omnibus spending bill, which Congress passed to avoid a government shutdown, protected funds for the Teen Pregnancy Prevention Program funding, providing $108 million for fiscal year 2018. Supporters cheered the change, but acknowledged that the funding is a temporary fix for a program whose longer-term future under President Donald Trump remains very much in doubt. And while Congress approved the spending bill early Friday, President Trump’s threat to veto it altogether adds one more level of uncertainty for this program.
For decades, policymakers have worked to reduce teen pregnancy numbers in the United States. Each year, teen pregnancies and births cost the U.S. an estimated $9.4 billion, according to the CDC. And teen births are also tied to lower income and education levels, compared to birth rates and outcomes among older age groups.
While teen pregnancies dropped under Obama’s tenure, reproductive health experts don’t credit any single program for the change, said Jesse Boyer, a senior policy manager with the Guttmacher Institute, a research institute that supports abortion rights.
Still, advocates argue the Teen Pregnancy Prevention Program has played an important role in the reduction of teen pregnancies in recent years.
What makes the program stand out is that it was the first federally funded program that supported adolescent sexual health and also included ongoing evaluations to determine if programs that local communities developed met the goals they set out to achieve, Boyer said.
One program called Love Notes, developed in Louisville, Kentucky, teaches students about the importance of healthy relationships and how to avoid dating violence and unprotected sex. Evaluators said adolescents who participated in the program were significantly less likely to become pregnant than their peers who were not in the program.
By August 2015, nearly 500,000 teens in 39 states and the District of Columbia were enrolled in the program through public schools, faith-based organizations and community centers. By 2018, the program had grown to reach 1.2 million teens nationwide, according to the Office of Adolescent Health in the Department of Health and Human Services.
But in July, the Department of Health and Human Services mailed notices to 81 schools, public health departments and community centers that received funding through the program with an update: The grants were being cancelled, and the program, which has had an annual cost of $101 million in recent years, would be shuttered in a matter of months.
The notices included two sentences that caught recipients off-guard: “This award also shortens the project period to end on June 30, 2018 at the end of this budget year.” At the time, many organizations had years remaining and millions of dollars left on their federal grants.
“It made no sense,” said Dr. Leana Wen, commissioner for Baltimore City Health Department. “Congress appropriated the funding that was available.”
Two years and $3.5 million remained on her department’s five-year teen pregnancy prevention grant. Wen said her staff contacted the Department of Health and Human Services and asked why their funding was canceled, but never received a response.
Baltimore was not the only city left with unanswered questions. Public Health officials in Seattle and King County, Washington, filed a lawsuit on Feb. 15 against the Trump administration, claiming the decision jeopardized years of evaluations already underway that were helping develop better means of helping teens avoid pregnancy.
“It’s like being in a marathon. I can see the finish line. I know we’re going to win,” Patty Hayes, the public health commissioner for Seattle and King County, said on a recent conference call with reporters to discuss her agency’s lawsuit. “Somebody is yanking us off the path. That’s what it felt like. It’s gut-wrenching.”
When the PBS NewsHour asked the Department of Health and Human Services to comment on why this program was being cancelled, the department pointed to an August press release that said it was “not working,” saying the agency’s own evaluation indicated that 73 percent of the program’s projects either had no impact or had a negative impact on teen behavior. Continuing it, the release said, “would be a waste of taxpayer money.”
“HHS is serious about helping youth, so maintaining the status quo cannot be an option,” it said.
The Trump administration and House Republicans have pushed instead to spend millions of dollars on abstinence-only programs, part of an effort the department called “sexual risk avoidance” in a November press release.
The omnibus spending bill the House released Wednesday included funding for the Department of Health and Human Services to fully pay for state-level sexual risk avoidance education programs. It did not include funding for the Teen Pregnancy Prevention Program.
But that changed by Thursday, after negotiations over the spending bill led to the restoration of $108 million for the Teen Pregnancy Prevention Program for fiscal year 2018. The House passed the bill and forward it to the Senate, who has until the end of the day Friday to vote. Congress must pass the bill Friday to avoid a government shutdown.
Democrats applauded the addition of short-term funding for the pregnancy prevention program.
“The Senate has made it clear that there is bipartisan support for evidence-based approaches to preventing teen pregnancy, and I am committed to working with members on both sides of the aisle to continue holding the Trump-Pence Administration accountable for everything it is doing to undermine these important investments and interfere with women’s access to care,” Sen. Patty Murray, D-Wash., said in a written statement to the NewsHour.
But while the program will live on at least through June, it’s unclear what will happen to it after that. Meanwhile the debate over how to handle the issue of teen pregnancy — through abstinence-only education, or, a program that encourages based not in abstinence-only education but instead on consent, contraception, consent, and communication, contraception, parent-child communication and healthy relationships — hasn’t abated.
For one, teens are having less sex now than they did a decade or two ago, according to the CDC’s Youth Risk Behavior Surveillance System. Forty-one percent of high school students who took the survey in 2015 said they had had sexual intercourse, down from 53 percent in 1995. The percent who say they use a condom grew from 46 percent in 1991 to 63 percent by 2003, but has tapered to 57 percent in recent years.
Since Trump took office, momentum to defund the Teen Pregnancy Prevention Program has been steadily growing among social conservatives. In July, after the Department of Health and Human Services notified grantees that the program would end, groups like the conservative Heritage Foundation cheered the move. Social conservatives have backed abstinence-only programs as morally-superior education that can also “provide the foundation for personal responsibility and enduring marital commitment,” the Heritage Foundation said in one report. They also say programs like the Teen Pregnancy Prevention Program indirectly keep afloat groups like Planned Parenthood, which they accuse of easing access to abortions.
“When programs that fail to produce results receive reduced funding or are terminated altogether, and when programs that generate results continue to receive funding, the result is a better allocation of scarce resources,” David Muhlhausen, a research fellow in empirical policy analysis at the Heritage Foundation, wrote in a report at the time.
Critics of the Trump administration’s proposed changes to adolescent sexual education, on the other hand, have continued arguing that abstinence-only education hasn’t stemmed teen birth rates.
In 2017, the Guttmacher Institute reviewed sexual health education in the U.S. and published a review in the Journal of Adolescent Health that suggested teens tend to engage in sex by senior year of high school, and that abstinence-only sex education wasn’t effective.
Going forward, Boyer, the senior policy manager at the Guttmacher Institute, said she and other advocates remain fearful that federal dollars could be redirected into abstinence-only education curriculum, regardless of what happens to funding for the program started under Obama.
To lower teen pregnancy numbers, Boyer argued, policymakers should encourage educators and public health officials to share a fuller menu of knowledge with young people. That way, she said, they can decide what’s best for their own sexual health and future.
“These programs cannot be one-size fits-all,” Boyer said.
Back in Baltimore, Ashley Cunningham said the funding battle has placed her job in jeopardy. Cunningham said she wasn’t sure if she’ll be back at the school teaching this curriculum this fall.
In a recent class, Cunningham said a student said they had a sexual partner who claimed to have a latex allergy and could not use conventional latex condoms. That’s when Cunningham recommends alternatives, such as polyisoprene condoms. Another student told Cunningham that if a female has sex but immediately goes to the bathroom and washes her body, she won’t get pregnant. Cunningham said she debunked that myth. Her classroom is a place where she can offer evidence-based sexual health curriculum, free from judgment.
“Sex is natural,” she said. “It’s going to happen, but I want them to make informed decisions.”