BY EARL LANE
WASHINGTON BUREAU
October 22, 2004

WASHINGTON — Leslee Unruh is proud of her connections with President George W. Bush. As founder and executive director of the private Abstinence Clearinghouse in Sioux Falls, S.D., Unruh has been a strong proponent of abstinence-until-marriage sexual education.

Bush sent a video greeting to the group's annual meeting this summer in Nashville, Tenn., Unruh said. In 2002, her Clearinghouse received a $2.7 million technical assistance contract from the Department of Health and Human Services for, among other things, developing criteria to judge whether abstinence curricula meet the restrictive language of the federal statute. "We really didn't have a good way to police [the programs] under the Clinton administration," Unruh said. "Now we do."

With a group of pro-abstinence officials in top positions in HHS, abstinence education has become a lucrative and controversial program that has grown dramatically under Bush.

Bush promoted abstinence education as Texas governor and spoke of it during his first presidential campaign. After his election, he followed through, asking in particular for generous increases in a program that bypasses the states and sends money directly to community organizations, including many faith- based groups critics consider a part of Bush's political base.

The administration requested $272 million for the fiscal year that began Oct. 1 for abstinence-until-marriage programs, up from $138 million in fiscal year 2004 and well above the $60 million at the end of the Clinton administration. It sought almost as much as the $278 million that went to family planning clinics in 2004 under another federal program, Title X, that has been flat-funded under Bush. Congress has not completed action, but the House voted a record $173 million for abstinence programs and the Senate appropriations committee approved nearly $175 million.

The campaign of Sen. John Kerry has said he supports comprehensive sex education that includes information about both abstinence and contraception. While there has been federal money for abstinence education since 1981, the current Bush administration has turned the program into a major policy initiative, both here and abroad. Under Bush's AIDS prevention plan, according to the nonprofit Alan Guttmacher Institute, at least one-third of U.S. global AIDS prevention funds must be used for abstinence-until-marriage efforts beginning in 2006.

Several key officials in HHS have presided over the ambitious abstinence agenda, one they championed before joining the administration and which many sex educators and health specialists argue is based more on ideology than science.

Proponents include Claude Allen, deputy secretary for Health and Human Services, a conservative who has been nominated for a federal judgeship; Wade Horn, assistant secretary for children and families and a proponent of marriage as a solution to poverty; Dr. Alma Golden, a pediatrician who is deputy assistant secretary for population affairs; and William Steiger, special adviser to Secretary Tommy Thompson.

Abstinence advocates also serve on the Presidential Advisory Council on HIV/AIDS, including former Rep. Tom Coburn (R-Okla.), a co-chairman who is running for Senate; Dr. Joseph McIlhaney, a Texas-based gynecologist and infertility specialist; and Anita Smith, co-founder of the nonprofit Institute for Youth Development, who heads the prevention subcommittee of the council.

Ideological purity
While every administration seeks to advance its agenda by appointing those who share its values, critics say the Bush administration has exhibited an unusual interest in ideological purity for its appointees.

There is little doubt that HHS and its component agencies have become flashpoints in the cultural war over such topics as abortion, family planning, AIDS and embryonic stem cell research.

In many ways, abstinence-only education is at the heart of the debate. Backers see it as a way to prevent pregnancies, abortion and sexually transmitted diseases in one package and an overdue effort to balance what children hear in a society awash in sexually provocative advertising and entertainment.
But critics say there is little data to justify rapid expansion of abstinence education, which they regard as an unproven intervention that ultimately may do as much harm as good among those who become sexually active without adequate information on contraceptives and disease prevention.

"There is no scientific evidence to suggest that abstinence-only-until marriage curriculums are effective in preventing HIV or other STDs [sexually transmitted diseases] or even pregnancy," said Judith Auerbach, vice president for public policy of the American Foundation for AIDS Research.

An immediate effect of the Bush initiative has been a financial windfall for some longtime advocates of abstinence education, critics say. Grants have gone to groups that create curriculum for abstinence courses, further fueling the growth of programs, said William Smith, director of public policy for the Sexuality Information and Education Council of the United States.

The group, which promotes comprehensive sex education that deals with contraceptive options, has examined some of the abstinence-only teaching materials and found them wanting. The group has criticized as "fear-based" a curriculum by Teen-Aid Inc. of Spokane, Wash., that compares relying on condoms to prevent disease to playing Russian roulette.

Risk of AIDS
LeAnna Benn, national director of Teen-Aid, defended the roulette analogy, saying a single condom failure can lead to transmission of the deadly HIV virus. Public health specialists say consistent use of condoms is highly effective in reducing the risk of AIDS. Though a federal study panel said in 2001 there is insufficient data on the effectiveness of condoms against most other sexually transmitted diseases, it said that "should not be interpreted as proof of the adequacy or inadequacy" of condoms to reduce risk of those diseases.

Michael Young, University of Arkansas professor of health science and developer of an abstinence curriculum called "Sex Can Wait," said many programs lack published evaluations in peer-reviewed journals. "The amount of money being spent on this is pretty ridiculous when you look at the lack of accountability for outcomes," he said.

In 2000, at the end of the Clinton administration, HHS developed performance measures for abstinence programs that included the birth rate of female participants and percentage of participants who have intercourse before marriage. The Bush administration dropped those in favor of attitudinal measures such as "the proportion of youth who commit to abstain from sexual activity until marriage."

Dr. Alma Golden said there had been problems with the earlier performance measures, including prohibitions in some school districts against asking students questions about their sexual behavior.

Teen pregnancies still high
The battle over abstinence-until-marriage programs is being played out against the emotional topic of sex education in a nation where 47 percent of high school students have had sex and the teen pregnancy rate, while falling, remains the highest in the industrial world.

When conservative members of Congress quietly inserted language in a 1996 welfare reform bill to provide $50 million annually in new money for abstinence education, they specified an eight-point definition, including the message that "sexual activity outside the context of marriage is likely to have harmful psychological and physical consequences."

According to HHS, programs may provide factual information about contraceptive methods, such as failure rates, but can't provide instruction in the use of condoms or other contraceptives nor promote their use for those who are sexually active.

Marcia Spector, executive director of the nonprofit Suffolk Network on Adolescent Pregnancy, said her group's board "grappled long and hard" on whether to apply to the state for funding. Her organization eventually received $175,000 to provide abstinence education to fifth- and sixth-grade students in the Riverhead School District.

On some of the eight points, such as the potential consequences of having a child out of wedlock, Spector said, the instructor may choose to remain silent. "Many of the kids we work with come from families out of wedlock," she said.

Such an approach is criticized by some abstinence advocates, who accuse state governments of undermining the intent of the 1996 law. In 2000, Congress established another abstinence program to bypass state governments and send grant money directly to community-based organizations.

Aimed at supporters?
The new program, requiring that all elements of the abstinence message be addressed, became the preferred vehicle for conservatives seeking abstinence money.

Golden rejected criticism by Smith and others that the abstinence money is aimed at one part of Bush's political base. She said the money is awarded competitively and said several early proponents of abstinence education recently lost funding.

Benn, of Teen-Aid, said she is disappointed by the size of the community grants, which she said are not large enough to saturate a state or region with abstinence programs. "We are basically in competition with family planning," she said. "This was going to give us an infrastructure. There is increased funding [nationally], but it is going to smaller and smaller organizations."

But for grant winners, the money is a welcome boost. In New York, Catholic Charities of Buffalo was awarded $800,000 in July, a renewal of a previous grant. Jim Nowak, assistant director of the program, called ProjecTruth, said Buffalo had an adolescent pregnancy rate of 133.7 per 1,000 in 2001, compared with 71 per 1,000 in the state and 101.8 per 1,000 in New York City. Under the grant, abstinence educators reached 16,000 teens in eight western New York counties during the first three years, Nowak said. Eighty percent of those who complete the program say they want to remain abstinent until marriage. But Nowak acknowledged the need for studies to track outcomes.

On Long Island, Catholic Charities for the Diocese of Rockville Centre has offered abstinence education since 1998, receiving federal money via the state. Local college students perform abstinence-themed skits in middle and high schools throughout Long Island, particularly in areas with high teen pregnancy rates. Kathleen Ryan, an administrator for Catholic Charities, said the program seems to be having an impact. "We see a change in attitude," Ryan said, with "peers saying it is OK to delay" having sex.

"Abstinence programs certainly have their place in sex education," said Kirsten Moore, president of the Reproductive Health Technologies Project. But she said their impact is limited. "You are unlikely to see the kind of cultural shift supporters [of abstinence education] want," Moore said.

Rifts among ranks
Even among abstinence proponents, there are rifts. Unruh has had issues with McIlhaney, considered one of Bush's gurus on abstinence, and a technical adviser on her federal contract. "He's what we call a 75-percenter," Unruh said. "He thinks abstinence is best, but ... "

McIlhaney founded the Texas-based Medical Institute for Sexual Health to provide scientific support for abstinence programs. There should be no compromise in the classroom in an abstinence education program, McIlhaney said, because students "understand if we are equivocating with them." But if students seek advice on condoms, he said, they should be referred for counseling by a clinician.