Texas' federally funded abstinence-only programs restrict information on condoms because they are barred by federal law from "promoting or endorsing" contraceptive use. Texas-based abstinence-only education programs also contend that encouraging abstinence while also teaching about "safe sex" or "safer sex" sends a "mixed message" to young people that is "misleading at best and, at worst, irresponsible."78 These programs also teach that condoms don't adequately protect against sexually transmitted diseases, particularly among teenage users, and therefore there is no such thing as "safe" or "safer" sex with condoms. As a result, abstinence-only programs omit any discussion of condoms and contraception altogether, or provide inaccurate or misleading information about condoms as a method of HIV/AIDS prevention.
Sally Fleming and Laura Wilson, high school health teachers from a McLennan County high school that uses McCAP abstinence-only materials, including Teen Aid's "Sexuality, Family and Commitment," told Human Rights Watch that prior to their school's adoption of McCAP's abstinence-only program, they were able to talk about condoms and other birth control methods. However, since the adoption of the abstinence-only curriculum, they are limited with respect to what they can say about contraceptives and their use.79 Fleming said, "Before McCAP, I could say, `If you're not having sex, that's great. If you are, you need to be careful and use condoms.' Boy, that went out the window." She expressed her concern that since her school adopted the abstinence-only curriculum, she has felt like she is "in a bad situation," needing to give her students more information about condoms and contraception, but restricted about what she can say. She noted that she cannot say, "Use a condom to prevent getting HIV," or "If you use condoms, your chances are better of avoiding disease," and cannot tell her students that they "need to use something to prevent HIV and STDS." 80
Fleming said that she thinks that all of the other teachers at her school would like to be able to speak more freely and that most parents want their children to be educated about everything. "As a health teacher, I don't believe in abstinence-until-marriage education, but I worry about breaking the rules. People here are afraid of being vocal because it'll come back to bite them. You should see how they butchered Planned Parenthood in the paper."81
Laura Wilson, who teaches at the same high school as Fleming, told Human Rights Watch that before her school district adopted the abstinence-only curriculum, she could talk a little more about different methods of contraception, including condoms, and how they worked. Now she cannot talk about contraception, except to say that no contraceptive method is perfect because all have failure rates. "I mention condoms like the book [Teen Aid's "Sexuality, Family and Commitment"] does. I tell them that they give a false sense of security about protection against STDs, because they're not 100 percent and that condoms may prevent HIV or not, but I wouldn't bet my life on it." She also said that the abstinence-only curriculum is "freeing" as well as limiting. "I don't discuss things outside the book. I don't want to be dishonest, but I am worried about keeping my job. Having Teen Aid makes the choice of how to teach a controversial subject much easier."82
The message that students receive in abstinence-only classrooms is that remaining abstinent from sex is the only way to prevent HIV. Sean G., a fifteen-year-old high school student who had recently completed the required health education class at a McCAP school, told Human Rights Watch that "[a]t the beginning of the class, my teacher said that she was not going to discuss methods to inhibit transmission of diseases except for abstinence."83 When asked whether he had learned how to prevent HIV, Sean replied, "other than abstinence? No."84 Linda P., a sixteen-year-old student at the same high school, told Human Rights Watch, "I don't know any other way but abstinence to prevent HIV,"85 a statement that was echoed by other McCAP students interviewed by Human Rights Watch.
In some abstinence-only programs, teachers do not mention contraceptives or condoms at all, believing that doing so would contravene state and federal restrictions. This is illustrated by the comments of Charmaine Heimes, who supervises "abstinence teachers" in Laredo Independent School District's abstinence-only program and is quoted at the opening of this section (other teachers in the Laredo program confirmed Heimes' statement).86 Students in these programs who ask questions about condoms or contraceptive use are directed to speak with their parents or to a counselor. (For the issue of referrals, see below.)
Restrictions on discussing condoms extend to teachers and other employees in school districts with abstinence-only programs, including those who do not themselves teach the federally funded abstinence-only classes. Jerry Ramirez, the health teacher at Cigarroa Middle School, in Laredo, Texas, told Human Rights Watch that he thinks that the very high teen pregnancy rate in Laredo indicates that his students need more comprehensive HIV/AIDS prevention education. He doesn't talk about HIV prevention in his classroom, though, because "Cigarroa [middle school] has an abstinence program. I can't mention condoms or birth control. If kids have a question about condoms or birth control, I refer them to their parents or to a counselor." Nor does he discuss HIV or other sexually transmitted diseases, unless a student raises the issue. "If a student asks a question, it's usually about transmission. I tell them that HIV is sexually transmitted, or that you can get it from a blood transfusion, or through intravenous drug use."87 Once, Ramirez caught some students with condoms at school and confiscated them. When the students asked him, "Why are you taking the condoms away? Shouldn't we be using condoms?" Ramirez told the students that he couldn't discuss this and advised the students that they should speak with their parents.88
Kay Coburn, the curriculum director at Temple School District, Bell County, Texas, which has adopted Scott & White's abstinence-only program and uses its materials, told Human Rights Watch that "Scott & White told us that if we teach anything but abstinence, they could lose their federal funding. We don't discuss condom use, except to say that condoms don't work."89 Dr. Coburn told Human Rights Watch that she thinks that students should be given more information about protecting against HIV and that there should be somewhere kids can go for referrals, but that she understands that state and/or federal guidelines limit the schools from providing this information.90
All employees in Temple School District, including bus drivers and janitors, participate in Scott & White's district-wide trainings. Kay Coburn explained that students sometimes communicate with employees other than teachers about personal issues and, therefore,
Restricting Access to Experts on HIV/AIDS Prevention
Pam Smallwood, who spent more than twenty years as the education director of Planned Parenthood of Central Texas in Waco before becoming the organization's executive director two years ago, told Human Rights Watch that Planned Parenthood and HIV/AIDS educators from the county health department used to provide comprehensive sex education presentations to public schools throughout McLennan County, which included information about condom use as a method to prevent pregnancy and HIV/AIDS. In the past few years, however, these organizations have stopped visiting many county schools. Smallwood told Human Rights Watch that as education director, she "used to spend most of [her] time in the schools," but that because McCAP is in all the school districts in McLennan County except Waco, Planned Parenthood now does few school presentations. "If McCAP weren't in all of those schools, Planned Parenthood and Raylene Silver [the HIV/AIDS and STD educator for the Waco-McLennan County Health District] would be in those schools."92 As Cheryl Cox, the health teacher at Robinson High School who teaches its abstinence-only curriculum, explained, Planned Parenthood used to come to speak to her class, "but it's a very conservative community and there was a bad vibe. The approach here is that the less we know, the better."93
Susan Nichols, a counselor for pregnant and parenting teens at a McLennan County high school that has adopted McCAP's abstinence-only curriculum, told Human Rights Watch that "if the school would allow discussion of condoms, I'd rather have someone from Planned Parenthood talk with them. . . . My job is to help the girls finish high school. I'm not an expert in STDs or condom use."94 At about the same time that Human Rights Watch spoke with Nichols, she invited Pat Stone, the education director of Planned Parenthood of Central Texas, to speak with her students about sexually transmitted diseases and birth control. However, Nichols said that she soon retracted the invitation because the principal told her that the school had had some problems with some information that Planned Parenthood had given in the past and parents might get upset if Planned Parenthood came to the campus.95
Although the City of Laredo Health Department, a partner in the "Mi Futuro/My Future" abstinence-only program, has an HIV/STD program whose staff includes health educators and prevention specialists, the HIV/STD program and its expertise are not incorporated into the abstinence-only program. As Christina Earles, an HIV/AIDS educator, explained, "the schools don't let us talk with the kids because we don't teach abstinence but prevention."96
Manuel Sanchez, the program coordinator for the City of Laredo's HIV/STD program, told Human Rights Watch, "in no way are we allowed to go into the schools" because the schools have their own funding to provide services related to HIV. "But this is just in theory. In fact, no HIV education is taking place."97 School nurses have told Sanchez that the HIV message to students is that there is no cure for HIV, so that they should be abstinent and that they cannot talk about safer sex because that would be considered as promoting sex.98
Nurses in Laredo high schools have asked Sanchez to come to Laredo schools to provide HIV education, but, as he has explained to the nurses, they must first get permission from the schools and then he would discuss this with the Texas Department of Health, which is his department's funding agency. None of the nurses have yet contacted him with such permission. In any event, Sanchez told Human Rights Watch that it might be difficult to get permission from the Texas Department of Health to do HIV prevention in schools because the Texas Education Agency gives funding to the school districts to provide this kind of service. Moreover, he would need the school board's and parents' permission before he could teach HIV prevention in the schools.99
Sanchez' experience at the health department suggests that Laredo students are not getting sufficient information about HIV. The health department periodically has interns from local high schools come for one to two weeks. According to Sanchez, many of them are hungry for information about HIV/AIDS and volunteer to work with the HIV/STD program.100
In May 2000, Raylene Silver, an HIV/AIDS educator with the Waco-McLennan County Health District, was invited to do a presentation to Cheryl Cox's high school health class in Robinson, Texas. Prior to the class, Silver was told that she would be allowed to pass out information about birth control, so she brought pamphlets produced by the Texas Department of Health to distribute to the students. When she arrived at the classroom, however, Cox told her, "We can't talk about birth control or prevention of HIV or STDs by using condoms. We're a McCAP school." Cox told Silver that she could put the birth control pamphlets on her desk but that she couldn't hand them out and that the students would have to ask for them specifically if they wanted one. Thus cautioned, Silver was limited to telling the students "If you know anyone who is sexually active, they've got to take responsibility and use protection."101
In May 2002, Cox told Human Rights Watch that she would have to get permission from the principal for an HIV educator to bring pamphlets about birth control into the classroom.102 Subsequently, Sharon Henson, the lead chair of the Robinson's school health education advisory council and an assistant principal at Robinson High School, told Human Rights Watch that she was "very pleased with McCAP," and that teaching abstinence-until-marriage "is what the school board and the community want." She said that the school was "not going to get into birth control," and that they didn't discuss "safe sex," but "save sex" - that is, save sex until marriage. Henson also cautioned Human Rights Watch, "I hope you're not out to hurt McCAP in any way. We're very pleased with what they've brought in."103
There is a broad scientific consensus, including among federal health agencies, that condoms, when used correctly and consistently, are highly effective in preventing the transmission of HIV/AIDS.104 Some Texas abstinence-only programs obscure this important fact and provide misleading information about the efficacy of condoms in protecting against transmission of HIV/AIDS and other sexually transmitted diseases.
McCAP's media campaign includes public service announcements on radio and television that advise as follows:
Screen: HERE COMES THE LIE.
Screen: "HPV, genital herpes, chlamydia, trichomoniasis, hepatitis B."
McCAP's "Truth for Youth" advertisement campaign teaches adolescents that condoms don't work. A Planned Parenthood employee told Human Rights Watch that after watching a "Truth for Youth" commercial with her teenage daughter, her daughter turned to her and said, "Mom, I thought that you told me that if I used condoms, it would help protect me against pregnancy, HIV and STDs. Why are you telling me this?" Her daughter also told her that many of her high school classmates had heard the "Truth for Youth" commercials and that some of the boys at school said that they didn't think that they had to use condoms any more when they had sex because condoms would not protect them or their partners. Teenage patients at Planned Parenthood also have told this employee that they heard on television that "condoms aren't as safe as everybody seems to think" and "my boyfriend says they don't work. He heard it on the radio."107
McCAP's media campaign regarding "lies about condoms" apparently undermines condom use even among adults. Raylene Silver, an HIV/AIDS educator in McLennan County, told Human Rights Watch that an adult injecting drug user told her that he did not use condoms because he heard on television that condoms don't work.108
McCAP reinforces the message that condoms don't work with pamphlets that instruct, "Danger . . . Beware . . . STDs are not prevented with condom use: 1) some STDs transmit skin to skin; 2) condoms have a 17% failure rate; that's 1 in 6,"109 and by providing curriculum materials to schools that report that a "meticulous review of condom effectiveness" found that condoms "appear to reduce the risk of heterosexual transmission of HIV infection by only 69 %,"110 that condoms break or slip as much as 25.5 percent of the time,111 and that "published reports indicate that condoms are effective in reducing the risk of contracting HIV about 55 to 90 percent of the time."112
Becky Mosby, the education director at McCAP, told Human Rights Watch that McCAP discusses contraception in terms of "human use reality rates." "I'm not going to tell you what the condom company says the rate is, because they're selling a product, so they'll promote it in the best light possible." And, "human use reality rates" are poor for teens and even for those at obvious risk of HIV infection. According to Mosby, "teens who use condoms consistently and every time they have sex are more likely to stop using condoms. And there's a huge study that shows where one married partner has HIV, they don't use condoms consistently."113 Other Texas abstinence-only programs also emphasize adolescents' poor history of condom use.114 However, even were they so inclined, these programs cannot address this concern by providing instruction regarding proper condom use because they are barred by federal law from "promoting or endorsing" contraception or otherwise providing information inconsistent with the federal abstinence-only guidelines.115
Sally Fleming, who teaches in a McLennan County school that uses McCAP materials, expressed concern about exaggerated ineffectiveness information provided to students by McCAP:
"Sex is Not a Game," a video produced by the Medical Institute for Sexual Health (Austin, Texas), includes information about sexually transmitted diseases and their incidence among young people. Discussion of condoms is limited to the advisory that "Condoms aren't much good against the most common sexual infection anyway. Condoms provide limited, if any, protection against HPV [human papilloma virus, a sexually transmitted disease]."117
Another Medical Institute publication suggests that condoms may "seem" to prevent HIV, but HIV's "low infectivity," rather than condom use, may explain some of the purported effectiveness of condoms:
Dr. McIlhaney told Human Rights Watch that he mentions condoms as a method of reducing the risk of HIV, but also says that once infected, it's for life and you'll probably die from AIDS or something else. He also advises that "anyone infected with HIV needs to consider never having sex again (at least not penetrative sex) because you can transmit HIV even using condoms."119
Linda Grisham, a science teacher at Temple High School who is working on Scott & White's new ninth grade curriculum, told Human Rights Watch that she plans to use an activity she learned at a recent teacher training to show how condoms are not effective. Participants are given cut-up pieces of plastic or latex of different strengths and thicknesses and asked to identify which one is a condom, a rubber glove, or a plastic bag. "We were shown how condoms were one of the thinnest kinds of plastic [sic] and how easy they were to break with a fingernail."120
Grisham explained that her HIV prevention curriculum promotes abstinence until marriage as the "way to go."
Dr. Patricia Sulak told Human Rights Watch, "I tell kids that condoms are effective in reducing the risk of HIV if used every time and before genital-to-genital contact. They will reduce the risk of HIV, but not other diseases. I tell them that they have to decide if condoms are good enough for them, given the percentages. I don't teach the sixteen steps of condom use or how to use them."122
Pledging Virginity to Prevent Disease, and "Renewed Virginity"
Programs offer two kinds of advice to sexually active youth: first, that they should commit to "secondary" or "renewed virginity" to protect against HIV and other sexually transmitted diseases; and second, that they should go to the doctor and get tested for HIV and other sexually transmitted diseases.
Linda Grisham tells students that "if you're sexually active, you can change your life and from here on in, `do the right thing and not have sex.' There's still an opportunity to have a second virginity and save your future." She also tells them that "if you're sexually active, you need to see a doctor and get tested for HIV" and other sexually transmitted diseases.126 Barbara Ducote likewise includes "second chance" virginity among HIV and pregnancy prevention strategies, telling her students that they "may have committed a sexual act in the past, but now commit to monogamy."127
This message also appears in the literature produced and distributed by abstinence-only organizations. For example, a pamphlet distributed by McCAP and produced by the Medical Institute advises, "So you've already had sex . . . . [S]et up an appointment with your doctor . . . . Claim your secondary virginity with pride today."128
Amy Cavender, a sexuality educator with Community Health Services in San Marcos, Texas, told Human Rights Watch that she is concerned that sexually active youth who have pledged "secondary virginity" may not seek the health care they need, believing that once they've signed the pledge, they'll be protected from both past and future infection.
Likewise, absent more complete advice about the role of testing in HIV prevention-that is, that HIV testing can rule out past risk and is not a prevention strategy in and of itself-advising sexually active students to get tested may actually put individuals at risk of contracting HIV and other sexually transmitted diseases. A recent study of the role of HIV testing in HIV prevention reported that more than 40 percent of women who participated in the study believed that getting tested is a good way to prevent HIV, and that receiving a negative test had no influence on safer sex behavior.130 Other studies have reached similar conclusions.131 In addition, students need to understand that there is a period of time after exposure during which HIV infection may not be detectable by HIV tests (the "window period") and therefore an HIV-infected person may receive a negative test result during this period.
There also is evidence that adolescents who pledge virginity may ultimately be at increased risk of HIV/AIDS infection. A study of virginity pledges often cited by abstinence-only groups found that although there is some evidence that these pledges delay intercourse by an average of eighteen months, as virginity pledges become the norm, they lose their allure and thus their effect. This study also found that virginity pledges have the unintended effect of placing some teens at higher risk of unintended pregnancy and STDs, because teens who break the pledge are one-third less likely than nonpledgers to use contraceptives once they do become sexually active.132
Referrals for Other Information
In practice, teachers in abstinence-only programs have varied practices with respect to the referrals they make. As already noted, teachers in Laredo's "Mi Futuro/My Future" programs do not discuss condoms at all. If asked about condoms, they advise students to speak to their parents or to a counselor for more information.134 Linda Grisham, a Temple High School teacher, told Human Rights Watch that if a student asked where to get condoms, she would say, "this is not what I am promoting. Abstinence is what you should be supporting," and would also tell the student to speak with his or her parents and, perhaps, with a doctor or a counselor.135 Barbara Ducote, who teaches at a Temple Middle School, told Human Rights Watch that if a student asked where to get condoms, she would send him to one of the local health clinics. She also provides the numbers of the local rape hotline, health clinic and free clinic to the students and encourages students to talk privately with her or a counselor if they have questions.136
Crowding Out Other Sources of AIDS Information
Since 1987, the CDC has provided funds and technical assistance to state, county and large-city education agencies for HIV prevention education.137 These funds are distributed via a grant program that funds HIV prevention education (the " CDC HIV/AIDS grant" or "HIV grant"); expanded health education that addresses other priority health risks (such as prevention of tobacco use, prevention of heart disease, diabetes and cancer and promotion of healthy lifestyle behaviors); and national training and demonstration centers for HIV prevention, chronic disease and local education agency support.138 All applicants must apply specifically for the HIV grant and only those programs that are approved for the HIV grant qualify for funding for the other programs.139 In 2002, the CDC received about $50 million to support HIV prevention education in forty-eight states, seven territories and nineteen large metropolitan areas.140
The CDC school health education funds are intended to be used to support state and local school health initiatives: "to expand and strengthen the capacity of [state and local education agencies] to plan, carry out and evaluate coordinated school health programs, to address significant health problems that affect young persons (especially HIV infection, tobacco use, sedentary lifestyle and dietary patterns that result in disease)."141 The CDC grantmaking guidelines require that AIDS-related written, audiovisual and pictorial materials used by grant recipients include information about the benefits of abstinence.142 Grant recipients are not, however, bound by CDC guidelines that recommend that adolescents be provided with information about the proper use of condoms to reduce the risk of HIV infection.143 In addition, grantees must still comply with their respective state education regulations. Texas schools, for example, must follow Texas' abstinence-only legislation.144
Texas' state education agency (the Texas Education Agency or TEA) receives about $300,000 annually in HIV grant funds for the state of Texas. TEA spends about one third of these funds on administration and distributes the remainder to twenty regional "Education Service Centers," which each receive between $5,000 and $8,000 to spend on HIV prevention activities.145 Dallas and Houston each get separate funding under the same grant.146
Texas began receiving CDC funds for school health programs for HIV/AIDS prevention in 1988. In 1995, the Texas Education Agency decided not to seek further funding from the CDC for school health programs for HIV/AIDS prevention, thereby forgoing $1.35 million ($450,000 for three years) in CDC funding.147 Texas Education Commissioner Mike Moses made this decision out of his concern that CDC requirements would conflict with Texas' new education code, which requires that course materials and instruction emphasize abstinence from sexual activity "as the only method that is 100% effective in preventing pregnancy, sexually transmitted diseases," HIV/AIDS, and the "emotional trauma associated with adolescent sexual activity," and which gives local school districts greater responsibility for their curricula.148
Despite Moses' concern, the grant guidelines do not promote or prohibit any specific instruction or methodology, but state that
Commissioner Moses reportedly notified the CDC that Texas would accept the CDC HIV/AIDS prevention grant if the CDC provided written assurance that Texas school districts would be allowed to teach the abstinence-only curriculum.150 Moses ultimately decided to accept the CDC HIV/AIDS funding, telling the state Board of Education that he changed his mind about the grant after receiving assurances from the CDC that the grant would not require Texas schools to teach a specific health curriculum.151 George W. Bush, then Texas governor, praised Moses' actions, stating "He accomplished exactly what he set out to do, and as a result, Texas schools will get federal funds without federal mandates on how to teach health education."152
For the past several years, Texas' statewide regional CDC HIV/AIDS prevention grants have mostly funded workshops about school health education advisory councils (such as how to set up a council), which are mandated by law to advise school boards regarding curriculum materials on sexuality education and education on HIV/AIDS and other sexually transmitted diseases.153 Otherwise the CDC HIV/AIDS grant has funded abstinence education trainings and trainings on the development of "refusal skills."154
Tommy Fleming, director of health and physical education, Division of Curriculum and Professional Development at the TEA, who oversees the administration of the statewide CDC HIV/AIDS grant, told Human Rights Watch that in the early 1990s, he worked with TEA to provide comprehensive workshops on HIV/AIDS prevention for public school teachers, school nurses and school administrators. These workshops advised that abstinence was the best prevention against HIV but also included instruction about condoms as a method of HIV prevention. Fleming hasn't given this kind of presentation (that is, including instruction about condom use as a means of HIV prevention) since at least 1995 and expressed doubt that any such information about condoms was being provided by the regional Educational Service Centers, except, perhaps, in Dallas and Houston. Fleming attributes this change in focus in part to the state's conservative views about sexuality education, as well as the 1995 Texas state law giving local school districts control over sexuality education and education about HIV/AIDS and other sexually transmitted diseases.155
Tamara Rhodes, an HIV/AIDS educator for the Region 16 Education Service Center, told Human Rights Watch that she plans to use the CDC HIV/AIDS grant funds to teach refusal skills and hold a training for school health education advisory councils on health problems in the area, including teen pregnancy and HIV/AIDS. She told Human Rights Watch that in her HIV/AIDS presentations, she does not teach about condoms as part of HIV prevention because she has been advised by school nurses that school administrators in her area won't allow her to do so and because of community concerns that people should remain abstinent until marriage to prevent pregnancy and disease.156
Clara Contreras, a health specialist for the Region 1 Education Service Center, which covers Laredo, has used the CDC HIV/AIDS grant to teach refusal skills and "self-control" in middle and elementary schools and has given training about school health education advisory councils. She also conducts HIV training for adult professionals in the schools. Contreras told Human Rights Watch "when I mention condoms, it's very brief. Some schools, like the abstinence-only schools, are not allowed to give out resources (like referrals to clinics or information about condoms or about the clinics)." This year, she would like to hold a skill development training, in which she will mention "very briefly that condoms may reduce the risk of HIV, but they can break. For that message to get to the classroom, the teachers would bring it back, but they're not allowed to speak about this unless the SHAC [school health education advisory council] allows them to."157
Like Texas, other states' abstinence-only policies have influenced their use of federal funding for HIV/AIDS prevention education. Ohio's commitment to abstinence-only education has influenced its decision to refuse federal funding for school health HIV/AIDS prevention programs altogether since 2000 out of concern that the funds would support programs that interfere with that commitment, while Nebraska has applied its state abstinence-only guidelines to programs funded by the CDC HIV/AIDS school health prevention grant.
Previously, Ohio received about $800,000 per year in CDC health education funding for both HIV/AIDS prevention and for a comprehensive school health education program that included funding for prevention education for heart disease, cancer and diabetes, programs to improve nutrition and increase physical activity, and antitobacco programs. In June 1999, the Ohio legislature passed an amendment to a state budget bill that prevented the Department of Education from spending CDC health education funding on sex education until the legislature held hearings approving a model health curriculum for the state.158 According to Rep. Jim Jordan, the Ohio legislator who pushed for the law that froze the money, "the goal of the hearings [was] to clarify that sex ed programs should emphasize abstinence" and to find out why the Education Department had accepted an HIV/AIDS training program that included information about contraceptive use.159
In January 2000, the legislature held two days of hearings. At the start of the hearings, an announcement was made that the Department of Education was planning to submit a workplan to the CDC that would require that HIV/AIDS education be provided consistent with abstinence-only education.160 After two days of hearings, no vote was taken and in March, an Ohio House of Representatives committee tabled the issue.161 As a result, the state Department of Education could not submit a workplan to the CDC and therefore could not receive any of the CDC health education funds. Because approval of the HIV/AIDS funding was required for approval of the funding for expanded school health education, once the state Department of Education could not accept the HIV/AIDS education grant, it could not accept funding to support other programs supported by the grant.162 Consequently, in rejecting the HIV/AIDS prevention money, the state also rejected thousands of dollars that were earmarked to support programs directed at education related to chronic diseases and other serious health problems. Ohio still receives no CDC health education funding under these grants.163
Since 1997, Nebraska has had a strict state school board policy that mandates that all state-sponsored health education comply with federal abstinence-only guidelines.164 Until 2001, the CDC-funded HIV education program there was exempt from these guidelines. When this exemption was brought to the attention of members of the state Board of Education in 2001, they asked the HIV prevention coordinator to draft and defend a policy that officially exempted the HIV program from the abstinence-only guidelines.165 An HIV/AIDS prevention policy was proposed that would allow the Nebraska Department of Education to provide schools with a program that was not exclusively abstinence-only, but abstinence-based (that is, teach students about both abstinence and safer sex, including condom use). After holding hearings to consider the policy, the Board voted 4-4 on a motion to allow the HIV program to be abstinence-based; since the vote was a tie, the proposed "abstinence-based" policy was rejected.166 The Board then adopted a new policy that requires that HIV/AIDS education be limited to grades kindergarten through six, instead of kindergarten through twelve; be used to provide teacher training only and not classroom education to students; and comply with abstinence-only guidelines mandated for sexuality education.167
The Commissioner of the Department of Education initially stated that the department would not renew its CDC grant when it expired in November 2001 because it could not find any abstinence-only curricula that did not include religious references and did not discuss condoms or other birth control options.168 The Department of Education ultimately decided to accept the funding, which it plans to use to assist local school districts in determining how to carry out HIV prevention education consistent with the required abstinence-only strategy and to find materials that reinforce abstinence as a method of HIV prevention.169
Federal Review of HIV/AIDS Prevention Programs
The Department of Health and Human Services also is reviewing the federal government's financial support of sixteen prominent AIDS advocacy organizations whose members joined in a loud protest of Secretary Thompson's July 2002 address at the International AIDS Conference in Barcelona. This review was initiated after twelve members of Congress, including Mark Souder, wrote to DHHS requesting that the agency provide an accounting of all U.S. federal assistance for the conference and the names and affiliations of individuals who attended the conference with federal assistance, and following an electronic mail request to DHHS by a staffer for the House Government Reform subcommittee on criminal justice, drug policy and human resources (which Souder chairs) requesting information on financial assistance provided to twelve organizations that "led the demonstration that shut down Secretary Thompson during his address last week."173
78 See, for example, The Medical Institute for Sexual Health, National Guidelines for Sexuality and Character Education (Austin, Texas: The Medical Institute for Sexual Health, 1996), p. 12; Teen Aid, Sexuality Commitment and Family: Student Text (Spokane, WA: Teen Aid, Inc., 1995), pp. 139-40. Studies in the United States and abroad have come to contrary conclusions. See, for example, UNAIDS, Impact of HIV and Sexual Health Education on the Sexual Behaviour of Young People: a Review Update (New York: UNAIDS, 1997) (review of sixty-eight country evaluations of sex education programs concluded that "little evidence was found to support the contention that sexual health and HIV education promote promiscuity... . Twenty-two [studies] reported that HIV and/or sexual health education either delayed the onset of sexual activity, reduced the number of sexual partners, or reduced unplanned pregnancy and STD rates."); Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (finding that sex education that discusses contraception does not hasten the onset of sex, increase the frequency of sex, nor increase the number of sexual partners); John B. Jemmott et al., "Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents," Journal of the American Medical Association, vol. 279, no. 19, May 20, 1998, pp. 1529-1536 (among sexually experienced youth, those in safer sex intervention reported less frequent intercourse than those in abstinence intervention).
79 Human Rights Watch telephone interview with Sally Fleming, May 4, 2002; Human Rights Watch interview with Laura Wilson, Waco, Texas, April 30, 2002. Sally Fleming and Laura Wilson are pseudonyms for teachers who requested anonymity.
81 Ibid. Planned Parenthood is an organization that provides sexuality education programs as well as comprehensive reproductive health care services to adolescents and adults, and advocates both in the U.S. and internationally to improve access to reproductive health services. Planned Parenthood of Central Texas, its Waco-based affiliate, provides reproductive health care services and education in the McLennan County area.
86 Human Rights Watch interview with Charmaine Heimes, master teacher, "Mi Futuro/My Future" Abstinence Education Program, Laredo, Texas, May 9, 2002; Human Rights Watch interview with Erika Ramirez, health trainer, "Mi Futuro/My Future" Abstinence Education Program, Cigarroa Middle School, Laredo, Texas, May 9, 2002; Human Rights Watch interview with Terry Cruz, health trainer, "Mi Futuro/My Future" Abstinence Education Program, Nixon High School, Laredo, Texas, May 9, 2002.
92 Human Rights Watch telephone interview with Pam Smallwood, May 6, 2002. Smallwood contends that several factors contributed to the decline in invitations for Planned Parenthood to speak in schools in the past ten years: the fact that Planned Parenthood began providing abortions eight years ago; the rise of the religious right; the pressure on teachers to focus on subjects tested on statewide competency exams; and the increasing pressure on schools to provide some sort of sex education. "McCAP came along at a perfect time. They promised to train teachers, provide materials and do it in a palatable way." Ibid.
95 Human Rights Watch telephone interview with Susan Nichols, June 19, 2002. Instead, Nichols obtained a pamphlet from Planned Parenthood about STDs and contraception, which she reviewed with her students herself. She felt constrained, however, from handing out this information to the students: "I didn't want to make a huge bunch of waves, so I just got a pamphlet from Planned Parenthood and talked about it with my students. I didn't want to hand out any pamphlets to the students. I didn't think that the school would be real pleased about that." Ibid.
104 National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention (Washington, D.C.: NIAID, NIH, DHHS, June 20, 2001) (hereafter "NIH study"). The NIH study also concluded that condoms can reduce the risk of gonorrhea transmission from women to men and of genital warts and cervical neoplasia, conditions associated with human papilloma virus (HPV) infection, but that epidemiological evidence was insufficient to assess condom effectiveness in preventing transmission of gonorrhea from men to women, syphilis, chlamydial infection, chancroid, trichomoniasis and genital herpes; and that there was no evidence that condoms reduced transmission of HPV. The study further stressed that "the absence of definitive conclusions reflected inadequacies of the evidence available and should not be interpreted as proof of the adequacy or inadequacy of the condom to reduce the risk of STDs other than HIV transmission in men and women and gonorrhea in men." Ibid., p. ii.
105 CastNet Multimedia, "Truth for Youth" radio advertisement sponsored by McCAP. McCAP's radio advertisements were aired during "drive time" (7:00 a.m. to 10:00 a.m. and 4:00 p.m. to 7:00 p.m.) from mid-April through the end of August 2002. Human Rights Watch telephone interview with Lori Robinson, media buyer, CastNet Multimedia, August 5, 2002; E-mail message from Lori Robinson to Human Rights Watch, August 5, 2002.
106 Television advertisement aired during 10:00 p.m. news, May 2002, sponsored by McCAP. McCAP's "Truth for Youth" television advertisements were aired from mid-April through the end of August. E-mail message from Lori Robinson to Human Rights Watch, August 5, 2002.
114 See, for example, Scott & White Sex Education Program, Teens and Sex: What are the Effects, second edition (Temple, Texas: Worth the Wait, Inc., 2001), slide 55; Scott & White Sex Education Program, What Adults Need to Know About Teens and Sex, second edition (Temple, Texas: Worth the Wait, Inc., 2001), slide 68.
115 Human Rights Watch telephone interview with Michele Lawler, director, Abstinence Education Program, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, June 3, 2002; Mathematica Policy Research Institute, Inc., The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report, p. 4.
117 "Sex is Not a Game," video produced by the Medical Institute for Sexual Health. A discussion guide accompanying the video asks "If we're practicing safe sex, what's wrong with it?" and answers "Condoms don't make sexual activity safe. They can slip or break, they must be used absolutely correctly and consistently 100% of the time (the CDC reports 7 steps to proper condom usage) and even if they are used consistently and correctly, condoms provide limited (if any) protection against some STDs, including HPV. HPV causes over 99% of all cervical cancer in women. 93% of clinically significant pre-cancerous lesions detected by Pap smears contain high risk strains of HPV." Discussion Guide accompanying Sex is Not a Game (Austin, Texas: Medical Institute for Sexual Health, 2001), p. 4.
123 McCAP distributes "Abstinence `til Marriage (ATM)" cards, which state that "The person whose signature appears above agrees to the ATM (Abstinence `til Marriage) terms. Sex outside of marriage is an indebtedness that can produce negative returns (i.e., STD's, pregnancy, abortion, unwanted memories and/or broken heart) and all assets can be potentially lost (death), however the returns of an investment in an ATM can yield greater respect for yourself, others and your future husband/wife. Adherence to the conditions of this ATM card can yield greater rates of return in fidelity between couples in future mergers and acquisitions (marriage)." Scott & White's "Abstinence pledge card" reads, "Starting today, I __________ commit to abstain from sexual activity until marriage. I understand this is the only proven way to protect myself from premarital pregnancy and giving someone an STD. I respect myself and choose to wait." The "Mi Futuro/My Future" pledge card reads, "I'm saving myself for my future marriage partner. I give myself the freedom to make abstinent choices, to ignore all negative pressures and to enjoy my years as a teenager safe from the risks of premarital sex and all its expected outcomes."
124 In 2001, McCAP collaborated to produce "A Night to Last a Lifetime" with five local churches, who "came together to honor parents and teens in the exchange of vows and commitment to sexual purity." McCAP, A Collaborator's Guide, at 3-2; see also "A Night to Last a Lifetime: A Family Declaration of Purity," February 12, 2002 (on video; available from McCAP).
130 Theresa M. Exner et al., "HIV Counseling and Testing: Women's Experiences and the Perceived Role of Testing as a Prevention Strategy," Perspectives on Sexual and Reproductive Health, vol. 34, no. 2, March/April 2002, pp. 76-83.
131 See, for example, Rani Marx et al., "Linking Clients from HIV Antibody Counseling and Testing to Prevention Services," Journal of Community Health, vol. 24, no. 3, June 1, 1999, pp. 201-214; Deborah Lupton et al., "Doing the Right Thing: The Symbolic Meanings and Experiences of Having an AIDS Antibody Test," Social Science and Medicine, vol. 41, no. 2 (1995), pp. 173-180.
132 Peter S. Bearman and Hannah Brückner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912. That pledgers "are less likely to be prepared for an experience that they have promised to forgo . . . suggests that pledgers, like other adolescents, may benefit from knowledge about contraception and pregnancy risk, even if it appears at the time that they do not need such knowledge." Ibid, p. 900.
134 Human Rights Watch interview with Charmaine Heimes, master teacher, "Mi Futuro/My Future" Abstinence Education Program, Laredo, Texas, May 9, 2002; Human Rights Watch interview with Erika Ramirez, health trainer, "Mi Futuro/My Future" Abstinence Education Program, Cigarroa Middle School, Laredo, Texas, May 9, 2002. It is unclear whether referral to a school-based counselor has any practical significance for students in schools with abstinence-only programs. As discussed above, counselors and other school-based health professionals may feel constrained to censor information about condoms and contraception.
137 The CDC's technical assistance includes assisting schools in policy development and with the development and dissemination of materials and resources, training teachers and other school personnel, monitoring prevalence of risk behaviors among students and the status of HIV education in different jurisdictions, and evaluating the impact of programs and activities. Centers for Disease Control and Prevention Program Announcement Number 805: School Health Programs to Prevent Serious Health Problems and Improve Educational Outcomes, p. 8.
138 Human Rights Watch telephone interview with Marty DuShaw, health education specialist, Division of Adolescent Health Services, Centers for Disease Control and Prevention, May 28, 2002; Centers for Disease Control and Prevention Program Announcement Number 805: School Health Programs to Prevent Serious Health Problems and Improve Educational Outcomes.
142 Ibid., p. 49. Grantees must comply with the CDC's Content of AIDS-Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions in Centers for Disease Control and Prevention (CDC) Assistance Programs, which requires that written, audiovisual and pictorial materials be reviewed consistent with 42 U.S.C. §§ 300ee(b), (c) and (d), a federal statute that mandates that AIDS-related instructional materials must include information about abstinence, and that messages should be guided by principles in CDC's Guidelines for Effective School Health Education to Prevent the Spread of AIDS, MMWR vol. 37(S-2), Jan. 29, 1988, pp. 1-14.
145 Human Rights Watch telephone interview with Kathy van Teecklenburgh, state HIV/STD program specialist, Region 10 Educational Service Center, May 5, 2002; Human Rights Watch telephone interview with Tommy Fleming, director, Health and Physical Education, Division of Curriculum and Professional Development, Texas Education Agency, May 22, 2002. Regional Educational Service Centers are charged with "assist[ing] school districts in improving student performance in each region of the system"; "enabl[ing] school districts to operate more efficiently and economically"; and "implement[ing] initiatives assigned by the legislature or the commissioner." Tex. Educ. Code § 8.002; see also Tex. Educ. Code § 8.051 (ESC core services and services to improve performance).
147 Letter from Mike Moses, commissioner of education, Texas Education Agency to Elizabeth Taylor, grants management officer, Grants Management Branch, Centers for Disease Control and Prevention, November 2, 1995. At the time of this decision, Commissioner Moses' predecessor had suspended the state's acceptance of previous grant funds for the previous eleven months, following a controversy over materials developed with the CDC grant. Associated Press, "Education Chief Says He Will Re-Examine AIDS Grant Rejection," San Antonio Express-News, November 15, 1995. At the same time, Texas also rejected a plan to obtain $500,000 from the CDC to supplement existing school health programs. According to Commissioner Moses, the Texas Education Agency lacked the resources "to apply for, let alone administer" this grant. Mike Moses, "Health Directions: Education Chief Answers Critics on Grant Money," Austin American-Statesman, December 9, 1995, at A13.
149 Centers for Disease Control and Prevention Guidance and Considerations for Planning Non-Competing Continuation Applications for Fiscal year 1995: Cooperative Agreements for State and Local Comprehensive School Health Programs to Prevent Important Health Problems and Improve Educational Outcomes, at 2; see also Centers for Disease Control and Prevention Program Announcement Number 805: School Health Programs to Prevent Serious Health Problems and Improve Educational Outcomes, pp. 9-10.
151 A. Phillips Brooks, "Moses Decides to Accept AIDS Grant; Education Chief Changes Mind After Being Assured of No U.S. Dictates," Austin-American Statesman, January 12, 1996, p. B1. Pete Hunt, who works on this HIV grant program at the CDC, told Human Rights Watch that there was no conflict between the federal requirements and Texas state law. The CDC pointed out to Moses the language in the grant that supported the state's flexibility to carry out HIV/AIDS prevention programs. Human Rights Watch telephone interview with Pete Hunt, team leader, Division of Adolescent Health Services, Centers for Disease Control and Prevention, June 26, 2001.
154 Human Rights Watch telephone interviews with Tommy Fleming, May 22, 2002 and June 13, 2002. "Refusal skills" are those skills necessary to reject unwanted sexual pressure or participation in other behavior that might put one at risk of HIV/AIDS.
158 Andrew Welsh-Huggins, "State Holding Hearings on Sex Education Training Grant," Associated Press Newswires, January 20, 2000. Rep. Jim Jordan sponsored two bills: one requiring committee hearings and a model health curriculum; a second preventing the department from spending the money on sex education until the hearings were held. Ibid.
162 Human Rights Watch telephone interview with Marty DuShaw, health education specialist, Division of Adolescent Health Services, Centers for Disease Control and Prevention, May 28, 2002; Human Rights Watch telephone interview with Pete Hunt, team leader, Division of Adolescent Health Services, Centers for Disease Control and Prevention, June 26, 2002. In 1999, Ohio passed a law requiring that "instruction in venereal disease education . . . emphasize that abstinence from sexual activity is the only protection that is one hundred per cent effective against unwanted pregnancy, sexually transmitted disease and the sexual transmission of a virus that causes acquired immunodeficiency syndrome." Ohio Rev. Code Ann. § 3313.6011 (Baldwin 2002).
164 Human Rights Watch telephone interview with Donlynn Rice, administrator of curriculum and instruction, Nebraska Department of Education, June 25, 2002; Nebraska Department of Education, Health Education Frameworks (1998).
166 Human Rights Watch telephone interview with Donlynn Rice, June 25, 2002; Angie Brunkow, "Schools Rethink Sex Ed: Telling Students About Condom Use Goes Against a State Policy of Teaching Abstinence Only," Omaha World-Herald, March 3, 2001, p. 1.
171 Ibid. CDC's guidelines for the content of HIV prevention materials instruct that no funds "be used to provide education or information designed to promote or encourage, directly, homosexual or heterosexual activity or intravenous substance abuse," and not be "obscene." Centers for Disease Control and Prevention, Content of AIDS-related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions in Centers for Disease Control and Prevention (CDC) Assistance Programs, http://www.cdc.gov/od/pgo/forms/hiv.htm (retrieved on August 5, 2002).
173 David Brown, "HHS Studies Funding of AIDS Groups. Protest at Speech Fueled Audit Request; Activists Cite Fear of Retaliation," Washington Post, August 19, 2002, p. A1; Letter from members of Congress to Secretary Thompson, July 17, 2001. The staffer later updated his request to expand the list to sixteen groups. Brown, "HHS Studies Funding of AIDS Groups." The members of Congress who wrote the letter all are members of the Congressional Values Action Team. E-mail message from Roland Foster to Human Rights Watch, August 19, 2002.