SUFFER THE CHILDREN:
TITLE X's FAMILY PLANNING FAILURE

Title X of the Public Health Service Act is a categorical grant issued by the federal government to fund family planning projects throughout the United States. Enacted in 1970, Title X was supposed to help reduce the unplanned pregnancy rate, especially in the teenager population. However, Title X has not only failed to reduce the teenage pregnancy rate, but teenage reproductive health has drastically worsened in every category.

Over the lifetime of Title X, the number of teenage clients has grown due to increases in both Title X funding and the overall number of enrollees in Title X clinics. Currently, an estimated 1.5 million Title X clients are teenagers, constituting approximately one-third of the program's total clientele. But even though more teenagers are being exposed to these family planning "services," the rates of out-of-wedlock births, abortions, sexually-transmitted diseases, and pregnancies have all risen significantly in the teenage population since the program's inception.

• Out-of-wedlock births -- Since the introduction of Title X, the teenage out-of-wedlock birth rate has doubled. The out-of-wedlock birth rate per 1,000 unmarried girls aged 15-19 rose from 22.4 in 1970 to 44.6 in 1992 (teen births have declined since 1992).

  This illegitimacy figure is especially important to note because Title X advocates have sought to claim "success" by pointing out that the overall teenage birth rate has declined. However, such a decline is only attributable to the decline in marital births, not in illegitimate births. In 1970, seventy percent of teenage births were marital; in 1991, 7 in 10 teenage births occurred outside marriage.

  The same trend toward out-of-wedlock childbearing is evidenced in the female population at large. In 1970 when Title X began, children living with one parent were more than four times as likely to be products of divorce as they were to have been born out-of-wedlock. But by 1993, the Census Bureau reports found that American children who live with one parent were almost equally divided between children of divorce and those born to unmarried parents.

• Abortions -- Over the lifetime of Title X, the teenage abortion rate has more than doubled. In 1972, the abortion rate per 1,000 girls aged 15-19 was 19.1; in 1990, the rate was 40.6. While the abortion rate grew rapidly from 1972 to the early 1980s, the rate has apparently reached a plateau, hovering between 40 and 43 abortions per 1,000 teenage girls over the last 10 years.

  While the rapid growth of the teenage abortion rate during the early years of Title X is no doubt attributable, in large measure, to the Roe v. Wade decision, the past decade's more stabilized abortion rate cannot be viewed optimistically. For during this time, a rapid rise also occurred in out-of-wedlock births.

  Interestingly, the women whom Title X clinics target -- low-income women, minorities, and unmarried young people -- have the highest abortion rates. And, the Alan Guttmacher Institute reports that half of all women having an abortion used a contraceptive method in the month during which they conceived.

• Sexually-Transmitted Diseases (STDs) -- Sexually-transmitted diseases among teenagers have increased dramatically despite the fact that many Title X clinics provide both contraception and STD screening. In fact, teenagers now have higher rates of gonorrhea than any other 5-year age group between 20 and 44. Currently, one in four sexually experienced teenagers -- about 3 million -- become infected with an STD every year.

  For the first time ever, teenage girls have the highest gonorrhea rates in the nation; teenage boys rank second. The rate in adolescent girls is 20 times higher than in women over 30, according to the U.S. Centers for Disease Control and Prevention (CDC). Infectious syphilis rates more than doubled among teenagers since the mid-1980s. Additionally, up to 15 percent of sexually experienced teenage girls are infected with human papilloma virus, many of them carrying a strain that can cause cervical cancer. Chlamydia also has spread explosively, currently infecting 22 percent of sexually active girls and 10 percent of sexually active boys. Finally, one in five reported full-blown AIDS cases is diagnosed among people in their 20s. Due to the virus' long incubation period (about 10 years), most were adolescents when they were infected, according to the CDC.

  Sexually-transmitted diseases can lead to cancer, pelvic inflammatory disease, ectopic pregnancy, infertility, and/or even death. Estimates from the general population indicate that between 100,000 and 150,000 women become infertile each year as a result of an STD, and about 15 to 30 percent of the 2.3 million U.S. couples who are infertile may be unable to conceive as a result of an STD. But beyond infertility, STDs also increase the likelihood of contracting HIV. According to some estimates, having an STD, such as gonorrhea, increases by as much as 100 times the chance of contracting HIV from an infected partner.

• Pregnancies -- Since the introduction of Title X, the out-of-wedlock pregnancy rate among 15-to 19-year-old girls has doubled. In the same time span, the overall teenage pregnancy rate (marital and nonmarital) increased 23 percent, climbing from 95.1 per 1,000 girls aged 15-19 in 1972 to 117.1 in 1990. So not only did the overall teenage pregnancy rate increase, but a greater proportion of these pregnancies are now out-of-wedlock. This trend is best evidenced by the growing rate of out-of-wedlock births. When Title X began, only 3 in 10 teen births were out-of-wedlock; now 7 in 10 teen births occur outside marriage.

  Despite the 23 percent increase in the overall teen pregnancy rate, Title X advocates still claim "success" by stating that "fewer sexually experienced teenagers become pregnant each year." Advocates often remark that the pregnancy rate among sexually experienced teenagers has decreased from 254 to 207 per 1,000 (19%) in the last two decades. However, this figure is derived from a statistical invention called the "sexually experienced teenage pregnancy rate" (SETPR) which obscures the disastrous changes in teenage sexual activity and ignores the real indices of social health, i.e., the rates of teenage pregnancy, abortion, out-of-wedlock births, and STDs. The fact is, a greater proportion of teenagers are sexually experienced today than 20 years ago.

  Consider the following hypothetical comparison of two nations, Country A and Country B:

  
  Country    # of teenage     # sexually     # pregnant    SETPR
            girls 15-19      active         annually           
  
    A        1,000,000        500,000       200,000       400
    B        1,000,000        100,000       50,000        500
  

  In this straightforward example, Country B has a 25% higher "sexually experienced teenage pregnancy rate" than Country A. But Country B has only one-fifth the sexual activity rate of Country A and one-fourth of its teenage pregnancy rate. In fact, it is obvious that Country A can have a lower SETPR than Country B while still having a higher sexual activity rate, a higher rate of STDs, a higher number of pregnancies, and both four times as many abortions and out-of-wedlock births as Country B! SETPR may be of some statistical interest at the margin, but as a measure of adolescent well-being it is not merely useless, but grossly misleading.

By all accounts, teenage reproductive health has suffered under Title X's watch. Yet, incredibly, Title X programs continue to receive increased government funding, currently reaching an all-time high of $193 million for fiscal year 1995. Why? Because there is no accountability or measure of effectiveness connected to the funding of the program. There has never been an evaluation component included in the grants; and in 1983, the Department of Health and Human Services discontinued collecting client data.

The federal government is not only funding a failed program, it is funding an unauthorized program. Title X's funding authorization officially expired in 1985, but the program continues to receive federal dollars every year through inclusion in the Labor/Health and Human Services Appropriations bill.

PROHIBITION OF ABORTION -- Section 1008 of Title X states that "none of the funds appropriated under this title shall be used in programs where abortion is a method of family planning." Yet many of the clinics which receive Title X funds perform abortions in addition to providing other family planning services. These clinics creatively "obey" the prohibition by maintaining separate budgets for abortion and family planning. However, when self-titled "family planning" clinics perform abortions and refer clients for abortion when contraception fails, an implicit assumption exists that abortion is indeed a method of family planning. Additionally, many Planned Parenthood (PP) clinics receive Title X funds. And while not all of these PP clinics perform abortions, Planned Parenthood's reputation as an abortion provider is undisputable. Thus, to the client, no relevant distinction is made between abortion and family planning; in fact, the prohibition has been reduced to a mere bookkeeping formality. Such a misuse of the statute must be immediately halted and the integrity of the prohibition's original intent restored.

Poor teenage reproductive health outcomes and Title X funding are clearly correlated. But the question that begs to be answered is, "What accounts for the correlation? What effect do contraceptive counseling and dispensing have on teenagers' sexual behavior?" While such questions cannot be answered easily, there are clues which point in a common direction.

• Sexual activity rates among teenagers are higher now than ever before. Currently, fifty-six percent of girls and 73 percent of boys have intercourse before age 18, compared to 35 percent and 55 percent in the early 1970s.

• A 1993 Public Health Reports article found that adolescent males who had been instructed in sexual biology and birth control were at a higher risk of early first intercourse than were those who had received no instruction.

• Research from Planned Parenthood shows that the number one reason, by far, that teenagers initiate sexual activity is peer pressure. By promoting contraceptive use among teenagers, Title X clinics reduce the number of outside forces bolstering teenagers' resolve to save sex for marriage.

MULTIPLE PARTNERS -- According to the Centers for Disease Control, "The initiation of sexual intercourse early in life is associated with an increased number of sex partners and a greater risk for sexually transmitted diseases (STDs)." Data show that one-half of sexually experienced teenage girls wait almost 18 months between first intercourse and having sex with a second sexual partner; another one-fourth wait almost 2 years. Thus, helping teenagers to delay sex initiation is especially important.

However, evidence also indicates that contraceptive use leads to increased sexual activity, with a greater number of partners. Consequently, the dispensing of prescription contraceptives without parental involvement by family planning clinics would serve to exacerbate this trend -- which is, in fact, what is happening today.

• Among sexually active girls aged 15-17, 55 percent have had 2 or more partners and 13 percent have had at least 6.

• Between 1971 and 1988, the percentage of sexually experienced women aged 15-19 living in urban areas who reported 4 or more sex partners increased from 14% to 31%.

• Forty-five percent of 15-24-year-olds who had initiated sexual intercourse before age 18 reported having had four or more partners; 75 percent reported having had two or more partners.

• Dr. Robert Kistner of Harvard Medical School, one of the developers of the oral contraceptive, subsequently acknowledged that use of contraceptives among teenagers is stimulating higher levels of promiscuity: "About ten years ago I declared that the pill would not lead to promiscuity. Well, I was wrong," he said (Family Practice News, 1977).

CONTRACEPTIVE FAILURE -- Not only does contraceptive use lead to increased sexual activity with a greater number of partners, but contraception is not terribly effective at protecting teenagers from unplanned pregnancy and/or STD infection. Indeed, one-third of teenage pregnancies occur while a contraceptive is being used, and this figure does not even take into account the STD transmission rate.

In part, this is due to the fact that no contraceptive method is highly effective in protecting simultaneously against pregnancy and infection. Contraceptives with the best record for reducing pregnancy risk offer little, if any, protection against STDs. On the other hand, condoms have a standardized failure rate of 15.7 percent at preventing pregnancy over the course of a year; in teenagers, the rate is even higher. In addition to a poor contraceptive record, condoms have not been shown to be effective at protecting women against STD infection. A recent Family Planning Perspectives article found that condoms may protect women against some STDs, but the data are equivocal. In several studies, condoms showed no protective effect against cervical human papilloma virus, chlamydia, or bacterial vaginosis in women.

Maternal and infant mortality might not seem, at first glance, to be related to a discussion of Title X's impact on teenagers; but, in reality, the two concepts are inextricably connected. Title X's mandate is to reduce maternal and infant mortality and to promote the health of mothers and children. However, Title X has miserably failed in fulfilling this mandate. America ranks 24th in the world in infant survival, a very low ranking for a developed country, let alone the wealthiest country in the world. And the problems associated with Title X -- out-of-wedlock births, teenage pregnancies, and STDs -- are major factors undermining maternal and infant health.

• Out-of-wedlock births -- Nicholas Eberstadt and others have shown that marital status at birth is the key indicator for infant mortality, transcending both ethnicity and poverty. And the out-of-wedlock teenage birth rate has soared under Title X's watch.

• Teenage pregnancy -- One major cause of infant mortality is low birth weight, which is directly related to teenage pregnancy. Thus it comes as no surprise that Title X's failure to reduce teenage pregnancy would also result in higher infant mortality.

• Sexually-transmitted diseases -- As was discussed earlier, STDs have a negative impact on women's health, possibly leading to cancer, infertility, and even death. Ectopic pregnancies, which can be caused by STDs, have quadrupled since 1970, and the rate of infertility among women has also dramatically increased. But in addition to women, STDs hurt infants. The infection of infants from the mother's STDs (including, but not limited to HIV) has become a significant problem and will only continue to worsen as nonmarital sexual activity remains unchecked.

(1) Remove all funding from Title X -- Title X has not only failed to reduce the rates of teenage pregnancy, out-of-wedlock births, and sexually-transmitted diseases, it has exacerbated these problems. The program's lack of evaluation criteria and its approach as an open-ended project grant have frustrated accountability.

Title X does not deserve to continue receiving taxpayer dollars and, in fact, should not be receiving federal dollars, as an unauthorized program. The federal government has a responsibility to use federal funds wisely, and it should not be funding programs which, by all accounts, have produced worsened health outcomes.

(2) If Title X comes up for reauthorization, do not reauthorize -- Title X's authorization expired in 1985. And Title X should remain unauthorized because it has never been shown to benefit the American public.

(3) Promote saving sex for the context of marriage -- If the federal government must play a role in "family planning," it ought to promote the optimum health message -- that sex should be saved for marriage. Research shows that people who postpone sexual activity until marriage and practice monogamy within marriage are more likely to be sexually satisfied, to have enduring marriages, and to be free from the ravages of out-of-wedlock pregnancies and sexually-transmitted diseases.

Gracie S. Hsu, M.H.S., is a policy analyst specializing in human sexuality and life issues at the Family Research Council, a Washington, D.C.-based research and advocacy organization.

                                                                                    
 Year     Title X   Number of    Pregnancy       Rate of     Abortions   Abortion   
          Funding     girls       rate per    out-of-wedlock     to      rate per   
           (per        aged     1,000 girls     births per     girls   1,000 girls  
          fiscal      15-19      aged 15-19       1,000        aged     aged 15-19  
           year)                (married and    unmarried      15-19                
                                 unmarried)     girls aged                          
                                                  15-19                             

                                                                                    
 1970         n/a   9,517,000                      22.4                             
 1971    6,000,000  9,741,000                                                       
 1972   61,815,000  9,985,000       95.1                      191,000      19.1     
 1973   100,615,000 10,193,000      96.1                      231,900      22.8     
 1974   100,615,000 10,350,000      98.8                      279,700      27.0     
 1975   100,615,000 10,466,000     101.1           23.9       326,780      31.2     
 1976   100,615,000 10,582,000     101.1                      362,680      34.3     
 1977   113,000,000 10,581,000     104.6                      396,630      37.5     
 1978   135,000,000 10,555,000     105.4                      418,790      39.7     
 1979   135,000,000 10,497,000     109.4                      444,600      42.4     
 1980   162,000,000 10,381,000     111.0           27.6       444,780      42.8     
 1981   161,671,000 10,095,000     109.9           27.9       433,330      42.9     
 1982   124,176,000 9,809,000      109.8           28.7       418,740      42.7     
 1983   124,088,000 9,515,000      109.3           29.5       411,330      43.2     
 1984   140,000,000 9,287,000      107.9           30.0       398,870      42.9     
 1985   142,500,000 9,174,000      109.0           31.4       399,200      43.5     
 1986   136,372,000 9,205,000      106.7           32.3       389,240      42.3     
 1987   142,500,000 9,139,000      106.6           33.8       381,640      41.8     
 1988   139,663,000 9,029,000      111.4           36.4       392,720      43.5     
 1989   138,320,000 8,840,000      114.9           40.1       370,900      42.0     
 1990   139,135,000 8,645,000      117.1           42.5       350,970      40.6     
 1991   144,311,000 8,371,000                      44.8                             
 1992   149,585,000 8,312,000                      44.6                             
 1993   173,418,000    n/a                         n/a                              
 1994   190,918,000    n/a                         n/a                              
 1995   193,349,000    n/a                         n/a                              

Sources: The Alan Guttmacher Institute; U.S. Bureau of the Census; Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control, Office of Population Affairs, U.S. Public Health Service.

1. "Advance Report of Final Natality Statistics, 1992," Monthly Vital Statistics Report, Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention," Vol. 43, No.5, Supplement, October 25, 1994.

2. "Births by age, marital status and race, 1988-1992," work tables from the Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention.

3. Cates, Willard, Jr. and Katherine M. Stone, "Family Planning, Sexually Transmitted Diseases and Contraceptive Choice: A Literature Update -- Part 1," Family Planning Perspectives, Vol. 24, No. 2, March/April 1992.

4. Eberstadt, Nicholas, "America's Infant Mortality Puzzle," The Public Interest, Fall 1991, p. 30.

5. "Family Planning Program History Table," Office of Population Affairs, Public Health Service, U.S. Department of Health and Human Services, December 12, 1994.

6. Family Practice News, December 15, 1977, as quoted by James H. Ford and Michael Schwartz, "Birth Control for Teenagers: Diagram for Disaster," Linacre Quarterly, February 1979, p. 76.

7. Hayes, Cheryl D., ed., Risking the Future: Adolescent Sexuality, Pregnancy and Childbearing, National Research Council, National Academy Press, Washington, D.C., 1987.

8. Henshaw, Stanley K. and Jennifer Van Vort, Abortion Factbook, 1992 Edition: Readings, Trends, and State and Local Data to 1988, The Alan Guttmacher Institute, April 1992.

9. Henshaw, Stanley K., "U.S. Teenage Pregnancy Statistics," The Alan Guttmacher Institute, April 4, 1994.

10. Ku, L., F.L. Sonenstein and J.H. Pleck, "Factors Influencing First Intercourse for Teenage Men," Public Health Reports, Vol. 108, pp. 680-694, 1993.

11. "Premarital Sexual Experience among Adolescent Women -- United States, 1970-1988," Morbidity and Mortality Weekly Report, Centers for Disease Control, Vol. 39, Nos. 51 & 52, January 4, 1991.

12. Roan, Shari, "America's Silent Epidemic: Despite Publicity about AIDS, Sexually Transmitted Diseases are Flourishing Among the Young," Los Angeles Times, October 26, 1994, p. A1.

13. Saluter, Arlene F., Marital Status and Living Arrangements: March 1993, U.S. Bureau of the Census, Current Population Reports, Series P20-478, U.S. Government Printing Office, Washington, D.C., 1994.

14. Schwartz, Michael, Testimony provided before the United States House of Representatives, Committee on Energy and Commerce, Subcommittee on Health and the Environment, Hearing on Title X of the Public Health Service Act, April 22, 1988, p. 141.

15. The Alan Guttmacher Institute, "Abortion in the United States," Facts in Brief, August 31, 1994.

16. The Alan Guttmacher Institute, "Sexually Transmitted Diseases (STDs) in the United States," Facts in Brief, September 1993.

17. The Alan Guttmacher Institute, "Teenage Reproductive Health in the United States," Facts in Brief, August 31, 1994.

18. The Alan Guttmacher Institute, "Women and Reproductive Health in the United States," Facts in Brief, August 1, 1994.

19. U.S. Bureau of the Census, Statistical Abstract of the United States, 1994, 114th edition, The Reference Press, Inc., Washington, D.C., 1994.

20. U.S. Bureau of the Census, "Preliminary Estimates of the Population of the United States, by Age, Sex, and Race: 1970 to 1981," Current Population Reports, Series P-25, No. 917, 1982.