“Abstinence Education: Assessing the Accuracy and Effectiveness of Federally Funded Programs” (2008), by Government Accountability Office

On 23 April 2008, the US Government Accountability Office, or GAO, released a report titled, “Abstinence Education: Assessing the Accuracy and Effectiveness of Federally Funded Programs,” hereafter “Abstinence Education,” in which it investigated the scientific accuracy and effectiveness of abstinence-only education programs sanctioned by individual states and the US Department of Health and Human Services, or HHS. GAO is a government agency whose role is to examine the use of public funds, evaluate federal programs and activities, and provide nonpartisan support to the US Congress. In “Abstinence Education,” GAO found that as of August 2006, a variety of factors in such programs, such as inaccurate medical information, contributed to overall conclusions that abstinence-until-marriage programs were unsuccessful at reducing the rates of adolescent pregnancy. In “Abstinence Education,” GAO recommends that HHS implement procedures to better assure the accuracy of educational materials used in abstinence programs and to set standards that measure the effectiveness of those programs.

In the US, there has been debate over whether abstinence-only education or comprehensive sex education is more effective in terms of reducing rates of adolescent pregnancy. In 2001, twenty-two percent of American women reported having a child before age twenty, and overall US adolescent pregnancy rates have continually been generally higher than rates in other developed countries. The US government is responsible for determining how to allocate federal funding for programs on effective sex education and programs that reduce adolescent pregnancy rates. Generally, abstinence-only education promotes sexual restraint and self-discipline until marriage as the only completely effective method of birth control. In contrast, comprehensive sex education discusses abstinence and contraception as means of reducing pregnancy, while also including information about reproductive choices, anatomy and puberty, relationships, and sexuality. Many supporters of abstinence-only education are often from certain religious or self-proclaimed conservative backgrounds, which researchers claim is due to the fact that many religions prohibit premarital sexual relations. Additionally, Republican Party leadership has historically favored abstinence-only education as compared to Democratic Party leadership. Those federally funded abstinence education programs are delivered by a variety of entities, including schools, human service agencies, and faith-based organizations.

GAO’s role is to examine the use of public funds, evaluate federal programs and activities, and support Congress in its oversight, policy, and funding decision-making. At the time of the report’s publication in 2008, Marcia Crosse was GAO’s Director of Health Care and was responsible for overseeing GAO evaluations related to biomedical research, disease surveillance, and public health preparedness. Crosse obtained a doctorate in social psychology from the University of North Carolina in Chapel Hill, North Carolina, and worked with a team of collaborators to produce “Abstinence Education.” Kristi Peterson, GAO’s Assistant Director at the time, Kelly DeMots, Cathleen Hamann, Helen Desaulniers, and Julian Klazkin were listed as major contributors to the report.

The report “Abstinence Education” is divided into six sections. The first section explains how GAO made the report to identify whether grantees were ensuring the accuracy and effectiveness of federally funded abstinence-only education programs. The second section is a document from the testimony given by Crosse to the Committee on Oversight and Government Reform that explains how GAO found that grantees’ efforts to ensure the accuracy and effectiveness of those programs were not sufficient. The third section provides background about the factors involved with the rise of US adolescent pregnancy rates. The fourth section discusses how there had been limited efforts at both the federal and state levels to evaluate scientific accuracy of the educational materials used in the three main federally funded abstinence education programs. In the fifth section, GAO discusses how existing efforts to assess the effectiveness of abstinence-until-marriage education programs have not followed a scientifically valid method. GAO ends with a sixth section that recommends inclusion of medically accurate information regarding the overall effectiveness of condoms in preventing the diseases the educational materials are designed to address.

In the first section of the report, GAO provides a brief summary in which it explains that the main focus was determining whether grantees ensured the accuracy and effectiveness of federally funded abstinence-only education programs. GAO explains that their methods included looking at three of the main federally funded abstinence-until-marriage programs, reviewing documents from those programs, and interviewing officials who worked in different divisions of HHS that provided oversight and funding for reproductive healthcare. Overall, GAO found that HHS and states did not properly substantiate the scientific accuracy of educational materials used in abstinence programs nor comprehensively assess the effectiveness of those programs.

“Abstinence Education” also includes a transcript of a testimony given by Crosse to the House Committee on Oversight and Government Reform, in which she explains on behalf of GAO that previous efforts at ensuring the accuracy and effectiveness of those programs had been insufficient. The transcript detailed the overall methods for the investigation and lists the three programs that GAO examined, which were the Abstinence Education State Program, Community-Based Abstinence Education Program, and Adolescent Family Life, or AFL, Program. According to HHS, in fiscal year 2007, forty of the fifty US states received some form of federal funding for abstinence education programs. The transcript also reveals that GAO found that improper procedures for ensuring the accuracy of the information provided in such programs violated a section of the Public Health Service Act, which it explains more in the final section.

Then, GAO provides background on factors contributing to rising adolescent pregnancy rates, while also discussing federal funding attempts at lowering those rates through abstinence education programs. That section opens with statistics from the Centers for Disease Control and Prevention that establish that high school students are more susceptible to certain sexually transmitted infections, or STIs, because they are more likely to engage in riskier sexual behaviors. Likewise, HHS’s 2006 strategic plan included an aim to reduce incidence of STIs and unintended pregnancies among high school students, as well as an aim to promote family formation and healthy marriages. Those aims prompted HHS to launch abstinence-until-marriage education programs. Given that HHS utilizes federal taxpayer dollars, the report included an audit by GAO to verify the accuracy and efficacy of those programs.

In the section titled “Federal and State Efforts to Assess Scientific Accuracy of Materials Used in Abstinence-Until-Marriage Education Programs Have Been Limited,” GAO reports that the Administration for Children and Families, or ACF, neither reviewed nor required its grantees to screen program materials for scientific accuracy. Because it was not mandatory, few state grantees had conducted such reviews. Additionally, GAO found inaccuracies in ACF program materials in two of the five states it reviewed. One such inaccuracy was educational material citing that human immunodeficiency virus, or HIV, can pass through condoms because condoms are made with latex, which is porous. However, scientific evidence does not support such a claim, and the CDC states that both male and female condoms reduce the risk of HIV transmission when used correctly. Given the lack of standardized accuracy checks in abstinence program educational material, GAO recommends in its report that HHS’s Secretary should develop procedures to help assure the accuracy of abstinence-until-marriage educational materials.

In “A Variety of Efforts were Made to Assess the Effectiveness of Abstinence-Until-Marriage Education Programs, but a Number of Factors Limit the Conclusions That Can Be Drawn,” GAO reports different ways that HHS, states, and researchers had made efforts to assess the effectiveness of the programs. GAO reported that both ACF and OPA required that their grantees use independent evaluators and supported grantees in their program evaluation efforts. Specifically, ACF and OPA required their grantees to contract with third-party evaluators, such as university researchers or private research firms, who were responsible for helping grantees develop, report, and monitor outcome measures designed to demonstrate the extent to which grantees’ abstinence education programs were attaining their intended goals.

Continuing in that section, GAO then reports that although some grantees made efforts to assess program effectiveness, many of their efforts were not scientifically valid. GAO establishes in its report that for a study to be scientifically valid, it must have random control or well-matched comparison groups and it must measure biological outcomes or reported behaviors rather than attitudes and intentions. Such biological outcomes or reported behaviors include rates of pregnancies, births, or STIs, in addition to assessing reported instances of first sexual intercourse and frequency of sexual activity. GAO states that it prefers those metrics because adolescent attitudes and intentions are not unequivocally indicative of actual behavior. GAO found that some of the journal articles on abstinence education that it reviewed lacked at least one of the characteristics of a scientifically valid study of program effectiveness. For example, those studies did not compare the responses of adolescent participants with a group that did not participate in an abstinence education program. Given that more localized studies on abstinence programs have not produced enough evidence supporting their effectiveness, according to GAO, future efforts should be directed toward more comprehensive evaluations of the overall efficacy of abstinence program.

Finally, in its last section, “Statutory Requirement to Include Information on Condom Effectiveness Would Apply to Certain Abstinence-until-Marriage Education Materials,” GAO discusses how a deficit in some abstinence education programs may violate a section of the Public Health Service Act. GAO states in the report that through the course of its work on abstinence education, it identified a federal statutory provision that was relevant to HHS’s State Program, Community-Based Program, and AFL Program grants. That provision requires that educational materials prepared by HHS’s grantees, among others, must specifically address STIs. Also, the provision requires that those materials contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing STIs. However, GAO includes a remark that an ACF official reported that materials prepared by abstinence-until-marriage education grantees were not subject to that provision but did not explain how or why they were excluded from that requirement. Therefore, GAO recommends to HHS that it reexamine its position regarding the provision. Further, they recommend it adopts measures to ensure that abstinence education materials comply with that requirement, where applicable.

Since GAO published its report in 2008, federal funding for abstinence education programs has changed. In 2009, the budget under the administration of then US President Barack Obama eliminated most federal funding for abstinence programs. Instead, the budget allocated funding for other forms of reproductive health education. Following the Obama Administration, as executive and legislative branches became conservative-controlled in 2018, the administration of US President Donald Trump issued a funding announcement that explicitly encouraged programs that emphasize abstinence and sex cessation support.

Overall, GAO’s report provides justification for further scrutiny as to the accuracy and efficacy of abstinence education programs and materials. GAO states that although there were some existing studies on abstinence education, the findings were inconclusive due to the study design. Given that they found inaccuracies in existing program materials, GAO’s report emphasizes the need for all education programs to be validated to ensure their factuality. Ultimately, in “Abstinence Education,” GAO reports on how the US government’s efforts to ensure the accuracy and effectiveness of federally funded abstinence education programs have been insufficient. It also provides several recommendations for how the government, and HHS specifically, can improve the accuracy and effectiveness of sex education programs.