Bush’s War on Sexual Health and Defensive Strategies Against It
Since George W. Bush became President of the United States in 2001, his administration has presided over what is likely the most far-reaching campaign attacking sexual and reproductive rights that has yet been seen in this country. The counts are many, but in this paper we will examine three of the more insidious attempts to trump contraceptive choice, reproductive freedom and scientific fact with a narrow view of religious morality: the promotion of abstinence-only education; a general attack on condom use by spreading misinformation and suppressing scientific evidence about condoms’ efficacy; and a more recent campaign against sex workers.
George W. Bush has publicly supported abstinence-only education at least since he was Governor of Texas, and as a presidential candidate he made it clear that he planned to expand these programs on the national level (Human Rights Watch, 2004). Indeed, since he took office, President Bush has relentlessly sought to impose abstinence-only education as the norm for youth in the United States and internationally.
Abstinence-only education is a program intended to replace comprehensive sexuality education with the strict promotion of abstinence from sex until marriage as the accepted norm for sexual behavior and as the only sure method of preventing out-of-wedlock pregnancy and sexually transmitted infections (STIs) (Girard, 2004). It was first instituted under the Reagan Administration in 1981 through the Adolescent Family Life Act and was further expanded through the welfare reform legislation pushed through Congress in 1996 under the Clinton Administration, which requires states receiving federal money to follow strict guidelines for abstinence education. In 2000, again under the Clinton Administration, Congress increased funding for abstinence-only programs through the Special Projects of Regional and National Significance Community-Based Abstinence Education (SPRANS) program operated by the U.S. Department of Health and Human Services (Girard, 2004).
The scope of these programs has shifted the face of sexuality education in U.S. public schools; whereas a mere 2% of secondary school students received abstinence-only education in 1988, by 1999 this figure had jumped to 23% (Darroch, 2000).
The 1996 legislation defines abstinence education with specific guidelines that, in addition to mandating teaching abstinence as the only method for preventing pregnancy and sexually transmitted infections (STIs), include teaching that sex within the context of marriage is the standard for sexual activity, and that having sex outside the context of marriage will likely lead to psychological and physical harm (Girard, 2004).
This standard for supposedly preparing youth for leading healthy sexual lives has numerous shortcomings, not least among them being the denial of young people’s right to full information and freedom of expression. On the level of public health outcomes, it can be particularly damaging to adolescents. Because these programs teach only about abstinence, they fail to prepare young people for when they do have sex, making them more at risk for pregnancy and STIs. Furthermore, by claiming that the only accepted context for sexual activity is marriage, abstinence programs alienate young people who do have sex, particularly gay, lesbian, bisexual or questioning youth who may never fit into the model offered.
Despite these glaring deficiencies, the Bush Administration has not only embraced abstinence education, but has also significantly increased the budgets for these programs. While total funding for abstinence-only programs in 2001 (the last budget approved by President Clinton) was $80 million, that figure has more than doubled, to $167 million, for fiscal year 2005. This was still substantially less than the $270 million requested by President Bush (Kaisernetwork.org, 2004a). The majority of this increase in funding has been through SPRANS, where grants made to community groups for abstinence-only education increased from $20 million in 2001 to $104 million for 2005 (United States House, 2004).
The expansion of the SPRANS programs is particularly disturbing given the fact that the content of the curricula used is not subject to review. A report prepared by the U.S. House of Representatives Committee on Government Reform in December 2004 found that “over 80% of the abstinence-only curricula, used by over two-thirds of SPRANS grantees in 2003, contain false, misleading, or distorted information about reproductive health” (United States House, 2004). More specifically, this report found that the majority of these curricula contained errors and distortions of public health information; gave false information and misleading use of data regarding the effectiveness of contraceptives, including condoms; and provided misleading or false information about the risks of being sexually active; among other problems.
In addition to increased funding for abstinence-only programs, the Bush Administration has increased pressure on groups that provide or advocate for comprehensive sexuality education. Two prominent sexual and reproductive rights groups – the Sexuality Information and Educational Council of the United States (SIECUS) and Advocates for Youth – were audited by federal agencies for the first time in their history in 2003 (Girard, 2004). Even the Centers for Disease Control, the federal agency charged with monitoring and protecting public health, adapted its materials to meet the agenda of the Bush Administration. In 2001, it removed a page on its Web site entitled “Programs that Work”, which were all comprehensive sexuality education programs, and altered its fact sheet about condoms to include abstinence messages (United States House, no date).
This kind of pressure has also been extended into the international sphere. The Bush Administration has repeatedly sought to impose abstinence-only education language into various United Nations statements and documents, including the United Nations’ Special Session on HIV/AIDS in 2001 and the Special Session on Children in 2002 (Center for Reproductive Rights, 2004). The HIV/AIDS legislation signed by President Bush in 2003 mandates that a minimum of 33% of funding for HIV/AIDS prevention must be dedicated to abstinence-only education (Boonstra, 2004). And a chilling effect has spread among international public health agencies, which feel pressure to include abstinence education in their programs in order to compete for U.S. funds even outside the HIV/AIDS package (Human Rights Watch, 2004).
Attacks on Condom Use
The Bush Administration’s strategy to impose abstinence-only education overlaps on many points with its efforts to discourage condom use through spreading misinformation, censoring scientific data about their effectiveness, and generally disparaging their use as an important contraceptive and preventive method (Girard, 2004). This is most notable in the approach to HIV/AIDS prevention, despite the fact that correct and consistent condom use has proven to be an effective means of preventing HIV (Hearst & Chen, 2004).
The first sign of what was to come in the attack against condoms came in 2001, shortly after George W. Bush became President, when the Centers for Disease Control and Prevention (CDC) removed a page from its Web site called “Facts about Condoms and their Use in Preventing HIV Infection.” The disappearance of this page, which contained information about how to use condoms correctly and emphasized that inconsistent or incorrect use of condoms were the main reasons for condom failure, caused an outcry among public health advocates in the United States. It was replaced several weeks later with a version that leaves out these important points and instead leads with a disclaimer that abstinence is the “surest way” to prevent infection with a sexually transmitted disease (Sexuality Information and Educational Council of the United States [SIECUS], 2003).
While the Web site affirms that condoms are “highly effective” in preventing HIV, the omission of key scientific information critical to HIV prevention greatly diminishes the usefulness of the site. What’s more, it points to a deeper strategy at work: the Bush Administration’s insistence on promoting its own moralistic agenda at the expense of effective measures to fight the HIV epidemic. President Bush’s early appointments to key public health posts reflect this bias, particularly the appointment of Randall Tobias, who has publicly questioned the effectiveness of condoms in preventing HIV, as the U.S. Global AIDS Coordinator (Human Rights Watch, 2004).
This is further evidenced in how the HIV/AIDS Act, the legislation that regulates funding for international HIV prevention efforts, has been implemented. A report released by the Government Accounting Office in 2006 showed that the policy of requiring 33% of HIV prevention funds to be spent on abstinence education has severely hindered local HIV prevention initiatives, particularly in the realm of reducing mother-to-child transmission. Seventeen of 20 countries surveyed reported that the spending requirements on abstinence limited their ability to fight HIV by responding to local needs, and 9 of the 15 target countries reported reducing the amount of money they had budgeted for programs to reduce mother-to-child transmission (Kaisernetwork, 2006).
Furthermore, while the Bush Administration purportedly endorses the ABC approach to HIV prevention – abstinence, be faithful, use condoms – its actions under this legislation fail to support education on condom use or condom promotion in any meaningful way. As stated previously, 33% of HIV prevention funds are required to go to abstinence-only education, but there is no similar requirement for condom education. Rather, the legislation explicitly states that groups that receive funding are not required to “endorse, utilize, or participate in a prevention method or treatment program to which the organization has a religious or moral objection” (Girard, 2004). And although the legislation insists that any information provided about condoms be scientifically accurate, it does not require that any information about condoms be given at all. This leaves the door open for groups that receive funding to spend 100% of the funds on abstinence without mentioning condoms as a prevention method.
The Bush Administration has also sought to disparage condoms through spreading misinformation or distorting the facts, particularly about condom failure rates. For example, in 2004 the Bush Administration considered adding a warning label to condom packages stating that they are not effective in preventing the human papillomavirus (HPV), the virus that causes cervical cancer, citing recent studies, including one conducted by the CDC (Kaisernetwork.org, 2004b). This was an outright distortion of the findings. While the CDC emphasized regular pap smears as the primary prevention method for HPV, the CDC report also indicated that there was evidence to suggest that condom use may reduce the risk of cervical cancer (Centers for Disease Control, 2004). The warning labels could have potentially discouraged condom use generally, and there was such a public outcry against this measure that this proposal was withdrawn (Boonstra, 2003).
This tactic of distorting information about condoms’ efficacy and failure rates is consistent with the Bush Administration’s overall strategy to disparage condoms and hence discourage their use. At a time when nearly five million people are infected with HIV every year (UNAIDS & World Health Organization, 2004), this policy is absolutely unconscionable given that the government’s own scientific studies have shown condoms to be extremely effective in preventing HIV and gonorrhea, not to mention in preventing unintended pregnancy (Boonstra, 2003).
Campaign Against Sex Workers
The Bush Administration’s attempts to impose its moralistic view of sexuality on the international sphere have been flagrant. The most obvious example of this was the Global Gag Rule, which Bush signed as his first official act as President. This executive decision denies funding to foreign organizations that provide abortion, lobby to change abortion laws, or counsel clients about abortion, even in cases where abortion is legal (Center for Reproductive Rights, 2003). It has been noted by several advocates of sexual and reproductive rights that such a policy would not be legal if applied to domestic organizations (Population Action International, 2005 and Center for Reproductive Rights, 2003b).
The HIV/AIDS Act of 2003 contained a similar gag rule in it, this time aimed at sex workers. It prohibited funding “any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking” (Girard, 2004). But while the Global Gag Rule on abortion could not be pressed on U.S.-based organizations, in June of 2005, the gag against prostitution was extended to apply to domestic organizations that provide services in other countries (USAID, 2005).
In addition to being a violation of free speech, this policy alienates the population of sex workers and their clients whose participation is critical to the fight against HIV/AIDS (Girard, 2004). Furthermore, by dismissing sex workers out of hand, this policy fails to take into account the reality of many women’s lives and the root causes of prostitution, including poverty and violence. Regardless of whether an organization works with sex workers directly, public health institutions must maintain their right to welcome all clients, without judgment.
On one hand, it is likely that this policy will also create a chilling effect, whereby international organizations are less inclined to work with sex workers so as not to forfeit U.S. grants. On the other, it forebodes a loss in funding for those organizations that are perhaps best positioned to do quality HIV prevention work: the ones that are committed to protecting privacy and serving the populations who are most in need. The government of Brazil, which has produced some of the most innovative programs in HIV/AIDS prevention, caused an uproar when it decided that it would rather lose $40 million in funding from the U.S. than comply with this policy (Kaisernetwork, 2005). In 2006, federal courts in New York and the District of Columbia struck down this policy as unconstitutional in that it violates First Amendment rights to free speech by restricting organizations’ use of privately-raised funds (New York Times, 2006). In March 2007, however, a federal appeals court reversed this decision, ruling that the U.S. can deny funding to organizations working on HIV/AIDS that do not publicly reject sex work and sex trafficking. This decision is being challenged and is likely to end up being reviewed by the Supreme Court.
Defensive Strategies for Advocates of Sexual and Reproductive Health
Given the radical nature and far-reaching extent of these policies, advocates of sexual and reproductive rights both in the United States and internationally need to step up their efforts to protect these rights.
To some extent, this community was taken off guard by the extremity of the Bush Administration’s attack on sexual and reproductive rights. It was clear that a conservative government would attempt to challenge the right to abortion in this country and bring back the Global Gag Rule. Advocates were totally unprepared, however, for the sweeping scope of the policies put forth by the Bush Administration that have chipped away at sexual and reproductive rights not just in the area of abortion, but also in promoting abstinence in lieu of comprehensive sexuality education, disparaging condoms and campaigning against sex workers, not to mention a host of other policies.
Now that many of these policies have been set in motion, the sexual and reproductive health community must step up its advocacy efforts to halt the erosion of such basic rights. Based on the experiences thus far in advocating for sexual and reproductive rights in the face of the Bush Administration’s assault, we propose three main lines of action: conducting and disseminating research to disprove anti-sexual health fallacies; encouraging governments to stand up to U.S. pressure in international forums; and arguing for access to sexual and reproductive health and rights as a means to bolster economic development and security worldwide.
Conducting research to disprove anti-sexual health fallacies
Many of the policies promoted by the Bush Administration are rooted in misinformation, misuse of information or outright errors. In some cases, research is already available that points to the weaknesses of these policies, and better dissemination of this research could help to open the eyes of the general population and augment the public outcry against these policies.
The myth about the effectiveness of abstinence-only education is a case in point. Despite the Bush Administration’s insistence that abstinence is the only method that is 100% effective against pregnancy and STIs, research has repeatedly proven that abstinence-only education programs do not work (Girard, 2004). While abstinence programs have had some impact on delaying sexual initiation, this has no bearing on the rate of STIs or unplanned pregnancies (SIECUS, 2005a). What’s more, because youth subjected to abstinence-only programs have not received any information about contraceptive options or prevention methods other than abstinence, they are wholly unprepared for the years when they are sexually active before marriage. Even among those youth who pledge to remain virgins until marriage, half will initiate sex by the time they are 19, but the average age of first marriage is 23, leaving a gap of several years (Brückner & Bearman, 2005). Theses conclusions on the ineffectiveness of abstinence-only education, and its potential harmful effects on youth, were re-affirmed in a 2006 position paper of the Society of Adolescent Medicine that was an extensive review of research in the field (Society of Adolescent Medicine, 2006).
Although virginity pledges delay sexual initiation for an average of 18 months, pledgers are one-third less likely to use contraception when they do have sex and tend to have the same incidence of STIs as their non-pledging counterparts (Brückner & Bearman, 2005). Furthermore, pledgers are many times more likely to have engaged in oral or anal sex than non-pledgers (SIECUS, 2005b).
In June 2005 a study of federal abstinence education programs conducted by the Mathematica Policy Research Inc. (Mathematica, 2005) found that these programs had no affect on young people’s intentions to abstain from sex; what did get across, however, were messages of fear and shame with regard to pre-marital sex (SIECUS, 2005a).
The ineffectiveness of abstinence programs in reducing STIs and unintended pregnancies was so glaring that the Bush Administration had to change its evaluation indicators for these programs to make them look more promising; in 2001, the measures of success for abstinence programs that had been developed under the Clinton Administration, including tracking sexual activity and births among participants, were replaced by new performance measures that have little scientific value in indicating their success, such as attendance and attitudes about abstinence (United States House, no date).
Fallacies about other sexual and reproductive health issues are rampant in Bush Administration’s policies and public discourse, and have come to be seen as truth when in fact they have no basis in science. The Bush Administration has repeatedly claimed that comprehensive sexuality education will increase promiscuity among teens, but research has shown that students at schools where condoms are available are less likely to be sexually active, and that sex education courses do not hasten sexual initiation or the frequency of having sex (SIECUS, 1997). Similarly, there is ample research about the effectiveness of condoms in preventing HIV and other STIs, not to mention its beneficial effect on preventing pelvic inflammatory disease, infertility and other reproductive health problems (SIECUS, 2004).
While the research exists to expose abstinence-only education as ineffective and other fallacies spread by the Bush Administration, there is still a need for research to explore the subtler nuances involved in these issues. For example, little research has been done to analyze the messages that are being transmitted by different sex education curricula and how effective they are in combining a positive view of sex with a reasonable degree of caution. In addition, while most studies focus on unintended pregnancy and STIs, very few have attempted more ambitious assessments of mental health effects. Such research could inform and advance the development of policies and curricula. One shortcoming in the research available on sex education is that it generally ignores the fundamental dimension of gender. Given the thorough genderization of sexuality, gender power inequalities and their multiple interactions with poverty and class divisions should be front and center in any research.
With sound scientific research on these and other issues, sexual and reproductive health advocates can make their case more effectively.
Encouraging governments to stand up to U.S. pressure
One of the most promising, though unexpected, outcomes of the Bush Administration’s attack on sexual and reproductive rights has been the response of the international community in the face of increasing U.S. pressure to conform to these radically anti-sex, homophobic, anti-choice policies. On several occasions, the Bush Administration’s representatives to international meetings on development, population and health issues have sought to delete language related to reproductive rights, reproductive health, condom use, and abortion, particularly as these topics relate to adolescents, and to insert instead language about abstinence and parental rights and responsibilities (Center for Reproductive Rights, 2004).
For example, at the United Nations Special Session on HIV/AIDS and the Special Session on Children, in 2001 and 2002 respectively, the U.S. delegation pushed for including language promoting abstinence education only. These efforts failed (PLANetWIRE, 2002a).
Again, in the meetings leading up to the 10-year review of the Program of Action of the International Conference on Population and Development (ICPD), the United States sought repeatedly to roll back the language that had been agreed upon by 179 nations, including the United States, in the original document. At the Asia-Pacific Conference in Bangkok in 2002, the U.S. delegation formally objected to using the terms “reproductive health” and “reproductive rights”, as well as to a paragraph about adolescent reproductive health that mentioned condom use for preventing HIV. The terms and passages were not deleted, with the U.S. being the only dissenting vote (Cohen, 2003). In response, the U.S. issued a “general reservation” to the document stating its policy that abstinence is “the preferred, most responsible, and healthiest choice for unmarried adolescents” (Girard, 2004).
Later, at a regional meeting for Latin America and the Caribbean in Santiago, Chile in 2004, the 37 nations represented withstood U.S. pressure and reaffirmed the ICPD Program of Action, while the U.S. was the sole dissenting vote. Finally, the victory that affirmed the strength of the international community came at the final meeting for the Latin American and Caribbean Region in Puerto Rico later the same year; after failing to gain allies in opposing the ICPD document, the U.S. remarkably decided to join the consensus, albeit with formal reservations about the language used (Cohen, 2004).
These occasions demonstrate that the international community can in solidarity resist the Bush Administration’s bullying on reproductive health and rights issues. Even those countries with close economic ties to the United States have stood up to the pressure exerted by U.S. delegations. In forums like those held under the auspices of the United Nations, the votes have enormous power symbolically and implications for policy. However, the fact that U.S. international aid is inextricably linked to U.S. policy still remains a challenge.
Many governments and international agencies depend on U.S. assistance to fund their programs, and it can be difficult to stand on principle when the very programs that are crucial to the health and well being of their populations are at stake. The response to the Global Gag Rule is a case in point. While several prominent international reproductive health organizations, including the International Planned Parenthood Federation (IPPF), refused to sign the restrictions of the Gag Rule and accepted the loss of U.S. funding, many non-profits felt they had no choice but to sign if they were to continue to provide services. The new gag against prostitution will likely have similar effects. The Bush Administration has also defunded the United Nations Population Fund (UNFPA) over the past several years citing the entirely false statements that UNFPA supports forced abortion in China, an assertion that even Bush’s own fact-finding team disproved (PLANetWIRE, 2002b).
What is encouraging about the cases of the Global Gag Rule and the defunding of UNFPA has been the response of the donor community to fill in the gaps. The European Commission and several other donors stepped up their funding for international sexual and reproductive health programs in the wake of the Gag Rule. And hundreds of thousands of private citizens signed on to the 34 Million Friends campaign to raise the money lost to UNFPA. Governments and organizations that fear that the loss of U.S. funding may usher in the collapse of their programs will be heartened by this recent history. In addition, in 2006 the British government publicly defied the Bush Administration by establishing a Safe Abortion Fund administered by the International Planned Parenthood Federation (IPPF) that gives money for safe abortion services and advocacy in developing countries. Although not restricted to organizations that have been cut off from American funding, this shows a remarkable difference in terms of policies between two close allies. The British initiated fund received support from other European governments soon after it was launched.
Arguing for sexual and reproductive health as an international public good
At the International Conference on Population and Development (ICPD) in 1994, participants explicitly recognized the relationship between sexual and reproductive health and the achievement of development goals. The Program of Action calls on the 179 signatory governments to “make accessible through the primary health-care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015” (United Nations Development Fund, 1994). It further defines reproductive health to include information, counseling and services for family planning, prevention and treatment of sexually transmitted diseases, including HIV; and abortion and post-abortion care. For many years, the ICPD Program of Action served as the roadmap for programming on sexual and reproductive health for both governments and nongovernmental agencies.
In 2001, the ICPD Program of Action was eclipsed by the Millennium Development Goals, a new framework for international development outlined by the United Nations General Assembly aimed specifically at eradicating poverty by 2015 (United Nations Millennium Project, no date). Although the MDGs fall short of emphasizing the overall goal of universal access to reproductive health care, three of the eight MDGs relate specifically to reproductive health issues: reducing child mortality, improving maternal health, and fighting HIV/AIDS. In addition, sexual and reproductive health and rights have direct implications for the achievement of several other goals, including those related to women’s empowerment, eradicating poverty and hunger, universal access to primary education, and environmental sustainability.
Since the MDGs were adopted as the framework for international development, advocates of sexual and reproductive health have sought to incorporate stronger language related to sexual and reproductive health and rights into the indicators and strategies for achieving these goals. And the agencies in charge of mapping a plan for the MDGs have taken note.
Several of the task forces charged with outlining strategies for achieving each of the goals have included language on sexual and reproductive health into their reports. For example, the Millennium Project Report’s Education and Gender Task Force stated that “Increasing women’s and adolescents’ access to a broad range of sexual and reproductive health information and services is one of the seven priorities for action identified by this Task Force.” Similarly, the Hunger Task Force noted that “ensuring universal access to reproductive health services is essential for improving the nutritional status of pregnant women and their children, in particular through the proper spacing of births.” Furthermore, several agencies have recently affirmed the importance of SRH to reaching the MDGs, including the 57th World Health Assembly, the Economic Commission for Latin America and the Caribbean, and the Commission on Population and Development, all of which stressed the importance of including sexual and reproductive health as an integral part of planning for the MDGs (IPPF/WHR, 2005). And at the 2005 World Summit, United Nations governments committed to “achieving universal access to reproductive health by 2015, as set out at the International Conference on Population and Development, integrating this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration, aimed at reducing maternal mortality, improving maternal health, reducing child mortality, promoting gander equality, combating HIV/AIDS and eradicating poverty” (United Nations, 2005, para. 57 g). After the concerted effort of advocates working on numerous fronts, the United Nations Secretary General recommended in 2006 the adoption of a “new target under Goal 5: to achieve universal access to reproductive health by 2015” (United Nations, 2006, para. 24). Work is now underway on the indicators for this target.
All of these documents reaffirm some basic truths: if we are to eradicate poverty and hunger, we must ensure that every woman has access to the services she needs to plan her family. If we are to reduce child mortality and improve maternal health, we must ensure that prenatal and postnatal care for women and their children is available and affordable. If we are to improve gender equality and empower women, we must ensure that equality extends to the sexual sphere, and that they are able to make choices about their sexual and reproductive lives. If we are to combat HIV/AIDS and fight its devastating consequences, we must ensure that adolescents and adults are informed about how HIV is spread, how to prevent HIV, how to use condoms correctly, and how to negotiate condom use with their sexual partners. If we are to ensure environmental sustainability, we must ensure that women have the means to regulate their fertility so that population growth slows to reflect the individual women’s fertility desires.
These arguments should inform programming around the MDGs, and as advocates we must report on their implications for sexual and reproductive health and hold governments to implementing programs that take into account the full recommendations of the UN Task Forces and the relationship between development issues and sexual and reproductive health.
The case for protecting and promoting sexual and reproductive health and rights is all the more pertinent in light of the increased emphasis on security in the United States and other nations. By addressing the root causes of poverty, hunger, and the lack of opportunities and resulting frustration experienced by so many women and men in the world, we will come that much closer to creating stable nations where every individual feels their well being is valued.
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