October 6, 2005

The Honorable David M. Walker

Comptroller General

U.S. Government Accountability Office

441 G St, NW

Washington, DC 20548

Dear Mr. Walker:

I am writing to ask that GAO investigate a contract for the review of
abstinence-only curricula that raises serious questions about both
ideological bias and financial conflicts of interest.

In January, I wrote to you along with nineteen other Members of Congress
and Senators to request that GAO review the processes within the
Department of Health and Human Services for determining the accuracy and
evaluating the effects of "abstinence-only" education.[^1] This request
stemmed from a report I released last December that found serious
scientific and medical errors in 11 of the 13 most popular federally
funded curricula.[^2] I am pleased that GAO has agreed to undertake this
investigation.[^3]

I am writing to ask that you address in your investigation a \$2.7
million dollar, three-year contract awarded by HHS for several tasks
related to abstinence-only education.[^4] These tasks include technical
assistance on medical accuracy for abstinence-only grantees; the
development of criteria to ensure that curricula comply with the
statutory definition of "abstinence," and the creation of a directory of
curricula that meet these criteria.[^5] The contract was awarded in
September 2002.[^6]

I am concerned for two reasons. The contract has been awarded to an
organization with a strong ideological bias and a history of ignoring
scientific evidence that challenges its positions. Moreover, the
organization that received the contract appears to have a significant
conflict of interest because it earns fees from abstinence-only resource
providers whose curricula it is being asked to evaluate.

My concerns are detailed below.

# The Contract

The Request for Proposals for the abstinence technical assistance
contract was issued on June 20, 2002.[^7] According to the Statement of
Work, the Contractor was to:

1.  Develop national criteria for the review of abstinence-only
    curricula, based on compliance with federal definitions of
    abstinence-only education;

2.  Develop and implement a procedure for the review of abstinence-only
    curricula, and produce a directory of approved curricula;

3.  Develop and implement a program to provide medically accurate
    training and information to federal abstinence-only grantees; and

4.  Develop and implement a program of consultation and technical
    support to federal abstinence-only grantees.[^8]

The total contract value was \$2.7 million dollars, distributed over the
first year plus two option years.[^9]

The agency has reported that the purpose of the criteria is to determine
if curricula are in compliance with the federal definition of
abstinence-only education. [^10] This is a peculiar question since the
legal definition is already quite precise. [^11]

In contrast, medical inaccuracy is known to be a problem in
abstinence-only curricula. A report I released last December found
serious scientific and medical errors in 11 of the 13 most popular
federally funded curricula, and this may have serious health
consequences.[^12] Yet the contract does not require review of curricula
for medical and scientific accuracy, providing only trainings on medical
accuracy for abstinence educators.

Inclusion in the directory of approved curricula will not be a
prerequisite for funding.[^13] However, it is reasonable to assume that
applicants for federally-funded abstinence programs will want to select
"approved" curricula to improve their chances of obtaining grants.

**\
**

**Selection of the Contractor**

The abstinence technical assistance contract was awarded to the National
Abstinence Clearinghouse on September 27, 2002.[^14] There are serious
questions as to how the Clearinghouse was selected and whether it is an
appropriately impartial and non-ideological contractor for the task.

First, it is uncertain how open the contracting process was. At its
annual conference in August, a staff member for the Clearinghouse
described the origins of the contract in the following way:

> So the government said look, we're paying you to teach abstinence
> education, and we want to make sure that where our money is going ---
> our money is going to quality programs. So **they came to us --- or,
> they put out a request for proposals** .... And we put together a plan
> to provide some technical assistance to help the government get what
> they're paying for.[^15]

The presenter may have misspoken.  However, the selection criteria in
HHS's request for proposals seem to point specifically to the
Clearinghouse.  The ideal party for establishing national criteria would
be non-ideological and able to impartially assess both the law and the
curricula involved.  However, the selection criteria include
"organizational experience in serving as a nationwide resource for
information and consultation on abstinence-only education."[^16] This
description closely matches that of the Clearinghouse, which represents
itself on its website as a "central location where materials and
training to effectively convey the abstinence-until-marriage message
could be provided" and which "serves agencies on a national, state and
local level."[^17] While a handful of other parties submitted proposals,
it is important to determine whether the selection criteria were stacked
in favor of the Clearinghouse from the start.[^18]

I am also concerned about the bias of the contractor. The National
Abstinence Clearinghouse is a vocal advocate for a narrow form of
abstinence-only-until-marriage education, often choosing ideology over
evidence. The mission of the Clearinghouse is "to promote the
appreciation for and practice of sexual abstinence (purity) until
marriage," and its official position statements include the following:

-   **"Masturbation** ... Sex therapists consider masturbation the first
    stage of sexual addiction for sex addicts. This practice should not
    be encouraged as a 'safe' sexual practice."

-   **"Images in Educational Materials** .... Diagrams of internal
    organs are acceptable, but images or pictures of external genitalia
    in any form, whether diseased or healthy, can be detrimental to the
    health of young men and women's minds."

-   **"Homosexuality** .... Research shows the homosexual lifestyle is
    not a healthy alternative for males or females. The male and female
    body are not anatomically suited to accommodate sexual relations
    with members of the same sex. Sexual practices in the homosexual
    lifestyle are considered very dangerous for disease, infection, etc.
    This lifestyle should not be encouraged as healthy or as an equal
    alternative to marriage."[^19]

In support of its ideological agenda, the National Abstinence
Clearinghouse has on multiple occasions misrepresented medical or
scientific data. For example, last year Texas A&M researchers found that
students became increasingly sexually active after abstinence-only
programs, paralleling trends among their peers in the state.[^20] A
principal investigator of the study stated, "The jury is still out, but
most of what we've discovered shows there\'s no evidence the large
amount of money we're spending is having an effect."[^21] Yet the
Clearinghouse issued a press release titled "Texas A&M Study Shows
Abstinence Education Works."[^22] Similarly, when last year researchers
Peter Bearman and Hannah Bruckner at Columbia and Yale Universities
found that teens who took "virginity pledges" were as likely to contract
STDs as those who did not, the Clearinghouse press release read:
"Bruckner and Bearman Study Shows Abstinence Education Works."[^23]

Clearinghouse President Leslee Unruh has also criticized crucial public
health interventions on ideological grounds. For example, in recent
clinical trials, new vaccines were highly effective in preventing the
transmission of the human papillomavirus strains associated with most
cases of cervical cancer.[^24] This intervention could save thousands of
women's lives in the United States and many more worldwide. Yet in a
Clearinghouse release, Ms. Unruh called the idea of routine vaccination
"an outrage" and stated that the costs "would be much safer spent on
abstinence education."[^25]

**Conflicts of Interest**

The Clearinghouse's financial relationship with publishers of curricula
also raises questions. The group makes money from curriculum providers
by selling benefits that include extensive advertising, distribution and
certification. There would appear to be a conflict when an organization
that solicits funds from resource providers is hired to determine which
of those resources are eligible for federal funding.

The Clearinghouse has a strong financial relationship with many
abstinence-only curriculum providers, offering individuals and groups
varying levels of "affiliation." At the higher levels, benefits include
publicity for speakers or materials. For example, for \$480 per year,
"Engagers" receive a consultation session, a quarter-page ad,
"distribution service," and a private session with President Leslee
Unruh.[^26] Prospective affiliates are told: "Getting a product into the
hands of consumers takes experience and the proper resources. The
Abstinence Clearinghouse has both and we can help Engagers reach their
product goals."[^27]

Similarly, for its annual conference this August, the Clearinghouse
offered resource providers varying levels of sponsorship that include
multiple forms of advertising.[^28] For example, at the highest level of
\$3,600, Gold Sponsor benefits included pamphlet inserts in the
registration bag, one booth space, and a full-page ad in the conference
binder.[^29] The Clearinghouse's message to resource providers was
unambiguous:

> The International Abstinence Leadership Conference is the world's
> largest gathering of like-minded abstinence managers, coordinators,
> educators and students. These 1,100 plus attendees have a combined
> annual budget totaling more than \$250 million. This amount will
> increase when the President's proposals for increasing the federal
> budget for abstinence education, fatherhood initiatives, and marriage
> preparation education are implemented. Resource providers should not
> be asking, "Can I afford to exhibit at this conference?" Instead they
> should ask, **"Is this a conference I can afford to miss?" The answer
> is a resounding "NO!"**[^30]

In addition, the Clearinghouse charges abstinence educators for
"Certification." The significance of certification is unclear;
conference attendees were told, "It's all about credibility."[^31]
Requirements for certification include a fee to the Clearinghouse and a
test on the fundamentals of abstinence education.[^32] However,
conference attendees were assured regarding the test that "We just want
to make sure ... that the information has gone in and stayed in for a
minute and then can be spewed back out, that's basically all we need."
[^33] Regardless of its debatable utility, the certification process
represents another financial interest between the organization and the
abstinence-only community.

With these strong financial relationships in place, it is difficult to
see how the National Abstinence Clearinghouse could be seen as a
disinterested arbiter of the eligibility of different curricula for
federal funding.

# Conclusion

The GAO study will cover how HHS has reviewed the accuracy and
effectiveness of abstinence-only programs it funds. I ask that as part
of this review, you assess HHS's contract for national criteria and a
directory and abstinence-only technical assistance.

Specific questions you may want to address include:

1.  How was the National Abstinence Clearinghouse selected as the
    contractor?

2.  What was the relevant training and expertise of the members of the
    expert panels that the Clearinghouse convened to develop and apply
    national criteria?

3.  Has HHS taken any steps to address potential conflicts of interest
    created by the Clearinghouse's commercial relationship with
    abstinence-only resource providers?

4.  Why doesn't the contract include criteria for assessing the medical
    and scientific accuracy of curricula themselves?

5.  What were the training needs identified by the contractor or
    subcontractors in the area of medical accuracy? Did HHS review the
    medical or factual accuracy of information provided at the trainings
    given by the two subcontractors?

If you have any questions, please contact my staff at (202) 225-5420.

> Sincerely,
>
> Henry A. Waxman
>
> Ranking Minority Member

[^1]: Letter from Rep. Henry A. Waxman et al. to Comptroller General
    David M. Walker (Jan. 18, 2005) (online at
    http://reform.democrats.house.gov/Documents/20050118130027-07348.pdf).

[^2]: House Government Reform Committee Minority Staff, *The Content of
    Federally Funded Abstinence-Only Education Programs* (Dec. 2004)
    (online at
    http://reform.democrats.house.gov/Documents/20041201102153-50247.pdf).

[^3]: Letter from Gloria L. Jarmon, GAO Managing Director for
    Congressional Relations, to Rep. Henry A. Waxman (Feb. 25, 2005).

[^4]: HHS, *Award Notice* --- *Abstinence Education Program* (Sept. 30,
    2002).

[^5]: HHS, Health Resources and Services Administration, Maternal and
    Child Health Bureau, *Statement of Work --- Abstinence Education
    Program* (June 20, 2002).

[^6]: HHS, *Award Notice*, *supra* note 4.

[^7]: HHS, Health Resources and Services Administration, *Statement of
    Work*, *supra* note 5.

[^8]: *Id.*

[^9]: HHS, *Award Notice*, *supra* note 4.

[^10]: Telephone Interview, House Government Reform Committee Minority
    Staff and HHS and HRSA Staff (Apr. 20, 2005).

[^11]: The Section 510 program was created in the Personal
    Responsibility and Work Opportunity Reconciliation Act of 1996. Pub.
    L. No. 104-193 (1996) (hereinafter "PRWORA"). PRWORA § 510(b) states
    that a qualifying program:

    > \(A\) has as its exclusive purpose, teaching the social,
    > psychological, and health gains to be realized by abstaining from
    > sexual activity;\
    > (B) teaches abstinence from sexual activity outside marriage as
    > the expected standard for all school age children;\
    > (C) teaches that abstinence from sexual activity is the only
    > certain way to avoid out-of-wedlock pregnancy, sexually
    > transmitted diseases, and other associated health problems;\
    > (D) teaches that a mutually faithful monogamous relationship in
    > context of marriage is the expected standard of human sexual
    > activity;\
    > (E) teaches that sexual activity outside of the context of
    > marriage is likely to have harmful psychological and physical
    > effects;\
    > (F) teaches that bearing children out-of-wedlock is likely to have
    > harmful consequences for the child, the child's parents, and
    > society;\
    > (G) teaches young people how to reject sexual advances and how
    > alcohol and drug use increases vulnerability to sexual advances;
    > and\
    > (H) teaches the importance of attaining self-sufficiency before
    > engaging in sexual activity.

[^12]: House Government Reform Committee Minority Staff, *supra* note 2.

[^13]: Telephone interview, *supra* note 10.

[^14]: HHS, *Award Notice* --- *Abstinence Education Program* (Sept. 30,
    2002). The National Abstinence Clearinghouse subcontracted with the
    Medical Institute for Sexual Health for Task 3, and the Institute
    for Youth Development for Task 4.

[^15]: National Abstinence Clearinghouse, *The Good, the Bad and the
    Ugly: HRSA Contract Explained* (presentation) (Aug. 6, 2005)
    (emphasis added).

[^16]: HHS, Health Resources and Services Administration, Maternal and
    Child Health Bureau, *Request for Proposals --- Section L,
    Instructions, Conditions, and Notices to Offerors or Quoters* 50
    (June 20, 2002).

[^17]: National Abstinence Clearinghouse, *About Us* (online at
    <http://abstinence.net/about/history.php> and
    http://abstinence.net/about/).

[^18]: According to the Federal Procurement Data Center, a total of 2-5
    parties submitted proposals to HHS. *Federal Procurement Data
    System: Fiscal Year 2003*.

[^19]: National Abstinence Clearinghouse, *Abstinence 101* (2005) 88-90.

[^20]: Patricia Goodson, B.E. Pruitt, et al., *Abstinence Education
    Evaluation Phase 5: Technical Report* (Sept. 2004).

[^21]: *Bush Pushes Sexual Abstinence for Teens Despite Data,* Reuters
    (Mar. 17, 2005).

[^22]: National Abstinence Clearinghouse, *Press Release:* *Texas A&M
    Study Shows Abstinence Education Works: Students More Likely to
    Abstain* (Jan. 31, 2005) (online at
    http://abstinence.net/library/index.php?entryid=1814).

[^23]: Hannah Bruckner and Peter S. Bearman: *After the Promise: The STD
    Consequences of Adolescent Virginity Pledges.* Journal of Adolescent
    Health (forthcoming March/April); National Abstinence Clearinghouse,
    *Press Release:* *Bruckner and Bearman Study Shows Abstinence
    Education Works* (Mar. 21, 2005) (online at
    http://abstinence.net/library/index.php?entryid=1927).

[^24]: L.A. Koutsky, K.A. Ault, C.M., Wheeler, et al., *A Controlled
    Trial of a Human Papillomavirus Type 16 Vaccine,* New England
    Journal of Medicine, 1645 (Nov. 21, 2002); Diane Harper et al.,
    *Efficacy of a bivalent L1 virus-like particle vaccine in prevention
    of infection with human papillomavirus types 16 and 18 in young
    women: a randomised controlled trial*, *The
    Lancet* 2004; 364:1757-1765.

[^25]: National Abstinence Clearinghouse*, Drug Companies to Manufacture
    HPV Vaccines and Push For Mandatory Use on Minors* (Apr. 13, 2005)
    (online at
    http://www.abstinence.net/library/index.php?entryid=1976).

[^26]: National Abstinence Clearinghouse*, Member Center* (Feb. 2, 2004)
    (online at http://www.abstinence.net/member/benefits.php).

[^27]: National Abstinence Clearinghouse, *Abstinence Clearinghouse
    Affiliate Program*: *Networking individuals and organizations*
    (pamphlet).

[^28]: National Abstinence Clearinghouse, *Abstinence Takes on
    Hollywood* (online at http://hollywood.abstinence.net/sponsors/).

[^29]: *Id.*

[^30]: *Id.* (emphasis in original).

[^31]: National Abstinence Clearinghouse, *The Good, the Bad and the
    Ugly: HRSA Contract Explained* (presentation) *supra* note 15.

[^32]: National Abstinence Clearinghouse, *Latest News: Certification
    Testing* (Aug. 31, 2005) (online at:
    http://www.abstinence.net/library/index.php?entryid=2246).

[^33]: National Abstinence Clearinghouse, *The Good, the Bad and the
    Ugly: HRSA Contract Explained* (presentation) *supra* note 15.