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# **April 2003**

# **Policy Brief ...............\....................................................Title X**

RSC Contact: Sheila Moloney, 202-226-9719

### Background on the Federal Title X Program

Title X (pronounced "title ten"), the only federal program exclusively
focused on contraception distribution, was established by the Family
Planning Services and Population Research Act of 1970 (P.L. 91-572).
Despite the fact that the Title X program's legal authorization to exist
expired on 9/30/85, Congress continues to appropriate money.

###### Teen Use

1/3 of Title X recipients are teens, according to U.S. Department of
Health and Human Services (www.hhs.gov)

###### Title X Funding

**Since its inception, Title X has received approximately \$5 billion.**

(A full funding chart for Title X is available at:
<http://opa.osophs.dhhs.gov/titlex/ofp-funding-history.html>)

###### FY 2003 \$275.138 million

FY2002: \$265.085 million

FY2001: \$253.932 million

FY2000: \$238.932 million

FY1999: \$214.932 million (Congress appropriated \$218 but there was an
across the board rescission)

FY1998: \$203.452 million

FY1997: \$198.452 million

FY1996: \$192.592 million (first fiscal year of Republican Congress)

FY1995: \$193.349 million

###### Planned Parenthood

According to the General Accounting Office, Planned Parenthood
Federation of America and its affiliates received \$51.1 million from
Title X in FY99 (24% of the Title X budget), the last year for which
these numbers are available.

# Source:GAO-02-81R Federal Funds for Reproductive Health

<http://www.gao.gov/new.items/d0281r.pdf>

###### Number of Clinics

According to HHS, in 2001-2002 over 4,500 clinics (up from 4,000 in
1998-99) will receive federal family planning money (including clinics
in Guam, Puerto Rico, Marianas Islands, etc.). They are listed by state
in a free, 268-page directory, "Family Planning, Grantees, Delegates,
and Clinics 2001/2002 Directory" (available from HHS clearinghouse:
301-654-6190) and are also available online
<http://opa.osophs.dhhs.gov/titlex/2001directory/ofp_directory_2001.html>

###### Federal Regulations Require Free & Confidential Teen Services:

It is important to note that Federal [Regulations]{.underline} (not
laws) require confidentiality and teen service.

Title 42---Public Health, Chapter 1---Public Health Service, Department
of Health and Human Services, Part 59---Grants for Family Planning
Services, Subpart A\--Project Grants for Family Planning Services (42
CFR 59)

---Federal Register Vol. 65, No. 128, revised Monday, July 3, 2000, pp.
41270-41280

> "Section 59.5 What requirements must be met by a family planning
> project?
>
> ... (4) Provide services **without regard of** religion, race, color,
> national origin, handicapping condition, **age,** sex, number of
> pregnancies; or marital status."
>
> "Section 59.11 Confidentiality.
>
> All information as to personal facts and circumstances obtained by the
> project staff about individuals receiving services **must be held
> confidential and must not be disclosed without the individual's
> documented consent,** except as may be necessary to provide services
> to the patient or as required by law, with appropriate safeguards for
> confidentiality. Otherwise, information may be disclosed only in
> summary, statistical, or other form which does not identify particular
> individuals."
>
> "Section 59.2 Definitions.
>
> ***Low income family*** means a family whose total annual income does
> not exceed 100 percent of the most recent Poverty Guidelines issued
> pursuant to 42U.S.C. 9902(2). "Low-income family" also includes
> members of families whose annual family income exceeds this amount,
> but who, as determined by the project director, are unable, for good
> reasons, to pay for family planning services. For example,
> **unemancipated minors who wish to receive services on a confidential
> basis** must be considered on the basis of their own resources."

[Federal Statute (42 USC Sec. 300a-4) Grants HHS Secretary Authority to
Define *"*Low-Income Family":]{.smallcaps}

Title 42---The Public Health and Welfare Chapter 6A---Public Health
Service Subchapter VIII---Population Research and Voluntary Family
Planning Programs --

> "Sec. 300a-4. Grants and contracts

**...** (c) Prerequisites; "low-income family" defined

> A grant may be made or contract entered into under section 300 or 300a
> of this title for a family planning service project or program only
> upon assurances satisfactory to the Secretary that -
>
> \(1\) priority will be given in such project or program to the
> furnishing of such services to persons from low-income families; and

\(2\) **no charge will be made in such project or program for services
provided to any person from a low-income family** except to the extent
that payment will be made by a third party (including a government
agency) which is authorized or is under legal obligation to pay such
charge.

**For purposes of this subsection, the term "low-income family" shall be
defined by the Secretary in accordance with such criteria as he may
prescribe** so as to insure that economic status shall not be a
deterrent to participation in the programs assisted under this
subchapter."

**[Child Abuse/Sexual Abuse, & Rape Reporting
requirements:]{.smallcaps}**

Since the Fiscal Year 1999 Labor/HHS/Education Appropriations Act was
signed by President Clinton, and every subsequent year, it has been the
law of the land that Title X family planning providers must obey state
laws requiring notification or the reporting of child abuse, child
molestation, sexual abuse, rape, or incest.

Current law, signed by President Bush, states:

"SEC. 212. Notwithstanding any other provision of law, no provider of
services under title X of the Public Health Service Act shall be exempt
from any State law requiring notification or the reporting of child
abuse, child molestation, sexual abuse, rape, or incest." --- PL108-7
(H.J.Res. 2)

**[Abortion Referrals]{.smallcaps}**

According to federal regulations, all clinics must make abortion
referrals, upon request, as well as dispense a "broad range of
acceptable and effective medically approved family planning methods,"
including the morning-after pill. Abortion referrals were stopped under
Presidents Reagan and Bush, but Clinton lifted the so-called "Gag Rule"
in January 1993, and HHS codified President Clinton's Presidential
Memorandum in the July 3, 2000, revised regulations.

"Section 59.5 What requirements must be met by a family planning
project?

> A project must: Offer pregnant women the opportunity to \[be\]
> provided information and counseling regarding each of the following
> options: ...Pregnancy termination. If requested to provide such
> information and counseling, provide neutral, factual information and
> nondirective counseling on each of the options, and referral upon
> request, except with respect to any option(s) about which the pregnant
> woman indicates she does not wish to receive such information and
> counseling."

###### Case Studies:

The following examples are ones that could have been prevented if
taxpayer-funded clinics were required to notify parents prior to
dispensing or surgically implanting contraceptive drugs or devices.

> In 1997 it was learned that a 13-year-old girl from McHenry Country,
> Illinois was sexually molested by her junior high school teacher (37
> years old when it ended) over a period of 18 months. The teacher
> repeatedly took his victim to a Title X clinic where she received
> injections of Depo Provera, without her parents' knowledge.

---See Congressional Testimony from July 2002
[http://energycommerce.house.gov/107/hearings/07112002Hearing632/Heisler1092.htm]{.underline}

> In January of 1998, a 16-year old in Walton County, Georgia,
> unbeknownst to her parents, went to receive a pelvic exam and an
> injection of the contraceptive drug Depo Provera. The young girl
> casually mentioned to the nurse that she had a heart murmur. The nurse
> told the girl she would need a doctor's note so the clinic would be
> immune from a malpractice claim. The family's doctor subsequently told
> the mother that had the chemical contraception been administered,
> there was a great probability [her child would have gone into cardiac
> arrest and possibly died]{.underline} because of her heart condition.
>
> ---Correspondence from Georgia State Rep. Len Walker, March 18, 1998

###### 

###### Majority of Teens Say They Should have to Ask Parents:

In a Nov '96-Feb '97 Gallup survey of 500 teenagers, ages 13 to 17, 66%
of the teens that were polled believed that parental consent \[stronger
requirement than notification\] should be required before minors receive
birth control.

###### Medical journals support notion that parental involvement affects behavior

The Journal of the American Medical Association affirms that this
parental involvement affects teens becoming sexually active:

> "Significant family factors associated with delaying sexual debut
> include high levels of parent-family connectedness, parental
> disapproval of their adolescent being sexually active, and parental
> disapproval of their adolescent\'s using contraception."

---"Protecting Adolescents from Harm," *JAMA*, September 10, 1997.

###### Dangers of contraceptive use in teens include pregnancy and death

According to manufacturer's warning, included in contraceptive
packaging. Side effects from contraception can include blood clotting,
bone deterioration, and blindness. It can cause death in girls with
heart conditions, and has been the cause of brain-stem stroke in
teenagers. As to effective birth control, the Alan Guttmacher Institute,
Planned Parenthood's research arm, reports, "47 percent of all
unintended pregnancies in the US occur while the woman is using
contraceptives\..."

###### Parental Notice Amendment History

The Istook/Barcia/Manzullo parental notice amendment to FY99 HHS
appropriations bill passed the House on 224-200 vote on October 8, 1998.

<http://clerkweb.house.gov/cgi-bin/vote.exe?year=1998&rollnumber=504>

The amendment requires:

1)  Title X clinics to follow state sexual abuse reporting laws,

2)  Parental notice before contraceptive drugs and devices are given to
    a minor,

3)  Abstinence counseling for minors to avoid HIV and STDs.

The House-Senate conference on the FY99 Omnibus (of which the HHS
appropriations bill was a part) dropped the substance of the amendment,
except the first requirement on state sexual abuse laws.

During the FY98 Labor/HHS/Education Appropriations House floor vote on
Sept. 9, 1997, an amendment was offered by Rep. Istook to \"require
parental notification.\" Rep. Castle offered a second-degree gutting
amendment that deleted the word \"require\" in the Istook amendment and
inserted \"*encourage* parental involvement.\" The gutting amendment
passed 220-201, Roll Call #378, thus nullifying true parental
involvement. There was also a gutting substitute offered by Rep. Obey to
Rep. Istook's amendment in July 12, 1996, which passed 232-193, Roll
Call #310.

###### 

###### Why They Said we Needed Title X

From the House debate (1970) on the original Title X authorization bill:

"Mr. CARTER. Mr. Speaker, the Family Planning Services and Population
Research Act of 1970 is greatly needed. Estimates have been made by
reliable authorities that by the year 2000 our population in the United
States will reach 300 million. It is entirely possible that productivity
in a nation even as wealthy as ours may not rise sufficiently to
properly feed, clothe, and care for this gigantic increase. The quality
of life could well be diminished."

\[Note: The United States population reached close to 300 million (281
million, not counting many illegal aliens) in 2000, up from 203 million
in 1970. By all accounts, the American population was well fed, clothed
and cared for in 2000.\]

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