United States Government Accountability Office

GAO Report to Congressional Requesters

ABSTINENCE 

EDUCATION 

Efforts to Assess the 

Accuracy and 

Effectiveness of 

Federally Funded 

Programs 

October 2006 

 

GAO-07-87 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

October 2006

ABSTINENCE EDUCATION 

Efforts to Assess the Accuracy and 

Effectiveness of Federally Funded 

Programs 

Highlights of GAO-07-87, a report to 

congressional requesters 

Reducing the incidence of sexually 

transmitted diseases and 

unintended pregnancies is one 

objective of the Department of 

Health and Human Services (HHS).

HHS provides funding to states and 

organizations that provide 

abstinence-until-marriage 

education as one approach to

address this objective. 

GAO was asked to describe the

oversight of federally funded 

abstinence-until-marriage 

education programs. GAO is

reporting on (1) efforts by HHS and

states to assess the scientific 

accuracy of materials used in these

programs and (2) efforts by HHS, 

states, and researchers to assess 

the effectiveness of these

programs. GAO reviewed

documents and interviewed HHS 

officials in the Administration for 

Children and Families (ACF) and 

the Office of Population Affairs 

(OPA) that award grants for these 

programs. 

What GAO Recommends

To address concerns about the 

scientific accuracy of materials 

used in abstinence-until-marriage

education programs, GAO 

recommends that the Secretary of

HHS develop procedures to help

assure the accuracy of such

materials used in programs 

administered by ACF. HHS agreed

to consider this recommendation.

HHS also provided information on 

steps it takes to assure accuracy, 

which we have incorporated into 

the report, as appropriate. 

Efforts by HHS and states to assess the scientific accuracy of materials used 

in abstinence-until-marriage education programs have been limited. This is 

because HHS’s ACF—which awards grants to two programs that account for 

the largest portion of federal spending on abstinence-until-marriage 

education—does not review its grantees’ education materials for scientific

accuracy and does not require grantees of either program to review their 

own materials for scientific accuracy. In contrast, OPA does review the 

scientific accuracy of grantees’ proposed educational materials. In addition, 

not all states that receive funding from ACF have chosen to review their 

program materials for scientific accuracy. In particular, 5 of the 10 states

that GAO contacted conduct such reviews. Officials from these states 

reported using a variety of approaches in their reviews. While the extent to 

which federally funded abstinence-until-marriage education materials are 

inaccurate is not known, in the course of their reviews OPA and some states 

reported that they have found inaccuracies in abstinence-until-marriage 

education materials. For example, one state official described an instance in 

which abstinence-until-marriage materials incorrectly suggested that HIV 

can pass through condoms because the latex used in condoms is porous. 

HHS, states, and researchers have made a variety of efforts to assess the 

effectiveness of abstinence-until-marriage education programs; however, a 

number of factors limit the conclusions that can be drawn about the 

effectiveness of abstinence-until-marriage education programs. ACF and 

OPA have required their grantees to report on various outcomes that the 

agencies use to measure the effectiveness of grantees’ abstinence-untilmarriage education programs. In addition, 6 of the 10 states in GAO’s review

have worked with third-party evaluators to assess the effectiveness of 

abstinence-until-marriage education programs in their states. Several factors,

however, limit the conclusions that can be drawn about the effectiveness of 

abstinence-until-marriage education programs. Most of the efforts to 

evaluate the effectiveness of abstinence-until-marriage education programs 

included in GAO’s review have not met certain minimum scientific criteria—

such as random assignment of participants and sufficient follow-up periods 

and sample sizes—that experts have concluded are necessary in order for 

assessments of program effectiveness to be scientifically valid, in part 

because such designs can be expensive and time-consuming to carry out. In 

addition, the results of efforts that meet the criteria of a scientifically valid 

assessment have varied and two key studies funded by HHS that meet these 

criteria have not yet been completed. When completed, these HHS-funded 

studies may add substantively to the body of research on the effectiveness of

abstinence-until-marriage education programs. 

www.gao.gov/cgi-bin/getrpt?GAO-07-87.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marcia Crosse 

at (202) 512-7119 or crossem@gao.gov. 
Contents 

Letter 1

Results in Brief 5

Background 7

Federal and State Efforts to Assess the Scientific Accuracy of

Materials Used in Abstinence-until-Marriage Education 

Programs Have Been Limited 14 

A Variety of Efforts Have Been Made to Assess the Effectiveness of 

Abstinence-until-Marriage Education Programs, but a Number of 

Factors Limit the Conclusions That Can Be Drawn 19 

Conclusions 39

Recommendation for Executive Action 40 

Agency Comments and Our Evaluation 40 

Appendix I HRSA’s Technical Assistance Contract for 

Abstinence Education 44 

Appendix II Methodology for Identifying and Reviewing 

Research Studies 49 

Appendix III Comments from the Department of Health and 

Human Services 51 

Appendix IV GAO Contact and Staff Acknowledgments 57 

Tables 

Table 1: Definition of Abstinence Education 9 

Table 2: Funding Provided by HHS for the Three Main Abstinenceuntil-Marriage Education Programs 12 

Table 3: ACF’s Reporting Requirements for the State Program and 

the Community-Based Program, Fiscal Year 2006 21 

Page i GAO-07-87 Abstinence Education
Abbreviations 

ACF Administration for Children and Families 

AFL Adolescent Family Life 

ASPE Office of the Assistant Secretary for Planning and 

 Evaluation 

CDC Centers for Disease Control and Prevention 

FAR Federal Acquisition Regulation 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

HPV human papillomavirus 

HRSA Health Resources and Services Administration 

NAC National Abstinence Clearinghouse 

NIH National Institutes of Health 

OMB Office of Management and Budget 

OPA Office of Population Affairs 

RFP request for proposal 

STD sexually transmitted disease 

TANF Temporary Assistance for Needy Families 

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Page ii GAO-07-87 Abstinence Education
United States Government Accountability Office

Washington, DC 20548 

October 3, 2006 

Congressional Requesters

Preventing sexually transmitted diseases (STD) and unintended 

pregnancies among adolescents is an important public health challenge. 

Although pregnancy and birth rates among female adolescents in the 

United States have been declining since the early 1990s, the rates continue

to be high when compared with those in other industrialized nations. The 

Centers for Disease Control and Prevention (CDC) reports that about 

141,000 children were born to girls 17 years old and younger in the United

States in 2003. CDC also reports that STDs disproportionately affect 

adolescents, with adolescents and young adults ages 15 to 24 acquiring 

almost half of the estimated 19 million new infections each year. 

Reducing the incidence of STDs and unintended pregnancies among 

adolescents is an important objective for the Department of Health and 

Human Services (HHS), which identifies as one of its goals the need to

reduce major threats to the health and well-being of Americans. Among 

the efforts it supports to reduce the incidence of STDs and unintended 

pregnancies among adolescents, HHS funds abstinence-until-marriage 

education programs. Abstinence-until-marriage education programs, also 

referred to as abstinence-only education programs, teach adolescents to 

abstain from sexual activity until marriage in order to avoid risks of 

unintended pregnancy, STDs, and related health problems.1

 The content of 

federally funded abstinence-until-marriage programs is required to be 

consistent with several principles, such as teaching that a mutually faithful 

monogamous relationship in the context of marriage is the expected 

standard of human sexual activity, and that abstinence from sexual 

activity is the only certain way to avoid STDs. Abstinence-until-marriage 

education programs are delivered by a variety of entities, including 

schools, human service agencies, faith-based organizations, youth 

development groups, and pregnancy crisis centers. Instructors can 

incorporate a variety of educational materials into their abstinence-untilmarriage education programs, including textbooks, student manuals, 

brochures, slide presentations, and videos. 

 1

Abstinence-until-marriage education programs also support HHS’s objective to promote 

family formation and healthy marriages. 

Page 1 GAO-07-87 Abstinence Education
The three main federally funded abstinence-until-marriage programs are 

the Abstinence Education Program (State Program), which is administered 

by HHS’s Administration for Children and Families (ACF); the CommunityBased Abstinence Education Program (Community-Based Program), 

which is also administered by ACF; and the Adolescent Family Life (AFL) 

Program, which is administered by HHS’s Office of Population Affairs 

(OPA) within the Office of Public Health and Science. Funding provided 

by HHS for the three abstinence-until-marriage programs increased from 

about $73 million in fiscal year 2001 to about $158 million in fiscal year 

2005. 

Recent studies have raised concerns about the accuracy of educational 

materials used in abstinence-until-marriage education programs and about 

the effectiveness of these programs. These studies have reported that 

some of the materials used in abstinence-until-marriage education 

programs contain, for example, scientifically inaccurate information about 

anatomy and physiology as they relate to reproductive health as well as 

misleading information about contraceptive failure rates and STDs.2

 State 

and federal agencies have also documented inaccuracies in abstinenceuntil-marriage educational materials. Further, studies examining the 

effectiveness of these programs have reported varied results. For example, 

some researchers have reported that abstinence-until-marriage education 

programs have resulted in adolescents reporting less frequent sexual 

intercourse or fewer sexual partners, while other researchers have 

reported that these types of programs did not affect the frequency of 

sexual intercourse or were ineffective in delaying the initiation of sexual

intercourse.3

You asked us to describe certain aspects of the oversight of federally 

funded abstinence-until-marriage education programs. Our objectives 

were to report on (1) efforts by HHS and states to assess the scientific 

 2

See K. L. Wilson et al., “A Review of 21 Curricula for Abstinence-Only-Until-Marriage 

Programs,” The Journal of School Health, vol. 75, no. 3 (2005), and The Content of 

Federally Funded Abstinence-Only Education Programs, United States House of 

Representatives, Committee on Government Reform-Minority Staff, Special Investigations 

Division (2004). 

3

See, for example, E. A. Borawski et al., “Effectiveness of Abstinence-only Intervention in 

Middle School Teens,” American Journal of Health Behavior, vol. 29, no. 5 (2005), and 

J. B. Jemmott III, L. S. Jemmott, and G. T. Fong, “Abstinence and Safer Sex HIV RiskReduction Interventions for African American Adolescents: A Randomized Controlled 

Trial,” Journal of the American Medical Association, vol. 279, no. 19 (1998). 

Page 2 GAO-07-87 Abstinence Education
accuracy of materials used in abstinence-until-marriage education 

programs and (2) efforts by HHS, states, and researchers to assess the 

effectiveness of abstinence-until-marriage education programs. You also 

asked us to describe how HHS selected a contractor for the abstinenceuntil-marriage technical assistance contract that was awarded in 

September 2002. This information is provided in appendix I. 

To describe the efforts by HHS and states to assess the scientific accuracy

of materials used in abstinence-until-marriage education programs, we 

reviewed published reports, program announcements, Federal Register

notices, agency Web sites, and other documents related to abstinenceuntil-marriage education. We focused our review on efforts related to the 

three main federally funded abstinence-until-marriage education programs 

administered by HHS, as well as efforts to review the accuracy of scientific

facts included in abstinence-until-marriage education materials. We did 

not assess the criteria used to determine the scientific accuracy of 

education materials or the quality of the reviews. We interviewed officials 

from ACF, the Health Resources and Services Administration (HRSA), 

OPA, and CDC. We also interviewed officials from the 10 states that 

received the largest share of federal funding (together accounting for 

51 percent of the total funding in fiscal year 2005) through the State 

Program for abstinence-until-marriage education.4

To describe efforts by HHS, states, and researchers to assess the 

effectiveness of abstinence-until-marriage education programs, we 

focused on efforts that examined the extent to which these programs 

achieved their program goals. In general, these goals include teaching 

adolescents to abstain from sexual activity until marriage in order to avoid 

unintended pregnancies, STDs, and related health problems. As part of our 

review, we compared these efforts to the design characteristics that 

experts have identified as important for a scientifically valid study of 

 4

The 10 states that received the largest share of funding in fiscal year 2005 through the 

State Program were Arizona, Florida, Georgia, Illinois, Louisiana, Michigan, New York, 

North Carolina, Ohio, and Texas. 

Page 3 GAO-07-87 Abstinence Education
program effectiveness.5

 We reviewed journal articles and other published

reports, agency budget submissions, program announcements, agency and 

grantee performance reports, Federal Register notices, agency Web sites, 

and other documents related to abstinence-until-marriage education. (For

a more detailed description of our literature review methodology, see 

app. II). We also interviewed officials from ACF, HRSA, OPA, CDC, the 

National Institutes of Health (NIH), the Office of the Assistant Secretary 

for Planning and Evaluation (ASPE), and 10 states that received the largest 

share of federal funding for abstinence-only education through the State 

Program in fiscal year 2005. We also interviewed individuals from the 

National Campaign to Prevent Teen Pregnancy, The Brookings Institution, 

ETR Associates, The Heritage Foundation, and Advocates for Youth, and 

researchers from Case Western Reserve University and Columbia 

University to obtain general information regarding the state of the 

research on abstinence-until-marriage education. We focused our review 

on efforts to assess the scientific accuracy of materials and the 

effectiveness of the programs during fiscal year 2006, and also reviewed 

the administration of the programs back to fiscal year 2001. We also 

attended conferences organized by ACF and OPA to learn about training 

that is provided to grantees on scientific accuracy and program 

evaluations. 

To describe how HHS selected a contractor for the abstinence-untilmarriage technical assistance contract that was awarded in September 

2002, we reviewed the Request for Proposals and other related contract 

documents. We also interviewed officials at HRSA, ACF, and the National

Abstinence Clearinghouse about the technical assistance contract. We 

performed our work from October 2005 through September 2006 in 

accordance with generally accepted government auditing standards. 

 5

See Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen

Pregnancy (Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001). The

experts identifying the design characteristics of a scientifically valid study for the National 

Campaign to Prevent Teen Pregnancy were drawn from institutions that include the 

National Institutes of Health, the Medical Institute for Sexual Health, the Alan Guttmacher 

Institute, the Institute for Research and Evaluation, and various universities. See David

Satcher, The National Consensus Process on Sexual Health and Responsible Sexual

Behavior: Interim Report (Atlanta: Morehouse School of Medicine, 2006). The panel

convened by David Satcher included experts from a variety of organizations, including the

Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American 

Academy of Pediatrics. In addition, characteristics of a scientifically valid study have been 

identified by other experts in the field of evaluation research. For example, see Carol H. 

Weiss, Evaluation (Upper Saddle River: Prentice Hall, 1998).

Page 4 GAO-07-87 Abstinence Education
Efforts by HHS and states to assess the scientific accuracy of materials 

used in abstinence-until-marriage education programs have been limited. 

This is because ACF—which awards grants through two programs that 

account for the largest portion of federal spending on abstinence-untilmarriage education—does not review its grantees’ education materials for 

scientific accuracy and does not require grantees of either program to 

review their own materials for scientific accuracy. In addition, not all 

states that receive funding through ACF’s State Program have chosen to

review their program materials for scientific accuracy. In particular, 5 of

the 10 states in our review conduct such reviews. Officials from these 

states reported using a variety of approaches in their reviews. In contrast,

OPA does review the scientific accuracy of AFL grantees’ proposed 

educational materials and any inaccuracies found must be corrected 

before the materials can be used. While the extent to which federally 

funded abstinence-until-marriage education materials are inaccurate is not 

known, in the course of their reviews OPA and some states reported that 

they have found some inaccuracies in abstinence-until-marriage education 

materials. For example, OPA has required that a grantee correct several

statements in a true/false quiz—including statements about STDs and 

condom use—in order for the quiz to be approved for use in its 

curriculum. In addition, one state official described an instance in which 

abstinence-until-marriage materials incorrectly suggested that HIV can 

pass through condoms because the latex used in condoms is porous. 

Results in Brief 

HHS, states, and researchers have made a variety of efforts to assess the 

effectiveness of abstinence-until-marriage education programs; however, a 

number of factors limit the conclusions that can be drawn about the 

effectiveness of abstinence-until-marriage education programs. To assess 

the effectiveness of their abstinence-until-marriage education programs, 

ACF and OPA have required their grantees to report on various outcomes 

that the agencies use to measure the effectiveness of grantees’ abstinenceuntil-marriage education programs. For example, as of fiscal year 2006,

states that receive funding through the State Program are required to 

report annually on four measures of the prevalence of adolescent sexual 

behavior in their state, such as the rate of pregnancy among adolescents 

aged 15 to 17 years. To assess the effectiveness of both its State and 

Community-Based Programs, ACF also analyzes trends in adolescent 

behavior, as reflected in national data on birth rates among teens and the 

proportion of surveyed high school students reporting that they have had 

sexual intercourse. OPA requires grantees of the AFL Program to develop

and report on outcome measures that demonstrate the extent to which 

grantees’ programs are having an effect on program participants. In 

addition, other HHS agencies and offices—ASPE, CDC and NIH—are 

Page 5 GAO-07-87 Abstinence Education
making efforts to assess the effectiveness of abstinence-until-marriage 

education programs. Further, 6 of the 10 states in our review that receive 

funding through the State Program have worked with third-party 

evaluators to assess the effectiveness of abstinence-until-marriage 

education programs in their states. Several factors, however, limit the 

conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts to evaluate the 

effectiveness of abstinence-until-marriage education programs that we 

describe in our review have not met certain minimum criteria—such as 

random assignment of participants and sufficient follow-up periods and 

sample sizes—that experts have concluded are necessary in order for 

assessments of program effectiveness to be scientifically valid, in part 

because such designs can be expensive and time-consuming to carry out. 

In addition, the results of efforts that meet the criteria of a scientifically

valid assessment have varied and two key studies funded by HHS that 

meet these criteria have not yet been completed. When completed, these

HHS-funded studies may add substantively to the body of research on the 

effectiveness of abstinence-until-marriage education programs. 

To address concerns about the scientific accuracy of materials used in 

abstinence-until-marriage education programs, we recommend that the 

Secretary of HHS develop procedures to help assure the accuracy of such

materials used in the State and Community-Based Programs. To help 

provide such assurance, the Secretary could consider alternatives such as 

(1) extending the approach currently used by OPA to review the scientific

accuracy of the factual statements included in abstinence-until-marriage 

education to materials used by grantees of ACF’s Community-Based 

Program and requiring grantees of ACF’s State Program to conduct such

reviews or (2) requiring grantees of both programs to sign written 

assurances in their grant applications that the materials they propose 

using are accurate. 

In commenting on a draft of this report, HHS agreed to consider requiring 

grantees of both ACF programs to sign written assurances in grant 

applications that the materials they use are accurate. In addition, HHS 

noted that all federal grant applicants attest on a standard form that 

information in their applications is correct. However, it is not clear that 

this serves the purpose of assuring the scientific accuracy of the 

educational materials. Further, the curricula to be used are not required to

be included with states’ applications. HHS’s written comments also stated 

that ACF requires that the Community-Based Program curricula conform 

to standards that are grounded in scientific literature by requiring certain 

types of information. However, the inclusion of certain types of 

Page 6 GAO-07-87 Abstinence Education
information does not necessarily ensure the accuracy of the scientific facts 

included in the abstinence-until-marriage materials. In addition, HHS 

noted in its written comments that we did not define the term scientific 

accuracy and stated that it disagreed with certain findings of the report 

because it was difficult to precisely determine the criteria employed by

GAO in making the recommendation as to scientific accuracy. However, 

the objective of our work was to focus on efforts by HHS and states to 

review the accuracy of scientific facts included in abstinence-untilmarriage education materials and not to perform an independent 

assessment of the criteria used or the quality of the reviews. With regard to 

effectiveness, HHS agreed that it may be too soon to draw conclusions 

about the effectiveness of ACF’s and OPA’s programs. 

Recent statistics from CDC show that many high school students engage in 

sexual behavior that places them at risk for unintended pregnancy and 

STDs. In 2005, 46.8 percent of high school students reported that they have 

ever had sexual intercourse, with 14.3 percent of students reporting that 

they had had sexual intercourse with four or more persons. The likelihood 

of ever having sexual intercourse varied by grade, with the highest rate 

among 12th grade students (63.1 percent) and the lowest rate among 9th

grade students (34.3 percent). CDC also has reported that the prevalence

of certain STDs—including the rate of chlamydia infection, the most 

frequently reported STD in the United States—peaks in adolescence and 

young adulthood. According to CDC, in 2004 the chlamydia rates among 

adolescents 15 to 19 years old (1,579 cases per 100,000 adolescents) and 

young adults 20 to 24 years old (1,660 cases per 100,000) were each more 

than twice the rates among all other age groups. 

Background 

HHS’s current strategic plan includes the objectives to reduce the 

incidence of STDs and unintended pregnancies and to promote family 

formation and healthy marriages. These two objectives support HHS’s 

goals to reduce the major threats to the health and well-being of 

Americans and to improve the stability and healthy development of 

American children and youth, respectively. Abstinence-until-marriage 

Page 7 GAO-07-87 Abstinence Education
education programs are one of several types of programs that support 

these objectives.6

The three main federal abstinence-until-marriage education programs—

the State Program, the Community-Based Program, and the AFL 

Program—provide grants to support the recipients’ own efforts to provide 

abstinence-until-marriage education at the local level.7

 These programs 

must comply with the statutory definition of abstinence education (see 

table 1).8

 6

HHS’s Family Planning Program, for example, also supports the objective to reduce the

incidence of STDs and unintended pregnancies by providing access to contraceptive 

supplies and family planning information, especially for low-income persons, at community

health clinics. This program is authorized under Title X of the Public Health Service Act. 

7

There are other federal sources of funding that are used for abstinence education, such as

the Temporary Assistance for Needy Families (TANF) Program that is administered by

ACF. Some states have allocated some of their TANF funding for abstinence education 

programs. For example, Florida has used TANF funds to provide community-based and

faith-based organizations with contracts to carry out abstinence education. Other sources 

of funding that are used for abstinence education include ACF’s Compassion Capital Fund 

and CDC’s Division of Adolescent and School Health grants. 

8

42 U.S.C. § 710(b)(2). This definition is also referred to as the A-H definition. This statutory

provision defines abstinence education for purposes of the State Program. Annual 

appropriations acts and program announcements have extended this definition to the

Community-Based and AFL Programs. See, e.g , Departments of Labor, Health and Human 

Services, and Education, and Related Agencies Appropriations Act, 2006,Pub. L. No. 109-

149,119 Stat. 2833, 2855-56. 

Page 8 GAO-07-87 Abstinence Education
Table 1: Definition of Abstinence Education

Abstinence education refers to an educational or motivational program that: 

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-ofwedlock 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. 

Source: Social Security Act, § 510(b)(2) (codified at 42 U.S.C. § 710(b)(2)).

The State Program The State Program, administered by ACF, provides funding to its 

grantees—states—for the provision of abstinence-until-marriage education 

to those most likely to have children outside of marriage.9

 States that 

receive grants through the State Program have discretion in how they use 

their funding to provide abstinence-until-marriage education. Some require 

that organizations apply for funds and use them to administer abstinenceuntil-marriage education programs. Others may directly administer such 

programs. At their discretion, states may also provide mentoring, 

counseling, and adult supervision to adolescents to promote abstinence 

from sexual activity until marriage. 

The Personal Responsibility and Work Opportunity Reconciliation Act of 

1996 established the State Program, and states were awarded grants 

beginning in fiscal year 1998.10 Funds are allotted to each state that 

submits the required annual application based on the ratio of the number 

 9

Through the State Program funds are also provided to insular areas and the District of 

Columbia.

10Pub. L. No. 104-193, § 912; 110 Stat. 2353-54 (codified at 42 U.S.C. § 710). 

Page 9 GAO-07-87 Abstinence Education
of low-income children in the state to the total number of low-income 

children in all states. States are required to match every $4 they receive in 

federal money with $3 of nonfederal money and are required to report 

annually on the performance of the abstinence-until-marriage education 

programs that they support or administer. In fiscal year 2005, 47 states, the 

District of Columbia, and 3 insular areas were awarded funding.11,12

The Community-Based 

Program 

The Community-Based Program, which is also administered by ACF, is 

focused on funding public and private entities that provide abstinenceuntil-marriage education for adolescents from 12 to 18 years old, with the 

purpose of creating an environment within communities that supports 

adolescent decisions to postpone sexual activity until marriage. The 

Community-Based Program provides grants for school-based programs, 

adult and peer mentoring, and parent education groups. The CommunityBased Program first awarded grants in fiscal year 2001.

13 Grantees of the 

Community-Based Program are selected through a competitive process 

and are evaluated according to several criteria, such as the extent to which 

they have demonstrated that a need exists for abstinence-until-marriage 

education for a targeted population or in a specific geographic location.

Grantees are required to report to ACF, on a semiannual basis, on the 

performance of their programs. For fiscal year 2005, 63 grants were 

awarded to organizations and other entities.14

 11In this report, we refer to U.S. territories and commonwealths as “insular areas.” 

12Some states and insular areas have not applied for funding under the State Program. 

California, Maine, and Pennsylvania did not apply for funding under the State Program in 

fiscal year 2005. In this report, when we refer to “states,” we are referring to all grantees of 

the State Program—including states, insular areas, and the District of Columbia. 

13The Community-Based Program is conducted under section 1110 of the Social Security 

Act. See 42 U.S.C. § 1310.

14In addition to the 63 grants awarded in fiscal year 2005, ACF is also responsible for other 

grants that the agency awarded before 2005. 

Page 10 GAO-07-87 Abstinence Education
The AFL Program supports programs that provide abstinence-untilmarriage education.15 The primary purpose of these programs is to find 

effective means of reaching preadolescents and adolescents before they 

become sexually active in order to encourage them to abstain from sexual 

activity and other risky behaviors. Under the AFL Program, OPA awards 

competitive grants to public or private nonprofit organizations or 

agencies, including community-based and faith-based organizations, to 

facilitate abstinence-until-marriage education in a variety of settings, 

including schools and community centers. Established in 1981, the AFL 

Program began awarding grants in fiscal year 1982. AFL Program grantees 

include school districts, youth development groups, and medical centers. 

Grant applicants are evaluated based on several criteria, such as the extent

to which they provide a clear statement of mission, goals, measurable 

objectives, and a reasonable method for achieving their objectives. 

Grantees are required to conduct evaluations of certain aspects of their 

programs and report annually on their performance. As of August 2006, 

OPA funded 58 abstinence-until-marriage education programs, and most of 

these were focused on reaching young adolescents from the ages of 9 to

14. 

Funding provided by HHS for abstinence-until-marriage education 

programs has increased steadily since 2001 (see table 2). For the three 

main programs combined—the State Program, the Community-Based 

Program, and the AFL Program—the amount of agency funding increased

from about $73 million in fiscal year 2001 to about $158 million in fiscal 

year 2005. Nearly all of this increase was for the Community-Based 

program; funding under this program increased by about $84 million from 

fiscal years 2001 through 2005. In fiscal year 2005, agency funding for the 

Community-Based Program constituted the largest share of the total 

funding (about 66 percent) for the three main programs combined. 

The AFL Program 

Funding for Abstinenceuntil-Marriage Education 

Has Increased 

 15See 42 U.S.C. § 300z et seq. The AFL Program also supports other projects for pregnant 

and parenting adolescents, their infants, male partners, and family members. The purpose

of these projects is to improve the outcomes of early childbearing for teen parents, their 

infants, and their families. However, in this report, when we use the term “AFL Program,” 

we are referring only to the abstinence-until-marriage component of the AFL Program. 

Page 11 GAO-07-87 Abstinence Education
Table 2: Funding Provided by HHS for the Three Main Abstinence-until-Marriage 

Education Programs 

Dollars in millions 

Fiscal year State Programa,b Community-Based Program AFL Program

2001 $43 $20 $10

2002 43 40 12

2003 44 55 13

2004 41 75 13

2005 41 104 13

Sources: ACF, OPA, and HRSA. 

Notes: Figures are rounded to nearest $1,000,000. Funding levels represent the total amount of 

grants awarded and funding for program-related support, such as technical assistance and 

evaluation. 

a

States that receive funding are required to match every $4 they receive of federal funds with $3 of 

nonfederal money. 

b

The amount of funding provided by HHS for the State Program has generally varied by year because 

the states that have applied for funding each year have varied. 

Within each of the three main abstinence-until-marriage education 

programs, the amount of individual grants varied.16 In fiscal year 2005, the 

State Program’s annual grants ranged from $57,057 to $4,777,916 and the 

median annual grant amount was $569,675. That same year, the 

Community-Based Program’s annual grants ranged from $213,276 to 

$800,000 and the median grant amount was $642,250. In fiscal year 2006,

the AFL Program’s annual grants ranged from $95,676 to $300,000 and the 

median grant amount was $225,000. 

Federal Agency 

Responsibilities Related to 

Abstinence-until-Marriage 

Education 

Five organizational units located within HHS—ACF, OPA, CDC, ASPE, and 

NIH—have responsibilities related to abstinence-until-marriage education. 

ACF and OPA administer the three main federal abstinence-until-marriage 

education programs. CDC supports abstinence-until-marriage education at 

the national, state, and local levels. CDC, ASPE, and NIH are sponsoring 

research on the effectiveness of abstinence-until-marriage programs. 

 16ACF awards formula grants under the State Program each year, and states have 2 years to

spend the funds they are awarded. In the Community-Based Program and AFL Program,

grantees develop multiyear projects—up to 5 years—for which the first year of funding is 

provided through competitive grants; for subsequent years, grantees may obtain funding 

through noncompetitive continuation grants.

Page 12 GAO-07-87 Abstinence Education
ACF is responsible for federal programs that promote the economic and 

social well-being of families, children, individuals, and communities. ACF 

administers and provides oversight of both the State Program and the 

Community-Based Program by, among other things, awarding grants, 

providing training and technical assistance to grantees, and requiring 

annual performance reporting from grantees. ACF has been responsible 

for the State Program since June 2004 and the Community-Based Program 

since October 2005. HRSA previously administered these programs. 

ACF 

OPA has responsibility for advising the Secretary of HHS on a wide range 

of reproductive health topics, including adolescent pregnancy and family 

planning. The office is also responsible for administering programs that 

provide services for pregnant and parenting teens and prevention 

programs, such as abstinence-until-marriage education programs. OPA 

administers and provides oversight of the AFL Program by awarding 

grants, providing training and technical assistance to grantees, and 

requiring annual performance reporting from grantees. 

OPA 

CDC is primarily responsible for the prevention and control of infectious 

and chronic diseases, including STDs. CDC provides funding to state and 

local education agencies in their efforts to support comprehensive school

health education and HIV/STD prevention education programs, and CDC 

officials told us that some of these are focused on abstinence. CDC also 

provides funding to several state education agencies to implement various 

abstinence projects, such as collaboration-building among agencies to 

increase the impact of their efforts to encourage abstinence. Further, CDC 

develops tools to assist state and local education agencies with their 

health education programs. CDC provides funding to several national 

organizations to build the capacity of abstinence-until-marriage education 

providers. Organizations’ activities include, but are not limited to, the 

development and distribution of educational materials. CDC is also 

sponsoring research on the effectiveness of an abstinence-until-marriage 

education program. 

CDC 

ASPE advises the Secretary of HHS in several areas, including policy 

development in health, human services, data, and science. ASPE is 

responsible for the development of policy analyses and it conducts 

research and evaluation studies in several areas, including the health of 

children and adolescents. ASPE is currently sponsoring research on the 

effectiveness of abstinence-until-marriage education programs. 

ASPE 

NIH is the primary federal agency that conducts and supports medical and 

behavioral research among various populations, including children and 

NIH 

Page 13 GAO-07-87 Abstinence Education
adolescents. NIH is currently sponsoring research on the effectiveness of 

abstinence-until-marriage education programs. 

Efforts by HHS and states to assess the scientific accuracy of materials 

used in abstinence-until-marriage education programs have been limited. 

ACF—which awards grants to two programs that account for the largest 

portion of federal spending on abstinence-until-marriage education—does 

not review its grantees’ education materials for scientific accuracy and

does not require grantees of either program to review their own materials 

for scientific accuracy. In addition, not all states funded through the State 

Program have chosen to review their program materials for scientific 

accuracy. In contrast to ACF, OPA has reviewed the scientific accuracy of

grantees’ proposed educational materials and corrected inaccuracies in 

these materials. 

There have been limited efforts to review the scientific accuracy of 

educational materials used in ACF’s State and Community-Based 

Programs—the two programs that account for the largest portion of 

federal spending on abstinence education. ACF does not review materials 

for scientific accuracy in either reviewing grant applications17 or in 

overseeing grantees’ performance. Prior to fiscal year 2006, State Program 

and Community-Based Program applicants were not required to submit 

copies of their proposed educational materials with their applications. 

While ACF required grantees of the Community-Based Program—but not 

the State Program—to submit their educational materials with their fiscal 

year 2006 applications, ACF officials told us that grantee applications and 

materials are only reviewed to ensure that they address all aspects of the

scope of the Community-Based Program, such as the A-H definition of 

abstinence education.18 Further, documents provided to us by ACF 

indicate that the agency does not review grantees’ educational materials 

for scientific accuracy as a routine part of its oversight activities. In 

addition, ACF also does not require its grantees to review their own 

Federal and State 

Efforts to Assess the 

Scientific Accuracy of 

Materials Used in

Abstinence-untilMarriage Education 

Programs Have Been 

Limited 

ACF Does Not Review 

Program Materials for 

Scientific Accuracy and 

Does Not Require Grantees 

to Do So, though Some 

State Grantees Have 

Conducted Such Reviews 

 17In reviewing grantees applications, ACF does examine several issues, including 

applicants’ stated program goals and need for assistance, their compliance with the A-H

definition of abstinence education, their intended approach in carrying out their objectives, 

and their budget plan. 

18HHS officials told us that if ACF finds inaccurate statements during this more general 

review process or if inaccuracies are brought to their attention at any time during the grant 

period, ACF officials work with the grantees to take corrective action. 

Page 14 GAO-07-87 Abstinence Education
materials for scientific accuracy. Similarly, when HRSA was responsible 

for the State and Community-Based Programs, the agency did not review 

materials used by grantees for scientific accuracy or require grantees to 

review their own materials. 

Not all grantees of the State Program have chosen to review the scientific 

accuracy of their educational materials. Officials from 5 of the 10 states in 

our review reported that their states have chosen to conduct such 

reviews.19,20 Officials in these states identified a variety of reasons why 

their states reviewed abstinence-until-marriage educational materials, 

including program requirements, state education laws and guidelines, and

past lawsuits, to ensure that materials used in abstinence-until-marriage 

programs were accurate. For example, Michigan’s Revised School Code 

states that materials and instruction in the sex education curricula, 

including information on abstinence, “shall not be medically inaccurate,”21

and Ohio’s fiscal year 2007 abstinence-until-marriage education program 

guidance states that abstinence-until-marriage educational materials 

“should be medically accurate in all assertions.”22

The five states we contacted that review abstinence-until-marriage 

educational materials for scientific accuracy have used a variety of 

approaches in their reviews. Some states contracted with medical 

professionals—such as nurses, gynecologists, and pediatricians—to serve 

as medical advisors who review program materials and use their expertise

to determine what is and is not scientifically accurate. Some states have

created checklists or worksheets to guide their staff conducting the review 

and document findings of inaccuracy or verification of a statement. All five 

states use medical professionals in conducting these reviews. One of the 

states requires that all statistics or scientific statements cited in a 

 19In addition to reviewing materials for accuracy, one state requires abstinence-untilmarriage providers to sign a written assurance that their materials are scientifically 

accurate. Officials from this state also reported providing abstinence-until-marriage 

education programs with public health consultants to provide technical assistance and 

training to help ensure the accuracy of their educational materials.

20In addition, some state officials we interviewed told us that review committees for local

school districts may review the scientific accuracy of educational materials that include

information about HIV and other STDs, including abstinence-until-marriage education 

materials. 

21Mich. Comp. Laws Ann. § 380.1507b(2)(West 2004). 

22See Ohio Department of Health, “Abstinence Education Program Request for Proposals

for Fiscal Year 2007,” (program announcement, 2005). 

Page 15 GAO-07-87 Abstinence Education
program’s materials are sourced to CDC or a peer-reviewed medical 

journal. Officials from this state told us that if statements in these 

materials cannot be attributed to these sources, the statements are 

required to be removed until citations are provided and materials are 

approved. Officials from this state told us they have also supplemented 

their review of program materials with on-site classroom observations to 

assess the scientific accuracy of the information presented to students. 

Officials from two of the five states reported that they have found 

inaccuracies as a result of their reviews. For example, one state official 

stated that because information is constantly evolving, state officials have

had to correct out-of-date scientific information. In addition, this official 

cited an instance where materials incorrectly suggested that HIV can pass

through condoms because the latex used in condoms is porous. In 

addition, this official provided documentation that the state has had to 

correct a statement indicating that when a person is infected with the 

human papillomavirus,23 the virus is “present for life” because, in almost all 

cases, this is not true. State officials who have identified inaccuracies told

us that they informed their grantees of inaccuracies so that they could

make corrections in their individual programs. One state official added

that she contacted the authors of the materials to report an inaccuracy. 

Some of the educational materials that states have reviewed are materials 

that are commonly used in the Community–Based Program. Officials from 

four of the five states that review materials for scientific accuracy told us 

that they have each reviewed at least one of the five curricula most 

commonly used in the Community-Based Program because programs in 

their state were using them: Choosing the Best, WAIT Training, Sex Can 

Wait, A.C. Green’s Game Plan Abstinence Program, and Worth the Wait. 

Based on ACF documents, we found that there were 58 different curricula 

used by grantees of the Community-Based Program in fiscal year 2005. 

However, more than half of the grantees of the Community-Based Program 

reported using at least one of these five curricula.

24

While there has been limited review of materials used in the State and 

Community-Based Programs, grantees of these programs have received 

some technical assistance designed to improve the scientific accuracy of 

 23The human papillomavirus (HPV) causes an STD called genital HPV infection.

24Some grantees of the Community-Based Program reported using more than one of these

curricula in fiscal year 2005. 

Page 16 GAO-07-87 Abstinence Education
their materials. For example, ACF officials reported that the agency 

provided a conference for grantees of the Community-Based Program in 

February 2006 that included a presentation focused on medical accuracy,

including a discussion of state legislative proposals that would require 

medical accuracy in abstinence-until-marriage education, and how to 

identify reliable data. In addition, in 2002, HRSA awarded a contract to the 

National Abstinence Clearinghouse requiring, among other things, that the 

contractor develop and implement a program to provide medically 

accurate information and training to grantees of the State and CommunityBased Programs.25 (See app. I for a description of HRSA’s process for 

awarding this contract). The portion of the contract that focused on 

providing medically accurate information to grantees was subcontracted 

to the Medical Institute for Sexual Health (Medical Institute),26 which has 

conducted presentations at regional educational conferences to provide 

grantees with medical and scientific information, such as updated 

information on condoms and STD transmission. The Medical Institute has 

also provided consultative services to grantees by responding to medical

and scientific questions.

OPA Reviews Materials 

Used by AFL Program 

Grantees for Scientific 

Accuracy 

In contrast to ACF, OPA reviews for scientific accuracy the educational 

materials used by AFL Program grantees. Specifically, OPA reviews its 

grantees’ proposed educational materials for scientific accuracy before 

they are used. Agency officials stated that they began to review these 

materials while litigation concerning the AFL Program was ongoing. OPA

continued to review these materials as part of a 1993 settlement to this 

lawsuit.27 The settlement agreement expired in 1998, though the agency has 

continued to review grantees’ proposed educational materials for accuracy 

as a matter of policy. OPA officials told us that grant applicants submit 

summaries of materials they propose to use, though the materials are not 

reviewed for scientific accuracy until after grantees have been selected. 

OPA officials said that after grants are awarded, a medical education 

specialist (in consultation with several part-time medical experts) reviews 

the grantees’ printed materials and other educational media, such as 

 25The administration of this contract was transferred to ACF in May 2005.

26The Medical Institute is a nonprofit organization that provides educational resources,

conferences, and seminars to educators, health professionals, pregnancy care centers, and 

faith-based groups about behaviors to decrease STDs and out-of-wedlock pregnancies,

including abstinence. 

27See generally Bowen v. Kendrick, 487 U.S. 589 (1988), 657 F. Supp 1547 (D.D.C. 1987). 

Page 17 GAO-07-87 Abstinence Education
videos. OPA officials explained that the medical education specialist must 

approve all materials before they are used. On many occasions, OPA 

grantees have proposed using—and therefore OPA has reviewed—

materials commonly used in the Community-Based Program. For example, 

an OPA official told us that the agency had reviewed three of the 

Community-Based Program’s commonly used curricula—Choosing the 

Best, Sex Can Wait, and A.C. Green’s Game Plan Abstinence Program—

and is also currently reviewing another curriculum commonly used by 

Community-Based Program grantees, WAIT Training.

28

OPA officials stated that the medical education specialist has occasionally 

found and addressed inaccuracies in grantees’ proposed educational 

materials. OPA officials stated that these inaccuracies are often the result

of information being out of date because, for example, medical and

statistical information on STDs changes frequently. OPA has addressed 

these inaccuracies by either not approving the materials in which they

appeared or correcting the materials through discussions with the 

grantees and, in some cases, the authors of the materials. In fiscal year 

2005, OPA disapproved of a grantee using a specific pamphlet about STDs 

because the pamphlet contained statements about STD prevention and 

HIV transmission that were considered incomplete or inaccurate. For 

example, the pamphlet stated that there was no cure for hepatitis B, but 

the medical education specialist required the grantee to add that there was 

a preventive vaccine for hepatitis B. In addition, OPA required that a 

grantee correct several statements in a true/false quiz—including 

statements about STDs and condom use—in order for the quiz to be 

approved for use. For example, the medical education specialist changed a 

sentence from “The only 100% effective way of avoiding STDs or unwanted 

pregnancies is to not have sexual intercourse.” to “The only 100% effective 

way of avoiding STDs or unwanted pregnancies is to not have sexual 

intercourse and engage in other risky behaviors.”

 28In addition, a CDC official told us that some of its grantees are producing educational 

materials with CDC funds to be used by abstinence-until-marriage education programs, 

which are likely to include State and Community-Based Program grantees. These materials 

are required to be reviewed for scientific accuracy. CDC officials told us that they have 

made corrections to some of these materials. Materials used in school-based HIV 

prevention education programs that are supported with CDC funds are also reviewed for 

scientific accuracy. A CDC official told us that some of these programs are abstinenceuntil-marriage education programs. 

Page 18 GAO-07-87 Abstinence Education
While OPA and some states have reviewed their grantees’ abstinence-untilmarriage education materials for scientific accuracy,29 these types of 

reviews have the potential to affect abstinence-until-marriage education 

providers more broadly. Such efforts may create an incentive for authors 

of abstinence-until-marriage education materials to ensure they are 

accurate. Thus, some authors of abstinence-until-marriage education 

materials have recently updated materials in their curricula following 

reports that questioned their accuracy. For example, one of the most 

widely used curricula used by grantees of the Community-Based 

Program—WAIT Training—has been recently updated and provides the 

updated information on its Web site. A representative from WAIT Training 

stated that the company recently revised its curriculum, in part, in 

response to a congressional review that found inaccuracies in its 

abstinence-until-marriage education materials. 

HHS, states, and researchers have made a variety of efforts to assess the 

effectiveness of abstinence-until-marriage education programs; however, a 

number of factors limit the conclusions that can be drawn about the 

effectiveness of these programs. ACF and OPA have required their 

grantees to report on various outcomes used to measure the effectiveness 

of grantees’ abstinence-until-marriage education programs,30 though the 

reporting requirements for each of the three abstinence-until-marriage 

programs differ. In addition, to assess the effectiveness of the State and 

Community-Based Programs, ACF has analyzed national data on 

adolescent birth rates and the proportion of adolescents who report 

having had sexual intercourse. Other organizational units within HHS—

ASPE, CDC, and NIH—are funding studies designed to assess the 

effectiveness of abstinence-until-marriage education programs in delaying

sexual initiation, reducing pregnancy and STD rates, and reducing the 

frequency of sexual activity. Despite these efforts, several factors limit the 

A Variety of Efforts 

Have Been Made to 

Assess the 

Effectiveness of 

Abstinence-untilMarriage Education 

Programs, but a 

Number of Factors 

Limit the Conclusions 

That Can Be Drawn 

 29In addition to OPA and some states, others have also reviewed the scientific accuracy of

abstinence-until-marriage education materials. See, for example, Wilson et al. 

30This reporting is a part of ACF’s efforts to collect evaluative information about these 

programs. These efforts include both performance measurement—the ongoing monitoring

and reporting of program accomplishments toward preestablished goals—and program

evaluation—individual systematic studies to assess how well a program is working. Both

types of assessments aim to support decisions to improve service delivery and program 

effectiveness. See GAO, Performance Measurement and Evaluation: Definitions and

Relationships, GAO-05-739SP (Washington, D.C.: May 2005), for more information on types

of assessments.

Page 19 GAO-07-87 Abstinence Education
conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts to evaluate the 

effectiveness of abstinence-until-marriage education programs that we 

describe in our review have not met certain minimum criteria that experts 

have concluded are necessary in order for assessments of program 

effectiveness to be scientifically valid, in part because such designs can be 

expensive and time-consuming to carry out. In addition, the results of 

some efforts that meet the criteria of a scientifically valid assessment have 

varied, and two key studies that meet these criteria have not yet been 

completed. 

HHS, States, and 

Researchers Have Made a 

Variety of Efforts to Assess 

the Effectiveness of 

Abstinence-until-Marriage 

Education Programs 

Efforts of HHS, states, and researchers to assess the effectiveness of 

abstinence-until-marriage education programs have included ACF and 

OPA requiring grantees to report data on outcomes of their abstinenceuntil-marriage education programs; ACF analyzing national data on 

adolescent behavior and birth rates; and other HHS agencies, states, and 

researchers funding or conducting studies to assess the effectiveness of 

abstinence-until-marriage education programs. 

ACF has made efforts to assess the effectiveness of abstinence-untilmarriage education programs funded by the State Program and the 

Community-Based Program. One of ACF’s efforts has been to require 

grantees of both programs to report data on outcomes, though the two 

programs have different requirements for the outcomes grantees must 

report. For the State Program, as of fiscal year 2006, grantees must report 

annually on four measures of the prevalence of adolescent sexual behavior 

in their states, such as the rate of pregnancy among adolescents aged 15 to

17 years, and compare these data to program targets over 5 years. To 

report on these four measures, states may choose the data sources they 

will use.31 States must also develop and report on two additional 

performance measures that are related to the goals of their programs.32

ACF and OPA Have Required 

Grantee Reporting of Data on 

Outcomes 

 31Previously, to report on the four measures, states have relied on either state or national 

data sources, such as CDC’s Youth Risk Behavior Surveillance System. 

32For example, in fiscal year 2002, state grantees developed such measures as the 

percentage of teens surveyed who show an increase in participating in structured activities 

after school hours; the percentage of live births to women younger than 18, fathered by

men age 20 and older; the percentage of program participants proficient in refusal skills; 

the percentage of high school students who reported using drugs or alcohol before

intercourse; and the percentage of high school students who had sexual intercourse for the

first time before age 13. 

Page 20 GAO-07-87 Abstinence Education
(See table 3 for a list of ACF’s fiscal year 2006 reporting requirements for 

the State Program.) 

Table 3: ACF’s Reporting Requirements for the State Program and the CommunityBased Program, Fiscal Year 2006 

State Program Community-Based Program

• Report on four performance measures: 

(1) rate of pregnancy among female 

teenagers aged 15 to 17, (2) proportion 

of adolescents who have engaged in

sexual intercourse, (3) incidence of 

youths 15 to 19 years old who have 

contracted selected STDs, and (4) rate 

of births among female teenagers aged 

15 to 17. 

• Report on program goals that are 

developed by grantees with a third-party 

evaluator. Such outcomes could include 

changes in knowledge about abstinence 

or declared behavior among participants 

of abstinence-until-marriage programs. 

• Develop and report on two additional 

performance measures that are related

to individual program goals. Past 

examples of these additional measures 

have included the percentage of high 

school students who reported using 

drugs or alcohol before intercourse and 

the percentage of high school students 

who had sexual intercourse for the first 

time before age 13. 

• Report on program “outputs”: the number 

of youth served, the hours of service 

provided to each youth, and the number 

of youths who complete the program. 

Grantees choose additional outputs that 

allow for effective monitoring and 

management of the project. The 

additional outputs may include tracking 

the number of staff trained to provide 

services, the number of events hosted, 

number of marketing materials 

distributed, and so forth. 

Sources: State and Community-Based Programs’ announcements, fiscal year 2006. 

As of fiscal year 2006, ACF requires Community-Based Program grantees 

to develop and report on outcome measures designed to demonstrate the 

extent to which grantees’ community-based abstinence education 

programs are accomplishing their program goals.33 ACF requires grantees 

of the Community-Based Program to contract with third-party evaluators, 

who are responsible for both helping grantees develop the outcome 

measures and monitoring grantee performance against the measures,34 but 

 33The fiscal year 2006 program announcement for the Community-Based Program provides 

examples of outcome measures that grantees could use, including increased knowledge of

the benefits of abstinence, the number of youths who commit to abstaining from premarital

sexual activity, and increased knowledge of how to avoid high-risk situations and risk 

behaviors. 

34Fiscal year 2006 Community-Based Program grantees are required to devote a minimum

of 15 percent of their requested budgets to performance monitoring by third-party 

contractors. 

Page 21 GAO-07-87 Abstinence Education
because this is a new requirement established for fiscal year 2006 grantees, 

ACF has not yet received the results of these evaluations. In addition to 

outcome reporting, ACF requires grantees of the Community-Based 

Program to report on program “outputs,” which measure the quantity of 

program activities and other deliverables, such as the number of 

participants who are served by the abstinence-until-marriage education 

programs. According to ACF officials, the agency requires grantees of both 

the State Program and the Community-Based Program to report on 

program outcomes in order to monitor grantees’ performance, target 

training, and technical assistance, and help grantees improve service 

delivery. (See table 3 for a list of ACF’s fiscal year 2006 reporting 

requirements for the Community-Based Program.) 

ACF’s fiscal year 2006 reporting requirements for grantees of the State 

Program are the same as HRSA’s when it administered the State Program. 

In contrast, ACF’s fiscal year 2006 reporting requirements for the 

Community-Based Program differ from HRSA’s reporting requirements for 

the program. For example, for Community-Based Program grants awarded 

in fiscal year 2001, HRSA required35 grantees to report on the effectiveness 

of their programs, as measured by program participation as well as 

behavioral and biological outcomes.36 These performance measures were 

modified for fiscal year 2002, in part HHS officials explained, because of 

concerns expressed by members of the abstinence-education community 

that the original performance measures did not accurately reflect the 

efforts of the grantees of the Community-Based Program. For grants 

awarded from fiscal years 2002 through 2004, HRSA required grantees of 

the Community-Based Program to report on a combination of program 

outputs, such as the proportion of adolescents who completed an 

abstinence-until-marriage education program, and measures of adolescent 

intentions, such as the proportion of adolescents who committed to 

 35Some grantees of the Community-Based Program may have to meet reporting 

requirements established by HRSA. Grants under this program are awarded for projects 

that may extend over a period of several years. Grantees that were awarded grants when

HRSA administered the program and have since received noncompetitive continuation 

grants for these projects are required to meet the reporting requirements in place at the

time they first received the competitively awarded grants. 

36In fiscal year 2001, HRSA required grantees of the Community-Based Program to report 

on the following four performance measures: the proportion of program participants who 

successfully complete or remain enrolled in an abstinence-only education program; the

proportion of program participants who have engaged in sexual intercourse; the proportion 

of program participants who report a reduction in risk behaviors, such as tobacco, alcohol, 

and drug use; and the rate of births to female program participants. 

Page 22 GAO-07-87 Abstinence Education
abstaining from sexual activity until marriage.37 For grants awarded in 

fiscal year 2005, when ACF assumed responsibility for the CommunityBased Program from HRSA, grantees were not required to report on any 

specific performance measures. 

OPA has also made efforts to assess the effectiveness of the AFL Program. 

Specifically, OPA requires grantees of the AFL Program to develop and 

report on outcome measures that are used to help demonstrate the extent

to which grantees’ programs are having an effect on program 

participants.38,39 According to OPA officials, the agency recommends that 

grantees report on outcome measures, such as participants’ knowledge of

the benefits of abstinence and their reported intentions to abstain from 

sexually activity, reported beliefs in their ability to remain abstinent, and 

reported parental involvement in their lives. To collect data on these 

outcome measures and any others, OPA requires all grantees funded in 

fiscal year 2004 and beyond to administer, at a minimum, a standardized 

questionnaire—developed by OPA—to their program participants, both 

when participants begin an abstinence-only education program and after 

 37Specifically, HRSA required grantees of the Community-Based Program to report annually 

on the following six performance measures: the proportion of program participants who 

successfully completed or remained enrolled in an abstinence-only education program; the 

proportion of adolescents who understood that abstinence from sexual activity is the only 

certain way to avoid out-of-wedlock pregnancy and STDs; the proportion of adolescents

who indicated an understanding of the social, psychological, and health gains to be realized 

by abstaining from premarital sexual activity; the proportion of participants who reported

that they had the skills necessary to resist sexual urges and advances; the proportion of

youth who committed to abstaining from sexual activity until marriage; and the proportion 

of participants who intended to avoid situations and risk behaviors, such as drug use and 

alcohol consumption, which make them more vulnerable to sexual advances and urges. 

38In addition to these outcomes, grantees of the AFL Program are required to report on

program outputs, such as the number of program participants, the average number of 

participants per session, and the average number of sessions attended by participants. 

Agency officials stated that OPA has implemented a new format for its grantees’ reports, 

which is intended to standardize their reporting on these outputs. 

39OPA’s grantees are required to perform evaluations of their programs that are directly tied

to their program objectives. For these evaluations, OPA requires grantees to develop 

research hypotheses that reflect the outcomes the grantees intend to achieve. This type of 

evaluation is generally considered to be an outcome evaluation—which assesses the extent 

to which a program achieves its outcome-oriented objectives. These evaluations focus on 

outputs and outcomes to judge program effectiveness but may also assess program process

to understand how outcomes are produced. In addition, grantees of the AFL Program are

required to perform implementation evaluations. 

Page 23 GAO-07-87 Abstinence Education
the program’s completion.40 The standardized questionnaire includes 

questions intended to obtain information on participants’ reported 

involvement in extracurricular activities, behaviors linked to health risks, 

attitudes and intentions about abstinence, and opinions about the 

consequences of premarital sexual activity. Like ACF, OPA requires its 

grantees to contract with independent evaluators, such as colleges or 

universities, which are responsible for evaluating the effectiveness of 

grantees’ individual abstinence-until-marriage education programs.41 In 

addition to evaluating the extent to which grantees are meeting their goals, 

OPA officials stated that the independent evaluators may also provide 

input to grantees of the AFL Program on other aspects of the program to 

improve their service delivery. Unlike ACF, OPA requires that the thirdparty evaluations incorporate specific methodological characteristics, 

such as control groups or comparison groups42 and sufficient sample 

sizes.43 In addition, OPA requires that the evaluations for grantees funded 

in fiscal year 2004 and beyond account for baseline and follow-up data 

obtained from the standardized questionnaires. 

OPA’s requirement that grantees use a standardized set of questionnaires, 

with data from these questionnaires used in evaluations, differs from 

OPA’s previous requirements. Previously, grantees of the AFL Program 

were not required to use a standardized method for collecting data that

 40OPA officials stated that grantees may also supplement the standardized questionnaire 

with additional data collection instruments to obtain information on the effectiveness of 

their abstinence-until-marriage education programs. 

41OPA has required that its grantees perform independent evaluations of their programs

since the program first awarded grants in 1982, and requires that grantees devote from 

1 percent to 5 percent of grant funds to the evaluation of their programs. In cases where a 

more rigorous or comprehensive evaluation is proposed, OPA may allow these grantees to 

use up to 25 percent of their grant funds. 

42A control group is a group of individuals or communities in a study that is compared to an

intervention group—a group in a study that is receiving or participating in the program

being studied. A control group is a randomly assigned group that does not receive the 

program. A comparison group is not randomly assigned like a control group. However,

individuals or communities in well-matched comparison groups should have similar 

characteristics. 

43Specifically, OPA requires that third-party evaluations of grantees of the AFL Program 

compare, when possible, randomized control or matched comparison groups with groups

receiving abstinence-until-marriage education. In addition, OPA requires that these 

evaluations include a sufficient sample size to ensure that any observed differences 

between the groups are statistically valid and that the evaluations include a follow-up 

assessment of program participants at least 6 months after the abstinence-until-marriage 

intervention has been tested. 

Page 24 GAO-07-87 Abstinence Education
could be used to assess the effectiveness of their programs; instead, 

grantees chose their own data collection instruments. As a result, an OPA 

official explained, the collected data varied from one project to another. 

OPA officials said that the agency developed the standardized 

questionnaire to ensure uniformity in the data collected and allow the 

agency to more effectively aggregate the data reported in evaluations of 

individual abstinence-until-marriage education programs. 

OPA officials told us that they plan to aggregate information from certain 

questions in the standardized set of questionnaires in order to report on 

certain performance measures as part of the agency’s annual performance 

reports.44 The measures include the extent of parental involvement in 

adolescents’ lives and the extent to which adolescents understand the 

benefits of abstinence. An agency official stated that the agency expects to

begin receiving data from grantees that are using these questionnaires in 

January 2007. OPA did not previously have long-term measures of the 

performance of the AFL Program. Its current measures were developed in

collaboration with the Office of Management and Budget (OMB) in 

response to an OMB review in 2004 that found that the AFL Program did 

not have any annual performance measures for measuring progress 

toward long-term goals. 

In addition to requiring their grantees to report on outcomes used to 

assess program effectiveness, both ACF and OPA have provided technical 

assistance and training to their grantees in order to support grantees’ own 

program evaluation efforts. For example, in November 2005 the two 

agencies sponsored an evaluation conference for abstinence-untilmarriage grantees that included presentations about evaluations and their 

methodology. Similarly, ACF’s Office of Planning, Research, and 

Evaluation sponsors annual evaluation conferences, and an ACF official 

told us that a recent conference placed “a significant emphasis” on the 

evaluation of abstinence-until-marriage education programs. In addition, 

HHS officials told us that ACF, along with ASPE, is funding a multiyear 

project that is designed to identify gaps in abstinence education evaluation

and technical assistance needs, develop materials on abstinence education 

evaluation, deliver technical assistance and capacity-building activities 

related to program evaluation, and develop research reports related to 

 44OPA prepares annual performance reports as a part of HHS’s responsibilities under the

Government Performance and Results Act, which include program performance measures

to help link funding decisions with performance and review of related outcome measures.

Page 25 GAO-07-87 Abstinence Education
abstinence education. OPA officials also told us that they attempt to help

ensure grantees’ progress and effectiveness by offering various technical

assistance workshops and conferences. For example, in May 2006 OPA 

provided a 2-day training conference to its grantees on the importance of 

program evaluations and administering evaluation instruments. In 

addition, OPA officials stated that the agency contracts with evaluation 

consultants, who review grantees’ evaluation tools and activities. OPA 

officials explained that these consultants provide in-depth technical 

assistance to grantees on how to improve grantees’ evaluations. 

Requiring outcome reporting from state and community-based grantees is

not ACF’s only effort to assess the effectiveness of its two programs. ACF 

also analyzes trends in adolescent behavior, as reflected in national data

on birth rates among teens and the proportion of surveyed high school 

students reporting that they have had sexual intercourse.45 ACF uses these 

national data as a measure of the overall effectiveness of its State and 

Community-Based Programs, comparing the national data to program 

targets. In its annual performance reports, the agency summarizes the 

progress being made toward lowering the rate of births to unmarried 

teenage girls and the proportion of students (grades 9-12) who report 

having ever had sexual intercourse. 

ACF Uses National Data on 

Adolescent Behavior as a 

Measure of the Overall 

Effectiveness of Its Two 

Programs 

ACF’s use of national data to assess the effectiveness of the State and 

Community-Based Programs represents a change from how HRSA 

assessed the overall effectiveness of these programs. Whereas ACF 

compares national data on adolescent behavior to program targets, HRSA 

aggregated data from its state and community-based grantees. HRSA’s 

state grantees were allowed to select the data sources used to gauge their 

progress against certain performance measures. For example, in its annual 

performance reports on the State Program, HRSA reported information on 

the percentage of its state grantees meeting target rates for reducing the

proportion of adolescents who have engaged in sexual intercourse, the 

incidence of youths aged 15 to 19 who have contracted selected STDs, and 

the rate of births among youths aged 15 to 17. To determine their progress 

in meeting their target rates, some state grantees, for example, reported 

national data from the Youth Risk Behavior Surveillance System, while 

 45Data on teen birth rates and adolescents’ reported sexual behavior are contained in the 

National Vital Statistics System and the Youth Risk Behavior Surveillance System, 

respectively. The former is a national data set of public health statistics reported by states 

to CDC, and the latter is a national data set based on nationwide surveys administered to 

high school students by CDC.

Page 26 GAO-07-87 Abstinence Education
other grantees reported state-collected data. After ACF assumed 

responsibility for the State and Community-Based Programs from HRSA, 

ACF began using national data on adolescent behavior as a measure of the 

programs’ effectiveness. According to ACF officials, the agency changed

how it assessed its programs out of concern over the quality of the data

state grantees were using in their performance reporting and because the

agency wanted to use parallel measures of effectiveness for both 

programs. For example, according to state performance reports for fiscal 

year 2001 that we reviewed, two reports did not include adolescent 

pregnancy rates that year because the states did not collect data on 

abortions among this population.46 In addition, ACF officials told us that 

they decided not to use national data on STDs as a measure of program 

effectiveness because the goal of reducing STD rates is not as central to 

the State and Community-Based Programs as reducing sexual activity and

birth rates among teens. However, one official stated that reducing STDs is

an important “by-product” of the programs. 

Some states have made additional efforts to assess the effectiveness of 

abstinence-until-marriage education programs, although they are not 

required by ACF.47 Specifically, we found that 6 of the 10 states in our 

review that receive funding through ACF’s State Program have made 

efforts to conduct evaluations of selected abstinence-until-marriage 

programs in their state. All 6 of the states worked with third-party 

evaluators, such as university researchers or private research firms, to 

perform the evaluations, which in general measure self-reported changes 

in program participants’ behavior and attitudes related to sex and 

abstinence as indicators of program effectiveness. To obtain this 

information, the third-party evaluators have typically relied on surveys 

administered to program participants at the start of a program, its 

conclusion, and during a follow-up period anywhere from 3 months to 

almost 3 years after the conclusion. The third-party evaluations for 4 of the

Some States Have Made 

Additional Efforts to Assess the 

Effectiveness of Abstinenceuntil-Marriage Education 

Programs 

 46In order to estimate pregnancy rates among adolescents, states use data on both birth 

rates and abortions among adolescents. 

47ACF does require grantees of the State Program to describe, in their grant applications, 

their plans for “tracking activities and measuring achievement” of their program goals and 

objectives. 

Page 27 GAO-07-87 Abstinence Education
6 states in our review have been completed as of February 2006, and the 

results of these studies have varied.48

Among the 4 states that have completed third-party evaluations, 3 states 

require the abstinence programs in their state to measure reported 

changes in participants’ behavior as an indicator of program 

effectiveness—both at the start of the program and after its completion. 

The 3 states require their programs to track participants’ reported 

incidence of sexual intercourse. In addition, 2 states require their 

programs to track biological outcomes, such as pregnancies, births, or 

STDs. In addition, 6 of the 10 states in our review require their programs to 

track participants’ attitudes about abstinence and sex, such as the number 

of participants who make pledges to remain abstinent. 

Some states also provide technical assistance to the abstinence-untilmarriage programs they support in their state. This assistance is designed 

to help programs evaluate and improve their effectiveness. Officials from 5 

of the 10 states in our review either told us or provided documentation 

that they provide technical assistance on evaluations to abstinence 

programs in their state. One state official said that the abstinence-untilmarriage programs supported by the state were found to be ill-prepared to

conduct evaluations themselves, and that she now requires these programs 

to dedicate a portion of their grants to contract with a third-party or state 

evaluator to assist them in program-level evaluations. Officials from 

another state told us that they contract with a private organization of 

public health professionals in order to provide evaluation consultation and 

technical assistance for the abstinence-until-marriage programs the state 

supports. 

 48See, for example, LeCroy & Milligan Associates, Inc., Abstinence Only Education 

Program: Fifth Year Evaluation Report, a report prepared for the Arizona Department of

Health Services, 2003; Patricia Goodson et al., Abstinence Education Evaluation: Phase 6, 

a report prepared for the Texas Department of State Health Services, 2005; MGT of 

America, Evaluation of Georgia Abstinence Education Programs Funded Under Title V, 

Section 510, a report prepared for the Georgia Department of Human Resources, 2005; 

Thomas E. Smith, It’s Great to Wait: An Interim Evaluation, a report prepared for the 

Florida Department of Health, 2001. 

Page 28 GAO-07-87 Abstinence Education
In addition to ACF and OPA, other organizational units within HHS have 

made efforts to assess the effectiveness of abstinence-until-marriage 

education programs. ASPE is currently sponsoring a study of the 

Community-Based Program and a study of the State Program.49 For the 

former program, ASPE has contracted with Abt Associates to help design 

the study, and an ASPE official told us that once the agency selects an 

appropriate design, it will competitively award a contract to conduct the 

study.50 For the latter program, ASPE has contracted with Mathematica 

Policy Research, Inc. (Mathematica), which is in the process of examining 

the impact of five programs funded through the State Program on 

participants’ attitudes and behaviors related to abstinence and sex.51 As of 

August 2006, Mathematica has published two reports on findings from its 

study—an interim report documenting the experiences of schools and 

communities that receive abstinence-until-marriage education funding, 

and a report on the first-year impacts of selected state abstinence-untilmarriage education programs.52,53 Mathematica’s final report, which has not 

been completed, will examine the impact of the State Program on 

behavioral outcomes, including abstinence, sexual activity, risk of STDs, 

ASPE, CDC, and NIH Are 

Funding Studies Designed to 

Assess the Effectiveness of 

Abstinence-until-Marriage 

Education Programs 

 49According to the House Appropriations Committee report accompanying the fiscal year 

2005 appropriation act for Labor, HHS, Education, and related agencies, the effectiveness 

of abstinence education programs should be determined by measures that include the 

prevention and reduction of adolescent pregnancies and STD infections, age at first sexual

activity and intercourse, frequency of sexual activity and intercourse, and numbers who 

postpone sexual activity or intercourse through adolescence. See H.R. Rep. No. 108-636, at

139-140 (2004). 

50According to ASPE officials, one factor that has contributed to delays in the initiation of

this study is the difficulty in recruiting schools to participate. 

51The five abstinence-until-marriage education programs being studied are My Choice, My 

Future! in Powhatan, Virginia; ReCapturing the Vision in Miami, Florida; Teens in Control 

in Clarksdale, Mississippi; Families United to Prevent Teen Pregnancy in Milwaukee,

Wisconsin; and Heritage Keepers in Edgefield, South Carolina. 

52See B. Devaney et al., The Evaluation of Abstinence Education Programs Funded Under 

Title V Section 510: Interim Report, a report prepared for ASPE, 2002. 

53See R. Maynard et al., First-Year Impacts of Four Title V, Section 510 Abstinence 

Education Programs, a report prepared for ASPE, 2005. Mathematica’s report on the firstyear impacts of selected state abstinence-until-marriage education programs focused on 

intermediate outcomes, including attitudes about abstinence, teen sex, and marriage; 

perceived consequences of teen and nonmarital sex; and expectations to abstain from 

sexual intercourse.

Page 29 GAO-07-87 Abstinence Education
risk of pregnancy, and drug and alcohol use.54 An ASPE official told us that 

the agency expects a final report to be published in 2007. 

Like ASPE, CDC has made its own effort to assess the effectiveness of 

abstinence-until-marriage education. CDC is sponsoring a study to 

evaluate the effectiveness of two middle school curricula—one that 

complies with abstinence education program requirements and one that 

teaches a combination of abstinence and contraceptive information and 

skills.55 In CDC’s study, five middle schools chosen at random will receive 

a program consisting of abstinence-until-marriage education exclusively; 

five schools will receive comprehensive sex education, which also 

includes information on contraception; and five schools will be assigned to 

a control group. The study will examine the relative effectiveness of the 

programs on behavioral outcomes such as reported sexual risk behaviors 

and changes in attitudes related to abstinence and sex. CDC plans to 

recruit approximately 1,500 seventh grade students into its study and will

follow them over a 2-year period. The agency expects to complete the 

study in 2009. 

NIH has funded studies comparing the effectiveness of education 

programs that focus only on abstinence with the effectiveness of sex 

education programs that teach both abstinence and information about 

contraception. As of August 2006, NIH is funding five studies, which in 

general are comparing the effects of these two types of programs on the 

sexual behavior and related attitudes among groups of either middle 

school or high school students. For example, in one NIH study, 

researchers are using groups of seventh and eighth grade adolescents to 

assess the impact of a variety of programs on, among other issues, 

adolescents’ reported sexual activities, knowledge, and beliefs. For this 

study, researchers are comparing these outcomes among students who 

received abstinence-until-marriage education; students who received a 

combination of abstinence and contraceptive education; and students who 

participated in a general health class, who serve as a comparison group. 

 54An impact evaluation assesses the net effect of a program by comparing program 

outcomes with an estimate of what would have happened in the absence of the program.

This form of evaluation is employed when external factors are known to influence the 

program’s outcomes, in order to isolate the program’s contribution to achievement of its 

objectives. 

55HHS officials told us that the two curricula being tested are intended to be comparable in 

length, intensity, and other characteristics. 

Page 30 GAO-07-87 Abstinence Education
NIH expects both this study and its other four studies to be competed in 

2006. 

In addition to the efforts of researchers working on behalf of HHS and 

states, other researchers—such as those affiliated with universities and 

various advocacy groups—have made efforts to study the effectiveness of 

abstinence-until-marriage education programs. This work includes studies 

of the outcomes of individual programs and reviews of other studies on 

the effectiveness of individual abstinence-until-marriage education 

programs. In general, research studies on the effectiveness of individual 

abstinence-until-marriage education programs have examined the extent

to which they changed participants’ demonstrated knowledge, declared 

intentions, and reported behavior related to sexual activity and abstinence. 

For example, some studies examined the impact of abstinence-untilmarriage education programs on participants’ knowledge of concepts 

taught in the programs, as well as participants’ declared attitudes about 

abstinence and teen sex. Some studies examined the impact of these 

programs on such outcomes as participants’ declared commitment to 

abstain from sex until marriage, participants’ understanding of the 

potential consequences of having intercourse, and participants’ reported 

ability to resist pressures to engage in sexual activity. Some of the studies 

we reviewed examined the impact of abstinence-until-marriage programs 

on participants’ sexual behavior, as measured, for example, by the 

proportion of participants who reported having had sexual intercourse and 

the frequency of sexual intercourse reported by participants. In general, 

the efforts to study and build a body of research on the effectiveness of 

most abstinence education programs have been under way for only a few 

years, in part because grants under the two programs that account for the 

largest portion of federal spending on abstinence education—the State 

Program and the Community-Based Program—were not awarded until 

1998 and 2001, respectively. 

Other Researchers Have Also 

Made Efforts to Assess the 

Effectiveness of Abstinenceuntil-Marriage Education 

Programs 

Several Factors Limit the 

Conclusions That Can Be 

Drawn about the 

Effectiveness of 

Abstinence-until-Marriage 

Education Programs 

Most of the efforts of HHS, states, and other researchers to evaluate the 

effectiveness of abstinence-until-marriage education programs included in

our review have not met certain minimum criteria that experts have 

concluded are necessary in order for assessments of program 

effectiveness to be scientifically valid. For example, most of the efforts 

included in our review did not include experimental or quasi-experimental 

designs, nor did they measure behavioral or biological outcomes. In 

addition, the results of some assessment efforts that meet the criteria of a 

scientifically valid assessment have varied, and two key studies that meet 

these criteria have not yet been completed. 

Page 31 GAO-07-87 Abstinence Education
In an effort to better assess the merits of the studies that have been 

conducted on the effectiveness of sexual health programs—including 

abstinence-until-marriage education programs—scientific experts have 

developed criteria that can be used to gauge the scientific rigor of these 

evaluations. For example, in 2001, the National Campaign to Prevent Teen 

Pregnancy—an organization focused on reducing teen pregnancy—

published a report by a panel of scientific experts that assessed the 

evidence reported on abstinence-until-marriage education programs in 

peer-reviewed journals and other literature.56 The panel developed criteria

that an evaluation of a program’s effectiveness must meet in order for the 

program’s results to be considered scientifically valid. In addition, in 2004, 

former U.S. Surgeon General David Satcher convened a panel of experts to 

discuss, among other things, best practices for evaluating the effectiveness 

of sexual health education programs—including abstinence-until-marriage 

education programs.57 This panel published a report in 2006 that describes 

similar scientific criteria that assessments of program effectiveness need 

to meet in order for their results to be scientifically valid. Further, experts 

we interviewed agreed that these criteria are important for ensuring that 

the results of a study support valid conclusions. In general, these panels, 

as well as the experts we interviewed, agreed that scientifically valid 

studies of a program’s effectiveness should include the following 

characteristics: 

Experts Have Developed 

Criteria to Evaluate Efforts to 

Assess Abstinence-untilMarriage Education Programs 

• An experimental design that randomly assigns individuals or schools to 

either an intervention group or control group, or a quasi-experimental 

design that uses nonrandomly assigned but well-matched comparison 

groups. According to the panel of scientific experts convened by the 

National Campaign to Prevent Teen Pregnancy, experimental designs or 

quasi-experimental designs with well-matched comparison groups have at

least three important strengths that are typically not found in other 

studies, such as those that use aggregated data: they evaluate specific 

programs with known characteristics, they can clearly distinguish between 

participants who did and did not receive an intervention, and they control 

for other factors that may affect study outcomes. Therefore, experimental 

and quasi-experimental study designs have a greater ability to assess the 

 56See Kirby. This panel included experts from NIH, the Medical Institute for Sexual Health,

the Alan Guttmacher Institute, the Institute for Research and Evaluation, and various 

universities. 

57See Satcher. This panel included experts from a variety of organizations, including the

Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American 

Academy of Pediatrics. 

Page 32 GAO-07-87 Abstinence Education
causal impact of specific programs than other types of studies.58 According

to scientific experts, studies that include experimental or quasiexperimental designs should also collect follow-up data for a minimum 

number of months after subjects receive an intervention.59 Experts 

reported that follow-up periods are important in order to identify the 

effects of a program that are not immediately apparent or to determine 

whether these effects diminish over time. In addition, experts have 

reported that studies should have a sample size of at least 100 individuals 

for study results to be considered scientifically valid.60

• Studies should assess or measure changes in biological outcomes or 

reported behaviors instead of attitudes or intentions. According to 

scientific experts, biological outcomes—such as pregnancy rates, birth 

rates, and STD rates—and reported behaviors—such as reported initiation

and frequency of sexual activity—are better measures of the effectiveness 

of abstinence-until-marriage programs, because adolescent attitudes and 

intentions may or may not be indicative of actual behavior. For example, 

adolescents may report that they intend to abstain from sexual intercourse 

but may not actually do so. 

Many of the efforts by HHS, states, and other researchers that we 

identified in our review lack at least one of the characteristics of a 

scientifically valid study of program effectiveness. That is, most of the 

efforts to assess the effectiveness of these programs have not used 

experimental or quasi-experimental designs with sufficient follow-up 

periods and sample sizes to make their conclusions scientifically valid. For 

Most Efforts to Assess the 

Effectiveness of Abstinenceuntil-Marriage Education 

Programs Have Not Used an 

Experimental or QuasiExperimental Design 

 58For example, experts have reported that the use of randomly assigned intervention and

control groups is particularly important when assessing the effectiveness of abstinenceuntil-marriage programs because adolescents who voluntarily participate in such programs 

may be self-selecting—that is, they may be more willing to accept the principles of—and be 

influenced by—such programs when compared with other adolescents. Mathematica’s

interim report on the evaluation of the State Program noted that selection bias can 

“seriously undermine the credibility” of study results.

59For example, one expert reported that studies assessing program effectiveness should 

obtain information on participants for at least 3 months after the conclusion of a program

when they are measuring behaviors that can change quickly, such as frequency of sex. For 

behaviors or outcomes that change less quickly, such as initiation of sex or pregnancy

rates, information on participants should be collected for at least 6 months after the

conclusion of a program. 

60The panel of experts convened by the National Campaign to Prevent Teen Pregnancy

agreed that large sample sizes are necessary to determine the magnitude of any discernable 

program effect and to ensure that results of any study of effectiveness are statistically 

valid. 

Page 33 GAO-07-87 Abstinence Education
example, ACF—and before it, HRSA—used, according to ACF officials, 

grantee reporting on outcomes in order to monitor grantees’ performance, 

target training and technical assistance, and help grantees improve service 

delivery. However, because the outcomes reported by grantees have not 

been produced through experimentally or quasi-experimentally designed 

studies, such information cannot be causally attributed to any particular 

abstinence-until-marriage education program. While ACF requires its fiscal 

year 2006 grantees of the Community-Based Program to contract with 

third-party evaluators to select and monitor outcomes for their programs, 

ACF is not specifically requiring these grantees to use experimental or 

quasi-experimental designs. Therefore, it is not clear whether these 

evaluations will include such designs. Similarly, ACF’s use of national data

on adolescent behavior and birth rates to assess its State and CommunityBased Programs is of limited value because these data do not distinguish 

between those who participated in abstinence-until-marriage education 

programs and those who did not. Consequently, these national data sets, 

which represent state-reported vital statistics and a nationwide survey of

high school students, cannot be used to causally link declines in birth rates 

and adolescent sexual activity to the effects of specific abstinence-untilmarriage education programs.61

Similarly, the efforts we identified by states and researchers to assess the 

effectiveness of abstinence-until-marriage education programs often did 

not include experimental or quasi-experimental designs. None of the state 

evaluations we reviewed that have been completed included randomly 

assigned control groups. For instance, one state evaluation that we 

reviewed only included students who volunteered to participate in the 

study. This evaluation report stated that the absence of a randomly 

assigned control group in the evaluation did not allow the evaluators to 

determine whether observed changes in participants’ reported sexual 

behavior—as indicated through surveys administered at the beginning and 

end of a program—could be attributed to the abstinence-until-marriage 

education program.62 Similarly, some of the journal articles that we 

reviewed described studies to assess the effectiveness of abstinence-until-

 61In addition, according to ACF and CDC officials, it is difficult to draw conclusions from

national data sets about the effectiveness of abstinence-until-marriage education programs 

because the national survey questions used to produce these data often do not identify the

specific type of program or intervention survey respondents may have participated in or 

received. 

62See Goodson et al. 

Page 34 GAO-07-87 Abstinence Education
marriage programs that did not include experimental or quasiexperimental designs needed to support scientifically valid conclusions 

about the programs’ effectiveness. In these studies, researchers 

administered questionnaires to study participants before and after they 

completed an abstinence-until-marriage education program and assessed 

the extent to which the responses of participants changed.63 These studies 

did not compare the responses of study participants with a group that did 

not participate in an abstinence-until-marriage education program. In 

addition, some of the studies used insufficient follow-up periods, thereby 

limiting the conclusions that can be drawn about the effectiveness of the 

abstinence-until-marriage education programs being studied. For example, 

two journal articles that we reviewed described studies that measured the 

effectiveness of abstinence-until-marriage programs in delaying the 

initiation of sexual activity from 1 to 2 months after completion of the 

program.64 Scientific experts consider this follow-up period too short to 

assess whether the programs had a valid effect. 

According to scientific experts, HHS, states, and other researchers face a 

number of challenges in designing experimental or quasi-experimental 

studies of program effectiveness. According to these experts, experimental

or quasi-experimental studies can be expensive and time-consuming to 

carry out, and many grantees of abstinence-until-marriage education 

programs have insufficient time and funding to support these types of 

studies. Moreover, it can be difficult for researchers assessing abstinenceuntil-marriage education programs to convince school districts to 

participate in randomized intervention and control groups, in part because 

of sensitivities to surveying attitudes, intentions, and behaviors related to 

abstinence and sex. For example, in a third-party evaluation of its 

program, one grantee of the State Program originally planned to 

administer follow-up surveys 1 year after participants finished their 

abstinence education program, but the evaluators decided not to conduct 

this follow-up because of confidentiality concerns and the difficulty of 

locating students. In addition, the contractors hired to design ASPE’s 

 63See, for example, S. M. Fitzgerald et al., “Effectiveness of the Responsible Social Values 

Program for 6th Grade Students in One Rural School District,” Psychological Reports, vol.

91 (2002), and J. E. Barnett and C. S. Hurst, “Abstinence Education for Rural Youth: An 

Evaluation of the Life’s Walk Program, “ The Journal of School Health, vol. 73, no. 7 (2003). 

64See, for example, D. A. Zanis, “Use of a Sexual Abstinence Only Curriculum with Sexually 

Active Youths,” Children & Schools, vol. 27, no. 1 (2005), and G. Denny et al., “An 

Evaluation of An Abstinence Education Curriculum Series: Sex Can Wait,” American 

Journal of Health Behavior, vol. 26, no. 5 (2002). 

Page 35 GAO-07-87 Abstinence Education
study of the effectiveness of the Community-Based Program have reported

difficulties finding school districts that are willing to participate in 

randomly assigned intervention and control groups receiving either 

abstinence-until-marriage education or comprehensive sex education. An

ASPE official told us that although a “randomized approach” is the best 

design for assessing the effectiveness of a program, the approach is also 

the most difficult to conduct. 

Another factor that limits the conclusions that can be drawn about the 

effectiveness of abstinence-until-marriage education programs is the fact 

that most efforts in our review to study the effectiveness of these 

programs did not measure changes in behavioral or biological outcomes 

among participants. Instead, most of the efforts we identify in our review 

used reported intentions and attitudes in order to assess the effectiveness 

of abstinence-until-marriage programs. For example, neither ACF’s 

community-based grantees nor OPA’s AFL grantees are required to report 

on behavioral or biological outcomes, such as rates of intercourse or 

pregnancy. Similarly, the journal articles we reviewed were more likely to

use reported attitudes and intentions—such as study participants’ reported 

attitudes about premarital sexual activity or their reported intentions to 

remain abstinent until marriage—rather than their reported behaviors or 

biological outcomes to assess the effectiveness of abstinence-untilmarriage programs. For example, in one journal article we reviewed, 

participants were asked to rate the likelihood that they would have sexual 

intercourse as unmarried teenagers; another journal article described a 

study in which participants rated the likelihood that they would have 

sexual intercourse in the next year, before finishing high school, and 

before marriage.65

Experts, as well as state and HHS officials, have reported that it can be

difficult to obtain scientifically valid information on biological outcomes 

and sexual behaviors. Specifically, experts have reported that when 

measuring an abstinence-until-marriage education program’s affect on 

biological outcomes—such as reducing pregnancy or birth rates—it is 

necessary to have large sample sizes in order to determine whether a small 

change in biological outcomes is the result of the abstinence-untilMost Efforts to Assess the 

Effectiveness of Abstinenceuntil-Marriage Education 

Programs Have Not Measured 

Behavioral or Biological 

Outcomes 

 65See, for example, L. Sather and K. Zinn, “Effects of Abstinence-Only Education on

Adolescent Attitudes and Values Concerning Premarital Sexual Intercourse, “ Family and 

Community Health, vol. 25, no. 2 (2002), and G. Denny, M. Young, and C. E. Spear, “An

Evaluation of the Sex Can Wait Abstinence Education Curriculum Series,” American 

Journal of Health Behavior, vol. 23, no. 2 (1999). 

Page 36 GAO-07-87 Abstinence Education
marriage education program. In addition, state and federal officials told us

that they have experienced difficulties obtaining information on sexual 

behaviors because of the sensitive nature of the information they were 

trying to collect. For example, one state official told us that her state’s 

effort to evaluate abstinence-until-marriage education programs was only 

able to measure changes in participants’ reported attitudes, instead of 

behaviors, because the evaluators needed to obtain consent from the 

parents of the program participants in order to ask them about their 

sexual behavior. The state official explained that the requirement to obtain 

consent from parents raised issues of self-selection, and therefore state 

officials decided to ultimately halt the study and only report on the 

attitudes that they had measured. In another example, ACF’s fiscal year 

2006 budget justification reports that ACF has had some difficulty in 

obtaining reliable data from state grantees, in part because questions 

about teenage sexual behavior are sensitive. OPA officials also 

acknowledged that many communities will not allow grantees to ask 

program participants questions about their sexual behavior because the 

communities believe such questions are too intrusive. One OPA official 

said that such restrictions affect the agency’s ability to measure behavioral

outcomes, explaining that OPA cannot measure what it cannot ask about. 

Among the assessment efforts we identified are some studies that meet the 

criteria of a scientifically valid effectiveness study. However, results of 

these studies have varied, and this limits the conclusions that can be

drawn about the effectiveness of abstinence-until-marriage education 

programs. Some researchers have reported that abstinence-until-marriage 

education programs have resulted in adolescents reporting having less 

frequent sexual intercourse or fewer sexual partners.66 For example, in one 

study of middle school students, participants in an abstinence-untilmarriage education program who had sexual intercourse during the 

follow-up period were 50 percent less likely to report having two or more 

sexual partners when compared with their nonparticipant peers.67 In 

contrast, other studies have reported that abstinence-until-marriage 

education programs did not affect the reported frequency of sexual 

Results of Some Scientifically 

Valid Assessment Efforts Have 

Varied, and Other Key Studies 

Have Not Been Completed 

 66See Borawski et al. See also T. L. St. Pierre et al., “A 27-Month Evaluation of a Sexual 

Activity Prevention Program in Boys & Girls Clubs Across the Nation,” Family Relations, 

vol. 44, no. 1 (1995). 

67See Borawski et al. 

Page 37 GAO-07-87 Abstinence Education
intercourse or number of sexual partners.68 For example, one study of 

middle school students found that participants of an abstinence-untilmarriage program were not less likely than nonparticipants at the 1 year 

follow-up to report less frequent sexual intercourse or fewer sexual 

partners.69 In addition to these varied findings, one study found that an 

abstinence-until-marriage program was effective in delaying the initiation 

of sexual intercourse in the short term but not long term.70 Experts with 

whom we spoke emphasized that there are still too few scientifically valid 

studies completed to date that can be used to determine conclusively 

which, if any, abstinence-until-marriage programs are effective. 

Additionally, among the assessment efforts we identified are some studies 

that experts anticipate will meet the criteria of a scientifically valid 

effectiveness study but are not yet completed. One of these key studies is 

the final Mathematica report, contracted by ASPE, on the State Program.71

The final report was originally slated for publication in 2005, but an ASPE 

official stated that the final report has been delayed until 2007 so that 

researchers can extend the follow-up period to improve their response 

rate and the reliability of the information they collect. Another key study is

CDC’s research on middle school programs, which is not expected to be

completed until 2009. 

Experts and federal officials we interviewed stated that they expect the 

results of these two federally funded studies to add substantively to the 

body of research on the effectiveness of abstinence-until-marriage 

education programs. One expert with whom we spoke said that she 

expects the final Mathematica report on participants’ behaviors to provide 

the groundwork for the field. Another expert we interviewed stated that 

 68See N.G. Harrington et al., “Evaluation of the All Stars Character Education and Problem 

Behavior Prevention Program: Effects on Mediator and Outcome Variables for Middle 

School Students,” Health Education & Behavior, vol. 28, no. 5 (2001). See also Jemmott, 

Jemmott, and Fong. 

69See Harrington et al. 

70See Jemmott, Jemmott, and Fong and J. B. Jemmott III, L. S. Jemmott, and G. T. Fong, 

reply to letter to editor, Journal of the American Medical Association, vol. 281, no. 16 

(1999), 1487. This study found that an abstinence-until-marriage program delayed the 

initiation of sexual intercourse at the 3-month follow-up period but not at 6 and 12 months. 

71According to several scientific experts, Mathematica’s study is an important one, in part 

because of its sound design: the study randomly assigns and compares control groups with 

groups receiving abstinence-until-marriage education and uses surveys to follow up with 

program participants for several months after their completion of a program. 

Page 38 GAO-07-87 Abstinence Education
the CDC study was very well-designed and she expects the results to 

contribute to the development of effective abstinence-until-marriage 

education curricula. 

There have been various efforts—by HHS, states, and others—to assess 

the scientific accuracy of educational materials used in abstinence-untilmarriage education programs and the effectiveness of these programs. 

However, efforts to evaluate both the accuracy and effectiveness of 

abstinence-until-marriage education programs have been, in various ways, 

limited. ACF, which administers the two programs that account for the 

largest portion of federal spending on abstinence-until-marriage education, 

does not review or require its grantees to review program materials for 

scientific accuracy. In addition, not all grantees of the State Program have 

chosen to review their materials. Because of these limitations, ACF cannot 

be assured that the materials used in its State and Community-Based 

Programs are accurate. Moreover, OPA, which reviews all grantees’ 

proposed abstinence-until-marriage educational materials, and states that 

review educational materials have found inaccuracies in some educational 

materials used by abstinence-until-marriage programs. 

Similarly, most of the efforts described in our review to assess the 

effectiveness of abstinence-until-marriage programs have not met 

minimum scientific criteria needed to draw valid conclusions about their 

effectiveness. Specifically, most efforts by agencies, states, and other 

researchers have not included experimental or quasi-experimental designs 

that can establish whether changes in behaviors or biological outcomes 

can be causally linked to specific abstinence-until-marriage education 

programs. While these types of studies are time-consuming and expensive, 

experts said that they are the only definitive way to draw valid conclusions 

about the effectiveness of these programs. In addition, among the 

assessment efforts we identified are some studies funded by HHS that 

experts anticipate will meet the criteria of a scientifically valid 

effectiveness study but are not yet completed. When completed, these 

HHS-funded studies may add substantively to the body of research on the 

effectiveness of abstinence-until-marriage education programs. 

Conclusions 

Page 39 GAO-07-87 Abstinence Education
To address concerns about the scientific accuracy of materials used in 

abstinence-until-marriage education programs, we recommend that the 

Secretary of HHS develop procedures to help assure the accuracy of such

materials used in the State and Community-Based Programs. To help 

provide such assurances, the Secretary could consider alternatives such as 

(1) extending the approach currently used by OPA to review the scientific

accuracy of the factual statements included in abstinence-until-marriage 

education to materials used by grantees of ACF’s Community-Based 

Program and requiring grantees of ACF’s State Program to conduct such

reviews or (2) requiring grantees of both programs to sign written 

assurances in their grant applications that the materials they propose 

using are accurate. 

HHS provided written comments on a draft of this report. (See app. III.) 

In its written comments, HHS stated that it will consider requiring grantees 

of both ACF programs to sign written assurances in grant applications that

the materials they use are accurate. Regarding accuracy, HHS’s written 

comments also noted that all applicants for federal assistance attest on the 

application form--Standard Form 424--that all data in their applications are 

“true and correct,” and that in the view of HHS, this applies to information 

presented in curricula funded by federal grants. However, as we stated in

the draft report, grantees of the State Program are not required to submit 

curricula as a part of their applications; therefore, the attestation in 

Standard Form 424 would not apply to curricula used by those grantees. In

addition, as stated in the draft report, some states have reviewed materials 

used in abstinence-until-marriage education programs, but these reviews 

occurred after they received funding from ACF. Further, while grantees of 

the Community-Based Program were required to submit copies of their 

curricula and a Standard Form 424 in fiscal year 2006 as part of their 

applications, none of the materials specifically require an assurance of 

scientific accuracy. Further, OPA and states have found inaccuracies in 

educational materials used by abstinence-until-marriage programs. 

HHS’s written comments also stated that ACF requires that curricula 

conform to HHS’s standards grounded in scientific literature. HHS’s 

comments refer to the curriculum standards for this program that detail

what types of information must be included in abstinence-until-marriage 

curricula, and the comments stated that the curricula must provide 

supporting references for this information. Further, HHS’s comments 

stated that ACF staff review the curricula to ensure compliance with these 

standards. The draft report stated this. However, a requirement that 

Recommendation for 

Executive Action 

Agency Comments 

and Our Evaluation 

Page 40 GAO-07-87 Abstinence Education
curricula include certain types of information does not necessarily ensure 

the accuracy of the scientific facts included in the abstinence-untilmarriage materials. For example, while education materials may include 

information on failure rates associated with contraceptives or STD 

infections, this information may be outdated or otherwise inaccurate or 

incomplete. HHS’s written comments also stated that if it finds inaccurate

statements during the review process or at any time during the grant 

period, ACF works with grantees to take corrective action. To ensure 

completeness, we have added this statement to the report. Further, HHS 

stated that 2 inaccuracies cited in the draft report had been corrected 

before our work began. We believe HHS is referring to inaccuracies 

identified by OPA during its review of materials for scientific accuracy and 

this reinforces the need for review of materials used by ACF’s grantees. 

As HHS noted in its written comments, we did not define the term 

scientific accuracy. HHS stated that it disagreed with certain findings of 

the report because it was difficult to precisely determine the criteria we 

employed in making the recommendation as to scientific accuracy. As we 

stated in the scope and methodology section of the draft report, the 

objective of our work was to focus on efforts by HHS and states to review 

the accuracy of scientific facts included in abstinence-until-marriage 

education materials. Performing an independent assessment of the criteria 

used by these entities to determine the scientific accuracy of education 

materials or the quality of the reviews was beyond the scope of the work. 

Regarding effectiveness, HHS’s written comments also described a 

number of actions it is taking to determine program effectiveness and 

improve the quality of programs and research. Specifically, HHS’s 

comments described (1) studies undertaken or funded by ASPE, CDC, and 

NIH; (2) technical assistance provided by OPA and ACF; (3) grantee 

evaluation requirements; and (4) ACF and OPA requirements for the 

amount of grant funds to be spent on evaluations. All of this information 

was included in our draft report. HHS’s comments also described a new 

effort funded by ACF and ASPE that is designed to build capacity for 

quality research in the field of abstinence education. We added 

information on this effort to the report. HHS’s written comments also 

describe evaluations that resulted from an Abstinence Education 

Evaluation Conference sponsored by ACF and OPA. While this conference 

was described in the draft report, we added more detail regarding the 

content of the conference. HHS’s written comments also describe OPA’s 

efforts to assess the effectiveness of the AFL Program. We had included 

this information in the draft report. 

Page 41 GAO-07-87 Abstinence Education
HHS’s written comments stated that it may be too soon to draw 

conclusions about the effectiveness of ACF’s and OPA’s programs, in part, 

because key studies have not been completed. We agree and discussed this 

in the draft report. As we noted in the draft report, key studies funded by 

HHS that experts anticipate will meet the criteria of a scientifically valid 

effectiveness study are not yet completed, but when completed these HHS 

funded studies may add substantively to the body of research on the 

effectiveness of abstinence-until-marriage education programs. 

In addition, the comments stated that having an inadequate amount of 

scientifically valid and conclusive evaluation studies is not unique to 

abstinence-until-marriage education programs, and a recent ASPE review 

of comprehensive sex education programs found mixed results on their 

effectiveness. However, the scope of our report was focused on 

abstinence-until-marriage education programs, and we did not review 

comprehensive sex education programs or make any comparisons 

between the two types of programs. 

HHS also provided technical comments, which we incorporated into the

report as appropriate. 

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

date. We will then send copies of this report to the Secretary of HHS and 

to other interested parties. In addition, this report is available at no charge

on GAO’s Web site at http://www.gao.gov. We will also make copies 

available to others upon request. 

If you or your staff have any questions about this report, please call me at 

(202) 512-3407 or crossem@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

Marcia Crosse 

Director, Health Care 

Page 42 GAO-07-87 Abstinence Education
List of Requesters 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

The Honorable Pete Stark 

Ranking Minority Member 

Subcommittee on Health

Committee on Ways and Means 

House of Representatives 

The Honorable Sherrod Brown 

Ranking Minority Member 

Subcommittee on Health

Committee on Energy and Commerce 

House of Representatives 

The Honorable Barbara Boxer 

The Honorable Maria Cantwell 

The Honorable Richard J. Durbin 

The Honorable Russell D. Feingold

The Honorable Dianne Feinstein 

The Honorable Tom Harkin 

The Honorable James M. Jeffords 

The Honorable Edward M. Kennedy 

The Honorable Frank R. Lautenberg 

The Honorable Patrick Leahy 

The Honorable Patty Murray 

United States Senate 

The Honorable Howard L. Berman 

The Honorable Lois Capps 

The Honorable Jay Inslee 

The Honorable Barbara Lee 

The Honorable Nita M. Lowey 

The Honorable Betty McCollum 

House of Representatives 

Page 43 GAO-07-87 Abstinence Education
Appendix I: HRSA’s Technical Assistance Appendix I: HRSAContract for Abstinence Education ’s Technical Assistance 

Contract for Abstinence Education 

The Health Resources and Services Administration (HRSA) awarded a 

contract to the National Abstinence Clearinghouse (NAC) in 2002 to 

provide assistance with its Community-Based Abstinence Education 

Program (Community-Based Program) and Abstinence Education Program 

(State Program).1

 NAC is a nonprofit educational organization whose 

mission is to promote the appreciation for and practice of sexual 

abstinence until marriage through the distribution of age appropriate, 

factual, and medically referenced materials. The purpose of the contract 

was (1) to develop national criteria for the review of abstinence-untilmarriage educational materials and to create a directory of approved 

materials; (2) to provide medical accuracy training to grantees; and (3) to

provide technical support to grantees, such as assistance with program 

evaluation.2

We are reporting on the steps that HRSA took to award the contract to 

NAC in response to concerns that have been raised by a congressional 

requester. In general, these concerns centered on the extent to which the 

selection process was competitive and whether HRSA identified the 

potential for an organizational conflict of interest. 

HRSA awarded the contract to address three concerns it had with the 

Community-Based Program during 2001, the first year of its 

implementation. First, HRSA officials needed guidance to determine 

whether abstinence-until-marriage education materials conformed to the 

 1

The administration of this contract was transferred from HRSA to the Administration of

Children and Families (ACF) in May 2005. 

2

The contract resulted in the development of criteria for reviewing abstinence-untilmarriage educational materials, and ACF included these criteria in the fiscal year 2006 

program announcement for the Community-Based Program. According to the 

announcement, ACF will evaluate grant applicants’ proposed educational materials to 

ensure compliance with the criteria. Medical accuracy training and technical support were 

provided to grantees as a result of the contract. According to an ACF official, a directory of 

approved abstinence-until-marriage educational materials was not completed. 

Page 44 GAO-07-87 Abstinence Education
Appendix I: HRSA’s Technical Assistance 

Contract for Abstinence Education 

definitional requirements of the Social Security Act.3 Second, many 

grantees lacked the medical background and training to ensure that they 

would provide medically accurate, science-based information in their 

programs. Third, grantees also lacked experience with the technical 

management of federal grants, including how to conduct evaluations of 

their programs. 

HRSA used full and open competition procedures to award the contract to 

NAC. In doing so, HRSA (1) publicly solicited proposals from potential 

contractors; (2) conducted technical evaluations of both the original 

proposals and the revised proposals for those considered to be in the 

competitive range; and (3) determined that NAC’s proposal represented 

the best overall value to the government. This process, which took place 

from May 2002 through September 2002, resulted in HRSA awarding NAC 

the contract with a potential value of nearly $2.7 million. 

HRSA issued a notice on May 20, 2002, on the FedBizOpps Web site, the 

government point of entry for notifying potential contractors of federal 

contract opportunities, indicating its intent to publicly request proposals 

from prospective contractors in June 2002.4

 On June 20, 2002, HRSA 

posted the solicitation on the FedBizOpps Web site indicating that the 

abstinence contract would be awarded using full and open competition 

procedures, that is, all responsible prospective contractors would be 

HRSA Used Full and Open 

Competition Procedures to 

Award the Contract to 

NAC 

 3

Section 510(b)(2) of the Social Security Act defines abstinence education as an 

educational or motivational program that: 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. 

4

The current FedBizOpps Web site address is http://www.fbo.gov /. Prior to October 1,

2005, the Web site address was http://www.eps.gov/. The solicitation number was 240-

MCHB-012(02)-abg. 

Page 45 GAO-07-87 Abstinence Education
Appendix I: HRSA’s Technical Assistance 

Contract for Abstinence Education 

provided the opportunity to compete.5 The solicitation, which was a 

Request for Proposals (RFP), described the contract objectives, which 

included (1) the development of national criteria for the review of 

abstinence-until-marriage educational materials and the development of a 

directory of approved materials; (2) the provision of medical accuracy

training to grantees; and (3) the provision of technical support to grantees, 

such as assistance with program evaluation. The RFP stated that HRSA 

intended to award a cost-reimbursement contract with fixed fee for a 

1-year base period and 2 option years.6

 This was a best value procurement; 

that is, HRSA reserved the right in the RFP to select for award the 

proposal that HRSA determined offered the best value to the government, 

even if it did not offer the lowest cost. Further, the RFP stated that the 

technical evaluation of the prospective contractors’ proposals would 

receive paramount consideration in the selection of the contractor. 

According to the RFP, this evaluation would include an assessment of the 

prospective contractor’s technical approach, the organizational experience

and expertise of the prospective contractor, the plans for personnel and 

management of the work, and the prospective contractor’s statement and

understanding of the project purpose. Other factors, such as the estimated 

cost, past performance under other contracts for similar services, and the 

subcontracting plan would also be considered in the selection process. 

Five prospective contractors submitted proposals to HRSA by July 31, 

2002, when proposals were due. 

HRSA established a review committee to conduct the technical evaluation

of the five proposals. This committee included three voting members and a 

nonvoting chairperson. The Director of HRSA’s Community-Based and 

State Programs and two analysts from other programs within the 

Department of Health and Human Services (HHS) served as the voting

members, and the chairperson of the review committee was a project 

officer of HRSA’s Community-Based Program. The committee members 

conducted the technical evaluation of the proposals, according to the 

 5

The Federal Acquisition Regulation (FAR) requires the contracting officer to ensure that

prospective contractors are responsible. FAR § 9.103. A responsible source refers to a 

prospective contractor that has, among other things, adequate financial resources, the 

necessary experience and technical skills to perform the work of the contract, a 

satisfactory performance record, and the ability to meet the delivery schedule. FAR § 9.104-

1. 

6

Cost-reimbursement contracts are used only when uncertainties involved in contract 

performance do not permit costs to be estimated with sufficient accuracy to use any type

of fixed-price contract. FAR § 16.301-2. 

Page 46 GAO-07-87 Abstinence Education
Appendix I: HRSA’s Technical Assistance 

Contract for Abstinence Education 

criteria in the RFP, as described above. Three proposals with the highest 

technical scores were determined to be in the competitive range,7

 with 

NAC’s proposal receiving the highest technical score. HRSA requested in 

writing that the competitive range offerors address certain technical and 

cost issues and submit revised proposals to HRSA by September 17, 2002.8

For example, HRSA requested that one of the prospective contractors 

other than NAC clearly describe its proposed management of day-to-day 

tasks of the contract and provide justification for several labor and travel 

expenditures. HRSA did not have oral discussions with the competitive 

range offerors. HRSA’s review committee evaluated the revised proposals 

and again gave NAC’s revised proposal the highest technical score. 

Although NAC’s estimated cost was not the lowest among the proposals in 

the competitive range, HRSA determined that NAC had proposed a 

realistic cost estimate for the contract. Accordingly, and in light of the 

NAC proposal’s high technical rating and the RFP’s evaluation criteria 

giving paramount consideration to the technical evaluation, HRSA 

determined that NAC’s proposal represented the best value to the 

government. HRSA awarded a contract to NAC on September 27, 2002. 

The contract had a 1-year base period of performance with an estimated 

value of $854,681, and included 2 option years for a total potential value of

$2,673,784. According to a HRSA official, this cost-reimbursement contract 

did not include a fee. All of the prospective contractors were made aware 

that a debriefing to explain the selection decision and contract award 

would be provided at their request. One prospective contractor requested

and received a debriefing from HRSA. No protests were filed with the 

agency challenging the award of the contract to NAC. There were no bid 

protests filed with GAO.9

HRSA officials told us that they did not identify any actual or potential 

organizational conflicts of interest during the acquisition process. As 

defined in the Federal Acquisition Regulation (FAR), an organizational 

conflict of interest arises where 

HRSA Identified No Actual 

or Potential Organizational 

Conflicts of Interest 

 7

Based on the ratings of each proposal against all evaluation criteria, the contracting officer

establishes a competitive range consisting of all of the most highly rated proposals. FAR § 

15.306(c)(1). 

8

HRSA officials, including an auditor, reviewed the cost proposals in the competitive range.

9

GAO’s Office of General Counsel resolves disputes concerning awards of federal 

contracts, which are known as bid protests. 

Page 47 GAO-07-87 Abstinence Education
Appendix I: HRSA’s Technical Assistance 

Contract for Abstinence Education 

• because of other activities or relationships, a person is unable or 

potentially unable to provide impartial assistance or advice to the 

government; or 

• the person’s objectivity in performing the contract work is or might be 

otherwise impaired; or 

• a person has an unfair competitive advantage.

10

An organizational conflict of interest may result when factors create an

actual or potential conflict of interest during performance of a contract, or

when the nature of the work to be performed under one contract creates 

an actual or potential conflict of interest involving a future acquisition.11

Under the FAR, contracting officers are required to analyze planned 

acquisitions to identify and evaluate potential organizational conflicts of 

interest as early in the acquisition process as possible, and to take steps to

avoid, neutralize, or mitigate significant potential conflicts of interest 

before a contract is awarded.12

According to HRSA’s contracting officer, HRSA did not identify any actual 

or potential organizational conflicts of interest. In reaching this 

conclusion, the contracting officer told us that he reviewed the statement 

of work, including the background and objectives of the proposed 

contract, the stated purpose of the contact, the criteria established to 

evaluate the proposals, the past performance of the competitors, and 

NAC’s proposal. HRSA’s contracting officer also told us that he did not 

formally document his assessment of organizational conflict of interest.13

 10FAR § 2.101. 

11FAR § 9.502(c). 

12The FAR requires contracting officers to exercise common sense, good judgment, and

sound discretion in determining whether a significant potential conflict of interest exists. 

FAR § 9.505. 

13The FAR requires HRSA’s contracting officers to formally document their assessment 

only when a substantive issue concerning a potential organizational conflict of interest

exists. FAR § 9.504(d). HHS acquisition regulations do not explicitly address the 

assessment of organizational conflict of interest. Therefore, FAR subpart 9.5 is the 

controlling regulation when HHS encounters an issue related to an organizational conflict

of interest. 

Page 48 GAO-07-87 Abstinence Education
Appendix II: Methodology for Identifying and Appendix II: Methodology for Identifying and Reviewing Research Studies 

Reviewing Research Studies 

To identify research studies that examine the effectiveness of abstinenceuntil-marriage education programs among adolescents and young adults, 

we searched two reference database systems, PubMed and ProQuest. We 

used the following keywords to search for research studies that were 

published from January 1, 1998, through May 22, 2006: “virginity,” 

“abstinence education,” “abstinence and curriculum,” “abstinence only,” 

“teen pregnancy and prevention,” and “abstinence until marriage.”1

 We 

reviewed the research article titles that were generated from the PubMed 

and ProQuest searches and identified articles that appeared to focus on 

the evaluation of the effectiveness of abstinence-until-marriage education 

programs. In cases where we could not determine, based on the title, 

whether a study appeared to focus on an abstinence-until-marriage 

education program evaluation, we reviewed a summary of the article to

obtain more information about the research study. We also examined 

previous summaries of the literature to identify additional research 

studies. 

We then selected research studies for inclusion in our literature review if 

they met three criteria. First, the study evaluated a group-based, 

abstinence-until-marriage education program. We did not select studies 

that evaluated one-on-one interactions, such as education programs 

focused exclusively on parent-child interactions, or that evaluated media 

campaigns. We reviewed the description of each education program and 

curriculum, as described in the study, to determine whether an abstinenceuntil-marriage education program was being evaluated. Education 

programs that were described as including detailed contraceptive 

information in their curricula, for example, were not classified as 

abstinence-until-marriage programs. Second, the study targeted 

adolescents and young adults in the United States, for example, by 

indicating that participants in the evaluation were high school or middle 

school students. Third, the study was a quantitative rather than a 

qualitative evaluation of an abstinence-until-marriage education program. 

We selected 13 research studies for inclusion in our literature review. 

 1

ACF first awarded grants under the State Program in fiscal year 1998. 

Page 49 GAO-07-87 Abstinence Education
Appendix II: Methodology for Identifying and

Reviewing Research Studies 

We reviewed the selected research studies to obtain detailed information 

about their methodologies and outcome variables. For example, we 

determined whether each study used an experimental or quasiexperimental design and whether the outcome measures included 

attitudes, behavioral intentions, behaviors such as initiation of sexual 

intercourse, or a combination of these. 

Page 50 GAO-07-87 Abstinence Education
Appendix III: Comments from the Appendix III: Comments from the Department of Health and Human Services 

Department of Health and Human Services 

Page 51 GAO-07-87 Abstinence Education
Appendix III: Comments from the 

Department of Health and Human Services 

Page 52 GAO-07-87 Abstinence Education
Appendix III: Comments from the 

Department of Health and Human Services 

Page 53 GAO-07-87 Abstinence Education
Appendix III: Comments from the 

Department of Health and Human Services 

Page 54 GAO-07-87 Abstinence Education
Appendix III: Comments from the 

Department of Health and Human Services 

Page 55 GAO-07-87 Abstinence Education
Appendix III: Comments from the 

Department of Health and Human Services 

Page 56 GAO-07-87 Abstinence Education
Appendix IV: GAO Contact and Staff Acknowledgments 

Page 57 GAO-07-87

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact Marcia Crosse, (202) 512-7119 or crossem@gao.gov 

In addition to the contact named above, Kristi Peterson, Assistant 

Director; Kelly DeMots; Pam Dooley; Krister Friday; Julian Klazkin; and 

Amy Shefrin made key contributions to this report. 

 Abstinence Education

Acknowledgments 

(290491) 
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