0:07      Kay Summers: From the School of International Service at American University in Washington, this is Big World where we talk about something in the world that truly matters. Of all the things in this world that really matter, perhaps none is more essential than human reproduction. Yet, for something so central to the human experience, education about sexuality and reproduction is always controversial. Any discussion about educating our children about the reproduction of our own species can get mired in a combination of politics and perceptions of morality that can be a recipe for bad public health policy.

0:40      KS: Today, we're talking about the politics and policy of reproductive health and sexuality education or as we all called it in high school health class, sex ed. I'm Kay Summers, and I'm joined by Rachel Robinson. Rachel is a professor in the School of International Service. She is a sociologist and demographer whose research focuses on global health interventions in sub-Saharan Africa. She's also the author of "Intimate Interventions in Global Health, Family Planning and HIV Prevention in sub-Saharan Africa." Rachel, thanks for joining Big World.

1:11      Rachel Robinson: Thanks, I'm so excited to be here.

1:14      KS: Rachel your research focuses on global health interventions in sub-Saharan Africa which includes sex ed. In your article, "Prioritizing Sexuality Education in Mississippi and Nigeria," you emphasized that there are similarities in the experiences of sex ed in Mississippi and Nigeria. What are these similarities?

1:33      RR: Right. There were a number of similarities. First and foremost, both places have very high rates of fertility. So, Mississippi has one of the highest rates of teen pregnancy in the US and, in Nigeria, a quarter of women have become pregnant or begun childbearing by the age of 19. The challenges faced around sex ed in both places were also quite similar. So they're socially conservative, which means that really there's tensions about whether schools, parents or religious leaders should have the authority to educate children and whether sex should even be discussed. They also have underfunded education and health sectors, which means there's not a lot of extra resources to go around for new curricula.

2:16      RR: So my co-authors and I found a few things really helped in the prioritization of sex ed in both places. One was homegrown nonprofit organizations who lobbied, linked people together, and provided legitimacy to ideas that otherwise might have seemed foreign.

2:33      RR: A second factor that was similar between both places was that people promoting sex ed found a way to describe it as a solution to a pressing social problem. So in Mississippi that was the cost of teen pregnancy and in Nigeria that was HIV AIDS.

2:48      RR: And then finally, another similarity was that compromise was really necessary in both places. So the content of the curriculum had to be made less expansive, words were changed, and the name was even changed in Nigeria from the National Comprehensive Sexuality Education Curriculum to the more euphemistic Family Life and HIV Education.

3:08      KS: Family life which that is the same kind of euphemism that they use at my daughter's middle school. Interestingly enough. Oh yeah, Family Life Education.

3:16      RR: Interesting.

3:18      KS: So you talked about the steps that they took in Mississippi and Nigeria, some of the compromises that were made over the last decade. Through your research, have you yet seen any outcomes from these implementations and if so what were the outcomes?

3:32      RR: So, first and foremost the initial outcome was that school districts did adopt sexuality education curriculum. So Mississippi by 2012 all school districts had to identify the policy that they would adopt. And in Nigeria, states had to implement the curriculum as well. But the reach of the policies was very, very uneven. So, in Mississippi, those districts that were reached by this organization Mississippi First, they were better able to access federal funding for more comprehensive sex ed and the funding is crucial because it's expensive to implement new curriculum. Teachers need training. Students need supplies. But we don't really know much about the extent of implementation or whether teens behavior has changed. There's researchers at Mississippi State University keeping track of that and, thus far, sort of the best thing that they've found is that more than three quarters of instructors surveyed believe that sex education was promoting healthy relationships.

4:36      RR: In Nigeria, there was great diversity in how different states prioritized this federal mandate. Some took it up right away, while others lagged. And some of those differences were for predictable reasons. So more cosmopolitan Lagos was an early starter but so were some very religious places like Kano in the north. So bureaucratic bottlenecks and lack of funding really hindered implementation. It wasn't until Nigeria received a large grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria that implementation began in earnest which was actually 10 years after the mandate that sex ed be offered. And they're sort of the best evidence of an effect is that in four states researchers concluded that the curriculum had increased students' confidence to refuse unwanted sex. But in terms of actual impacts on pregnancy or sexually transmitted infections it remains unknown.

5:30      KS: Right. Rachel when we talk about sex ed, I think it's important to note that not all sex ed is created equal. There's a big difference between comprehensive sex ed which you referenced and abstinence-only sex ed. There's an ongoing debate in the United States and different countries on which version of the curriculum leads to positive outcomes. I know in the US this dates back at least to the late '90s and probably earlier. A little background. The President's Emergency Plan For AIDS Relief or PEPFAR is the US initiative addressing the global HIV AIDS epidemic primarily in Africa. And it's been around since 2003. Until 2008 PEPFAR's legislation required that one third of all prevention funding be spent on abstinence and faithfulness programs. Although the budget stipulation for abstinence and faithfulness programs was relaxed after 2008, these prevention efforts continue to receive funding in sub-Saharan Africa including 67 million US dollars in 2012 and 45 million US dollars in 2013. Rachel, what are your thoughts on abstinence programs in general and on government support for these types of programs?

6:41      RR: So the government's support comes from a political place, as opposed to a scientific one. Basically abstinence only education focuses on telling teens to abstain from sex, does not generally cover contraception and condoms, and often does not discuss sexually transmitted infections. The thing that it has going for it is that it can cover many of the same things including skills building around decision making and negotiation, the biology of reproduction, these types of things. But the US emphasis on abstinence only education is a direct reflection of our domestic politics, which then, to the detriment of those living in other places, influences the quality of programming provided with US foreign funding dollars. Research has shown that the emphasis of PEPFAR on abstinence only education had absolutely no effect on HIV outcomes in sub-Saharan Africa.

7:42      KS: Which is a pretty stark statement to be able to make.

7:52      KS: Rachel Robinson, it's time to take five. This is when you, our guest, get to reorder the world as you'd like it to be by singlehandedly instituting five policies or practices that would change the world for the better. Specifically, what five policies would you institute to influence reproductive health?

8:10      RR: First, I would legalize abortion. Not only is access to safe abortion a fundamental precursor to women achieving full human rights, but unsafe abortion is a major cause of preventable death.

8:22      RR: Second, I would make contraception freely and widely available to people of all ages. Contraception enables the full participation of women in society by allowing them to decide when they want to get pregnant. But it also prevents maternal and infant deaths through reductions in fertility and longer spacing between pregnancies.

8:42      RR: Third, I would decriminalize homosexuality. The criminalization of homosexuality increases the risk of HIV and leads to worse health outcomes for those who are HIV positive in countries around the world.

8:55      RR: Fourth: reverse bans on needle exchange. Needle exchange is a proven method for reducing the transmission of diseases such as HIV and hepatitis but also helps link drug users to treatment and other needed services.

9:09      RR: And fifth, I would implement universal health coverage, which means access for all to appropriate health services without financial hardship.

9:19      RR: The US can affect all of these areas through its oversized role in both global governance and global health financing. But ultimately, these are all matters that countries and states have to prioritize themselves, which in many cases will take collective action by citizens in conjunction with health professionals and other civil society groups.

9:37      KS: Thank you.

9:38      RR: Of course.

9:47      KS: As we look at the politics and policy of reproductive health, there is a bigger discussion. Alongside sex ed, family planning plays a large role in reproductive health. With the Trump administration's decision to reinstate the global gag rule, or the Mexico City rule, international NGOs that provide family planning services around the world must either lose US funding or stop providing abortion services or advocacy. How does this decision affect the people who have relied on these services? What does this mean to women in these countries?

10:21      RR: It means that they have access to a lot fewer services. So, just for some context, the US provides more funding for family planning than any other country in the world. So about 500 million dollars per year or about 40 percent of the total global funding for family planning. And when the funding is affected by the global gag rule, not only does the availability of family planning services decline, but there's also research showing that because clinics close there's actually negative outcomes for infant and child health as a result of the funding cuts that occur. So, these spillover effects in conjunction with then the decline in contraceptive use that occurs lead to increased infant child mortality and then also others have shown an increase in abortion.

11:16      KS: Well by the same token where we say that Planned Parenthood provides services in addition to abortion services, many of these organizations also provide different kinds of healthcare services for women that are very necessary and also spill over into child-health issues. Healthy mom, healthy babies. So, it's very frustrating when you start thinking about it.

11:37      RR: Oh yeah, it's extraordinarily frustrating. And one of the other factors that causes negative outcomes is largely the uncertainty around the policy. So most organizations have a tendency to actually pull back further than they need to because they don't want to risk losing their funding, in essence, so the policy has more extreme effects than it's even intended to.

12:02      KS: People in various places around the world, and I include the US in this group, fear that sex ed makes young people more sexually active. But evidence has shown that this is just not the case. Given that this false narrative is taken hold for so many years, what kinds of tactics can dispel these fears, either in the US, abroad? How do you make this stop?

12:25      RR: Right. So, there is no evidence that sex ed makes teens have sex. That's true everywhere in the world. In terms of the impacts of sexuality education, they're actually quite modest. So high quality studies have found that comprehensive sex ed helps delay sexual initiation, increases contraceptive use, and reduces rates of teen pregnancy and sexually transmitted infections. And then, similarly, high quality research has found that abstinence only programs have some positive effects, but the general conclusion is that the comprehensive sex ed programs are more effective and that the abstinence only programs have either null or even sometimes negative effects. And so, all of this is tempered by the fact that the quality and length of the programming matters. So you can imagine a three week course of one hour sessions is unlikely to change anyone's behavior. But longer programs that go more in-depth and that are taught by someone who is comfortable talking about the issues will be much more effective.

13:30      RR: So, what kind of tactics dispel this type of narrative? One of the ones that I heard in both Mississippi and Nigeria is that if you don't do it, meaning if you don't talk to your kids about sex or if the school doesn't, someone else will. And that will be either the media or peers who will either have misinformation or will emphasize the types of information that are not most helpful.

13:57      RR: Another strategy has been that highlighting that the name sex ed does not mean teaching teens how to have sex but it really does sound like that. And that the comprehensive sexuality education includes instruction on many skills that parents really want their kids to have. So negotiation, good decision making, empowerment, those types of things.

14:20      RR: And then a third strategy is the one that proponents used in both Mississippi and Nigeria, which is linking sex ed to other desirable outcomes. So reducing the cost of teen pregnancy to taxpayers, reducing HIV rates. It helps by making it about health as opposed to about sex. You can get a bit more purchase.

14:41      KS: Right. I remember when I first heard about your book and the study, the research that was kind of comparing and contrasting Mississippi and Nigeria, and it's kind of an immediate gut check when you realize that a state in what we consider the most developed country is being compared to a country in the developing world with relation to its sexual education practices. And I have to believe, I think you referenced this earlier, that a lot of it has to do with the socially conservative environment of both those locations. You emphasize that local organizations are a big part of promoting sex ed and family planning. What kinds of obstacles do those organizations face in socially conservative areas like Mississippi and Nigeria?

15:27      RR: Well it turns out, actually, they face some of the same challenges regardless of where they are. And one of the things is local organizations tend to be small and resource poor. And so funding is one of the main obstacles that they face. And I say that because that means that organizations have to spend their time looking for money as opposed to helping the populations that they want to serve. So that's one negative aspect.

15:54      RR: But the other negative aspect is that they then become beholden to the whims of their funders and funders are notorious for changing what they want organizations to focus on. So even if an organization is very committed to, let's say sex ed, if their prime donors, which is to saying "Oh no we're going to do women's empowerment now," that can really have an impact on their work.

16:22      RR: Opposition from other organizations and actors in civil society is another challenge that organizations face and that does come up more in conservative places. But even in the most cosmopolitan of places, religious organizations, not to vilify them particularly, but other organizations that disagree with empowering women, for example, can pose a significant challenge.

16:48      RR: And then, finally, one thing that particularly mires groups working in the U.S. is that any conversation about family planning quickly can be linked to abortion. And that is just a lightning rod.

17:03      KS: It's the lightning rod.

17:05      RR: And so even organizations, a family planning organization could have no stance on abortion but would become linked to the issue and would have to fight that particular battle even if they had not chosen to.

17:18      KS: All right Rachel Robinson, here's the big last question. What would it look like if public health policy wasn't driven by politics, but rather was determined exclusively by health outcomes? What would that look like?

17:32      RR: I think it would mean healthier people. It would mean people who can exercise their rights as humans to live their lives fully in a state of well-being that enables them to do everything else that is important in life in terms of contributing to society, to the economy, to their families.

17:59      KS: Yeah, being able to exercise their agency to make decisions completely based on the right healthcare decision and not based on what big pharma is promoting right now or what is politically out of favor, in favor, and what is being funded at the federal level and just, all kinds of things would change.

18:21      RR: It would reduce inequality, particularly in this country, in the United States. That would bring us closer together if we made a fundamental commitment to providing full healthcare to everyone.

18:35      KS: Rachel Robinson, thank you for joining Big World. It's been a pleasure to speak with you. It's not always fun to talk about this stuff, but it's so important and I really thank you.

18:43      RR: Thank you very much.

18:45      KS: Big World is a production of the School of International Service at American University. Our theme music is "It Was Just Cold" by Andrew Codeman. Until next time.

19:01 Jenna Spinelli: Hi everyone My name is Jenna Spinelli, and I host the Democracy Works podcast, a show that explores what it means to live in a democracy. In the same way that Big World shines a light on complex global issues, we examine things like the free press, gerrymandering, and civics education. New episodes are released each week and feature conversations with people who are working to build and sustain healthy democracies in the US and around the world. Democracy Works is produced by the McCourtney Institute for Democracy at Penn State and WPSU Penn State, Central Pennsylvania's NPR station. Find us at democracyworkspodcast.com or by searching Democracy Works wherever you listen to podcasts. Thanks for your time, and we hope you'll check us out.