MEMORANDUM To: Senate Democrats From: Senate Health, Education, Labor, and Pensions Committee, Democratic Staff Re: Update on President Trump’s Appointments at HHS: A Dangerous Direction for Women’s Health Date: July 5, 2018 Over the past year and a half, President Trump and Vice President Pence have shown a heartless and unrelenting commitment to undermining and rolling back women’s health and rights. To this end, they have appointed individuals to positions of influence who have dedicated their careers to denying women the opportunity to make their own reproductive health decisions. Last June, we provided background information on Charmaine Yoest, then Assistant Secretary of Public Affairs, and Teresa Manning, then Deputy Assistant Secretary for Population Affairs (DASPA), at the Department of Health and Human Services (HHS). These two individuals were among the most outspoken opponents of programs, policies, and practices that advance women’s access to health care, and both had spent their careers actively opposing and spreading misinformation about constitutionally-protected reproductive health care, including safe, legal abortion. Fortunately, neither individual continues to serve in the Department. 1 In May, however, Diane Foley was named the new DASPA; she is now the lead political appointee overseeing the Title X family planning program. Throughout her career, Dr. Foley has been an outspoken opponent of abortion and advocate for abstinence-only education, and she too has spread misinformation about women’s health and sex education. The Title X program funds a nationwide network of health care centers that serve millions of people – including women, people of color, and LGBTQ people – annually. This year, the Trump-Pence Administration has taken dangerous steps to limit access to reproductive health care by restricting provider participation in the Title X program. The February 2018 funding opportunity announcement (FOA) and May notice of proposed rulemaking (NPRM) could shift the program’s traditionally comprehensive, evidence-based approach to distributing the funds authorized by the Congress to an approach rooted in ideology. Dr. Foley’s leadership of this program should raise alarms about the future ability of women – especially low-income, uninsured, or otherwise underserved women – to access quality, affordable reproductive health care when they need it, both because of the extreme nature of her opposition to women’s access to reproductive health care and the additional influence she would have if the proposed TrumpPence Administration policies go into effect. 1 Charmaine Yoest left HHS in February 2018 and now serves as the Associate Director for the Office of National Drug Control Policy. https://www.statnews.com/2018/02/16/yoest-ondcp-departure/. Teresa Manning abruptly left HHS in January 2018, but did not provide a reason for her departure. https://www.washingtonpost.com/news/powerpost/wp/2018/01/12/antiabortion-activist-to-step-down-as-head-ofhhss-family-planning-division/?utm_term=.3dcc4723c624. 2 Below you will find background on the DASPA’s role and responsibilities, as well as a brief overview of Dr. Foley’s extreme and inaccurate views on women’s reproductive health and sex education. Role of the Deputy Assistant Secretary for Population Affairs in Title X As the head of the Office of Population Affairs, the DASPA is responsible for implementation of the Title X program. 2 According to a 2009 Institute of Medicine (IOM) review of the Title X program, “the DASPA’s status as a political appointee is one of the most significant issues affecting the Title X program.” 3 The Trump-Pence Administration’s recently proposed changes to the program seek to place greater authority in the DASPA to dictate the direction of the program than ever before. The Trump-Pence Administration’s reforms to the Title X program will shift it away from an approach focused on providing access to reproductive health care to low-income populations to an approach emphasizing ideology and certain religious beliefs at the expense of health care access. These changes remove the safeguards previously in place to ensure the program funded providers who offered a variety of services, including choice of different contraceptive methods, in the areas of greatest need. The Trump-Pence Administration’s changes place greater discretion in the hands of conservative Administration officials to direct funding towards antiabortion groups and abstinence-only advocates. If finalized, the reforms seek to offer greater discretion to the Department to make decisions about whether providers can continue to participate in the Title X program. For example, under the proposed regulation from the Trump-Pence Administration, the Department would be empowered to determine whether an applicant has sufficiently proven they meet the physical separation criteria and may deem an application ineligible before it has the opportunity to go through the competitive review process. 4 If implemented, the Trump-Pence Administration’s Title X reforms could shift Title X funding away from providers who offer comprehensive, evidence-based family planning services to abstinence-based programs and crisis pregnancy centers. Under Foley’s leadership, Title X funding could be spent on programs that have been repeatedly proven not to reduce teen pregnancy rates or rates of sexually transmitted diseases, while depriving millions of women of reproductive health care they need. Dr. Diane Foley, Deputy Assistant Secretary for Population Affairs Diane Foley is a Colorado-based pediatrician. She most recently served in private practice and as the Director of Medical Ministries for Global Partners of the Wesleyan Church. 2 https://www.hhs.gov/opa/about-opa/ https://www.nap.edu/catalog/12585/a-review-of-the-hhs-family-planning-program-mission-management 4 Federal Register Vol. 83, No 106 page 25511 https://www.gpo.gov/fdsys/pkg/FR-2018-06-01/pdf/FR-2018-0601.pdf 3 3 From 2013 to 2016, Foley was the President and CEO of Life Network, a Christian anti-choice organization that operates two crisis pregnancy centers (CPCs) in Colorado. CPCs work to prevent women from accessing abortion, typically by employing misleading, manipulative tactics and spreading misinformation. Life Network is an affiliate of CareNet, which operates one of the largest networks of CPCs in the country. Life Network receives funding from Focus on the Family, a global Christian ministry that opposes abortion, divorce, and LGBTQ rights. 5 In addition to operating CPCs, Life Network conducts abstinence-only education in Colorado schools and promotes recovery programs for what they call “post-abortion syndrome.” 6 Before serving as CEO, Foley was the Director of Life Network’s abstinence-only education program, Education for a Lifetime (EFL). Described on its website as a “hope-filled, biblically based message,” the EFL program provides abstinence-only education for middle and high school students in and around Colorado Springs. 7 Their five-day high school program tells students that “premarital sex makes you prone to infidelity while reducing your ability to bond with your future spouse,” suggesting that no sex is safe outside of a marital relationship. 8 They also operate a three-day relationship program called “soul-mate training.” 9 Dr. Foley strongly opposes women’s constitutionally-protected right to abortion. Foley is vehemently anti-abortion. • She compared abortion to slavery and the Holocaust: “That sounds a lot like what our nation went through in the 1800s, right? When somebody decided somebody’s life wasn’t worth living or they weren’t quite as much – they were worth what, three-fifths of a human? Is that right? What about what was happening in Europe during the World Wars, where there were groups of people who they determined weren’t worth as much?”10 • She advocates for what she calls “a biblical worldview,” which she summarizes as, “The destruction of conceived human life – whether embryonic, fetal, or viable – is a direct attack on the unique act of God’s [sic] because every human life is created in His image and has incredible value.” 11 • She characterized abortion as “a battle that is happening in the heavenly realms that Satan doesn’t want to lose.” 12 5 https://rewire.news/article/2018/05/30/trumps-hhs-installs-fake-clinic-leader-oversee-family-planning-funds/; https://www.splcenter.org/fighting-hate/intelligence-report/2005/dozen-major-groups-help-drive-religiousright%E2%80%99s-anti-gay-crusade#10 6 https://www.elifenetwork.com/outreaches/bridges-of-hope/ 7 https://www.elifenetwork.com/outreaches/education-for-a-lifetime/; http://educationforalifetime.com/mission-andpurpose/ 8 https://www.csindy.com/coloradosprings/sex-lies-and-duct-tape-science-and-morality-make-for-strangebedfellows-in-d-11/Content?oid=1672302 9 https://www.csindy.com/coloradosprings/sex-lies-and-duct-tape-science-and-morality-make-for-strangebedfellows-in-d-11/Content?oid=1672302 10 https://www.youtube.com/watch?v=HgYZ63dXlWM 11 https://www.youtube.com/watch?v=HgYZ63dXlWM 12 https://www.youtube.com/watch?v=HgYZ63dXlWM 4 Foley has promoted the idea that having an abortion results in substance use or mental health conditions, despite there being no evidence to support this claim. • In a 2016 speech, Foley argued that women who receive abortions have trouble interacting “in a normal way”: “Many find a need because of the pain to deny what happened and they shut down their emotions and become very cold and unapproachable emotionally and have a lot of difficulty then reacting and responding to other people in a normal way.” 13 • Foley suggested that having an abortion results in depression and substance abuse: “I speak with people as they come up to me and they will talk about the fact that they have been dealing with depression and they’ve been dealing with a significant substance abuse, and I look at their history and I see that they’ve had an abortion or two. And I will say to them, has your counselor talked to you about the possible association between this? Oh, no. Did they take a history to find out you had one? Oh, yes. Never once is there a conversation as a part of this. That is such an incredible denial on the part of medical and mental health professionals that I find that hard to comprehend. … There is difficulty with relationships, many times there is use or abuse of alcohol or other drugs, depression, suicidal thoughts, a decreased self-esteem, many times we see this as risky sexual behaviors that come out as a part of that.” 14 o The evidence overwhelmingly contradicts Foley’s assertion that there is a causal relationship between abortion and mental health issues. Numerous studies have found there is no conclusive evidence linking abortion to mental health conditions. 15 o An analysis from the Turnaway Study, a longitudinal study that observed women who obtained an abortion and women who were denied an abortion, found “having an abortion does not adversely affect women’s mental health either at the time of the abortion or over five years after receiving abortion care.” 16 o The American Psychological Association Task Force on Mental Health and Abortion found “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se.” 17 • Foley advocates for recognition of “post-abortion stress” or “post-abortion traumatic syndrome”: “‘There is actually a true, emotional diagnosis that is now starting to be recognized—even though if you look at national media and secular media, they still try to ignore the fact—but there is actually a diagnosis called post-abortion stress and also postabortion traumatic syndrome, that is a result directly of someone having an abortion or being involved with an abortion that happens,’ she said. ‘Here is the thing that is incredible to me. I am a trained physician, went through training, got not one single lecture throughout the course of my training about this situation.’” 18 13 https://www.youtube.com/watch?v=HgYZ63dXlWM https://www.youtube.com/watch?v=HgYZ63dXlWM 15 https://www.guttmacher.org/gpr/2006/08/abortion-and-mental-health-myths-and-realities;; https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2592320 16 https://www.ansirh.org/news/no-evidence-emerging-mental-health-problems-after-having-abortion; https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2592320 17 http://www.apa.org/pi/women/programs/abortion/ 18 https://tonic.vice.com/en_us/article/wjbpnm/diane-foley-crisis-pregnancy-center-title-x 14 5 o In 2015, the Turnaway Study issued two publications on the mental health and emotional consequences of abortion, and they found “no evidence of ‘postabortion trauma syndrome.” 19 The American Psychiatric Association does not recognize “post-abortion trauma” or any related category as an identifiable mental health condition. 20 Foley believes there should be additional state and federal restrictions on abortion. • Foley believes the current regulations of abortion “put[] women at risk”: “The way abortions are done, there is not enough supervision or regulation for them and it puts women at risk. There are not the same standards as other surgical centers, there are not the same requirements in terms of having the same hospital privileges in case something goes wrong. What I’m concerned about is that there is a sense that it’s healthcare for women and there are a lot of things about it that are not good healthcare.” 21 o A 2018 report by the National Academies of Sciences, Engineering, and Medicine concluded “that legal abortions are safe and effective” and pose lower risks of death than tonsillectomies, dental procedures, colonoscopies, or childbirth. 22 The report also found that state laws that impose restrictions on the provision of abortion services may increase the clinical risks and cost of care for patients and limit providers’ ability to provide patient-centered care. • In support of placing restrictions on abortion facilities, Foley said, “If you think back over the history of our country, in the United States, laws were put in place to protect people who didn’t really have a voice. When you think about that and you really are logically and ethically trying to follow that back, there may be the need for legislation to help protect the most vulnerable people.” 23 Foley has also been critical of adoption as an option for women facing an unplanned pregnancy. • “The next choice is, let’s do an adoption plan. Well, that’s a double death, because not only does it interrupt their [the parents] plans for the next several months, right? But then their child is going to be adopted, and they’re going to grow up thinking they’ve been abandoned by their parents. So they’re going to have all kinds of issues with their life. So that’s a double death. That’s worse. Unless you think I’m making this up, I hear this every day.” 24 Dr. Foley is an outspoken advocate for abstinence-only education. Foley opposes comprehensive sex education or discussions of the effectiveness of condom use with middle and high school students. • Foley argued that contraceptive education results in higher rates of sexually transmitted infections (STIs) and teen pregnancy: “The only thing contraceptive education helps with 19 https://obgyn.ucsf.edu/news/ansirh-post-abortion-trauma-rates https://www.prochoiceamerica.org/wp-content/uploads/2016/12/9.-Congress-Should-Not-Legitimize-theMythical-Post-Abortion-Syndrome.pdf 21 https://news.vice.com/article/the-battle-over-abortion-could-make-a-big-difference-in-colorado-this-election 22 https://www.nap.edu/catalog/24950/the-safety-and-quality-of-abortion-care-in-the-united-states 23 https://rewire.news/article/2018/05/30/trumps-hhs-installs-fake-clinic-leader-oversee-family-planning-funds/ 24 https://www.youtube.com/watch?v=HgYZ63dXlWM 20 6 • • is the physical consequences of sexual activity… Not only do condoms offer inadequate protection against STIs, but more importantly, teen sexual activity can have permanently damaging effects that should be considered in the fight against teen pregnancy.” 25 She also believes comprehensive sex education does not work: “Does comprehensive work? Studies show that it does not decrease the pregnancy rate. And it increases condom use for only three to six months.” 26 o Research has shown that teenagers who received comprehensive sex education have a far lower risk of teen pregnancy than those who receive abstinence-only education. 27 Foley believes that sex education cannot teach both abstinence and condom use: “I don't think you can do those two things in the same class setting, because I think the message of waiting for sex gets diluted if you are saying, ‘But, just in case, use a condom.’” 28 Foley opposes teaching condom use, calling it “difficult” (“By the time you get to step six, you forget why you are even using the condom”). 29 After Colorado passed a law requiring that a comprehensive sex education program be “evidence-based, culturally sensitive, medically accurate, age-appropriate, and reflective of positive youth development approaches,” Foley argued that abstinence-only education fit those requirements. • Foley suggested that “[a]bstinence, risk avoidance is a lifestyle choice and not a form of birth control. It is about setting boundaries, developing healthy relationships and refusal skills.” 30 • Foley argued that abstinence education is a necessary part of a comprehensive program, because “most [teens] are not having sex.” She also argued that abstinence education is “culturally sensitive” because “avoidance doesn’t leave anyone out. It teaches that is the healthiest choice of whatever your orientation.” 31 o 62 percent of high school seniors have had sex. 32 25 https://ciphermagazine.wordpress.com/2009/12/09/the-price-of-pregnancy-prevention/ http://gazette.com/new-colorado-sex-education-law-adds-clarity/article/1501493 27 http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&featureID=1041; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194801/ 28 https://www.csindy.com/coloradosprings/sex-lies-and-duct-tape-science-and-morality-make-for-strangebedfellows-in-d-11/Content?oid=1672302 29 https://www.csindy.com/coloradosprings/sex-lies-and-duct-tape-science-and-morality-make-for-strangebedfellows-in-d-11/Content?oid=1672302 30 http://gazette.com/new-colorado-sex-education-law-adds-clarity/article/1501493 31 http://gazette.com/new-colorado-sex-education-law-adds-clarity/article/1501493 32 http://www.advocatesforyouth.org/publications/publications-a-z/413-adolescent-sexual-behavior-i-demographics 26