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Examining the Title X Family Planning Program's (Public Law 91-572) legislative history through a feminist lens

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Title:
Examining the Title X Family Planning Program's (Public Law 91-572) legislative history through a feminist lens a thematic analysis and oral histories with key stakeholders in Florida
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Book
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English
Creator:
Vamos, Cheryl A
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University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Reproductive Health
Policy
Public Health
Contraception
Unintended Pregnancy
Dissertations, Academic -- Community and Family Health -- Doctoral -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

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Summary:
ABSTRACT: The Title X Family Planning Program (Public Law 91-572), enacted by President Richard Nixon in 1970, provides federal funds for voluntary, confidential family planning services to all women, regardless of their age or economic status. This federal legislation aspired to prevent unintended pregnancies and poor birth outcomes to those in most need. However, over the past three decades, Title X has faced political, financial and social challenges. Despite its enormous success in improving the health and well-being of women and children by decreasing unintended pregnancies, the need for abortions and providing key comprehensive preventive services, without a newfound political will similar to that during which it was conceived, the future of Title X may be in jeopardy.This study grounded theoretically and methodologically in a feminist policy analysis approach, critically examined the maturation of Title X by employing a mixed methodology design that consisted of a thematic analysis on Title X's legislative history and the conduction and analysis of oral histories. In Phase I, themes were extracted from the federal bills included in Title X's legislative history, which assisted in the identification of the issues that this policy has endured. In Phase II, a semi-structured interview guide was developed based upon the themes and findings from the thematic analysis as well as from pre-determined constructs from McPhail's Feminist Policy Analysis Framework, to explore key informants' perceptions, recollections and experiences regarding the Title X program. By examining Title X through a feminist lens, various issues were exposed and critically examined, including issues that are typically ignored by traditional policy analyses.Moreover, understanding the historical underpinnings and evolutions of a policy and recognizing past failures and achievements are necessary in order to make informed future decisions. Implications for research, practice and policy are discussed.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Cheryl A. Vamos.
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Title from PDF of title page.
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Document formatted into pages; contains 392 pages.
General Note:
Includes vita.

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aleph - 002029537
oclc - 436943447
usfldc doi - E14-SFE0002932
usfldc handle - e14.2932
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ABSTRACT: The Title X Family Planning Program (Public Law 91-572), enacted by President Richard Nixon in 1970, provides federal funds for voluntary, confidential family planning services to all women, regardless of their age or economic status. This federal legislation aspired to prevent unintended pregnancies and poor birth outcomes to those in most need. However, over the past three decades, Title X has faced political, financial and social challenges. Despite its enormous success in improving the health and well-being of women and children by decreasing unintended pregnancies, the need for abortions and providing key comprehensive preventive services, without a newfound political will similar to that during which it was conceived, the future of Title X may be in jeopardy.This study grounded theoretically and methodologically in a feminist policy analysis approach, critically examined the maturation of Title X by employing a mixed methodology design that consisted of a thematic analysis on Title X's legislative history and the conduction and analysis of oral histories. In Phase I, themes were extracted from the federal bills included in Title X's legislative history, which assisted in the identification of the issues that this policy has endured. In Phase II, a semi-structured interview guide was developed based upon the themes and findings from the thematic analysis as well as from pre-determined constructs from McPhail's Feminist Policy Analysis Framework, to explore key informants' perceptions, recollections and experiences regarding the Title X program. By examining Title X through a feminist lens, various issues were exposed and critically examined, including issues that are typically ignored by traditional policy analyses.Moreover, understanding the historical underpinnings and evolutions of a policy and recognizing past failures and achievements are necessary in order to make informed future decisions. Implications for research, practice and policy are discussed.
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Examining the Title X Family Planning Program’s (Public Law 91-572) Legislative History thro ugh a Feminist Lens: A Thematic Analysis and Oral Historie s with Key Stakeholders in Florida by Cheryl A. Vamos A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Community and Family Health College of Public Health University of South Florida Major Professor: Ellen Daley, Ph.D. Eric Buhi, Ph.D. Charles Mahan, M.D. Marilyn Myerson, Ph.D. Kay Perrin, Ph.D. Date Submitted: April 8, 2009 Keywords: Reproductive Health, Policy, Public Health, Contraception, Unintended Pregnancy Copyright 2009, Cheryl A. Vamos

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Dedication To all those who work towards upholding reproductive health as a human right

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ACKNOWLEDGMENTS Many people have supported me throughout this journey. Dr. Ellen Daley, thank you for your invaluable mentorship, frie ndship, passion for women’s and reproductive health, and for your endless guidance, s upport, patience and time throughout my entire doctoral program. Dr. Eric Buhi, thank you for your support, encouragement, expertise in sexual health and policy, a nd for your talent in bringing ne w perspectives to research. Dr. Charles Mahan, thank you for your extraordin ary expertise in reproductive health and policy, your generosity to help students, and fo r your legacy of being a true public health leader. Dr. Marilyn Myerson, thank you fo r your support, passion for women’s health, and for introducing me to the importance of feminist research me thods. Dr. Kay Perrin, thank you for your time, patience, and enc ouragement throughout my doctoral program, for your realism and ability to make things cl ear, and for always being there to listen to new ideas. My parents, John and Diane Vamos, for your love and support, your encouragement, your generosity in providing me with opportunities, and for your value in education; for which none of this would be possible without you. My brothers J and Bob and my sister Sandy, for your support and for your uncanny ability to make things fun. I would also like to thank Dee Jeffers, for your encouragement, your help and guidance during the dissertation process, and for your expertise in maternal and child health. Cheryl McCoy, Government Documents Librar ian at the University of South Florida Tampa Library, for your invaluable time in guiding my through the policy process and for your assistance in compiling the legislativ e history. Dr. Rasheeta Chandler, for your assistance with the qualitative analyses; a nd Elizabeth Outler, Lawton Chiles Legal Information Center, University of Florida, fo r your assistance with the policy documents.

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i TABLE OF CONTENTS List of Tables ................................................................................................................ ... viii List of Figures ............................................................................................................... ..... ix Abstract ...................................................................................................................... ..........x Chapter One: Introduction ...................................................................................................1 Statement of the Problem .........................................................................................2 The History of Title X..............................................................................................3 Need for the Study……………………… .............................................................11 Purpose of the Study ..............................................................................................12 Research Questions ................................................................................................12 Phase I: Thematic Analysis on Title X’s Legisl ative History ....................13 Phase II: Oral Histories ..............................................................................13 Overview of Study .................................................................................................14 Assumptions ...........................................................................................................16 Significance ...................................................................................................... ......16 Organization of Dissertation ..................................................................................17 Definition of Key Terms ........................................................................................18 Chapter Two: Literature Review .......................................................................................21 Background of Women’s Health ...........................................................................21 Historical Underpinning of Women’s Health ............................................21 Definition of Women’s Health ...................................................................22 Women’s Health Care: Access and Coverage ...........................................23 Background on Reproductive Health……………………………………………. 25 Reproductive Health as a Human Right .....................................................25 Definition of Reproductive Health……. ....................................................26 Reproductive Health Care and Services ....................................................27 Adverse Outcom es from Unprotected Sexual Activity .............................29 Unintended Pregnancies .................................................................30 Sexually Transmitted Infections ....................................................33 Background on Family Planning ...........................................................................35 Definition of Family Planning ..................................................................35 History of Family Planning ........................................................................35 Contraceptive Use ..................................................................................... .39 Family Planning Clinics .............................................................................40 Policy and Reproductive Health ............................................................................44 The Role of Policy in Reproductive Health ...............................................44

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ii Reproductive Health Policy: A Controversial Topic .................................47 A Review of Title X ...................................................................................51 Legislative History of Title X ........................................................52 Introduction to Policy Studies ................................................................................56 Policy Analysis ....................................................................................... ...56 Feminist Research and Methodology.........................................................60 Feminist Policy Analysis ...........................................................................63 The Feminist Policy Analysis Framework ......................................67 Values ................................................................................69 State-market control ...........................................................69 Multiple identities ..............................................................69 Equality ..............................................................................70 Special treatment/protection ..............................................70 Gender neutrality ...............................................................71 Context ...............................................................................71 Language ............................................................................72 Equality/rights and care/responsibility ..............................72 Material/symbolic reforms .................................................72 Role change and role equity ...............................................73 Power analysis ...................................................................73 Other ..................................................................................73 Application of the Feminist Policy Analysis Framework ..........................73 Chapter Three: Methodology .............................................................................................76 Purpose of the Study .................................................................................. 76 Justification of a Feminist Policy Analysis ................................................76 Phase I: Thematic Analysis on Ti tle X’s Legislativ e History Study .........78 Research Questions ........................................................................78 Sources of Data ..............................................................................78 Data Analysis .................................................................... .............79 Reliability of Coding..........................................................80 Phase II: Oral Histories ..............................................................................81 Background on Oral History ..........................................................81 Justification of Oral History...........................................................83 Justification of the State of Florida as a Case Study ......................83 Instrument Development and Refinement .....................................84 Pilot-Testing .......................................................................85 Procedure .......................................................................................86 Getting Ready .....................................................................87 Sampling and recruitment ......................................87 Interviewing ................................................................... .....90 Setting ....................................................................90 Interview procedure ...............................................91 Interviewer characteristics .....................................92 Field notes and researcher’s journal ......................93

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iii Transcribing ........................................................................93 Auditing ..............................................................................94 Editing ............................................................ .....................95 Final Touches ......................................................................95 Management of Data ......................................................................96 Data Analysis .................................................................................97 Reliability of Coding...........................................................98 Issues Related to Oral Histories .....................................................99 Memory ...............................................................................99 Legal Concerns .................................................................100 Ethical Issues in Qualitative Research .....................................................100 Synergism of Data....................................................................................102 Issues Relate d to Conducting Qualitative Research ................................102 Trustworthiness ............................................................................102 Credibility ........................................................................103 Dependability ...................................................................103 Confirmability ..................................................................103 Transferability ............................................................... ...104 Researchers Bias ..........................................................................105 Part I: Thematic Analysis of Title X’s Legislative History..............................................................................105 Part II: Oral Histories .......................................................106 Chapter Four: Results ......................................................................................................109 Phase I: Thematic Analysis of Title X’s Legislative History ..............................109 Question 1: What legislative bills that proposed changes to Title X were enacted into law? .............................................................................109 Question 1a: What changes did Title X incur from these enactments as refl ected in the language of its public law ........................109 Question 2: What are the themes that emerge from the proposed legislative bills? .......................................................................................110 Administration .............................................................................111 Attempts to extend or repeal Title X ................................111 Administrative and grant requirements ............................112 Coordination with State activities ....................................112 Use of funds .....................................................................113 Administration of grants to populations ..........................114 Admi nistration related to par ticular grant sections ..........114 Data collection and reporting ...........................................115 Appropriation ...............................................................................116 Appropriation for Title X .................................................116 Appropriation from related legislation and policies ........117 Requirements of Funds/Services ..................................................117 Types and range of services .............................................117 Adoption and abortion services .......................................118

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iv Information and education ...............................................119 Minors ..............................................................................120 Restrictions of Funds/Services .....................................................121 Abortion services .............................................................121 Other prohibition of funds ...............................................122 Related Legislation ......................................................................123 Related Policies ............................................................................124 Global and national institutes, administrations and centers ..............................................................................124 Other policies ...................................................................124 Technical Amendments ...............................................................125 Question 2a: Do the themes that emerge from the proposed legislative bills differ depending on whether they were enacted into law? ...................................................................................................125 Question 2b: What are the themes that emerged from the proposed legislative bills by administration? ..........................................................126 Richard M. Nixon (R) Administration .........................................126 Gerald R. Ford (R) Administration ..............................................127 James (Jimmy ) E. Carter (D) Administration ..............................128 Ronald W. Reagan (R) Administration ........................................128 George H. W. Bush (R) Administration .......................................129 William J. Clinton (D) Administration ........................................130 George W. Bush (R) Administration ...........................................131 Question 2c: How do the proposed legislative bills support or Challenge Title X for each of the themes that emerge? ...........................131 Administration .............................................................................132 Support .............................................................................132 Challenge .........................................................................132 Appropriation ...............................................................................133 Support .............................................................................133 Challenge .........................................................................133 Requirements of Funds/Services ..................................................134 Support .............................................................................134 Challenge .........................................................................134 Related Legislation ......................................................................135 Support ............................................................................135 Challenge ........................................................................135 Related Policies ............................................................................135 Support ............................................................................135 Challenge ........................................................................136 Technical Amendments ...............................................................136 Phase II: Oral Histories ........................................................................................136 Oral History Results .................................................................................137 Sample Population and Demographics ........................................137

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v Values ..........................................................................................139 State-Market Control ...................................................................141 The role of the government ..............................................141 Social control ...................................................................142 Stigma ..............................................................................145 Multiple Identities ........................................................................146 Political Contexts .........................................................................151 Abortion ...........................................................................150 Family planning methods .................................................152 Adolescents/minors ..........................................................155 Abstinence-only education ...............................................167 School-based clinics.........................................................168 Parental notification and emancipation of minors ...........169 Administration and politics ..............................................160 Additional political moments ...........................................164 Social and Cultural Context .........................................................165 Clinic and staff .................................................................169 Funding ........................................................................................171 Equality/Rights and Care/Responsibility .....................................174 Integration ....................................................................................178 Funding ............................................................................179 Policies and programs ......................................................179 Integration as continuum of care ......................................182 Logistical issues in policy integration ..............................183 Barriers .........................................................................................185 Recommendations ........................................................................195 Achievements ...............................................................................199 Chapter Five: Discussion and Conclusions ......................................................................202 Synthesis of Research Findings ...........................................................................202 Phase I: Thematic Analysis of Title X’s Legislative History ..................202 Phase II: Oral Histories ............................................................................210 Values ..........................................................................................210 State-Market Control ...................................................................210 Multiple Identities ........................................................................212 Political Context...........................................................................212 Social and Cultural Context .........................................................215 Funding ........................................................................................217 Equality/Rights and Care/Responsibility .....................................216 Integration ....................................................................................218 Barriers .........................................................................................218 Recommendations ........................................................................219 Achievements ...............................................................................220 Summary of Oral Histories ..........................................................220 Synergism of Qualitative Data .................................................................221

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vi Limitations ...............................................................................................225 Delimitations ............................................................................................229 Strengths ..................................................................................................230 Implications for Research Policy and Practice ....................................................232 Research ...................................................................................................232 Theoretical Implications ..............................................................234 Policy .......................................................................................................236 Practice .....................................................................................................239 Future Directions .....................................................................................241 Conclusion ...........................................................................................................244 References .................................................................................................................... ....246 Appendices .................................................................................................................... ...265 Appendix A. Family Pl anning Services and Population Research Act of 1970 ........................................................................................................... ......266 Appendix B. Characte ristics of Feminist Social Research……………… ..........271 Appendix C. Feminist Policy Framework: Through a Gendered Lens……… ...272 Appendix D. Principles a nd Standards of the Oral History Association .............275 Appendix E. Or al History Evaluation Guidelines ................................................279 Appendix F. Sa mple Oral History Project Letter .................................................288 Appendix G. Informed Consent for Oral History ................................................290 Appendix H. Final Oral History Guide ................................................................294 Appendix I. Tables ...............................................................................................2 97 Appendix J. Figures .............................................................................................38 2 About the Author ................................................................................................... End Page

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vii List of Tables Table 1. Demographic characteristics of the oral history sample (N=6) ...............139 Table 2. Barriers that Title X and family planning programs and services encounter in Florida as perceived by participants ....................................185 Table 3. Participants’ recommendations to improve Title X and family planning services in Florida .....................................................................195 Table 4. Achievements of Title X and fa mily planning services in Florida as as perceived by participants .....................................................................199 Table 5. Examples of how legislat ive bills proposed supported and challenged Title X policy according to thematic category, 1970-2008 ................................................................................................208 Table 6. Number and percenta ge (%) of selected demographics of Title X Clients ............................................................................................. .....297 Table 7. Selected teen re productive health indi cators, Florida vs. United States ......................................................................................... ...299 Table 8. Healthy People 2010: Objectives related to reproductive health and family planning .................................................................................30 1 Table 9. Selected char acteristics of women by pre gnancy classification and abortion rate, 2001 ............................................................................306 Table 10. Main federal family planning statues .......................................................308 Table 11. Frames used in family planning and abortion policies ............................309 Table 12. Legislative history for Title X (P.L. 91-572) ............................................310 Table 13. Amendments enacted into law affecting Title X (P.L. 91-572): 91st-110th Congress sessions .....................................................................365 Table 14. Bills included in Ti tle X’s (P.L. 91-572) legislative history, classified by theme ................................................................................... 373

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viii List of Figures Figure 1. Ten U.S. Departme nt of Health and Human Services (HHS) Regional ............................................................................................ .....382 Figure 2. Actual and Infl ation-Adjusted Title X Appropriation, 1980-1999 .........383 Figure 3. Women’s Fertility Years ........................................................................384 Figure 4. Family Planning Timeline, 1960-1999 ...................................................385 Figure 5. Percentage of C ontraceptive Users by Contraceptive Methods .............387 Figure 6. Reported Public Expe nditures on Family Planning Client Services, by Funding Source, United States, FY 2006 ..........................................388 Figure 7. Reported Public E xpenditures on Family Plan ning Client Services, by Funding Source, Florida, FY, 2006 ..................................................389 Figure 8. The reproductive process ........................................................................390 Figure 9. The legislative process ...........................................................................391 Figure 10. Synerg ism of the qualitative data ...........................................................392

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ix Examining the Title X Family Planning Program’s (Public Law 91-572) Legislative History thro ugh a Feminist Lens: A Thematic Analysis and Oral Historie s with Key Stakeholders in Florida Cheryl A. Vamos ABSTRACT The Title X Family Planning Program (P ublic Law 91-572), enacted by President Richard Nixon in 1970, provides federal f unds for voluntary, confidential family planning services to all women, regardless of their age or economic status. This federal legislation aspired to preven t unintended pregnancies and poor birth outcomes to those in most need. However, over the past three decades, Title X has faced political, financial and social challenges. Despite its enormous success in improving the health and wellbeing of women and children by decreasing unintended pregnancie s, the need for abortions and providing key comprehensiv e preventive se rvices, without a newfound political will similar to that during which it was conceived, the future of Title X may be in jeopardy. This study grounded theoretically and methodologically in a feminist policy analysis approach, critically examined th e maturation of Title X by employing a mixed methodology design that consisted of a thematic analysis on Title X’s legislative history and the conduction and analysis of oral historie s. In Phase I, themes were extracted from the federal bills included in Title X’s legislative history, which assisted in the identification of the issues that this policy has endured. In Phase II, a semi-structured interview guide was developed based upon the themes and findings from the thematic

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x analysis as well as from pre-determined c onstructs from McPhail’s Feminist Policy Analysis Framework, to explore key info rmants’ perceptions, recollections and experiences regarding the Titl e X program. By examining Title X through a feminist lens, various issues were e xposed and critically examine d, including issues that are typically ignored by traditional policy analyses Moreover, understa nding the historical underpinnings and evolutions of a policy and recognizing past failures and achievements are necessary in order to make informed future decisions. Implications for research, practice and policy are discussed.

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1 CHAPTER ONE: INTRODUCTION “No American woman should be deni ed access to family planning assistance because of her economic condition” President Richard Nixon, 1969 Even though women spend half of their lif etime being fertile, of those American women who want children, most only expre ss a desire for two children (The Alan Guttmacher Institute [AGI], 1997). Access to fa mily planning services and consistent use of a contraceptive method are essential in pr eventing unintended pregnancies, especially among the most vulnerable populations as it is estimated that “10% of American women at risk of unintended pregnancy who do not practice contraception ac count for 53% of all unintended pregnancies” (AGI, 1997). In the United States, many reproductive he alth and related pub lic health issues have been identified as national objectives in Healthy People 2010, the nations’ blueprint for improving health among Americans over the next decade (U.S. Department of Health and Human Services [DHHS], 2000). Re productive health services, and more specifically, family planning servi ces, are critically important in this quest, and assist in preventing unintended pregnancies and sexually transmitted infections (STIs) as well as in supporting women’s autonomy in choosing wh en, if and how many children they bear. Family planning clinics rece ive funds from a variety of sources: Medicaid, state funds, Title X, Social Services Block Grant (T itle XX of the Social Security Act), and the Maternal Child Health Block (MCHB) (Title V) grant (McF arlane & Meier, 2001; AGI,

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2 1997). Medicaid serves as the largest s ource of funding (Sonfield, Alrich, & Gold, 2008); unfortunately, in most states there ar e many women do not qualify because of the strict eligibility requirement s, which often requires a woman to be low income, single, and a mother (or pregnant) (AGI, 1997). Publicly funded family planning clinics ar e an important part of the public health system: family planning clinics pr ovide services to those in mo st need as clinics are often located in areas with high densities of low-income women, including minority, immigrant, and hard-to-reach populations and can deliver culturally sensitive services (AGI, 2000). Statement of the Problem Although family planning is one of the top 10 public health achievements in the 20th century (Centers for Disease Control a nd Prevention [CDC], 1999), the U.S. has the highest rates of unintended pr egnancy and STIs of all i ndustrialized countries, with almost half of all pregnancies being unint ended (Finer & Henshaw, 2006). Unintended pregnancies have significant public health consequences for the mother, baby and the general community (Finer & Henshaw, 2006) Moreover, undiagnosed and untreated STIs can lead to long-term effects in women such as pelvic inflammatory disease (PID), ectopic pregnancy and tubal fact or infertility, and can cause neonatal ophthalmia (a form of bacterial conjunctivitis that often re sults from untreated chlamydia), nenonatal pneumonia, mental disabilities and fatal neon atal infections and/ or death among infants (CDC, 2007d; World Health Organization [WHO], 2008b).

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3 Family planning clinics face a myriad of challenges, including complicated health care financing from multiple sources, the ri sing costs of services, the need for broader and comprehensive services, and the multifacet ed task of improving contraceptive-related behaviors among clients (AGI, 2000; Dailar d, 1999, 2001; Gold, 2002). More than 17 million women in the U.S. are uninsured and women who are young, low-income, of color and who reside in southern states are at greatest risk (Salganicoff, 2008; The Henry J. Kaiser Family Foundation [KFF], 2007b). Mo reover, the number of U.S. women (1344 years) in need of publicly funded cont raceptive services an d supplies in 2004 was 17,396,650 (Guttmacher Institute, 2006). In light of the above challenges, the need and significance of family planning se rvices as part of the broader public health infrastructure are being overshadowed with countless political, financial and ideological barriers. The History of Title X The Title X Family Planning program (F amily Planning Services and Population Research Act of 1970) was enacted by Pres ident Richard Nixon in 1970 and amended the Public Health Service Act to serve as the only federal program that exclusively focuses on family planning services (Office of Popul ation Affairs [OPA], 2008) (see Appendix A). Developed with bipartisan support, Title X’s goal was to “assist in making comprehensive, voluntary family planning se rvices readily available to all persons desiring such services” (Family Planning Se rvices and Population Research Act, 1970). The origins of Title X arose from a growing body of evidence in the 1960’s demonstrating adverse reproductive outcomes: low-income women having twice the rates of unwanted pregnancies compared to affl uent women; closely spaced pregnancies

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4 leading to poor health among mothers a nd babies; and high rates of unintended pregnancy, especially among teenagers outco mes all resulting from unequal access to contraceptives among low-income women (AGI 1997; Gold, 2001). In light of these findings, there was bipartisan agreement th at the government should support “voluntary family planning programs as a means of expanding economic development, alleviating poverty, avoiding welfare dependency and im proving the health of women and their families” (AGI, 1997). In the mid-1960’s, various federal laws were amended to permit existing programs to delivery family planning serv ices (AGI, 1997). In 1965, the Office of Economic Opportunity provided federal funds for planning services in conjunction with “War on Poverty” (AGI, 1997). In 1967, state welfare agencies were required to offer family planning services under Title IV-A of the Social Security Act (AGI, 1997). However, implementation of family planning programs across the U.S. varied as states controlled the majority of funding, thereby, necessitating a national voluntary family planning program (Gold, 2001). Also during this time, the first presiden tial message on population in the U.S. was delivered by President Nixon on July 18, 1969 (Kraft, 1994). Nixon’s message to Congress focused on domestic population gr owth, the need for funding for population research, the establishment of a family pla nning office, and “called for a national goal of providing ‘adequate family planning services within the next 5 years to all who want them but cannot afford them’” (Kraft, 1994, p. 626). In response to the growing discussion on population and family planning need s, Title X of the Public Health Service

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5 Act was established (Kraft, 1994). The purposes of the Act as outlined in its statute (Family Planning Services and Population Research Act, 1970) are the following: (1) to assist in making comprehensive vol untary family planning services readily available to all persons desiring such services; (2) to coordinate domestic population a nd family planning research with the present and future needs of family planning programs; (3) to improve administrative and operat ional supervision of domestic family planning services and of popul ation research programs re lated to such services; (4) to enable public a nd nonprofit private entities to plan and develop comprehensive programs of family planning services; (5) to develop and make readily availa ble information (including educational materials) on family planning and populat ion growth to all persons desiring such information; (6) to evaluate and improve the effectiv eness of family planning service programs and of population research; (7) to assist in providing trained man power needed to effectively carry out programs of population research a nd family planning services; and (8) to establish an Office of Population Affairs in the Department of Health, Education, and Welfare as a primary fo cus within the Federal Government on matters pertaining to popul ation research and family planning, through which the Secretary of Health, Educati on, and Welfare (hereafter in this Act referred to as the “Secretary”) shall carry out the purposes of this Act. ( §2) Today, Title X is administered by the Office of Family Planning of the Office of Population Affairs (OPA), Office of Public Health and Science, U.S. Department of Health and Human Services (OPA, n.d.). OPA administers Title X funds to 10 regional offices (see Figure 1) which manages, reviews and awards the competitive grants, and oversees the programs performances within its region (RTI Intern ational, November 2006). Title X grantees can provi de services directly through th eir own clinics or allocate their awarded funds to delegate s or subcontractors (RTI Inte rnational, November 2006). “Eighty-seven grantees, and th e 1,173 delegates or subcontractors that received Title X funding through [the regional offices], provide d Title X-funded services at 4,426 service sites in the 50 U.S. states and eight U.S. te rritories and jurisdictions” (RTI International,

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6 November 2006, p. 8). The clinic settings of the grantees (or their delegates) include heath departments, Planned Parenthood affilia tes, hospitals, univers ity health centers, independent family planning clinics, and ot her public and non-pr ofit agencies (OPA, 2008). In 2006, greater than 66% of all family pl anning clinics were f unded in part by the Title X program (Gold, Sonfield, Richards, & Frost, 2009). Title X funds assist in supporting the following activit ies: contraceptive services and related counseling; preventive health services such as patient education; breast and pelvic examinations; cervical cancer screen ings; pregnancy diagnosis and counseling; STI and HIV/AIDS prevention, education, counseling, testing a nd referrals; provider and other family planning clinic personnel training; informa tion dissemination; community education and outreach activities; and data collection and re search to improve the delivery of family planning services (OPA, 2008). The amount an individual pays for Title X services is contingent on their income (sliding scale based), an d even though clinics are open to all individuals “regardless of their religion, race, color, national origi n, handicapping condition, age, sex, number of pregnancies, or marital status” (Grants for Family Planning Services, 2000), of the more than five million clients that are served each year, clients are predominantly women, young, poor, low-income and uninsured (AGI, 1997; Gold, 2001; RTI International, November 2006). If a client’s income is belo w the federal poverty le vels the services are free, if the income is greater than 250% of the federal poverty level services are charged the clinic’s full fee, and if the income is between 100% and 250% services are charged

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7 based on a sliding scale; whereas services for minors are based on the minor’s incomes (OPA, 2001). In 2005, a total of 5,002,961 clients, 4,740,168 females (95%) and 262,793 males (5%) received family planning services th rough Title X funding (RTI International, November 2006). As mentioned above, the ma jority of the clients were young (26% are teenagers and 50% are in their twenties), White (64%) or Black/African American (19%), and poor (66% have income levels 100% of the federal poverty level) (RTI International, November 2006). See Table 6 for the Number and Percentage (%) of Selected Demographics of Title X Clients for the demographic breakdown of age, race, ethnicity, and income, respectively. The principa l health insurance coverage that clients’ reported varied in 2005, as clients reported be ing uninsured (60%), having public health insurance (20%), having pr ivate insurance (8%) or was not reported (12%) (RTI International, November 2006). Since inception, several key regulations ha ve been distinguished within Title X law: services provided under Title X must be delivered voluntarily to women, and not be contingent on participation in any othe r program; services mu st be confidential; associated preventive services must be offered; and funds cannot be used for abortions (Grants for Family Planning Services, 2000; OPA, 2001). Moreover, clinic personnel must practice “nondirective counseling”, allo wing pregnant women to receive unbiased information so she can choose what is best fo r her out of all of the available options and provide referrals to any information regardi ng her options that she may request (Grants for Family Planning Services, 2000). Sta ndards for reproductiv e health care are

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8 established by law and grantees are required to comply with th e services and protocols as outline in Title X’s guidelines (OPA, 2001). Title X represents a key mechanism by which women can obtain the necessary family planning services they need. Title X also provides a network that connects family planning systems nationwide (AGI, 1997; Gold et al, 2009). Furthermore, Title X has revolutionalized reproductive health services as standards for care were developed for the program by the American College of Obst etricians and Gynecologists in 1976, which emphasized including preventative health care in all family planning visits, a protocol adopted and made routine among many public an d private health care services today (AGI, 2000). Moreover, Title X has instituted specialized training fo r nurse practitioners allowing services to be delivered in ma ny underserved areas (AGI, 2000). Over 5,000 nurse practitioners have passed through accr editation programs specializing in women’s health between 1972 and 2000 (Dailard, 2001). The impact of Title X has been immense, with services preventing 1 million unintended pregnancies each ye ar, particularly among low-income and unmarried women and teenagers (AGI, 1997; Gold, 2001). In a ddition, of the 20 million pregnancies that have been prevented over the last two decad es, 9 million abortions have subsequently been avoided (AGI, 2000). Among adolescent s, 5.5 million pregnancies were prevented, decreasing the teenage pregnancy rate by 20% and also signifi cantly decreasing the number of abortions among this population (G old, 2001). Nationally, it is estimated that for every $1 spent on family planning, $4.02 is saved in Medicaid from pregnancy and newborn associated costs (Frost, Finer, & Ta pales, 2008). At a state-level, the costeffectiveness of family planning has proven to be even greater as one study conducted in

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9 Florida found that for every $1 spent on fam ily planning, $16.91 is saved in health and social welfare costs (Florida Department of Health, 2008). Moreover, because of early detection and treatment of various medica l conditions – including but not limited to breast cancer, cervical cancer and STIs th e health and well-being of women, children and families have been greatly improved (Gold, 2001). Regardless of the tremendous achievement s and positive impacts that Title X has had on reproductive health and overall well-b eing, the intended pur pose and goals that President Nixon envisioned have lost mo mentum. In the 1980’s, sharp funding reductions occurred under Pr esident Reagan’s administra tion, and even though funding allocations for Title X have risen slightly, funding is allocated at an amount 60% lower than that of 20 years ago (AGI, 2000; Gol d, 2001). See Figure 2 for the Actual and Inflation-Adjusted Title X Appropriati on, 1980-1999. Therefore, throughout its maturation, Title X funding has not kept on par with inflation or demand (Ranji, 2005). “Some conservatives also see budget cutting as an ideological goal in itself, viewing public programs as anathema to the ideals of an ‘ownership society’ and as a disincentive for Americans to purchase private insurance” (Sonfield & Gold, 2005, p. 5). President Reagan also instituted legisl ation in 1987, known as the “gag rule,” forbidding clinics receiving Title X funding fr om disseminating information or referrals on abortions. Even though the provision of information and referrals on all medical options were mandated under Titl e X’s guidelines and this legi slation violated patients rights for information, President Reagan’s “g ag rule” was upheld by the U.S. Supreme Court in 1991 but finally w ithdrawn by President Clint on in 1993 (AGI, 2000; Gold, 2001).

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10 Various other legislative policies and ad ministrations challenged the future of Title X. In 1982, the Reagan administrati on proposed a new regulation known as the “Squeal rule,” requiring written parental consent before mi nors could receive services as Title X clinics. This type of legislati on was re-introduced in 1998 by Rep. Ernest Istook (R-OK) (H.R. 4721, 1998); however, it was not passed but an additional amendment was developed requiring Title X clin ics to encourage family participation (AGI, 1997). In addition, opponents have sponsored various bills that have proposed reallocating Title X funds to other programs (Turnbull & Kaeser, 199 8), such as proposals to transfer Title X funds to the MCH block grant and commun ity and migrant health centers which contained no stipulation that funds had to be used for family planning services, thus eliminating the nation’s voluntary family pl anning program altogether (AGI, 1997). The above are only a few examples of a ttempts to hinder this federal policy, and social and economic barriers continue to jeop ardize the future of Title X. Opponents of family planning funding insist that family pl anning services destab ilize parental control and object family values, advertise “artificia l” methods of family planning, and increase nonmarital sex, thus propagating teenage pr egnancy and the use of abortions (AGI, 2000). Moreover, given the economic conditio ns such as the escalating costs of contraceptives, laboratory and examinations health care financi ng, higher numbers of uninsured Americans, and limited legislative funding, it remains a c onstant struggle for family planning services to be able to fulfill their mission of providing essential family planning services, especially to those who need it the most.

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11 Need for the Study Irrespective of the political upheavals, nonfactual arguments and financial barriers, Title X has been responsible for preventing unintended pregnancies, allowing couples to choose when, if, and how many ch ildren they bear, improving birth outcomes, acting often as the point of entry for health care among many women (Center for Reproductive Rights, 2004), and positively impacting social and workforce environments. Previous Title X analyses and evaluations have focused on the policy’s outputs (i.e., number of family planning serv ice users, type of birth control dispensed, etc.) (RTI International, N ovember 2006) and not whether the program is meeting its overall goals, such as providing family pla nning services to those in most need and supporting women in their reproductive rights (M cFarlane & Meier, 2001). Furthermore, it has been more than a quarter of a century since Title X has been examined (Gold et al, 2009). The literature on Title X that is ava ilable focuses on the need for more funding and the growing role of health provide rs (Dailard, 1999, 2001; Gold, 2002). Other literature outlines priority questions for future family planning research such as reaching high-priority populations a nd strengthening family planning clinical practices (Sonenstein, Punja, & Scarcella, 2004). Therefore, based on a re view of the literature as well as contacts with local and national repr oductive policy experts, including personal communication with the Al an Guttmacher Institute1, to the author’s knowledge there is no comprehensive policy analysis that critically examines Title X. 1 Phone conversation with Rachel Benson Gold, Director of Policy Analysis at the Alan Guttmacher Institute.

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12 Purpose of the Study Because of the paucity of research that comprehensively examines Title X, the proposed study aims to fill this gap by exploring the maturation of Title X since enactment by critically examining the political barriers that this pol icy has confronted. The specific aims are the following: 1) to identify the histori cal underpinnings and evolu tions of this policy; 2) to explore issues that are typically ignored by trad itional policy analyses; 3) to recognize past failures and achiev ements to inform future decisions; and 4) to assess the utility of the McPhai l’s Feminist Policy Analysis Framework (FPAF) in guiding a policy analysis on Title X. The proposed study utilized a mixed quali tative methodology design consisting of a thematic analysis of Title X’s legislative hi story and oral historie s conducted with past Title X key stakeholders. A feminist policy analysis approach was implemented as family planning policy predominantly affects women and children and was, and largely remains today, legislation th at is dominated by patriarc hal views and assumptions. Through these methodologies, the research stri ved to gain a deeper understanding of the various issues that are embedde d within this policy and to hi ghlight key areas of political concern, which can help gui de future policy actions. Research Questions The purposes of this research study are 1) to critically ex amine the political maturation of Title X from 1970 to today; and 2) to explore key informants’ recollections and experiences from being involved with Titl e X; and 3) to gain a deeper insight into

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13 various issues, including su ccesses and failures of this program, as perceived by key informants. Phase I: Thematic Analysis on Title X’s Legislative History Phase I involved a thematic analysis of Title X’s federal legislative history, which includes legislative bills proposed fr om 1970 to 2008, (Congress Sessions 91 through 110), to assist in identifying common themes that have emerged over the life of this policy. The specific research questio ns for Phase I are the following: Question 1: What legislative bills that propos ed changes to Title X were enacted into law? Question 1a. What changes did Title X incur from these enactments as reflected in the language of its public law? Question 2: What are the themes that emer ge from the proposed legislative bills? Question 2a. Do the themes that emerge from the proposed legislative bills differ depending on whether they were enacted into law? Question 2b. What are the themes that emerged from the proposed legislative bills by presidential administration? Question 2c. How do the proposed legisla tive bills challenge or support Title X for each of the themes that emerged? Phase II: Oral Histories Phase II involves conducting oral histories with past key Title X stakeholders in order to explore their recollections, percep tions and experiences regarding the Title X program. Themes identified from the thematic analysis of Title X’ s legislative history and themes outlined in McPhail’s (MFPAF) helped guide the development of a semi-

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14 structured interview guide. For instance, que stions asked of the stakeholders included issues surrounding the political challenges a nd support for Title X that have occurred over the years as well as ques tions concerning the value and societal contexts in which this policy was implemented. Overview of Study A feminist policy perspective was used as the theoretical and methodological approach in this study as Title X is associ ated with issues concerning sexuality and reproduction and predominantly involves fema le, young, and low-income populations. In Phase I, a thematic analysis was performe d on Title X’s legislative history, which includes both House and Senate bills that were enacted into public law as well as House and Senate bills that were proposed and were not enacted into public law (see research questions presented above). The secondary data that was utilized for the thematic analysis are the full text of the House and Senate bills that are included in Title X’s legislative history (see Chapter 2 for a descri ption of the methodology and results of Title X’s legislative history). Data were analyzed using the interrelated steps as outlined in Ulin, Robinson & Tolley (2005): reading, coding displaying, reduci ng, and interpreting. Texts were read while taki ng notes and attaching labels/codes for emerging themes; pieces of texts were classified by their thematic areas and reduced to essential points. Interpretation of the data was ongoing to indi cate how themes relate, diverge, and apply to the research questions a nd how meanings relate to th e context of the policy. The researcher kept an analytic journal, and gaps within the meanings of the texts and unanswered questions that emerge from the anal ysis were further addressed in Phase II.

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15 In Phase II, a semi-structured interv iew guide was developed based upon the emerging themes from Phase I and constructs from MFPAF, to assist in conducting oral histories with former Title X key stakehol ders at a state-level (such as Florida Department of Health/family planning program personnel, key legislators/policy makers, etc.). The oral histories performed at a stat e-level assisted in cap turing key stakeholders’ recollections and assisted the researcher in gaining a deeper insight into various issues and successes/failures of this policy as percei ved by the key stakeholders. The state of Florida has been chosen as a case study to sample key Title X stakeholders from for several reasons: Florida is the 4th largest state in the nation and consists of a diverse population; Florida ranks poorly in many reproductive health outcomes, including having the lowest prevalence rate of current re versible contraception use among women 18-44 years (Sappenfield, 2007), has the 6th highest teen pregnanc y rate, and has the 2nd highest AIDS rate (The Healthy Teens Campaign, n.d.) (see Table 7 for additional Selected Teen Reproductive Health Indicators, Florida vs. United States); and because this study is grounded in feminist epistemology, the research er’s situated orient ation – being a woman and currently residing within the state – pos itioned the context of the policy and the location of the case study to be advantageous (Laible, 1997). Oral histories were audiorecorded, transcribed, uploaded into a qualitative software program (QSR International Pty Ltd., NVivo Version 8, 2008) and analyzed us ing rigorous open, axial, and selective coding (see Chapter Three for a more extens ive description of th e methodology). Those oral histories in which participants voluntary agreed to have archived were given to the Special Collections Department at the Univ ersity of South Florida Library (Tampa campus) to be made available to the st ate of Florida and the general public.

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16 Assumptions The International Conference on Populat ion and Development’s (United Nations Populations Fund [UNPF}, 1995) proclamation that reproductiv e health rights are basic human rights serves as a central tenant fo r this study. Reproductive health rights are grounded in the notions of wome n being able to have contro l over their bodies, having autonomy over when, if and how many childre n they bear, and having equal rights as compared to men. Therefore, an assumpti on undertaken by the rese archer involves the belief that all women should have access to comprehensive reproductive health care. Other assumptions related to this study incl ude the following: 1) information contained within the secondary data documents are true representations of data and are not falsified by the author(s); and 2) key Title X stakehol ders will report their recollections during the oral histories to the best of their knowledge and/or memory. Significance The research study critically examined T itle X through a feminist policy analysis lens and presents many research, practice a nd policy implications. First, this policy critically examined and challenged the so cial, economic and political factors that undermine the Title X program, which may ignore and contest women’s needs for voluntary and confidential family planning se rvices and exposed and made meaning out of such issues that are typi cally absent in traditional pol icy analyses. Second, this study expanded the utility of McPhail’s FPAF, which was developed within the field of social work, by applying it within the field of public health. Third, the inclusion of an in-depth state-level examination highlighted key issues barriers and constraints in which key Title

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17 X stakeholders confront while overseeing and implementing this policy on a day-to-day basis. Fourth, this study is rooted in a key public health and femini st principle of being action-oriented and strives to create cha nge by discussing possibl e recommendations that could improve health for all women. Wit hout a firm understanding of the historical dimensions from which a policy originates and an acknowledgement of its successes, failures and barriers that a policy has faced throughout its maturation, it is impossible to analyze and interpret the current status and to make well-informed future recommendations for that policy. Organization of Dissertation Proposal The two chapters following this introductory section consist of in-depth discussions concerning the body of public health and policy literature that surrounds Title X and the methodology that will be employed in this study. Title X is the only federal policy that is devoted solely to family pl anning, and because of its affect on the overall health and well-being of women and the natu re of this study being guided by feminist research, a discussion surrounding the broader to pics of women’s health and reproductive health is warranted. In Chapter Two, a background on women’s health, reproductive health and family planning is presented. Wome n’s health is discussed in terms of its historical underpinnings and the current status of wo men’s health care access and coverage. Reproductive health is discussed as a basic human right and the range of associated reproductive health care and services. In addition, two adverse reproductive health outcomes – unintended pregnancy and STIs – ar e reviewed. Family planning is discussed

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18 in terms of its historical underpinnings and the types and roles of fam ily planning clinics. In addition, a review of Title X is included. Also included in Chapter Two is a review of public policy as a field of study and the c ontributions of femi nist research and methodology to policy analyses. A more detail ed description of McPhail’s FPAF is also presented. In Chapter Three, the purpose of the st udy and the research questions are rearticulated. A detailed description of the methodology including data collection and analysis procedures for both the thematic anal ysis of Title X’s legislative history (Phase I) and the oral histories (Phase II) are provided. Justifications for these two methodologies as well as a description of how triangulating methods and observers will greatly enrich our understanding of Title X ar e given. Issues rela ting to conducting this type of qualitative research (memory, legal concerns, ethical issues trustworthiness, and researcher bias) and the limitations of this study are also include d in this chapter. Definitions of Key Terms Abortion: Termination of pregnancy before the fetu s is viable and capable of extrauterine existence, usually less than 20 weeks of gestation (or when the fetus weighs less than 500g).” (Lowdermilk & Perry, 2007, p. 1115) Conception: “Union of the sperm and ovum resulting in fertilization; formation of the one-celled zygote.” (Lowdermilk & Perry, 2007, p. 1120) Contraception: “Prevention of impregnation or c onception.” (Lowdermilk & Perry, 2007, p. 1120)

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19 Family Planning: “The ability of individuals and c ouples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and th e treatment of involuntary infertility.” (World Health Organization, 2008b) Fertility: “Quality of being able to repr oduce.” (Lowdermilk & Perry, 2007, p. 1124) Feminism: “The policy, practice, or advocacy of po litical, economic, and social equality for women.” (Alexander, LaRosa, Bader, & Garfield, 2007) (p.10) Policy: “Policies are revealed through texts, practices, symbols, and discourses that define and deliver values including goods a nd services as well as regulations, income, status, and other positively or negatively valued attrib uted.” (Schneider, 1997) Therefore, in the proposed study, policy will refer to 1) the House and Senate bills included in Title X’s legislative history in Ph ase I; and 2) in a more general sense, the administration of Title X program (the delivery of family planning services) in Phase II. Policy Analysis: “The generic name for a range of techniques and tools to study the characteristics of established policies, how the policies came to be and what their consequences are.” (Collins, 2005, p.192) Pregnancy: “The condition of having a developi ng embryo or fetus in the body after successful conception. ” (Venes, 1997, p. 1730) Note: Conception is defined as “the onset of pr egnancy marked by implantation of a fertilized ovum in the ut erine wall.” (Venes, 1997, p. 467) Reproductive Health: “Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive sy stem and to its functions a nd processes. Reproductive

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20 health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to re produce and the freedom to deci de if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnanc y and childbirth and pr ovide couples with the best chance of having a healthy in fant.” (United Nations Population Fund, 1994, paragraph 7.2) Reproductive Health Care: “The constellation of methods techniques and services that contribute to reproductive heal th and well-being by preven ting and solving reproductive health problems. It also includes sexual he alth, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.” (Un ited National Population Fund, 1994, paragraph 7.2) Unintended Pregnancy: Pregnancies that are report ed to have been either unwanted (i.e., they occurred when no children, or no more children, were desired) or mistimed (i.e., they occurred earlier than desired) (Santelli, Hatfield-Timajc hy, Gilbert, et al, 2003, p. 94)

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21 CHAPTER TWO: LITERATURE REVIEW Background on Women’s Health Historical Underpinnings of Women’s Health The Office of Women’s Health (1998) acknowledges that Women’s Health reform has been organized since the 19th century, dating back to the Popular Health Movement when women were encouraged to eat healthy, the corset was eliminated, and abstinence was practiced as a method of contro lling family size. Over time, subsequent periods witnessed many advances for women’s health such as the escalating employment opportunities during WWII, the publication of th e high prevalence of sex before marriage (The Kinsey Report), and the proposal of the Equal Rights Amendment (Weisman, 1998). However, it is the Grassroots Moveme nt (1960’s-1970’s) that is often thought of as providing fuel for the wo men’s health platform. During this movement, the Food and Drug Administration (FDA) approved the birth control pill (1960), giving women a real sense of sexual freedom; the Civil Rights Ac t was passed (1964); Our Bodies, Ourselves was published; The National Black Women’s H ealth Project was formed; self-help and consciousness-raising groups appeared across th e country; and health issues such as the over-use of hysterectomies and pro-abortion rights were argued (Weisman, 1998). In addition, the past few decades have witnessed the formulation of various policies: the U.S. Public Health Services’ Task Force on Women’s Health argued for the inclusion of women in federally sponsored re search; the National Institute of Health’s

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22 Office of Research on Women’s Health ensure d women’s inclusion in clinical trials, promoted women in scientific careers, and implemented research on diseases affecting women; and the Women’s Health Equity Ac t allocated funding to women’s health research (Weisman, 1998). Most recently, the establishments of the CDC Office on Women’s Health, the Health Resources and Services Administration’s (HRSA) Office on Women’s Health, and the Nati onal Centers of Excellence in Women’s Health (CoE) are examples of women’s health being placed on the national agenda (Mottl-Santiago, 2002; Ruzek, 1993; Weisman, 1998). Definition of Women’s Health In review of the above advancements a nd policies, it is evident that women’s health has not been promoted based soley on women’s “maternal” at tributes, but rather with the intention to improve and promote thei r general health and social statuses. The United Nations (1995) defines women’s health as the following: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infi rmity. Women's health involves their emotional, social and physical well-b eing and is determined by the social, political and economic context of their lives, as well as by biology. (paragraph 89) The definition and approach to women’s heal th is holistic, as notions of social, mental and spiritual well-bei ng in addition to the physical well-being are included. Such a biopsychosocial view places women within a larger context and has implications for educational attainment, culture social support and opportuniti es for advancement within society (Ruzek, 1993). In a ddition, women’s health utili zes a life-span approach recognizing that one’s health status occurs over a con tinuum and does not exist in isolation. Moreover, because the definiti on is comprehensive and broad in scope,

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23 women’s health addresses various issues, in cluding but not limited to the following: body image, eating disorders, suicide, sexual ha rassment, women in the workforce, chronic diseases, menopausal and post-menopausal co ncerns, and caregivi ng issues. Women’s health is inclusive in its p opulation, addressing health concer ns of lesbians, people with disabilities, and women who choose to or cannot reproduce. The philosophy of women’s health places women as being “more than re productive entities whose health care is defined by the status of their reprodu ctive organs” (Walker & Wilging, 2000). Women’s Health Care: Access and Coverage Women constitute 50.8% (151,963,545) of the U.S. population (U.S. Census Bureau) and have a longer life expectancy compared to men (National Center for Health Statistics, 2006). In addition to these demographic differences, women also hold distinctive positions within economic and so cial environments and perform unique roles within communities and families. Regardle ss of women’s irreplaceable functions and responsibilities througho ut society, basic rights such as access to health care are not within reach for all women. Health insurance is a critical factor for women in being able to access and receive timely preventative, primary and specialty care (KFF, 2007b). The sources of health insurance coverage for women ages 18 to 64 years include the following: employersponsored insurance (63%) (38% job-based own name and 25% j ob-based dependent); uninsured (18%); Medicaid (10%); individual/private (6 %); and other sources (3%) (KFF, 2007b; Salganicoff). However, women w ho do have health insurance can still face barriers in receiving care such as higher premiu ms and co-pays. For example, one in six women with private insurance had to postpone or go without care due to high costs in

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24 2004 (Henry J. Kaiser Family Foundation & He alth Research and Educational Trust, 2007). Moreover, women are more at risk comp ared to males for losing health insurance because of a life event (i.e. divorced, widow ed) as they are more often covered as dependents (KFF, 2007b). More than 17 millio n women (18-64 years) are uninsured and women who are young, low-income, of color and who reside in southern states are at greater risk (KFF, 2007b; Salganicoff, 2008). Medicaid is the state-federal health insurance program for low-income individuals. Over three-qua rters (69%) of its recipien ts are women (KFF, 2007a, 2007b). However, regardless of the fact that the majority of Medicaid en rollees are women, 69% of Medicaid is allocated to the elderly and the disabled (American Medical Association, 2007). Medicaid eligibility is based on categoric al criteria (pregnant, a mother of a child < 18 years, 65 years, or have a disability) a nd income cuttoffs (based on category classification and state of re sidence) (KFF, 2007a). Medica id recipients face various social and economic hardships and are more likely “to be of reproductive age, poor, minorities, less educated, and parents” (KFF, 2007a). Approximately two-thirds (64%) of Medicaid recipients who are adults and female are among reproductive years (18-44 years) (KFF, 2007a). Services covered by Me dicaid are broad and include inpatient and outpatient care, prescription drugs, long-term care, care for chronic conditions and disabilities, prenatal care, family pla nning and preventive services (KFF, 2007a, 2007b). Medicaid serves as the larges t funder of family planning serv ices (Sonfield et al., 2008). Policies at all levels of government (feder al, state, county) as well as individual health insurance policies influence wome n’s access and coverage to health care (Salganicoff, 2008). For instance, mandated bene fits can vary greatly by state, such as

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25 the following services: cancer screening; r econstructive surgery post-mastectomy; direct access to obstetricians and gynecologists; c ontraceptive coverage; in fertility diagnosis and treatment; and human papillomavirus (HPV) vaccination (S alganicoff, 2008). Similarly, women’s access to private insura nce may be limited based on age and preexisting conditions. In addition, even if a woma n does meet the eligibil ity criteria, not all services that are important to her health and well-being (i.e. prescription drugs, contraception, maternity care, preventive serv ices, etc.) may be covered (Salganicoff, 2008). Background on Reproductive Health Reproductive Health as A Human Right Reproductive health is just one dimension included in the holistic composition of women’s health. Reproductive health is r ecognized as a basic, yet fundamental human right in which “governments are legally and morally obligated to protect, respect and fulfill” (Center for Reproductive Rights, n.d.). The right to reproductive health care and to reproductive self-determi nation are two key principles that acknowledge women’s roles in society and advocates for the abolishment of gender discrimination and inequalities (Center for Reproduc tive Rights, n.d.). Other values that are intertwined with reproductive rights are ones that are also re flected in the United States Constitution and the Universal Declaration of Human Rights: “human dignity, self-determination, equality and non-discrimination” (Center for Reproductive Rights, n.d.). The importance of reproductive health as a human right and its affects on women, families, the community and global developmen t has received intern ational attention. A

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26 landmark event, The Intern ational Conference on Popula tion and Development (ICPD) was a conference held in Cairo, Egypt in 1994, and in which 179 states attended and discussed the importance of reproductive h ealth (UNPF, 1995). ICPD recognized the importance of empowering, educating and provi ding family planning services to women in men, and advocated for universal fa mily planning by 2015 (UNPF, 1995). The conference urged involvement by Governments and resulted in a Programme of Action, which outlines an agenda for population and development for the next 20 years (UNPF, 1995). It was at this momentous conference in which the following definition of reproductive health was also developed below. Definition of Reproductive Health Reproductive health is a stat e of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that peopl e are able to have a satis fying and safe sex life and that they have the capability to reprodu ce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the righ t of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choi ce, as well as other methods of their choice for regulation of fertility which ar e not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provi de couples with th e best chance of having a healthy infant. ( UNPF, 1994, paragraph 7.2) Reproductive Health rights are grounded in the notions of women being able to have control over their bodies and having equal rights as compared to men. The International Conference of Parliamentarians on Populati on and Development articulate such notions in the following statemen t: “The empowerment of women and the improvement of their political social, economic and health status are highly important ends in themselves. We further believe that human development cannot be sustained

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27 unless women are guaranteed e qual rights and equal status with men” (United Nations Population Information Network, 1994). In the U.S., many reproductive health issues have been documented as national priorities in its quest to improve health among Americans. Healthy People 2010 is a governmental document that comprehensively list s sets of health objectives developed by scientists and serves as a blueprint for improving health over the next decade (DHHS, 2000). Priority issues directly relating to reproductive health include the following: access to quality health care; cancer; family planning; HIV; maternal, infant, and child health; and sexually transmitted diseases (DHHS, 2000). See Table 8, Healthy People 2010: Objectives Related to Reproductive Health and Family Planning, for a wideranging list of objectives and measures aimed at improving reproductive health Reproductive Health Care and Services Reproductive health care is defined as the following: “the constellation of methods, technique s and services that contribute to reproductive health and well-being by prev enting and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relati ons, and not merely counsel ling and care related to reproduction and sexually transmitted dis eases” (UNPF, 1994, paragraph 7.2) Reproductive health care and services are ge nerally defined as including the following topics: “contraception, STD and other screeni ng, maternity care, abortion, and infertility” (Ranji, 2005). Internationa lly, components of a reproducti ve health program may be broader and often include th e following: safe motherhood; health of the newborn and breastfeeding; family planning; aborti on care; prevention and management of STDs/HIV/AIDS; infertility; ad olescent reproductive health; maternal nutrition; female genital mutilization; violence against women; and reproductive tract cancer. However,

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28 the interconnectedness of reproductive health wi th other health conditions as well as with societal and structural systems (insurance, employment benefits, etc.) substantiates the need for services to be inclus ive and wide-rangin g (Ranji, 2005). Prenatal and interconception care are al so critical components of reproductive health. Preconception care refers to “a se t of interventions to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management” (D'Angelo et al., 2007). Interconception care refers to “the time between pregnancies, in cluding but not restrict ed to, the postpartum period” (D'Angelo et al., 2007). The goal of prenatal and interconception care is to encourage healthy behaviors, prevent hea lth problems, and cont rol existing health conditions before conception to maximize the health and well-being of both mother and baby (D'Angelo et al., 2007). Preconception and postpartum behaviors, experiences and health conditions that are ta rgeted during preconception a nd interconception care include the following: tobacco use; alcohol use; multiv itamin use; contraceptive nonuse; dental visit; health counseling; phys ical abuse; stress; underwei ght, overweight, and obesity; diabetes; asthma; hypertension; heart problems; anemia; previous low birth weight infant; previous preterm infant; depression; a nd social support (D'Angelo et al., 2007) The CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care has set forth the fo llowing 10 recommendations to improve preconception health and health care in the U.S.: 1) Indivi dual responsibil ity across the lifespan; 2) Consumer awareness; 3) Preven tive visits; 4) Interv entions for identified risks; 5) Interconception care; 6) Pregnancy checkup; 7) H ealth insurance coverage for women with low incomes; 8) Public health programs and strategies; 9) Research; and 10)

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29 Monitoring improvements (CDC/ATSDR Pr econception Care Work Group and the Select Panel on Preconception Care). The above recommendations present many implications for family planning services and fu rther justify the critical role that family planning has on the overall health and well-being of reproductive-age women. Reproductive health services and more sp ecifically, family planning services are critically important in preventing unin tended pregnancies and allowing women the autonomy of choosing when, if and how many children she bears. Women spend approximately half of their lifetime being fertile; however, of those women who want children, most only express a desire for two children (AGI, 1997). See Figure 3 Women’s Fertility Years. Specifically, the Na tional Center for Health Statistics report that of the average of 3.3 pregnancies that women have, 1.8 births are actually wanted (Ventura, Mosher, Curtin, Abma, & Henshaw, 2000). Because women can spend over 40 years of their lives trying to avoid or get pregnant, reproductiv e health and family planning services are crucial in managi ng women’s health, including emotional and overall well-being. Adverse Outcomes from Unprotected Sexual Activity Public health issues that are interrelat ed with unprotected sexually activity are diverse and can include, but are not limited to, the following: vi olence and abuse; rape/incest; power differentia ls; drugs and alcohol; ment al health issues; and body image/low self-esteem. Infertility is anothe r public health issue of reproductive health concern that could in part be due to a previous STI or other source of chronic inflammation (i.e. pelvic inflammatory dise ase) that has gone undi agnosed and untreated and is often disregarded during a reproductive health visit. Issues of infertility may not

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30 present an immediate concern to policy makers when compared to unintended pregnancy and STIs and often persist under the radar because of the patchwork of reproductive health services that a woman receives (B rady, 2003). Graham (1998) identifies yet another set of reproductive health outcomes: unwanted pregnancy; pe rineal tear; breast abscess; dysmenorrhoea; vesico-vaginal fist ula; chronic anemia; postnatal depression reproductive tract infection; cervica l cancer; and maternal death. Unintended pregnancy and STIs are tw o other adverse reproductive health outcomes that result from unprotected sexuall y activity and both of these consequences carry a multitude of adverse health and psychosocial reactions. Both unintended pregnancy and STI’s “discriminate biological ly against women” (Cates & Stone, 1992, p. 75), result from the same antecedent behavior (sexual activity), and disproportionately affect adolescents (Cates & Stone, 1992). Moreover, women are “socially, economically and biologically more vulnerable to STIs than men” (Brady, 2003, p. 135). The high prevalence of unintended pregnancy and ST I (including HIV) “warrants a renewed commitment to meeting the more comp lex protection needs of young women, which require the support of family planning and other reproductive health programs” (Brady, 2003, p. 135). Therefore, the researcher acknow ledges the diverse inventory listed above regarding the plethora of adverse reproducti ve health outcomes; however, because the focus of this study relates to a U.S. fam ily planning policy, only unintended pregnancy and STIs will be included in the review of adverse reproductive health outcomes. Unintended Pregnancy Unintended pregnancy is as a serious pub lic health problem for reproductive age women (CDC, 2007b) and the larger community. It is estimated th at one in 20 women

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31 has an unintended pregnancy each year (IOM 1995). Of the 6.4 million pregnancies in the U.S. in 2001, almost half were unintended (3.1 million) (Finer & Henshaw, 2006). These unintended pregnancies either resulted in births (44%), abor tions (42%) or fetal losses (14%) (Finer & Henshaw, 2006). Of women who had an unintended pregnancy that ended, resulted in an unplanned birth or who had an abortion, 48%, 40%, and 54% reported using contraceptives in the month that they conceived, respectively (Finer & Henshaw, 2006). In addition, disparities in unintended pregnancies are evident as this rate disproportionately affects women who are young (18-24 years), low-income, cohabitating and who are of a minority group (Finer & Henshaw, 2006). See Table 9 for Selected Characteristics of Women by Pregnancy Classifi cation and Abortion Rate, 2001. There are a multitude of medical, economic and social consequences that result from an unintended pregnancy. As stated above, approximately half of unintended pregnancies end in abortion, and even though medical complications from abortions can arise, medical risks from abortions are signifi cantly less then the ri sks associated with childbearing (IOM, 1995). However, there can be emotional and psychological issues associated with abortions due to the difficult decision that a woman must make as well as the various political barriers such as findi ng an abortion provider and navigating through federal and state barriers, which further exacerbates a woman’s distress (IOM, 1995). Women with an unintended pregnancy ar e more likely to receive late and/or inadequate prenatal care (IOM, 1995). Sim ilarly, women with an unintended pregnancy are less likely to receive preconception care, which is even more critical in optimizing both the health of the mother and baby (IOM, 1995). Receiving preconception and prenatal care is important in addressing a broa d spectrum of health c oncerns such as diet,

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32 weight, exercise, smoking, alcohol and drugs, environmental exposures, and vaccinations, as well as reproduc tive (i.e. pelvic inflammatory disease, STIs, etc.) and chronic diseases (i.e. diabetes, hypertension, cardiovascular diseas e, etc.) (IOM, 1995). Women with an unintended pregnancy are mo re likely to suffer from depression and experience domestic violence as well as enga ge in negative health behaviors such as smoking, tobacco and illicit drug use. Unintende d pregnancies are also more likely to be associated with low birth weight and in fant mortality (IOM, 1995). Moreover, unintended pregnancies are generally asso ciated with poorer child health and development, such as lower verbal capabi lities and physical a buse or neglect (IOM, 1995). Mothers with an unintended pregnancy are more likely to be unmarried or to be divorced regardless if the marriage took pl ace before or after conception (IOM, 1995). Children from unintended pregnancies are more likely to drop out of high school, perform poorly on standardized tests, have lo wer grade point averages have inconsistent school attendances, have low college expectatio ns, are less likely to attend college, have lower rates of college graduation, and are le ss successful in obtaining and keeping a job (IOM, 1995). Early childbearing and unintended pre gnancy present unique yet detrimental challenges for both mother and baby (IOM, 1995). Teenage mothers who are less than 15 years of age have a greater maternal deat h rate compared to women 20-24 years (IOM, 1995). Teenage mothers are also more likel y to have “poor weight gain, pregnancyinduced hypertension, anemia, STIs, and cephalopelvic disproportion” (IOM, 1995, p. 59). Teenage mothers are less lik ely to complete high school, ar e more likely to be single

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33 parents, and are more likely to have other children (IOM, 1995). In addition, teenage mothers are more likely to earn lower wages a nd live in poverty (IOM, 1995). Infants of teenage mothers are more likely to be of lo w birth weight (< 2,500 grams), to die within the first 28 days, have sudden infant death syndrome, and in general acquire various illnesses and injuries (IOM, 1995). On the other end of the reproductive lif e span, unintended pregnancy later in life are attributed to higher rates of maternal mortality and morbidity, and higher rates of spontaneous abortion, toxemia, venous thrombosis, hypertension, and diabetes mellitus (IOM, 1995). Infants of older mothers are more likely to endure “chromosomal defects, congenital malformations, fetal distress and low birth weight,” (p. 60) as well as have a higher incidence for Downs Syndrome (IOM, 1995). The medical consequences from late childbearing often are associated with the presence of chronic diseases and/or preexisting medical conditions (IOM, 1995). Sexually Transmitted Infections Of the 19 million new STI infections that o ccur each year, more than half of them are among youth (15-24 years). In addition, sim ilar to unintended pre gnancies, the public health impact of STIs disproportionately affects women and children (CDC, 2007d). In 2006, rates for chlamydia, gonorrhea and syphilis among U.S. women were 515.8, 134.3 and 1.0 per 100,000 population, respectively (CDC 2007c). Also in 2006, rates for chlamydia, gonorrhea and syphilis among women in Florida were 425.1, 137.1, and 1.1 per 100,000 population, respectively (CDC, 2007c). The above rates are significantly higher in comparison to the Healthy People 2010 targets (s ee Table 8 for the Healthy

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34 People 2010: Objectives Related to Reproduc tive Health and Family Planning, Focus Area 25 – Sexually Transmitted Infections). In 2005, an estimated 9,708 women were diagnosed with HIV/AIDS of which 80% of these new cases were due to high-risk heterosexua l contact (CDC, 2007a). The human papillomavirus (HPV) affects approximately 20 million Americans, with 6.2 million new infection occurring each year (C DC, 2008). Approximately 50% of sexually active men and women are infected with HP V at some point during their lives (CDC, 2008). Specifically among women, the prev alence of HPV is approximately 26.8% (about 1 in 4) among 14-59 years olds (Dunne et al., 2007). The estimated number of new STIs that occur each year among pregna nt women include the following: bacterial vaginosis (1,080,000); herpes simplex virus 2 (80,000); chlamydia (100,000); trichomoniasis (124,000); gonorrhea (13,2000) ; hepatitis B (16,000); HIV (6,4000) and syphilis (<1,000) (CDC, 2007d). STIs are often asymptomatic and go undiagnosed; if not treated, chlamydia and gonorrhea can lead to pelvic inflammatory di seases, ectopic pregnancy and tubal factor infertility (CDC, 2007d). The presence of an STI during a woman’s pregnancy can lead to various adverse outcomes for the baby: chlamydia and gonorrhea can cause neonatal ophthalmia; chlamydia can cause neonatal pneum onia; an outbreak of herpes simplex has the potential to lead to fatal neonatal infections; and syphilis infections passed to the fetus in utero can cause physical and mental deve lopmental disabilities and/or fetal death (CDC, 2007d).

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35 Background of Family Planning Definition of Family Planning Family planning refers to the “the ability of individuals and c ouples to anticipate and attain their desired number of children a nd the spacing and timing of their births. It is achieved through use of contraceptive me thods and the treatment of involuntary infertility” (WHO, 2008b). The Intern ational Planned Parenthood Federation has identified 10 rights of every family planni ng client: safety, info rmation, access choice, privacy, confidentiality, dignity, comfort, c ontinuity, and option (H uezo & Diaz, 1993). History of Family Planning Even though humans have been practicing various forms of fertility control for centuries, issues relating to family pla nning did not enter the policy arena until the 20th century. Discussing birth control was taboo and distributing birth control information through the mail or across state lines was considered a federal offense under the Comstock Law enacted back in 1873 (PBS Online, 2001). The law was amended in 1936 where only doctors were legally permitted to mail birth control (PBS Online, 2001). Oral contraceptives (“the birth cont rol pill”) entered the market in the 1960’s giving women for the first time a chance to express th eir sexual freedom while controlling their childbearing capacity. Even though the birth c ontrol pill was available, it was not until 1965 that the Supreme Court permitted married couples the right to use contraceptives ( Griswold v. Connecticut 1965), and in 1972 when the right was extended single people ( Eisenstadt v. Baird 1972). Margaret Sanger, a pioneer in the fam ily planning movement during the early 1900’s, is known as the most prominent fo rce in advocating for women’s rights and

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36 family planning as she made it her mission to provide women with reproductive freedom through the distribution of birt h control information and services. Sanger observed many women while working in New York as a nurse and midwife, as we ll as her own mother, suffer and die from childbearing (Steinem, 1992). With the goal of preventing this type of morbidity and mortality from happening to other women, she began distributing information on birth control in various articles entitled, What Every Girl Should Know and in her own publication, The Woman Rebel and began providing birth control methods in community clinics; acts that re sulted in her arrest on numerous occasions (Steinem, 1992). Sanger founded the Ameri can Birth Control League in 1921, an institution that became the Planned Parent hood Federation of America in 1942 (Steinem, 1992; The Margaret Sanger Papers, 2005). She was instrumental in organizing the First American Birth Control Conference in New York City as well as the first international population conference (Steinem, 1992). Sanger al so helped establish leagues and clinics throughout the nation and rallied at all levels of government for birth control legislation (The Margaret Sanger Papers, 2005). “By word and deed, she pioneered the most radical, humane and transforming political move ment of the century ” (Steinem, 1992). In the same decade that the birth control pill was approved by the FDA, the federal government, through its War on Pove rty, began subsidizing family planning services through the administra tion of grants by the Office of Economic Opportunity in 1965 (AGI, 2000). The federal involvement in family planning followed the already established southern states’ i nvolvement in family planning (McFarlane & Meier, 2001). In 1937, North Carolina was the first state to support family planning program and was followed by other southern states (Alabama Florida, Georgia, Mississippi, South

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37 Carolina, and Virginia) (McFarlane & Meie r, 2001). The government’s efforts at expanding the provision of family planning services to low-income women aimed to alleviate poverty and improve health among mothers and children (AGI, 2000). In the late 1960’s, the Social Security Act was amended to allow Medicaid and other state welfare agencies to be reimburse d for family planning services (AGI, 2000). However, untrained welfare agency employees, inconsistencies in eligibility and service provisions and a patchwork of reimbursements deemed the family planning effort ineffective as not all intended recipients we re being reached (AGI, 2000). Therefore, in 1970, the first and only national law (Title X of the Public Health Service Act) solely responsible for family planning services wa s enacted (AGI, 2000). See Figure 4 for a Family Planning Timeline that details a co mprehensive family planning history from 1960-2000. Family planning policies were perceived differently by the administrations that were in office. For instance, Presidents Nixon and Ford had difficulties dealing with dissemination of the family planning program in light of the New Federalism (the practice of transforming federa l responsibility and giving gr eater power to the states) (McFarlane & Meier, 2001). During the Ca rter years, Title X’s accountability was challenged as there was reduced levels of trackin g patient data as well as the fact that the program was being transformed to the Bureau of Community Health Services within HRSA which directed funds to comprehensive health centers centers that had less of a vested interest in the prog ram’s accountability (McFarlane & Meier, 2001). The Reagan administration not only restructured federali sm, but also directly opposed public family planning (McFarlane & Meier, 2001). Even though Reagan consolidated categorical

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38 grants into block grants, Title X prevailed, albeit with a sharp cut in funding (McFarlane & Meier, 2001). Also during the Reagan administration, Marjory Mecklenburg was the first deputy assistant secretar y for population affairs, an individual who was the “former president of the Minnesota Citizens Concerned for Life and a founder of the National Right to Life Committee” (McFarlane & Me ier, 2001, p. 50). The lack of Title X authorization from the Reagan administration continued into the Bush administration and since 1986, there has been zero authorization dollars provided under the Title X program (Congressional Research Repor ts for the People, 2008). During the Clinton administration some positive changes were made as the gag rule was repealed two days into his term and two family planning supporters Jocelyn Elders and Philip Lee were appointed as th e surgeon general and the assistant secretary for the DHSS, respectively (McFarlane & Me ier, 2001). However, in 1996 under Bill Clinton, the Personal Responsib ility and Work Opportunity Reconciliation Act (P.L. 104193) was enacted which eliminated the requireme nt for “states to provide family planning services to welfare recipien ts” (McFarlane & Meier, 2001, p. 52) and did not have any funds earmarked for family planning (McFarla ne & Meier, 2001). The Welfare Reform Act also allotted $50 million dollars each year to states to fund abstinence-only education programs (McFarlane & Meier, 2001). Ther efore, policies affecting family planning funding have deteriorated over time throughout the various administrations. However, despite various setbacks, the only federal pla nning devoted solely to family planning has remained intact.

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39 Contraceptive Use Contraception use as a means to control fertility is a universal human behavior that has been practiced in various cultures th rough recorded history (McFarlane & Meier, 2001). However, what has changed throughout history is the social, moral and legal restrictions of fertili ty control and technology that has improved the safety and efficacy of contraceptive methods (McFarlane & Meier, 2001). The National Center for Health Statistics published national estimates of contraception use from the 1982, 1995, and 2002 National Surveys of Family Growth (NSFG) (Mosher, Martinez, Chandra, Abma, & Wilson, 2004). Data from the 2002 NSFG reveal that almost all women (98%) of reproductive age (15-44 years) who have had sex have used a contraceptive method (Mosher et al., 2004). Sixty-two percent (n=38,109,000) of the 62 million women of re productive age were currently using a contraceptive method; whereas 31% of women were either in fertile, pregnant, postpartum or trying to become pregnant were not sexually active or have never had intercourse, thus did not require a contra ceptive method (Mosher et al., 2004). The remaining 7% of women were at risk for an unwanted pre gnancy and were not using a contraceptive method (Mosher et al., 2004). Among women using contraception, 64% we re using a reversible method and the remainder relied on male or female steriliz ation. The pill was the most common method of contraception for women less than 30 year s of age, never-married women and women with a college degree; sterilization was th e most common method of contraception for women older than 35 years. These two cont raceptive methods (pil l and sterilization) have been the leading methods among Am erican women since 1982. Among all women

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40 of reproductive age (62 million), 56% and 22% of women visited a private doctor or publicly funded family planning clinic, resp ectively, for family planning or related services (Mosher et al., 2004). The most frequently used contraceptiv e methods among women who were using contraception, listed from most to least common, were the fo llowing: birth control pill; tubal sterilization; male condom; vasectom y; 3-month injectable; withdrawal; IUD; periodic abstinence (calendar); implant, 1-m onth injectable, or patch; periodic abstinence (natural family planning); diaphragm; and other (sponge, cervical cap, female condom and other methods). See Figure 5 for th e Percentage of Contraceptive Users by Contraceptive Method. Dual method use (c ondoms and another method) was practiced by 15% of contraceptive users, most of w ho were primarily teens or never-married women (Mosher et al., 2004). However, the number of women (13-44 years) in need of publicly funded contraceptive services and s upplies in the U.S. and in Florida in 2004 were 17,396,650 and 895,150, respectively (Guttmacher Institute, 2006). Family Planning Clinics The majority of women today in the U.S. receive family planning services from private physicians; however, many services and supplies are excluded by insurance companies (AGI, 2000). Moreover, Medicaid allows their recipien ts to see private physicians; however, not all obstetricians and gynecologists accept these recipients, largely due to the low reimbursement rate s (AGI, 2000). As stated above, in 2004, the number of women in need of publicly funded contraceptive services and supplies was 17,396,650; an increase of 6.1%, or 1 million more women in need, between 2000 and 2004 alone (AGI, 2006). Family planning clinic s are an important part of the public

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41 health system as they are uniquely positioned to address the needs of the most vulnerable. Generally, family planning clinics are locate d in areas with higher densities of lowincome women, including minority and immigr ant populations (AGI, 2000). Because of their locations, they ar e able to connect with hard-toreach populations and can deliver culturally sensitive services, often through th e use of non-English languages (AGI, 2000). Family planning clinics rece ive funds from a variety of sources. Medicaid is the largest source of funding, followed by state f unds, Title X, Social Services Block Grant (Title XX of the Social Security Act), and th e Maternal Child Health Block Grant (Title V); however, Titles V and XX include family planning services as a very small portion of their programs (AGI, 1997). See Figure 6 for Reported Public Expenditures on Family Planning Client Services, By Funding Source, United States, FY 2006 and Figure 7 for Reported Public Expenditures for Family Pl anning Client Services, By Funding Source, Florida, FY 2006. Unfortunatel y, many women do not qualify for Medicaid as eligibility in most states usually requires a woman to be single, a mother (or pregnant), and low income, with the income ceiling at approximate ly 46% of the federal poverty level (AGI, 1997). Originally, Title X pr ovided one in two dollars for publicly funded family planning services, an amount that has diminished to one in five in 1994 (AGI, 2000; Nestor, 1982; Sollom et al., 1996). The types of agencies that provide fa mily planning services are diverse and consist of heath departments, Planned Parenthood affiliates/clinics, hospitals, university health centers, independent family planni ng clinics, and other public and non-profit agencies (OPA, 2008). The services provided by family planning cl inics include a wide range of contraceptives at a lower cost as well as the associated health education and

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42 counseling (AGI, 1997). In addition, most fa mily planning clinics also provide the following: Pap tests; breast and pelvic exams; blood pressure screens; prenatal, postpartum and well-baby care; immunizations ; services for Special Supplemental Food Program for Women, Infants and Children (W IC); anemia tests; collection of sexual histories; and education, information and counseling on STDs, including condom negotiation (AGI, 1997). Approximately half of the clinics routinely test for gonorrhea, chlamydia and syphilis (AGI, 1997). As with other sectors of health care in the U.S., many family planning services are confronted by a myriad of challenges includi ng health care financing, the rising costs of services, the need for broader and comprehensive services, and the multifaceted task of improving contraceptive-related behavior s among clients (AGI, 2000). The broader range of reproductive health services that fa mily planning clinics are being called upon to provide to their clients incl ude specialized STD services, reproductive cancers, issues affecting post-menopausal women, addressing issues throughout a woman’s lifespan, prenatal care, adoption counseling, as well as reproductive issues affecting men (AGI, 2000; Dailard, 2001). Moreover, th e number of uninsured women continues to rise as are the number of managed care networks, but the nu mber of Medicaid covered recipients is not increasing (AGI, 2000). Thus, many women are left without family planning service coverage and are reliant upon pub licly funded family planning clinics, which are already struggling to keep up with the demand. As witnessed in a recent and widely publici zed event, another issue facing family planning clinics is the rise in costs of cont raception which has increased 3to 4-fold in the past year, greatly affecting the ability of college and low-income women to purchase

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43 and use birth control (Davey, November 22, 2007). The Deficit Reduction Act of 2005 is identified as the cause of the rise in cost of contraception as this federal act limits the practice of drug manufactures selling contraceptives to he alth centers and community clinics at discount rates (Davey, November 22, 2007). Moreover, women’s choice of contraceptive can be curtailed, as even though new long-lasting hor monal methods (i.e. implants, injectables, interuterine devices) have low failure rates and are becoming more popular, they have higher up-front costs compar ed to other contrace ptive methods (AGI, 2000). For instance, the cost of an inj ectable for one year for one woman is approximately the same amount required to pr ovide oral contraceptives to three women for that same time period (Dailard, 2001). Ther efore, in light of the continually rise in costs, increasing contraceptive use among lowincome women can be difficult amidst the primary challenge of educati ng and choosing the best contra ceptive method for a client and promoting correct and consistent us e for that method (AGI, 2000). Moreover, escalating costs related to screening and diagnostic test s are also becoming more expensive, such as the new liquid-based Pap smear tests, the HPV DNA test, and the DNA-based chlamydia and gonorrhea tests (Dailard, 1999, 2001). Access and consistent use to contraceptiv e services is critically important in preventing unintended pregnancies, especia lly among the most vulnerable populations, as “10% of American women at risk of unintended pregnancy who do not practice contraception account for 53% of all unintende d pregnancies” (AGI, 1997). The need for family planning and related services is obvi ous. The growing number of the uninsured and the estimated one million low-income wo men (< 250% of the poverty level) who are at risk for pregnancy but are not using a ny form of contraceptives necessitate the

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44 continual and expanded provision of family planning services (Dailard, 1999). Furthermore, the fact that the U.S. has the highest rates unintended pregnancies and STIs of all western nations heightens the impor tance of providing primary, secondary and tertiary prevention services to those in most need. As Steward, Shields, and Hwang (2003) stat e: “If Title X were a stock, it would be every analyst’s top pick” (p. 1). Stewar d et al (2003) point out the following: 1) “family planning pays spect acular dividends” by giving women the opportunity to continue education, allowing couples to explore otherwise limited economic opportunities, and improves health and well-being for children; 2) “has enormous growth potential” (p. 1), as funding is currently provided at a 57% rate lower th an rates in 1980; 3) “outperforms the other investments” as Title X services provide basic preventive services and reduces unintended pregnancies, STIs, and other illnesses, screens for early detection of a range of cancer, and promotes health lifestyle behavi ors (i.e. smoking); 4) and is cost-effective as Title X “yields an impr essive return on its investment” (p. 1) by saving dollars that would have been di rected towards other health costs. Policy and Reproductive Health The Role of Policy in Reproductive Health Policy development is one of the three core functi ons of public health along with assessing the health amo ng populations and assuring access to health care and services (IOM, 1988). The role and forms of policies in pub lic health are diverse and consist of “authoritative decisions that are made in the legi slative, executive, or judicial branches of government” (Longest, 1998, p. 4). Examples of the broad spectrum of public health

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45 policies include the following: smoking bans; sp eed limits for automobile drivers; school entrance immunization requirements; restaura nt inspections; nutritional labels on foods; and health financing programs su ch as Medicaid and Medicare. Some policies in the U.S. are beneficial towards reproductive health such as the National Breast and Cervical Cancer Early Detection Program (BCCEDP), The Special Supplemental Nutrition Program for Women, In fants, and Children (WIC), baby safe haven laws, and access to prenatal care th rough Medicaid. However, there are many current policy issues that de ter the advancement of repr oductive health. These policy issues often undermine basic reproductive h ealth rights by making reproductive health care non-accessible to portions of the population or by restricting full access and coverage to comprehensive care (Center fo r Reproductive Rights, n.d.). For instance, controversies over abstinence-only educa tion, abortion, emergency contraception, HPV vaccination and religious/moral refusal clauses are just a few of the long list of policy issues that relate directly to Title X, adversely affect th e rates of unintended pregnancy, STIs, and other health conditions (i.e. cervical cancer), and that plague women’s health advocates today. In addition, as mentione d above, the rising costs of contraception fuelled by the Deficit Reduction Act of 2005 and the inadequate patchw ork of private and public health insurance coverage resulting in the growing numbers of the uninsured also serve as important policies inhibiting wo men’s reproductive health. “Access to reproductive health information and services has been among the most polarizing of the policy issues facing women’s h ealth” (Salganicoff, 2007, p. 274). Fertility control policies have been shown to be cyclical in nature in the U.S. (McFarlane & Meier, 2001). Contraception and abortion were both legal in 1800 and

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46 outlawed in the 20the century until 1965 a nd 1973, respectively (McFarlane & Meier, 2001). However, these policy changes were not legislatively-base d, but arose out of judicial support and public opin ions (McFarlane & Meier, 20 01). Nonetheless, fertility control policies with respect to access, have only been on the policy agenda since the mid-to-late 20th century (McFar lane & Meier, 2001). A pr imary reason that fertility control is considered a recent phenomenon is becau se of its long history in the restrictions of fertility control practices (McFarlane & Meier, 2001). Before fertility control policies were form ally put on the agenda in the later half of the 20th century, issues relating to reproduc tion, and specifically the increasing reproduction rates, were framed as populati on control policies. Around the end of the 1950’s, the rapidly increasing population and the newly developed fertility control technologies contributed to the population control paradigm (Lane, 1994). However, from the mid-1980’s onward, there was a “ policy shift from popul ation control to reproductive health” (Lane, 1994, p. 1303). La ne (1994) identifies three problems in framing policies as population control: it norma lizes coercive policies; favoring fertility limitation over individual rights is an ethical violation; and it does not meet the needs of individuals (Lane, 1994). Toda y, developed nations such as the U.S. primarily frame reproductive health and fertility control issu es and policies as family planning and not population control. Public polices that focus on fertility control generally act on one of the progression of steps involved in reproduction: sexual interc ourse; conception; gestation and parturition (Davis & Blake, 1956; McFarl ane & Meier, 2001). See Figure 8 for The Reproductive Process. However, there is no one family planning policy in the U.S., and

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47 the patchwork of family planning polices that the U.S. does have are multistatutory as they arise from four main federal statues: T itle V of Social Security Act (Maternal and Child Health and Crippled Children Act); Title X of Public Health Service Act (Family Planning Services and Population Research Act); Title XIX of Social Security Act (Medicaid); Title XX of Social Security Ac t (Black Grant to the States for Social Services) (McFarlane & Meier, 2001). S ee Table 10 for the Main Federal Family Planning Statues. Family planning programs are directly or i ndirectly affected by all policies of the reproductive process. For instance, a family planning programs can be in jeopardy when they are linked to abortion and/or sexual behaviors among minors (McFarlane & Meier, 2001). Furthermore, the likelihood of success wi thin a fertility control policy depends on how one defines achievement for that program (McFarlane & Meier, 2001). For instance, policies that decrease the costs of contracep tion would be successful in reducing the rate of unintended pregnancy; whereas, policies that increase morality restrictions by enforcing parental notificati on and/or patient counseling ba sed on ideological premises would create a barrier for individuals in obtai ning contraceptives, thus increasing the rate of unintended pregnancy (McFarlane & Meier, 2001). Reproductive Health Policy: A Controversial Topic The framework for reproductive health polic ies is often driven by moral standards and cultural norms (Cook et al, cited by Buse, Martin-Hilb er, Widyantoro, & Hawkes, 2006). Such policies are often le ft out of the policy agenda be cause they involve cultural taboos (sexuality) and populations consisti ng of women, children and the poor (Buse et al., 2006). The disconnect be tween sexuality beliefs and behaviors among Americans

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48 greatly affects fertility control politics as we ll as the broad range of adverse reproductive outcomes (McFarlane & Meier, 2001). In addition, research and policy pertaining to reproductive and sexual health is often reactive rather than proactiv e, where political and ideological arguments are challenged and eviden ce-based data used to advance health is often undermined (Gruskin, 2004). Clarke (1990) discusses the controversial nature of reproductive sciences and presents four major domains that shape such debates: “1) association with sexuality and reproduction; 2) association w ith clinical quackery and ho tly debated treatments; 3) association with controversial social movements; and 4) capac ity of reproductive sciences to create ‘Brave New Worlds ’ ” (Clarke, 1990, p. 21). The first domain, association with sexuali ty and reproduction, deals with the fact that reproduction is often stig matized and is perceived as “dirty work” (Clarke, 1990). Such negative connotations associated with reproductive sciences has continued over the decades, as seen by the opposition that challeng ed Alfred Kinsey’s work and those that continue to challenge sex education in schools (Clarke, 1990). The second domain, association with clinical quack ery and hotly debated treatments, refers to the long history of unusual and often unsafe medical experime nts and “treatments” in the reproductive sciences. For instance, experiments that tran splanted monkey testes into men and other mammals (sheep, horses, dogs, etc.) for “se xual and geriatric rejuvenation” (Clarke, 1990, p. 23), the use of diethylstilbestrol (DES) for “female problems” which caused serious side effects, including death, and th e introduction of the contraceptives such as the Dalkon Shield attributed sk epticism controversy to the re productive sciences (Clarke, 1990). The third domain, links to social movements, identifies how reproductive

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49 sciences have been intertwined with the “b irth control, eugenics and population control movements” (Clarke, 1990, p. 24). Thr oughout these three movements, positive and negative consequences were produced; however, it was difficult for scientists to separate sexuality from reproduction (Clarke, 1990). For instance, much support and funding were obtained to promote these movements, whereas at the same time, opposition around these movements escalated, often focusi ng on the following five major issues: “contraception; abortion; sterilization; infe rtility services; and reproductive research” (Clarke, 1990, p. 24). The fourth domain, “Brave New Worlds,” concerns how the reproductive sciences challenge and/or threaten what some people believe is the “n atural order of life” (Clarke, 1990, p, 25). Opposition arising from Catholic s and fundamentalists assert that the reproductive sciences disrupt the natural order; whereas some feminists assert that the reproductive sciences transform women into breeders and introduce medical and ethical issues into women’s lives (Cla rke, 1990). Other stakeholders in the plethora of debates that surround reproductive scie nce research involve lawyers, ethicists, agricultural scientists, politicians and th e general public (Clarke, 1990). McFarlane & Meier (2001) analyzed the politics of fertility control and argued that fertility control falls under the umbre lla of morality politi cs as such policies redistribute values that the government d eems worthy. The authors define fertility control as “the actions of i ndividuals or couples to limit the number of children they biologically produce or to space the timing of their children’s births” (McFarlane & Meier, 2001, p. 1). McFarlane & Meier ( 2001) acknowledge that fertility control involves the status of women, affects econom ic and social well-being, and overtime,

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50 fertility control politics have become less eff ective. Morality polit ics interfere with the framing of reproductive health issues and the frames applied to family planning policies are often the same frames found in abortion policies (McFarlane & Meier, 2001). See Table 11 for Frames Used in Fertility Contro l (Family Planning and Abortion) Policies. Regardless of which side of the issue an individual or entity falls, the framing of fertility policies reduce the myriad of issues into si ngle arguments greatly affecting a policy’s future (McFarlane & Meier, 2001). The actors involved in reproduc tive health research and policy can be classified into the following categories: “university-based demographers and other social scientists; activist groups; research organizations; non-governmental organizations; private philanthropies; governmental agencies; a nd multinational agencies” (Lane, 1994, p. 1304). All actors play a role in the contr oversial nature of reproductive and fertility politics. Lane (1994) argues that social scientists should play a larger role in that their research is embedded with policy implicati ons. Lane (1994) suggests women’s rights, women’s access to health care, differences in mortality rates due from disparities within health care, and embedded issues and fact ors surrounding policy need to be examined more thoroughly. “As a nation we talk a good deal about compassion, but U.S. policies are putting the lives of young women at risk by pursuing health strategies conceived by ideologues who ignore social realities and best medical practices. Surely, our young women – and the world’s – deserve better” (Germain, 2004, p. 17). Advocates urge the government to step up their responsibility and commitment to reproductive health as they believe that “the government should ensure that women have the information and services they need to safe guard their health and to exercise their individual

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51 responsibilities in re gard to sexual behavior, repr oduction, and family formation” (Boonstra & Gold, 2002, p. 46). A Review of Title X Title X Family Planning Program (Family Services and Population Research Act of 1970) was enacted in 1970 by President Richard Nixon and serves as the only federal program devoted solely to family services through the provision of federal funds for voluntary, confidential family planning servic es to all women, regardless of their economic status. This federal legislation as pired to prevent unint ended pregnancies and poor birth outcomes to those in most need and has helped avoid millions of pregnancies and abortions, especially among the younger and low-income women. Currently, Title X is administered by the Office of Family Pl anning of the Office of Population Affairs (OPA), Office of Public Health and Scien ce, U.S. Department of Health and Human Services (OPA, n.d.). OPA administers Ti tle X funds to 10 regional offices which manage, review and award the competitive grants, and oversees the programs’ performance within its regions (RTI Interna tional, November 2006). Title X grantees can provide services directly th rough their own clinic s or allocate thei r awarded funds to individual clinics (AGI, 1997). Title X clinic settings include heath departments, Planned Parenthood affiliates/clinics, hospitals, unive rsity health centers, independent family planning clinics, and other public an d non-profit agency types (OPA, 2008). Since its inception, the following key regula tions have been distinguished within Title X law: services provided must be volunt arily delivered to women; services must be confidential; associated preventive services must be offered; funds cannot be used for abortion; and clinic personnel must practice “n ondirective counseling” (Grants for Family

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52 Planning Services, 200; OPA, 2001). Recently, Title X law was revised to also include that clinics receiving funds must encourage family participation (Grants for Family Planning Services, 2000; OPA, 2001). Regardless of preventing over 1 million unintended pregnancies each year, thus also decreasing the need for abortions (Gol d, 2001), over the past three decades Title X has faced political, financial and social barrie rs. Originally, Title X provided one in two dollars for publicly funded family planning se rvices, an amount that has diminished to one in five in 1994 (AGI, 2000; Nestor, 1982; Sollom et al., 1996). Similar to other reproductive health policies, Title X continues to be ch allenged by political opposition often grounded in moral, cultural and ideologica l claims. Reproductive health policies, such as Title X, are controversial because of their association with human sexuality and reproduction; arguments that often surpass re productive health right s and evidence-based public health data. Despite its enormous success in improving the health and well-being of women and children by decreasing uni ntended pregnancies and abortions, and providing key comprehensive preventive services, without a newfound political will similar to the administration from which it wa s conceived, the future of Title X may be in jeopardy. Legislative History of Title X Tracing the legislative history of a po licy or program is a common approach utilized by researchers to assist in analyzi ng a policy (San Diego St ate University, 2007). A legislative history is “a chronology of events and the documents generated in the legislative process” (Litwack, 2006). Attorney s, courts and federal agencies often use legislative histories when there is a need for law interpretation (Jarrett & Nyberg, 2008;

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53 McKinney & Sweet, 2001). Legi slative histories are also used in determining why Congress amends existing public laws or enacts new public laws, even though the meaning and intention behind the law may a ppear to be ambiguous (McKinney & Sweet, 2001). Moreover, scholars often compile a le gislative history to aid in examining the legislative process and how the legislative pr ocess affects a specific topic or public policy (Wilhelm, 1999). Generally, the first step in compiling a legi slative history is to identify relevant legislation or bills and then to research subs equent materials that trace the bill through the legislative process (Maine State Law and Le gislative Reference Library, 2008; San Diego State University, 2007). See Figure 9 for the Le gislative Process. There are various steps outlined by library research services that illu strate the range of documents that could be compiled and the different sources in which the documents can be found when compiling a legislative history for a federal or stat e public law (Edwards, n.d.; Jarrett & Nyberg, 2008; Litwack, 2006; San Diego State Universi ty, 2007; Wilhelm, 1999). The range of documents that could be included in a legisl ative history include, but are not limited to, the following: house or senate bill; comm ittee reports; committee hearings; committee testimony; congressional debates; floor deba tes; president’s message; and regulations resulting from the enactment of the public law (Edwards, n.d.; Ja rrett & Nyberg, 2008; San Diego State University, 2007). A legislative history was conducted on T itle X to review House and Senate bills that proposed amendments to Title X since enactment (91st-100th Congress, January 3, 1969 – August 31, 2008). A systematic search of bills was employed utilizing two secondary sources: Congressional Record (1970-1988) and LexisN exis Congressional

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54 (1990-2008). Legislative bills can only be searched online through the LexisNexis Congressional database st arting at the year 1989 (101st Congress) to present (2008, 110th Congress); thus, a government print publica tion (Congressional R ecord) was used to search for bills from 1970 (91st Congress) to 1988 (100th Congress). As Wilhelm (1999) states, “by combining traditional paper source s with electronic ones, a researcher can delve into Congress’ business and explor e the decisions that have brought this government into its third century” (p. 498). The Congressional Record is “the official record of the proceedings and debates of the United States Congress” (GPO Acce ss, 2008b). The Congressional Record is published by the Joint Committee on Printing and includes the 1) Congressional Record Index and the 2) History of Bills and Resolutions (GPO Access, 2008a). The Congressional Record Index lists various polic y issues/topics by their legislative activities (i.e., editorials, history of bills and resolutions, etc.). Multiple search terms were used to produce the most comprehensive legislative history and to ensure the net was cast wide enough to include all applicable bills and included th e following: abortion; birth control; contraception(iv e); family planning; health; population; public health; and Public Health Service Act. Therefore, fo r each of the search terms listed above, the researcher searched the History of Bills and Resolution section in the Congressional Record for that search term and recorded all of the bills that appeared to be applicable to Title X. The above process for abstracting bills wh ich were to be included in Title X’s legislative history was employed for each Congress session between the 91st and 100th Congress sessions (1969-1988). However, because the Congressional Record only

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55 indexes bills, lists the bills’ progress through the legislative process, and provides a brief synopsis for each bill, a thorough examination of each bill’s full text was required once the researcher obtained the arch ived full texts of the bills in microphiche from a federal library depository (University of Florida). Th e researcher included all bills that appeared to be applicable to Title X as represented by the Congressional Reco rd, and therefore, it is possible that some of the bi lls included in Title X’s legislat ive history as depicted in the Supplemental Appendix were excluded prior to the study if the full text of the bill did not affect Title X policy. The above changes to Title X’s legislative history reflect the fluidity and iterative proce ss of qualitative research. LexisNexis Congressional, a division of Reed Elsevier Inc., is “the most comprehensive online resource available for c ongressional publicati ons and legislative research” (LexisNexis Congressional, 2008). Through LexisNexis Congressional, researchers can trace a law’s intent by identi fying and reviewing legislative documents and can monitor legislation for the specific public policy of intere st. Similar to the Congressional Record bills from 1989 (101st Congress session) to th e present, ending at bills proposed on or before August 31st, 2008 (110th Congress session) were searched online via the LexisNexis Congressional database. LexisNexis is an electronic database and contains both the “Bill Tracking” and “Bill Full Text” versions of a bill that was proposed since 1989 or later. The following search terms were used in these fields: “Title X AND family planning,” “Title X,” and “family planning.” The separa te search terms of “Title X” and “family planning” were used to ensure that any possible relevant bills were not inadvertently excluded if they did not contain the full program title in their text but referenced the program soley by its title

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56 or a related phrase such as the “voluntary family planning program/clinics.” See the Supplemental Appendix for the Legislative Hist ory for Title X (Family Planning Services and Population Research Act of 1970). Introduction to Policy Studies Policy Analysis Public policy is not new field of stud y as literature documenting this field originated with Harold Lasswell expressing the need for a distinctive science approximately 50 years ago (Birkland, 2005). However, a complete understanding of the fundamentals of this science has emerged onl y in the past two d ecades (Birkland, 2005). The study of public policy is multidisciplin ary and includes professionals from the natural, applied, social and behavioral sciences (Birkland, 2005). These diverse backgrounds of public policy serve both as a strength, incorporating multiple perspectives into a policy, as well as a weakness, lacking a unifying discipline wh ere shared training, language and methodology are used (Birkland, 2005). Birkland (2005) acknowledges the variety of definitions of public policy and provides the following examples: “The term public policy always refers to the actions of government and the intentions that determine those actions” (C. E. Cochran, Mayer, Carr, & Cayer, 1999); “Public Policy is the outcomes of the st ruggle in government over who gets what” (C. E. Cochran et al., 1999); “Whatever governments choose to do or not to do” (Dye, 1992); “Public policy consists of political decision of implementing programs to achieve society goals” (C. L. Cochran & Malone, 1995); “Stated most simply, public policy is th e sum of government activities, whether acting directly or through agents, as it has an influe nce on the life of citizens” (Peters, 1999).

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57 Perhaps just as important is grasping a firm understanding of wh at one is referring to when they use the word “policy,” as this term can encompass th e range of activities and actors involved in the policy process. One policy definition states, “policies are revealed through texts, practices symbols, and discourses that define and deliver values including goods and services as well as regulations, income status, and other positively or negatively valued attributed ” (Schneider & Ingram, 1997). Policies are usually categorized into a typology that aid in better understanding the development, implementation and argum ents surrounding that policy (Birkland, 2005). Previously, policies we re categorized into topica l categories (e.g. education policy, health policy, etc.); however in 1964, Theodore Lowi created the policy typologies that are still most co mmonly referred to today: di stributive, redistributive and regulatory policies (Birkland, 2005). Distributive policies grant benefits to small subset of the population with the costs arising fr om the general popul ation (Birkland, 2005; McFarlane & Meier, 2001). Redistributive policies grant benefits to one section of the population while inflicting cost s from another section of the population (Birkland, 2005; McFarlane & Meier, 2001). McFarlane (2001) categorizes fertility control policies as redistributive as they re distribute values that the government deems worthy. Regulatory policies generally restrict or re gulate activity among the popul ation and can be further classified into two types: competitive regulatory policy and protective regulatory policy. Competitive regulatory policy “is policy that limits th e provision of goods or the participation in a market to a select group of people or organizations”; whereas protective

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58 regulatory policy “is policy that regulates some ac tivity for the protection of the public” (Birkland, 2005, p. 144). Policy analysis is a “generic name for a range of techniques and tools to study the characteristics of established policies, how the policies came to be and what their consequences are” (Collins, 2005, p. 192). Othe r definitions of policy analysis include “the process through which we identify and eval uate alternative policies or programs that are intended to lessen or resolve social, economic, or physical problems” (Patton & Sawicki, 1986, p. 17); and “an applied disciplin e which uses multiple methods of inquiry and argument to produce and transform policy-relevant information that may be utilized in political settings to resolve public problems” (Dunn, 1981, p. 60). Heineman, Bluhm, Peterson and Kearny (1990) broadly define an analyst duties as collecting and organizing data, applying the appropriate analytical techni que, clarifying the i ssues and formulating alternatives and recommendations. A policy an alysis can perform various functions, such as increase understanding of the policy pr ocess, trace a specific proposal through the policy process stages, examine the origins of a policy, evaluate th e effects of a policy, and/or suggest policy recommendations (Heineman et al., 1990). The purpose, procedures and resulting pr escriptions of a policy analysis vary depending on the specific analysis chosen. For instance, Dunn presents the following five procedures: definition; prediction; prescrip tion; description; and evaluation (Dunn, 1981); whereas Bardach proposes the following “e ight-fold path”: define the problem; assemble the evidence; construct the alternativ es; select the criteria; project the outcomes; confront the trade offs; deci de; and tell your story (Bardac h, 2005); and Patton & Sawicki created the following six-step process: verify ; define and detail the problem; establish

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59 evaluation criteria; identify alternative policie s; evaluate alternativ e policies; display and select among alternative policies; and monitor policy outcomes (Patton & Sawicki, 1986). Regardless of the analysis chosen, tr aditional policy analysis often “identify and calculate effects of policies with apolitical, objective, ne utral methods” (Marshall, 1997, p. 3). Therefore, traditional policy analyses use a positivist, gender neutral approach and ignore the fact that all approaches are political (McPhail, 2003; Shaw, 2004). Traditional tools used by po licy analysis can be extens ive and include cost-benefit analysis, decision-tree methods, simulations and models, experiments and forecasting simulations (e.g. Delphi, risk as sessment, game theory, etc.) (Heineman et al., 1990). An assumption underlying policy analysis is that decisions result from a rational process which is enhanced by the analytical tools ut ilized (Heineman et al., 1990). However, a policy analysis does not only ha ve to produce data or concrete solutions but can serve more of a “enlightenment” purpose that outlin es the issues and problems and gains new perspectives into future policy actions (Heineman et al., 1990; Weiss, 1982). Unfortunately, the potential contributions of a policy are often diminished to sheer quantitative statistics and lack real meani ng to everyday lives. An example of how a measure in health policy often ignores and doe s not recognize the beneficial impact of a policy on a woman’s life is the Disability Adjusted Life Y ear (DALY) (Berer, 2002). The DALY is an example of a calculation that is often used to assess the performance of a health service, initiative or policy and is defined as “the su m of the years of life lost due to premature mortality (YLL) in the population and the years lo st due to disability (YLD) for incident cases of the health condition” (WHO, 2008a). The DALY is a health gap measure that extends the concep t of potential years of life lost due to premature death

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60 (PYLL) to include equivalent y ears of 'healthy' life lost in st ates of less than full health, broadly termed disability (WHO, 2008a). On e DALY represents the loss of one year of equivalent full health” (WHO, 2008a). Bere r (2002) eloquently ques tions the lack of practical utility and significance of such measures as she states the following: “What about the number of years of healthy life not lost due to preventive health care and sex education? The extent of morbidity prevented over women’s lifetimes by modern contraceptive use and st erilization alone, with coverage of up to 70% of women of reproductive age in a growing number of countries, or the numbers of women not harmed because of safe abortion services, or not infertile because of STD treatment or prevention due to consistent use of condoms, are astronomical. How are these being counted? Can they really be compared to the numbers with malaria or TB a nd found less important? (p. 8) Feminist Research & Methodology Feminism can mean different things to different individuals and groups, but is generally defined as “the policy, practice, or advocacy of political, economic, and social equality for women” (Alexander, LaRosa, Bader, & Garfield, 2007, p. 10). Due to its broad yet comprehensive definition, feminism can be classified into various categories, not limited to the following: liberal; radical; Marxist and Socialist; psychoanalytic; gender; lesbian, existentialist; postmodern; multicultural; global and ecofeminism (Saulnier, 1996; Tong, 1998). Similarly, feminist research is not a “monolithic ideology;” rather, it uses multiple perspect ives, frameworks and methodologies to “shape explanations for women’s oppression and thei r proposed solutions for its elimination” (Tong, 1998, p. 2). To take on a feminist “standpoint” refers to having an awareness of the effect one’s social location can exude on one’s lived experience (Nielsen, 1990). The feminist standpoint recognizes that one ’s experiences and interpre tations help form knowledge,

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61 and thus knowledge is not value-free (Rixecker, 1994). In addition, because context and situational reality are key con cepts of a feminist standpoint, it is still important that a researcher remains objective (Rixecker, 1994). Accounting for situat ed orientation is necessary, as Harding affirms: “a feminist st andpoint epistemology re quires strengthened standards of objectivity. The sta ndpoint epistemologies call for recognition of a historical or sociological or cultural relativism – but not for a judgmental or epistemological relativism” (Harding, 1991, p. 142). Feminist research aims to eliminate biases and identify weaknesses found in traditional patriarchal models and to em brace alternative explanations, including anomalies (Nielsen, 1990). Feminist research “seeks to identify and purge andocentric bias in traditional disciplines, to reshap e dominant paradigms so that women’s needs, interests, activities a nd concerns can be analyzed and understood systematically and to develop research methodologies that ar e neither gender-biased nor gender-blind” (Hawkesworth, 1994, p. 97). Feminist resear ch questions who conducts the research, what are the underlying assump tions and hypotheses, why and how is the research being conducted, how are the results going to be applied and what are the consequences (Elekonich, 2001; Wyer, 2001). Feminist researchers often choose issues that do not have definite solutions (Reinharz, 1992). In addition, issues chosen by feminist researchers are commonly ones ignored and distorted by traditional social scie nce researchers (i.e. gendered nature of language, incest, housework) and ones that fo cus on formerly excluded groups of women (Armstead, 1995; Nielsen, 1990). Feminist scholar s use gender as a key variable as they claim gender organizes social structures and oppression (H awkesworth, 1994). Ursel

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62 (1992) re-states Meillassoux’s assertion that “‘ the origins of women’ s subordination lie in their essential and irreplaceable function as re producers’ being the core of the inequities that women continually face” (p. 24). We bb (1993) simplifies feminist research as “research on women, by women, for women” (p. 422); wherea s, Harding (1987) argues that as long as the researcher occupies the same “plane” as the subjective issue, men can also participate in feminist research. Feminist research also can be consid ered a practical application to critical theory as it challenges existing thought, rejects obj ectivity and deems knowledge as socially constructed (Nielsen, 1990). Su ch research critically examin es how social, political and economic forces shape the cont exts of women’s lives (Spa nier, 2001). In addition, the traditional “dualistic worldview” is challenged and different constructions and meanings not previously researched ar e brought to the forefront (B aker, Shulman, & Tobin, 2001). To conduct “feminist research” implies that the researcher will form a friendship while being cognizant of the challenges and cons equences of blurring the “subject-object separation,” and will become involved with both subject and research matter (Nielsen, 1990). Reinharz (as cited in Nielsen, 1990) de scribes feminist rese arch as “contextual, inclusive, experiential, involved, socially relevant, multimethodological, complete but not necessarily replicable, open to the environment, and inclusiv e of emotions and events as experienced” (p. 6). Feminist methodology combines multiple methods to “cast [the] net as widely as possible” (p. 201) so the most complete understanding of the issue can be obtained (Reinharz, 1992). The methodology often challenge s the researcher to take risks and be reflexive (Reinharz, 1992). Such research is long in duration and the “process of

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63 discovery” in this “quest for truth” (Rei nharz, 1992, p. 211) is documented. The results as well as the “journey” can be conveyed creatively in the way that its written or displayed (i.e. photography) and does not have to follow the traditional scientific report (Reinharz, 1992). Since there are many inte rpretations of feminist research, it is impossible to describe such exhaustive re search in a concise manner. However, Appendix B provides a list of Ch aracteristics of Feminist Soci al Research as described by Neuman (2003a). In essence, feminist me thodology is part of a “larger intellectual movement that represents a fundamental shift away from traditional social science methodology” (Nielsen, 1990, p. 1). Feminist Policy Analysis A feminist perspective of policy analysis is defined as “the portion of problem definition in which actors, their motivations and beliefs, their resources, and the various decision sites are systematically scrutinized in order to unde rstand what characteristics a successful solution must have” (Patton & Sawi cki, 1986, p. 133). Political factors are an integral component of the a policy analysis (Patton & Sawicki, 1986). Patton & Sawicki (1986) discuss the terms that should be incl uded when conducting a po litical analysis as outlined by Arnold and Meltsner: actors; motiv ations; beliefs; resources; and sites. Actors involve individuals or groups that are concerned or are currently/potentially involved with the problem (Patton & Sawick i, 1986). Motivations are the “motives, needs, desires, goals, and objectives of th e actors” (Patton & Sawicki, 1986, p. 134). Beliefs refer to the values and attitudes he ld by the actors and participants (Patton & Sawicki, 1986). Resources can include such things as money, time and skills that actors’ possess and making the best use out of the resources (Patton & Sawicki, 1986). Sites

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64 refer to the who, where and when questions regarding the policy (i.e. administrative procedure) (Patton & Sawicki, 1986). Th e extent of how political a public policy problem is can vary; whereas problems with no political issues can focus entirely on the technical aspect of the policy as they are fr ee from such political constraints (Patton & Sawicki, 1986). Feminist scholars have researched and put on the agenda various critical policy issues that directly and indi rectly affect women (i.e. insu rance, pensions, affirmative action, pay equity, welfare, family leave, rape, child care, domestic violence, housing, etc.) (Hawkesworth, 1994). Th e second-wave of the feminist movement (1970’s) can be known as the platform where organizations a nd actors rallied for change for existing policies and the development of new policies which affect women (Mazur, 2002). Such a platform is an example of a policy window, as the women’s health movement in the 1970’s facilitated putting various programs and services on the political agenda. A central premise of feminist policy is the recognition of econo mic, cultural and political factors embedded throughout the po licy cycle (Hawkeswor th, 1994). Marxist feminists have argued the inte rconnectedness of family, market and state systems (Scott, Thurston, & Crow, 2002). Feminist scholarship contributes to polic y analysis by being receptive and aware of the context that su rrounds policy (Rixecker, 1994). Feminist standpoint epistemology also contributes to policy analysis by providing a more varied toolbox and allowing the analyst to choose the most appropriate methods for that particular policy and context (Rixecker, 1994). Because there is no one feminist approach, there is often not a unifying consensus of elements that make a policy women friendly (Gottfried, 2003).

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65 Similar to other social issues, policy pe rtaining to health often marginalizes young, poor and minority women (Munch, 2006). Fe minist policy can reveal how race, class and sexuality are often packaged w ith gender, and recogni zes the fallacy of clumping all women in one group (Marshal l, 2000). Kriege r and Fee (1994) acknowledge the role of social epidemiology w ithin reproductive hea lth issues as they state the following: “reproduc tive ills are not simply asso ciated with the biological category “female” but are differentially e xperienced according to social class and race/ethnicity” (Krieger & Fee, 1994, p. 272). Unfortunate ly, marginaliz ed populations often do not have the power or voice to advocat e for their rights. However, it is this group that necessitates publicly funded re productive health se rvices, as bell hooks eloquently states, “more people occupy the margins than the center” (hooks, 1993, p. 399). Even though previous scholars have di scussed the importance of including a feminist perspective when analyzing a polic y, such works present the theoretical and practical implications inherent within a policy without prescribing a methodology or framework in carrying out such a task. For instance, Marshall presents a discussion of the theories and implication of conducting a Critical Feminist Policy Analysis, a relatively new field of inquiry, by applying th is analysis to the field of education (Marshall, 1997). Marshall (1997) argues that traditional polic y analyses need to be dismantled and reconstructed. Methods for broadening a nd reframing questions should arise from theories and methods that include notions of gender, power and politic s (Marshall, 1997). Policy analyses should:

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66 recognize value-driven agendas and those that identify the dominant narratives driving policy and the ways they become dominant. This is where we connect the world of politics, policy analysis and feminist and critical theory, framing analyses that aim to uncover how policies a nd politics (in the form al arena and in the politics of silence and am biguity) continue to disadva ntage girls and women in education systems and conduct analyses with the purpose of upsetting such systems of dominance. (Marshall, 1997, p. 8) An analysis should include multiple key st akeholders’ perspectives, which often are conflicting, to help voice key stakeholders’ st ories and raise question that might have otherwise not have been heard (Marshall, 1997). In general, a critical feminist policy analysis is informed by feminist theory a nd develops questions that examine gender in the myriad of policy issues that affect indi vidual’s lives everyday as well their overall lived experiences (Marshall, 1997). Furthermor e, utilizing a feminist critique highlights “questions about what is public and what is private and who decide s” (Marshall, 1997, p. 18). Bensimon & Marshall (2003) indicate that the following attributes of a welltrained policy analyst can fac ilitate change concerning how higher learning institutions approach studying policy: 1. Recognize that past policies construc ted in arenas where the discourse was conducted without feminist critique ar e flawed and conduct policy archeology (Scheurich, 1994, cited in Bensimon & Marshall, 2003); 2. Re-construct policy arenas and discour ses, knowing the need to engage and even champion the needs and voices of pe ople heretofore excluded, or included in token ways; 3. Include feminist questions as they sc rutinize decision premises, language, and labels while constantly asking, “what do feminisms tell me to critique?” 4. Employ alternative methodologies (e.g., narr ative and oral history) to uncover the intricacies of meaning systems in individuals and collects stories both to

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67 expose the emotional and personal results of exclusions but also to create alternative visions that tr anscend boundaries “to shape the formation of culturally appropriate social and educationa l policy” (Gonzalez, 1998, p.99, cited in Bensimon & Marshall, 2003) 5. Search for the historically created and embedded traditions, social regularities, and practices that inhibit women’ s access, comfort, and success; 6. Take an advocacy stance, knowing that policy analysts are change agents, carriers of insurrectionist strategies and subjugate d knowledges that will be subjected to discourses of derision by powerful forces benefiting from the status quo. (p. 346) Buse et al (2006) argues: …what is needed is a continuing appro ach to collection of information and development of understanding on four elem ents central to policy-making: opportunities and constrains within the po licy context of a sp ecific sexual and reproductive health issue; the formal and informal processes by which decisions are made; the stakeholders who might be affected by a proposed reform; and the influence, interests, positions, and degree of commitment of various stakeholder groups in relation to a specific policy fo r sexual and reproductive health…. we need to undertake political analysis; to understand the ideas, interests, and institutions operating within a pa rticular policy c ontext (p. 2101). The Feminist Policy Analysis Framework McPhail (2003) determined that “there is not an explicated policy framework that lists a set of questions that constitutes a fe minist standpoint” (p. 41) and thus, developed her own “Feminist Policy Analysis Framework: Through a Gendered Lens”. The primary purpose of a framework “is to provi de the analyst with a model – a set of questions – for systematically analyzing a policy” (Karger & Stoe sz, 1998, p. 41). The framework chosen should match the scope of the project as well as correspond with the analyst’s ideology, values, di scipline and skills (McPhail, 2003). McPhail’s FPAF presents questions that can systematically guide an analyst duri ng a policy examination

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68 (McPhail, 2003) and can and should be applied to all policies as all policies affect women and are “gendered if we just ask the questi ons that expose the gendered assumptions and implications” (McPhail, 2003, p. 44). McPhail (2003) asserts that the goals of the framework are the following: to make women visible; to end the sexi st oppression of women; to be clear but to not introduce bias when using the model; and to incl ude men and women into a picture which previously only included men. Ensuring that women are present in a policy refers to recognizing how women are treated similarly or differently in comparison to men, how the policy is rooted in assumptions and stereotypes concerning women, and how the policy regulates and/or constrains the lives of women (McPhail, 2003). Ending women’s oppression involves empowering women and ensuring equal power within society (McPhail, 2003). Because policies are not value free, the framework acknowledges bias and sets forth the goals of the analysis fr om the beginning. Furthermore, the framework includes men and women in its gendered analys is as “feminist anal ysis is about putting women into a picture that has largely been drawn by men. But it is about rethinking, and, in the end, about drawing a new picture th at includes women and men” (Pascall, 1997, p.10, cited in McPhail, 2003). McPhail’s FPAF includes many questions that can be asked during a policy analysis which fall under the following thirteen constructs listed below (McPhail, 2003). See Appendix B for the Feminist Policy Framework: Through a Gendered Lens.

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69 Values State-market control Multiple identities Equality Special treatment/protection Gender neutrality Context Language Equality/rights and care/responsibilit y Material/symbolic reforms Role change and role equity Power analysis Other McPhail (2003) admits that the questions are not and can never be complete and that asking all of the questions that are listed in a policy analysis is not feasible. However, these questions can assist in systematically analyz ing a policy through a feminist lens (McPhail, 2003). Values Determining whether core feminist values are present within the policy could be questioned through using this fr amework. McPhail (2003) lists numerous feminist values that result from previous fe minist literature as well as from the National Association of Social Work: e limination of false dichotomies; the reconceptualization of power; valuing process equally with product; renaming or re defining reality consistent with women’s reality; acknowle dging that the personal is political; holism, nonhierarchal relationships; acceptance of a spiritual di mension; diversity; collectivity and the importance of connections or webs of relati onships; commitment to social justice; and respect of the inherent dignity and wo rth of all people (McPhail, 2003). State-market control Although McPhail does not explicitly discuss this construct, the questions that she lists under this c onstruct in her framework involve issues relating to work, social control, and the how women’s gender relationships could make them vulnerable or dependent on the state or men (McPhail, 2003). Multiple identities As mentioned above, there are multiple forms of feminisms such as, but not limited, to the following: liberal; radical; Marxist and Socialist;

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70 psychoanalytic; gender; lesbian, existentia list; postmodern; multicultural; global and ecofeminism (Saulnier, 1996; Tong, 1998). Th erefore, McPhail (2003) wanted to be inclusive and not restrictive in which feminist perspectives informed the questions in the framework to assist in illuminating any contradi ctions present within the policy as well as to enrich the overall policy analysis. In addition, McPhail (2003) acknowledges that a woman’s identity does not only encompass her gender, but her “race, ethnicity/national origin, sexual identity, class, religion, and level of ability” (McPhail, 2003, p. 51). Collins (2000) posits the terms “intersectional ity” and “matrix of domination” to refer to the overlapping identities and how these id entities are organized to oppress women, respectively (McPhail, 2003). Equality Even though The Declaration of I ndependence claims that all men are created equal, throughout history women have be en fighting to have the same rights that are granted to men, as demonstrated by the Equal Rights Amendment proposal (McPhail, 2003). However, notions of equality have been debated among feminist scholars and the idea concerning whether women are fundamentally similar or different than men is still ongoing (McPhail, 2003). Similar to other cons tructs in this framework, equality can both advance and deter women’s rights and oppo rtunities. For instan ce, “while treating women the same as men would provide a sign ificant improvement in the lives of many women, treating men and women the same will not solve the problems of institutional discrimination. In such a stratified societ y, similar treatment is inherently unequal treatment” (Kendrgian, 1991, p. 221 cited in McPhail, 2003). Special treatment/protection The treatments and prot ection that are given to women can be both liberating a nd regulating (McPhail, 2003). In some instances, women

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71 will be granted with certain protections only wh en they are viewed as being different then men as illustrated in the following example: …the Supreme Court ruled in Cal. Fed. V. Guerra that there is no contradiction between the Pregnancy Discrimination Act of 1978 and the California statue that mandates unpaid maternity leaves of up to four months. To the extent that pregnancy is like other tem porarily disabling conditions, the PDA treats it as such. To the extent that it is different – it produces a baby – the st ate law treats it as different. (Baer, 1999, cited in McPhail, 2003, p. 49) In addition, in the past such “s pecial treatment” was used to exclude women being able to hold certain jobs and pos itions (McPhail, 2003). Gender neutrality Similar to the constructs of equality and special treatment/protection, the gender neutrality of a policy can be both helpful and harmful (McPhail, 2003). For instance, the same po licy can differential impact women and men, as on one side women may need to be recogniz ed as being a gender th at requires special provisions, where on the other side women may need to be recognized in a gender neutral light so they are not afflic ted by the differential impact of a policy (McPhail, 2003). Context As states above, the economic, political and social environments in which women live are critically important wh en analyzing a policy (McPhail, 2003). In addition, the context can refer to the location of the policy or the historical underpinnings in which that policy exists (McPhail, 2003). Mo reover, the context can also be the effects and/or implications that one policy has on another policy (McPhail, 2003). For example, a federal bill that seeks to ma ke killing a fetus a separate criminal charge in addition to the charge related to violence against a pr egnant women, may appear to benefit the women; where in actuality su ch a bill may be grounded in an anti-choice motive which really is attempting to overtu rn Roe v. Wade (McPhail, 2003).

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72 Language The language used within a po licy can help to include women; however, the language used can also assist in covering up the overt ge ndered nature that arises from the social problem and thus the ge ndered nature that carri es over to the policy (McPhail, 2003). For instance, using the term firefighter inst ead of fireman helps include women into the profession by making the polic y gender neutral (McPhail, 2003). On the other hand, using the term parent in a welfar e policy ignores the fact that most welfare assistance program recipients are female, thus covering up the overt gendered nature of the policy (McPhail, 2003). Equality/rights and care/responsibility This construct refers to the public and private spheres in a woman’s life and how “wom en will continue to be disadvantages in the public sphere as long as they are unequa lly burdened with caretaking work in the private sphere” (McPhail, 2003, p. 52). Women being at a disadvantage because of these two spheres can be referred to as an imbalan ce between equality and care or rights and responsibilities (McPhail, 2003). The burden of such work and commitment should not fall only on women, but should be shared by the government, corporations and men (McPhail, 2003). Material/symbolic reforms Symbolic reforms are ofte n a “legal redress” of a policy issue that stems from policymakers needing to improve their public image or needing to gain more political support from certain populations (McPhail, 2003). On the one hand, symbolic reforms typically have little resource a llocation, political enforcement, and thus does not produce polic y outputs or have a large impact on the social problem when compared to material reforms (McPhail, 2003). On the other hand,

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73 symbolic reforms can serve as a platform th at creates an increase in activism around an issue and can serve as a bridge for fu ture policy initiativ es (McPhail, 2003). Role change and role equity Role equity is often easier to achieve than role change as role equity refers to providing th e same rights to women so they can access and benefit from the same opportunities that have been previously granted to men (McPhail, 2003). Role change is often more difficult as it strives to create new roles for both men in women in the quest of improving women’s role and often challenges and threatens the power traditionally held by men (McPhail, 2003). Power analysis Power can contribute to the formation of a problem, or can influence the development of a policy and the policy outcomes (McPhail, 2003). The individuals or entities that hold power before, during a nd after a policy, and the presence of any shift in power could be examined in a policy analysis (McPhail, 2003). Other Although McPhail does not explicitly di scuss this construct, the questions that she lists under this cons truct in the framework appear s to be a section that can address miscellaneous issues. For instance, how the problem is soci ally constructed and represented, how the policy undermines any previous policy gains for women, and how feminist scholarship informs the policy issues are listed as possibl e questions that an analyst could ask during a feminist policy analysis. Application of The Feminist Policy Analysis Framework McPhail’s FPAF has been used to conduct a feminist comparative policy analysis of the State Children’s Health Insurance Progr am (SCHIP) in the stat es of California and Texas (Kanenberg, 2007). This study aimed to examine whether the SCHIP Program was a gendered and an oppressive policy for women and the overall policy’s effect on

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74 women (Kanenberg, 2007). In general, the study found that the pol icy is gendered and oppressive for women as “patriarchal assu mptions of women in relation to family, household, and economy were found in the areas of SCHIP that relate to eligibility for services and service delivery (Kanenberg, 2007, p. iii). However, it was also found that the policy challenged “tradi tional androcentric norms of women’s dependence upon men and partners by encouraging women’s partic ipation in the labor market” (Kanenberg, 2007, p. iii). Furthermore, it was found that SC HIP redirects women’s reliance from their partners to the state and that SCHIP restricts women’s “capacity to make choices or take actions without penalty in relation to labor, employment, health, wellbeing, and autonomy” (Kanenberg, 2007, p. iii). Kanenberg (2007) concluded with a set of strengths and limitations from using McPhail’s FPAF. Kanenberg (2007) iden tified the framework as being a “strong mechanism” in examining a policy as it explic itly provides questions that an analyst can ask. The constructs within the policy allowe d a deeper examinati on into how the policy includes and affects women, an examination th at is absent among other policy analyses (Kanenberg, 2007). However, McPhail’s FPAF was lengthy and time-consuming and thoroughly including all of the constructs may not be feasible; thus que stions may need to be re-structured based on th e particular policy topic (Kanenberg, 2007). In addition, Kanenberg (2007) found that the framework does not adequately examine whether the policy is gendered or oppressive to women a nd thus added these overarching questions to her analysis. Furthermore, even though the framework acknowledges the multiple feminist approaches, notions relating to cla ss and race were not overtly stated, and thus

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75 should be included, especially when analyzi ng policies that affect low-income women (Kanenberg, 2007).

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76 CHAPTER THREE: METHODOLOGY Qualitative research explores the “broader psychological, social, political, or economic contexts in which research questi ons are situated” (Ulin et al., 2005, p. 139). This study was grounded in a feminist policy analysis approach and utilized a mixed qualitative methodology design cons isting of a thematic analysis on Title X’s legislative history and the conduction and analysis of or al histories. Through these methodologies, the research strived to gain a deeper unde rstanding of the various issues that are embedded within this policy and to highlight key areas of concern, which can help guide future policy actions. Purpose of the Study The purpose of this study was to explore the maturation of Title X since enactment and to critically examine the myri ad of barriers that it has confronted. Examining the evolution of a policy over time is crucial in understanding the dynamics of that policy (Gottfried, 2003) “Greater understanding of historical antecedents and achievements and the various ways gender-biase d beliefs and attitude s have and continue to permeate women’s health care practice, pol icy and research is vital …[in order] to foster change” (Munch, 2006, p. 28). Justification of a Feminist Policy Analysis The research questions and methodologies were employed through a feminist lens to assist the researcher in critically examin ing the various political barriers that have

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77 undermined Title X and to understand these i ssues through the perceptions of key Title X and family planning stakeholders. Previous Title X analyses and evaluations have focused on outputs, funding needs, and the growin g role of providers. However, there is a paucity of research that cr itically examines the broader political, economic and social factors embedded within Title X and what this policy means for women and the greater community. A feminist policy analysis was conducted as family planning policy predominantly affects women and children and was, and largely remains today, legislation that is dominated by patriarc hal views and assumptions. In addition, a feminist policy analysis incor porates many issues related to power, control, context, language, equality and rights; co ncepts that are not only abse nt, but which are completely disregarded in traditional policy analyses. Also, a feminist policy analysis takes into account the controversial nature of a policy and the fact that the issues inherent within a policy are value-laden. Furthermore, a feminist policy analysis recognizes and appreciates the multiple perspectives and identi ties inherent within feminist research, thus is more inclusive in comparison to other pers pectives. Moreover, using a feminist policy analysis allows for multiple methodologies to be used and recognizes the political and value-laden nature of policies. Therefore, because Title X involves women, sexuality and reproduction, and populations that are pre dominantly low-income and young, a feminist policy analysis was an ideal theore tical and methodological approach.

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78 Phase I: Thematic Analysis of Title X’s Legislative History Research Questions Phase I involved critically analyzing the legislative history of Title X, which includes House and Senate bills proposed between the 91st Congress (January 3, 1969) and the 110th Congress (ending on August 31, 2008), through the iden tification of common themes that have emerged over the lif e of this policy. The specific research questions for Phase I were the following: Question 1: What legislative bills that propos ed changes to Title X were enacted into law? Question 1a. What changes did Title X incur from these enactments as reflected in the language of its public law? Question 2: What are the themes that emer ge from the proposed legislative bills? Question 2a. Do the themes that emerge from the proposed legislative bills differ depending on whether they were enacted into law? Question 2b. What are the themes that emerged from the proposed legislative bills by administration? Question 2c. How do the proposed legisla tive bills challenge or support Title X for each of the themes that emerged? Sources of Data A thematic analysis was performed on th e latest full text version of the bills (N=293) that are included in Title X’s legi slative history (see Supplemental Appendix). As mentioned in the literatur e review (see Chapter #2), th e Congressional Record and LexisNexis Congressional were the two secondary sources of data used to conduct a

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79 systematic search of House and Senate bills that proposed amendments to Title X. Multiple search terms were used to produ ce the most comprehensive review and to ensure the net was cast wide enough to incl ude all applicable bills and included the following: abortion birth control contraception(ive) family planning health population public health Public Health Service Act (Congressional Record); and Title X AND family planning Title X and family planning (LexisNexis Congressional). Data Analysis Qualitative data analysis assisted the researcher in analyzing all of the data collected and in interpreting th e context and meaning of such data (Ulin et al., 2005). Various approaches to qualitative data anal ysis exist; however, because the qualitative data for this phase of the st udy consists of secondary data, data were analyzed using the in-depth and interrelated st eps as outlined in Ulin et al (2005): reading, coding, displaying, reducing, and interpreting. First, the researcher was immerged into the data by reading the texts multiple times and taking notes (Ulin et al., 2005). Du ring the continuous reading, labels or codes were attached to the emerging themes (Ulin et al., 2005). Analytic memos were used to document the researcher’s reasoning and thoughts during the coding process. The analytic memo linked the data to the research er’s interpretation and helped establish how each theme was coded. Pieces of texts were displayed and classified by their thematic areas (Ulin et al., 2005). The displayed them es were then reduced to essential points (Ulin et al., 2005). Interpreta tion of the data was ongoing an d indicated how the themes relate, diverge, and apply to the research questions and how meanings related to the context of the policy as well as beyond (Ulin et al, 2005). The researcher kept a separate

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80 personal analytic journal to record their though t process, interpreta tion and any questions that emerged, and to record their personal t houghts, feelings and pe rception and how such ideas and emotions might influence/bias the inte rpretation of the results. Gaps within the meanings of the texts as well as other una nswered questions that emerge from the analysis were documented and further addressed in Phase II. Reliability of Coding An additional researcher who holds an advance degree in public health (PhD) and who has expertise in qualitativ e data collection and analysis was solicited to review and code a proportion of the legislative bills to ensure coding was conducted in a reliable, consistent and accurate manner. Originally, it was proposed that the additional researcher would review and code 10% of the legislativ e bills – one-half of these bills would come from the full text of the bills that were retrieved by microfiche (Congress Sessions 92 100) and one-half of these bills would come from the full text of the bills that were retrieved through the online da tabase (Congress Sessions 101 -110) (see Chapter #2 for a description of these two databases). However, because there were more bills included in Title X’s legislative history than anticipated and to ensure that a greater variety of bills (bills that contained differe nt purposes and language) were reviewed by the additional researcher, 10% of the bills originating from microfiche and 10% of the bills originated from the online database were reviewed (N=38). The two researchers (the primary and the secondary researcher) independently reviewed and coded the bills over a total series of five meetings. During the first reading, both researchers reviewed and coded the bills independently and then met to discuss the codes that were applied and the reason ing behind the coding. Any discrepancies

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81 regarding the coding were disc ussed, and the boundaries fo r each of the codes were established to ensure that each code was mutually exclusive. An initial codebook consisting of the agreed upon codes was then developed and used for subsequent coding. As new codes were established they were added to the codebook and discussed between the two researchers. The bills that were revi ewed were divided into four phases, thus the above procedure for the reliability of coding was done over four meetings. To further establish inter-ra ter reliability afte r the final series of coding, the two researchers met again for a fifth time to review all of the codes and the sections of the bills that were coded to ensure the codes prope rly described that particular section of the bill text and to ensure that coding was bei ng performed in a systematic manner. The additional researcher found no evidence of resear cher bias from the primary researcher. Any discrepancies revealed during the reliabil ity of coding were not due to the coding procedure or the attachment of codes, but were only due to the actual labels of the code. Both researchers applied similar codes and meanings of the codes; however in some cases the actual code name differed sli ghtly, and thus the researchers agreed upon a single code name to describe each of the codes. Phase II: Oral Histories Background on Oral History Oral history “collects spoken memories a nd personal commentaries of historical significance through recorded in terviews” (Ritchie, 1995, p. 1). Oral history can be traced back over three thousand years a go when peoples’ sayings in China were collected, over two thousand y ears ago when the ancient Gree k historians collected oral

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82 histories, and then finally to one of the earliest recorded oral history transcript held at the Columbia Oral History Resear ch Office that contains tes timony of the bloody New York City draft riots of 1864. (Davis, Back, & M acLean, 1977; Ritchie, 1995). However, the modern oral history movement is often cred ited to historian Allan Nevins of Columbia University who initiated an oral hist ory program in 1948 (Davis et al., 1977). Oral history as a methodology is multidisci plinary and is not exclusive to people who have a degree in history (Ritchie, 1995). Ho wever, it is expected that the principles, standards and guidelines set fo rth by the Oral History Associ ation are abided by and the ethics and rigorousness of this particular methodology are sustained (Ritchie, 1995). See Appendix C for Principles and Guidelines of Oral History Associ ation and Appendix D for Oral History Evaluation Guidelines. Sim ilar to interviews, both the interviewer and the participant engage in an interaction and produce a jo int product. However, “an interview becomes an oral history only when it has been recorded, processed in some way, made available in an archives, librar y, or other repository, or reproduced in relatively verbatim form as a publication” (Ritchie, 1995, p. 6). Thus, an interview can be labeled an oral history if a researcher conducts the interview in the above manner at the same time upholding the ethica l and legal standard s (Ritchie, 1995). In essence, by preserving the interview the researcher leaves candid data in its most primitive source for future examination and interpretation by ot her researchers and for general public use (Ritchie, 1995).

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83 Justification of Oral Histories Oral histories can be employed as th eir own methodology or can be combined with other methodologies to assist the rese archer in obtaining a more comprehensive understanding of a particular phenomenon, proce ss or event. Specifically, oral histories can supplement other data and/or knowledge that have been collected, fill in any gaps in available data or in the researcher’s analys is, document stakeholders’ perceptions on an issue, and help identify any trends over time (Ritchie, 1995). Oral histories help researchers understand how people make se nse of a phenomenon and elicit people’s motivations and subsequent behaviors rega rding that phenomenon (Ritchie, 1995). The “how” and the “why” are important questions in which answers can often not be found in other factual-type sources (Ritchie, 1995). Therefore, the purpose for conducting oral histories is “to ask the questions that have not been asked a nd to collect the reminiscences that otherwise would be lost ” (Sullivan, C.L., cited in Ritchie, 1995, p. 21). In addition, feminist researchers have relied on oral histories as one of their tools in their toolbox of methodologies; thus, conducting oral histories aligns with both the theoretical and methodological nature of this project. Justification of the State of Florida as a Case Study Florida was chosen as a case study in whic h past key Title X stakeholders for the oral histories will be sampled from for several reasons. First, the state of Florida is the 4th largest state in the na tion (U.S. Census Bureau, 2000), consists of a diverse population (U.S. Census Bureau, 2006), includi ng special population groups such as immigrants, migrant workers and the elderl y, and greater than 20% of its population (n=2,819,200) are uninsured (Families USA, 200 3). Second, the stat e of Florida ranks

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84 poorly in many reproductive health outcomes. Florida ranks last in the prevalence of current reversible contraception use among women 18-44 years (Sappenfield, 2007), has the 6th highest teen pregnancy rate, and has the 2nd highest AIDS rate (The Healthy Teens Campaign, n.d.) in the U.S. See Table 7 for additional Selected Teen Reproductive Health Indicators, Florida vs. United States). Third, because the research is grounded in feminist epistemology, the researcher’s s ituated orientation being a woman and currently residing within the state positioned the context of the policy and the location of the case study to be advantageous (Laible, 1997), as this phase of this study involves examining personal experiences and recollect ions from family planning stakeholders regarding Title X at a state-level. Instrument Development and Refinement The oral history interview guide was developed based on themes and findings from the thematic analysis on Title X’s le gislative history and from pre-determined constructs identified from McPhail’s Femini st Policy Analysis Framework (MFPAF). In addition, questions were devel oped to allow participants to reflect and provide their understandings of the achievemen ts and challenges that this policy exudes, and to provide personal examples and stories from their experiences. An interview guide was drafted based upon the themes and constructs mentioned above, and was reviewed by a panel of expert s (N=6), which included individuals with expertise in reproductive health, adolescent health, qualitative research, feminist research methods, and public health policy, and who hold a doctoral degree (PhD or MD), and included the author who devel oped the framework. Feedback from the panel of experts was positive and minor changes suggested i nvolved re-framing and re-wording questions

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85 to reflect practical experience instead of theoretical orienta tion, and re-ordering questions to enhance the organization and flow of the interview. There was only one construct, equality/responsibility which necessitated more thought and refinement compared to the rest of the interview guide. The equality/responsibility construct in MFPAF involves balancing the rights and res ponsibilities among women and me n in relation to women’s “adopted roles”. This construct is very rele vant to this policy; however, because 95% of Title X clients are women and the fact that women are the individuals who have greater responsibility biologically, incor porating a question that includ es the role of men required more modification and dialogue. Pilot-Testing The interview guide was pilot-tested w ith two individuals who have extensive knowledge in reproductive heal th and maternal and child health, including knowledge and experience with national and state policies, programs, and best practices that focus on improving women’s health. Neither of the i ndividuals who participated in the pilottesting were then eligible to be incl uded in the final oral history sample. The procedure for conducting the pilot or al histories mirrored the procedure that was implemented for the final oral historie s. The pilot oral histories followed the interview guide, which also included opport unities to discuss ot her information and experiences that perhaps was not covered thr ough the pre-constructe d questions. At the conclusion of the oral history, several feas ibility and administration questions were asked, such as the following: Was the length of the interview sufficient to adequately address all of the questions? Where there any questions that you were not able to respond to?

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86 Are there any questions or issues that you think are important to include that we did not discus during the in terview given the purpose and realm of this study? o For instance, were there any questio ns that did not make sense given the purpose and realm of this study? Overall, are there any other comments that you would like to make regarding the administration or content of this interview? In general, feedback regarding the oral history was very positive. The overall feasibility and the administration of the interv iew, the validity of a nd appropriateness of the interview guide, and the length of the in terview were deemed acceptable. However, similar to the feedback received during the c onstruction of the interview guide, the pilot sample participants stressed the importance of delivering questions that were practical (practice-based) and to transl ate any theoretical-orientated questions into statements that concern personal values, percep tions and experiences, in orde r for the participants to better understand and answer the questions. See Appendix H for the final Oral History Interview Guide. Procedure Davis (1977) outlines the follo wing 8-step process of an oral history: 1) Getting Ready; 2) Interviewing; 3) Tr anscribing; 4) Auditing; 5) Ed iting; 6) Finishing Touches; 7) Serving Users; and 8) Reaching the Public. All of the steps with the exception of the last two steps will be used in this study. St ep 7, “Serving Users,” will be omitted as this step involves the following: indexing tapes; indexing transcripts; creating an authority file; cataloging a collection; creating an inte rnal tracking system; and developing a shelf list (Davis et al., 1977). Step 8, “Reaching the Public,” will be omitted as this step involves the following: book cat alogues; regional and stat ewide cooperation; published biographies; additional repositories; microfil ming; and publicity (Davis et al., 1977).

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87 These last two steps will be the performed by the Special Collections Department at the University of South Florida Library (Tampa campus). However, the researcher will be the individual that is responsib le for all of the other steps (Step 1 through Step 6) in the oral history process. Getting Ready Davis et al (1977) asserts that “careful planning and pr eparation are key elements in successful oral history interviewing” (p. 9) Preliminary research is imperative and provides many benefits to the interviewer, par ticipant as well as to the product itself. Having a prior knowledge of a topic can assist when developing the structure and content of the interview guide, and can assist the interviewer in probing specific content areas that need clarification or seem contradi ctory (Ritchie, 1995). In addition, conducting preliminary research will allow the intervie wer to engage in a 2-way conversation with the participant, and to interject if the part icipant gets too far off topic or is having a difficult time remembering something (Ritchie, 1995). Therefore, the oral histories were conducted after the thematic an alysis of Title X’s legislat ive history (Phase I) so the researcher was emerged in the information related to Title X and family planning. Sampling and recruitment. Types of oral histories can include biographical projects, topical projects or pr ojects focused on a particular event, and thus, interviewers select participants based on the purpose and scope of their project (Davis et al., 1977). The oral histories for this st udy are classified as a topica l project and the researcher selected individuals who 1) had an integral role in the admini stration, oversight, or implementation of the Title X and family pl anning program in Florida or who 2) were policy makers and played a role regarding this policy at the governmental level.

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88 Sequential and snowball sampling was used to recruit participants. Sequential sampling was used to select potential pa rticipants based on specific char acteristics that they possess (i.e. past/present employment position, experience with the Title X and family planning program, etc.) and to select participants that would provi de valuable information and would bring a deeper understanding to th e research (Neuman, 2003c). Purposive sampling is another common sampling techni que that researcher s use in selecting particular people or cases but was not used in this study. The major difference between these sampling techniques is that in purposive sampling the researcher selects an exhaustive list of people/cases until it is no l onger feasible for the re search to enroll new people/cases (i.e. time, financ ial resources, effort, etc.); whereas in sequential sampling, the researcher selects people/cases until there is some diversity present within the sample and when saturation is reached (Neuman, 2003c). Snowball sampling is another sampling technique that was utilized to identify potential participants. Snowball sampling refe rs to receiving referrals from one or two cases and in which those next cases identif y additional referrals, and so on (Neuman, 2003c). In snowball sampling, the cases iden tified will have some sort of link or connection with one or more of the other peop le in the network, and the researcher stops enrolling additional participants into the study for various reasons, such as if the network is getting too large and it is no longer realistic to include all potential participants and/or no new names are identified (Neuman, 2003c). In addition, sequential and snowball sampling also aided in selecti ng participants who differed in their opinions regarding the Title X program and who also differed in thei r personal and professional values regarding

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89 reproductive health, family planning, and th e function and purpos e of public health clinics in general. Specifically, prospective participants we re identified from communication with past and current Title X, family planning a nd other reproductive hea lth stakeholders. A list of potential participants was developed and the researcher attempted to prioritize the names according to the various relevancies: the job position that was held (or currently hold); the expected expertise a nd knowledge that they possess regarding this topic and/or the particular research questions; and by name s that are continually identified as being critical people to interview. Those individuals who did not curre ntly reside in the state of Florida were excluded from the sample. Ritchie (1995) argues that meeting a nu merical expectation in regards to the number of interviews conducte d can sacrifice the depth and quality of the interview. Moreover, Ritchie (1995) points out that human istic reasons, such as participant’s age, accessibility, health and willingness to share information, can also interfere with the number of interviews that ar e able to be collected. However, adequate numbers of interviews need to be conducted to capture a range of people’s reco llections, perceptions and thoughts regarding Title X and family plan ning services in Florida. Therefore, conducting approximately 8 oral histories was projected. Because oral historians often interview the “gatekeeper” of that community or phenomenon who is thought to have the most e xpertise and who is often the oldest in age (Ritchie, 1995), such persons will be contacte d first. However, because of geographical, time, cost and other feasibili ty constraints of the resear cher, as well as any possible limitations that potential participants might face, the order of the interviews needed to be

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90 flexible. The initial contact for potential participants was done via telephone, email or postal mail, depending on the type of contac t information the researcher was able to obtain during the sequential and snowball sampling. The following information was explained to potential participants: an intr oduction of the research er; the purpose and the scope of the study; why they were being consid ered as a valuable source (i.e. their past experience in a particular position); what they could expect to happen during the interview; an explanation of the Legal Rele ase Form (transferring the copyright of the interviews from the participant to the interv iewer for publication purposes); how the data would be stored; and the intende d distribution and implication( s) from the results of the study (Davis et al., 1977; Ritchie, 1995). If the initial contact was done via telephone, those participants were sent th e same letter that is given to participants who were first contacted by email or postal mail. See Appe ndix E for Sample of Oral History Project Letter. It was important for the participants to have a written document that explains the scope of the study, what will be expected from their participation, and the researcher’s contact information for future reference and to establish legitimacy (Ritchie, 1995). In addition to collecting information related to a participant’s job position and expected expertise, other background information were also conducted prior to the interview, such as Curriculum Vitas and a review of any pertinent public and/ or professional publications that participants authored or that were written about them. Interviewing Setting. The location of the interviews was at a place that was convenient for the participant. It was assumed that most interv iews would occur in a city in Florida in which the participant was curre ntly residing, and would be ei ther at the participant’s

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91 place of employment or their home. However, if none of those places were appropriate, the researcher made other arrangements where the interview could take place (i.e. reserve a conference room at a local library, etc.). The ideal location of the interview was a comfortable room that is private, quiet and free from distractions (Ritchie, 1995). The actual interview was expected to ta ke approximately one and a half to two hours (Ritchie, 1995). Ritchie (1995) acknowledg es that there is no ideal length of an interview and that it is the in terviewer’s responsibility to a ssess the participants’ status with regards to attention span and fatigue However, the whole interview process, including equipment setup/takedown, Inform ed Consent and Legal Release Form, the actual interview and the post-interview/debr iefing discussion was expected to last approximately two and a half hours. Interview procedure. The researcher used the inte rview guide to help keep the interview semi-structured and focused, and to help elicit information that was specific to the research questions and the a priori themes. The preliminary preparation (Step 1: Getting Ready) that had been done prior to the interview was greatly be neficial during the interview as the inte rviewer was knowledgeable enough on the subject matter to provide names, dates and questions in a non-leadi ng manner which kept the conversation moving (Ritchie, 1995). However, at the same time the interview was also flexible in order to capture the participants’ candid stories, e xperiences and perceptions. Being flexible during the interview was an important element to oral histories as well as to the purpose of this study as it allowed data to be gathered and shared an d lead to greater insight on this topic that might have not otherwise been obtained throug h other methodologies.

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92 After the interviewer asked any other addi tional questions that might have arisen during the interview, the interview was concluded with a natural “wrap-up” question (Ritchie, 1995). This last portion of the in terview consisted of a general question that was not addressed earlier “something that causes participants to reflect on their lives, to compare recent events with their earlier years, to draw conclusions about major events, or to look ahead to the future” (Ritchie, 1995, p. 82) In addition, the participants had an opportunity to put on record any additional t houghts or feelings th at they thought were important to share (Ritchie, 1995). At the e nd of the interview when the recording had stopped, it was re-explained to the participan ts how the tapes would be stored and the intention of the oral history to be archived in the Special Collections Department at USF and translated into manuscripts for pub lication purposes by the researcher. The participants were also asked what mode of communication (i .e. email, mail, in-person) they would prefer to receive a copy of the transcript in durin g the reviewing stage (see the “Finishing Touches” description below for explan ation of this step). Furthermore, a more personal and informal discussion followed, as “you cannot simply walk out the door with someone’s life story, their candid reflectio ns, and sometimes their extremely personal observations” (Ritchie, 1995, p. 82). Theref ore, a statement of appreciation was conveyed to the participants as well as an indication of how valuable their contribution was to the study (Ritchie, 1995). Interviewer characteristics. Interviewing is a skill th at people are either born with, have to learn throughout life, or is a sk ill that cannot be graspe d and/or mastered for some individuals (Davis et al., 1977). A ccording to Davis (1977) a good oral historian should have the following interviewing charac teristics: curious; attentive; listens

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93 carefully and is an empathic listener; patient; thoughtful; and can formulate concise, simple and straightforward questions. Mo reover, the intervie wer should create an atmosphere that facilitates and welcomes the participant to explore and delve deep into his/her memory (Davis et al., 1977). Othe r characteristics of a good interviewer as described by Ulin et al (2005) include th e following: having unconditional respect for others; a genuine demeanor; enthusiasm; an awareness of both their own as well as the participant’s nonverbal reactions (i.e. body language); and having the ability to synthesize and explore what is being conveyed to them. Field notes and researcher’s journal The use of good field notes as “careful documentation” were used during the interview process. Field notes recorded the context of the interview, the series of “events” that unfold, and thus were used as an “audit trail” to help reconstruct the interv iew for the researcher (Ulin et al., 2005). In addition, the use of a journal, or a “researche r’s diary,” was used to docum ent the researcher’s thoughts, feelings and concerns regarding the data. Keeping good field notes and a researcher’s journal aided the researcher in acknowledging their values so that the data were analyzed in a more honest and critical manner (Gbrich, 1999). Transcribing Transcription is an important part of the or al history process. Most oral historians consider the tape the actual “o ral history” document as it cons ists the participant’s words in the most truest sense; whereas the transcript reflects what the researcher believes is the “intended meaning” the participant was conve ying. The length of time for transcription is expected to take approximately 6 to 8 hours per each hour of interview (Ritchie, 1995).

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94 Interviews were transcribed verbatim, by “recreating the speakers’ dialects or accents and [reflecting] the sound and pace of the interview” (p. 35) to preserve the content and quality of the inte rview (Davis et al., 1977). Sp ecial attention was given to the facts stated and the style of speech conve yed during the transcri ption process (Davis et al., 1977). For instance the order of the words spoken remained unchanged in attempts to not distort the pa rticipant’s intended meaning, th e grammar of the transcript was not corrected as conversational speech us ually contains grammatical inaccuracies in comparison to written speech, pauses and hesita tions were incorporated when possible to reflect the participant’s thought and speech pa tterns, and expressions and emotions were incorporated by using parentheses to convey any non-verbal communicat ion (Davis et al., 1977). A professional transcriptionist transc ribed the audio-recorded interviews into word documents. Auditing Auditing involved proofreading the transcri pt to ensure the written format of the interview was accurate and reflect ed the original interview (Davis et al., 1977). Auditing was a tedious step in the oral history process but was critical in ensuring the transcription was done correctly and that the candid data were captured truthfully. The transcripts were read for spelling and t ypographical errors and were proofread against the audiorecorded interview (Davis et al., 1977). Speci fic issues that were considered during the auditing process were outlined by Davis et al (1997) and include the following: all words and sounds were included; words that were spok en were in the correct order and were not misunderstood or mistyped; and punc tuation was correctly typed.

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95 Editing Editing was similar to auditing in that the editor checked for spelling and typographical errors and ensured the correct use of punctuation. However, during editing the transcript was read as if one was a firsttime reader and the flow and readability of the document was enhanced (Davis et al., 1977). Often, it was in the editing step where clarification statements were included and were inserted by entering words/phrases in brackets to enhance the comprehensions and me aning of the participant’s words (Davis et al., 1977). Moreover, emphatic pauses were inserted in the corre ct places and the consistency concerning how certain words were typed was ensured (i .e. either using US vs. U.S.) (Davis et al., 1977). A second read ing was also necessary to ensure clarity, readability and semantic fl ow (Davis et al., 1977). Finishing Touches The Finishing Touches step in the oral history pro cess usually entails obtaining a review from the participant, a final read and edit, and deve loping and formatting the final version of the transcript (Davis et al., 1977). Davis et al ( 1977) directs the researcher to deliver a copy of the edited transcript to the participant to help fill in any unclear or inaudible words that are on the transcripts a nd to ascertain that what is typed on the transcript is indeed the words spoken by the participant (D avis et al., 1977). However, because the topic of these oral histories conc erns a policy that is controversial, involves populations that are often ma rginalized (the poor, the young, women, etc.), and focuses on reproductive health and family planning, a divisive and controversial public policy topic, the edited transcript wa s not be delivered to the par ticipant for feedback but a copy will be delivered to the part icipant at the end of the research study as a courtesy.

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96 Participants were not given an opportunity to provide feedback, as there was a risk that participants would edit the transcript, such as adding or deleting words or phrases, essentially denying any comments that were said or inserting co mments that were not spoken during the actual interview. A title page and a preface were drawn up to precede the final transcript as directed by Davis (1977). The title page consisted of the title of the oral history project, the name of the participant, and the copyright in formation (Davis et al., 1977). The preface contains a couple of brief paragraphs that ex plain the nature of th e project, background information on the interviewer, a more detailed summary of the participant and their expertise, including any releva nt biographical information, a nd a statement outlining that the transcript is a historical document a nd that the sponsoring institution is not accountable for any of the information stated in the transcript (Davis et al., 1977). Management of Data Separate files for each participant were kept in a locked filing cabinet and included the following informati on: copies of all letters of correspondence; a copy of the Legal Release Form; biographical information collected; and notes taken during and after the interview (Ritchie, 1995). Fu rthermore, a summary log of all oral histories was kept and included the following information: name of person interviewe d; date, location, and length of interview; and date of transcripti on, auditing, and the date of when the tape was submitted to the Special Collections Departme nt at the USF library (Ritchie, 1995). The researcher kept all files, logs and other notes in a locked fi ling cabinet at all times. The tapes were also kept in a lock ed filing cabinet by the resear cher until they were turned over to the Special Collections Department at USF. A copy of the tape and/or transcript

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97 was given to each participant as proper oral history etiquette, to show appreciation for their time and effort, and to demonstrate how valuable their contribu tion was to the study (Ritchie, 1995). Data Analysis The five principles outlined by Ulin et al (2005) were relevant to this study and servde as a foundation for analyz ing the oral histories. Firs t, reality is experienced and understood differently by individuals and of ten deviates from the researcher’s own perspectives and assumptions (Ulin et al., 2005). Thus, the researcher was aware of their own perspectives and assumptions and critic ally evaluated possibl e explanations that arose from the data, and not fr om what the researcher believe d to be true (Ulin et al., 2005). Second, contextual factor s such as one’s social, ec onomic and religious holdings can shape participant’s knowledge, behaviors and reasoning (Ulin et al., 2005). Third, “theory both guides qualitative research and results from it” (Ulin et al., 2005, p. 141). Fourth, exceptions in the data can highlight different “truths” and can help bring different voices and understandings to an issue that would have ot herwise been overlooked (Ulin et al., 2005). Fifth, human be havior can unfold in a slow and nonlinear fashion and thus analysis must remain an iterative activity where the researcher continually raises questions, reflects, theorizes and verifies their findi ngs (Ulin et al., 2005). Transcripts were uploaded into the qual itative software pr ogram NVivo 8 (QSR International Pty Ltd., 2008). The technique i nvolved with analyzing the oral histories entailed rigorous coding including open coding, axial coding and selective coding. Open coding consisted of a first pass r eading of the transcripts and applying the initial codes. Axial coding consisted of connecting raw data to emerging themes, performing intensive

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98 analyses around one theme at a time, and testing postulated relationships. Selective coding entailed scanning the data and selecting specific relationships and validating those relationships by matching the codes with their corresponding passages (Grbich, 1999; Neuman, 2003e; Ulin et al., 2005). In addi tion, the constant comparative method was employed to compare codes with the correspondi ng text and to make su re that the lifted text was indeed described by the appropriate code (Ulin et al, 2005). The constant comparative method was also used to look at e ach individual code’s boundaries, to ensure that there was no overlapping of codes, and to ensure that each code was mutually exclusive (Ulin et al, 2005). Reliability of Coding Similar to the thematic analysis on Title X’s legislative history (Phase I), the reliability of the coding for the oral history data was also assessed. The same researcher who assisted in conducting the reliability of coding in Phas e I also assisted with the reliability of coding in Phase II. The two researchers independently read and coded two of the six oral history transc ripts using a preliminary codebook that was developed based on findings from Phase I and the pre-dete rmined constructs from MFPAP. The researchers also applied any new codes and ma de notes according to these new codes as they arose during the coding process. The researchers met and compared their coding based on the preliminary codebook, as well as discussed any new codes that emerged throughout the coding process. Any discrepa ncies regarding the coding were discussed, and the boundaries for each of the codes were established to ensure that each code was mutually exclusive. In addition, it was assu red that each code properly described that particular section of text. Coding between the two researchers was completed in a

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99 consistent manner and no major discrepancie s were found. Any slight variations in coding arose from the naming (label) of new codes, and thus, rese archers discussed and agreed on the name, meaning and boundaries of the new codes. The secondary researcher who was assisting in the reliability of coding found no evidence of researcher bias and deemed that the coding from the primary researcher was being conducted in a systematic, thorough and reflective fashion. Issues Related to Oral Histories Oral histories are a unique type of interview where the researcher gathers individuals’ experiences thoughts, feelings and other reco llections regarding a particular phenomenon. Because oral hist ories illicit information based on individuals’ memories and is stored and made available for public us e, a discussion relating to memory and legal concerns is provided below. Memory Oral history is “an activ e process in which intervie wers seek out, record, and preserve such memories” (Ritchie, 1995, p. 12) Not every event is stored in one’s memory and people will recall what they pe rceive as being important. In addition, thoughts, behaviors and actions can change in significance depending on what the future held regarding that phenomenon. Therefore, Ritchie (1995) outlines the following questions that can assist a researcher when evaluating the credibility of the participant’s responses: Were they in a position to experience even ts firsthand or are they simply passing along secondhand information? What biases may have shaped their original perceptions? Have participants forgotten much of thei r past because it wa s no longer important to them or because the events were so routine that they were simply not

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100 memorable? How differently do participants feel now about the events they are recalling? What subsequent incidents may have caused them to rethink and reinterpret their past? How closely does their testimony agree with other documentary evidence from the period, and how do they explain the discrepancies? (p. 14) Therefore, the researcher was cognizant of the limitations of one’s memory, while at the same time appreciated the value of this unique methodology in captu ring individuals’ experiences and stories and how it gave meaning to the history of Title X (Ritchie, 1995). Legal Concerns The copyright of the interview remains w ith the participant ev en if the interview is not registered with the Copyright Office for 50 years af ter the participant’s death (Ritchie, 1995). Therefore, because it is the re searcher’s intent is to publish the findings from this study, a Legal Release From wa s required from those participants who voluntary chose to have their transcripts archived. A “deed of gift” or “contract” was signed by both parties (the interviewer and the participant) prior to the interview, which assigned the copyright to th e interviewer, and acknowledged that a copy of the oral history would be archived in the Special Collections Department at USF and made available to the public (Ritchie, 1995). Ethical Issues in Qualitative Research Ethical issues are always extremely important when conducting any type of research, but are even more imperative wh en your research involves human subjects. There are several ethical issues that are inherent within this proposed research study. First, autonomy or respect for persons, must be u pheld and involves participants having

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101 the right to adequate information concerning the research study and having the right to “voluntary” participate (Ema nuel, Crouch, Arras, Moreno, & Grady, 2003). The research process should never commence until informed consent is obtained, and even then, informed consent must be continually received throughout the entire research process. In addition, respect for persons also refers to “giving weight to autonomous persons’ considered opinions and choices while refr aining from obstructing their actions unless they clearly detrimental to ot hers” (Emanuel et al., 2003, p. 34). Therefore, all responses provided by participants were documented and valued. In addition, approval was obtained from the University of South Florida’s Institutional Review Board prior to conducting the commencement of this study. Privacy anonymity and confidentiality are other ethical princi ples that need to be accounted for during this resear ch. The research proposed to conduct oral histories, and because one of the functions of this type of methodology is to collect individuals’ recollections, perceptions a nd their untold stories con cerning a certain phenomenon, and to make this information available to the public, participants’ na mes are labeled on the archive tape/transcript. However, for publi cation purposes, participants’ names will be excluded and any quotes included in professional presentation s and manuscripts will be labeled generically such as “female, polic ymaker” or “male, department of health employee.” Other ethical principles th at guide the qualitative re search stem from the “nonnegotiable journalistic norms of accuracy the right to know and making one’s moral position public ” (Ulin et al, 2003). The results and th e forthcoming publications strive to accurately depict the information that evolved from the interview process. Such “truth”

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102 is not confined to “neutrality” or the researcher’s bias, as the goal of the research study was to reveal understandings and key stakeh olders’ insight concerning the many issues intertwined within the Title X program (Ulin et al, 2003). Synergism of Data The proposed two-phased study greatly enriched our unders tanding of Title X over the past three decades and provided a d eeper appreciation of the successes and oppositions that it endured. The triangulation of methods (Neuman, 2003b), or in this study, the synergism of data conducting both a thematic anal ysis on Title X’s legislative history and oral histories, allowed a critical examinati on of the policy at a broader theoretical level to be merged with the knowledge, behaviors, motivations and recollections of stakeholders who were/are responsible with its implementation on a dayto-day basis at a state-level. In addition, the triangulation of observers (Neuman, 2003b) provided multiple and perhaps alternative r ecollections of the same phenomenon (Title X) that further added depth and insight in to this complex and value-laden policy. Issues Related to Conducting Qualitative Research Trustworthiness The approach in evaluating the quality, rigorousness and overall value of qualitative research is often referred to as trustworthiness (Ulin et al., 2005). In 1985, Lincoln and Guba identified the followi ng four terms to replace the measures internal validity external validity reliability and objectivity used in positivist quantitative research: credibility; dependabi lity; confirmability ; and transferability (Marshall &

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103 Rossman, 1989; Ulin et al., 2005). Lincoln and Guba (1985) expr essed a need for criteria that addressed the question: how do you know whether “the findings of an inquiry are worth paying attention to, worth taking account of?” (cited in Ulin et al., 2005, p. 25). Credibility refers to one’s confidence in the f act that the findi ngs are a truthful representation of the data (Ulin et al., 2005). To ensure credibility of the results, the researcher ascertained whether the participan ts understood and agreed with the findings (also known as member checks) (Ulin et al., 200 5). In this way, cred ibility was assessed by incorporating the themes and findings from the thematic analysis on Title X’s legislative history into the oral history in terview guide to see to what extent the participants agreed or disagreed with the researcher’s interpretation. Dependability refers to whether another resear cher could replicate the study (Ulin et al., 2005). Dependability in this study was assured by conducting the two methodologies accurately and systematica lly and by upholding any principles and standards that were unique to each method. In both phases, the analyses rigorously followed the data analysis procedures descri bed previously and were carried out in an ethical fashion. Specific to the oral historie s, the principles and standards developed by the Oral History Association (see Appendix C) were upheld and abided by throughout the entire process to guarantee that resu lts produced were derived accurately. Confirmability refers to “a way of knowing that, even as a coparticipant in the inquiry, the researcher has maintained the di stinction between pers onal values and those of the study participants” (Ulin et al., 2005, p. 27). Therefore reflexivity must entail the researcher acknowledging the influence of thei r own role, assumptions and biases on all phases of the research, from conception through analysis and the dissemination of results

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104 (Ulin et al., 2005). Regarding the oral histories, even though the interviews were a twoway conversation that produced a joint product, it was impera tive that the data reflected the recollections, experiences and perceptions of the participants (U lin et al., 2005). An audit trail was one technique that was em ployed to document how and why the results were drawn and to ensure that the research er was “conscious of th eir own subjectivity” (Ulin et al., 2005, p. 168). An audit trail traced how the researcher derived their conclusions and ensured that such conclusions were grounded in the data. Ulin et al (2005) lists the following information which were used as an audit tr ail: the raw data (i.e. secondary data used in the thematic analysis, tapes from the oral hist ories); data reduction and analysis products (i.e. codes, themes and analytic notes used throughout the qualitative analyses); data reconstr uction and synthesis products (i.e. the merging/converging of themes from both pha ses which are triangulated); process notes (analytic notes, entries from the researcher’s journal, notes taken during the interviews); materials relating to intentions and disseminatio n (i.e. study protocol, I RB, letters sent to participants); and instrument materials (i .e. interview guides, procedural notes). Transferability refers to the extent that the findings can be inferred to other populations, events or contexts (Ulin et al., 2005). Disagr eement over transf erability in qualitative research involves researchers believ ing that it is impossible to transfer results to a different environment/context; whereas others argue that findings can be loosely applied (Ulin et al., 2005). Nonetheless, a study can enhance its transferability if 1) conclusions are drawn accurately from the da ta; 2) if the setting, context, participant characteristics, and researcher-participant dynami cs are described; and 3) if the research

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105 develops or is guided by theory in which the theoretical constructs can be examined in a different study with another population or context (Ulin et al., 2005). Researcher Bias Researcher biases affect every stage of the research process, from the questions that are asked, the theories that are use d, the methodologies that are employed, and how the results are interpreted a nd reported. Therefore, by firs t acknowledging one’s biases, and then by implementing the various safeguard s listed above to minimize one’s biases, the researcher can stay immersed in the inte rview process and great er attention can be placed on the meaningful and fruitfulness of the “data” produced. In addition, a researcher analyzing a policy must be cogni zant of the values unde rmining a policy and how such values play an important role throughout the policy proc ess (Heineman et al., 1990). Furthermore, the researcher anal yzing a policy “needs to recognize that contradictory beliefs and irrational positions are not aberrations but inherent facts of the political system that have to be confront ed with both flexibility and persuasion” (Heineman et al., 1990, p. 5). Phase I: Thematic Analysis on Title X’s Legislative History The analysis process of qualitative research is complex and Gbrich (1999) identifies three areas where the researcher’s interpretation is cr itical. First, the researcher applies “frames” around the text and this “active interaction” lifts the data out of the text while keeping it in context (G brich, 1999). Second, the “researc her’s interpretive focus” (Gbrich, 1999, p. 220) affects the meaning-maki ng as the researcher’s intention for the data (i.e. explain gaps, reveal contradictions, prove a certain idea, etc.) will be present within the analysis (Gbrich, 1999). Third, the researcher’s position related to the data

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106 and how the researcher develops or forms m eaning also affects the analysis and thus, results (Gbrich, 1999). Therefore, it is importa nt to acknowledge that the researcher is also “tool” in this qualitative study. Phase II: Oral Histories Interviewer bias involves the actions and behavior s that the inte rviewer engages in which can distort, mislead or alter the vera city of the participants ’ responses. Neuman (2003d) identified six categories in which inte rview bias can occur: 1) errors by the respondent; 2) unintentional errors or interv iewer sloppiness; 3) intentional subversion by the interviewer; 4) influence due to the in terviewer’s expectations ; 5) failure of an interviewer to probe or to probe properly ; and 6) influence on the answers due to characteristics of the interviewer’s. The first category of interviewer bias, errors by the respondent involves the respondent forgetting, lying, misunderstand ing the question, or being embarrassed because the presence of another indi vidual (Neuman, 2003d). Ensuring that the interviewer created a comfortable atmosphere that facilitates an open and truthful conversation helped control for this type of bias. The second category of interviewer bias, unintentional errors or interviewer sloppiness involves mistakes on the interviewer’s part, such as misreading, omitti ng, asking questions in the wrong order, or not fully understanding th e respondent’s answers correctly (Neuman, 2003d). The interviewer was familiar with and followed the semi-structured interview guide which helped control for this type of bias. In addition, any uncertainty regarding the content and clarity of the respondent’s answers were verified during the transcription, auditing and editing stages of the oral histories. The third category of interviewer bias, intentional

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107 subversion by the interviewer involves the interviewer pur posively altering, re-wording or omitting questions and/or respondent’s an swers (Neuman, 2003d). Again, this type of bias was control for by the interviewer abiding by the semi-structured interview guide and accurately transcribing the transcripts. Ho wever, because the oral histories were an iterative process and allowed fo r unsolicited recollections to be discussed, being flexible in the questions that were asked by the interviewer were warranted. The fourth category of interviewer bias, influence due to the interviewer’s expectations involves the interviewer expecting the respondent to answer a certain way based on previous answers or based on the re spondent’s characteristics such as their appearance or their living situation (Neu man, 2003d). It was important that the interviewer did not judge the participant or the answers that the participant provided and that the interviewer remained open-minded dur ing the interview. Because one of the purposes of conducting oral histories is to collect knowledge and memories from participants, all answers provi ded by participants were valu able as they were conveying the participants’ perceptions on a particular phenomenon in th e truest sense. The fifth category of interviewer bias involves the interviewer not probing or not probing effectively (Neuman, 2003d). This type of bias was controlled for by ensuring that the interviewer was experienced in conducti ng interviews and th rough the conduction of mock and pilot interviews that increased the researcher’s familiarity with the nature and content of the questions. The sixth categor y of interviewer bias involves the various characteristics of the interviewer (i.e. interviewer’s appearan ce, tone, attitude, reactions to answers, outside comments, etc.) that can influence participants’ answers (Neuman, 2003d). To help eliminate this type of bias the interviewer made sure their dress and

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108 grooming was non-threatening, and that the ve rbal and non-verbal cues exuded (speech and body language) were nonjudgmental, thus emphasizing how they were open to receiving a full range of responses, can eliminate this type of bias.

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109 CHAPTER FOUR: RESULTS Phase I: Thematic Analysis of Title X’s Legislative History Phase I involved critically analyzing the legislative history of Title X, which includes House and Senate bills (N=293) proposed between the 91st Congress (January 20, 1969) and the 110th Congress (ending on August 31, 200 8), through the identification of common themes that have emerged over the life of this policy. As mentioned in the preceding chapter, the following in-depth and inte rrelated steps as outlined in Ulin et al (2005) were utilized to analyze the legisl ative bills: reading; coding; displaying; reducing; and interpreting. In th is section, the results from th e thematic analysis of Title X’s legislative history are pr esented by research question. Question 1: What legislative bills that proposed changes to Title X were enacted into law? According to the legislative history of Title X that was compiled for this study, of the 293 bills that were proposed, 20 (6.8%) bills were enacted into law. Table 12 lists the bills included in Title X’s legislative history and depicts the bills that were enacted into law (enacted bills are designated by an asterisk and are in bold font). Question 1a: What changes did Title X incur fr om these enactments as reflected in the language of its public law? Title X has remained a viable policy th at has undergone limited structural and content changes since its enactment almost four decades ago. See Table 13 for a description of the amendments affecting Ti tle X policy. In general, the most common amendment involved providing appropriation to the family planning program. Other amendments included various administrativ e and operational amendments, requirements

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110 and restrictions of Title X services, and minor technical changes. Such changes reflected in this legislative history that were enacted into law include the following: Appropriation Establishing reporting requirements Ensuring economic status is not a deterren t for individuals to participate in the program Providing training regarding adoptio n information and referrals Granting Title X entities the abilit y to apply for AIDS grants Granting Title X to be covered as an enti ty in which drugs can be purchased by the State under the State plan for medical assi stance (Title XIX of the Social Security Act) Providing infertility services and adolescents services Encouraging family participation Offering and encouraging HIV services Providing nondirective pregnancy counseling Counseling minors on resisting at tempts of sexual coercion Requiring notification or reporting of child abuse, child molestation, sexual abuse, rape or incest according to State laws Prohibiting funds for abortions (except wher e the life of mother would be endangered if the pregnancy was carried to term) Prohibiting funds for promoting or opposing any legislative proposal or candidate for public office Minor technical amendments (renumbering sections, grammatical and punctuation changes) Question 2: What are the themes that emer ge from the proposed legislative bills? A variety of themes emerged and th e language contained in the proposed legislative bills included both implicit and explicit meanings and changes to Title X policy. A panel of experts, which consiste d of the primary researcher, the additional researcher engaged in the reliability of c oding, and an expert in reproductive health, reviewed the themes that emerged from the proposed legislative bills and assisted in classifying the themes into the following se ven major broad categories: Administration; Appropriation; Requirements of Funds/Services; Restrictions of Funds/Services; Related Legislation; Related Policies; and Technical Amendments. See Table 14 for the list of

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111 bills included in Title X’s le gislative history (1970-2008) by theme. A summary of each of these major broad categories that includes a description of the types of themes and the corresponding amendments that we re proposed are provided below. Administration The proposed bills included in Title X’s legislative history often contained language affecting the administration of th e Title X program, including the following: attempts to extend or repeal the program ; administrative and grant requirements; coordination with State activiti es; use of funds; administra tion of grants to specific populations; administration of grants related to particular program sections; and data collection and reporting. Attempts to extend or repeal Title X. Bills proposing to extend and repeal certain sections of Title X, as well as the entire progr am were found. Certain sections of Title X (e.g., project grants and contracts, training, re search, information and education) as well as the entire program were proposed to be extended anywhere between 1 and 5 years. Bills also proposed to repeal certain sections of Title X, such as the formula grants (where the Secretary is authori zed to make grants “to State he alth authorities to assist in planning, establishing, maintaining, coordi nating, and evaluating family planning services)” (P.L. 91-572, Sec. 1002), and proposed to repeal the entire Title X program. In addition, other bills proposed transferring Title X funds to the Veterans affairs to “to provide for increased funding for veterans health care” (109 H.R. 5967; 110 H.R. 6712), thus attempting to eliminate Title X altogether. Bills expanding Title X’s purpose such as proposals articulating that Title X’s purpose should include “stren gthening domestic research in the fields of human

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112 reproduction, the provision of family pla nning services, and popul ation dynamics, and coordination of such research with the present and future needs of family planning programs” (93 S. 1708) were also found. Administrative and grant requirements. Descriptions regardin g the specifics of the administrative and accounting responsibilit ies for Title X were stated. For instance, requirements that projects use no more than 10% of funds for administrative purposes was proposed. Of note, administrative cost s for Medicaid range from 4% to 6%, administrative costs for a Health Maintena nce Organization (HMO) range from 8% to 12% (which is deemed as efficient), and ad ministrative costs of 15% to 20% would be found in a “well-run commercial health insu rer” (Henderson, 2005). In addition, bills proposing that the amount of the project grant awarded must not be less than the total amount of the grant, that the grant amount must not be less th an 90% of the costs of the project, and that the grant am ount must not be less than 40% for alternativ es to abortion programs were also found. Furthermore, bills proposed a criminal penalty for applicants if false statements were provided, and that entities would be responsible for 100% of the grant amount if any provisions were violated and would be d eemed ineligible to reapply in future funding cycles. Specific content to be included in the application for Title X funds were also stated. More over, the scope of the appli cation included preferences to grants that give priority to alternatives to abortions, assuring the right of local and regional entities to apply, and allowing lowincome individuals to participate in the decision-making process of the project. Coordination with State activities. Coordination with State and other programs as a stipulation of the Title X grant were found, such as bills proposing a statewide plan for

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113 coordinated and comprehensive family planni ng services and arrangements for provisions with other providers for broader and comprehe nsive maternal and child health services. Similarly, it was proposed that State comprehe nsive health planning agencies should be able to comment on Title X grant applications; however, such reviews and comments should not delay the review of the Title X appl ication. In addition, it was articulated that States should retain their autonomy, and that an applicant would not be denied Title X funds on the basis that their State laws are more restrict ive regarding unemancipated minors. Furthermore, it was proposed that the Governor for each State should designate an agency to administer Title X funds, or es tablish a direct payment method for eligible clients or entities. Use of funds. Specifications related to the use of and restriction of funds were stated, such as the allotments and reallotments of funds and indications of what funds could and could not be used for. For instan ce, bills proposed that funds should be used for acceptable family planning methods and se rvices, Contraceptive Research Centers, and loan repayments for qualified health professionals who conduct contraceptive research. On the contrary, bills proposed that funds could not be used for inpatient services and land and major construction purcha ses. Bills also proposed that purchased equipment and products from Title X funds must be American-made. Bills also stated that funds must origin ate from that particular section (training, research, or information and education), and funds from other areas and sections of the program cannot be used to carryout such func tion. In addition, language prohibiting any “Federal official from ex pending any Federal funds for any population control or population planning program or any family pl anning activity” (109 H.R. 777) was found.

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114 Administration of gr ants to populations. Bills also included language regarding the populations to be served by the grant ap plicants. For instance, bills establishing family planning services in Native Hawaiia n Health Centers, bills stressing the importance of low-income individuals bei ng the priority population of the family planning program, and bills allocating family planning funds to Indian ( sic ) populations were proposed. Bills also proposed the defini tion of “low-income” to be defined by the Bureau of Labor Statistics of the Department of Labor where other language contained in bills stipulated that “low-income” shall be defined by the Secretary. In addition, language articulating that the economic status of the individual must not be a deterrent for receiving services and that se rvices must not be contingent upon one’s family’s income were provided. Administration related to particular program sections. Proposals to amend the sections of research training, and information and education in Title X law were also documented. Bills were proposed that articulat ed that each section (research, training, and information and education) must meet objectives specified in the legislative and administration recommendations. Specific to the research section of Title X law, bills proposed included the provision of research to be performed on clinical management, delivery of services and evaluation, and pr ogram implementation to improve family planning services. Bills also proposed funds for Title X research to include natural family planning methods and contraceptive development and marketing rights for recipients, but also stated th at funds should be limited to 50% if such research is under contract with a profit-making entity. Speci fic research initiativ es proposed included contraceptive development and evaluation activ ities, particularly stating that such

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115 research should not duplicate National Institute of Health projects. Moreover, bills also proposed funds for research to be carried ou t by the Secretary and/or Deputy Assistant Secretary, articulated that research should pr omote the area of social science, and that research funds could cover travel expenses and go towards university-based research centers. Specific to the training section of Title X law, bill s proposed included training for clinical training (including OB /GYN nurse practitioners and nur se midwives), educators, counselors, and other personnel, and indicate d that such training should also include training on natural family planning methods In addition, it was proposed that the Secretary should make sure that such trai ning is not already being supported by other Federal assistance. Specific to the information and education section of Title X law, bills proposed that an Advisory Committee should approve information and education materials used by clinics and that training shoul d be available for providing in formation and education to individuals. Other specif ics regarding information a nd education amendments are discussed under the “ Requirements of Funds/Services ” below, as such proposals concern the content and provision of services that are to be delivered to participants. Data collection and reporting. Bills relating to the admi nistration of the program that described data collection efforts, the criteria and require ments of the information that should be included in the plans and reports, and that such repo rting should also describe the program’s objectives and achievements related to carrying out the program’s purpose were proposed. Requirements of reporting al so included deadlines for submission, which ranged from “due as soon as possible” to 6 months. Other data reporting requirements

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116 that were proposed included other sources of funding received by grantees, the number and demographics of individuals served, the ty pes of services chosen by participants, the number of individuals at risk, and the exte nt that Title X reduced rates of unintended pregnancies, abortions, STI’s and reduced fede ral and State expenditures. In total, 85 bills were proposed under the Administration category and only 4 (4.7%) of these bills were enacted into law. Appropriation Appropriation bills were the most common type of bills that were proposed and directly and indirectly affected family planning programs and services that are established under Title X. Appropriation am endments either originated from bills specifically amending Title X, or from bills whose focus was not on Title X, but whose focus was on another related legislation or policy. Appropriation for Title X. Bills that proposed appropriation for Title X took various forms, including general statemen ts of appropriation and appropriation for specific sections in Title X’s policy. For in stance, some bills indicated appropriation for “family planning” or “Title X”, in which it is assumed that the sponsors of these bills were allocating funds for this program, wit hout specifying how and where the funds were to be used within the program. On the c ontrary, other bills proposed appropriation for specific sections in Title X’s policy, such as for project grants and contracts, research, training, and information and education. In addition, bills that proposed approp riation for demonstrations projects for infertility, projects to study the effect of parental consent on family planning services, STD education programs, preventive health services, program pl anning and evaluation

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117 efforts, services for adolescents (including appr opriation specifically for teens at risk for pregnancy), and for loan repayment for pers onnel conducting contraceptive research were found. Moreover, appropriation was proposed u nder Title X legislation for Contraceptive Research Centers and for contraceptive development and evaluation activities. Appropriation from related legislation and policies Bills proposing appropriation also originated from related le gislation in which Title X was not the main focus of the bill, but where there was a line item for Title X and family planning services somewhere throughout the bill text. For inst ance, the Adolescent Family Life Program, Women and HIV Outreach and Prevention, the National Population Sciences and Family Planning Services Administration, Population Research Centers (a ppropriation for the policy as well as for the construction for the Centers), the Office of Population Affairs, and the United Nations Population Fund were all different bills in which included appropriation specifically for Title X. In total, 138 bills were proposed under the Appropriation category and only 15 (10.9%) of thes e bills were enacted into law. Requirements of Funds/Services Requirements of Funds/Services were the most common type of bills included in Title X’s legislative history and these b ills proposed changes and/or requirements regarding what services or provisions a Title X-funded enti ty must provide. Generally, these bills proposed specific family planning services, in formation and education and other related activities. Types and ranges of services. Provisions proposed to Title X policy pertaining to service delivery included pr oviding the following: servi ces in a nondiscriminatory manner (where no individual shall be exclude d); services delivered to both sexes;

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118 offering a broad range of family planning methods, including natural family planning methods; and providing nondirective counseling and referrals (including information on prenatal care and delivery, infant care, fost er care, adoption, and te rmination). Service provisions also included having personnel w ho can speak the predominant language in that community and who can provide services according to the context of that culture and to the specific individual, and having pe rsonnel who hold professional degrees and who are trained to provide pregnancy management options (with exemptions for not providing certain information or services if it conflicts with one’s religious or moral beliefs). Moreover, proposals were found indicating volu ntary participation on the clinics’ and personnel’s part, in which clinics and personne l are not required to provide services if such services are contrary to their religi ous and moral principles, and that personnel cannot be terminated if they do not advise, provide, or refer i ndividuals on abortion, drugs, and methods of contraception because of their religious or moral beliefs. In addition, bills proposing that condoms admini stered by Title X clinics must be FDAapproved and must be followed by information on the benefits and risks associated with condom use were found. Demonstration project s were also proposed for a variety of purposes, including to assist in alleviating infertility prob lems, projects targeted at adolescents and projects focusing on providing pregnancy testing and counseling. Adoption and abortion services. Many bills proposed some form of adoption information or services to be available from Title X clinics, such as providing nondiscriminatory adoption services at th e clinic, providing a doption center contact information in the form of brochures, or increasing the awareness of the option of adoption among clients through the use of public campaigns (television, radio, billboards,

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119 brochures, etc.). In additi on, bills proposing requirements regarding abortions services specified the following; Informed Consent must be obtained; oral and written risks of abortions must be provided; a two-day waiting period after the Informed Consent procedure but before services can be perfor med must be abided by; and entities must obtain parental consent for abortion counseli ng and services provided and that entities must be in compliance with Stat e parental notification laws. Information and education. Amendments to the information and education section of Title X’s policy included specific cont ent that was to be delivered to recipients as well as the mechanism and outlets of such information and education. For example, bills proposed that individuals should be “enabled” to make responsible choices regarding human sexuality, pregnancy and pa renthood; individuals should be provided with the benefits and risks of all servi ces provided; projects funded by Title X must maintain a strong, family-based society; and that materials sh ould be distributed regarding voluntary family planning and the causes and consequences of demographical characteristics and trends. In addition, propos al articulated that recipients should be informed on the biological and physiological facts on human life, including human life at each stage of development starting at fertilizatio n and of their legal rights and the benefits and services available for carrying a fetus to term (including options of raising the child and adoption). Furthermore, bills included information specific to HIV, proposing that entities must inform individuals on the eff ectiveness of methods in preventing HIV in comparison to abstinence, informing how to avoid HIV infection (abstain from homosexual relations, heterose xual relations outside of monogamous marriage, and sharing needles used for IV drugs), and how HI V will develop into AIDS, a fatal disease.

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120 Bills pertaining to breast and cervical can cer were also proposed, indicating that information, skills and referrals regarding breast and cervical ca ncer must be delivered in a cultural competent manner and that client s should receive education on self-breast exams. Moreover, bills proposed general am endments to the information and education section of Title X law, articulating that such section should include development, evaluation and dissemination activities and th at information and education must be provided based on voluntary basis to individuals. Other bills proposed that information developed and disseminated should be community-based and suitable to that partic ular community, with information delivered through community organizations and with an emphasis on adolescent s and parents, and that information should include the broad ra nge of methods and services available. Furthermore, bills focusing on information and education specific to the adolescent population were found, such as those proposing th at information and education to parents should transmit values of family life and sexua l responsibilities, a nd those proposing that information and education should promot e the postponement of premarital sexual relations. Minors. Bills proposed various requirements that focused on minors, such as providing information and educat ion to minors stating that ab stinence is the only way to avoid pregnancy, providing counseling to minor s to assist minors in resisting sexual coercion, and removing the confidentiality mandate as it pertained to minors. In addition, bills proposed that no Title X providers were exempt from State laws requiring the reporting of child abuse (including child mole station, sexual abuse, rape, or incest). Moreover, bills proposed parental notificati on requirements (for contraceptive services

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121 and abortion counseling and services) and propos ed grants to study the effect of parental notification to “determine the impact of family planning services in a State that has in effect a law prohibiting the use of public f unds for the provision of family planning services to an unmarried minor without the prior written consen t of the parent or guardian of the minor” (101 S. 2997). Furthermore, it wa s proposed that if an entity does perform abortions, that entity could not receive Titl e X funds unless they are in compliance with State law on parental notificat ion and certify as such with the Secretary. Also, bills proposed that unemancipated minors could not be denied services based on economic status. Of note, no proposed bills regarding the sterilization of mi nors were found in this legislative history. Current guidelines state that Title X funds can only cover sterilizations for those indivi duals who are at least 21 years of age at the time informed consent is obtained. In total, 141 bills were proposed under the Requirements of Funds/Services category and only 12 (8.5%) of th ese bills were enacted into law. Restrictions of Funds/Services Bills included in Title X’s le gislative history were found that proposed restrictions regarding on Title X’s funds and the servic es that the program delivered. Generally, these bills proposed the restriction of specifi c family planning services, information and education and other related activities. Abortion services. Since Title X was enacted back in 1970, its law has stated that no funds could be used for abortion services; however, the theme of restricting abortions has emerged through the history of Title X legislation. Amendments focused on abortions have included bills indicating the prohibition of funds for abortions, the prohibition of funds for abortions with exem ptions (except if the mother’s life is

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122 endangered), the prohibition of funds as a me thod of family planning, and that funds are prohibited to promote, encourage, refer, or provide abortion services In addition, bills have proposed that clinics must provide a cert ification of exclusion of abortions and that clinics must be in compliance with State pa rental notification laws regarding abortion. Moreover, other bills have indicated that no grant or contract may be awarded to any organization that provides services or referrals on abortions (with some exemptions if the life of the mother is endangere d and/or if services are directly administered by the State or another political subdivision), thus inhibi ting clinics in receiving any Title X funds for family planning programs if they do counsel or provide abortion servi ces in their clinics with other funding. On the contrary, bills proposed that “except as provided in Title X, no program for which funds are authorized by th is Act [Public Health Service Act] which directly or indirectly provi de health services shall exclude from such programs or services the provision of aborti ons as a health service” (95th S. 2697); thus, proposing that abortion services are permitted to be provi ded through all health programs under the Public Health Service Act, ex cept under the Title X program. Other prohibition of funds. Bills included in Title X’s legislative history also proposed the prohibition of several services including the following: family planning coercion; distribution of information and e ducation in public or secondary schools; the distribution of emergency contraception to minors and in schools; involuntary sterilization; activ ities related to providi ng any funds that support or oppose a legislative proposal or candidate; and Title X benefits to aliens. In total, 50 bills were proposed under the Restrictions of Funds/Services category and 10 (20.0%) of these bills were enacted into law.

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123 Related Legislation Bills included in Title X’ s legislative history were found within legislation of separate policies; however, such bills had language with integrated text affecting Title X. For instance, bills were found that focuse d on separate policies from Title X, but which had language indicating that such polic ies should attempt to maximize the use of Title X funds and coordinate with the T itle X program. Such bills included the following: Adolescent Pregnancy Grant; A dolescent Pregnancy Prevention, Care, and Research Grant; Adolescent Family Life Demo nstration Projects; Family Life Education; Women’s Health Equity Act; Women’s Health Research Act; Women’s and AIDS Outreach and Prevention Act; and Matern al and Infant Care Coordination. Other bills proposed distinctive services to be included as part of the Title X program such as the following: routinely offer and encourage counseling, preventative and tests related to HIV; including the Title X program as one of th e covered entities that could utilize the State plan for medical assi stance for drug purchases ; granting Title X the ability to use State funds under Federal-State matching funds for purchasing drugs for minors; employing the same restrictions to gl obal family planning efforts as those applied to Title X (e.g., United Nation Population F und; Foreign Assistance Act of 1961); and automatically certifying Title X as an esse ntial community provider (Health Security Act). In addition, demonstration projects were proposed that aimed to examine the effectiveness of policies in assisting indivi duals in leaving welfare, which included the Title X program and which focused on providing family planning information, information on where services can be obt ained, and improving coordination between

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124 State programs. In total, 39 bills were proposed under the Related Legislation category and only 2 (5.1%) of these bill s were enacted into law. Related Policies Related policies were revealed from Title X’s legislative history, which included the establishment of global and national inst itutes, administrations and centers and the establishment of broader policies and values relati ng to family planning. Global and national institutes, administrations, and centers. Bills establishing global and national population and/or family planning administrations and research centers were proposed such as the following: Administration on Reproductive Research and Family Planning Council on Global Resources, the Environment, and Population National Center for Family Planning Serv ices (including an Advisory Council) National Center for Population Science (including an Advisory Council) National Institute of Population Growth National Institute for Research on Hu man Reproduction and Population Change (including a Scientific Peer Review Committee which w ould evaluate and review all grants and programs of the Institute) National Population Sciences and Fam ily Planning Services Administration Office of Family Planning and Population Science Office of Population Policy Other policies. Other policies included those that proposed that the U.S. should endorse family planning prin ciples, that the President should support family planning initiatives in the U.S. and abroad, expressed the sense that the administration of Title X should be respected, and recognized the impor tance of Title X. Other bills proposed policies relating to reducing and stabilizing population grow th, providing the universal availability of high quality family pla nning, providing safe and effective choices regarding family planning methods, upholding th e rights to privacy, and exercising the

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125 right for individuals to decide whether and the number of childr en they bear. In total, 51 bills were proposed under the Related Policies category and none (0%) of these bills were enacted into law. Technical Amendments Although few in number, bills were found that proposed combining House and Senate bills which included amendments to Title X, re-titling vari ous sections within Title X law, and incorporating other t echnical and grammatical changes (i.e. adding/deleting commas, periods; re-numbering sec tions, etc.) to Title X policy. In total, 10 bills were proposed under the Technical Amendments category and 4 (40.0%) of these bills were enacted into law. Question 2a: Do the themes that emerge fr om the proposed legisl ative bills differ depending on whether they were enacted into law? Generally, the bills that were enac ted into law involved a mixture of authorizations of appropriation, administra tive and operational amendments, technical amendments, and amendments related to provisions, requirements, and restrictions of funds and services. However, because ther e were almost 300 bills included in this legislative history, there were many bills th at involved the above topics that were not enacted into law. Therefore, the themes th at emerged from the proposed legislative bills did not differ qualitatively depending on wh ether they were enacted into law. However, of noteworthiness, none of the bills und er the section, Related Policies, were enacted in this study’ s legislative history. These bills included the proposal of global and national institutes, administrati ons and centers, and broader policies and

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126 values relating to family planning. Thes e broader policies and values proposed endorsing, supporting and recognizing the importa nce of family planning and/or Title X. Question 2b: What are the them es that emerged from the pr oposed legislative bills by administration? There were almost 300 bills included in Title X’s legislative history and as described above the bills can be classified into the following major broad categories: Administration; Appropriation; Requiremen ts of Funds/Services; Restrictions of Funds/Services; Related Legislation; Relate d Policies; and Technical Amendments. However, because of the volume of bills that were included and reviewed and because all of the bills in each administration included themes that can be classified into all of the major broad categories above, it is most feasible to discuss th e different administration in regards to what was being proposed. Richard M. Nixon (R) Administratio n, January 20, 1969 – August 9, 1974 (91st Congress House, D-243/R-192, Senate D-57/R-43; 92nd Congress House D-254/R-180, Senate D54/R-44; 93rd Congress House D-239/R-192, Senate D-56/R-42) The majority of the bills that proposed establishing global and national institutes, administrations and centers in regards to population and family planning were proposed during the Nixon administration. For inst ance the Administra tion on Reproductive Research and Family Planning, the National Population Sciences and Family Planning Services Administration, the National Institu te for Research on Human Reproduction and Population Change, and the Office of Family Planning and Populations Science were all institutes, administrations and centers that had bills establishing and outlining their missions and functions. Such initiatives also proposed establishing a population policy in the U.S. and included utilizing a scientific pe er review committee to review and evaluate

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127 all grants and programs regarding populati on and family planning (established under the proposed National Institute for Resear ch on Human Reproduction and Population Change). Other proposed bills included extending Title X for future years, providing appropriation and amending the plans and reports section of the law. In addition, it was proposed that State comprehensive health planning agencies should comment on grant applications, that research c onducted using Title X funds shou ld promote social science, and that funds should be limited to support preventative family planning services, infertility services, and the related medical, in formation and educational activities. It is of note that no bills relating to abortions we re proposed during the Nixon administration. Gerald R. Ford (R) Administra tion, August 9, 1974 – January 20, 1997 (94th Congress House D-291/R-144, Senate D-60, R-37) Although this administration only covered one Congress session (94th Congress), similar to the Nixon administration, the Ford administration also proposed administration bills and bills that proposed the establishmen t of global and national administrations and centers regarding population and family planni ng. However, bills were also found that proposed the following: planning and repor ting requirements from receiving funds; stipulations that a broad array of family pl anning methods must be available, including natural family planning; ensuring that economic status is not a deterr ent to participation; and prohibiting funds from being used in othe r sections (i.e. funds for research must originate from the research funding sectio n). Moreover, declaring a population policy within the U.S. was also proposed. Howeve r, bills proposing measures related to abortions began to emerge dur ing the Ford administration.

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128 James (Jimmy) E. Carter (D) Admini stration, January 20, 1977 – January 20, 1981 (95th Congress House D-292/R-143, Senate D-61/R-38; 96th Congress House D-276/R-157, Senate D-58/R-41) The Carter administration was the fi rst administration to propose several amendments such as the following: demonstr ation projects for infertility services; enforcing a 2-day waiting peri od after Informed Consent is given for abortion services; recognizing the impact of population policy on national and intern ational growth; and adopting a national policy and encouraging ot her countries to do the same to improve general welfare, the stan dard of living and to control population growth. Ensuring that local entities are assured the right to apply for family planning grants was also an amendment that was propos ed continuously during this administration. Similarly, this administration proposed provi ding information and education that was developed and disseminated through the community, with an emphasis on reaching parents and adolescents. Furthermore, this administration proposed bi lls pertaining to the specifics of the content of the informati on and education and pr oposed that pregnancy counseling should include information on the biological and physiol ogical facts of life and of the legal rights and the benefits a nd services of carryin g a child to term. In addition, this administration proposed bills relating to extending and providing appropriation for Title X. Ronald W. Reagan (R) Administration January 20, 1981 – January 20, 1989 (97th Congress House D-243/R-192, Senate R-53/D-46); 98th Congress House D-269/R-165, Senate R-54/D-46; 99th Congress House D-252/R-182, Senate R-53/D-47; 100th Congress House D-258/R-177, Senate D-55/R-45) During this administration, bills relating to abortion were also proposed; however, proposals indicating that no gran t or organization (except if such services are directly

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129 administered by a State or politic al subdivision) can be awarded to an that entity provides abortions or referrals for abor tions, unless the life of the mother would be endangered by carrying the child to term were revealed. Bills regarding informing pregnant women on their legal rights, benefits and services of ca rrying a child to term were also proposed, but bills proposed in this administration extended such information to include options of raising the child and adoption. In addition, bill s stipulating that Title X grant recipients and personnel must not be terminated based on that fact that they do advise, provide, or refer individuals on methods of contraception, abortion or sterilization were proposed. However, bills related to the clinical tr aining for OB/GYN nurse practitioners, and training for educators, couns elors and other personnel bega n to emerge during this administration. Proposals related to community-based in formation and education were also found, but bills relating to enabling individuals to make responsib le choices regarding human sexuality, pregnancy and parenthood, and ha ving an Advisory Committee review such community-based information emerged during this administration. Appropriation bills were also documented in this administration. However, bills proposing to repeal the Title X program first emerged dur ing this administration. George H.W. Bush (R) Administra tion, January 20, 1989 – January 20, 1993 (101st Congress House D-259/R-174, Senate D-55/R-45; 102nd Congress House D-267/R-167, Senate D-56/R-44) The themes that emerged during this ad ministration were similar to those of previous administrations; however, several ne w amendments were proposed. For instance bills related to providing HIV counseling a nd testing and education on self-breast exams

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130 were first introduced in this administrati on. Bills pertaining to enhancing women’s health and prevention efforts towards wo men and AIDS were also proposed. In addition, bills stipulated that the same restrictions applied to Title X (regarding information, counseling, and services) shoul d be applied to global family planning funding and activities. Proposal s related to establishing fam ily planning project grants for Indians ( sic ) and Native Hawaiian health centers were also found. Moreover, bills proposed that clinics must ab ide by State parental notification laws and that pregnancy information and counseling must be nondirective. William J. Clinton (D), January 20, 1993 – January 20, 2001 (103rd Congress House D258/R-176, Senate D-57/R-43; 104th Congress House R-230/D-204, Senate R-53/D-47; 105th Congress House R-227/D-207, Senate R-55/D-45; 106th Congress House R-222/D211, Senate R-55/D-45) Similar to the previous administrations bills related to appropriation, adoption services, ensuring personnel speak the predom inant language in that clinic’s community, and women and AIDS initiatives were propose d. However, several new bills that were not previously proposed in ear ly years were introduced and involve the following: encouraging family participation among minors; having clinic staff be fluent in the language and sensitive to the culture of those in their community; providing no exemptions to providers regarding their St ate law requirements on the notification and reporting of child abuse, child molestations, se xual abuse, rape or incest; and providing counseling to minors to assist them in resis ting attempts to coerce minors into engaging in sexual activities. In addition, it was proposed to maximize the use and plan for coordinated services between th e Maternal and Infant Care Coordination grants and Title X, and to automatically certify Title X clin ics as an essential co mmunity provider under

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131 the Health Security Act. Moreover, in th is administration, bills related to prohibiting funds to support oppose a legislativ e proposal or candidate emerged. George W. Bush (R) Administration, January 20, 2001 – January 20, 2009 (107th Congress House R-221/D-212, Senate R-50/D-50; 108th Congress House R-229/D-205, Senate R-51/D-48; 109th Congress House R-232/D-202, Senate R-55/D-44; 110th Congress House D-233/R202, Senate D-49/R-49) The most revealing finding when examining the bills that were proposed during this administration was that the majority of the bills were perpetually proposed (meaning that the structure and te xt of these proposals were identical from year to year). Such text came from larger appropria tion bills and stipulated the following information: appropriation for Title X under the Public Health Service Act; prohibiting funds for abortions; encouraging family particip ation among minors; prohibiting funds for supporting/opposing a legislativ e candidate or proposal; no t exempting Title X clinics from State laws requiring notification/reporti ng of child abuse, child molestation, sexual abuse, rape or incest; providing nondirec tive counseling and se rvices; and providing counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities. Question 2c: How do the proposed legislative bi lls support or challenge Title X for each of the themes that emerge? Examples of how the legislative bills s upport or challenge Ti tle X are organized under the broad categories used above (Adminis tration; Appropriation; Requirements of Funds/Services; Restrictions of Funds/Services; Related Legi slation; Related Policies; and Technical Amendments). It is important to note that the descri ption below regarding how the bills included in the legislative hi story support or challenge the Title X program was grounded in the researcher’s assumptions related to this study and in the principles of

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132 reproductive health referred to in Chapter One. For instance, the proclamation that reproductive health rights are ba sic human rights serves as a ce ntral tenet for this study. Reproductive health rights are grounded in th e notions of women being able to have control over their bodies, having autonomy over when, if and how many children they bear, and having equal rights as compared to men. Therefore, an assumption undertaken by the researcher involves the belief that all women should have access to comprehensive reproductive health care, and thus bills suppor ting or challenging Title X are examined through this perspective. Administration Support. Stipulations on the proportion of th e grant amount, such as the grant amount awarded must not be less that the tota l amount of the grant, and that the grant amount must not be less than 90% of the cost of the project are examples of how the maximum amount of funding was attempted to be maintained. In addition, the proposal that low-income individuals s hould participate in the grant, that grants should coordinate with State and other health se rvices, and that entities should not be denied funding due to the fact that their St ate laws are more restrictive, fu rther supports the administration of Title X. Moreover, the bills proposing the use of funds for contraceptive research centers, research, and training for a variety of personnel also supports the administration of Title X. Challenge. The most significant challenge that Title X faced over its legislative history was the bills th at proposed to repeal the entire pr ogram and/or transfer funding to other programs and polices. In addition, b ills proposing that the grant amount must include at least 40% of funding for alternatives to abortions and that funds must come

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133 from a particular section of the grant (i .e. funds towards training must specifically originate from the training section), constr ained programs to focus on alternatives to abortions, while inhibiting their ability to provide nondirective counseling and services and hindering their flexibility of maximizing th e use of their awarded funds to best meet the needs of their patients. Appropriation Support. Many bills supported Title X by proposing appropriation for the program as a whole, by proposing appropriation fo r sections of the program (i.e., research or information and education), or for propos ing appropriation for one or more of the following services: demonstrati on projects for infertility and adolescents; STD education; preventative health services; program pla nning and evaluation ac tivities; and loan repayment programs for professionals involved in contraceptive research. Challenge. In the preceding chapters it was noted that Title X has endured significant cuts in funding and has not kept up with demand in relation to the number of individuals in need of family planning services the cost of services, and the growing role of family planning providers. However, from the data itself that were produced from the thematic analysis on Title X’s legislative hi story, this theme did not emerge, except for the bills that proposed to repeal Title X or to transfer its funds to other programs and policies as mentioned above, as often, bills would not identify the funding amount, or because a comparison of the funding levels was not possible through the thematic analysis. However, an examination of the difference in appropriation throughout the years was included in the literature review in previous chapters. The limitation of the thematic analysis of Title X’s legislative hist ory of not being able to highlight the funding

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134 challenges that this policy has faced throughout its history will be discussed further in the next chapter. Requirements of Funds/Services Support. A plethora of bills proposed various provisions and services that would support Title X’s mission in providing family pla nning services to all those in need. For instance, bills proposed the following provisi ons and services that would directly and indirectly benefit the health of the individuals who seek Title X services: providing a range of family planning methods, includi ng natural family planning methods and infertility services; providing nondiscri minatory and nondirective counseling and services; staffing personnel who are familiar with the culture and who can speak the predominant language in that clinic’s community; provi ding cultural and competent breast and cervical cancer screening servic es; developing and disseminating communitybased information and education; and ensuri ng voluntary participati on for all services. Challenge. In contrast, many bills proposed amendments to Title X that would negatively impact Title X recipients’ heal th. For instance, permitting entities and personnel the option of not having to provide nondirective counseling or services due to religious or moral beliefs w ithout including a stipulation th at ensures the client will receive such nondirective couns eling and services from another staff member restricts a client’s options concerning their health choices. In addition, bills proposing waiting periods (i.e. 2-day waiting periods) after the Informed Consent process for abortion services and bills prohibiting an entity from receiving any Title X funds if they do counsel or provide ab ortion services with other funds (not Title X funds) also negatively impacts woman’s choices. Furthermore, ch allenges regarding providing services to

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135 adolescents were proposed, such as not being able to provide family planning information or disseminate family planning services in schools, removing c onfidentiality mandates for adolescents, and ensuring compliance wi th parental notification State laws. Moreover, the proposal regarding informing i ndividuals’ that in order to prevent HIV infection one must refrain form all homosexual activity institutes a bias towards sexual orientation without providing positive risk factor reduction education. Related Legislation Support. All of the proposed bills classified under Related Legislation directly or indirectly supported Title X. For instance, bills proposed to maximize the use of Title X funds to effectively provide family planning services, and to coordi nate services with other policies and programs distinct from Title X to assist in serving and meeting more individuals’ health needs supported Title X’ s goals. In addition, bills recognized the overlap and integrated nature of health a nd social problems and proposed demonstration projects for welfare recipients to assist in providing them with family planning information, including what services were av ailable and where they could go to receive services. Challenge. No proposed bills included in the legislative history classified under Related Legislation were found to challenge Title X policy. Related Policies Support. All of the proposed bills classified under Related Policies directly or indirectly supported Title X. For instance, various global and na tional population and family planning administration and centers were proposed that would establish and promote research and policy pertaining to population growth and family planning.

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136 Furthermore, these bills endorsed family pl anning principles, recognized the importance of family planning services and expressed the sense that such services should be valued. In addition, these bills promoted high quality, safe and effective family planning choices to allow individuals the right to choose if, when and how many children they bear. Challenge. No proposed bills included in the legislative history classified under Related Policies were found to challenge Title X policy. Technical Amendments Bills classified as Technical Amendments proposed minute typographical and grammatical changes, such as adding/dele ting semi-colons and colons and re-numbering sections in the act to reflect am endments. Bills classified as Technical Amendments also included those bills proposing to combine House and Senate bills. Therefore, Technical Amendments cannot be discussed in relation to whet her they support or challenge Title X policy as such changes only affected the law’s syntax. Phase II: Oral Histories Phase II involved conducting oral histor ies with past and present key Title X stakeholders to explore their recollections perceptions and expe riences regarding the Title X program. Oral histories were chos en as the appropriate qualitative methodology to supplement findings from the thematic anal ysis on Title X’s legisl ative history (Phase I), to assist in obtaining a more comprehensive understand ing of this policy, including highlighting barriers and achievements, and to document stakeholders’ perceptions on a controversial reproductive health policy that has been enacted for nearly four decades.

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137 Oral History Results Sample Population and Demographics Past and present key stakeholders were recruited in Florida through sequential and snowball sampling. Florida was chosen as a ca se study in which to sample past/present key Title X stakeholders due to demographi c reasons, having poor reproductive health indicators and outcomes, and because of the re searcher’s situated or ientation. The oral histories for this study are classi fied as a topical project and thus, individuals selected 1) had an integral role in the administration, ove rsight, or implementation of the Title X and family planning program in Florida and/or 2) were policy makers/actors and played a role regarding this policy at the governmental level. Sequen tial and snowball sampling was performed until the list of names was exhausted and no new names were identified (Neuman, 2003a). Prospective participants were identif ied from communication with past and current Title X, family pla nning and other reproductive hea lth stakeholders. A list of potential participants was deve loped and the researcher attempted to prioritize the names according to the various relevancies: the job position that was held (or currently hold); the expected expertise and know ledge that they possess regard ing this topic and/or the particular research questions; and by names that were continually identified as being critical people to interview. Those individuals who did not currently reside in Florida were excluded due to logisti cal and feasibility reasons. In addition, it was proposed that individua ls who differ in their opinions regarding the Title X program and who also differ in their personal and professional values regarding reproductive health, family pla nning, and the function and purpose of public

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138 health clinics in general w ould be included. Two particip ants who oppose Title X were recruited; however both participants canceled the oral history meeting due to immediate and unforeseen family problems and/or other conflicts. Although efforts were directed towards recruiting individuals and organi zations who oppose the Title X program and who hold differing values and beliefs, a nd there was some contact with these individuals/oppositions in some situations, incl uding such individuals in the final sample of this study proved to be unsuccessful due to difficulties in establishing direct contact (including individuals who have limited cognitive function and who are in a long-term nursing home due to advancing age, and those who are now deceased) and/or other feasibility limitations. In total, six participants completed or al histories. Among these participants, 4 were female and 2 were male. Three of th e individuals held or currently hold roles relating to the administration, oversight a nd implementation of Title X and family planning-related services, and th ree of the individuals held or currently hold roles related to the policy, legislative and judicial activ ities of Title X, family planning and other health services in Florida. See Table 1 below for the dem ographic characteristics of the participants.

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139 Table 1. Demographic characteristics of the oral history sample (N=6) Demographic Characteristics N Percent Sex Male Female 2 4 33% 67% Race/Ethnicity White African American Native American Asian/Pacific Islander Other 6 0 0 0 0 100% 0% 0% 0% 0% Age (Range 52-63 years) 50-55 years 56-60 years 61-65 years 1 3 2 17% 50% 33% Role Administration, oversight and/or implementation role regarding Title X and family planning-related services Policy, legislative and/or judicial role regarding Title X and family planning-related services 3 3 50% 50% The results below are categorized under the a priori themes, themes from Phase I and constructs from MFPAF. Other themes that emerged throughout the oral histories are also included under these sections as they apply and relate to these same categories. Values This theme originates from MFPAF and involves examining the underlining values within a policy and establishing whet her they reflect core feminist values (McPhail, 2003). Participants were asked wh at they thought the underlining principles of Title X were and what they thought the policy was trying to achieve. Many participants discussed Title X as a policy that delivers services and provides women with choices regarding their childbear ing – the choice to have or to not have children and the choice of when and how many children to have. “Well, I believe, that it was intended to help women and families choose when to have children or to have children at all and prov ide health services and health education and

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140 counseling for the family and the women, to understand what the – were to make an effective choice.” (Policy/Legislative, Female) Such notions of choice were also discusse d in regards to giving low-income women choices regarding having children. “So the main purpose is giving women the choice if and when they have children?” (Interviewer) “And based on her income so that it’s not an accident of poverty that you would end up with children that you would rather have waited for” (Policy/Legislative, Female) “So I really feel that our programs in Maternal and Child Health and Family Planning were extending the same kinds of choices to women who normally would not have them.” (Policy/Legislative, Female) “The concept of family planning was always considered to be preventing unwanted childbirth and the philosophy that we took to it was much more that it was empowering lower income women to have the same choices that women who had access to health care had and that was family planning, planning when you wanted to have your family.” (Administrative/Implementation, Male) This question also sparked discussion s about family planning “freeing” women from more traditional roles and providing th e ability to purse other things in life. “Being a young person during that era in general, I think that the ab ility to have family planning for women meant that they were freed up from some traditional roles and had more options to determine when they wanted to have a family and they could have a reproductive life plan, although that termi nology was not used that far back.” (Administrative/Implementation, Female) “…they wanted to be able to be gainfully employed, do something good for their children. Again, that reinforced freeing up of women and allowing them to really have a life.” (Administrative/Implementation, Female) When asked what they thought the policy wa s trying to achieve, other participants stated missions that related to the public health function of this policy, such as the policy’s role in birth spacing and the subsequent positive effect on women’s health preventing unintended pregnancies and preventi ng disease. In addition, participants

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141 perceived this policy as providi ng guidance regarding the partic ular entities and providers that could be involved with the Title X progr am, and the particular services, such as information and contraceptives, that we re to be dispersed to individuals. State-Market Control The theme of state-market control orig inates from MFPAF and involves whether a policy makes women more vulnerable or de pendent upon men, the state, or some other version of a patriarchal society (McPhail, 2003 ). In addition, this construct refers to whether a policy demonstrates any form of social control over women. The role of government. When asked about the government’s role in family planning, all participants expressed that the government should definitely have a role in making family planning services av ailable for all individuals. “I think the government has a role to take care of people, to assist people in taking care of themselves and their health. They can’t bitch about it on one si de and people are not working on the other side and have a baby every year when she doesn’t want to. I think that we have a responsibility for all health care including family planning. Not to force you to go, but to make sure that that serv ices are there and to take care of them.” (Policy/Legislative, Female) However, even though all participants stat ed that health care, including family planning services, should be available to all individuals, what did di ffer in participants’ responses was how and by whom family planni ng services would be paid for and which level of government should be responsible. “I – well, see, this kinda leads me to thin k into a different fram e and that is national healthcare insurance. [laughter]. And I thin k that there should be services, health insurance for everybody and that insurance s hould cover family planning and I think with limited resources, you do have to target it, but I think the best answer to that question is a national health insurance that covers reproductive health.” (Administrative/Implementation, Female)

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142 “Well what we’ve been doing is sort of a partnership and it’s been kind of slapdash in Florida as far as my experie nce with it. I thin k it would be nice if we had general good health care provided by the federal go vernment in whatever form that takes for everybody and that it should include reproduc tive healthcare. I don’t that it’s right, I don’t think it was right in Roe v. Wade t hat some states made abortion legal and some didn’t, that was silly. You can’t treat Amer icans differently – their privacy rights and their rights to decide when and whether to have children and be healthy shouldn’t be determined by what state line they cr oss.” (Policy/Legislative, Female) “My personal philosophical belie f is that health care, whic h goes the gamut, if I can buy it from a health care professi onal because I am middl e income, that same level of service and choice for that service should be availa ble to everyone in the country. I am very much an advocate for universal health care…it is the access to the care, that is the most important thing. Then the bur eaucracy and politics can figur e out who is getting the money for it and how it is getting provide d.” (Administrative/ Implementation, Male) When followed up with additional probes as king if such services provided by the government would make women reliant upon th e government, no participant thought that this would be true. Participants had strong f eelings that the government is and should be providing family planning services to individu als who would not be able to afford or access such services otherwise. “I can’t even imagine this would make so meone more reliant upon the government. My experience as a woman is basically that if you have the money you go to the doctor and if you didn’t have the money you go to the gover nment. But if you get what you need it doesn’t matter it’s not being reliant on the government, it’s being able to get something you need from the government…On the opposite side of that is if the government doesn’t give it to you the government is punishing y ou because you don’t ha ve the money to get what other people consider to be a basi c need.” (Policy/Legislative, Female) Social control. When asked whether they believ ed that Title X contains any elements of social control over a women’s body, such as playing a role in controlling women’s fertility, there was a mi xture of responses. Some pa rticipants believed that this policy does not place any cont rol over a woman’s body as th e program originated in a time when there was a shift in thinking and the key stakeholders and administrators were children of the 60’s and “were already cha nged folks” (Administrative/Implementation,

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143 Male). Others responded that Title X contai ns no elements of social control because the program and services are voluntary, is not requ ired of any woman, and is available to all women of all economic and social statuses. “No, because it is a fully vol untary program. If a woman choo ses not to utilize a method of contraception, then that is her choice.” (Administra tive/Implementation, Female) “I don’t think anybody who tried to pass Title X is now, well you know that may not be true, but most people who are implementing Ti tle X I don’t see them as doing this as eugenics, I really don’t.” (P olicy/Legislative, Female) Moreover, Title X was discussed as empower ing women and giving women control over their bodies, rather than enforcing any form of social control. Ag ain, such beliefs dealt with the fact that women choose to seek serv ices and can discontinue receiving services at any time. “Not in my opinion, and in fact it’s more empowering than disem powering from what I can see because nothing in Title X that I’m aw are of says if you have a failure of birth control, and have a kid, then we’ll make you get sterilized. There’s nothing in Title X that says if you have a failure of birth control then we’ll have to cut you off and you’ll have a whole bunch of kids. I mean…it’s all within th e power of the person seeking the services, to determine whether to continue them or use them.” (Policy/Legislative, Female) Two other participants responded to this question by stating that this program may contain elements of social control, specifi cally for the African Am erican population. It was discussed that the idea of Title X contai ning elements of social control was also perceived this way by African Americans legislators. “Well to the extent that it’s aimed at poor people sure, and poor people are randomly not white people, they are just proportional people of color. I don’t mean that there are not a lot of poor white people there certainly are. I’m sure that there’s some people out there who believe that programs providing family pl anning to people who are low income is mainly a way to keep people of color from having more children and they’re not happy about that and they’re racist and I don’t think that’s true but some people believe that.” (Policy/Legislative, Female)

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144 “You know, I think that, you k now, there were some African Americans early on that felt like this was population control for them, and I guess I was really hurt when that was said because we never saw it in that respect. In fact, at one time, we were putting some of the money that we were – we, actually, th ere was some general revenue for family planning that we were putting in sterilizations ; and what we ended up doing is we didn’t change that, is some state legi slators, some black legislat ors, had problems with that.” (Administrative/Implementation, Female) In addition, some participants openly di scussed how Title X and family planning services in the State overtly practiced soci al control measures. These social control measures involved inappropriate and unethic al measures of providing family planning, including sterilizations, to women in the early days (1970’s and 1980’s) as well as in more recent times (1990’s). “And I think it could have that connotation. I definitely do… But, yeah, some people, absolutely. In fact, there were some times when we had some sterilizations that were not done appropriately and some people lost their jobs over that…And that’s why, with sterilizations, there were guidelines…and we really set that up and if somebody did not follow those guidelines then they were made to find other monies to pay for it and we held money back for it and we held money back from them. So, I mean, we put in [safeguards] – we’d try to – yeah.” (Administrative/ Implementation, Female). “We had concerns…because in the early 1990’s [Name] wanted to require women to have family planning and give incentives. He had incentives he wanted to give them and gave women after they had a baby if they were poor…” (Policy/Legislative, Female) “To have sterilizations?” (Interviewer) “…Yes, and they used family plannin g.” (Policy/Legislative, Female) Another discouraging finding regardi ng state-market control, and more specifically, social control, were part icipants’ knowledge and experiences of governmental measures to control and limit women’s reproductive choices over the years and how such measures continue to be initiated to this day. “Now there is thinking that during this time there has been some constraint around public policy related to family planning and, in fact, at ve ry high levels there have been some things that have been constraining and even very recently some regulations promulgated that potentially could limit wome n’s ability to make their choices. So there are people who are already talking about with a new national agenda coming forward

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145 that there maybe some opportuniti es for broader more open policy.” (Administrative/Implementation, Female) Stigma. The idea that receiving Title X services may be stigmatizing for individuals was discussed througho ut the oral histories. Most participants did not think that there was anything in the Title X policy or the services administered through Title X that could be perceived as stigmatizing by indi viduals seeking the services. Participants expressed that clinics ensure confidentialit y, and reiterated the fact that women are coming to the clinics by their own voluntary choice. However, some participants recognized that there might be some reluctan ce to seek Title X serv ices, but that would have to do more with cultural issues. The infl uence of cultural factors in relation to Title X is discussed more in the Multiple Identities section below. However, one participant did share a pers onal story in where friends of the family were suffering through some bad economic times but did not want to resort to having to go to the health department to receive fam ily planning services. These individuals “took chances” and the woman got pregnant. However, it was cheaper for th is particular couple to abort the pregnancy rather than to carry the pregnancy to term and not have health insurance to pay for the pregnancy. This story was followed up by the following quote: “And so, yes, I’m sure that it’s stigmatizi ng for some people and you’d make some people very uncomfortable and that they are judged and different things – I hope that doesn’t happen, but I’m sure that it did.” (Adm inistrative/Implementation, Female) “Because it is considered a “s ocial program”?” (Interviewer) “Yes.” (Administrative/Implementation, Female)

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146 Multiple Identities The theme of multiple identities originat es from MFPAF and recognizes that there are multiple forms of feminism and such different perspectives could help illuminate any discrepancies or contradictions present with in a policy. Furthermore, this construct acknowledges that like the presence of multiple feminisms, a woman’s identity does not only pertain to her gender, but can pertai n to other identities such as her “race, ethnicity/national origin, sexua l identity, class, religion, a nd level of abil ity” (McPhail, 2003, p. 51). Subsequently, McPhail (2003) asse rts that such overlapping identities and how these identities are organized to oppr ess women or restrict their access and participation within a policy should be examined. Some participants acknowledged that Title X does address the needs of all individuals in Florida and many “types” of women seek Title X services. It was expressed that women of all economic status including women with health insurance, will seek family planning services from Title X clinics because they are more comfortable in receiving services from Title X clinics than “traditional” physicians’ offices, and that more confidentiality is maintained at Title X clinics. “Because it does have a sliding fee scale, then it is available for women who cannot pay anything or to women who have the means to pay a full fee.” (Administrative/Implementation, Female) “Simple answer, yes. We always felt when I was in up there involved in it and something that carried through as a philosophy all th e way through my career was that none of those demographics mattered. What mattered wa s that you really di d not have a choice economically to get it in the private sect or….There was no targeting by demographics that did not have to do with economics. That almost became the only issue.” (Administrative/Implementation, Male) “We had a number of women even as physicians who chose to be in a public health setting as opposed to other settings, they liked coming and being able to see a family

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147 practitioner [nurse practitioner] as opposed to the traditional male practitioner, or the male gynecologist, OB/GYN’s. I saw the gam ut of all levels of income coming in.” (Administrative/Implementation, Female) “And you know, I mean, I can remember back in the old days when I was shoe leather public health, I mean, we actually, you know, y ou got a lot of kids and you got kids that came from very good families that would come in because they didn’t want, although their families had insurance, they didn’t want their parents to know that – they didn’t want them to get a statement…or havi ng their doc – this is pre-HIPAA – although everything was supposed to be confidential, you know?” (Administr ative/Implementation, Female) Furthermore, immigrant and undocumented groups in Florida were discussed, and participants revealed that they believe thes e populations should be able to receive family planning services. However, it was unclear as to whether participants believed that these populations should be able to receive family pl anning services because health care should be available to all individuals residing in Florida, or if these populations should receive family planning services because the conseque nces of not receiving such services would have a negative impact in Florida’s communities. “I had mentioned earlier illegal aliens. Flori da, agricultural state, less and less as we build more and more and we pave over fiel ds. It had a very large Hispanic migrant population. And consequently, it had a very large undocumented population. We believe that any health problem that came up, any health situation that came up in that population would have an adverse impact or could in our community. Consequently, everyone needed access to all of our servic es.” (Administrative/ Implementation, Male) “That’s where [Title X] immigrant populations are allowed to enter and actually receive services even if they’re undocumented. You know we can have a whole discussion of immigration and all that sort of thing, but you know I th ink that’s a penny a pound, penny foolish, whatever it is. If you’re not going to give health education to undocumented immigrants than you’re going to live w ith the consequences. Aren’t you?” (Policy/Legislative, Male) However, one participant spoke about the fact that Title X is obviously not addressing the needs of all individuals in Flor ida because efforts tend to be reactive rather than proactive. For instance, the needs of all individuals are not being met because there

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148 are limited efforts to prevent pregnancies, and family planning is discussed only after a woman becomes pregnant, to help avoid or plan better for future pregnancies. “No [the needs of all individuals are not being addressed]. I th ink that’s just really been an eye-opening thing. You know, family planning is always – not always, that’s not right. It’s almost, how do I say this? T hat, it’s almost like it’s in re sponse. It’s always an “after the fact” thing. You know someone comes in, well, for instance, if they’re going to the Health Department and they’re pregnant, well cer tainly they talk about family planning for the future. It’s a response at that poi nt, but obviously, they’re probably too late. That’s how they got pregnant in the first place. Well, a lot of them.” (Policy/Legislative, Male) Other participants spoke about how T itle X does not address the needs of all individuals because services are not culturally sensitive. When asked if Title X addresses the needs of all women in Flor ida, one participant responded: “Probably not. I can’t speak for now. I think, you know, we’re much more, the whole system is much more culturally sensitive and ethnic sensitive than it used to be. And I think, you know, previously, you know, if we had translations in English and Spanish, we felt we had done extremely well. And knowing that in South Florida, everybody’s Spanish is not the same, you know…And so we pr obably didn’t do everythi ng that we could do…You know, and sometime when I think abou t how we would do things, you know, I kinda [deep breath] makes me feel very unc omfortable.” (Administr ative/Implementation, Female) In addition, there were particular groups of people that participants thought were not adequately addressed through family pla nning efforts. Men were mentioned as a population whose needs were not being addresse d through Title X. A lthough, the role of males was discussed in anothe r section of the oral histor y, one participant stated the following when asked about what individua ls were not gettin g their needs met: “Probably not of men. Title X does vasect omies. I don’t think that women know that…Women are primarily the health care seekers and if you look at the insurance companies and the health insurance, the pe ople they want in there are young men 19 to 24, and that is who don’t go because that is their healthiest time.” (P4)

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149 Another participant alluded to the fact that el ders (with regards to safe sex practices) and disabled individuals were not addressed th rough family planning efforts. Although not exclusively focused on Title X, this partic ipant suggested that you could address the needs of elders and the disabled by having a larger component of family planning in Medicaid. Similar to the response regarding addressi ng the needs of indivi duals, participants responded that low-income individuals were the population in which the majority of family planning efforts focused their attenti on on. However, one participant explained that extending efforts and trying to bring wo men in to receive services was unlikely because current resources, such as funding and time (scheduling appointments), were already limited. “Beyond Title X – first of all, there is us ually not enough funding or not enough patient slots to really go out and advertise.” (Administrative/Implementation, Female) Another participant re-iterated that in pr ior decades, efforts were being focused on whatever population was coming in the door. Although, this participan t did explain that some advertisement was done in the 1970’s and 1980’s, but how such outreach was not successful because community leaders were not being reached. “Oh, I think we were targeting people that came in the door. We did some, you know, we made up some posters and different things and tried to work with some people in the communities. In fact, I’ve got a paper I wrot e somewhere, once I left for family planning, on how to do – where their outreach should be targeted and who the …[although], what we did not do is we did not bring in…we di dn’t bring in the comm unity – recognize the community leaders in that population and bring them in to, you know, and for them to understand what we were doing and have them be advocates.” (Administrative/Implementation, Female)

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150 Political Context The construct of context, originating fr om MFPAP, is vital to analyzing a policy and refers to the economic, political and so cial environments in which women live (McPhail, 2003). In addition, the context in which a policy exists can include the effects and/or implications that another policy exer ts over the particular policy that is being studied (McPhail, 2003). The effects that othe r policies have on the political context are important to consider when examining a ny reproductive health policy. Moreover, aligning with the purpose and scope of this study, examining the context in which this policy takes place will assist in uncovering the historical evolution of this policy and the many issues and barriers that it faces. Accordingly, context proved to be a very important topic, and was both embedded th roughout the entire oral histories and discussed at great lengths by pa rticipants. The findings from the oral histories related to context are broadly organized be low into 1) political contexts and 2) social and cultural contexts. Abortion. When asked about periods in time when there was an increase in political activity surrounding an issue, all participants mentioned abortion as one of these “hot” political topics. Most participants e xpressed a sense of frus tration when talking about abortion, while at the same time acknowle dging that this issue has always and will continue to be in the forefront during a ny reproductive health policy discussion. For instance, participants provided statements indicating how abortion and family planning were distinct services, yet how these services always got confused with each other in the minds of legislators and others in the community.

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151 “I think one thing that peopl e tended to do, was associate abortion with fa mily planning and we always said once somebody was pregnant, it was no longer family planning, although somebody may be counseled on their options. You know, once that they were pregnant, it was their decision what it was that they were going to do – you know, we never paid for abortion.” (Administrative/Implementation, Female) “There are from time to time people who may associate the Title X program and family planning services that are prov ided through that program w ith other places that call themselves family planning, but also o ffer abortion. For that reason, sometimes our programs and Title X get mixed up with that, so we will have to answer questions and concerns that may be raised in that re gard.” (Administrative/ Implementation, Female) “I have not talked about abortion as part of fa mily planning. I see that as two different things. Politically, it can never be lumped into family planning. It can be lumped into reproductive. Because of the word “planning” being in there politically. You are planning to have an abortion.” (Pol icy/Legislative, Female) One participant explained re-occurring instances where the opposition would attempt to “catch” her and the program dealing with a bortion issues and stated the following: “And I could always tell when I was here, ri ght before a legislat ive session started, I would start getting phone call s with people saying, “I’m pregnant. I want an abortion. Where do I go?” And so, you know, I knew I was trying – somebody was trying to catch me. (Administrative/Implementation, Female) “Wanting to catch you in that, to gather evidence to decrease the funding?” (Interviewer) “Yes, [cut the funding], right.” (Adm inistrative/Implementation, Female) As mentioned above, abortion has always been a political controversy that has been intertwined with family planning. Partic ipants discussed that unfortunately, issues surrounding abortion are always present and cont inue to be introduced in each legislature session. When discussing abortion legislati on and how that impacts Title X and family planning programs, one particip ant stated the following: “In Congress you have perpetual people. You have somebody who is there for 25 or 30 years and they will introduce the same bill ever y year. Why not? It is not going anywhere, but it is there if they get a piece of it. It is the kind of thing that if you don’t – if something is not on bar against it, it will move it one more step restrictive than it was the previous year.” (Administrative/Implementation, Male)

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152 “Well I think the reas on the topic [abortion] keeps being brought back up is because interest groups don’t even want there to be a Title X and in order to make it more politically charged, they try to change Title X’s focus with a pro-abortion focus, and I hate using that phrase because it’s pro-choi ce…and then the legislators would come out and say oh well, you can’t give the one t hat only does family planning any money because really they’re the same group. I me an, it’s just a way to mess with women’s bodies.” (Policy/Legislative, Female) There were also discussions about the re gulations on abortion clinics, the entities that provided abortion services and how th at influenced the Title X program. “Also in that period of time and the early 80’ s is when the aborti on clinics became an issue. I can’t remember what year it started and what triggere d it. That was not triggered by Title X as far as I know. When we got involved with it, we had Title X that had contracted with Planned Parenthood clinics. It was in certain communities and Planned Parenthood was a provider of a community clinic for women. Folks who opposed family planning were very much opposed to Planned Pa renthood. I know that there is a lot of pressure not to contract with them, things of that nature.” (Administrative/Implementation, Male) In addition, one participant expl ained that one of her roles was to work on behalf of a coalition that was composed of three differe nt reproductive rights organizations and to deflect any criticisms that the clinics repres ented in the coalition might have faced in regards to abortion. Issues surrounding the Gag Rule (prohibi ts personnel from providing information, counseling and services on abortions) and “opt ions-counseling” (provi ding participants with information on all pregnancy management options) were also re vealed as political controversies and were discussed among at leas t four of the particip ants. Participants spoke about how the Gag rules would really affect a small county that had limited number of clinics, and how if the clinics that were in th e next county had doctors that would not discuss abortions, how such rules would really have a negative impact on

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153 women. In addition, participants spoke a bout providing and not providing options counseling because it was su ch a political agitation. “I think that when people came into Title X, and this is one of the ways that we changed some of our programs, was the options-couns eling, is they came in and there were pregnant and you would lose the options. Th e model of family planning, the far right didn’t like that [options c ounseling], so we no longer pai d for that. If they, found somebody who was pregnant, they ceased to be a family planning client and then, they were a prenatal client…’Cause people had such a problem with the whole optionscounseling, we just opted not to do options -counseling under family planning. That was done – that we used a different fund each tim e for that. And that’s where we made some people very unhappy.” (Administrat ive/Implementation, Female) “The whole period when there was the Gag Ru le and then Russell v. Sullivan and Clinton definitely impacted the board of legislatur e. They cut Planned Parenthood in Florida seriously for some state fundi ng that they were receiving…ju st based on the fact that Planned Parenthood said listen you know we ’re for the whole woman, and abortion is legal, we do not perform them, we do not vi olate Title X, but we’re not gonna shut up, and that was quite exciting.” (P olicy/Legislative, Female) “Basically, because we are Title X in public clinics that I have been associated with, we have really not had an association with abortion because we have to be non-directive in our counseling. We don’t even say if someone sa ys to me that they want an abortion, I can’t really say to them “Okay, go over here .” I need to be nondirective and say there are providers who do that, you might be abl e to find that info rmation in the phone directory or on the internet.” (Adm inistrative/Implementation, Female) Two participants spoke in detail ab out political activity surrounding family planning programs and abortion when Gover nor Martinez attempted to make abortion illegal in Florida. This part icipant explained how she had al ways been responsible for the two separate programs and ac tivities surrounding family pl anning and abortion, and how that was not always easy and necessarily good for the Title X program. Regardless, with support and hard work from health leaders, they were able to “d eflect a lot of the criticisms away from the [Title X] program”, and after all of that commotion, actually secure more money for family planning. This participant stated that her leadership

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154 conveyed to Governor Martinez that, “You know, if you didn’t fool with my family planning, there wouldn’t be as many abortions.” Throughout the discussions, participants spoke about how abortion affects Title X. There was confusion among legislators and other interest groups regarding the difference in what these services provide and a never-ending political battle to use abortion as a means to dismantle not only Titl e X but other policies and programs as well. Perhaps the discussion of how abortions affect Title X in the oral histories is best summarized by the following quotes: “Oh, I see people alleging that there are abortio n agendas in all kinds of women’s health issues in this legislatur e. I mean, it’s hilarious! So I think it’s universal.” (Policy/Legislative, Female) “Abortion is the lightening rod so that a lot of the opposition to Ti tle X family planning has been that somehow we will cause less children to be born and that some people believe we should not be doing that…Because th ey are both so involved with pregnancy and the birth of a child, it is logical for any legislation or any program that does anything around this area of conception to draw controversy to it.” (Administrative/Implementation, Male) “Well, I would say you know, I’d keep the abor tion stuff out of it because you – that dog gets a lot of fleas on it when you bring that piece into it. You just get a lot of household detractors when you bring that piece into it. I mean that’s a logical debate that could be had that they need to probably create a new Title under that particular Act of Congress and deal with those monies, up down and a ll around, separate from Title X. Call it another Title of some sort. It ju st – it’s just so damn volati le.” (Policy/Legislative, Male) Family planning methods. All but one participant specifically mentioned particular family planning methods as polit ically controversial. Most discussions involved emergency contraception (EC), the la ck of knowledge that people had for this method and how that would create problems for family planning programs as a whole. In addition, participants discussed the probl ems involved in making EC available in

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155 hospitals and how increasing EC access in hospitals is still a struggle and continues to be a bill that gets introduced into the state legislature each year. “And, you know, we did some stuff with the le gislature as far as emergency rooms with rape victims and all requiring them – you would – hard road to hoe with Catholic hospitals, but once you found the do ctors, you just slid that u nder that table, and they just didn’t want a big policy about it because they could get way with doing more.” (Administrative/Implementation, Female) Although less frequently discussed, other part icipants recalled times when the rhythm method, IUD’s, and Norplant created political noise surrounding family planning as well. Adolescents/minors. Participants were asked to discuss their experiences regarding working in the area of Title X and fa mily planning in relati on to adolescents. Most participants stressed that enabling adol escents the right to receive family planning services is always a struggle. No part icipant had any positive comments or conveyed encouragement in their discussions about fa mily planning and adolescents. However, one participant did say that were was mo re positive support and interest in family planning if teen pregnancy was an issue and if they then could direct family planning towards teens; however, this would vary by community, and even though no one wanted teens to become pregnant, it was a qu estion of what was being taught. Generally, participants stressed the im portance of maintaining adolescents’ confidentiality for a variety of purposes, incl uding that adolescents did not want their parents or health insurance companies to find out that they were seeking family planning services, and because of the possibility of se xual abuse. One participant did note that after doing quality assurance and chart revi ews, many adolescents did come into the clinic with a parent. This same participant also added that it is wise to do a pregnancy test on all adolescents, just in case the adol escent came in because they were afraid that

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156 they were pregnant, and not because they had come in to seek contraceptive services. Challenges with regards to follow-up with adolescents were also noted, such as the following: “And so, I think the challenge for them was staying in the program. You know, they may come into it when they were sexually active and then, they would quit and then they would come back when they had another partner ; and so, it was a continuity of staying with the program whether or not you were going through droughts of sexually activity.” (Administrative/Implementation, Female) Another participant describes personal strugg les that can occur when providing family planning services to adolescents: “I think that it is very hard to separate one ’s personal views and opinions. You may think that you hold certain kinds of opinions and values and that you can keep those very separate and that you don’t bring your bias es into the work that you do, but it was brought home to me very clearly a few tim es when I would have someone who were children of people that I knew and maybe went to church with or was associated with in other social ways that would come into me for family planning and I had to separate my feelings and make sure that I maintained th eir confidentiality and supply them with the method if that is what they c hose to do or counsel with th em and at the same time I’m having that tug within me of, you know, this child’s parent really ne eds to know what is going on and be a part of their life and it is ha rd for me to understand that they are that disconnected from knowing what their chil dren are doing. I think that is probably a struggle that many of my colleagues have also talked to me about and tried to deal with over the years.” (Administrat ive/Implementation, Female) Participants also talked about how pub licity that focused on family planning or broader reproductive health issues that wa s taking place in the media could make adolescents perceive that this was a barrier for them, and thus, they would then not come into the clinics. For instance, examples of the publicity surround EC was mentioned as being a topic in the news that would deter adolescents from going into a clinic and receiving any type of family planning servic e. In addition, participants discussed the political attempts to prohib it adolescents from receiving any family planning services through age requirement legislation.

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157 “Before Governor Chiles was Governor – or Martinez was there. When Governor Graham was Governor – who ever was Governor in the early 80’s, there was a little spike in the 80’s for senator votes and a c ouple of senators who ar e now dead who really wanted to require age requireme nt for girls to get any kind of family planning to include Title X. That was the early 80’s.” (Policy/Legislative, Female) Similar to above where part icipants noted that the topi c of abortion gets thrown into legislation to create barriers, part icipants also discussed how by including adolescents into a policy, either red flags w ould instantly get raised or the policy would get overlooked altogether. “I think it is real red herri ng. It is something that if the legislatures can’t do something about important issues they can throw in an adolescent or throw in a pedophile or abortions and it seems to cover up the $50 billion shor tfall in the budget. I think that it is used for that and I think that is a terrib le thing.” (Policy/Legislative, Female) This participant goes on furthe r to say that including adol escents creates a diversion: “…and because people get so much emotion in it Look how many of them actually never pass. They spend a lot of time with all of th e crazy people going nut s and all of us that might be working on other important issues having to defend that we can’t focus on homelessness. I can’t work on homelessness be cause I’m trying to defend something that is never going to pass. To me that is child abuse and our legislature is tremendously guilty of that, playing these kind of games. They are just the audien ce. What do you do?” (Policy/Legislative, Female) Abstinence-only education. All participants expressed that even though they provided or supported abstinence informa tion along the family planning continuum, opposition promoting abstinence-only education continued to affect Title directly and indirectly. All participants agreed that in formation on abstinence, practicing safe sex and using family planning method are critical me ssages that need to be heard among youth. One participant acknowledged that if people want to be pro-life, they also need to accept sex education that includes contraception and prevention messages. “Education improves awareness, regardless of whatever the subject matter is. I mean, I’ve told my pro-life friends that I – you know you talked about the whole thing coming

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158 full circle on the health e ducation, I honestly don’t believe you can have it both ways. If you want to be pro-life, then you have to have appropriate health education. I don’t see them mutually exclusive. I see them in clusive.” (Policy/Legislative, Male) However, any political noise regardi ng abstinence education always posed a negative threat to Title X and family pla nning programs. Often, participants would mention how abstinence-only education crea ted barriers for family planning and how they have to work towards ensuring th at family planning was separated out. “So, it’s interesting the way things work. Y ou know, I think that when – and this was actually under Bill Clinton’s administrati on, that the money for abstinence fed the far right and allowed – gave them strength and pow er to further attached the program and that was one of my big downfalls. Because we got some money. I mean, we weren’t real crazy about getting it, but that gave them an inroad into the departments and then they were they were slamming a lot of the fam ily planning program as a result of them being the abstinence program.” (Administrative/Implementation, Female) “One other place that there became a lot of controversy had to do with abstinence only education that came out in legislation around 1996 and made f unds available out of Title 5, which is the MCH Block Grant for abstin ence-only education; and developing a plan for how those dollars would be used in Flori da we went extensively through the state and listened to what all of the various stakeholde rs had to say before ac tually coming up with the plan for how we would im plement, and we kept that very separate from family planning very purposely because of what we heard from folk s in the field.” (Administrative/Implementation, Female) School-based clinics School-based clinics were mentioned by at least three participants as being another controversia l topic when dealing with adolescents. Participants mentioned that those opposing sc hool-based clinics felt that these clinics would increase adolescents’ access to family planning and incorrectly thought that this also included abortion services Participants explained th at school-based clinics focus more on psychosocial issues, chronic diseases (i.e., diabetes) and medications (i.e., Attention Deficit Disorder) a nd in fact do not exclusively focus on family planning. One

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159 participant describes providing family planni ng services in school-based clinics only that have such services discontinued once the new state administration came in. “I think having services where kids are is a hard part and I remember our first schoolbased clinic, which was in Gadsden County and contraception was a part of that and that was under Bob Graham’s Administration and it was on campus and his response was, “I don’t want any state money used for it” and so, and we chose not to use any Title X money and we funded it out of Title V m oney. So, they had a school based clinic on campus that was providing contraceptives and then when Bob Martinez came into office, the first thing he did, his first day of office, was ha ve it moved off of campus.” (Administrative/Implementation, Female) Parental notification and emancipation of minors When talking about adolescents and family planning services, all but one participant br ought up issues related to parental notification and the emancipati on of minors. The statute related to the emancipation of a minor was discussed, wher e a minor would be provided the authority to sign and take responsibility for her own hea lth care if there was a case that her health could be adversely affected if health care was not obtained. “There were four or five ways a minor could become emancipated for health care. I don’t recall what they all were, but one of them wa s if the service would prevent – I can’t recall how it was worded. A minor could approve their ow n health care if that by not getting the health care would be adversely affecting th em. That was the one, that last one was the one that was used most of the time for providing teenagers access to family planning because the doctor had to sign that if he did not give this teenager family planning services she was at risk for major health problems and the most major health problem was pregnancy. In those days too, maternal mortality was an issue.” (Administrative/Implementation, Male) Participants also discussed their pe rsonal struggles and opinions regarding delivering family planning services. One partic ipant related a personal story from a client where the adolescent did not want to be put on family planning; however, the mother brought her daughter into the clinic and placed her on family planning anyway. In this particular story, the mother was prostituting th at child in another state and wanted the

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160 child to be on the pill. This participant fu rther expressed how they would always try to see the adolescent separate from the parent to talk to them privately and inquire what their wishes were regarding family planning. Another participant discussed how parent al consent was very much a political battleground even though Title X law indicates that services must be confidential. Legislators were often pressure d into dealing with the issue of parental consent, even though they knew that such consent was not goi ng to be in the child’s best interest. “Title X was done very different and then when legislators started getting into the act, it became more if a football and a political ki nd of thing. Not because anybody doesn’t believe it is there. An example would be between 1980 and 1983, somewhere in there, we were fighting over whether or not there shoul d be parental notice for consent for family planning even though it was unconstitutional or against the policies of Title X and legislators actually t ook me aside and said, “we don’t rea lly want to pass it, but we have too – because our constituents expect us to”, which I heartily disagreed with….it has just been a political football and political camera and legislators have done that.” (Policy/Legislative, Female) Administration and politics. Throughout the oral histories, many threads regarding how administrations a nd politics greatly affect the health and success of Title X and family planning programs became appare nt. While this theme is intertwined and entrenched with many other th emes in the results section, a separate narrative on this topic is warranted. Although e xpected, what is worthy of not e is that most discussions surrounding administrations and politics were perceived as negative experiences and adversely affecting Title X and family pl anning programs in Florida by participants. As previously mentioned above, partic ipants spoke about Governor Martinez’s actions of removing school-based clinics in Gadsden County dur ing his first day in office and his attempts to make abortion illegal in Florida. Governor Bush was also discussed

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161 at great lengths by many participants as se rving as an oppositional force and barrier to family planning programs. “Under Jeb is when it got really ickey becaus e that’s when all of a sudden [Name] was gone, family planning was nowhere on the we bsite. If Florida had family planning services, you couldn’t [fi nd it] if you wanted t o. Legislature sort of realized – what is it they call plausible liability? Th ere is so little money and they have not hit us at the money level – which leaves family planning alone. Under Jeb it came off of the website – abstinence came in…” (Policy/Legislative, Female) “Jeb was anti-family planning. Now it has settled back down.” (Policy/Legislative, Female) Governor Bush was believed to be the Gove rnor who created the most difficulties for family planning. One participant discussed him as actively going after family planning and trying to shut family planning down, wher e most of the other governors generally left family planning alone. In addition, it was re ported that Governor Bush would not even speak to stakeholders about family planni ng and other legislator s and staff persons stopped such communication dealing with family planning as well. It was also discussed how family planning was affected differently with each state administration: “Every Governor has a spike one way or another. Chiles being the most positive. Graham being actually the most positive. Chiles did increase it. It has always been there as controversial. Graham put the money in and started a state progr am. I would say that each decade has had spikes around it.” (Policy/Legislative, Female) Another participant continued to speak about even though state legi slators would “fight tooth and nail” about health e ducation in schools, they neve r discussed that this same health education related to family planning was going on in health departments, and that is either because “they did not know or th at they chose to look the other way.”

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162 Although less discussed than state administrations, the effect of federal administrations on family planning was al so mentioned. In comparison to some participants feeling that Title X and fam ily planning was affected by different state administrations, another participant expresse d that they did not feel any big changes occurred to Title X and family planning programs at the federal level. “I never saw any full-scale tips to stop fam ily planning or health education in the health departments by the Republic an Administrations or the Republican Congress. I guess my point is the status quo in those areas, was chugging along even as the conservative movement was running America.” (P olicy/Legislative, Male) In addition, the idea of how agendas and priorities would continually get switched depending on which administration was in power was often reported. Participants discussed this flip-flop in ideals as “schizophrenia” in pol itics. For instance, one participant noted that one of the first thi ngs that President Obama did was overturn the Gag rule. Participants also talked in general about the political climate in Florida over the years. “When I was a kid, conservative meant no change. Liberal meant change. Well, you could have change with conservative principl es. I mean, Florida continues to be very progressive.” (Policy/Legislative, Male) Other political topics or “buttons”, as pr eviously reported above, dealt with issues relating to adolescents and abortions. How these issues would create such “diversions” for other issues that have absolutely nothing to do about family planning. Participants spoke less a bout particular opposition organizations than expected. Even though participants discussed at great lengths about the types and forms of political and social contexts, barriers and oppositions that Title X encountered, it was expected that experiences would involve discussions re garding particular organizations. However,

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163 two participants did mention two organiza tions that opposed family planning. One participant spoke about a time when Governor Bush and a long time advocate in Florida who opposed various family planning and comprehensive sex education activities constructed “some wired opposition letters” wh ich incorrectly stated that the only teenagers that were to be eligible for a family planning waiver were those that already had children. Another partic ipant spoke about th e Florida Catholic Conference actively opposing family planning issues in fr ont of the Florida legislative body. “I remember that the more money that we got in Title X, the more the folks who were against family planning became active. I remember distinctly. Probably 1980 to 1985, I can’t remember the years that we were getti ng legislative money. I was very active in the legislature and testifying before committees and things like that. I remember the Catholic Dioceses. I can’t remember the names of the two people.” (Administrative/Implementation, Male) “Was it the Florida Catholic Conference?” (Interviewer) “Yes, [Name] is one of the women and [Nam e], I can’t remember [Last Name] first name…I distinctly remember that we used to be – we would be mee ting with them to try and get them to agree. Because they very much supported maternal child health activity. They wanted to seek care for women and care for women who were pregnant and care for the children. So it was a question how to fit family planning into that so they would not oppose us in family planning issues.” (Administrative/Implementation, Male) Other participants discussed opposition groups in terms of what that oppositional group’s motives were. For instance, one part icipant spoke about how people who believe in eugenics would create a commotion and would stir up controversies with religious people regarding the control that they perc eived family planning programs had on human lives. “The people who believe in eugenics, you k now, maybe they wouldn’ t call it that, but people who believe in population control comp licate the situation sometimes because they get the religious people al l worked up who say well, you can’t be playing God like that and things get a little wacky – but those are the main things t hat politicize Title X programs.” (Policy/Legislative, Female)

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164 Additional political moments. Additional political moments that participants remembered as heightened political activities were issues related to HIV/AIDS, oral sex, welfare reform and stem cell research. The same participant mentioned the first three issues listed (HIV/AIDS, oral sex and welfare reform). This participant referred to HIV/AIDS as an issue that required increase funds fr om Florida’s government and increased activity around the gay populati on including “contraceptives” [researcher’s interpretation is that the participant was refe rring to protection (i.e. condoms) when they said “contraceptives”]. This pa rticipant also spoke about or al sex as being a political issue affecting family planning. “The second thing is the whole second virg inity deal or having oral sex and not considering that sex and as being a virgin when you’re married, that whole thing has come out of this pre or post 1980 state/nati onal debate on health education…It’s kind of weird kind of – that is ki nd of family planning, if y ou know what I’m saying.” (Policy/Legislative, Male) This participant also identified welfare refo rm as being an additional issue affecting family planning programs and services in Florida. “Health education is a huge part of welfare re form. Again, what I said was that if a teen mom has a second child, she’s pretty much been buried, just stat istically. You know certainly you are saddened that she’s entered the system in the first place of being an unwed and teen mom. But you just have to really – as part of welfare reform, what we did is when we were getting them welfare to work, there is a education component and a family planning component to keep them fr om – of them understanding what’s going to happen if they get pregnant again, to provide those family planning components. That then – that is the wages program. It weaves There’s a weaving of those family planning benefits in our welfare system and that became because of that. I wa s part of that whole thing. I’m very proud of it.” (Policy/Legislative, Male) The other participant who mentioned an additional political moment affecting

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165 Title X and family planning discussed stem cell research. This participant felt like the controversies surrounding stem cell resear ch negatively affects women and creates additional burdens when seeki ng family planning services. “I think it’s been affected somewhat by st em cell and this whole pi ece on family planning works after conception with the zygote and it you know, so I think some of that has impacted the program.” (Adminis trative/Implementation, Female) “Negatively or positiv ely?” (Interviewer) “Yes, negatively. I think that most of the people, the consumers, so to speak, or the participants, they don’t care about all of that stuff, you know? And it’s – all they do is they want help. You know, they know they don’t want more children right now or whatever and so, all this other stuff is just noise to them…but I do personally feel like some of the whole policy pieces make it harder for women…” (Administrative/Implementation, Female) Social and Cultural Context Social and cultural issues were broadl y discussed and participants spoke on a variety of issues such as individuals not being comfor table with their sexuality, individuals marrying later in lif e, and a shift in males becoming more involved with their children. One participant repor ted that some cultural and social contexts have not changed throughout time, as there have alwa ys been issues related to sexuality, pregnancy and marriage. “The point of it is there’s always been dirt y secrets throughout Americ a in our cities, and our towns, in rich neighborhoods and poor neighborhoods, white, green, purple, and blue neighborhoods. These issues have always been there, we just have chosen not to raise them. The good old days, the ‘50s weren’t what they made them out to be, it’s just people just very quietly went and got married when they got pregnant.” (Policy/Legislative, Male). Florida was also referred to as a sl ower and more conservative state, and administering family planning programs in communities could have been seen as “pushing the social envelop.” However, it wa s reported that Florida was able to adapt to

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166 social and cultural changes that were occurri ng in the community settings and such credit belongs to the communities and are not attrib uted to any specific federal guidelines. “What I do recall is that there was nothing prescriptive about it that prevented us from adapting to community standards. I know ther e were clinics that had to be able to produce written material and languages and at e ducational level, at the reading level of the particular population. I remember we used to do things in Spanish and English. Later, after I left it used to come out in Creole, Haitian Creole as the third recognized larger group. I know in certain communitie s they were putting things out in other languages. So there was nothing that prohi bited a community from adapting to its population….We don’t need the feds to show us that we need to be more sensitive to a particular population. We have enough health professionals who can recognize what their population and their c hanges are.” (Administrati ve/Implementation, Male) With that said, participants thought that multilin gual and cultural differences are probably still not addressed adequately enough. One participant also discussed how each county in Florida is required to have a Community Advisory Board. These Commun ity Advisory Boards included a broad range of stakeholders and consumers reflect ing the diverse cultural needs in that community. When asked how they see family planning policies accounting for social and cultural issues, one pa rticipant replied: “All of our county health departments ar e required to have a Community Advisory Board. They seek to have a broad array of stake holder be there. I know that as far back as when I was in the clinics, which the last was in 1989, we tried really hard to have a broad based multi-cultural multi-level of education and input to review brochures, to give us ideas about what kinds of things that they felt were in their perception positives or negatives, things that needed to be changed. So I would say that we tr ied really hard to meet those cultural needs. Among them there are some folks who believe only in natural family planning, so certa inly that would be an option that we would offer. I think that you have to listen to your stakeholders, your consumers.” (Administr ative/Implementation, Female) Participants also discusse d that issues related to pr egnancy could differ between social and cultural groups. For instance, it was stated that some young, low-income females often choose to become pregnant because they want a baby or because that is the

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167 norm of their environment in which they live. Other social and cultu ral issues concerned the use of birth control. “African American women are told that it is genocide and it doesn’t help that a majority of our nurses are African American and the doc tors have always been White. There is all of these little things.” (P olicy/Legislative, Female) In addition, religion and the influence of the Church were given as examples where using birth control is looked down upon or is taboo. The social acceptance of unwed mother s was also mentioned as a social and cultural issue that does not adva nce family planning initiatives. “If American is built on a f oundation of its citizens that ar e raised with unwed mothers and no father figure, then the foundation will crumble.” (Policy/Legislative, Male) When asked if there were any particular popu lations or demographics that need better efforts regarding family planning services, this same participant continued to discuss how particular ethnic and racial groups need to take grater responsibi lity regarding having children out of wedlock. “Well, I certainly do. But, that gets into th e whole deal that Black American has to take responsibility for Black America’s problems. Up to this point, the Jesse Jackson’s of the world want to find the boggieman somewhere else and blame everybody else. I think we have to have people step up in the Latin and the Black communities around the country like Bill Cosby has just needs to be part of it.” (Policy/Legislative, Male) This participant spoke about how African American children from two-parent families in previous decades used to be the norm for the family unit composition. “They had a family unit just like everybody else That was the rule. You didn’t hardly see any kids that were Black in the 70’s in the ru ral areas out from that were not being raised with a dad and a mom.” (Po licy/Legislative, Male) Participants discussed their uncertainty as to whether Title X and family planning services “reached out” to indi viduals adequately. It was mentioned that there was no

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168 follow-up with patients so in the event that a patient was “offended” by the program or some other element related to the clinic e nvironment, personnel were not aware of these problems and therefore could not address any so cial or cultural conc erns. Participants also commented on the fact that there are no efforts to bring women into family planning as there used to be in previous decades. “Again, this goes back to what we said a minut e ago, that I think that the social cultural context since we are not out th ere telling women to come in and encouraging them to. We are not doing that anymore, to my knowledge like we used to. The health department would encourage ladies to come in. Bring their child and come in and have their Pap smear.” (Policy/Legislative, Female) Similarly, the social and cultural context of clinics and serv ices depended on how individuals in the community pe rceived such services. In addition, the perceptions that individuals held were not specific to fam ily planning services but rather how they perceived health services in general in their community. “If a small rural health department were perceived by poor whites as being a black people clinic, poor whites would elect not to go for any of their services. They would wait for immunization clinics to come out into th e community or somethi ng like that. If there was that stigma, it also trans ferred to family planning. I ne ver saw family planning used separately than the rest of the he alth services. So it is just a question in the community of how it is perceived. In a lot of rural comm unities it was where poor people got services.” (Administrative/Implementation, Male) “We were not giving access or choice of ac cess through Title X to a particular group, it was really how the social cultural knew you in that community as to who used the health department for clinic services.” (A dministrative/Implementation, Male) Social and cultural barriers pertaining to males was also discussed concerning the difficulties that exist when trying to include males as recipients of services as well as including males as the partne r of another individual who was receiving services. For example, one participant recalled how a family planning advertisement in the form of a poster on the clinic wall was not effective in conveying prevention messages to males.

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169 “I think that we also have to be careful what we put on our walls. There was a time when some of our clinics would put posters to try and discourage teen pregnancy and it would be a man who was pregnant pushing a baby carriage and said “What do you mean more careful” if he was the one that got pregnant and stuff. That, to me, would be off putting for me to be involved in family pl anning. We have to think about that.” (Administrative/Implementation, Female) Another participant discussed challenges of welcoming men into the clinic, while at the same time being able to see the female patien t alone, especially when there is some sense of male dominance in that relationship. “There are some cultures and it may not even be – it may be a subgroup part of the population where there is something of a ma le dominance kind of setting and there may be women who their partner may choose that they should not be getting any kind of family planning, it makes things either less natural and make things more out of their control or various kinds of th ings. So there may be times when a woman is accompanied to a clinic area and really her bottom line is she would really like to have family planning very confidentiality, but has probl em getting away from that partner trying to ask for that services. In trying to be inclusive in a family planning clinic and welcoming to men at the same time, how do you make sure that if th ey are saying, “Well, my partner can come back with me”, they really don’t want their partner to come back with them….Sometimes you have to make a decision to say “We’d be happy to have your partner come back. There is some parts of this that the room is too tight and can we do this, this and this with your partner with you, then we’ll do this and then your partner can come back” so that you can at least have some of that alone time. I think that would be the toughest piece.” (Administrative/Implementation, Female) It was also mentioned that more public information campaigns on Title X should be delivered so individual can be aware that this program exists. However, such awareness campaigns should be directed towa rds all women and not just to particular social and ethnic groups. “Yeah, but no social engineering. I mean, don’t advertise more in the Black community than you do in other places, that’s tac ky you know, um yes, make the information available in Spanish so people know but don’t run out there knocking on doors just in the Hispanic community.” (Policy/Legislative, Female) Clinic and staff. Most of the participants conveye d that family planning clinics and staff put forth much effort in trying to be socially and cultural ly sensitive to their

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170 clients’ needs. Regardless of such effort s, participants acknowledged that greater improvements are still needed concerning social and cultural sensitivities. “I think that’s awful that fo lks are not comfortable and I thin k that one thing that we try to work at, that we probably weren’t very su ccessful, is making c linics in the health department be user friendly, so to speak, you know, customer fr iendly; and that they would be responsive to peopl e’s needs, not make people wa it all day; they would treat ‘em with respect and, for some people, that’s a very hard nut to crack and I think, to me, I just can’t understand people going into public health that don’t hav e compassion. But, I do also understand that people do it just for – that it’s a job.” (Administrative/Implementation, Female) Participants recalled back to the early years of family planning and Title X where the majority of the clinic sta ff were older southern women. “Back then, and I don’t want to generalize because generalization is not fair, but these were older southern white women. It was going to take a whole turnover of staff, which was occurring rapidly because these were ol der women, but there were women in their upper 50’s and 60’s in these rural communities and they were going to be retiring over the next X number of years. That’s what it really took or takes to make social change happen. You just don’t pass a law.” (Adm inistrative/Implementation, Male) Another participant discussed where providers and staff in the clinics could often hinder an individual’s choice in receiving services. “Also the kinds of provider that you have. Y ou need to recruit staffing that reflects the population or they may not be as comfortable. It doesn’t mean that necessarily if you have difficulty recruiting the nurses or physi cians or whatever, but some of your other staff assistants and receptionists and others who can help convey a more comfortable setting for clients.” (Adminis trative/Implementation, Female) When asking a different participant if there ar e any other social or cultural issues that hinder family planning programs, the participant replied: “You mean other than doctors and pharmacists and nurses should not have to do things they don’t want to do?!” (Policy/Legislat ive, Female) [Interviewer’s comment: Participant was expressing her opposition and frustration regarding the provision of excusing providers from counseling/providi ng services because it is against their religious or moral beliefs]

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171 In another example, this same participan t discussed challenges regarding the provider being of a different nationality than the recipient of services. “I know the health departments are trying to get bili ngual nurses. It used to be in Florida our doctors, especially our doctors because y ou could not get them where people trying to get a vice versa who were from India or Pakistan, and you put them out in the middle of North Florida. It was not very pret ty.” (Policy/Legislative, Female) Funding Funding is a theme that arose from the th ematic analysis on Title X’s legislative history (Phase I). Funding for any policy is cr itical in shaping the success of that policy and previous literature has stated that fundi ng for Title X has decreased 60% from yearyear when considering inflation (AGI, 2000; Gold, 2001). Thus, part icipants were asked what their experiences and pe rceptions were regarding a ny changes in funding over the years. The majority of the participants tho ught that funding for Title X and family planning has remained the same, or has decreas ed slightly, but has certainly not increased by any significant amount or kept up with in flation, population increases, the rising costs of services or demand. “I think it’s been kept fairly consistent but yes, losing ground because of inflation.” (Policy/Legislative, Female) “It has been pretty stagnant or in some ca ses declining….If there had been increases, they have been really small kind of increase s that probably don’t account for cost of living and demand.” (Administra tive/Implementation, Female) “We got increases. We got some general re venue increases and I think that we have gotten some Title X increases and dribs and drabs, but no big influx of money. The influx of money that we got into the pr ogram was always general revenue.” (Administrative/Implementation, Female)

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172 In contrast, participants did acknowle dge decreases in funding for family planning. “My last year here, that was probably, w hat, 1999? I – there was a big – or maybe 1998, there was – wasn’t big, but it was the first de crease that we had – we really experienced. And sometimes, there were some small de creases when they needed to cut overall budgets, but, you know, to deliberately say th e budget was targeted by legislature for decreases, not while I was here, but I think it has been when – since I left” (Administrative/Implementation, Female). “Title X all but disappeared in my years subs equent to being up a the state level. When I was at the state level – money drives the syst em, it truly does. When we were at the state level and we had money, we could make programs happen. Family planning and the people from the state office had much more im pact and influence at th e county level. That is true of all of the programs that I worked in that had funding to them.” (Administrative/Implementation, Male) This same participant then went on and talk ed about the flexibility of the program in earlier years because of other sources of f unding; however, it would not be worthwhile to continue to receive funding if the funding was continuously cut back as you still have to follow the strict guidelines and regulations. “In the early years I remember if you got Ti tle X funding, then ever ything that you did had to come under the Title X guidance fund. Some places got a mix of funding so it gave you a little flexibility. Again, fr om when I – after ’85 when I was out at the county health department, Title X funding became less and less significant to the point where don’t give it to me if I have to follow your regulati ons, it is not worth it kind of thing.” (Administrative/Implementation, Male) One participant also discussed how in previous decades, family planning programs could really make a difference and posi tively affect services, as clinics were not being driven by dollars and reim bursements as they are today. “In many cases in public health it was better – because in the early years we were not driven by dollars. Now it is all reimburse ment. Then if you needed to spend an hour, if the doctor, or a nurse practitioner needed to spend an hour with the patient, they did it routinely. It was not a question of you had to do 23 patients a day kind of thing in order to make the reimbursement to be able to pay for your posit ion kind of thing.” (Administrative/Implementation, Male)

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173 Other responses revealed how there we re conscious decisions made to not increase funding for family planning programs. “For example, during the time that we were beginning to implement abstinence only education, there was opportunity that Temporar y Assistance to Need y Family’s dollars were also available that poten tially could have gone into a family planning realm, but a conscious choice was choose to put some of those dollars into abstinence.” (Administrative/Implementation, Female) Of interest, three partic ipants specifically spoke about funding and Title X in terms of prevention and how Title X was not often perceived as a policy that received immediate attention. Participan ts conveyed how frustrating it would be to try and “sell” family planning programs to legislators. One participant stated that if you wanted to put your “green eye shades” on, the cost benefits and savings th at family planning programs could provide were “unbelievable.” Howe ver, another participant spoke about the difficulties in “selling” family planning on its prevention capabilities but how such efforts could have a positive economic impact. “It seemed like none of our arguments about prevention, which have an economic impact, meant anything…it is the lack of i mmediacy. We could not even demonstrate there was a connection between family pl anning and better birth outcome, which puts it almost only a year away to the satisfacti on of folks…you could not say in smaller populations that if this woman was on a fam ily planning method for two years, decided to have a pregnancy, came off whatever methods she was using, conceived, had a baby, the baby would be healthier, the outcome would be better. You could not get close enough.” (Administrative/Implementation, Male) Yet, another participant expressed her frustr ation with how legisl ators do not understand the true meaning of prevention. After a di scussion about communicating prevention to legislators, the interviewer concluded from the participant’s remarks with: “I guess prevention is not in th eir vocabulary?” (Interviewer) “Yes it is. It is cross your legs!” (Policy/Legislative, Female)

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174 In addition to Title X funding, other fundi ng sources were briefly mentioned that help support family planning programs. For instance, the Maternal and Child Health Block Grant (Title V), general revenue, Stat e dollars and Medicaid were also referenced as proving some funding for family planni ng services. Moreov er, one participant commented on how there are options and flex ibility regarding what funding section you could include health educatio n-related programs (i.e. sex education), as such funding could either be included in the education or health budget. However, one participant summarized how Florida currently stands with funding related to family planning services. “Bob Graham gave the first million in state m oney that ever went into family planning. That was not Title X or was not matched to Me dicaid or matched to Title X. The actual free-standing state dollars he gave when he was Governor in the 80’s, $8 million. I think now we have $5. That should show you how far we have come in 20 years!” (Policy/Legislative, Female) Equality/Rights and Care/Responsibility The theme of equality/responsibility orig inates from MFPAF and refers to women being disadvantaged in public spheres yet bur dened in private spheres (McPhail, 2003). Such “imbalance between rights and respons ibilities” (McPhail, 2003, p. 52) calls for males to increase their responsibility so women are not continually disadvantaged. Participants responded to ques tions surrounding whether males play a role and have any responsibility pertaining to family planning and if so, what roles and responsibilities do males have and what roles and responsibili ties do they believe males should have regarding Title X and family planning issues.

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175 All participants discussed the roles of males in family planning as a significant challenge and gap that persists throughout service de livery activities. Some participants pointed out that women were not in Congre ss in any significant numbers and were not involved in the beginnings of the Title X policy. Similarly, even though women are now represented in legislatures in greater numbers, it was men tioned that many women do not feel comfortable playing larger roles because of the way they may be perceived by others. “Even now if you look at some of the legi slation, we have a lot of women who won’t – they don’t want to be trapped or seen as that crazy woman, whereas the guy, it is just something else they did. It is a big political inequity there. And ashame for women that they have allowed themselves to take the lesser role.” (Policy/Legislative, Female) There was a consensus among participants that males need to be playing larger roles in family planning; however, the challenge of including males and the difficulties of extending greater roles to males without taking away power fro m women was stated. “I think it gets complicated b ecause if you say that you have a role and that role impacts the woman in giving him extensive control, we certainly don’t want to do that.” (Policy/Legislative) Males were discussed as playing a signi ficant role in determining whether they would have children, and played a negative role in cases dealing with sexual coercion and domestic violence. In additi on, participants referred to males as “predators” in some situations and blamed the media for incorrec tly portraying males’ roles and diminishing their responsibilities. “There are some negative things; I think that the way that the media deals with sex is absolutely undermining responsib ility that they feel that men have for the outcome of sexual encounters and is really taking away from a great deal of progress I thought we were making with having women be viewed as equally dignified people. There’s an awful lot of objectifying and degrading going on out there.” (Policy/Legislative, Female)

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176 In other situations, participants discussed the need to enforce confidentiality measures, as some women did not want their husbands or partners knowing they were seeking family planning services. “I think, for some families, they’re the deci sion makers as far as more children, whether or not there are gonna be childre n, and, so to speak, in some situations, that they’re actually the predators, especially with th e young girls.” (Administrative/Implementation, Female) Participants discussed various issues th at complicate the ability to include males in family planning. Such issues largely rela ted to the social and cultural implications associated with responsibility and the pers onal gains and tradeoffs that males would benefit from if they participated in family planning services. “To me, unless you have a long term m onogamous or near monogamous relationship, where it the pay off, where is the investment? The investment is in the women. The man is investing in the women and the more that he has invested in the wo man, the more likely he will anticipate that impacts the woman. Th is is seen as impacting the woman, not him.” (Administrative/Implementation, Male) “Men by their nature are not responsible fo r this arena.” (Poli cy/Legislative, Male) Lack of communication was also mentioned as a barrier to include males, in the fact that many young women and men have sexu al relations but do not engage in any communications. “I never understood how you could take your clothes off for somebody and not talk to them.” (Policy/Legislative, Female). Other social and cultural discussions incl uded society’s acceptance of having children out-of-wedlock. “I’ll tell you one of the ways and when you, you’ ve lost this battle a ll ready because it’s okay to have children out of wedlock. I mean this is all – this fight’s over. America’s lost.” (Policy/Legislative, Male)

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177 This same participant also discussed the cha nge in the social and cultural fabric in the African American communities by recalling how the majority of the African American children in the 1970’s were being raised by both parents, and where many African American children today are raised by single families. This participant then goes on to say: “This is where you see this whole – first of all, it deteriorated in the Black community. Now, it’s deteriorating in the White community It’s okay to have babies out of wedlock. When that happens, hell… then the government’ s in response, right. At that point, we’re in response mode.” (Pol icy/Legislative, Male) Where there were some previous experi ences and opportunities to involve males did not have to do with family planning serv ices specific to pregnancy prevention, but to the prevention of STI’s. Participants stated that because knowledge and awareness of STI’s have improved over time in the general public, males are often willing to use condoms. However, participants noted that such condom use does not necessarily equate to males getting the correct education and counseling on pr egnancy prevention and that more progress in this area is needed. “I’ve also represented groups that have been trying to deal with the HIV/AIDS problem and males need to know more that they need to use condoms and it’s not just for birth control it’s because of all kinds of good reasons and I thin k we’re doing better with that but we’re not doing great.” (P olicy/Legislative, Female) In addition, participants recalle d the difficulties in previous y ears of trying to bring men in for STI services. “In the old days, I’m sure it is not like this now, but if a youn g woman came into a clinic and she had an STD, we’d give here a prescripti on for her partner too. It was not going to happen. It was better to give her 20 days wort h instead of 10 and tell her to give 10 of them to him.” (Policy/Legislative, Female)

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178 Areas of opportunities where interventions could improve the male role were discussed as programmatic and creative solu tions and included both past, present and future efforts. For instance, it was mentione d that vasectomy services were a great piece that were already included in family planning efforts. “I think that it is an import ant role and we have had more emphasis over the past years with some grants that are especially focuse d on males. I think that we have a relatively inexpensive mechanism for families who choos e to have no more children. A vasectomy is something that we can offer with Title X. I don’t think that men necessarily know about it.” (Administrative/Implementation, Female) Child enforcement laws were also another mechanism that involve males and could provide an outlet to give males a gr eater role and increase their awareness regarding their responsibility in family planning matters. “…and now there are all kinds of things out there like mandatory el ectronic deposit from your paycheck and just all kinds of good stu ff and I think it’s ma king men more aware that there are consequences to havin g fun and saying whoops you’re problem.” (Policy/Legislative, Female) Similarly, a different participant menti oned how the State has been involved and implemented other sanctions for those who do not pay their child support. Furthermore, it was suggested that sports physicals could serve as an environment that presents an opportunist time to educate, counsel and provide family planning-related services to adolescent males. Such education could incl ude biological and reproductive health information, as well as information on respecting partners and preventing sexual coercion and rape. Integration The theme of policy integration emerged fr om the thematic analysis of Title X’s legislative history and because the integrati on of Title X with other policies, programs

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179 and services has the ability to positively and negatively affect the effectiveness and success of family planning services, inte gration served as an important topic. Funding. As previously discussed in the funding section under Political Context the funding for programs arose fr om distinct policies and thus, the funding, guidelines and accountability were often specific for that particular policy. However, some overlap of services did occur from the differently funded programs and there was much effort from the State in trying to str eamline the delivery of services. “Well, we tried to make the policies all work together. The funding definitely came down in silos, so that was the hard part. The wa y that we looked at it though, was that there was this pot of money and you stirred it up and th en you – this is what you get...I mean, but that’s not the way the health department s or the community saw it because there were all these funding silos that came down. We – I think we tried with our policies to make things work together and I th ink [Name] was bit – was very in strumental in that. It used to be family planning did all of their po licies and everybody else did all their own policies, but we tried to get them to wo rk together and how that is going now, I don’t know; how the county’s really accepted that, I’m not sure, but that’s what I used to say. You know, it just all goes into a big cauldr on and you just stir it up and make it work for ‘ya.” (Administrative/Implementation, Female) Policies and programs. Participants often recalled times where maternal and child health and family planning programs would be integrated. “And so, Title V would sometimes pay for, oh, I can’t remember, I may have gotten that flipped. But, anyway, Title V would pay for some reproductive health things, like some of the oral contraceptives and stu ff like that, so there was a real merging of the program so that they could be kind of a, so that they could be seen as a continuum of care for women in an effort to show that whole continuum .” (Administrative/Im plementation, Female) “Since family planning and maternal and child health were the two components in it, I and the supervisor for family planning work very closely toge ther. We each had different responsibilities because we had federal money that had to be accounted for, put out to county health departments or private contra cts to provide services and we had to respond back on federal documents, plans, an annual plan, for example. We were by in large providing services to the same groups of people. So if we were using the health department to provide family planning, we were also using the health department to provide maternal and child health services so it was logical for us to integrate our

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180 planning process. That is where my role and responsibility came in really in the integration.” (Administra tive/Implementation, Male) Particular maternal and child health programs, such as Healthy Start and The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were also mentioned where efforts to in tegrate Title X services occurred. “I think that one of the good things we did was when Healthy Start was created we made a big link between follow-up with family planning and Healthy Start, although we didn’t give the Healthy Start Coalitions control of family planning, but you know, we tried to work with them so they coul d understand the important link.” (Administrative/Implementation, Female) WIC was also mentioned as an example wh ere information could get added into an interview or examination to facil itate the integration of programs. “There have been steps to integrate Title X family planning with other programs that have been mandated. The more automatic they can be. For example, like WIC. In WIC a child comes in, they pull them up on the com puter and it is my understanding, if it sill is, if that child is out of compliance with th eir immunization if flags in the WIC file.” (Administrative/Implementation, Male) Although less overtly discussed in th e arena of program integration, one participant did recall how certain policies woul d have to remain separated and distinct from other policies due to th eir controversial nature. In addition, program integration could often require that both programs would then have to abide by certain guidelines and meet certain requirements. “I know that the health policies for HIV/ AIDS, Title X has tried to keep themselves separate to keep any of the other controversy of other issues politically and already controversial issues so that – one of the i ssues that had to be watched policies regarding AIDS was the partner notification, making su re that did not spill over to STDs.” (Policy/Legislative, Female) In contrast, another participan t felt that the integration HIV/AIDS and Title X programs have gone over smoothly. However, this pa rticipant discussed how individuals go to

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181 specific health services and pr oviders and how such separate sources of health care are not streamlined. “Well I think it’s been fairly harmonious. I mean the he alth policies with HIV/AIDS and Title X have suited each other extremely well The breast cancer screening, which I wasn’t aware of, but delighted to hear about the idea of when I was a young women you couldn’t get birth control services anywhere but the public health department and they were wonderful and I couldn’t a fford not to go there, you kn ow was a fabulous thing but the other health care services didn’t come from the public health department because they couldn’t afford to pay for them, which is kind of ironic. And the STD programs were at the public health departme nt, you didn’t go to your regul ar doctors for that but the public health department didn’t treat your so re throat. Somewhere there needs to be better coordination but I am really glad that there has been emphasis put on that but it’s been severely under funded so it’s hard to imagine who’s brilliant idea it was to do this good thing and then starve it.” (P olicy/Legislative, Female) When followed up by asking how they would sugge st to better integr ate family planning with other policies, this same participant responded: “You know I think that’s the question of Am erica. Why is it that most women will go see their gynecologist once a year but ignore any other preventive health care or other health care that there is. I mean I read something th e other day that said that’s partially why women live longer cause they at least go see their gynecologist once a year so somebody is looking to see how health y they are…So I think it’s sort of a thing where we’ve like accidentally fallen into that women need to do this and the rest of the stuff can be ignored, I mean if necessary. So I’m not sure ther e is an easy way to integrate the health services because it’s become a mentality. It’s like if you don’t need anything else, at least go see your gynecologist.” (P olicy/Legislative, Female) Participants also discussed how many pub lic health policy issues overlap and how one needs a firm understanding of all of th ese different public health pieces. For instance, one participant discussed how we lfare reform and other issues such as Medicaid, the workforce and family planning are all inter-connected. “But you can’t do welfare reform wit hout understanding and impl ementing and having a blending of Medicaid issues, wo rkforce issues, family planning issues. I mean it’s all tied together….But they’re all, but, they’re over lapping, but they’re a ll indispensable. You pull one piece out and it has a huge impact. You know welfare and work and childcare and all those and how that affects family planning. I mean all these building blocks together” (Policy/Legislative, Male)

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182 Integration as continuum of care. Many participants discussed past efforts and the need for continually efforts to be focu sed on seeing an individual as a whole person, integrating their needs, and tail oring health care to fit them. “As we have seen that individual as a whol e person more, it is easier to integrate anything across. It is where we stay in t hose individual services that it becomes more difficult to integrate…I think that it is easier, yes, if you ar e looking at the person as the whole person. You are my patient, but I’m concerned about whether you are on a birth control method now as much as I’m concerned about what your diet is or that you have yeast infections frequently if you are a female of a certain age. I’m concerned with all of it because I’m responsible for all of your he alth.” (Administrative/Implementation, Male) “There were other things, other policies th at sort of had gone al ong that people just didn’t question and they hadn’t really paid attenti on to some of the things both as far as needs assessment of the patient as well as do cumentation and indivi dualized kind of care. I think that from 1980 to the current time we hav e made a lot of progress in that. We offer more options…I think that sometimes peopl e also make too many assumptions based on their own personal experiences versus what that individua l woman needs and we try to build policies that are more re flective of individual needs.” (Administrative/Implementation, Female) “We’ve worked really, really hard to try and do a more integrative approach and more of a life span type of approach. As a matter of fact, we’ve merged out family planning program in with our MCH section that we call Infant Maternal and Reproductive Health. A part of that is trying to build more of the reproductive life planning thinking about preconception health and helping to a ssure that women who do go on to have a pregnancy are as healthy as they can be prio r to that. Sort of maximizing and building on availability of funds to that – since we know a lot of wo men the only way to get health care is in the family planni ng clinics, if we can somehow be thinking more broadly about what the program offers and how it links to other programs we might be better able to build on that help and that is sort of the philosophy that we have built upon.” (Administrative/Implementation, Female) When followed up with whether there were a ny struggles or challe nges with trying to integrate the differently funded pr ograms this participant replied: “Yes. In fact, we had people who accused me of wanting to k ill the family planning program because it would not be as distinct ive if it was integrated in. That it would take away some of the power of the program. I had the totally opposite view. That if you can build and assure that other programs ar e linking women into their services and attracting men who should have a part of that role, then you are really going to be a

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183 much more effective program. It has been a challenge.” (Administrative/Implementation, Female) However, one participant mentioned that Florid a has not done well in integrating policies and positively affecting women’ s health care as a whole. “I think of how the money comes down, we have not done a good job integrating into the whole women’s health care, so this part of th e money for this and this part of money for this. I think that’s one of the things that have made family pl anning not be able to be seen as care for women. It is nobody’s fault; it is ju st how legislators legi slate money. This one doesn’t want to do breast exams and this one doesn’t want to have to do family planning. So you have to take the money where you can get it and when it comes out, it comes our in pieces.” (Policy/Legislative, Female) Logistical issues in policy integration. The data and technology component of integration was mentioned as being an important factor in facilitati ng the integration of programs. “In the earlier days whenever integration wa s attempted it added paperwork. When we were on a paper system, it meant another form. They had form committees to really restrict the creation of more forms. It wa s insane. I cannot remember how many forms a family planning patient had to fill out. There was no methodology for us to keep you from writing your name, address, social se curity number, demographics on every form.” (Administrative/Implementation, Male) The technical side of integration and how technology could assist with the procedural flow was discussed. “The more you can integrate electronically so that it is not a discre tionary kind of thing. Because when you do a categorical program, if I’m an STD worker, I want to accomplish the goals and outcomes in STD. The fact that you’re family planning or not family planning, you have two kids or three kids, or whatever, matters less to me. If it automatically shows up as a box that has to get checked, yes, I have to do something affirmative because it is right there in front of me. So as we automate those kinds of things more, it is easier to integrat e.” (Administrative/Implementation, Male) Staff was also discussed as being a factor that could crea te a barrier in integrating health programs. For instance, it was menti oned that every time an additional policy was

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184 integrated into existing protocols that meant there was additional work and burden for the employee and some employee resistance might occur. “If you ask me to talk about, well, I noti ce that you are not on any family planning methods, would you like to be. So I checked off a box that says that I have discussed family planning. If you say, yes, I woul d, then I have to go into another 5 minute discussion about how to go about that. You ha ve just given me more work and there is another piece of paper.” (Adminis trative/Implementation, Male) It was mentioned that the integration could be perceived as being eas y and worthwhile for staff if staff could understand a nd appreciate the benefit that this integration would have on the patient.

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185 Barriers Participants were asked to discuss what th ey perceive are some of the barriers th at Title X and family planning programs and services encounter in Florida. Barriers that participants discussed included poli tical, social, ideologi cal and operational ba rriers and are presented in Table 2 below. Table 2. Barriers that Title X and family planning programs and services encounter in Florida as perceived by participants Barrier Quote Accessibility of care “You then have to look at the barrier of the accessibility of care. We started a school clinic in Leon County at a high school. We started it because it was the high school that had the highest pregnancy rate. We did that for about three years and we offered family planning there until they changed pr incipals and we could not offer family planning on the campus. Give me a break.” (Administrative/Implementation, Male) Clinic barriers “And I think that there’s a balance there that you can work b ecause, you know, any time you would have to – somebody would have to wait a month for an appointment, you might as well forget it, you know? (Administrative/Implementation, Female) “But, you know, I think that we’ve missed the boat on kids You know, we may have tried to get them appointments during the school day, rather than after school or making clin ics more accessible to them, taking the services to them; and, you know, and I think that that’s true with all wome n, you know? You set up somewhere and you don’t – and it may be off of the transportation route or whatever…hours and convenience.” (Administrati ve/Implementation, Female) “I think the whole cultural and custom er friendly sensitivity is an issue; and I think understanding populations and what works for them; and then, having the time to do that and paying attention to that, you know? How do you spend an hour with this teen that desperately needs help and you’ ve got a waiting room full of people and you’re backed up and you’re gonna – know you’re gonna be there until 7:00 or 8:00 p.m. and you got people waiting that had an appointment earlier, you know?” (Adm inistrative/Implementation, Female)

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186“Again, when you deal with low income families, male or female, no work, no pay. Our clinics by and large are not evening clinics, are not Saturday, Sunday clinics. I have to take off from work.” (Administrative/Implementation, Male) “I give you bus tokens to get to the clinic that takes you two hours to get there and two hours to come back. That is four hours. You are in the clinic for two ho urs, if you are lucky. We have just used your entire day. Me, I leave work, I’m getting paid because I’m on sick leave or whatever. I go to my doctor’s office, it takes me the same two hours, I’m back. I’ve used four hours or three hours of my day that I was paid for anyway but I get – I’m there for five hours. We just don’t take into consideration all of these thi ngs.” (Administrative/Implementation, Male) “Sometimes I would be passing through the waiting room and somebody would see me and recognize that I was the nurse in the clinic and would say “You know, I really have to ge t back.” “Well, what are you here for?” “I just need to pick up some more pills. I’m not due for an exam.” Somebody had told them, Oh, no, we are not going to see you to 1:00 or 1:30.” So I would go in and due what needed to be done with them. Find out that they were on their lunch break and that because they had been able to have the fam ily planning program, and now their children were old enough that they were able to either go to child care or go to school, they had gone back to work and they didn’t want to get pregnant again.” (Administrative/Implementation, Female) “I don’t think that anyone is really – I think that one of the challenges that health departments have is that, for example, I have a friend who does main tenance work and housekeeping for people. She doesn’t have a Pap smear in a really long time. No matter how much I can convince her to go to the doctor, she is still thinking like we were when we were younger and you sat all day and you got to see somebody, so that is an age thing and that is an advertising thing.” (Policy/Legislative, Female) We want you to come to family planning, but you are to ting three little kids. You can’t leave them anywhere, you don’t have anyplace to leave them. You get on a bus now for that same two hour trip one way and the other with three little kids, you got to be damn motivated to come .” (Administrative/Implementation, Male) “I think that you – I would go back to – I would work at – all of this is after money. I would look at some of the total programs to make more providers that are not seen as much as health departments. Something that is not seen – one of the barriers that I think young people have is they don’t want to go to a health provider.” (P olicy/Legislative, Female) [Interviewer: Because there is a stigma associated?] “I think there should not be, but for some of these kids the families have money but they don’t have a dime of their own. I think until they get to college and they can get to the campus that they don’t do anything. There doesn’t seem to be a stigma in going to an abortion clinic than there does to a health department, I haven’t quite understood that…I think

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187that would be one of the things that I would try to make it so that there were a multitude of providers.” (Policy/Legislative, Female) Cost “I think that the issues around the cost of contraception. Be ing able to provide a broad array of types of contraception. Because of the limits to funding and those increasing cost s we sometimes have to make some choices about what it is that we really do offer as far as what we provide. If some one makes a choice that they wanted to have something that is not on our formulary, then they have to go out and purchase it. Are they going to be able to? Is that really equal access that way? I see especially for young college women this being a major hurdle; some of the services no longer have pharmacies. There is one here in town that just recently clo sed and that was one of the ways that they could get more affordable contraception without going to a Title X clinic that is already overwhelmed with others and maybe doesn’t especially fit that culture of the college age student as well as it does other populations.” (Administrative/Implementation, Female) “So the health department is not seeing the poor women, who is seeing them?” (Policy/Legislative, Female [Interviewer: Right. Title X clinics get all of the backlash the safety net.] “They charge $175, so I don’t’ know how much of a safety net that is….You have to look at it like this. If my job working with my sister who is in charge of a big kitchen, I get paid $11 an hour, I have a good time, I would do it for free, but it would take me two days, two full working days…” (Policy/Legislative, Female) Demonstrating the public health achievements and importance of program “And, you know, I think it would be a great thing and, you know, and I think the whole public health piece of family planning and being able to show what family planning does for families; and, like I said earlier, the whole reduction in maternal mortality and those types of things; and sa ying, “Hey, look, we identified these many women with hypertension. We have so many women with breast masses. We found and were able to treat STDs, bladder infections. We were…”, you know?” (Administrative/Implementation, Female) [Interviewer: Very comprehensive.] “Comprehensive. You know, you gotta, you know – you know we were able to provide so many non-smoking, stop smoking programs and we identifie d people with anorexia and got them treatment so that they can be in a better health situation later on, and, you know, we’ ve identified these people that are using drugs. The whole thing is you may try to get them into treatment, but then you don’t want them to quit using the program.” (Administrative/Implementation, Female) “Well yeah, the fact that its not important to legislators…” (Policy/Legislative, Female) [Interviewer: So getting more of the key sta keholders on board to support the program?]

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188“And convincing men that this just isn’t wo men stuff.” (Policy/Legislative, Female) Education “Then you have to overcome the education. The educati on of, okay, I’m going to have sex. How do I not become pregnant? Once you got me convinced that I don’t want to become pregnant, how do I get the knowledge of what I should do?” We had a probability one time, I know when my peri od is, I know when I’m most fertile, I know when it is. I’m not going to – playing the odd versus taking respon sibility.” (Administrative/Implementation, Male) “And so, we did an education program in the sororities, mind you, and there is so little knowledge about how their bodies worked. I was shocked. Here they a re, these supposedly bright young wome n, getting ready to go on spring break, that didn’t understand how their bodies worked and how and when they could get pregnant and those types of things.” (Administrative/Implementation, Female) [Interviewer: So, this is where maybe it’s not only Title X’s responsibility, but other progr ams such as school health could come into the picture.] “Yeah, and also, you know the college campuses – you know, the college infirmaries and different things, that they have a roll in education for young people.” (Administrative/Implementation, Female) [Interviewer: So, it seems like a big gap…] “Yes.” (Administrative/Implementation, Female) “Part of our dilemma was informing and educating family that they had that choice, that it was not a question that if you had sex and you had kids, it was just one of those things that fell from the sky, but that indeed you could plan it.” (Administrative/Implementation, male) “There continue to be, as you mentioned, bills that come out that have to do in directly with family planning and those may be about in the school setting sexuality education must be factually and medically accurate and offer a full range of information and not abstinence-only, whereas current la w in Florida says that all sexuality education will be abstinence-based. There is always going to be that kind of tension.” (Administrati ve/Implementation, Female) “You know we probably need to do a better job with – I’ll tell you what – I’m trying to go with this. I know we’ve got health education when we test people for HIV. I was involved in a fair amount of the HIV/AIDS legislation. You know, when they’re tested then th ey become positive and there’s an education comp onent. Well, hell, that’s – you know they’re gonna die. We don’t want them to spread it around killing other people.” (Policy/Legislative, Male) [Interviewer: It’s prevention] “Yeah. I mean we missed the boat on that one.” (Policy/Legislative, Male)

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189Funding “I think funding.” (Administrative/Implementation, Female) “Certainly funding is always at the top of the list, havi ng enough resources.” (Administra tive/Implementation, Female) “The lack of money.” (Policy/Legislative, Female) [Interviewer: Funding?] “Yes” (Policy/Legislative, Female) “I think at the services level, which is the individual level too, is that the agencies are there, the money is not there.” (Policy/Legislative, Female) “Geography is definitely an influence but I do n’t think that’s dictated by Title X, I think that’s dictated by lack of resources.” (Policy/Legislative, Female) “Budget, which is a vicious circle. I mean I was absolutely appalled when I found out yesterday that they had cut extra amount of family planning funding that Nancy [Pelosi] tried to put into the bail out. I mean my initial reaction was oh great, all we need is more hungry neglected children running around when the economy is so bad. So it’s really counter productive, it’s penny wise and foolish not to adequately f und family planning services but that’s what this legislature says, we don’t have the money and the way to fix that is to cut. I disagree but you know I’m not a legislator.” (Policy/Legislative, Female) Involvement of children “One again, I told you, when contraceptives and schools systems just don’t mix. It just – it also will bring out a big segment of people that believe yeah. It’s okay. The health department or I need to get it somewhere. I’m in agreement with all that. Then they get real defensive or irrational when you use the word “school grounds.” That’s an ongoing discussion that you got to have all the time.” (Policy/Legislative, Male) [Interview: So one barrier would be just because the educati on involves children that’s a population that just attracts controversy, attracts opposition?] “People scrutinize it very – there’s a – nothin g is more scrutinized than children’s curriculum. That’s real important statement. I mean analytical from political, back handed just – I mean you can be uneducated and still do a very critical view of curriculum. Now, your thought processes may be you know – they may be totally common sense and not analytical. People are going to make a judgment on curricu lum regardless of everything.” (Policy/Legislative, Male) [Interviewer: Because it involves children?] “Because it involves children.” (P olicy/Legislative, male)

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190Leadership changes “Reagan’s people made it a little bit more difficult, but it wasn ’t – we were able to work through that because the programs were so strong, and through Clinton, I think the programs remain fairly strong.” (Administrative/Implementation, Female) “Where you have good professional public he alth, and I qualify that because I’m not sure that is a consistency that stays over time. As we see leadership change, you see some of this get stronger or weaker over time.” (Administrative/Implementation, Male) “Well, I think that when Reagan came in, there was, although, the people that headed it at the national level, tried I mean, they put people in charge of family planning that trie d to stifle the program, but the programs within the states themselves were so strong that there weren ’t, in Reagan’s time, there wasn’t much that they could do to stop the program, you know? And so, although they kept trying to rewrite the guidelines, they never could quite get ‘em pushed through. So, you know, it was like going through and havin g to prove what you were doing. You were following the Title X guidelines because everybody assumed that you weren ’t, you know?” (Administrative/Implementation, Female) “At that point in time again the people that were in it, we fe lt that we were out there doing good and we – the reality is we were bureaucrats and the bureaucracy is what really ma kes or breaks the program, swings it from one side to another. You get the political changes fr om the top and you have to do things differently. You have to consider things that you didn’t consider before. By and large, you are driven by the same motivation, with long term change towards the conservative end of the world. You risk having a bureaucra cy of a different set of ideals. That could change the whole perspective on the way things are done.” (Administrative/Implementation, Male) Not addressing all problems/issues “We tend, unfortunately, to bring solutio ns to the problems that are the easiest to address which to me mean not that they are not important, but less important.” (Administrative/Implementation, Male) Not taking responsibility “Plus, I also have the social barrier of this is not my fau lt if these things happen. Whatever you want to blame it on. We are today, it seems to me, a culture of nothing is my fault as an individual. It is society’s fault, my mother’s fault, my sister’s fault, that person’s fault, but it is not mine.” (Administrative/Implementation, Male) [Interviewer: Responsibility.] “That is something that we have to get past. We really ha ve a barrier. The idea of taking responsibility for one’s own actions. Again, as we mentioned earlier, this is not only in the family pl anning sexual activity, it is in everything. You talk about trying to get the male involved. Where is the whole scheme of things?” (Administrative/Implementation, Male)

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191“For example, I can dumb down a brochure, I had it tested for readability and I can bring it down to the second grade level. I can give you vouchers to get you on the busses. I can pr ovide you a taxi. I can do all of these things, but I’m not touching the real issues that are driving you to take respons ibility for your own behavior and have the ability to make the decisions.” (Administra tive/Implementation, Male) “That’s the big problem with the Democratic Party that it has told Blacks for 100 years now, “You’re a victim.” What ever’s gone wrong, it’s not your fault. What does Bill and H illary say? Us, the Rose you k now – the Rose law records, just happened to find them in my – upstairs in my be droom. Clinton you know and Monica, it’s the right wing conspiracy. We hadn’t done anything wr ong….Well, you know when the top – your standard-bearer says I’m not responsible for the fact I was screwing around with this aide It’s them trying to trick me. I mean it goes back to the whole moral – rather than – I’m not saying this as a f uddy-duddy. You know there a re rights and wrongs in life.” (Policy/Legislative, Male) [Interviewer: So personal responsibility?] “Absolutely…Wait, and the trick is with all of the __ __specials, how do you weave that in between personal responsibility, health education, con sequences and, yes, contraceptives? Isn’t that the crux of this whole discussion?...Personal responsibility and the negative conse quences such as the whole thing about child support.” (Policy/Legislative, Male) “You want people to take responsibility for each themselves and each other. If they are in a relationship, how do we overcome that?” (Administrative/Implementation, Male) Research and information “What are [the] family planning – the big family planning people, you know it was Alan Guttmacher and then the other – you know the big family planning?...” (Policy/Legislative, Male) [Interviewer: Planned Parenthood?] “Planned Parenthood. I don’t – they’re no friends of mine, but yo u know having said that, they constantly put out data. Of course, the right marginalizes anything they have to say. I mean that’s as you know, and this is important for this, whoever’s side that they’re on marginalized or tries to marg inalize the data by who’s putting it out as opposed to the data itself, right…I mean that’s this is – that’s the crux of – one of the biggest cruxes of this debate is you can’t get people to even agree upon…the data to bu ild a baseline for a discussion…That’s probably one of the most important things to come out of your whole dissertation.” (Policy/Legislative, male) “I think the – some public’s willingness to not accept evide nce based research – I think th at whole thing on evidencebased research is a real, real issue for some pe ople.” (Administrative/Implementation, Female) “I think also that political overlay and, I guess, decisions on whether or not to rely on the science or what some might

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192call a “pseudo science” of public opinion on things wheth er it be RU486 getting mixed up with Plan B in people’s mind as the what they do and, therefore, what is going to be allowed and available.” (Administrative/Implementation, Female) Politics “I think at the policy level it is going to be people to keep politics out of the policy. I think that is huge. People provide health care, that’s what they do.” (Policy/Legislative, Female) “I think political climate.” (Admin istrative/Implementation, Female) “Well, again, I haven’t looked at the law that we passed, how it’s been tweaked by the Republicans in the past 10 years. But we passed a good law that says there’ s comprehensive health education K-12, with an opt-out. I walked the walk and carried the heavy water. A lot of people don’t even k now it’s there. See, that’s the problem you also got a schizophrenic here is if you talk about it too much, then you start attracting flies. Then y ou start finding people who didn’t know it and then they get irritated about it.” (Policy/Legislative, Female) Sexuality “One barrier I think continues, and that is how people in Florida look at sexuality and th e effort to deny when it’s happened. It is happening to your child ren, not my children. That is a barrier that has to be overcome.” (Administrative/Implementation, Male) “I just wish people could get comfortable with th eir own sexuality and not be so fearful of the – “ (Administrative/Implementation, Female) [Interviewer: So, more of the soci al, cultural shift in awareness?] “Mmm Hmm. It’s kind of like the way the Europeans just see sexuality. “that’s just the way we are” and, you know, understand that, you know, we’re getting married, like kids are getting married later…” (Administrative/Implementation, Female) “I think other problems involve prudish people who don’t think sex should ever be talked about or should never be done, especially their own children and then you’ve got denial and these programs look like their helping their children do things that their parents don’t want them to do.” (Policy/Legislative, Female) Social “We also have to overcome a barrier where it is socially not acceptable to have an unwanted pregnancy. Your right as

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193acceptability/Social standards a 15-year old to say that I want a baby. Yes, I as a 62-year old can say that’s the stupidest thing I’ve ever heard, but A, I cannot keep you from having th at baby. B, I’m not sure I should be able to have an interference with your individual right. The barrier of why is a 15-year old with a baby seem like some solution to some issues that you have? Why would I give you the benefits that you think it will give you by beco ming a mother at that age? So there is a cultural social issue or barrier that we have to overcome so that young women do not want to have babies.” (Administrative/Implementation, Male) Stigma related to receiving care Then we realized when we analyzed the data after a couple of years, we were getting a third of our girls coming into the high school pregnant. They were becoming pregnant in middle school. We shifted to a middle school clinical program. The key was at that point in time, and it addresses what you a re asking now, I think, in a round about way, you could come to the clinic for any plenty of different services. By coming to the clinic y ou are not saying to your classmates or our friends, I’m sexually active, I want family planning, bec ause you could come for some other kinds of stuff. There was no stigma attached to it. So we have to get to the point and overcome the barrier of by going to a clinic, by going to a doctor or nurse practitioner, whoever, for services, I’m sa ying that I am whatever, society wants to label me. (Administrative/Implementation, Male) Values and beliefs [Interviewer: So even when you tried to use the argume nt of the economic impact of unintended pregnancies and carrying the pregnancy to term, you still cannot sell the economic impact to people on the other side of the issue?] “Well some of them it’s religious and I’m ok with that if they need to be that way they need to be that way, but for the people who don’t have that reasons who say well she’s a slut let her suffer, well I can’t accept that.” (Policy/Legislative, Female) [Interviewer: So funding, but it seems like there is also some cultural problems and family ideologies, acceptance and religions…] “I mean the Pope still won’t get off his anti-birth cont rol, so you know, that’s not happening anytime soon.” (Policy/Legislative, Female) “And I think, unfortunately, it’s driven by the political whim s of people and I – you know, how do you, you know, to me, it’s a balance. I think people are – you know, we’re wonderf ul – I mean, how fortunate we are to live in this society and if you want to believe that family pla nning is bad and all of that, that’s fin e and good, but just deal with it for yourself and not put your feelings on everybody else and how y ou make that happen, trying to force your opinions into everybody else’s. And people could say the same thing ab out me, you know? But, don’t, you know, don’t compromise the program because of your feelings an d, you know, it may be right for you a nd your family, but that doesn’t mean it

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194necessarily portends well for the folks over on the – they don’t believe the same thing.” (Administrative/Implementation, Female) [Interviewer: Having the options and choices available?] “Well, yeah.” (Administrati ve/Implementation, Female) [Interviewer: And within that, people pick on an individual basis?] “Right. Right. And if people want na tural family planning, that’s fine. If people wanna wait ‘til marriage, that’s great, you know? I think that, that’s – I think that those are – that’s so important and I think that we’ve seen the pregnancy rate jump back up and whether or not that’s related to the family planning program not being as available or what’s going on, the whole teen pregnancy jumping back up to it; and if you’ve always looked at the STD rates for kids over the years, I’m not sure that they’ve changed a whol e lot from the time that more restrictive policies were put in and funding was taken away. So, I’m not sure t hat it’s – those voices just need to settle down.” (Administrative/Implementation, Female)

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195 Recommendations Participants were asked to recommend a nd discuss changes that they thought would help improve Title X and family planning programs and services in Florida. Participants’ recommendations in cluded broad and concrete chan ges and are presented in the Ta ble 3 below. Table 3. Participants’ recommendations to improve Ti tle X and family planni ng services in Florida Recommendation Quote Access and availability of services “Then broadening the question to the utopia, it should be access for whatever health services are available that you need that are prescribed for you. I don’t pretend to sugg est that we should provide he art lung transplants for anyone that requires a heart lung transplant. I’m very much an advo cate of prevention of the lo w cost solution first. Give everybody access to preventive health ca re. Give everyone access to primary health care. Give everyone access to secondary health care.” (Administrative/Implementation, Male) “All right, I am going to mess up your question. I am going to say if I could make Florida a perfect world for family planning, it would cost no more than five dollars a month for any women, no matter what her income, to get family planning.” (Policy/Legislative, Female) [Interviewer: So would the woman pay the five dollars or would the government pay that?] “If the women could afford that than she would pay it and if she couldn’t than the government would pay for it.” [Interviewer: So the change would be decreasing the cost of the services so that all women could receive the services?] “Yes.” (Policy/Legislative, Female) “Certainly, another thing we haven’t talked about was – it was there when I got there. It’s probably out there, but we don’t talk about it anymore is the whole crack kids and just abusing substances and what th at does to your child.” [Interviewer: So, treatment programs?...Prevention programs?”] “Yeah, prevention programs.” (Policy/Legislative, Male) Awareness of services “Well I’d like for there to be more public information progr ams, I would like for there to be more people aware that Title X exists, even though they probably don’t have the resources if they did know, but I would like for it not to be something you have to look for or search for…That plus a better public relations campaign. Not public relations in terms of persuasion but in terms of awareness, availab ility….but yeah funding costs for everybody and information.” (Policy/Legislative, Female)

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196“What I would really like to see is a more – one of the thi ngs that we have had lately across the board not just for family planning is that outrage has b ecome something of a negative word, but we need for some high risk population who maybe don’t have either the personal wherewithal to know ab out all things that are available to them, some kind of intensive follow up. For example, around the Family Planning Waiver in particular. I think that we need to do more to let people know about the availability. I almost feel like we sort of hidden the fact that exists for some people.” [Interviewer: Do you think that would take funding to ha ve more of a social marketing program to let people know what it is, like bring more pamphlets or education to providers?] “It is the social marketing kinds of concepts that we need to do. I think that we need to get away from thinking in public health that pamphlets work. People rely on other means. We n eed to have a buzz going and virtual opportunities to get the word out. Some of it has to do with allowing those policies and the availability of things to be put forward to be asked for.” (Administrative/Implementation, Female) Better research “Well, if you could wave a magic wand, I would say better re search. I mean, you got all of this stuff that Alan Guttmacher does, but sometimes they’re seen as tainted because of their associ ation with Planned Parenthood, but some good research from CDC and NIH as for as the benefits. You’d think people would know that, but the willingness to accept that – I think that we will, probably come Tu esday, be in a better situati on at noon time on Tuesday.” (Administrative/Implementation, Female) [Note: Partici pant is referring to the swearing in of President Obama] Consistent and flexible policies “I tried to think about this whenever I read the questions earlier and I had a tough time with it because I’m not sure that a utopia exists. I think that we need to somehow get away from having politics and sort of disease of the month mentally about what we focus on and have more of a consisten cy of policy that really allows what is in the law to be made available.” (Administrative/Implementation, Female) [Interviewer: Any certain legal laws…] “I’m not sure. I think that we have a flexible broad ability with things that are currently in law. I think that when you begin to try and tweak down too tightly without offering that flexibility that you could inadvertently limit what you can do.” (Administrative/Implementation, Female) Continue the political will “Again, you just – you gotta – this is longitudinal. You gotta constantly try to bring the stakeholders to the table and push as much health educati on in the school system as politically feasible at the time. You got to come back the following year and do it again. Then say, it’s a lifelong ende avor. It’s going to have ebbs and flows just like any other political issue, but you’ve got to be vigilant about it. It’s just something you can’t ever quit. Failure is not an option. It can’t be an option” (Policy/Legislative, Male) [Interviewer: So, it’s a constant struggle.]

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197“It is a constant struggle, but you’re talking about the survival of America.” (Policy/Legislative, Male) Continuity of services regardless of location “Having seen a number of other states, I think there needs to be categorical funding. I do not think that states and localities function off the same book of what is right. You sh ould have the same service avail ability whether you get it in North Florida, South Florida, or Mississippi .” (Administrative/Implementation, Male) Follow-up with high-risk individuals and streamline services “Maybe we need to be thinking about the family planning waiver automatically as opposed to having people just sign up to get it and there is some challenges with t hat.” (Administrative/Implementation, Female) [Interviewer: That would be sign up at the federal level?] “They have to apply for it. For instance, right now if y ou were considered a Sober woman, which are the women who are getting Medicaid because they are pregnant, they automatica lly for the first year are eligible and they don’t have to go ask for getting on the waiver whereas others have to provide all kinds of docu mentation, the income, and so forth, and go through a full application proc ess to get all of that. If we could make that fewer barriers.” (Administrative/Implementation, Female) [Interviewer: Streamline the process?] “Right. If we could do some of the intensive follow-up fo r those highest risk women who say they are coming out of prison and we already know that maybe they are HIV pos itive, maybe they already ha ve had several children and they don’t really want to get pregnant, but yet they don’t want a p ermanent method. If we could do some intensive follow-up to let them know this is an availability for them. And ma ke it automatic so they don’t have to jump through a lot of hoops because they may not have paperwork…” (A dministrative/Implementation, Female) Funding “The biggest thing is the money. In Leon County when we analyze our family planning client load, we have been decreasing for a number of years. As service deliveries b ecame more expensive as th ey do every year. Health care inflation far exceeds regular inflation. We serve less and l ess patients because the budget line didn’t increase. There is no cost of living. When the federal government gives out m oney, there is no inflationary rider that goes along with it. Each year you are paying more and more for fewer and fewer services so we found less wome n getting services. Unless you have new resources to throw at it, you are falling furt her and further behind. Your p opulation is increasing, your general population is increasing in Florida. If need based on the community situation is rising and you find yourselves serving less and less women. Then the new funding comes out. Ne w funding is not supposed to replace, it is supposed to embellish or provide added services. So now you give me new money to increase the number of patients, but not to maintain the number of patients. So you get into almost a deat h spiral with funding. That happened in family planning. I don’t know if it still exists or doesn’t.” (Administrative/Implementation, Male)

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198Maximize the potential of the Medicaid Family Planning Waiver “For example, with Medicaid, the match for family planning is 90 to 1. We put in 10 cents, the rest of that dollar comes down from the feds. 90 cents for every 10 cents that we put up With that 90/10 match, we have such an opportunity and if we could just put a small amount in to do that intensive follow up for the high-risk women and men. Although the uptake in most waivers that have offered family planning service s to men, as you mentioned earlier, has been very low. There could be some opportunity there.” (A dministrative/Implementation, Female) [Interviewer: What would need to be done to use it more effectively?] “Every year you have to write a waiver. There are some c hallenges with having a waiver for family planning versus it having be one of the optional Medicaid services in the stat e. To give you an example. For pregnant women, the state can have this special option that they can cover women during their pregnancy only for Medicaid and in Florida we go up to 185 percent, and actually there is leeway that you could go higher. Florida chooses to go to 185 and used to be at 150. So there is a political decision that is made as to what the legislature would allow….Florida does not fully avail itself of how broad that could be…” (A dministrative/Implementation, Female) “I would really do something about that wavier.” (Policy/Legislative, Female) [Interviewer: Family planning waiver?] “It is a waste. That money has not done what it is supposed to do.” (Policy/Legislative, Female) [Interviewer: Do you think the idea is go od, it just needs to be more effective?] “Why if you have a baby can’t you get fa mily planning?...I don’t really understand that as a concept myself. I mean, our state saw that waiver as a way to misuse money and that ’s what we did. We looked at it and it was very scary, the money had not been used for what it should have been.” (Policy/Legislative, Female) Sex education in schools “I would continue to go forward with that – that I di d almost 20 years ago now. Follow through with age appropriate health education in K-12. Hit them. Start hitti ng them slowly.” (Policy/Legislative, Male) Title X policy/guidelines “I don’t know that there are changes to Title X policy other than the ones that limit who you can contract, who you can do business with, the rate of service that you can provid e. I don’t know the policies well enough to suggest changing them.” (Administrative/Implementation, Male) “If I was going to make changes in the family planning program and the Title X policy in Florida it would be to make the family planning program and Title X a little bit more liberal. I could be wrong because I have not looked at in years.” (Policy/Legislative, Female)

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199 Achievements Participants were asked to reflect on so me of the achievements and/or successes that Title X and family planning programs have had on the lives of women and comm unities in Florida. Participants’ res ponses are reported in Table 4 below. Table 4. Achievements of Title X and family planning se rvices in Florida as perceived by participants Achievement Quote Empowerment “I think that there’s some things that yo u can’t – that’d be difficult to measure – the empowerment of families, of being able to control fertility in families. So, I don’t know if family size has actually changed a whole lot with the introduction of Title X, but that would be something interesting to look at.” (Administrati ve/Implementation, Female) Enforcement of child abuse “Then also, a couple of years, right before I left we changed the law. We found the demographics that – who was getting these girls pregnant, it wasn’t the 16 year olds getti ng pregnant by 17 year old boys. It was by the 21 and 25year old men. We made sure that we stiffened the penalties and that there was actually enforcement of child abuse, if the child was under – for statutory rape, under the age of 16 wh ich is the law in Florida. We played with that whole thing to get these guys arrested and this sort of thing.” (Policy/Legislative, Male) Family planning as model program/setting standards “…and I don’t know, it was just – there was a lot of new things and family planning kind of was in a position at that – in the early, the late ‘70s and early ‘ 80’s, to guide. Because the fe ds required certain things, it then kind of helped set the standards for some of the other programs that were coming along.” (Administrative/Implementation, Female) [Interviewer: Kind of best practices?] “Yeah.” (Administrative/Implementation, Female) “And I think to this day, we probably have one Spanish or maybe one – and we have started doing Creole and knowing that Haitian populations don’t always read, you know, it’s, you know, reaching out in a different way. And we probably don’t do everything that we could do and I k now that a lot of folks, a lot of ot her states have turned to Florida through the years, as far as our translations and different things like that.” (Adm inistrative/Implementation, Female) Family planning as one of the top public health achievements of the century “I think that it is listed as one of APHA’s top accomp lishments of the last centuries to have family planning.” (Administrative/Implementation, Female)

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200 Family planning methods “I think that we do have technical guidelines, and we have trai ning available, that we have been able to get past some of the hurdles of explaining the science behind some of the newer methods that we do have now…working with the pharmacy, ways that we maximize the availability and try to have some of the more modern methods available.” (Administrative/Implementation, Female) Funding and availability of services [Interviewer: Okay, after us talking this afternoon, what do you think are some of the overall achievements or successes that Florida can be proud of regarding family planning?] “That they haven’t stopped funding it yet [laughs]…” (Policy/Legislative, Female) [Interviewer: That’s there’s still some funding left?] “Yes, I’m sorry that’s not the slightest bit funny, but yes I th ink one of the greatest successe s we have achieved is to get Florida to support it financially. Not a whole lot past that.” (Policy/Legislative, Female) “I think the fact that they have kept it in all 67 health de partments and they have done a lot of branch clinics in some of the migrant areas and some of the bili ngual areas are really succe sses. I think – you are not talking to maternal health?” (Policy/Legislative, Female) [Interviewer: Family planning.] “I think that is it. I really think that we are probably one of the only states that have all of the counties to the extent tha t we do, however small that may be. And I think the fact that we have held onto some of the family planning services in light of all of the…I think that everybody has been very good at being very quiet about the fact and some of the nimrods are now…They don’t need to know. They could not re ad the budget anyway.” (Policy/Legislative, Female) Health care options “I think it has given women more options into hea lth care.” (Administrative/Implementation, Female) Healthier populations “I think we have healthier populations and people that are more sensitive to what’s – their own health status.” (Administrative/Implementation, Female) Improved HIV/AIDS prevention education “Well, yeah I have been here for two and a half decad es and there have not been majo r changes. I mean there have been enormous changes in terms of HIV/AIDS prevention educat ion and those have been fabulous, as a side effect part of that has resulted in some proliferal family planning in creases, but not significant.” (P olicy/Legislative, Female) Improved infant mortality rates “Well, I would like to say that the program is partially res ponsible. Again, it’s a synergistic affect with a reduction in infant mortality rates that we had starting back in the ‘80s and coming forward. I mean, not they’re really stagnant, but

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201I think that, along with improving access to prenatal ca re and improving reimbursement rates and Healthy Start played a big role; but, also, family planning and having family planning as part of that was a real synergistic affect in improving infant mortality.” (Admin istrative/Implementation, Female) Integration with other policies/programs “I think looking at it from a more integrative approach t hat is an achievement and that it is still tough at times.” (Administrative/Implementation, Female) “Yeah, sure. I mean the Wages Program, Welfare Reform. It’s clearly got the family planning component weaved all through it. We were empathetic that – and Don Winstead, I was telling you – I to ld you his name. He handled a lot of that. He’s making sure that the family planning stuff was wo ven in through the Wages Program.” (Policy/Legislative, Male) Progress with adolescents “And, you know, whether some kid comes in or some young woman comes in for family planning, it’s like I say with any teens, they may not hear everything you have to sa y, but something’s weakened around the edges.” (Administrative/Implementation, Female) [Interviewer: If they could leave with one message…] “Yeah and I think – you have to be careful about choosing the messages so that the message that’s the most important is the one that gets through and we had a god run of it We really did.” (Administrative/Implementation, Female) Reducing unintended/mistimed pregnancies and associated consequences “Perhaps, by helping with some of that unintended, mis timed kinds of pregnancy may indirectly have some impacts on things like child abuse and neglect or even for women w ho have familial disorders, the ability to really think about it and plan whether or not they want to take the risk of having a child. We have both permanent and reversible methods available, so I think that is the other opt ion.” (Administrative/Implementation, Female)

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202 CHAPTER FIVE: DISCU SSION AND CONCLUSION Chapter Five has been divided into the following three sectio ns: 1) Synthesis of Research Findings; 2) Implications for Resear ch, Policy and Practice; and 3) Conclusion. The Synthesis of Research Findings provide s a summary of the findings for the two phases of the study, synthesizes and discusses the synergism of the qualitative data, and outlines the limitations and strengths of this study. The Implications for Research, Policy and Practice discusses the implications of the research findings in these three areas of public health, including a discus sion of the utility of the th eoretical framework used in this study and discourse connecting this resear ch to the current reproductive and political climate. The Conclusion reiterates the fr uitfulness of the stu dy and provides closing remarks. Synthesis of Research Findings Phase I: Thematic Analysis of Title X’s Legislative History Phase I involved conducting a thematic anal ysis on Title X’s legislative history to assist in identifying common themes that ha ve emerged over the lif e of this policy. According to Title X’s legislative history th at was compiled for this study, 20 out of 293 bills (6.8%) were enacted into law. For almost 4 decades, Title X has remained a viable policy that has undergone limited structural and content changes since enactment. As illustrated in the Supplemental Appendix, the most common amendment involved authorizing appropriations for this program. Although the thematic analysis highlighted Appropriation as a major theme, this methodology was unable to evaluate the monetary

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203 specifications over time. However, the litera ture review presented the significant funding cuts that this policy has faced over the years, even when considering inflation. Other amendments included administrative and ope rational amendments, requirements and restrictions, and minor technical amendments. A variety of themes emerged from th e thematic analysis and bills proposed changes that would both directly and indir ectly affect Title X law. Themes were classified under the following seven broad major categories: 1) Administration (attempts to extend or repeal Title X; administrative and grant requirements; coordination with state ac tivities; use of funds ; administration of grants to populations; administration rela ted to particular program sections; data collection and reporting); 2) Appropriation (appropriation for Title X; and appropriation from related legislation and policies); 3) Requirements of Funds/Services (types and range of services; adoption and abortion services; informati on and education; and minors); 4) Restrictions of Funds/Services (abortion services; a nd other prohibition of funds) 5) Related Legislation (such as Adolescent Family Life Demonstration Projects; Women’s Health equity Act; Matern al and Infant Care Coordination); 6) Related Policies (Global and National Institutes Administrations, and Centers; and other policies; endorsing family planning principles; upholding rights and choices with regards to family planning); and 7) Technical Amendments Due to the high volume of bills that were included and reviewed in Title X’s legislative history, all of the themes that were classified under the above broad seven categories were found throughout all administ rations. However, a difference in the content that was being proposed was found th roughout the different administrations.

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204 The majority of the bill s that proposed during the Richard M. Nixon (R) Administration (January 20, 1969 – August 9, 1974; 91st Congress House, D-243/R-192, Senate D-57/R-43; 92nd Congress Hous e D-254/R-180, Senate D-54/R-44; 93rd Congress House D-239/R-192, Senate D-56/R-42), related to establishing global and national institutes, administrations and centers, and bills related to establishing a U.S. population policy. Other bills during Nixon’s administration included those proposing to extend Title X and amending the plans and reports section of Title X law. Of note, no bills relating to abortion were proposed during the Nixon administration. During the Gerald R. Ford (R) Administration (August 9, 1974 – January 20, 1997; 94th Congress House D-291/R-144, Senate D-60, R-37), bills also proposed amen dments to the “plans and reports” requirement section of the law and bills related to abortions began to emerge during this administration. During the James (Jimmy) E. Carter (D) Administration (January 20, 1977 – January 20, 1981; 95th Congress House D-292/ R-143, Senate D-61/R-38; 96th Congress House D-276/R-157, Senate D-58/R-41), several new types of bills were proposed, such as demonstration projects for infertility se rvices, recognition of th e impact of population policy on national and intern ational growth, and adop ting a national policy and encouraging other countries to do the same to improve genera l welfare, the standard of living and to control population growth. In addition, bills related to the development, content and dissemination of community-based information were proposed in this administration. Such information focuse d on pregnancy counseling that including information on the biological and physiological facts of life and of the legal rights and benefits and services of carrying a child to term.

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205 During the Ronald W. Reagan (R) Administration (January 20, 1981 – January 20, 1989 ; 97th Congress House D-243/R192, Senate R-53/D-46); 98th Congress House D269/R-165, Senate R-54/D-46; 99th Congress House D-252/R182, Senate R-53/D-47; 100th Congress House D-258/R-177, Senate D-55/R-45) bills also proposed including information on the biological and legal rights an d benefits of carrying a child to term, but further added information regarding raising the child and adoption options. Bills proposed during this administra tion also stipulated that T itle X grantees and personnel must not be terminated based on the fact that they do not advi se, provide, or refer individuals on methods of contraception, abortio n or sterilization. However, during the Reagan administration, bills began to propose clinical training for OB/GYN nurse practitioners, and training for educators, c ounselors and other personne l. Of note, bills that proposed to repeal the Title X program first began to emerge during this administration. During the George H.W. Bush (R) Administration (January 20, 1989 – January 20, 1993; 101st Congress House D-259/R-174, Sena te D-55/R-45; 102nd Congress House D267/R-167, Senate D-56/R-44), new proposals related to pr oviding HIV counseling and testing, and education on self-breast exams we re introduced. Other proposals that began to emerge included those establishing fam ily planning project grants for Indians ( sic ) and Native Hawaiian health centers, bills indicating that clinics must abide by State parental notification laws and that pregnancy inform ation and counseling must be nondirective. During the William J. Clinton (D) (January 20, 1993 – January 20, 2001; 103rd Congress House D-258/R-176, Senate D-57/ R-43; 104th Congress House R-230/D-204, Senate R-53/D-47, Senate; 105th Congre ss House R-227/D-207, Senate R-55/D-45;

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206 106th Congress House R-222/D211, Senate R-55/D-45), new bills proposed included the following: encouraging family participation among minors; having clin ic staff be fluent in the language and sensitive to the culture of those in their community; providing no exemptions to providers regarding State law requirements on notific ation and reporting of child abuse, child molestation, sexual abuse, rape or incest; and providing counseling to minors to assist them in resisting attemp ts to coerce minors into engaging in sexual activities. Other new bills proposed during this administration in cluded: maximizing the use and plan for coordinating services between the Maternal and Infant Care Coordination grants and Title X; automatically certifying Title X clinics as an essential community provider under the Health Security Act; and prohibiting funds to support or oppose a legislative proposal or candidate. During the George W. Bush (R) Administration (January 20, 2001 – January 20, 2009; 107th Congress House R-221/D-212, Sena te R-50/D-50; 108th Congress House R229/D-205, Senate R-51/D-48; 109th Congre ss House R-232/D-202, Senate R-55/D-44; 110th Congress D-233/R-202, Senate D-49/R-49) th ere were no bills that were found that proposed new types of amendments all bill s proposed included amendments that were found in other administrations. However, the most revealing finding during this administration was that the same types of b ills were perpetually proposed (meaning that the structure and text of these proposals were id entical from bill to bill and year to year). Such text were often included in larger appr opriation bills and sti pulated the following information: appropriation for Title X under the Public Health Service Act; prohibiting funds for abortions; encouraging family participation among minors (meaning to encourage minors to involve their parents in their family planning-related decisions);

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207 prohibiting funds for supporting/opposing a le gislative candidate or proposal; not exempting Title X clinics from state law requi ring notification/reporting of child abuse, child molestation, sexual abuse, rape or incest; providing nondire ctive counseling and services; and providing counseli ng to minors on how to resist attempts to coerce minors into engaging in sexual activities. As mentioned previously, th e bills that were proposed and included in Title X’s legislative history were found to both support and challenge Title X. Examples of how the bills supported and challenged Title X according to the seven broad categories are highlighted in Table 5 below.

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208 Table 5. Examples of how legislative bills proposed supported and challenged Title X policy according to thematic category, 197 02008 Category Support Challenge Administration Grant awarded must not be less than 90% of cost of the project Low-income individuals should participate in the grant Grants should coordinate with State and other health services Entities should not be denied funding due to the fact that their State laws are more restrictive Funds can be used for contraceptive research centers Funds can be used of research purposes Funds can be used for training purposes Repeal program Transfer funds to a different program Grant amount must include at least 40% of funding for alternative to abortions Funds must come from a particular section of the grant (i.e. funds towards training must specifically originate from the training section) Appropriation Appropriation for entire program (Title X) Appropriation for specific sections of Title X law (i.e. research, information and education, or training section) Appropriation for infertility or adolescent demonstration projects; STD education; preventative health services; program planning and evaluation activities; loan repayment programs for professionals involved in contraceptive research Transfer funds to other programs Requirements of Funds/Services Providing a range of family planning methods, including natural family planning methods and infertility services Providing nondiscriminatory and nondirective counseling and services Staffing personnel who are familiar with the culture and who can speak the predominant language in that clinic’s community Permitting entities/personnel th e option of not having to provide nondirective counseling or services due to religious or moral beliefs Waiting periods (i.e. 2 days) after the Informed Consent process for abortion services Prohibiting an entity from receiving any Title X funds if they do counsel or provide abortion services with other funds

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209 Providing cultural and competent breast and cervical cancer screening services Developing/disseminating community-based information and education Ensuring voluntary participation for all services Not being able to provide family planning information or disseminate services in schools Removing confidentiality mandates for adolescents Ensuring compliance with parental notification state laws Informing individuals that in order to prevent HIV infection one must refrain from all homosexual activity Related Legislation Maximizing the use of Title X funds to effectively provide family planning services Coordinating services with other polices and programs distinct from Title X to assist in serving and meeting more individuals’ health needs Demonstration projects for welfare recipients to assist in providing them with family planning information (including where/what services were available) No bills classified under Related Legislation were found to challenge Title X policy Related Policies Endorsing family planning principles Recognizing importance of family planning services Expressing the sense that family planning services should be valued Promoting high quality, safe and effective family planning choices to allow individuals the right to choose if, when and how may children they bear No proposed bills classified under Related Policies were found to challenge Title X policy. Technical Amendments N/A N/A

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210 Phase II: Oral Histories Phase II involved conducting oral historie s with past key Title X stakeholders to explore their recollections, perceptions and e xperiences regarding the Title X program in Florida. A priori themes, which originated from Phas e I findings and selected constructs from MFPAF, assisted in eliciting rich da ta regarding stakehol ders’ experiences in working with Title X and family planning programs and services in Florida. Values The values and underlining principles of Title X as perceived by participants included providing empowerment and choices to women, promoti ng public health, and providing concrete functions to personnel such as technical guidance. Participants discussed Title X as a key policy in em powering women and pr oviding them choices regarding their fertility; that is, giving women, particularly low-income women, the choice to decide if, when and how many child ren they would bear. In addition, this policy freed women from more traditional roles, thus enabling them to explore other things in life such as employment and other life opportunities. In addition, participants thought that the policy met many public hea lth missions related to improving women’s health such as birth spacing, preventing unint ended pregnancies and preventing disease. Moreover, the policy provided technical gu idance such as outlining the entities, providers, services and information that could be included under this policy. State-Market Control All participants strongly felt that the government should have a role in family planning and this role was clearly defined as providing women the access and availability to voluntarily participate in family planning programs and services Even though the

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211 vision regarding the health economics of providing such services was unclear (participants discussed a range of possibilities from universal health care to a $5 flat fee of service to be paid by the individual and/ or the government), a ll participants thought that these services must be made availabl e to women. However, when followed up with an additional question whether the governme nt providing such services would make women reliant upon the government, no particip ant thought this was true because these services are a basic human need and right. There was a mixture of responses related to whether Title X contains elements of social control over women’s bodi es. Some participants did not think that this policy contained any elements of social control over women’s bodies because the services are voluntary, available to all women regardless of socio-economic status, and empower women and give them the control over their fe rtility. By contrast, other participants did believe that family planning services exuded control over wo men’s bodies and referenced previous experiences where inappropriate a nd unethical measures of providing family planning services occurred in Florida. In addition, such governmental measures to control and limit women’s reproductive choi ces were mentioned as various policies continue to be proposed and enacted to this day which hinder women’s reproductive freedom. Most participants did not feel that Ti tle X was a stigmatizing policy as clinics ensure confidentiality when an individual vo luntarily chooses to seek services. Any stigma discussed generally referred to more of a reluctance of women to seek services because of social and/or cultu ral barriers. However, one participant did share a story where a couple who was facing economic hard ship chose not to seek services, took

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212 chances, got pregnant, and then had to te rminate the pregnancy because they had no health insurance to help with costs if the pregnancy was carried to term. Multiple Identities Many participants believed that Title X does address the needs of all individuals in Florida and discussed how women of all economic statuses seek Title X services and how even providers prefer to work in th is public health set ting. Immigrant and undocumented individuals were mentioned as a special population in Florida that has access to these family planning services as well Other individuals felt that Title X does not adequately address the needs of all i ndividuals in Florida as there are still many unintended pregnancies, and efforts are ofte n reactive rather than proactive where family planning is discussed only after a wo man becomes pregnant as a way to avoid future pregnancies. In addition, the lack of cultural sensitivity in family planning programs was discussed as a barrier in meeti ng the needs of all individuals. Men, the elderly (concerning their needs for sexual hea lth information), and the disabled were specifically mentioned as indivi duals who are not addressed in family planning programs. However, participants revealed that extendi ng efforts and being more inclusive regarding the individuals who seek family planning services is unlikely due to the lack of current resources such as funding and time in clinics’ schedules. Political Context. Participants revealed various political issu es and controversies that affected Title X and family planning in Florida. The topic of abortion was discussed by all participants and serves as an issue that always has a nd continues to plague reproductive health policies. Participants spoke about how cont roversies surrounding abor tion continue to be

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213 introduced into proposed legislation and negati vely effect family planning services by limiting what entities can receive funding and what services can be provided. Specifically, issues surrounding the Gag ru le (prohibits personnel from providing information, counseling and services on abor tions) and options-c ounseling (providing information on all pregnancy management options) were referred to as attempts that negatively affected women and their health, especially thos e residing in smaller counties in Florida that have limited access and options In addition, aborti on was referred to as one of those controversial and divisive topi cs that creates much confusion surrounding family planning and has the potential to di smantle Title X and other important health policies. Five out of six participants mentioned family planning methods as being politically controversia l. In particular, family planning methods such as EC, the rhythm method, IUD’s, and Norplant were identified as methods that created controversies, generally because of the l ack of knowledge that legisl ators and the political opposition hold regarding these methods and/or because of their mechanism of action. Participants discussed that even though family pla nning clinics include abstinence along the continuum of family planning methods, this fa ct gets disregarded and this misconception adversely affects Title X. The controvers ial topic of abstinence-only would create negative publicity for family planning progr ams and would overshadow and threaten the successes that family planning progr ams provide to individuals. Most participants discussed how ensuring adolescents the right to receive family planning information and services is a consta nt struggle. No encouraging or positive experiences were discussed. Participants stressed the importance of maintaining

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214 confidentiality and providing follow-up care to this populatio n. The issues related to parental notification, and the emancipation of minors, were discussed as two provisions that restricted and permitted adolescents the ability to receive family planning services, respectively. Personal experiences regardi ng the numerous political and legislative attempts to prohibit adolescen t from receiving services (i .e., shutting down school-based clinics that provided family planning inform ation; difficulties in separating their own personal struggles and opinions dealing with this population, etc.) were revealed. As with abortion, including a dolescents in a policy also creates a diversion among stakeholders and results in that policy be ing perceived as more controversial. The oral histories revealed many threads regarding how administration and politics affect the success of Title X. A lthough intertwined with other themes, participants provided personal examples of how administratio n and politics would negatively impact Title X and family planni ng programs such as the removal of schoolbased clinics and attempts to illegalize abortions in Florida. In a ddition, it was discussed how family planning was affected differently with each Governors’ administration and how agendas and priorities would continue to change depending on which administration was in office. Such “flip-flop” of the ad ministrations’ and legislatures’ agendas and values was referred to as “schizophrenia” in politics. Overall, Governor Bush was identified as the governor that most opposed family planning and who created the most opposition for family planning, including attempts to shut down family planning programs and services. Other political issues identified by particip ants as creating poli tical controversies and barriers for family pla nning included the following: HIV/AIDS; oral sex; welfare

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215 reform; and stem cell research These issues created an increase in political activity and either directly or indirectly affected family planning. Most often these issues would add unnecessary controversy to family planning and would create addi tional burdens when providing and receiving family pla nning services in Florida. Social and Cultural Context Various social and cultural issues were di scussed as affecting Title X and family planning services in Florida. Participants broadly identified individuals not being comfortable with their sexualit y, individuals marrying later in life, and a shift in males becoming more involved with their children as social and cultural factors affecting family planning. In contrast, particip ants also discussed social a nd cultural barriers in providing family planning services to males. Flor ida was referred to as a slower and more conservative state; regardless, much consider ation was given to how counties in Florida were able to respond to the cultural need s of individuals and how each county had a Community Advisory Board which was co mprised of diverse stakeholders and consumers. However, participants ac knowledged that greater improvements in addressing the social and cultural needs of indi viduals seeking services are still needed. The issue concerning young, low-income females wanting to become pregnant, the social acceptance of unwed mothers, and the need for particular groups to take greater responsibility for having children out-of-wedloc k were mentioned as social and cultural barriers that interfere with fam ily planning initiatives. Soci al and cultural issues related to the use of birth control, such as the reluctance of so me African American women to use birth control, and the infl uences that religion and church can have on family planning services were discussed. Participants not ed that public information campaigns and

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216 initiatives to improve follow -up with clients are neede d. Moreover, even though the effort of providing socially and culturally se nsitive services was r ecognized, participants discussed how improvements regarding such sensitive issues are vital and it is essential to understand how such services are being perceived by communities. Funding When asked to comment on how they have seen the funding for Title X change over the years, the majority of participants reported that funding has remained the same, or has decreased slightly, but no significant increases in fundi ng were made. In previous years, Title X funding was characterized as be ing somewhat flexible, as there were other sources of funding (i.e., MCH Block Grant, ge neral revenue, State do llars, Medicaid) that could be used for family planning services as well, and clinics were not driven by money and reimbursements, as is the nature of hea lth care today. It wa s also mentioned that health education related to family planning wa s flexible in that it had the opportunity to be placed in either the education or health budget. However, it was noted that as funding decreased and did not keep up with inflation, population increases, co sts of services, and demand, the same guidelines and restrictions still had to be abided by. Overall, participants discussed their frustration in communicating and demonstrating the effectiveness of family planning a nd securing more funding for prevention. Equality/Right and Care/Responsibility Participants were asked whether they thought males play a role in family planning, and which roles and responsibilities do they believe males should play in the arena of Title X and family planning. All par ticipants discussed that including males into Title X and family planning remains both a significant challenge and a gap in the delivery

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217 of family planning services. Participants re called that males served as the majority who were involved with Title X legislation in the beginning and even though there are now more women represented in legislature than before, males still hold the dominant voice in the legislative arena. In addition, the de licate balance of including males and having them play larger roles while not taking aw ay any power from women was discussed. Negative roles that males currently play were identified as being the decisionmakers regarding whether a couple should ha ve children, having dominate roles related to sexual coercion, domestic violence, and bei ng “predators” in some situations. The media was also mentioned as a venue that inco rrectly portrays and continues to diminish males’ responsibilities regarding family pla nning. Other issues regarding the role of males in family planning that were identifie d by participants involve d social and cultural factors such as the following: males’ lack of responsibility ; males’ perceived lack of benefits; ensuring confidentiality when providing family planning services to women; the lack of partner communication in sexual matters; and society’s acceptance of having children out-of-wedlock. It was stated that males greatly need education and counseling regarding family planning. Opportunities a nd interventions to include males included vasectomy services, upholding child enforcem ent laws and enforcing child support and the associated sanctions to increase males’ awareness of their res ponsibility regarding the consequences of unprotected se xual relations. Sports physic als were also mentioned as an opportune time to educate, counsel and pr ovide family planning-related services to adolescent males.

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218 Integration Integrating Title X and family planning w ith other policies, programs and services was seen as both positively and negatively affecting the success of Title X. It was mentioned how funding comes down from distinct policies, where policies have specific guidelines and accountabilities; however, some overlap and streamlining of the delivery of services has been done in the past. Specific examples where efforts to integrate Title X occurred included the area of maternal and child health, such as Healthy Start and WIC. The difficulties of integrating policies and programs due to their controversial nature were discussed, and participants suggest ed that often keeping policies distinct is best, especially in order to keep both pr ograms from abiding by the same stringent guidelines and requirements. The need to integrate health care policies and programs based on the premise of the continuum of car e, where an individua l is recognized as a whole person who requires holistic care and di stinct needs and services was stressed by participants. However, barrier s to integration included data and technology issues (i.e. ease of data collection, automatic and computer ized forms, paper work burden, etc.) and staff’s willingness to adopt the integration of programs. Integrating policies requires a firm understanding of public health, and one participant discussed how welfare reform, Medicaid, workforce development, and family planning are multiple issues that are all inter-connected and require expa nsive knowledge and understanding. Barriers Participants discussed polit ical, social, ideological a nd operational barriers that Florida faces regarding Title X and family pl anning services. The following topics were identified as barriers that affect Title X and family planning efforts in Florida:

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219 Accessibility of care Clinic barriers Cost of services and contraception Demonstrating the public health achievements and importance of program Education (barriers related to educating individuals on the biological part of family pla nning and the inclusion of sex education in schools) Funding Involvement of children Leadership changes Not addressing all problems/issues Not taking responsibility Research and information Politics Sexuality Social acceptability/Social standards Stigma related to receiving care Values and beliefs Recommendations Participants were asked to comment on what changes or recommendations they would like to see implemented in Florida to improve Title X and family planning services. Participants’ recommendations included the following topical areas: Access and availability of services Awareness of services Better research Consistent and flexible policies Continue the political will Continuity of services regardless of location Follow-up with high-risk individual s and streamlining of services Funding Maximize the potential of the Medicaid Family Planning Waiver Sex education in schools Title X policy/guidelines

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220 Achievements Participants were asked to reflect on the achievements an d/or successes that Title X and family planning programs have had on the lives of women and communities in Florida. Participants described the following as achievements in Florida regarding Title X and family planning services: Empowerment Enforcement of child abuse laws Family planning as model program/setting national standards Family planning as one of the top public health achievements in the past century Family planning methods Funding and availability of services Health care options Healthier populations Improved HIV/AIDS prevention education Improved infant mortality rates Integration with ot her policies/programs One of top public health achie vements in the past century Reducing unintended/mistimed pregnancies and associated consequences Summary of Oral Histories Oral history findings assisted in providing a more rich and comprehensive view of this policy, and included specific examples of how this policy affects the roles and experiences of key stakeholders working in the area of family planning. The many issues and examples that were discussed by particip ants brought great richne ss and depth to this controversial and politicallyand valueladen policy. In addition, barriers, recommendations and achievements were highlighted by key stakeholders, who documented the historical maturation of this policy while providing insight into possible future policy and programmatic directions.

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221 Synergism of the Qualitative Data The synergism of the two phases of this study allowed for a critical examination of Title X at a broad and theoretical level to be merged with the recollections and experiences of this policy as perceived by ke y stakeholders. Many of the themes that emerged from the thematic analysis on Title X’s legislative history (Phase I) were also revealed during the oral histor ies (Phase II). See Figure 10 for an illustration of the common themes that emerged in both phases of the study. In general, these themes both implicitly and explicitly affect the purpose, function, utility and substance of the Title X program and included, but are not limited to the following topics: empowering women and providing them with a choice regarding their fertility; funding; technical guidance (requirements/restrictions) from Title X grants ; providing family planning services to all individuals; providing a range of family planning methods; and improving public health and impacting the health of women, families and communities. Furthermore, the effect that various administrations and the surrounding politics have on this policy (“schizophrenia in politics”), and the highlighting of the cont roversial issues dealing with abortion and adolescents, further confirms the un certainty of this policy and its future role in providing the necessary family planning and related preventative health care to those in most need. By way of highlighting the themes that were consistent between the two phases, a description of similarities is presented in the following sectio n. Participants verified that the values and underlining principles of Title X include providing choices to women, particularly low-income women, regarding when if and how many children they bear. In addition to the “health” functions of this policy, participants also discussed how Title X

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222 could empower women to take control of th eir lives and help “free” them from more traditional roles by enabling them to be able to participate in employment, and such notions mirror the origins of Title X law regarding this act’s purpose of alleviating poverty and expanding economic development. The thematic analysis on Title X’s legislative history revealed that Title X has undergone limited structural and content changes and this was verifi ed during the oral histories as participants responded that they did not believe the federal administration made any significant changes to the Title X policy over the years. Appropriation was one of the major categories that resulted from the thematic analysis and participants stressed the impor tance of funding during the oral histories as well. The majority of partic ipants reported that funding has remained the same, or has decreased slightly, but there have been no significant increases in Title X funding over the years. The lack of appropriate funding for such a critical public health policy that serves as the only policy that is devoted solely to providing voluntar y and confidential family planning services is di sheartening. As one participan t stated, an achievement of this policy over the years is “that they haven’t stopped funding it yet.” Although the thematic analysis did not allow for a critic al examination of the funding levels over the years, such a dramatic decrease in Title X f unding at the federal level over the years has been previously established and was certainly recognized during the or al histories. In addition, unfortunately the data specifying the funding that Florida received from Title X in its first few decades are no longer availa ble from Florida state archives. However participants in this study co rroborated with the national lite rature recognizing Title X as a significantly under-funded program, and acknowledged that today’s health care is driven

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223 by reimbursements, the demand and costs for se rvices are escalating, and that there are not even enough clinical resour ces (i.e., patient slots/scheduli ng) to adequately attend to the current Title X clients. The various requirements and restrictions of funds and services that were revealed through the thematic analysis on Ti tle X’s legislative hi story also emerged during the oral histories. Controversie s over nondirective couns eling, abortions and delivering services to adolescents were common themes throughout the bills and oral participants echoed such st ruggles and provided many exam ples where they confront these issues on a daily basis at a state-level. Other restrictions, such as prohibiting involuntary ster ilization were revealed during the thematic analysis. Participants recalled a few unfortunate times where involuntary sterilizations occu rred in Florida in previous decades and the critical importance of ensuring that such unethical procedures do not occur again and upholding the sterilization guidelin es. Of note, no specific changes regarding sterilizations were enacted into law according to the thematic analys is of the bills included in this legislative history. However, sterilizati ons guidelines for family planning services were developed over the course of Title X and it is possibl e that such guideline s were enacted under a different law, which was not included in this study’s legislative history. The influence that administrations and politics can have on Title X and other family planning programs and services were elicited through the th ematic analysis and were discussed in detail during th e oral histories. Participan ts identified Governor Bush (R) as the governor that most opposed and who created the most opposition for family planning, including his attempts to shut dow n family planning programs and services

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224 altogether. At the federal level, George W. Bush (R) was president and the thematic analysis revealed that no “new” types of amendments were found during George W. Bush’s administration. However, although indirectly related to this study, this was a time when many antireproductive h ealth and women’s health legi slation persisted throughout George W. Bush’s administration. Such issu es plaguing public health advocates during this federal administration included, but wa s not limited to, abstinence-only education, the Gag Rule, attempts to gain momentum to overturn Roe v. Wade, restrictions on partial-birth abortion, and obstacles allo wing emergency contraception to go over the counter. Another finding from both phases c oncerned how many bills in Title X’s legislative history were found to be perpetua lly proposed; meaning that the structure and text of these proposals were similar (and of ten identical) from year to year. A few participants explained that the introduction and re-introduction of such bills acknowledge the political will that legislator s have regarding a particular issue, and how legislators hope that even if the bi ll in its entirety does not get passed and enacted into law, at least a piece of the bill will get pushe d though, ultimately making an issue “one more step restrictive than it was the previous year.” Participants also reflected on how fam ily planning and related issues would be affected differently according to which ad ministration was in office, and how such agendas and priorities would continue to ch ange and can be known as “schizophrenia” in politics. In addition, participan ts noted that the topics of abortion and/or adolescents can be thrown into practically a ny legislation to create barrie rs, and that these two “hot political issues” were a means to not only to dismantle Title X but other policies and

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225 programs that as well. Participants noted th at these issues can “charge” any legislation on the table. The confirmation of these common them es verifies many of the political, economic, and social issues that are discusse d in the literature. Through an examination of the issues directly from th e original source of data (p roposed and enacted legislative bills), findings from this study indicate that su ch issues are present and have the potential to greatly jeopardize the future of this polic y and its ability to im prove the health of women, families and communities. In additi on, the oral histories with key Title X stakeholders in Florida further authenticate ma ny of the barriers and successes that this policy has faced throughout its enactment. Fu rthermore, the oral histories presented a first-hand picture of how these issu es play out at a state level. In preparation for formal dissemination through the preparation of manuscripts, these findings and their theoretical application will be discussed in light of other literature. Particularly, these findings will be placed in the context of the larger body of knowledge regarding feminist policy analysis a nd the controversial na ture of reproductive health. In addition to a discussion of the liter ature – which will typically be placed in the final section of the manuscript, disseminati on of findings will incl ude the strengths and weaknesses of the methodology a nd will further address principl es related to qualitative research and researcher bias by extending and confirming the reliability of coding and using measures of inter-rater reliability. Limitations There are several limitations inherent in this study, which must be reviewed when considering the findings. First, because of the voluminous nature of the number of

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226 federal bills proposed since 1970 that containe d amendments affecting Title X, it may not have been logistically feasible to include and review every bill as part of this legislative history. In addition, multiple secondary source s had to be used to research and compile the legislative history and such sources we re not consistent in the way data were presented. However, the secondary data collection was performed systematically, utilized multiple search terms and sources, a nd serves as the only le gislative history for Title X that includes all bills proposed (regardless of enactment); thus, an exhaustive search was performed which produced a vast and comprehensive legislative history. Second, the thematic analysis of Title X’s legislative history identified common themes that have emerged over the life of this family planning policy. However, such identification and classification of themes does not thoroughly examine each single bill in detail and does not provide an in-depth polic y analysis for each proposal. Similarly, only the full text version of the bills was used as data and other policy -type documents (i.e., hearings, committee reports, othe r legislative briefs) were not reviewed. Nonetheless, the thematic analysis does provide a comprehensive examination of Title X’s legislative history in its entirety, which was th e purpose of this phase of the study. The third limitation considers the samp ling of the participants for the oral histories. Sequential and snowball sampling techniques were utilized and participants were selected based on their expected expertise and knowledge that they possess regarding Title X and family planning in Flor ida, and included those individuals that were continually identified as being critical people to inte rview by other key informants. Regardless, other past Title X key informan ts may not have been identified, and thus, were not able to participat e in this study. In additi on, even though the researcher

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227 attempted to include a diverse sample in rega rds to race/ethnicity, all participants’ selfreported being White, and thus, future research should include stakeholders from diverse racial/ethnic backgrounds. Furthermore, it was proposed that in dividuals who hold di ffering opinions and beliefs regarding Title X and family pla nning programs and those who hold differing personal and professional values regarding re productive health, family planning, and the function and purpose of public health services would also be include d. However, efforts were directed towards including the oppositio n and some potential participants were contacted, but including such individuals in this present study proved to be unsuccessful due to difficulties in establishing direct c ontact (including individua ls who have limited cognitive function and who are in a home due to advancing age, and those who are now deceased) and/or other feasibility constraints. Thus, including key stakeholders who hold differing views and who oppose Title X and fam ily planning programs serves as future research. The fourth limitation concerns the potentia l for social desirability bias among oral history participants. Because this topic is ve ry controversial, is politically divisive, and deals with issues relating to sexuality, partic ipants may have responded according to what they thought the correct answer was and/or wh at they thought the re searcher wanted to hear, rather than providing an honest account of their recollections and experiences regarding Title X and family planning in Florida. Fifth, issues related to memory and recal l bias also serve as a limitation in this study. Oral histories by nature are a historical account of a past phenomenon, process or event. Individuals often recall only what they perceive as being important and not every

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228 event and story is stored in memory. However, the researcher can evaluate the credibility of responses by considering the following: were these events experienced firsthand or is this secondhand information; what bias es may have influenced participants’ recollections/experiences; is this informati on verified with other documentation; how has the future context shaped participants’ feeli ngs and recollectio ns (Ritchie, 1995). Sixth, researcher bias serves as a lim itation in this study. Researcher bias can affect every stage of the rese arch process, and thus, the re searcher must first acknowledge his or her biases and then apply various safeguards to minimize such biases. For instance, in Phase I, the way that the resear cher applied the frames and lifted the text out of the data, the “research ers interpretive focus” (G rbrich, 1999, p. 220), and the researcher’s position to the data and how mean ing was developed or formed all played a role in the researcher’s interpretation and could have contributed to researcher bias (Grbrich, 1999). In Phase II, interviewer bias could have distorted, mislead or altered the veracity of the participant’s responses. Neuman (2003d) identifies the following six categories in which interview bias can occur: 1) errors by the res pondent; 2) unintentional error or interviewer sloppiness; 3) intentiona l subversion by the interv iewer: 4) influence due to the interviewer’s expectations; 5) failu re of an interviewer to probe or to probe properly; and 6) influence on the answers due to characteristics of the interviewer’s. In Chapter Three, the researcher discussed at length how research er bias would be minimized; however, such bias still serv es as a limitation and requires mention. The seventh limitation con cerns the researcher in this study who critically examined a U.S. policy while not being a U.S. citizen. Therefore, some aspects regarding the culture, context, government and the policy process may be unfamiliar to the

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229 researcher. However, the researcher has obtained a Masters degr ee and is a Doctoral Candidate in public health at a U.S. ins titution, and comes from an English-speaking country (Canada) that shares many similarities with the U.S. In addition, throughout the research process a series of checkpoints and experts we re consulted, including the additional researcher who was involved in th e reliability of coding for both phases, a panel of experts (doctoral committee and aut hor of framework used in this study), two key informants who served as the pilot sample, and two government document librarian specialists from two different Florida university. The eighth limitation to this study is that the findings from the oral histories cannot be generalized to all Title X stakeholders in Florida or to all Title X stakeholders in the U.S. However, the oral histories enriched our understanding of how Title X and family planning programs affect key stakehol ders at a state-level and provided an invaluable opportunity of co llecting meaningful recollecti ons, which might have been otherwise lost. Such unique and personal perspe ctives are a central characteristic to oral histories and serve as a major difference when compared to in-depth interviews; in-depth interviews aim for saturation in responses, whereas oral histories are not expected to achieve saturation but aim to elicit personal reflections and experi ences as perceived by the individual to add richness and meaning to the phenomenon under study. Delimitations This study critically examined and explored the myriad of issues, including the successes and failures that Title X has confr onted, so informed future policy decisions can be made to improve the health and well-being of women and the broader community. However, in addition to state Title X and family planning administrators and policy

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230 makers, there were other key stakeholders th at were not included in the oral history sample. Health providers and clinic staff th at provide direct fam ily planning and related preventative health services and counseling a nd the clients who are the recipients of the Title X program were not be included, and thus these sample exclusions are a delimitation to this study and serve as an area for future research. Strengths This study demonstrated many strengths a nd provided a critical examination of Title X through a feminist policy analysis lens First, this study filled a gap in the research by comprehensively examining Ti tle X from 1970 to 2008 and contributed to existing literature which has focused only on the policy’s outcomes (i.e., number of family planning service users, types of birth control dispensed, etc. ) (RTI International, November 2006) by exploring whether the prog ram is meeting its overall goals, such as providing family planning services to those in most need and supporting women in their reproductive rights (McFarlane & Meier, 2001). Second, this study was innovated in its methodology and approach. Grounding this study theoretically and me thodologically in a feminist pol icy analysis assisted the researcher in critically examining the poli tical, economic and soci al barriers that are embedded in this policy and which have undermined Title X. A feminist policy analysis approach also permitted the use of multiple and unique methods (thematic analysis on Title X’s legislative history and oral histories with past key Title X stakeholders in Florida), which took into account the controvers ial nature of the policy and the fact that the issues inherent within a policy are politicallyand va lue-laded. Furthermore, a feminist policy analysis approach incorpor ated many issues incl uding but not limited to,

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231 power, control, context, language, and equality and rights – concepts th at are often absent and disregarded in traditional policy analyses. Third, this study produced a comprehensive legislative history on Title X and included all House and Senate bills that were proposed, a nd did not include just those bills that were enacted into law. By including all bills proposed, the researcher was able to identify all of the themes that emerged th rough the life of this policy, and highlighted the political will that pers ists in both supporting and challenging this policy. Furthermore, by conducting a thematic analysis of Title X’s legislative history, this study was able to go directly to the data (the legisla tive bills) to identify the issues that confront this policy, rather than relyi ng on the discourse that is pres ented in the literature to identify such issues. Fourth, the findings from the oral hist ories complemented the findings from the thematic analysis of Title X’s legislative hist ory, and responses from the oral histories did indeed confirm that these issues are encount ered at a state-level and are experienced by stakeholders. Such a holistic perspective of the historical maturation of Title X provides an in-depth understanding and brings life to this policy. Fifth, by choosing oral hi stories (versus another methodology), stakeholders’ experiences and perceptions regarding Title X and family planning in Florida were able to be collected over a span of almost four decades. These oral histories assisted in supplementing the findings from Phase I, and provided a voice regarding the daily experiences that state-level st akeholders confront when working in the area of family planning. In addition, or al histories assisted in looking at changes and trends in the many issues that surround Title X.

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232 Sixth, this study was able to apply and assess the utility of MFPAF, a framework which originated in the field of social work, to a controve rsial public health policy (see research implications below). Seventh, this study was able to provide an in-depth exploratio n of the maturation of Title X since enactment and successfully addressed the following original specific aims that were developed: 1) identify the historical underpinni ngs and evolutions of this policy; 2) explore issues that are typically ignored by traditional policy analyses; 3) recognize past failures and achie vements to inform future decisions; 4) assess the utility of MFPAF in guiding a policy analysis on Title X. Implications for Research, Policy and Practice Research Future research should continue to record and examine all of the legislative bills that propose amendments for Title X, regardless if those bills become enacted into law. Tracing the evolution of Title X and the vari ous issues that this policy faces provides important information to policy makers as well as to reproductive health advocates. In addition, another legislative history could be compiled fo r this policy; as future technology is improved and/or databases ar e enhanced, a more seamless and precise documentation of all of the bills propos ed from 1970 to the current time could accomplished. Future research should also include and address the experiences and perceptions of those key stakeholders in Florida who oppose Title X and family planning programs in

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233 Florida. Although this study attempted to incl ude these individuals in the oral history sample, such efforts were unsuccessful. Moreov er, other levels of stakeholders should be included in future research. These stakeholde rs include health provi ders and other clinic personnel as well as the recipien ts who receive family planning services. In addition, key stakeholders from other states should be included in future research to compare achievements, barriers and recommended polic y changes with those found in the state of Florida. Although qualitative data allow researchers to really explore in -depth individuals’ perceptions and experiences and provide opportun ities to ask questions and to fill in any gaps in meanings, quantitative research would be useful to quantify responses to provide aggregate data and to explor e relationships regarding fam ily planning services across different variables. For instance, future research could examine the frequency of different amendments proposed and/or create sc ores for the themes th at were identified in the thematic analysis and assess how such amendments/themes vary or relate to other variables (i.e., sponsor’s party affili ation, year of proposal, etc.). Other research could focus on social ma rketing techniques to examine the efforts that would effectively increase awareness of Title X services and provide outreach to high-risk individuals. However, as stated by the participants in this study, such efforts aimed at increasing the number of individuals seeking se rvices and improving service delivery is not useful if the funding to support Title X is provided at a level that does not even support current recipients.

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234 Theoretical Implications McPhail (2003) developed the “Feminis t Policy Analysis Framework: Through a Gendered Lens” after she determined that “the re is not an explicated policy framework that lists a set of questions that constitutes a feminist st andpoint” (p. 41). Thus, MFPAF presents thirteen constructs and provides ex amples of questions that can be asked during a policy analysis. See Appendix C fo r the framework in its entirety. After conducting a systematic literature review and to the author of the framework’s knowledge, this framework has so far only been applied to a limited number of analyses, including only one published study, in which Kanenberg (2007) conducted a feminist comparative policy analysis of the State Children’s Health Insurance Program (SCHIP) in the states of California and Texas. MFPAF assisted this study in revealing that SCHIP is a gendered and oppressive policy for women, holds many patriarchal assumptions of women, redirects women’s de pendence upon their partners to the state, and restricts women’s choices by asserting penalties relating to “labor, employment, health, wellbeing, and autonom y” (Kanenberg, 2007, p. iii). Similar to Kanenberg’s (2007) conclusion, this framework fills the theoretical gap by providing a deep examination into how a policy affects women and by explicitly providing sample questions that a researcher can ask during a policy examination. This study also serves as an example of assessing the utility of this fr amework and concludes that this framework clearly presents many cons tructs that are grounded in feminist theory. It also allows a researcher to critically ex amine the many issues related to power, control, context, language, and equality and right s – concepts that are often absent and disregarded in traditional policy analyses. In addition, a strength of this framework is its

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235 flexibility, which also serves as a limitation, as there is room for a researcher to adapt and modify both the constructs a nd the specific questions that guide a policy examination. However, limitations of this framework were found. Similar to Kanenberg’s (2007) assessment, this framework is lengthy, time-consuming and questions may need to be re-structured based on th e policy under consideration. McPhail (2003) and Kanenberg (2007) also acknowledge that incl uding all of the constructs ma y not be feasible. For this study, five of the constructs were directly ap plied and helped guide the oral histories. Other constructs were not included either becau se they did not apply to this policy topic or because they did not align with the scope and purpose of this study. For instance, the construct material/symbolic reform was omitted because this policy is not just a “legal redress” and does not just serve as a placeholder, meaning this policy does not just serve as an example of political effort. Title X does provide concrete se rvices to many women and families around the nation and significantl y contributes to preventing unintended pregnancies and improving overall health. The current study found that the major limitati on of this framework was its lack of ability to provide specific questions that could be dire ctly applied to this policy examination. Although the essence and prem ise of the questions did provide some guidance, in many cases these questions need ed considerable re-wording to adequately reflect the policy under study and to make questions meaningful to the participants and to the examination itself. Overall, however, the utility of this framework was positive and provided guidance into conducting a policy examin ation that was theoretically and methodologically grounded in a feminist policy approach. As McPha il (2003) has stated,

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236 this framework serves as the only feminist fr amework to specifically provide constructs and questions that can help a researcher when analyzing a policy from a feminist standpoint. Constructs used in this study permitted a thorough examination into many important political and social issues that are often not addressed in traditional policy analyses. MFPAF assisted this study in provi ding a historical and feminist perspective into a sensitive and controversially public he alth policy that has been around for almost four decades but which has been the ta rget of much scrutiny and opposition. Future theoretical implications could in clude revising and refining this framework to better address the range of policy topics th at could utilize this framework. In addition, this framework is still in its infancy, and a lthough the constructs we re very helpful in framing the topics and ques tions, the specific questions provided under each construct should be revised and evaluated with other polic ies. Moreover, because of the plethora of research concerning policy analyses that mi ght benefit from a femi nist standpoint, other theories and frameworks could be develope d to supply researcher s with choices and flexibility when choosing a feminist policy an alysis theory or framework and to better address the multidisciplinary nature of policies. Policy The findings from this study have several policy implications. Perhaps the most substantial policy implication is that Title X necessitates the appropr iation of funds that match the demand of those in need of publicly funded family planning services, and which take into consideration inflation, popula tion increases, the rising number of those uninsured, and the rising costs of services. The literature review and the findings from the oral histories reiterate how crucial it is to have adequate funding to support this public

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237 health program which so many people rely on as their source of reproductive care (and often their only source of general health care) and the call for this program to serve all those who are still in need of publicly-funded family planni ng services. In addition, as proposed for many decades in the federal legislature, the U.S. should establish and declare a population and family planning policy that respects the right s of individuals to choose when, if and how many children th ey bear, and which provides access to confidential and high-quality family planning ch oices. There is no single family planning policy in the U.S. and the multistatutory nature of family planning (programs and services originating from separate policies and funding streams) has proven to be ineffective and insufficient in providing fam ily planning services to all individuals. Participants in the oral hist ories emphasized that reproductive health must be seen as basic health care and that the government has a responsibility to ensure that all individuals have access to safe and affordable choices. Although participants did differ on the exact mechanisms of th e funding of this health care (i.e., private insurance, governmental-sponsored, patient co-pay, etc.), all participants were very clear that family planning services must be available to a ll individuals regardless of how and by whom such services would be paid for and which level of government s hould be responsible. Participants agreed that a policy or program encompassing a basic level of reproductive health care must be established. Such effort s require a political will to fight for these basic human rights and to recognize and make family planning a priority in the U.S. Also, improved unification and/or coordination of policies that provide family planning services are needed. This policy implication also extends to broader policy implications of remodeling the U.S. health care infrastructure and ensuring access and

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238 coverage to health care services, including fa mily planning services, to all individuals regardless of income and other demographics (national origin, r ace/ethnicity, gender, etc.). The thematic analysis identified seve ral related legislation bills that were not specifically focused on Title X, but which had language articulating the proposal to coordinate various programs (i.e., Adoles cent Pregnancy Grant, Women’s Health Research Act) with the Title X program. Participants also stressed the benefits and challenges of coordinating and integrating Title X with other programs. Challenges identified by participants included not making a policy more restrictive because of the other merging policy’s guidelines, admini strative and reporting burden, technological issues and personnel barriers. Participants explained that the more seamless and less taxing you can make policy integration and the ability of personnel wo rking directly with these programs to see an individual (or progr am recipient) holisti cally and to recognize the importance of the “continuum of care ,” the easier and more effective policy integration would be. Moreover, this study has demonstrated th e negative effects th at other reproductive health-related policies exert on to Title X. For inst ance, abstinenceonly education, restrictions on abortion and em ergency contraception, religious and moral refusal clauses for health providers, parental notification/c onsent laws, school-based clinics, and the Deficit Reduction Act of 2005 (P.L. 109171, which limits the practice of drug manufactures selling contraceptives to hea lth centers, university clinics and community clinics at discount rates) all collectively dir ectly or indirectly challenge and create barriers for Title X.

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239 Practice The findings from this study suggest many implications for practice to better improve family planning services. Participan ts discussed many social and cultural factors that interfere with being able to provide services to all individuals from diverse demographic backgrounds and that interfere w ith individuals choosing to seek services. As mentioned in the Research section above, participants stressed that clinics and services must be socially and culturally sensi tive to individuals’ ne eds. One participant suggested implementing a follow-up assessmen t with individuals to examine their experiences of receiving services from the clinic and to identify what changes could be implemented to better address their needs. Other clinic barriers (clinic location, hours of operation, customer-friendliness, etc.) were discussed as playing a large role in whether individuals s eek services. Social marketing research could be conducted to asse ss and address services to better meet the needs of the clients. In a ddition, cultural competency trai ning should be routinely done with clinic personnel, including efforts to en sure personnel are fluent in the predominant language of that community. Moreover, becau se of religious moral refusal clauses, protocols should be in place and enforced which clearly outline that an additional staff member must be working during that shift and be made available to counsel and provide nondirective services to an individual. Howe ver, ideally, only those individuals who can counsel and provide services in a non-judgmental manner and who can address all of the options regarding pregnancy prevention and management should be working in family planning designated clinics.

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240 Other social factors discussed relate d to young and low-income women choosing to become pregnant, the social acceptance of unwed mothers, and a lack of taking responsibility (among males and females) for one’s choices. Education and awareness efforts should focus on the positive effects of waiting until one is ready to become pregnant, the health benefits of proper pregnancy spacing, the benefits of raising a child in a monogamous and committed relationship, and the hard work, dedication and partnership that is needed to take on the responsibility of raising a child. Participants stated individuals’ lack of knowledge and understanding regarding their bodies, the reproduction process, and other biological information served as a barrier to family planning. It is extremely important that individuals are aware of these important facts of human life and of safe sex practices. Family plan ning clinics certainly have a role in educating indi viduals on this matter, but su ch education must start in childhood. Therefore, trained health educati on teachers should deliv er age-appropriate and medically accurate information related to sexuality, reproduction and preventative practices in schools, which includes info rmation on abstinence and contraception. Similarly, as adolescents need better sexual education, family planning services should also direct efforts toward s this population. It is essent ial that confidential services are delivered to adolescents. Family pla nning clinics should str ongly encourage family participation to adolescents; however, parent al notification and c onsent practices often deter adolescent from seeking services, and ultimately negatively affect adolescents’ reproductive health. Also, the need to include men into family planning efforts was stressed. However, including men remains a challenge as participants indicated that increasing

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241 men’s involvement must not take away a ny power from women. Education efforts targeted towards men could include increas ing their knowledge on issues related to sexuality, the reproduction pr ocess, sexual dominance and coercion, and sexual abuse. Moreover, men must take greater responsibil ity in preventing unint ended pregnancies and must acknowledge and accept responsibility when an unplanned pregnancy does occur. Efforts to include males during women’s family planning visits should be promoted for those in healthy (non-abusive) relationships. In addition, vasectomy services could be more available and better advertised and utilized in Title X clinics. Future Directions Participants recalled many wonderful e xperiences and achievements that they were involved in regarding Title X and family planning in Florida. However, there was a consensus of pessimism and realism regardi ng this reproductive heal th policy topic as it is and always has been under political attac k. Participants discussed the influence of administrations and politics as serving as obsta cles that hinder their ability to promote and provide comprehensive family planni ng services through th eir administration, implementation, legislative and/or judicial roles. There was also a sense that issues related to sexuality are a cultural taboo in the U.S. and that social norms and attitudes obstruct efforts to promote education, responsibility and prevention as it relates to sexuality and family planning. These issues are not new and participants ’ recollections and experiences validate these social controversies. Overall, the oral histories added life to Title X and provided rich detail and understandings that were missing in Title X’s legislative history.

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242 With that said, the legisl ative bills that are perpet ually proposed must not be underestimated as they demonstrate the trem endous political will to support and oppose Title X. In addition, as one participant commented, those individuals who oppose family planning will continue to propos e legislation that undermines and negatively affects Title X, with the hope that if the bill in its en tirety does not get passed, perhaps one provision will pass which will bring the opposition anothe r step closer in defying women in their reproductive rights. The current political climate that surrounds Title X and other reproductive health policie s is an uncertain one. Bills on the topics of abstinence-only e ducation, parental notification/consent and abortion continue to get propos ed each legislative session. However, to date, 17 states have opted out of receiving the federal fundi ng (Title V) for abstinence-only education (Advocates for Youth, 2009). In addition, during his third day in office President Obama overturned the Global Gag Rule (prohi bited international non-governmental organizations from receiving U.S. federal funds if abortion counseling and services were provided) (National Women’s La w Center, 2009). Furthermore, a proposal similar to the one that was in the economic stimulus package, but which got cut, was entered by President Obama into his $3.6 trillion budget plan for 2010. This proposal confirms President’s Obama commitment to assuring a ll individuals have access to health care and includes providing funding to “increase access to family planning services for lowincome women” and “would allow states to expand eligibility for family planning services under Medicaid” (National Pa rtnership for Women and Families, 2009). In the first-quarter of 2009, the Gutt macher Institute published the report, Next Steps for America’s Family Planning Progr am: Leveraging the Potential of Medicaid

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243 and Title X in an Evolving Health Care System (Gold, Sonfield, Richards, & Frost, 2009). This report identifies Medicaid as providing the “core clinical care” of family planning, while Title X fills the “gaps in services and coverage” (Gold et al., p. 4, 2009). In their new framework for national family planning, the authors call for Medicaid to serve as the primary funding source for family planning and for Title X to fill in Medicaid’s gap regarding those individuals in eligible and those services that are not covered under Medicaid (Gold et al, 2009). Recommendati ons for policymakers include establishing a new publicly-subsidized framework for family planning that leverages Medicaid’s and Title X’s strengths (Gold et al, 2009). Specifi c future recommendations that this report outlines are the following (Gold et al, 2009): Maximize Medicaid and Title X synergies and leverage their strengths Provide family planning covera ge at an equal or greater level than that used for Medicaid-covered pregnancy-related care Extend examination of the Title X program including how services are used to fill in health care gaps Recognize Title X’s role in family pla nning infrastructure (operating needs, technology, clinic locations and hours, training of personnel) Leadership role of the Office of Popu lation Affairs (OPA) regarding accessing low-cost contraceptives with manufactures Cooperation with all agencies to limit is olation and facilita te coordination of efforts Maintain safety-net providers that are community-based Acknowledge and promote importance of fa mily planning as basic health care This report also recognizes that current Ti tle X assessments have relied on aggregate counts of recipients and servic es, and that this policy has not been formally examined in over a quarter of a century (Gol d et al, 2009). A call to “reinv igorate” the national family planning program requires a commitment and change to the domains of financing, infrastructure and leader ship (Gold et al, 2009).

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244 The U.S. is certainly in unprecedented tim es with the economic downfall, families and communities in great hardship, and a c ontinually failing and taxed health care infrastructure. However, with policies and programs such as Title X that serve the great functions of providing preventative, high qua lity, voluntary, and confidential family planning services to those in most need, there certainly is potential to promote health and well-being among all individuals. As Rachel Benson Gold recently stated, “the national family program is smart government at its best” (Dreweke, 2009). Conclusion Title X was enacted in 1970 and still se rves today as the only policy devoted solely to providing voluntary and confidentia l family planning services to all those in need regardless of age or economic status. Title X has been responsible for preventing unintended pregnancies, pr eventing poor birth outcomes, decreasing the need for abortions, and providing key comprehensiv e preventive services and improving the health and well-being form women, families and communities. Despite its enormous public health successes, for the last 38 y ears this policy has received considerable scrutiny and opposition, and continues to f ace many political, social and economic challenges. Through the thematic analysis on Title X’ s legislative history and oral histories with key Title X stakeholders, this multiple methodological qualitative study critically examined Title X at a broader theoretical level and merged findings with the knowledge, recollections, and perceptions of Title X st akeholders who experi ence this policy on a day-to-day basis. A comprehensive and richer understanding of the historical

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245 underpinnings and evolutions of this policy was achieved, and past and present failures and achievements were discussed. Such fi ndings are imperative, as without a firm understanding of the historical dimensions from which a policy originates, it is impossible to examine and interpret the curren t status and to make well-informed future recommendations for that policy. Implications for research, practice and policy were also provided. At the time of this writing, the U.S. faces a significant economic downturn and is considered to be in a recession. With in creasing numbers being unemployed and lacking basic resources, including health care, it is ev en more imperative that all individuals have access to voluntary, confidentia l and quality family plan ning services. Preventing unintended pregnancies and improving health among women, children and families is not only a women’s issue. Family planning aff ects all individuals and all communities and can have a positive effect on medical, economic and social arenas if the commitment and resources are there. Without a newfound politic al will in which this policy was enacted, Title X may be in jeopardy. However, with a new administration and a new commitment to personal responsibility, prevention, a nd an agenda of health care reform, the possibilities that family planning could have on the lives of women and communities is encouraging for all those who fi ght for reproductive rights.

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246 REFERENCES 42 Code of Federal Regulations (CFR) Part 59. Grants for Family Planning Services. Retrieved May 15, 2008, from http://opa.osophs.dhhs.gov/title x/ofp_regs_42cfr59_10-1-2000.pdf Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2007). New dimensions in women's health (2nd ed.). Sudbury, MA: Jone s and Bartlett Publishers. American Medical Association. (2007). Medi caid made simple. Retrieved October 1, 2008, from http://www.ama-assn.org/am a1/pub/upload/mm/16/medicaid-madesimple.pdf Armstead, C. (1995). Writing contradictions: Fe minist research and feminist writings. Women's Studies International Forum, 18 627-636. Baker, P., Shulman, B., & Tobin, E. H. (2001) Difficult crossings: Stories from building two-way streets. In M. Maralee, B. Subramaniam & L. H. Weasel (Eds.), Feminist science studies (pp. 157-172). New York, NY: Routledge. Bardach, E. (2005). A practical guide for policy analysis : The eightfold path to more effective problem solving Washington, DC: CQ Press. Bensimon, E. M., & Marshall, C. (2003). Like it or not: Feminist cr itical policy analysis matters. The Journal of Higher Education, 74 (3), 337-349. Berer, M. (2002). Health care reforms: Implications for se xual and reproductive health services. Reproductive Health Matters, 10 (20), 6-15.

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247 Birkland, T. A. (2005). An introduction to the policy pr ocess: Theories, concepts, and models of public policy making (2nd ed.). Armonk, New York: M.E. Sharpe, Inc. Boonstra, H., & Gold, R. B. (2002). Overha uling welfare: Implication for reproductive health policy in the United States. Journal of the American Medical Women's Association, 57 41-46. Brady, M. (2003). Preventing sexually transm itted infections and unintended pregnancy, and safeguarding fertility: Trip le protection needs of young women. Reproductive Health Matters, 11 (22), 134-141. Buse, K., Martin-Hilber, A., Wi dyantoro, N., & Hawkes, S. J. (2006). Management of the politics of evidence-based sexua l and reproductive health policy. Lancet, 368 2101-2103. Cates, W., & Stone, K. M. (1992). Family planning, sexually transmitted diseases and contraceptive choice: A literature update Part I. Family Planning Perspectives, 24 75-84. CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. (2006). Recommendations to improve preconception health and health care: United States. Morbidity and Mortality Weekly Report, 55 (RR06), 1-23. Centers for Disease Control a nd Prevention. (n.d.). National Ce nter for Health Statistics. VitalStats http://www.cdc.gov/nchs/vitals tats.htm [December 2007 database] Centers for Disease Control and Prevention. (1999). 10 Great public health achievements United States, 1900-1999. MMWR 48 241-243. Retrieved April 7, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

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248 Centers for Disease Contro l and Prevention. (2007a). HIV/AIDS surveillance report, 2005 Retrieved March 15, 2008, from http://www.cdc.gov/hiv/topics/sur veillance/resources/reports/ Centers for Disease Contro l and Prevention. (2007b). PRAMS and unintended pregnancy Retrieved March 15, 2008, from http://www.cdc.gov/prams/UP.htm Centers for Disease Contro l and Prevention. (2007c). STD surveillance 2006 Retrieved March 15, 2008, from http:// www.cdc.gov/std/stats/toc2006.htm Centers for Disease Contro l and Prevention. (2007d). Surveillance 2006: Women and infants Retrieved March 15, 2008, from http://www.cdc.gov/std/ stats/womenandinf.htm Centers for Disease Contro l and Prevention. (2008). Genital HPV infection: CDC fact sheet Retrieved March 15, 2008, from h ttp://www.cdc.gov/std/HPV/STDFactHPV.htm Centers for Disease Contro l and Prevention (2008). Percentage of students who ever had sexual intercourse, Florida vs United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/Questy earTable.asp?Loc2=XX&submit1=GO&cat =4&Quest=Q58&Loc=FL&Year=2007&By Var=CI&colval=2007&rowval1=Sex &rowval2=None&compval=yes&Graphval=yes&path=byHT Centers for Disease Contro l and Prevention (2008). Percentage of students who had sexual intercourse for the first time befo re age 13 years, Florida vs. United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/Questy earTable.asp?Loc2=XX&submit1=GO&cat

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249 =4&Quest=Q59&Loc=FL&Year=2007&By Var=CI&colval=2007&rowval1=Sex &rowval2=None&compval=yes&Graphval=yes&path=byHT Centers for Disease Contro l and Prevention (2008). Percentage of students who had sexual intercourse with four or more pe rsons during their life, Florida s. United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/Questy earTable.asp?Loc2=XX&submit1=GO&cat =4&Quest=Q60&Loc=FL&Year=2007&By Var=CI&colval=2007&rowval1=Sex &rowval2=None&compval=yes&Graphval=yes&path=byHT Center for Reproducti ve Rights. (2004). Title X family planning: America must continue its commitment to reproductive health Retrieved March 3, 2008, from http://www.reproductiveright s.org/pub_fac_titlex2.html Center for Reproducti ve Rights. (n.d.). Reproductive rights federal policy agenda: Advancing what's right for women and the nation Retrieved March 3, 2008, from http://www.reproductiverights.org/ pdf/federal%20policy%20agenda%201220%20w_logo.pdf Clarke, A. E. (1990). Controversy and development of repr oductive sciences. Social Problems, 37 (1), 18-37. Cochran, C. E., Mayer, L. C., Carr, T. R., & Cayer, N. J. (1999). American public policy: An introduction New York, NY: St. Martin's Press. Cochran, C. L., & Malone, E. F. (1995). Public policy: Perspectives and choices New York, NY: McGraw-Hill. Collins, P. H. (2000). Black feminist thought (2nd ed.). New York, NY: Routledge.

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250 Collins, T. (2005). Health policy analysis: A simple tool for policy makers. Public Health, 199 192-196. Congressional Information Service (Volum es 1970-1989). Retrieved from the Lawton Chiles Legal Information Center, Fredric G. Levin College of Law, University of Florida. Congressional Research Repor ts for the People. (2008). Title X (Public Health Service Act) Family Planning Program Retrieved September 4, 2008, from http://opencrs.cdt.org/document/RL33644 D'Angelo, D., Williams, M., Morrow, B., Cox, S., Harris, N., Harris on, L., et al. (2007). Preconception and interconception health status of women who recently gave birth to a live-born infant: Pregnanc y Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. Morbidity and Mortality Weekly Report, 56 (SS10), 1-35. Dailard, C. (1999). Title X family planning clin ics confront escalati ng costs, increasing needs. The Guttmacher Report on Public Policy, 2 (2), 1-3. Dailard, C. (2001). Challenges facing fa mily planning clinics and Title X. The Guttmacher Report on Public Policy, 4 (2), 8-11. Davey, M. (November 22, 2007). Big rise in cost of birth control on campuses The New York Times Retrieved February 28, 2008, from http://www.nytimes.com/2007/11/22/health /22contraceptives.html?pagewanted=1 &_r=1 Davis, C., Back, K., & MacLean, K. (1977). Oral history: Form tape to type Chicago, IL: American Library Association.

PAGE 264

251 Davis, K., & Blake, J. (1956). Social stru cture and fertility: An analytic framework. Economic Development and Cultural Change, 4 211-235. Deficit Reduction Act of 2005. Pub. L. No. 109-171, 120 Stat. 4 (2005). Dreweke, J. (February 24, 2009). 1.94 million unintended pregnancies and 810,000 abortions are prevented each year by pub licly funded family planning services Guttmacher Institute: Media Center. Dunn, W. (1981). Public policy Analysis: An introduction. Englewood Cliffs, NJ: Prentice-Hall. Dunne, E., Unger, E., Sternberg, M., McQuillia n, G., Swan, D., Patel, S., et al. (2007). Prevalence of HPV infection among females in the United States. Journal of the American Medical Association, 297 (8), 813-819. Dye, T.R. (1992). Understanding public policy (7th ed.). Englewood Cliffs, N.J.: Prentice Hall. Edwards, R.C. (n.d.). Researching legislative history Retrieved September 2, 2008, from http://www.ilga.gov/commission/lrb/lrbres.htm Eisenstadt v. Baird, 405 U.S. 438 (1972). Elekonich, M. (2001). Contesting territories: Female-female aggression and the song sparrow. In M. Maralee, B. Subr amaniam & L. H. Weasel (Eds.), Feminist science studies (pp. 97-105). New York, NY: Routledge. Emanuel, E. J., Crouch, R. A., Arras, J. D., Moreno, J. D., & Grady, C. (2003). Ethical and regulatory aspects of clinical research: Readings and commentary Baltimore, MD: John Hopkins University Press.

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252 Families USA. (2003). Who's uninsured in Florida and why ? Retrieved September 3, 2008, from http://www.familiesusa.org/asset s/pdfs/the-uninsured-state-factsheetnov2003/Uninsured-in-Florida.pdf Family Planning Services and Population Research Act of 1970, Pub. L. No. 91-572, § 1, 84 Stat. 1504 (1970). Finer, L. B., Darroch, J. E., & Frost, J. J. (2002). U.S. agencies providing publicly funded contraceptive services in 1999. Perspectives on Sexual and Reproductive Health, 34 (1), 15-24. Finer, L. B., & Henshaw, S. K. (2006). Disp arities in rates of uni ntended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38 (2), 90-96. Florida Department of Health. (2008). Family planning services Retrieved October 1, 2008, from http://www.doh.state.fl.us /Family/fchdescription.html Frost, J. J., Finer, L. B., & Tapales, A. (2008). The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. Journal of Health Care for the Poor and Underserved, 19 (3), 778-796. Gbrich, C. (1999). Qualitative research in health: An introduction. Thousand Oaks, CA: Sage Publications, Inc. Germain, A. (2004). Playing pol itics with women's lives. Science, 305 17. Gold, R. B. (2001). Title X: Th ree decades of accomplishments. The Guttmacher Report on Public Policy, 4 (1), 5-8. Gold, R. B. (2002). Nowhere but up: Rising costs for Title X clinics. The Guttmacher Report on Public Policy, 5 (5), 6-9.

PAGE 266

253 Gold, R. B., Sonfield, A., Richards, C. L., & Frost, J. J. (2009). Next steps for America's family planning program: Leveraging the pot ential of Medicaid and Title X in an evolving health care system. New York, NY: Guttmacher Institute. Gottfried, H., & Reese, L. (2003). Gender, policy, politics, and work: Feminist comparative and transnational research. Review of Policy Research, 20 (1), 3-20. GPO Access. (2008a). Congressional Record Index (CRI): Main page/search Retrieved August 18, 2008, from http://www .gpoaccess.gov/cri/index.html GPO Access. (2008b). Congressional Record: Main page Retrieved August 18, 2008, from http://www.gpoaccess.gov/crecord/index.html Griswold v. Connecticut 381 U.S. 479 (1965). Gruskin, S. (2004). Stalled on the road to reproductive health. American Journal of Public Health, 94 (8), 1297. Guttmacher Institute. (2006). Women in need of contracep tive service and supplies, 2004 Retrieved April 8, 2008, from http:// www.guttmacher.org/pubs/win/win2004.pdf Harding, S. (1991). Whose science? Whose knowledge?: Thinking from women's lives. Ithica, NY: Cornell University Press. Harding, S. (Ed.). (1987). Feminism and methodology Milton Keynes and Indiana: Open University and Indiana University Press. Hawkesworth, M. (1994). Policy stud ies within a feminist frame. Policy Sciences, 27 (23), 97-118. Heineman, R. A., Bluhm, W. T., Pe terson, S. A., & Kearny, E. N. (1990). The work of the policy analyst Chatham, New Jersey: Chatham House Publishers, Inc.

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254 Henderson, T. M. (2005). Medicaid topics: State-by-state compar isons administrative costs. Washington, DC: American Acad emy of Family Physicians State Government Relations. Retrieved March 24, 2009, from http://www.aafp.org/online/etc/medialib/ aafp_org/documents/policy/state/medicai d-adm-costs.Par.0001.File.tmp/stateadvo cacy_MedicaidAdministrativeCosts.pdf hooks, b. (1993). The significance of femi nism. In G. B. N. Gayle (Ed.), Sociology: An introduction From the classi cs to contemporary feminism (pp. 400-418). Toronto, ON: Oxford University Press. Huezo, C., & Diaz, S. (1993). Quality of care in family planning: Clients' rights and providers' needs. Advances in Contraception, 9 (2), 129-139. Institute of Medicine. (1988). The future of public health Washington, D.C.: National Academy Press. Institute of Medicine. (1995). Consequences of unintended pregnancy. In S.S. Brown & L. Eisenberg (Eds.), The best intentions: Uninte nded pregnancy and the wellbeing of children and families (pp. 50-90). Washington, D.C.: National Academy Press. Jarrett, P., & Nyberg, C. (2008). Federal legislative history Retrieved August 28, 2008, from http://lib.law.washingt on.edu/ref/fedlegishist.html Henry J. Kaiser Family Foundation & Health Research and Educational Trust. (2007). 2007 Employer health benefits survey Retrieved April 17, 2008, from http://www.kff.org/insu rance/7672/upload/76723.pdf

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255 Kanenberg, H. E. (2007). A feminist comparative policy ana lysis of the State Children's Health Insurance Program: California and Texas. University of Houston, Houston, Texas. Karger, H. J., & Stoesz, D. (1998). American social welfare policy: A pluralistic approach (3rd ed.). New York, NY: Longman. Kraft, M. E. (1994). Population policy. In S. S. Nagel (Ed.), Encyclopedia of Policy Studies (2nd ed., pp. 617-642). New Yor k, NY: Marcel Dekker, Inc. Krieger, N., & Fee, E. (1994). Man-made me dicine and women's health: The biopolitics of sex/gender and race/ethnicity. International Journal of Health Services, 24 (2), 265-283. Lane, S. D. (1994). From population control to reproductive health: An emerging policy agenda. Social Sciences Medicine, 39 (9), 1303-1314. LexisNexis Congressional. (2009). Legislative histories, bills and laws Retrieved February 2, 2009, from LexisNexis Congressional database. LexisNexis Congressional. (2008). LexisNexis Congressional: Overview Retrieved September 3, 2008, from LexisNexis Congressional database. Litwack, H. (2006). Research guide: Federal legislative history Retrieved August 25, 2008, from http://www.nesl.edu/r esearch/RSGUIDES/WEB3.HTM Longest, B. B. J. (1998). Health policy making in the United States Chicago, IL: Health Administration Press. Maine State Law and Legisla tive Reference Library. (2008). Compiling a legislative history Retrieved September 2, 2008, from http://www.state.me.us./eg is/lawlib/leghist.htm

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256 Marshall, C. (1997). Feminist critical pol icy analysis: 1. A persp ective from primary and secondary schooling Bristol, PA: Falmer Press, Taylor & Francis Inc. Marshall, C. (2000). Policy discourse analysis: Negotia ting gender equity. Journal of Education Policy, 15 (2), 125-156. Marshall, C., & Rossman, G. B. (1989). Designing qualitative research Newbury Park, CA: SAGE Public ations, Inc. Mazur, A. G. (2002). Theorizing femini st policy. In S.S.E. Meehan. (Ed.), Equality politics and gender London: Sage. McFarlane, D. R., & Meier, K. J. (2001). The politics of fertility control: Family planning and abortion policies in the American states Washington, DC: CQ Press. McKinney, R. J., & Sweet, E. A. (2001). Federal legislative history research: A practitioner's guide to comp iling the documents and sifting for legislative intent Retrieved August 25, 2008, from h ttp://www.llsdc.org/fed-leg-hist/ McPhail, B. (2003). A feminist policy anal ysis framework: Through a gendered lens. The Social Policy Journal, 2 (2/3), 39-61. Mosher, W. D., Martinez, G. M., Chandra, A., Abma, J. C., & Wilson, S. J. (2004). Use of contraception and use of family pla nning services in the United States: 19822002. Vital and Health Statistics No. 350 December 10, 2004. U.S. Department of Health and Human Services, Center s for Disease Control and Prevention, National Center for Health Statistics. Mottl-Santiago, J. (2002). Women's public health policy in the 21st century. Journal of Midwifery & Women's Health, 47 228-238.

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257 Munch, S. (2006). The women's health movement: Making policy, 1970-1995. Social Work in Health Care, 43 (1), 17-32. National Center for Health Statistics. (2006). Health, United States, 2006: With chartbook on trends in the health of Americans Retrieved March 2, 2008, from http://www.cdc.gov/nchs/data/hus/hus06.pdf#027 National Partnership for Women and Fam ilies. (February 27, 2009). Obama proposes $3.6T spending plan; Includes option to e xpand Medicaid family planning. Daily Women's Health Policy Report. National Women's Law Center. (2009). Obama overturns global gag rule. Retrieved March 1, 2009, from http://www.womens take.org/2009/01/breaking-news-obamaoverturns-global-gag-rule.html Nestor, B. (1982). Public funding of contraceptive services, 1980-1982. Family Planning Perspectives, 14 (4), 198-203. Neuman, W. L. (2003a). Chapter 4: The meanings of methodology. In Social Science Research Methods: Qualitative and Quantitative Approaches (pp. 68-94). Boston, MA: Allyn and Bacon. Neuman, W. L. (2003b). Chapter 6: Qualitativ e and quantitative research designs. In Social Research Methods: Qualitative and Quantitative Approaches (5th ed., pp. 137-168). Boston, MA: Allyn and Bacon. Neuman, W. L. (2003c). Chapter 8: Qu alitative and quantitative sampling. In Social Research Methods: Qualitative and Quantitative Approaches (5th ed., pp. 210236). Boston, MA: Allyn and Bacon.

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258 Neuman, W. L. (2003d). Chapter 10: Survey research. In Social Research Methods: Qualitative and Quantitative Approaches (5th ed., pp. 263-307). Boston, MA: Allyn and Bacon. Neuman, W. L. (2003e). Chapter 15: Analysis of qualitative data. In Social Research Methods: Qualitative and Quantitative Approaches (5th ed., pp. 438-467). Boston, MA: Allyn and Bacon. Nielsen, J. M. (Ed.). (1990). Feminist research methods: Exemplary readings in the social sciences Boulder, CO: Westview Press. Office of Populati on Affairs. (2001). Program guidelines for proj ect grants for family planning services Retrieved August 25, 2008, from http://www.hhs.gov/opa/familyplanning /toolsdocs/2001_ofp_guidelines_complete .pdf Office of Populati on Affairs. (2008). Title X Family Planning Program Retrieved August 25, 2008, from http://www.hhs.gov/opa/pubs/downloa d_pubs/titlex_fpp_fact_sheet_pdf.pdf Office of Populati on Affairs. (n.d.). Family planning Retrieved January 15, 2008, from http://www.hhs.gov/opa/familyplanning/index.html Parental Notification Act of 1998, H.R. 4721, 105th Cong. (1998). Patton, C. V., & Sawicki, D. S. (1986). Basic methods of policy analysis and planning Englewood Cliffs, New Je rsey: Prentice-Hall. PBS Online. (2001). People & events: Ant hony Comstock's "Chasity" Laws. Retrieved March 2, 2008, from http://www.pbs.org/wgbh/amex/pil l/peopleevents/e_comstock.html

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259 Personal Responsibility and Work Opportuni ty Reconciliation Act of 1996, Pub. L. No. 104-193, 110 Stat. 2105 (1996). Peters, B. G. (1999). American public policy: Promise and performance Chappaqua, N.Y.: Chatham House/Seven Rivers. QSR International Pty Ltd. (2008), NVivo qualita tive data analysis software, Version 8. Ranji, U. R. (2005). Reproductive health care for women: Coverage, access and financing Retrieved March 4, 2008, from http://www.kaiseredu.org/tutori als_index.asp#WomensHealth1 Reinharz, S. (1992). Feminist methods in social research New York, NY: Oxford University Press, Inc. Ritchie, D. A. (1995). Doing oral history New York, NY: Twayne Publishers. Rixecker, S. S. (1994). Expanding the discursi ve context of policy design: A matter of feminist standpoint epistemology. Policy Sciences, 27 119-142. RTI International. (November 2006). Family planning annual report: 2005 National summary Research Triangle Park, NC.: RTI. Ruzek, S. B. (1993). Towards a more inclusive model of women's health. American Journal of Public Health, 83 6-8. Salganicoff, A. (2007). Women's health po licy: Are the times really a-changing? Women's Health Issues, 17 274-276. Salganicoff, A. (2008). Women's health policy: Coverage and access to care Retrieved March 2, 2008, from http://www.kaiseredu.or g/tutorials/nonelde rly/player.html

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260 San Diego State University. (2007). Researching U.S. public polic y: Tracing a legislative and regulatory history Retrieved August 25, 2008, from http://infodome.sdsu.edu/reser ach/guides/gov/uspolicy.shtml Sappenfield, W. (2007). Prevalence of current contra ception use among non-pregnant 18-44 year old women, at-risk of pregnancy, by state, Behavioral Risk Factor Surveillance System, 2002 and 2004 Florida Department of Health. Unpublished data. Saulnier, C. F. (1996). Feminist theories and social work: Approaches and applications New York, NY: The Haworth Press, Inc. Schneider, A. L., & Ingram, H. (1997). Policy design for democracy Lawrence, KA: University Press of Kansas. Scott, C. M., Thurston, W. E., & Crow, B. (2002). Development of healthy public policy: Feminist analysis of conflict, collaboration and social change. Health Care for Women International, 23 530-539. Shaw, K. M. (2004). Using femi nist critical policy analys is in the realm of higher education. The Journal of Higher Education, 75 (1), 56-79. Sollom, T., Gold, R. B., & Saul, R. (1996). P ublic funding for contraceptive, sterilization and abortion services, 1994. Family Planning Perspectives, 28 (4), 166-173. Sonfield, A., Alrich, C., & Gold, R. B. (2008). Public funding for family planning, sterilization, FY 1980-2006 New York, NY: Guttmacher Institute. Sonfield, A., & Gold, R. B. (2005). Conserva tives' agenda threatens public funding for family planning. The Guttmacher Report on Public Policy, 8 (1), 4-7.

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261 Sonenstein, F. L., Punja, S., & Scarcella, C. (2004). Future directions for family planning research: A framework for Title X family planning service delivery improvement research Urban Institute. Spanier, B. (2001). Your silence will not pr otect you. In M. Maralee, B. Subramaniam & L. H. Weasel (Eds.), Feminist science studies (pp. 258-274). New York: NY: Routledge. Steinem, G. (1992). Margaret Sanger: Her cr usade to legalize birt h control spurred the movement for women's liberation. Time Magazine Retrieved March 2, 2008, from http://www.time.com/time/time 100/leaders/profile/sanger.html Steward, F. H., Shields, W. C., & Hwang, A. C. (2003). Title X: A sure-fire investment with at leas t 300% return. Contraception, 68 (1), 1. The Alan Guttmacher Institute. (1997). Title X and the U.S. family planning effort Retrieved January 15, 2008, from h ttp://www.guttmacher.org/pubs/ib16.html The Alan Guttmacher Institute. (2000). Fulfilling the promise: Public policy and U.S. family planning clinics Washington, D.C. The Alan Guttmacher Institute. (2004). U.S. teenage pregnancy sta tistics: Overall trends, trends by race and ethnicity and state-by-state information Retrieved October 1, 2008, from www.guttmacher.org/pubs/ state_pregnancy_trends.pdf The Alan Guttmacher Institute. (2006). One million new women in need of publicly funded contraception. Guttmacher Policy Review, 9 (3). The Henry J. Kaiser Family Foundation. (2007a). Medicaid's role for women Retrieved March 4, 2008, from http://www.kff .org/womenshealth/upload/7213_03.pdf

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262 The Henry J. Kaiser Family Foundation. (2007b). Women's health insurance coverage Retrieved March 4, 2008, from http://www.kff.org/wome nshealth/upload/6000_06.pdf The Library of Congress. (n.d.). Thomas: Public Laws Retrieved January 25, 2009, from http://www.thomas.gov/bss/d111/d111laws.html The Margaret Sanger Papers. (2005). Birth control organizations : American birth control league Retrieved March 2, 2008, from http://www.nyu.edu/projects/sanger/secu re/aboutms/organization_abcl.html The United Nations. (1995). Report of the Fourth World Conference on Women. Retrieved April 25 2008, from http://www.un.org/esa/gopherdata/conf/fwcw/off/a--20.en Tong, R. P. (1998). Feminist thought: A more comprehensive introduction (2nd ed.). Boulder, CO: Westview Press. Turnbull, W., & Kaeser, L. (1998). Domestic, international family planning programs at risk. The Guttmacher Report on Public Policy, 1 (1), 3-4. U.S. Census Bureau. (2000). United States -States; and Puerto Rico: GCT-PH1-R. Population, housing units, area, and dens ity (geographies ranked by total population): 2000 Retrieved September 3, 2008, from http://factfinder.census.gov/servlet/ GCTTable?_bm=n&_lang=en&mt_name=DE C_2000_SF1_U_GCTPH1R_US9S&form at=US-9S&_box_head_nbr=GCT-PH1R&ds_name=DEC_2000_SF1_U&geo_id=01000US

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263 U.S. Census Bureau. (2006). Florida Population and housing narrative profile: 2006 Retrieved September 3, 2008, from http://factfinder.census.gov/servle t/NPTable?_bm=y&-geo_id=04000US12&qr_name=ACS_2006_EST_G00_NP01&-ds_name=&-redoLog=false U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving health (2nd ed). Retrieved March 2, 2008, from http://www.healthypeople.gov/ Document/pdf/uih/2010uih.pdf Ulin, P. R., Robinson, E. T., & Tolley, E. E. (2005). Qualitative methods in public health: A field guide for applied research San Francisco: Jossey-Bass. United Nations Population Fund. (1994). Part One: Programme of Action of the International Conference on Populat ion Programme of Action of the International Conference on Population and Development Retrieved February 28, 2008, from http://www.unfpa.org/icpd/icpd_poa.htm#ch7 United Nations Populations Fund. (1995). Summary of the ICPD Programme of Action Retrieved February 28, 2008, from h ttp://www.unfpa.org/icpd/summary.htm Ursel, J. (1992). Private lives, public policy: 100 years of state intervention in the family. Toronto, Ontario, Canada: Women's Press. Venes, D. (Eds.). (1997). Tabler’s cyclope dic medical dictionar y. Philadelphia: F.A. Davis Company. Ventura, S. J., Mosher, W. D., Curtin, S. C., Abma, J. C., & Henshaw, S. (2000). Trends in pregnancies and pregnancy rates by outco me: Estimates for the United States, 1976-1996 Retrieved February 29, 2008. from http://www.cdc.gov/nchs/dat a/series/sr_21/sr21_056.pdf

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264 Walker, L. O., & Wilging, S. (2000). Rediscove ring the "M" in "MCH": Maternal health promotion after childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29 229-236. Webb, C. (1993). Feminist re search: Definitions, methodology, methods and evaluation. Journal of Advanced Nursing, 18 416-423. Weisman, C. S. (1998). Two centuries of women's health activism Paper presented at the History and Future of Women's H ealth. Retrieved April, 24, 2008, from http://www.4woman.gov/owh/ pub/history/2century.htm Weiss, C. H. (1982). Policy research in the context of diffuse decision-making. In D.B.P. Kallen et al. (Eds.), Social Science Research and Public Policy-Making (pp. 534). Windsor, England: NFER-Nelson. Wilhelm, K. (1999). Making hist ory tracing retrospective U. S. legislative histories. Journal of Government Information, 26 (5), 485-499. World Health Organization. (2008a). Disability adjusted life years (DALY) Retrieved March 3, 2008, from http://www.w ho.int/healthinfo/boddaly/en/ World Health Organization. (2008b). Family planning Retrieved March 15, 2008, from http://www.who.int/topics/family_planning/en/ Wyer, M. (2001). Over the edge: Developing fe minist frameworks in the sciences and women's studies. In M. Maralee, B. Subramaniam & L.H. Weasel (Eds.), Feminist science studies (pp. 72-80). New York, NY: Routledge.

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265 APPENDICES

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266 Appendix A. Family Planning Services and Population Research Act of 1970

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271 Appendix B. Characteristics of Feminist Social Research Advocacy of a feminist value position and perspective Rejection of sexism in assumptions concepts, and research questions Creation of empathic connections between the researcher and those he or she studies Sensitivity to how relations of gender a nd power permeate all spheres of social life Incorporation of the resear chers’ personal feelings a nd experiences in to he research process Flexibility in choosing research tech niques and crossing boundaries between academic fields Recognition of the emotional and mutual-dependence dimensions in human experience Action-oriented research that seeks to facilitate personal and society change Neuman, W.L. (2003). Social research methods: Qualitative and quantitative approaches (5th ed., pp. 88). Boston, MA: Allyn and B acon. Reprinted with permission of the publisher. (Neuman, SOCIAL RESEARCH METHODS: QUALITATV&QUANTATV, 2003. Reproduced by permission of Pearson Education, Inc.)

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272 Appendix C. The Feminist Policy Framework: Through A Gendered Lens A. Values 1. Do feminist values undergird the policy? Which feminism, which values? 2. Are value conflicts involved in the pr oblem representations either between different feminist perspectives or be tween feminist and mainstream values? B. State-Market Control 1. Are women’s unpaid labor and work of caring considered and valued or taken for granted? 2. Does the policy contain elements of social control of women? 3. Does the policy replace the patriarchal male with the patriarchal state? 4. How dose the policy mediate gender rela tionships between the state, market, and family? For instance, does the policy increase wo men’s dependence upon the state or men? C. Multiple Identities 1. How does gender in this policy interact with race/ethnicity, sexual identity, class, religion, national origin, disability or ot her identity categories? 2. Are white, middle-class, heterosexual wo men the assumed standard for all women? 3. Does the policy address the multiple identities of women? The multiple oppressions a single woman may face? D. Equality 1. Does the policy achieve gender equality ? Are there equality of results or disparate impacts? 2. Does the policy treat people differently in order to treat them equally well? Does the policy consider gender differences in order to crea te more equality? 3. If the positions of women and men were reversed, would this policy be acceptable to men? E. Special Treatment/Protection 1. Does any special treatment of wome n cause unintended or restrictive consequences? 2. Is there an implicit or explicit double standard? 3. Does being labeled different and special cause a backlash that can be used to constrain rather than to liberate women? F. Gender Neutrality 1. Does presumed gender neutrality hide th e reality of the gende red nature of the problem or solution?

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273 Appendix C. (Continued) G. Context 1. Are women clearly visible in the policy? Does the pol icy take into account the historical, legal, social, cultural, and polit ical contexts of women’s lives and lived experiences both now and in the past? 2. Is the policy defend as a traditional “women’s issue”, i.e. “pink policy?” How is a policy that is not traditionally defined as a women’s issue” still a “women’s issue”? 3. Is the male experience used as a sta ndard? Are results extr apolated from male experience and then applied to women? 4. Have the programs, policies, methodol ogies, assumptions, and theories been examined for male bias? 5. Is women’s biology treated as normal rath er than as an exception to a maledefined norm? H. Language 1. Does the language infer male dominance or female invisibility? 2. Are gendered expectations and la nguage encoded in the policy? I. Equality/Rights and Care/Responsibility 1. Is there a balance of rights and respons ibilities for women and men in this policy? 2. Does the policy sustain the pattern of men being viewed as public actors and women as private actors, or does the policy challenge this dichotomization? 3. Does the policy bring men, corporati ons, and the government into caring and responsible roles? Is responsibil ity pushed uphill and redistributed? 4. Does the policy pit the n eeds of women against the ne eds of their fetus or children? 5. Are women penalized for either their role s as wives, mothers or caregivers or their refusal to adopt these roles? J. Material/Symbolic Reform 1. Is the policy merely symbolic or dies it come with teeth? Are there provisions for funding, enforcement and evaluation? 2. Are interest groups involved in ov erseeing the policy implementation? 3. Is litigation possible to refine and expand th e law’s interpretation? 4. What is the strength of authority of the agency administering the policy? 5. Is there room to transform a symbolic reform into a material reform? How? K. Role Change and Role Equity 1. Is the goal of the policy ro le equity or role change? 2. Does the type of change proposed a ffect eth chance of successful passage?

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274 Appendix C. (Continued) L. Power Analysis 1. Are women involved in making, shaping, and implementation of the policy? In which ways were they involved? How were they included or excluded? Were the representatives of women selected by women? 2. Does the policy work to empower women? 3. Who has the power to define the problem? What are competing representations? 4. How does this policy affect the balance of power? Are there winners and loser? Is a win-win solution a possibility? M. Other 1. Is their social construction of the problem recognized? What are alternative representations of the problem? 2. Does this policy constitute backlash for previous women’s policy grains? 3. How does feminist scholarship inform the issue? McPhail, B.A. (2003). A feminist policy an alysis framework: Th rough a gendered lens. The Social Policy Journal, 2 (2/3), 39-61. Reprinted with permission of the publisher.

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275 Appendix D. Principles and Standards of the Oral History Association The Oral History Association promotes or al history as a method of gathering and preserving historical information through record ed interviews with participants in past events and ways of life. It encourages those who produce and use oral history to recognize certain principles, ri ghts, technical standards, a nd obligations for the creation and preservation of source materi al that is authentic, useful and reliable. These include obligations to the interviewee, to the profession, and to th e public, as well as mutual obligations between sponsoring or ganizations and interviewers. People with a range of affiliations and spons ors conduct oral history interviews for a variety of purposes: to creat e archival records, for individual research, for community and institutional projects, and for publicati ons and media productions. While these principles and standards pr ovide a general framework for guiding professional conduct, their application may vary according to the nature of specific or al history projects. Regardless of the purpose of the interviews, oral history should be c onducted in the spirit of critical inquiry and social responsibility and with a recognition of the interactive and subjective nature of the enterprise. Responsibility to Interviewees: 1. Interviewees should be informed of the purposes and procedures of oral history in general and of the aims and anti cipated uses of the particular projects to which they are making their contributions. 2. Interviewees should be informed of the mu tual rights in the oral history process, such as editing, access restrictions, copyrights, prior use, royalties, and the expected disposition and dissemination of all forms of the record, including the potential for electronic distribution. 3. Interviewees should be informed that they will be asked to sign a legal release. Interviews should remain conf idential until interviewees have given permission for their use. 4. Interviewers should guard against ma king promises to interviewees that the interviewers may not be able to fulfill, such as guarantees of public ation and control over the use of interviews after th ey have been made public. In all future uses, however, good faith efforts should be made to honor the spirit of the interv iewee's agreement. 5. Interviews should be conducted in accord with any prior agreements made with the interviewee, and such agreements s hould be documented for the record. 6. Interviewers should work to achieve a balance between the objec tives of the project and the perspectives of the interviewees. They should be sensitive to the diversity of social and cultural experiences and to the imp lications of race, gender, class, ethnicity, age, religion, and sexual orientation. They should encourage interviewees to respond in their own style and language and to addre ss issues that reflect their concerns.

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276 Appendix D. (Continued) Interviewers should fully explor e all appropriate areas of inqu iry with the interviewee and not be satisfied with superficial responses. 7. Interviewers should guard against possi ble exploitation of interviewees and be sensitive to the ways in which their intervie ws might be used. Interviewers must respect the rights of interviewees to refuse to discu ss certain subjects, to restrict access to the interview, or, under Guidelines extreme circumstances, even to choose anonymity. Interviewers should clearly explain these options to all interviewees. 8. Interviewers should use the best recording equipment within their means to accurately reproduce the interviewee's voi ce and, if appropriate, other sounds as well as visual images. 9. Given the rapid development of new tec hnologies, interviewees should be informed of the wide range of potentia l uses of their interviews. 10. Good faith efforts should be made to ensure th at the uses of record ings and transcripts comply with both the letter and spirit of the intervie wee's agreement. Responsibility to the Public and to the Profession: 1. Oral historians have a responsibility to maintain the highest prof essional standards in the conduct of their work and to uphold the standards of the various disciplines and professions with which they are affiliated. 2. In recognition of the importance of oral hi story to an understanding of the past and of the cost and effort involved, interviewers a nd interviewees should mutually strive to record candid information of lasting value and to make that information accessible. 3. Interviewees should be selected based on the relevance of their experiences to the subject at hand. 4. Interviewers should possess interviewing skills as well as professional competence and knowledge of the subject at hand. 5. Regardless of the specific interests of the project, in terviewers should attempt to extend the inquiry beyond the spec ific focus of the project to create as complete a record as possible for the benefit of others. 6. Interviewers should strive to prompt informative dialogue th rough challenging and perceptive inquiry. They should be grounded in the background of the persons being interviewed and, when possible, should carefu lly research appropriate documents and secondary sources related to subjects about which the interviewees can speak. 7. Interviewers should make every effort to record their interviews using the best recording equipment within their means to reproduce accurately the interviewee's voice and, if appropriate, image. They also s hould collect and record other historical documentation the interviewee may possess, incl uding still photographs, print materials, and other sound and moving image recordings, if appropriate. 8. Interviewers should provide complete documentation of their preparation and methods, including the circumst ances of the interviews. 9. Interviewers and, when possible, inte rviewees should review and evaluate their interviews, including any summaries or transcriptions made from them.

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277 Appendix D. (Continued) 10. With the permission of the interviewees, interviewers sh ould arrange to deposit their interviews in an archival repository that is capable of both preserving the interviews and eventually making them available for genera l use. Interviewers should provide basic information about the interviews, includi ng project goals, sponsorship, and funding. Preferably, interviewers shoul d work with repositories befo re conducting the interviews to determine necessary legal Guidelines arrangements. If interviewers arrange to retain first use of the interviews, it should be only for a reasonable time before public use. 11. Interviewers should be sens itive to the communities from which they have collected oral histories, taking care not to reinforce thoughtless st ereotypes nor to bring undue notoriety to them. Interviewers should take every effort to make the interviews accessible to the communities. 12. Oral history interviews should be used and cited with the same care and standards applied to other historical sources. Users have a responsibility to re tain the integrity of the interviewee's voice, neither misrepresenting the interviewee's words nor taking them out of context. 13. Sources of funding or sponsorship of oral history projects shoul d be made public in all exhibits, media presentations, or public ations that result from the projects. 14. Interviewers and oral history programs should conscientiously consider how they might share with interviewees and their communities the rewards and recognition that might result from their work. Responsibility for Sponsoring and Archival Institutions: 1. Institutions sponsoring and maintaining oral history archives have a responsibility to interviewees, interviewers, the profession, and the public to maintain the highest technical, professional, and ethical standards in the creation and archival preservation of oral history interviews and related materials. 2. Subject to conditions that interviewees set, sponsori ng institutions (or individual collectors) have an obligation to : prepare and preserve easily usable records; keep abreast of rapidly developing technol ogies for preservation and di ssemination; keep accurate records of the creation and processing of each interview; and iden tify, index, and catalog interviews. 3. Sponsoring institutions and archives s hould make known through a variety of means, including electronic modes of distribution, the existence of interviews open for research. 4. Within the parameters of their missions and resources, archival institutions should collect interviews generated by independent re searchers and assist interviewers with the necessary legal agreements. 5. Sponsoring institutions should train inte rviewers. Such training should: provide them basic instruction in how to record high fidelity interviews and, if appropriate, other sound and moving image recordings; explain the obj ectives of the program to them; inform them of all ethical and legal considerations governing an in terview; and make clear to interviewers what their obligations are to the program and to the interviewees.

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278 Appendix D. (Continued) 6. Interviewers and interviewees should receive appropriate acknowledgment for their work in all forms of citation or usage. 7. Archives should make good faith efforts to ensure that uses of recordings and transcripts, especially those that employ ne w technologies, comply with both the letter and spirit of the interviewee's agreement. Oral History Association. (2008). Principles and standards of the Oral History Association Retrieved February 27, 2009, from http://www.oralhistory.org/network/mw/i ndex.php/Evaluation_Guide. Reprinted with permission from the publisher.

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279 Appendix E. Oral History Evaluation Guidelines Program/Project Guidelines Purposes and Objectives a. Are the purposes clearly se t forth? How realistic are they? b. What factors demonstrate a significant need for the project? c. What is the research desi gn? How clear and realistic is it? d. Are the terms, conditions, and objectives of funding clearly made known to judge the potential effect of such funding on the scholarly integrity of th e project? Is the allocation of funds adequate to allow the project goals to be accomplished? e. How do institutional relationships affect the purposes and objectives? Selection of Recording Equipment a. Should the interview be recorded on sound or visual recording equipment? b. Are the best possible recording equipmen t and media available within one's budget being used? c. Are interviews recorded on a medium th at meets archival preservation standards? d. How well has the interviewer master ed use of the equipment upon which the interview will be recorded? Selection of Interviewers and Interviewees a. In what ways are the interviewers and interviewees appropriate (or inappropriate) to the purposes and objectives? b. What are the significant omissions and why were they omitted? Records and Provenance a. What are the policies and provisions for maintaining a record of the provenance of interviews? Are they adequa te? What can be done to improve them? b. How are records, policies, and procedures made known to interviewers, interviewees, staff, and users? c. How does the system of records enha nce the usefulness of the interviews and safeguard the rights of those involved? Availability of Materials a. How accurate and specific is the publicizing of the interviews? b. How is information about interviews dire cted to likely users? Have new media and electronic methods of distribution been considered to publicize materials and make them available?

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280 Appendix E. (Continued) c. How have the interviews been used? Finding Aids a. What is the overall design for finding aids? Are the finding aids adequate and appropriate? b. How available are the finding aids? c. Have new technologies been used to develop the most effective finding aids? Management, Qualifications, and Training a. How effective is the mana gement of the program/project? b. What are the provisions for supervision and staff review? c. What are the qualifi cations for staff positions? d. What are the provisions for systematic and effective training? e. What improvements could be made in the management of the program/project? Ethical/Legal Guidelines What procedures are followed to assure th at interviewers/programs recognize and honor their responsibility to the intervie wees? Specifically, what procedures are used to assure that: a. The interviewees are made fully aware of the goals and objectives of the oral history program/project? b. The interviewees are made fully aware of the various stages of the program/project and the nature of th eir participation at each stage? c. The interviewees are given the opport unity to respond to ques tions as freely as possible and are not subjected to st ereotyped assumptions ba sed on race, ethnicity, gender, class, or any ot her social/cultural characteristic? d. The interviewees understand their rights to refuse to discu ss certain subjects, to seal portions of the interviews, or in extr emely sensitive circumstances even to choose to remain anonymous? e. The interviewees are fully informed about the potential uses of th e material, including deposit of the interviews in a repositor y, publication in all forms of print or electronic media, including the In ternet or other emerging technolog ies, and all forms of public programming? f. The interviewees are provided a full and easily comprehensible explanation of their legal rights before be ing asked to sign a contract or d eed of gift tran sferring rights, title, and interest in the tape(s) and transcript(s) to an admi nistering authority or individual? g. Care is taken so that th e distribution and use of the material complies with the letter and spirit of the interviewees' agreements? h. All prior agreements made w ith the interviewees are honored?

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281 Appendix E. (Continued) i. The interviewees are fully informed about the potential for and disposition of royalties that might accrue from the use of their interviews, including all forms of public programming? j. The interviews and any other related materials will remain confidential until the interviewees have released their contents? What procedures are followed to assure th at interviewers/programs recognize and honor their responsibilities to the professi on? Specifically, what procedures assure that: a. The interviewer has cons idered the potential for public programming and research use of the interviews and has endeavored to prevent any exploita tion of or harm to interviewees? b. The interviewer is well trained to conduc t the interview in a pr ofessional manner, including the use of appropr iate recording equipment and media? c. The interviewer is well grounded in the background of the subject( s) to be discussed? d. The interview will be conducted in a spirit of critical inquiry and that efforts will be made to provide as comple te a historical record as possible? e. The interviewees are selected based on th e relevance of their experience to the subject at hand and that an appropriate crosssection of interviewees is selected for any particular project? f. The interview materials, including reco rdings, transcripts, re levant photographic, moving image, and sound documents as well as agreements a nd documentation of the interview process, will be placed in a repository after a reasonable period of time, subject to the agreements made with the interviewee and that the repository will administer their use in accordance with those agreements? g. The methodologies of the program/project, as well as its goals and objectives, are available for the general public to evaluate? h. The interview materials have been properly cataloged, in cluding appropriate acknowledgment and credit to the intervie wer, and that their avai lability for research use is made known? What procedures are followed to assure that interviewers and programs are aware of their mutual responsibilities and obli gations? Specifically, what procedures are followed to assure that: a. Interviewers are made aware of the progr am goals and are fully informed of ethical and legal considerations? b. Interviewers are fully informed of all the tasks they are expected to complete in an oral history project? c. Interviewers are made fully aware of their obligations to the oral history program/sponsoring institution, regard less of their own pers onal interest in a program/project? d. Programs/sponsoring instit utions treat their interviewers equita bly by providing for

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282 Appendix E. (Continued) appropriate compensation, acknowledging all products resulting from their work, and supporting fieldwork pract ices consistent with profession al standards whenever there is a conflict between the parties to the interview? e. Interviewers are fully inform ed of their legal right s and of their responsibilities to both the interviewee and to the sponsoring institution? What procedures are followed to assure that interviewers and programs recognize and honor their responsibilities to th e community/public? Specifically, what procedures assure that: a. The oral history materials and all work s created from them will be available and accessible to the community that participated in the project? b. Sources of extramural funding and sponsorsh ip are clearly noted for each interview of project? c. The interviewers and project endea vor not to impose their own values on the community being studied? d. The tapes and transcripts will not be used unethically? Recording Preservation Guidelines Recognizing the significance of the recording for historical and cultural analysis and the potential uses of oral history intervie ws in nonprint media, what procedures are followed to assure that: a. Appropriate care and stor age of the original recordings begins immediatel y after their creation? b. The original recordings are duplicated and stored according to accepted archival standards [i.e. stored in closed boxes in a cool, dry, dust-free environment] c. Original recordings are re-duplicated onto the best preservation media before significant deterioration occurs? d. Every effort is made in duplicating tape s to preserve a faithf ul facsimile of the interviewee's voice? e. All transcribing, auditing, and other uses are done from a duplicate, not the original recording? Tape/Transcript Processing Guidelines Information about the Participants: a. Are the names of both interviewer and interviewee clearly indicated on the tape/abstract/transcript and in catalog materials? b. Is there adequate biographical informa tion about both interviewe r and interviewee? Where can it be found?

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283 Appendix E. (Continued) Interview Information a. Are the tapes, transcripts, time indices, abstracts, and other materials presented for use identified as to the program/project of which they are a part? b. Are the date and place of the interview indicated on the tape, transcript, time index, and abstract and in appropriate catalog material? c. Are there interviewers' statements about the preparation for or circumstances of the interviews? Where? Are they generally av ailable to researchers? How are the rights of the interviewees protected ag ainst improper use of such commentaries? d. Are there records of contracts between the program and the interviewee? How detailed are they? Are they available to researchers? If so, with what safeguards for individual rights and privacy? Interview Tape Information a. Is the complete original tape preser ved? Are there one or more duplicate copies? b. If the original or any duplicate has been edited, rearranged, cut, or spliced in any way, is there a record of that action, in cluding by whom, when, and for what purposes the action was taken? c. Do the tape label and appropriate catal og materials show the r ecording speed, level, and length of the interview? If videot aped, do the tape label and appropriate catalog information show the format (e.g., U-Matic, VHS, 8mm, etc.) and scanning system and clearly indicate the tracks on whic h the audio and time code have been recorded? d. In the absence of transcripts, are there suitable finding aids to give users access to information on the tapes? What form do they take? Is there a r ecord of who prepared these finding aids? e. Are researchers permitted to listen to or view the tapes? Are there any restrictions on the use of the tapes? Interview Transcript Information a. Is the transcript an accurate record of th e tape? Is a careful record kept of each step of processing the transcript, including who transcribed, audited, edited, retyped, and proofread the transcripts in final copy? b. Are the nature and extent of changes in the transcript from the original tape made known to the user? c. What finding aids have been prepared for the transcript? Are they suitable and adequate? How could they be improved? d. Are there any restrictions on access to or use of the transcripts? Are they clearly noted? e. Are there any photo materials or other s upporting documents for th e interview? Do they enhance and supplement the text? f. If videotaped, does the transcript cont ain time references and annotation describing the complementary visuals on the videotape?

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284 Appendix E. (Continued) Interview Content Guidelines Does the content of each interview and the cumulative content of the whole collection contribute to accomplishing the objec tives of the program/project? a. In what particulars does each interview or the whole collection succeed or fall short of the objectives of the project or program? b. Do audio and visual tapes in the colle ction avoid redundancy and supplement one another in inte rview content and focus? In what ways does the program/project contribute to hist orical understanding? a. In what particulars does each interview or the whole collection succeed or fall short in making such a contribution? b. To what extent does the material add fresh information, fill gaps in the existing record, and/or provide fresh insights and perspectives? c. To what extent is the information reli able and valid? Is it eyewitness or hearsay evidence? How well and in what manner does it meet internal a nd external tests of corroboration, consistency, and explication of contradictions? d. What is the relationship of the interview information to existing documentation and historiography? e. How does the texture of the interview im part detail, richness, and flavor to the historical record? f. What is the nature of the informati on contributed? Is it facts, perceptions, interpretations, judgments, or attitudes, and how doe s each contribute to understanding? g. Are the scope, volume, and represen tativeness of the population interviewed appropriate and sufficien t to the purpose? Is there enough te stimony to validate the evidence without passing the point of diminishing returns? How appropriate is the quantity to the purposes of the study? h. How do the form and structure of the in terviews contribute to making the content understandable? i. To what extent does the audio and/or video recording capture unique sound and visual information? j. Do the visual and other sound elements complement and/or supplement the verbal information? Has the interview captured processes, objects, or ot her individuals in the visual and sound environment? Interview Conduct Guidelines Use of Other Sources a. Is the oral history tec hnique the best way to acquire th e information? If not, what other sources exist? Has the interviewer used them a nd sought to preser ve them if

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285 Appendix E. (Continued) necessary? b. Has the interviewer made an effort to consult other releva nt oral histories? c. Is the interview technique a valu able way to supplement existing sources? d. Do videotaped interviews complement, not duplicate, existing sti ll or moving visual images? Interviewer Preparation a. Is the interviewer well inform ed about the subject s under discussion? b. Are the primary and secondary sources us ed to prepare for th e interview adequate? c. Has the interviewer mastered the use of appropriate recordi ng equipment and the field-recording techniques th at insure a high-fidelity recording? Interviewee Selection and Orientation a. Does the interviewee seem appr opriate to the subjects discussed? b. Does the interviewee understand and respond to the interview purposes? c. Has the interviewee prepared for th e interview and assisted in the process? d. If a group interview, have compositi on and group dynamics been considered in selecting participants? Interviewer-Interviewee Relations a. Do interviewer and interviewee collaborate with each other toward interview objectives? b. Is there a balance between empathy a nd analytical judgment in the interview? c. If videotaped, is the interviewer/inte rviewee relationship maintained despite the presence of a technical crew? Do the technical personnel understand how a videotaped oral history inte rview differs from a scripted production? Technique and Adaptive Skills a. In what ways does the interview show th at the interviewer has used skills appropriate to: the interview ee's condition (health, memory, metal alertness, ability to communicate, time schedule, etc.) and the interview location and conditions (disruptions and interruptions, eq uipment problems, extraneous participants, background noises, etc.)? b. What evidence is there that the interviewer has: thoroughly explored pertinent lines of thought? followed up on significant clue s? Made an effort to identify sources of information? Employed critical ch allenges when needed? T horoughly explored the potential of the visual environment, if videotaped? c. Has the program/project used recording equipment and media that are appropriate for the purposes of the work and potential nonprint as well as print uses of the material?

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286 Appendix E. (Continued) Are the recordings of the highest a ppropriate technical quality? How could they be improved? d. If videotaped, are lighting, compositi on, camera work, and sound of the highest appropriate technical quality? e. In the balance between content and t echnical quality, is the technical quality good without subordina ting the interview process? Perspective a. Do the biases of the interviewer interf ere with or influence the responses of the interviewee? b. What information is available that may inform the users of any prior or separate relationship between th e interviewer and interviewee? Historical Contribution a. Does the interviewer pursue the inquiry with histor ical integrity? b. Do other purposes being served by th e interview enrich or diminish quality? c. What does the interview contribute to th e larger context of hist orical knowledge and understanding? Independent/Unaffiliated Researcher Guidelines Creation and Use of Interviews a. Has the independent/unaffiliated resear cher followed the guidelines for obtaining interviews as suggested in the Program/Project Guideline section? b. Have proper citation and documentati on been provided in wo rks created (books, articles, audio-visual productions, or other public presenta tions) to inform users of the work about the interviews used and the permanent locati on of the interviews? c. Do works created include an explanation of the interview projec t, including editorial procedures? d. Has the independent/unaffiliated researcher arranged to deposit the works created in an appropriate repository? Transfer of Interviews to Archival Repository a. Has the independent/unaffiliated research er properly obtained the agreement of the repository before making representa tions about the dispositi on of the interviews? b. Is the transfer consistent with agreements or understandin gs with interviewees? Were legal agreements obtained from interviewees? c. Has the researcher provided the repository with adequate descrip tions of the creation of the interviews and the project? d. What is the technical quality of the recorded interviews? Are the interviews

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287 Appendix E. (Continued) transcribed, abstracted, or i ndexed, and, if so, wh at is the quality? Oral History Association. (2008). Oral history evaluation guidelines Retrieved April 11, 2007, from http://www.oralhistory.org/net work/mw/index.php/Evaluation_Guide Reprinted with permission from the publisher.

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288 Appendix F. Sample Oral History Project Letter December 1, 2008 Dear Dr./Mr./Ms. ______________ I am a Doctoral Candidate in the Department of Community and Family Health, College of Public Health, University of South Florida (USF). For my dissertation, I am conducting a study that aims to examine how the Title X Family Planning Program (Public Law 91-572) has evolved from 1970 to today and to understand some of the political, economical and social factors that this policy has faced over the years. I am contacting you as you have b een identified as having a w ealth of information and experience in working with Florida’s family planning and Title X programs. Particularly, I am interested in speaking with past/present Title X key stakeholders, like yourself, and collecting through audio-recordings of oral histories, some of your experiences and recollections in working with Title X at a state-leve l. If you are willing to participate in this study, I would like to sit down with you for about 2 hours to ask you some questions, at a time and lo cation that is convenient for you. I have attached a draft list of questions to this letter that I will be asking you in order for you to get a sense of the scope of this study. These questions are just a sample of the types of questions I would ask you and you do not have to answ er any question(s) that you are not comfortable answering. In addition, I am in terested in hearing any of your thoughts and stories regarding family planning and Title X that may not be captured in my questions. Also with your permission, I would like to audio-record our inte rview and archive the videotape with the Special Colle ctions department at the USF Library, Tampa, Florida. Because our interview is going to be record ed and used for scholarly and publication purposes, I would need for both of us to sign a Legal Release Form, that documents that you understand that our intervie w will be available for public viewing from the Special Collections at USF and that I may publish some of the findings from interviewing past/present Title X key stakeholders. Howe ver, if you prefer to not have your name published, I can omit your name in any of the fi ndings or quotations in the publications to ensure your confidentiality and anonymity in the publica tions. This document is a standard form when conducti ng Oral Histories, and if you have any questions about the form please do not hesitate to ask.

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289 Appendix F. (Continued) I believe that you have some memorable and fa scinating experiences and stories to share regarding your work in family planning and Title X programs in the state of Florida. This study serves as a great hist orical source to collect and shar e your stories. Please feel free to ask me any questions that you may ha ve. You can reach me anytime on my cell phone at (813) 777-3255 or by email at cvamos@health.usf.edu I have also included the name, phone number and email of my major professor if would like to ask her any questions as well. I look forward to hearing from you and to le arn more about your e xperiences working in public health and family planning. Sincerely, Cheryl A. Vamos, MPH Doctoral Candidate Department of Community and Family Health College of Public Health University of South Florida Work Phone: (813) 974-0420 Work Fax: (813) 974-5172 Cellular Phone: (813) 777-3255 Email: cvamos@health.usf.edu Major Advisor: Ellen M. Daley, PhD Assistant Professor Department of Community and Family Health College of Public Health University of South Florida Phone: (813) 974-8518 Fax: (813) 974-5172 Email: edaley@health.usf.edu

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290 Appendix G. Informed Consent for Oral Histories Informed Consent to Participate in Research Information to Consider Before Taking Part in this Research Study IRB Study # _______________ Researchers at the University of South Flor ida (USF) study many topi cs. To do this, we need the help of people who agree to take pa rt in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: Oral Histories with Key Titl e X Stakeholders in Florida The person who is in charge of this resear ch study is Cheryl Vamos, MPH, Doctoral Candidate. This person is called the Principal Investigator. However, other research staff may be involved and can act on be half of the person in charge. The research will be done at the University of South Florida and the oral history will be collected at a location th at is convenient to you. Purpose of the Study The purpose of this study is to Explore individuals’ experiences, recolle ctions and perceptio ns regarding the Title X Family Planning Program. You are being asked to participate in th is study because you have been identified as having information and e xperiences that relate to the Title X Family Planning Program in Florida. This study is being conducted as part of a dissertation. Study Procedures If you take part in this study, you will be asked to Sit down with the Principal Investigator fo r an oral history (i nterview) and reflect on your experiences, recollections and pe rception regarding the Title X Family Planning Program. There will only be one vis it and this visit is expected to last approximately 2 hours. The visit will take place at a time and location that is convenient for you. With your permission, the oral history will be audio-recorded. The Principal Investigator will be the only person w ho will have access to these tapes. The audio-recorded oral history will be transcribed into a typed document. Your name

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291 Appendix G. (Continued) or other personal identifiable information will not be used. By law, the audiorecorded tapes will be destroyed by the Principal Investigator after 3 years. OPTIONAL After the dissertation is completed, you ha ve the option of having the oral history archived in the Special Collections Depa rtment at University of South Florida (USF) Library. If you voluntarily choose to have your oral history archived after the dissertation is completed your oral history will be made available to the public and you will no longer remain anonymous. If you voluntarily choose to archive your oral history at the USF Ta mpa library, a member of the Special Collections Department from the USF Libr ary will contact you at a later date and an additional Legal Release Fo rm will need to be signed. If you do not wish to have your oral history archived in the Special Collections Department at the USF Libr ary and made available to the public, you can still participate in the study and you will remain anonymous and no personal identifiable information will be used. You have the alternative to choose not to participate in this research study. Benefits The potential benefits to you are: To have the opportunity to discuss and share your past experiences regarding the Title X Family Planning Program to an empathetic listener. To contribute information and insight that may help inform future policy decisions regarding Title X Family Planning Program. Furthermore, if you choose to have your oral history archived in the Special Collections Department at the USF Librar y after the dissertation is completed (an optional benefit not contingent on part icipating in the di ssertation), you will have the opportunity to share past expe riences and stories th at could influence public health and to make an historical co ntribution to the Stat e of Florida as well as to the general public. Risks or Discomfort There are no risks associated with the research. However, because the topic of this study involves family planning and policy, some pa rticipants may have very strong feelings regarding these topics. However, because you have had previous public health and/or policy work experiences, no risks or discomfort are anticipated.

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292 Appendix G. (Continued) Compensation We will not pay you for the time you voluntee r while being in this study. You will not need to travel to participate and the visit will take place at a time and location that is convenient to you. Confidentiality We must keep your study record s as confidential as possible. The audio-tapes from your oral history will be kept in a locked filling by the Principal Investigator for 3 years. After this time, the Principal Investigator will destroy the audio-tapes. The audio-tapes be given to the USF Libr ary and made available to the public only if you voluntarily choose to have your oral history archived in the Special Collections Department at the USF Library after the dissertation is complete If you do not want to have your oral history archived in the Special Collections Department at the USF Librar y after the dissertation is complete, the Principal Investigator will keep your audi o-tapes locked in a filling cabinet and will destroy the audio-tapes after 3 years. However, certain people may need to see your study records. By law, anyone who looks at your records must keep them completely confidential. The only people who will be allowed to see these records are: The research team, including the Principal Investigator and other research staff. Certain government and university peopl e who need to know more about the study. For example, individuals who provi de oversight on this study may need to look at your records. This is done to make sure that we are doing the study in the right way. They also need to make sure that we are protec ting your rights and your safety. These include: o The University of South Florida Ins titutional Review Board (IRB) and the staff that work for the IRB. Other individuals who work for USF that provide other kinds of oversight may al so need to look at your records. o The Department of Health and Human Services (DHHS). We may publish what we learn from this study. If we do, we w ill not let anyone know your name. We will not publish anything else that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. Y ou should not feel that there is any pressure to take part in the st udy, to please the investig ator or the research staff. You are free to participate in this research or withdr aw at any time.

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293 Appendix G. (Continued) There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study. Questions, concerns, or complaints If you have any questions, concerns or comp laints about this study, call the Principal Investigator, Cheryl Vamos, MPH, Doctoral Candidate at (813) 777-3255. If you have questions about your rights as a par ticipant in this study, general questions, or have complaints, concerns or issues you want to discuss with someone outside the research, call the Division of Research In tegrity and Compliance of the University of South Florida at (813) 974-9343. If you experience an unanticipated problem re lated to the research call the Principal Investigator, Cheryl Vamos, MPH, Doctoral Candidate at (813) 777-3255. Consent to Take Part in this Research Study It is up to you to decide whether you want to take part in this study. If you want to take part, please sign the form, if the following statements are true. I freely give my consent to take part in this study. I understand that by signing this form I am agreeing to take part in research. I have received a copy of this form to take with me. _____________________________________________ ____________ Signature of Person Taking Part in Study Date _____________________________________________ Printed Name of Person Taking Part in Study Statement of Person Obtaining Informed Consent I have carefully explained to the person taki ng part in the study what he or she can expect. I hereby certify that when this person signs th is form, to the best of my knowledge, he or she understands: What the study is about. What procedures/interventi ons/investigational drugs or devices will be used. What the potential benefits might be. What the known risks might be. Signature of Person Obtaining Informed Consent Date Printed Name of Person Obtaining Informed Consent

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294 Appendix H. Final Oral History Guide Hello. Thank you very much for talking wi th me today. Before we get started, I just want to remind you that you can choos e to skip any questions that you do not wish to answer. Also, I am very interes ted in hearing about your experiences and stories in working with family planning and Title X programs, so please feel free to share and to go into detail about these past ex periences. With that said, I would like to make it clear that when I refer to fa mily planning programs and Title X in my questions, I am most interested in issues rel ated to Title X since that is the policy that I am studying. Q. Could you tell me a little bit about the ro les and duties that you were responsible for regarding family planning programs and Title X at your previous [current] employment position? How long did you hold these position(s)? Q. When you think about family planning pr ograms and Title X in Florida, what are some of the immediate thoughts that come to mind? Probe: Are there any positive or negative thoughts that you would attribute with the Title X program? Q. What were some of your experiences in working with family planning programs and Title X in Florida? What were some positive experiences? What were some negative experiences? Q. What do you think the family planning pr ograms and Title X try to achieve? For instance, what do you believe is the core mission and function of this program? Q. Do you believe that Title X contains elemen ts of social control over women’s bodies? For instance, does Title X play a role in controlling women’s fertility? Is there anything in the Title X program or policy that you think might stigmatize or regulate women’s bodies or their health? Q. What role do you think the government should have in making family planning programs and the related preventive services available to women? Do you think family planning programs, like Title X, increase women’s dependence upon the state? Q. Do you think Title X adequately addresses the needs of all individuals in Florida – specifically, in terms of diffe rent characteristics such as gender, race/ethnicity, sexual identity, socioeconomic status, religion, national origin, disa bility, or other characteristics? Why or why not?

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295 Appendix H (Continued) Do you think that Title X primarily addre sses the needs and put s the majority of effort into a particular population of women? Q. Looking back, do you recall any periods in time when there was a spike or sharp increase in political activity, either go od or bad, surrounding family planning programs and Title X? To what do you attribute that in crease in politi cal activity? What were the issues surrounding that increase in politic al activity? How did that time affect your role or the Title X program? Q. Do you believe that Title X takes into acc ount any of the political and legal contexts that surround family planning and women’s health? (Probe: For in stance, throughout time certain issues have become more prevalent such as abstinence-only education, emergency contraception, providing services to minors…) Have these types of political and legal contexts or issu es changed or remained the same over time? Are there any other political or legal issues that stand out in your mind that we haven’t yet mentioned? Q. Funding for any health program is really important in shaping the success of that program. How have you seen the funding for family planning programs and Title X change over time? Q. The issue of adolescents using family planni ng services is another topic that receives a lot of attention. What have you experienced when working in the area of family planning and Title X regarding delivering services to this population? Q. The topic of abortion is a very controversial topic in the United States. Since the enactment of Title X, funds cannot be used for abortions; however, legislative proposals reiterating that Title X funds ca nnot be used for abortions con tinue to be stressed. What role do you think abortion plays in family planning programs and Title X and could you talk a little bit about your e xperiences with family planning programs and Title X in light of this controversial topic? Q. Do you think Title X takes into account a ny of the cultural and social contexts of women in Florida? (Probe: For instance, Florida is becoming more of a diverse population in terms of race/ethnicity; there ha s been a shift of wo men marrying later, rates of sexuality activity and ST I’s among teens have risen, etc.) Have these types of social or cultural contexts changed or remained the same over time? Are there any other cultural or social issues that stand out in your mind that we haven’t yet mentioned?

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296 Appendix H. (Continued) Q. Title X is a policy under the umbrella area of family planning and 95% of Title X clients are females. However the issue of family planning is much broader and does involve men. Do you think males play a role in family planning? If so, what roles do they play? What roles should ma les play in family planning? Probe: For instance, recipients of family planning services, a governmental/administrator role, a role in contributing to the rate of unintended/unplanned pregnancies, an advocate for community health? Q. Family planning programs and Title X are of ten intertwined with other health polices. For instance, as research and technology has advanced over the years, policies relating to HIV/AIDS, breast cancer, maternal and child health, and other prev entive health policies have emerged. Could you talk a little bit about how you think family planning programs and Title X have fit into other health policies? How have you perceived and what have been your experiences regarding the integration and coordination of th ese different health policies? Q. What do you believe are some of the barrie rs that family planning programs and Title X have encountered within the state of Florida? Q. What changes would you make to family planning programs and Title X policy in order to make the program more effective? Q. What do you believe are some of the achie vements or successes that family planning programs and Title X have had on the lives of women and communities in Florida? Q. Aside from what you and have discussed t oday about Title X, is there anything else that you think would be useful to men tion about the administration, operation or implementation of family planning programs a nd Title X that we have not previously discussed? Q. Is there anything else that you would like to share about your experiences in working with Title X and family planni ng in the state of Florida? Thank you very much for your time and fo r discussing your valuable experiences regarding Title X and family planning in Florida.

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297 Appendix I. Tables Table 6. Number and percentage (%) of sele cted demographics of Title X clients Characteris tic Male Female All Users Sex Male 262,793 (5%) Female 4,740,168 (95%) Age (in years) Under 15 12,081 (5%) 58,759 (1%) 70,840 (1%) 15-17 28,123 (11%) 520,956 (11%) 549,079 (11%) 18-19 30,684 (12%) 651,006 (14%) 681,690 (14%) 20-24 76,760 (29%) 1,513,034 (32%) 1,589,794 (32%) 25-29 45,187 (17%) 876,238 (18%) 921,425 (18%) 30-34 24,319 (9%) 495,129 (10%) 519,448 (10%) 35-39 16,339 (6%) 301,561 (6%) 317,900 (6%) 40-44 11,911 (5%) 181,579 (4%) 193,490 (4%) Over 44 17,389 (7%) 141,906 (3%) 159,295 (3%) Race/Ethnicity Hispanic or Latino Not Hispanic or Latino Ethnicity Unknown Hispanic or Latino Not Hispanic or Latino Ethnicity Unknown Hispanic or Latino Not Hispanic or Latino Ethnicity Unknown American Indian or Alaska Native 273 (0%)* 2,119 (1%) 389 (0%)* 3,388 (0%)* 28,524 (1%) 972 (0%)* 3,661 (0%)* 30,643 (1%) 1,361 (0%)* Asian 1,065 (%0)* 5,510 (2%) 183 (0%)* 3,153 (0%)* 112,989 (2%) 2,046 (0%)* 4,218 (0%)* 118,499 (2%) 2,229 (0%)* Black or African American 1,830 (1%) 54,730 (21%) 1,601 (1%) 22,613 (0%)* 874,336 (18%) 14,191 (0%)* 24,443 (0%)* 929,066 (19%) 15,792 (0%)* Native Hawaiian/ Pacific Islander 3,153 (1%) 8,193 (3%) 43 (0%)* 3,907 (0%)* 43,220 (1%) 430 (0%)* 7,060 (0%)* 51,413 (1%) 473 (0%)* White 39,717 (15%) 99,305 (38%) 6,817 (3%)* 684,385 (14%) 2,267,457 (48%) 85,435 (2%) 724,102 (14%) 2,366,76 2 (47%) 92,252 (2%) More than one race 3,276 (1%) 2,519 (1%) 1,059 (0%) 74,556 (2%) 37,745 (1%) 8,388 (0%)* 77,832 (2%) 40,264 (1%) 9,447 (0%)* Unknown or Not reported 18,564 (7%) 5,575 (2%) 6,872 (3%) 321,213 (7%) 85,920 (2%) 65,300 (1%) 339,777 (7%) 91,495 (2%) 72,172 (1%) Income Level 100% and below 3,316,699 (66%) 101-150% 879,666 (18%) 151-200% 324,358 (6%) 201-250% 129,097 (3%) Over 250% 242,241 (5%) Unknown or Not reported 110,900 (2%) Insurance Status Public health insurance 1,016,853 (20%) Private health insurance 377,372 (8%) All/some FP services 62,515 (1%)

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298 No FP services 29,641 (1%) Unknown FP coverage 285,216 (6%) Uninsured 2,998,508 (60%) Unknown or Not reported 610,228 (12%) Percentage is less than 0.5% FP = family planning Adapted from, RTI International. (November 2006 ). Family planning annual report: 2005 National summary Research Triangle Park, NC.

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299 Table 7. Selected teen reproductive health indicators, Flori da vs. United States Indicator Florida United States Teen pregnancy rate, girls, 15-19, per 1,000, 2000197 84 Teen birth rate, girls, 15-19, per 1,000, 2005242 41 Proportion of high school students who have ever had sex, 20073 49.5% 47.8% Proportion of high school students who had sex for the first time before age 134 8.2% 7.1% Proportion of high school stude nts with four or more lifetime sexual partners, 20075 16.4% 14.9% 1. The Alan Guttmacher Institute. (2004). U.S. teenage pregnancy statistics: Overall trends, trends by race and ethnicity and state-by-state information Retrieved October 1, 2008, from www.guttmacher.org/pubs/st atepregnancytrends.pdf 2. Centers for Disease Control and Prevention. National Center for Health Statistics. (n.d.). VitalStats http://www.cdc.gov/nchs/vitalstatshtm [December 2007] 3. Centers for Disease Cont rol and Prevention (2008). Percentage of students who ever had sexual intercourse, Florida vs. United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/QuestyearTable. asp?Loc2=XX&submit1=GO&cat=4&Quest=Q58&Loc=F L&Year=2007&ByVar=CI&colval=2007&rowval1=Se x&rowval2=None&compval=yes&Graphval=yes& path=byHT 4. Centers for Disease Cont rol and Prevention (2008). Percentage of students who had sexual intercourse for the first time before age 13 years, Florida vs. United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/QuestyearTable. asp?Loc2=XX&submit1=GO&cat=4&Quest=Q59&Loc=F L&Year=2007&ByVar=CI&colval=2007&rowval1=Se x&rowval2=None&compval=yes&Graphval=yes& path=byHT 5. Centers for Disease Cont rol and Prevention (2008). Percentage of students who had sexual intercourse with four or more persons during their life, Florida s. United States, 2007, YRBSS Retrieved October 1, 2008 from http://apps.nccd.cdc.gov/yrbss/QuestyearTable. asp?Loc2=XX&submit1=GO&cat=4&Quest=Q60&Loc=F L&Year=2007&ByVar=CI&colval=2007&rowval1=Se x&rowval2=None&compval=yes&Graphval=yes& path=byHT

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300 Table 8. Healthy People 2010: Objectives related to reprodu ctive health and family planning Focus Area Objective Description Baseline (1998) Target (2000) 1. Access to Health Care 1-1 Increase the proportion of persons with health insurance. 83%1 100% 1-2 Increase the proportion of insured persons with coverage for clinical preventive services. Developmental 1-3 Increase the proportion of persons appropriately counseled about health behaviors Developmental 1-3f Unintended pregnancy (females aged 15 to 44 years) 19% 50% 1-3g Prevention of sexually transmitted diseases (males aged 15 to 49 years; females aged 15 to 44 years) Developmental 1-3h Management of me nopause (females aged 46 to 56 years) Developmental 1-4 Increase the proportion of persons who have a specific source of ongoing care. 1-4a All ages. 87% 96% 1-4b Children and youth aged 17 years and younger. 93% 97% 1-4c Adults aged 18 years and older. 85% 96% 1-5 Increase the proportion of persons with a usual primary care provider. 85% 77% 3. Cancer 3-1 Reduce the overall cancer death rate. 202.4 cancer deaths per 100,000 population2 159.9 deaths per 100,000 population 3-3 Reduce the breast cancer death rate. 27.9 breast cancer deaths per 100,000 females2 223 deaths per 100,000 females 3-4 Reduce the death rate from cancer of the uterine cervix. 3.0 cervical cancer deaths per 100,000 females2 2.0 deaths per 100,000 females 3-11 Increase the proportion of wo men who receive a Pap test. 3-11a Women aged 18 years and older who have ever received a Pap test. 92%2397% 3-11b Women aged 18 years and older who received a Pap test within the preceding 3 years. 79%2390% 3-13 Increase the proportion of women aged 40 years and older who have received a mammogram within the preceding 2 years. 67%260% 3-14 Increase the number of States that have a statewide population-based cancer registry that captures case information on at least 95 percent of the expected number of reportable cancers. 21 state (1999) 45 3-15 Increase the proportion of cancer survivors who are living 5 years or longer after diagnosis. 59%470% 9. Family Planning 9-1 Increase the proportion of pregnancie s that are intended. 51% (1995) 70% 9-2 Reduce the proportion of births occurring within 24 months of a previous birth. 11% (1995) 6% 9-3 Increase the proportion of females at risk of unintended pregnancy (and their partners) who use contraception. 93% (1995) 100% 9-4 Reduce the proportion of females experiencing pregnancy despite use of a reversible contraceptive method. 13% (1995) 7% 9-5 Increase the proportion of health care providers who provide emergency contraception. Developmental 9-6 Increase male involvement in pregnancy prev ention and family planning efforts. Developmental 9-7 Reduce pregnancies among adolescent females. 68 pregnancies per 1,000 females aged 15 to 17 years (1996) 43 pregnancies per 1,000 9-8 Increase the proportion of adolescents w ho have never engaged in sexual intercourse by age 15 years. 9-8a Females. 81% (1995) 88% 9-8b Males. 79% (1995) 88%

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301 9-9 Increase the proportion of adolescen ts who have never engaged in sexual intercourse. 75% 9-9a Females. 62% (1995) 75% 9-9b Males. 57% (1995) 75% 9-10 Increase the proportion of sexually active, unmarried adolescents aged 15 to 17 years who use contraception that both effectively prevents pregnancy and provides barrier protection against disease. Condoms 9-10a Females. 62% (1995) 75% 9-10b Males. 72% (1995) 83% Condoms plus a hormonal method 9-10c Females. 7% (1995) 9% 9-10d Males. 8% (1995) 11% Increase in Contraceptive Use at Last Intercourse by Sexually Active, Unmarried Adolescents Aged 15 to 17 Years. Condoms 9-10e Females. 39% (1995) 49% 9-10f Males. 70% (1995) 79% Condoms plus a hormonal method. 9-10g Females. 7% (1995) 11% 9-10h Males. 16% (1995) 20% 9-11 Increase the proportion of young adults w ho have received formal instruction before turning age 18 years on reproductive health issues, including all of the following topics: birth control methods, safer sex to prevent HIV, prevention of sexually transmitted diseases, and abstinence. 64%5 (1995) 90% 9-12 Reduced the proportion of married couples whose ability to conceive or maintain a pregnancy is impaired. 13%6 (1995) 10% 9-13 Increase the proportion of health insura nce policies that cover contraceptive supplies and services. Developmental 13. HIV 13-1 Reduce AIDS among adolescents and adults. 19.5 cases per 100,0007 1.0 new cases per 100,000 persons 13-2 Reduce the number of new AIDS cases among adolescent and adult men who have sex with men. 17,847 new cases7,8 13,385 new cases 13-3 Reduce the number of new AIDS cases am ong females and males who inject drugs. 12,099 new cases7,8 9,075 cases 13-4 Reduce the number of new AIDS cases among adolescent and adult men who have sex with men and inject drugs. 2,122 cases7,81,592 13-5 Reduce the number of cases of HIV infec tion among adolescents and adults. Developmental 13-6 Increase the proportion of sexually active persons who use condoms. 13-6a Females aged 18 to 44 years. 23% (1995) 50% 13-6b Males aged 18 to 49 years. Developmental 13-7 Increase the number of HIV-positive pers ons who know their serostatus. Developmental 13-8 Increase the proportion of substance abus e treatment facilities that offer HIV/AIDS education, counseling, and support. 58% (1997) 70% 13-9 Increase the number of State prison systems that provide comprehensive HIV/AIDS, sexually transmitted diseases, and tuberculosis (TB) education. Developmental 13-10 Increase the proportion of inmates in State prison systems who receive voluntary HIV counseling and testing during incarceration. Developmental 13-11 Increase the proportion of adults with t uberculosis (TB) who have been tested for HIV. 55%985% 13-12 Increase the proportion of adults in p ublicly funded HIV counseling and testing sites who are screened for common bacterial sexually transmitted diseases (STDs) (Chlamydia, gonorrhea, and syphilis) and are immunized against hepatitis B virus. Developmental 13-13 Increase the proportion of HIV-infected adolescents and adults who receive testing, treatment and prophylaxis consistent with current Public Health Service treatment guidelines. Testing 13-13a Viral load testing Developmental 13-13b Tuberculin skin testing (TST) Developmental Treatment 13-13c Any antiretroviral therapy 80% 95%

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302 13-13d Highly active antiretroviral therapy (HAART) 40% 95% Prophylaxis 13-13e Pneumocystis carinii pneumonia (PCP) prophylaxis 80% 95% 13-13f Mycobacterium avium complex (MAC) prophylaxis 44% 95% 13-14 Reduce deaths from HIV infections. 4.9 deaths per 100,000 persons2 0.7 deaths per 100,000 persons 13-15 Extend the interval time between an initial diagnosis of HIV infection and AIDS diagnosis in order to increase years of lif e of an individual infected with HIV. Developmental 13-16 Increase years of life of an HIV-inf ected person by extending the interval of time between an AIDS diagnosis and death. Developmental 13-17 Reduce new cases of perinatally acquired HIV infection. Developmental 16-1 Reduce fetal and infant deaths. 16. Maternal, Infant, and Child Health 16-1a Fetal deaths at 20 or more weeks of gestation. 6.8 per 1,000 live births plus fetal deaths (1997) 4.1 per 1,000 live births plus fetal deaths 16-1b Fetal and infant deaths during perinatal period (28 weeks of gestation to 7 days or more after birth). 7.5 per 1,000 live births plus fetal deaths (1997) 4.5 per 1,000 live births plus fetal deaths 16-1c All infant deaths (within 1 year). 7.2 per 1,000 live births 4.5 per 1,000 live births 16-1d Neonatal deaths (within the first 28 days of life). 4.8 per 1,000 live births 2.9 per 1,000 live births 16-1e Postneonatal deaths (between 28 days and 1 year). 2.4 per 1,000 live births 1.2 per 1,000 live births 16-1f All birth defects. 1.6 per 1,000 live births 1.1 per 1,000 live births 16-1g Congenital heart defects. 0.53 per 1,000 live births 0.38 per 1,000 live births 16-1h Reduce deaths from sudden infant death syndrome (SIDS). 0.72 deaths per 1,000 live births 0.25 deaths per 1,000 live births 16-2 Reduce the rate of child deaths. 16-2a Children aged 1 to 4 years. 34.6 per 100,000 18.6 per 100,000 16-2b Children aged 5 to 9 years. 17.7 per 100,000 12.3 per 100,00 16-4 Reduce maternal deaths. 7.1 maternal deaths per 100,000 live births 3.3 maternal deaths per 100,000 live births 16-5 Reduce maternal illness and co mplications due to pregnancy. 16-5a Maternal complications during hospitalized labor and delivery. 31.2 per 100 deliveries 24 per 100 deliveries 16-5b Ectopic pregnancies. Developmental 16-5c Postpartum complications, including postpartum depression. Developmental 16-6 Increase the proportion of pregnant women w ho receive early and adequate prenatal care. 16-6a Care beginning in first trimester of pregnancy. 83% of live births 90% of live births 16-6b Early and adequate prenatal care. 74% of live births 90% of live births

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303 16-7 Increase the proportion of pregnant women who attend a series of prepared childbirth classes. Developmental. 16-9 Reduce cesarean births among low-risk (full term, singleton, vertex presentation) women. 16-9a Women giving birth for the first time. 18% 15% 16-9b Prior cesarean birth. 72% 63% 16-10 Reduce low birth weight (LBW) and very low birth weight (VLBW). 16-10a Low birth weight (LBW). 7.6% 5.0% 16-10b Very low birth weight (VLBW). 1.4% 0.9% 16-11 Reduce preterm births. 16-11a Total preterm births. 11.6% 7.6% 16-11b Live births at 32 to 26 weeks of gestation. 9.6% 6.4% 16-12 Increase the proportion of mothers who ach ieve a recommended weight gain during their pregnancies. Developmental 16-13 Increase the percentage of healthy full-te rm infants who are put down to sleep on their backs. 35% (1996) 70% 16-14 Reduce the occurr ence of developmental disabilities 16-14a Mental retardation. 131 rate per 10,00010 (1991-1994) 124 rate per 10,000 16-14b Cerebral palsy. 32.2 rate per 10,00011 (1991-1994) 31.5 rate per 10,000 16-14c Autism spectrum disorder. Developmental 16-14d Epilepsy. Developmental 16-15 Reduce the occurrence of sp ina bifida and other neur al tube defects (NTDs). 6 new cases of spina bifida or another NTD per 10,000 live births (1996) 3 new cases per 10,000 live births 16-16 Increase the proportion of pregnancies be gun with an optimum folic acid level. 16-16a Consumption of at least 400 micrograms of folic acid each day from fortified foods or dietary supplem ents by nonpregnant women aged 15 to 44 years. 21% (19911994) 80% 16-16b Median RBC folate level among nonpregnant wome n aged 15 to 44 years. 160 ng/ml (1991-1994) 220 ng/ml 16-17 Increase abstinence from alcohol, ciga rettes, and illicit drugs among pregnant women. 16-17a Alcohol. 86% (19961997) 94% 16-17b Binge drinking. 99% (19961997) 100% 16-17c Cigarette smoking. 87% 99% 16-17d Illicit drugs. 98% (19961997) 100% 16-18 Reduce the occurrence of fetal alcohol syndrome (FAS). Developmental 16-19 Increase the proportion of mothers who breastfeed their babies. 16-19a In early postpartum period. 64% 75% 16-19b At 6 months. 29% 50% 16-19c At 1 years. 16% 25% 16-20 Ensure appropriate newborn bloodspot screen ing, followup testing, and referral to services. 16-20a Ensure that all newborns ar e screened at birth for conditions mandated by their State-sponsored newborn sc reening programs, for example, phenylketonuria and Development

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304 hemoglobinopathies. 16-20b Ensure that followup diagnos itc testing for screening positives is performed within an appropriate time period. Development 16-20c Ensure the infants with di agnosed disorders are enrolled in appropriate service interventions with an appropriate time period. Development 16-21 Reduce the hospitalization for life-threaten ing sepsis among children aged 4 years and under with sickling hemoglobinopathies. Developmental 25. Sexually Transmitte d Diseases 25-1 Reduce the proportion of adolescents and y oung adults with Chlamydia trachomatis infections. 25-1a Females aged 15 to 24 years at tending family planning clin ics. 5.0% (1997) 3.0% 25-1b Females aged 15 to 24 years attending STD clinics. 12.2% (1997) 3.0% 25-1c Males aged 15 to 24 years attending STD clinics. 15.7% (1997) 3.0% 25-2 Reduce gonorrhea. 123 new cases of gonorrhea per 100,000 (1997) 19 25-3 Eliminate sustained domestic transmission of primary and secondary syphilis. 3.2 cases of primary and secondary syphilis per 100,000 (1997) 0.2 per 100,000 25-4 Reduce the proportion of adults with genital herpes infection. 17%12 (19881994) 14% 25-5 Reduce the proportion of persons with hu man papillomavirus (HPV) infection. Developmental 25-6 Reduce the proportion of females who have ever required treatment for pelvic inflammatory disease (PID). 8%13 (1995) 5% 25-7 Reduce the proportion of childless females with fertility problems who have had a sexually transmitted disease or who have re quired treatment for pelvic inflammatory disease (PID). 27%14 (1995) 15% 25-8 Reduce HIV infections in adolescent and young adult females aged 13 to 24 years that are associated with heterosexual contact. Developmental 25-9 Reduce congenital syphilis. 27 new cases of congenital syphilis per 100,000 live births (1997) 1 new case per 100,000 live births 25-10 Reduce neonatal consequences from ma ternal sexually transmitted diseases, including chlamydial pneumonia, gonococcal and chlamydial ophthalmia neonatorum, laryngeal papillomatosis (from human pap illomavirus infection), neonatal herpes, and preterm birth and low birth weight associated with bacterial vaginosis. Developmental 25-11 Increase the proportion of adolescents who abstain from sexual intercourse or use condoms if currently sexually active. 85%15(1999) 95% 25-12 Increase the number of positive messages re lated to responsible sexual behavior during weekday and nightly primetime television programming. Developmental 25-13 Increase the proportion of Tribal, State, and local sexually transmitted disease programs that routinely offer hepatitis B vaccines to all STD clients. 5%1690% 25-14 Increase the proportion of youth detention fac ilities and adult city or county jails that screen for common bacterial sexually transmitted diseases within 24 hours of admission and treat STDs (when necessary) before persons are released. Developmental 25-15 Increase the proportion of all local health departments that have contracts with managed care providers for the treatment of nonplan partners of patients with bacterial sexually transmitted diseases (gonorrhea, syphilis, and chlamydia). Developmental

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305 25-16 Increase the proportion of sexually active females aged 25 years and under who are screened annually for gen ital chlamydia infections. Developmental 25-17 Increase the proportion of pregnant fema les screened for sexually transmitted diseases (including HIV infection and bacterial vaginos is) during prenatal health care visits, according to recognized standards. Developmental 25-18 Increase the proportion of primary care pr oviders who treat patients with sexually transmitted diseases and who manage cas es according to recognized standards. 70% 90% 25-19 Increase the proportion of all sexually tran smitted disease clinic patients who are being treated for bacterial STDs (chlam ydia, gonorrhea, and syphilis) and who are offered provider referral services for their sex partners. Developmental 1. Percent of persons under age 65 years who were covered by health insurance in 1997 (age adjusted to the year 2000 standard population). 2. Age adjusted to the year 2000 standard population. 3. Includes women without a uterine cervix. 4. Percent of persons with invasive cancer of any type were living 5 years or longer after diagnosis in 1989–95. 5. Percent of females aged 18 to 24 years reported having received formal instruction on all of these reproductive health issues before turning age 18 years. (Data on males will be available in the future.) 6. Percent of married couples with wives aged 15 to 44 years had impaired ability to conceive or maintain a pregnancy. 7. Persons aged 13 years and older. 8. Risk is redistributed; adjusted for delays in reporting. 9. Adults aged 25 to 44 years. 10. Children aged 8 years in metropolitan A tlanta, GA, having an IQ of 70 or less. 11. Children aged 8 years in metropolitan Atlanta, GA. 12. Percentage of adults aged 20 to 29 years had genital herpes infection in 1988–94 (as measured by herpes simplex virus type 2 [HSV-2] antibody). 13. Percentage of females aged 15 to 44 years required treatment for PID in 1995. 14. Percent of childless females aged 15 to 44 years with fertility problems had a history of STDs or PID treatment in 1995. 15. Percent of adolescents in grades 9 through 12 abstained from sexual intercourse or used condoms in 1999 (50 percent had never had intercourse; 14 percent had intercourse but not in the past 3 months; and 21 percent currently were sexually active an d used a condom at last intercourse). 16. Percent of State and local STD programs offere d hepatitis B vaccines to clients in accordance with CDC guidelines in 1998. Tribal ST D program data are developmental. Adapted from, U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving health (2nd ed) Retrieved March 2, 2008, from http://www.healthypeople.gov/ Document/pdf/uih/2010uih.pdf

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306 Table 9. Selected characteristics of wome n by pregnancy classification and abortion rate, 2001 Pregnancy Rate1Unintended Pregnancies Characteristic Number of Pregnancies Total Intended Unintended % of Total % Ending in Abortion Abortion Rate Unintended Birth Rate All Women 6,404 104 53 51 49 48 21 22 Age <15 29 3 0 3 100 51 1 1 15-19 811 82 15 67 82 40 23 34 15-17 271 46 6 40 87 39 14 21 18-19 540 137 29 108 79 41 37 53 20-24 1,681 174 70 104 60 49 45 46 25-29 1,566 168 96 71 43 50 32 32 30-34 1,364 133 89 44 33 49 19 20 35-39 766 69 49 20 29 60 10 6 40 186 16 10 6 38 56 3 3 Marital Status Married 3,496 119 87 32 27 27 8 20 Unmarried 2,909 90 23 67 74 58 33 24 Marital History Never married 2,331 92 22 70 77 57 35 26 Formerly married 578 82 30 52 63 67 29 14 Cohabitation status Cohabitating 1,026 197 59 138 70 54 63 54 Not cohabitating 1,883 69 17 52 76 61 27 18 Income as % of pregnancy <100 1,513 182 69 112 62 42 42 58 100-199 1,652 144 62 81 57 50 36 35 200 3,266 78 48 29 38 54 13 11 Education2 < High school diploma 878 151 75 76 50 36 22 40 High school diploma/GED 1,699 115 61 54 47 46 21 25 Some college 1,501 91 43 47 52 60 25 16 College graduate 1,485 109 83 26 24 55 12 10 Race/ethnicity White 3,552 88 53 35 40 44 13 17 Black 1,182 141 43 98 69 58 49 35 Hispanic 1,278 144 67 78 54 43 30 40

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307 1. Rate per 1,000 women 2. Among women aged 20 and older. Finer, L.B., & Henshaw, S.K. (2006). Dispari ties in rates of uninte nded pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38 (2), 90-96. Reprinted with permission from the publisher.

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308 Table 10. Main federal family planning statues Statute Grant and Admini strative Mechanisms Title V of Social Security Act (Maternal and Child Health and Crippled Children Act) Formula grants matched by the states; administered by state health departments Title X of Public Health Service Act (Family Planning Services and Population Research Act) Project grants administered by regional offices of U.S. Public Health Service Title XIX of Social Security Act (Medicaid) Reimbursement of providers for individual services; administered by state health or welfare departments; no federal ceiling on expenditures Title XX of Social Security Act (Black Grant to the States for Social Services) Block grants to stat e welfare departments McFarlane, D.R., & Meier, K.J. (2001). The politics of fertility control (p. 48). Washington, DC: CQ Press. Reprinted with permission from the publisher.

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309 Table 11. Frames used in fertility cont rol (family planning and abortion) policies Frame Explanation Used in Family Planning Policies Used in Abortion Policies Sanctity of life Human life begins at conception and is sacred. Sometimes Yes Woman’s right A woman has the right to control her own body. Yes Yes Legal but discouraged Abortion should be legal bur discouraged. No Yes Government noninvolvement Government involvement in fertility control should be eliminated. Yes Yes Welfare Individuals should be responsible for themselves. Yes Yes Children and families Parents should make decisions for minors in their families. Yes Yes Health risks/health benefits The health risks and benefits of fertility control should be considered. Yes Yes McFarlane, D.R., & Meier, K.J. (2001). The politics of fertility control (p. 10). Washington, DC: CQ Press. Reprinte d with permission from the publisher

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310 Table 12. Legislative history for Title X (P.L. 91-572) Year Administration H. Maj./ Min.1 S. Maj./ Min.2 Legislation Sponsor(s) CoSponsor(s) Summary of Legislation Committee Last Legislative Activity Final Status Senate Bills 1971 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd S.J. Res. 108 Cranston Taft; Cook; Hart; Inouye; Packwood; Spong; Allott; Bayh; Beall; Bentsen; Burdick; Byrd; Cannon; Case; Chiles; Dole; Goldwater; Harris; Hatfield; Humphrey; Javits; Magnuson; Mathias; McGee; McGovern; Metcalf; Nelson; Percy; Proxmire; Saxbe; Stevenson; Tower; Tunney; Williams To declare a United States policy of achieving population stabilization by voluntary means. Labor and Public Welfare Referred to Senate Committee Not Enacted Senate Bills 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd S. 3442 Kenedy Cranston; Eagleton; Hughes; Javits; Mondale; Pell; Randoph; Schwiker; Stevenson; Williams To amend the Public Health Service Act to extend and revise the program of assistance under that act for the control and prevention of communicable diseases Labor and Public Welfare Presented to the President Enacted P.L. 92449* House Bills 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.R. 14341 Staggers Springer To amend th e Public Health Service Act to increase the fiscal year 1973 authorizations for project grants for health services development and for project grants and contracts for family Foreign Commerce Referred to House Committee Not Enacted

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311 planning services. 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.R. 14672 Conyers 0 To amend the Public Health Service Act to increase the fiscal year 1973 authorizations for project grants for health services development and for project grants and contracts for family planning services. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.R. 16986 Esch Alexander; Frenzel; Harrington; Schwengel To establish a National Institute of Population Growth and to transfer to the Institute the functions of the Secretary of Health, Education, and Welfare, and the Director of the Office of Economic Opportunity relating to population research and family planning services. Government Operations Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.R. 17053 Scheuer 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.R. 17153 Scheuer Badillo; Bingham; Chisholm; Conyers; Dellums; Diggs; Eckhardt; Edwards-CA; Fauntroy; Fisher; Halpern; Hawkins; Helstoski; HicksWashtingon; Metcalfe; Mink; Mitchell; Nix; Rangel; Rees; Rosenthal; Stokes; Thompson-NJ; Udall To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.J. Res. 789 Rees 0 To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1972 Richard D D 92nd H.J. Udall Horton; To declare a United St ates policy of Government Referred to Not

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312M. Nixon (R) (254)/ R (180) (54)/ R (44) Res. 837 Badillo; Anderson-IL; Foley; Cleveland; Green-Oregon; Dellenback; Harrington; Gude; HicksWashington; Halpern; Leggett; Morse; Preyer-NC; Robison-NY; Scheuer; Stafford; Waldie; Vander Jagt achieving population stabilization by voluntary means. Operations House Committee Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.J. Res. 849 OKonski 0 To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.J. Res. 853 Matsunaga 0 To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1972 Richard M. Nixon (R) D (254)/ R (180) D (54)/ R (44) 92nd H.J. Res. 904 McCoskey 0 To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted Senate Bills 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd S. 1136 Kennedy Williams; Randolph; Pell; Nelson; Mondale; Eagleton; Cranston; Hughes; Hathaway; Javits; Dominick; Schweiker; Beall; Stafford To extend through fiscal 1974 certain expiring appropriations authorization in the Public Health Service Act, the Community Mental Health Centers Act, and the Developmental Disabilities Services and Facilities Construction Act, and for other purposes. Labor and Public Welfare Presented to the President Enacted P.L. 9345* 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd S. 1708 Cranston Baker; Bayh; Brooke; Case; Goldwater; Hart; Inouye; Jackson; To amend title X of the Public Health Service Act to extend appropriations authorizations for 3 fiscal years and to revise and improve authorities in such title for family planning services Labor and Public Welfare Referred to Senate Committee Not Enacted

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313 McGee; McGovern; Metcalf; Moss; Packwood; Stevenson; Taft; Williams programs, planning, training and public information activities, and population research. House Bills 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 1723 Carter 0 To amend title X of the Public Health Service Act to extend for three years the program of assistance for population research and voluntary family planning programs. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 3381 Dellums 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 3621 Erlenbron 0 To amend title X of the Public Health Service Act to extend for 3 years the program of assistance for population research and voluntary family planning programs. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 4767 Esch 0 To establish a National Institute of Population Growth and to transfer to the Institute the functions of the Secretary of Health, Education, and Welfare and of the Director of the Office of Economic Opportunity relating to population research and family planning services. Government Operations Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 5000 Vander Jagt 0 To amend title X of the Public Health Service Act to extend for three years the program of assistance for population research and voluntary family planning programs. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 5940 du Point 0 To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 6021 Dellums Schroeder; Eckhardt; Abzug; Badillo; Bingham; Brown-CA; Chisholm; Conyers; de Lugo; To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purpose. Interstate and Foreign Commerce Referred to House Committee Not Enacted

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314Fauntroy; Fisher; Hawkins; Hicks; Jordan; Koch; Metcalfe; Mink; Nix; Rees; Rosenthal; Stark; Thompson-NJ; Udall; Won Pat 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 6139 du Point 0 To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 6222 Dellums Benitez; Rangel; Holtzman; Stokes; Diggs; Young -GA; Meeds; Moakley; Fraser; Kastenmeter; Reid; Lehman; Burke-CA; Harrington; Edwards -CA; Bell To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 6601 Dellums Legett; Mitchell -Maryland; Waldie To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 6834 du Point Bevill; Bingham; Buchanan; Cleveland; Conyers; Coughlin; Dellenback; Esch; Fisher; Frenzel; Harrington; Leggett; McCloskey; McCormack; Mallary; To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted

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315Mazzoli; Nix; Podell; Seiberling; Stark; Whitehurst 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 7467 Fulton 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 7468 Fulton 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 7735 Ashley 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 8172 du Point Bevill; Bingham; Brown-CA; Buchanan; Cleveland; Conyers; Coughlin; Dellenback; Esch; Fisher; Frenzel; Harrington; Horton; Leggett; McCloskey; McCormack; Mallary; Mazzoli; Nix; Podell; Seiberling; Stark; Whitehurst To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 11995 Conable 0 To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1973 Richard M. D (239)/ D (56)/ 93rd H.J. Res. 90 Matsunaga 0 To declare a United States policy of achieving population stabilization by Government Operations Referred to House Not Enacted

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316Nixon (R) R (192) R (42) voluntary means. Committee House Bills 1974 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 12155 Culver 0 To promote public health and welfare by expanding and improving the family planning services and population research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1974 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 12323 Bennett 0 To amend the Public Health Service Act. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1974 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 13750 Duncan 0 To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1974 Richard M. Nixon (R) D (239)/ R (192) D (56)/ R (42) 93rd H.R. 14214 Rogers Satterfield; Kyros; Preyer; Symington; Roy; Nelsen; Carter; Hastings; Heinz; Hudnut To amend the Public Health Service Act and related laws to revise and extend programs of health revenue sharing and health services, and for other purposes. Interstate and Foreign Commerce Presented to the President Vetoed Senate Bills 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th S. 66 Kennedy Javits; Williams; Randolph; Pell; Nelson; Mondale; Cranston; Hathaway; Schweiker; Stafford To amend title VIII of the Public Health Service Act to revise and extend the programs of assistance under that title for nurse training and to revise and extend programs of health revenue sharing and health services. Labor and Public Welfare Presented to the President; Presidential veto message; Senate overrode Presidential veto; House overrode Presidential veto Enacted P.L 9463* 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th S. 318 Bartlett Garn Prohibiting use of Health, Education, and Welfare funds for abortion. Labor and Public Welfare Committee discharged re-referred to Committee on Finance Not Enacted House Bills 1975 Gerald R. Ford D (291)/ D (60)/ 94th H.R. 2133 Carter 0 To revise and extend through fiscal year 1976 the programs authorized by title X Interstate and Foreign Referred to House Not Enacted

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317(R) R (144) R (37) of the Public Health Service Act for family planning and population research. Commerce Committee 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 2954 Rogers Preyer; Symington; Carney; Scheuer; Waxman; Hefner; Florio; Carter; Heinz To amend the Public Health Service Act and related laws to revise and extend programs of health revenue sharing and health services, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 4235 Rogers Oberstar; Badillo To amend the Public Health Service Act and related laws to revise and extend programs of health revenue sharing and health service, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 4925 Rogers Preyer; Symington; Scheuer; Waxman; Hefner; Florio; Carney; Wirth; Carter; Heinz To amend the Public Health Service Act and related laws to revise and extend programs of health revenue sharing and health services, and for other purposes. Interstate and Foreign Commerce Amended and passed House; Proceedings vacated. Laid on the table (S. 66 passed in lieu) Not Enacted 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 5719 du Point Horton; BrownCA; Schroeder; Ottinger; Esch; Abzug; Spellman; Stark; Solarz; Prtichard; Pattison-NY; Carr; DuncanOregon; Harrington; Litton; Cleveland; Tsongas; Conyers; Martin-NC; Charels H. Wilson-CA; Frenzel; Treen; McCormack; Bell To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1975 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 5720 du Point Moss; Waxman; Charels Wilson-TX; Richmon; Fraser; To promote public health and welfare by expanding and improving the family planning services and population sciences research activities of the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted

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318Holtzman House Bills 1976 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.R. 12327 Vigorito 0 Prohibiting use of Health, Education, and Welfare funds for abortion. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1976 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.J. Res. 125 Matsunga 0 To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1976 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.J. Res. 559 Matsunaga Horton To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1976 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.J. Res. 764 Matsunaga Horton; BrownCA; Scheuer; Weaver; du Pont; Carter; Won Pat To declare a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted 1976 Gerald R. Ford (R) D (291)/ R (144) D (60)/ R (37) 94th H.J. Res. 769 Matsunaga Udall; Waxman To decl are a United States policy of achieving population stabilization by voluntary means. Government Operations Referred to House Committee Not Enacted House Bills 1977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 3598 Rogers Satterfield; Preyer; Scheuer; Waxman; Florio; Maguire; Ottinger; Markey; Walgren; Carter; Madigan To amend the Public Health Service Act, the Community Mental Health Centers Act, title V of the Social Security Act, and the program of assistance for home health services to authorize appropriations for fiscal year 1978. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 4975 Rogers Satterfield; Preyer; Scheuer; Waxman; Florio; Maguire; Ottinger; Markey; Walgren; Carter; Madigan To amend the Public Health Service Act to authorize appropriations for fiscal year 1978 for biomedical research and related programs. Interstate and Foreign Commerce Presented to the President Enacted P.L 9583*

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3191977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 4976 Rogers Satterfield; Preyer; Scheuer; Waxman; Florio; Maguire; Ottinger; Markey; Walgren; Carter; Madigan To amend the Public Health Service Act, the Community Mental Health Centers Act, title V of the Social Security Act, and the program of assistance for home health services to authorize appropriations for fiscal year 1978 for health services programs, and for other purposes. Interstate and Foreign Commerce Amended and passed House; Referred to Committee on Human Resources Not Enacted 1977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 7806 Oakar Oberstar To amend the Public Health Service Act to provide assistance for counseling of, and preparation and distribution of information for pregnant women. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 7912 Gephardt 0 To prohibit use of Federal funds to perform abortions except where the life of the woman would be endangered. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1977 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 7977 Dephardt 0 To prohibit use of Federal fund to pay for, promote, or encourage abortions except where necessary to save the life of the mother. Interstate and Foreign Commerce Referred to House Committee Not Enacted Senate Bills 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th S. 2522 Cranston Williams; Javits; Riegle To amend title X of the Public Health Service Act to extended appropriations authorizations for 5 fiscal years. Human Resources Presented to the President Enacted P.L 95613* 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th S. 2614 Helms 0 To amend the Public Health Service Act to provide alternatives to abortion. Human Relations Referred to Senate Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th S. 2697 Magnuson 0 To amend the Public Health Service Act to exclude any prohibitions relating to the provisions of abortions. Human Resources Referred to Senate Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th S.J. Res. 64 Matsunaga 0 To declare a U.S. policy of achieving population stabilization by voluntary means. Human Resources Referred to Senate Committee Not Enacted House Bills 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 10553 Rogers Carter To amend the Public Health Service Act and related health laws to revise and extend the programs of financial assistance for the delivery of health services. Interstate and Foreign Commerce Referred to House Committee Not Enacted

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320 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 11007 Beilenson 0 To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 11925 Beilenson Gammage; Walgren; Pritchard; Beard-RI; McCloskey; Jenrette; Akaka; Edwards-CA; Gore; Conyers; Ottinger; Keys; Simon; Bedell; Patterson-CA; Wirth; Hughes; Pattison-NY; Rosenthal; Kastenmeier; Bonior; Fraser; Weiss; LaFalce To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate on Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 11926 Beilenson Markey; Moffett; Waxman; Dellums; Pursell; Bonker; BurkeCA; Price; Blanchard; John L. Burton; Garcia; Seiberling; Florio; Maguire; Mineta; Mikva; Frenzel; Udall; Leach; Edgar; Thompson To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate on Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 12370 Rogers Preyer; Scheuer; Florio; Maguire; Markey; Ottinger; Walgren; Carter; Madigan To amend the Public Health Service Act and related health laws to revise and extend the programs of financial assistance for the delivery of health services, and for other purposes. Interstate and Foreign Commerce Amended and passed House; Laid on the table (S. 2522, S. 2474 passed in lieu) Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 12400 Baucus 0 To provide alternatives to abortion through prohibition of sex discrimination on the basis of pregnancy, to provide health care services for pregnant adolescents before and after childbirth, to allow an income tax deduction for expenses incurred in connection with the adoption of a child, to prohibit the sale of children in interstate and foreign commerce, to facilitate the placement of children in need of adoption, and to prevent unwanted conceptions and to reduce the need for abortions through improved and expande d family planning Education and Labor; Interstate and Foreign Commerce; Judiciary; Ways and Means Referred to House Committees Not Enacted

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321services and population research activities. 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 12894 Beilenson Goodling; AuCoin; Ashley; Mikulski; Leggett; Panetta; Kostmayer; Harkin; Collins IL; Emery; Broadhead; Mitchell Maryland; Stark; Chareles Wilson -TX; Whalen; Hamilton; Schroeder; Brown -OH To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 13111 Green 0 To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 13278 Patten 0 To promote public health and welfare by preventing unwanted conceptions and reducing the need for abortions among all women, especially teenagers, through improved and expande d family planning services and population research activities by the Federal Government, and for other purposes. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.R. 13852 Harrington Bedell; Downey; Edwards-CA; Frenzel; Garcia; Kastenmeier; Markey; McKinney; Pattison-NY To declare the need for an explicit population policy and to establish an Office of Population Policy. Government Operations; International Relations Referred to House Committees Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.J. Res. 532 Scheuer Horton; Beilenson; Meyner; Solarz; Richmond; Seiberling; Akaka; Long-Maryland; Dellums To declare a U.S. policy of stabilizing its population by voluntary means which respect human dignity within a reasonable period of time. Interstate and Foreign Commerce; Post Office and Civil Service Referred to House Committees Not Enacted 1978 James E. Carter (D) D (292)/ R (143) D (61)/ R (38) 95th H.Res. 1408 Boling 0 Providing for the consideration of the bill (H.R. 12370) to amend the Public Health Service Act and related health laws to revise and extend the programs of financial assistance for the delivery of health services, and for other purposes. Committee on Rules Considered and agreed to Not Enacted House Bills 1979 James E. Carter (D) D (276)/ R (157) D (58)/ R (41) 96th H.R. 1593 Frenzel 0 To declare the need for an explicit population policy and to establish an Office of Population Policy. Government Operations; International Operations Referred to House Committees Not Enacted

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3221979 James E. Carter (D) D (276)/ R (157) D (58)/ R (41) 96th H.R. 2501 Oakar N/A To amend the Public Health Service Act to provide assistance for counseling of, and preparation and distribution of information for pregnant women. Interstate and Foreign Commerce Referred to House Committee Not Enacted 1979 James E. Carter (D) D (276)/ R (157) D (58)/ R (41) 96th H.R. 5062 Ottinger N/A To declare a national policy goal of national population stabilization, and to establish an Office of Population Policy. Government Operations Referred to House Committee Not Enacted Senate Bills 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th S. 288 Cranston 0 To provide for the extension of the authorization of appr opriations for title X of the Public Health Service Act. Labor and Human Resources Referred to Senate Committee Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th S. 1102 Kennedy Randloph; Williams; Pell; Eagleton; Riegle; Metzenbaum To revise and extend certain health services programs, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th S. 1771 Hatfield Cranston; Gorton; Mathias; Matsunaga To establish in the Federal Government a global foresight capability with respect to natural resources, the environment, and population; to establish a national population policy; to establish an interagency Council on Global Resources, Environment, and Population, for other purposes. Governmental Affairs Referred to Senate Committee Not Enacted House Bills 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 907 Ottinger N/A To establish a national population policy and to establish an Office of Population Policy. Government Operations; Post Office and Civil Services Referred to House Committees Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 2446 Philip M. Crane 0 To amend title X of the Public Health Service Act to provide that grants and contracts may not be made under that title to any entity which provides abortion counseling to minors without the knowledge and consent of their parents or guardians. Energy and commerce Referred to House Committee Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 2447 Philip M. Crane 0 To prohibit payment of any Federal funds to or for the benef it of any entity which provides abortion counseling to minors without the consent of their parents or guardians. Energy and Commerce Referred to House Committee Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 2807 Waxman N/A To amend the Public Health Service Act to extend the programs of assistance for family planning and programs relating to genetic diseases, to extend the program of Energy and commerce Referred to House Committee Not Enacted

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323assistance for pregnant adolescents, and for other purposes. 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 2848 Oakar 0 To amend the Public Health Service Act to provide assistance for counseling of, and preparation and distribution of information for pregnant women. Energy and Commerce Referred to House Committee Not Enacted 1981 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 3982 Jones-OK N/A To provide for reconciliation pursuant to section 301 of the First Concurrent Resolution on the budget for the fiscal year 1982. Budget Presented to the President Enacted P.L. 9735* Senate Bills 1982 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th S. 2322 Jepsen 0 To require parental notification by any federally funded entity providing contraceptive devise or abortion service to an unmarried minor. Labor and Human Resources Referred to Senate Committee Not Enacted House Bills 1982 Rnald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 5238 Waxman Weiss; Walgren; Wyden; Moffett; Leland; Ottinger; Wirth; Mottl; Akaka; Barnes; Beilenson; Dixon; Shamansky; Taylor To amend the Federal Food, Drug, and Cosmetic Act to facilitate the development of drugs for rare diseases and conditions, and for other purposes Energy and Commerce; Ways and Means Presented to the President Enacted P.L. 97414* 1982 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.R. 6355 Waxman 0 To make technical corrections in health and other laws amended by the Omnibus Budget Reconciliation Act of 1981 and for other purposes. Energy and Commerce Reported with amendment; Debated; Failed of passage under the suspension of the rules Not Enacted 1982 Ronald W. Reagan (R) D (243)/ R (192) R (53)/ D (46) 97th H.Con. Res. 206 Gejdenson Schroeder; AuCoin; Beilenson; Bingham; Brown-CA; John L. Burton; Phillip Burton; Chisholm; Clay; Collins-IL; Collins-TX; Conyers; Coughlin; Crockett; Dellums; Downey; Dunn; Edgar; Fascell; Fauntroy; Fazio; Ferrago; Foglietta; Ford-MI; Forsythe; Frank; Frost; Garcia; Gore; Gray; Green; Holland; Hollenbeck; Howard; Jeffords; Leach-Iowa; Leland; Lowry-Washington; Markey; Matsui; Mavroules; Mikulski; Obertar; Ottinger; Patterson; Pease; Peper Peyser; Pritchard; Rangel; Ratchfrod; Richmond; Rosenthal; Scheuer; Endorsing certain family planning principles and urging the President to take certain actions in support of family planning both in the United States and abroad. Energy and Commerce; Foreign Affairs Referred to House Committees Not Enacted

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324 Schneider; Schumer; Seiberling; Solarz; Stark; Udall; Washington; Waxman; Weaver; Weiss; Williams-Montana; Wilson; Wirth; Wolpe; Won Pat; Wyden Senate Bills 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. 1025 Hatfield 0 A bill to establish in the Federal Government a global foresight capability with respect to natural resources, the environment, and population; to establish a national population policy; to establish an interagency Council on Global Resources, Environment, and Population, and for other purposes. Governmental Affairs Referred to Senate Committee Not Enacted 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. Con. Res. 21 Cohen Packwood; Hollings; Bradley A c oncurrent resolution expression the sense of the Congress respecting the administration of title X of the Public Health Service Act. Labor and Human Resources Agreed to in Senate Not Enacted House Bills 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 512 Philip M. Crane 0 A bill to prohibit payment of any Federal funds to or for the benefit or any entity which provides abortion counseling to minors without the consent of their parents or guardians. Energy and Commerce Referred to House Committee Not Enacted 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 513 Philip M. Crane 0 A bill to amend title X of the Public Health Service Act to provide that grants and contracts may not be made under that title to any entity which provides abortion counseling to minors without the knowledge and consent of their parents or guardians, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 2491 Ottinger N/A A bill to establish in the Federal Government a global foresight capability with respect to natural resources, the environment, and population; to establish a national population policy; to establish an interagency council on global resources, environment, and population, and for other purposes. Government Operations; Post Office and Civil Service Referred to House Committees Not Enacted 1983 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H. Con. Res. 93 Gray Lowry-Washinton; Porter; Jeffords; Conable; Anthony; McKernan Concurrent resolution expressing the sense of Congress respecting the administration of title X of the Public Health Service Act. Energy and Commerce Referred to House Committee Not Enacted Senate Bills 1984 Ronald D R 98th Hatch Hawkins; Inouye A bill to revise an d extend Labor and Presented to Enacted

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325W. Reagan (R) (243)/ R (192) (53)/ D (46) H.R. 2301 programs for the provision of health services and preventive health services, to establish a program for the provision of home and community-based services, and for other purposes Human Resources the President P.L. 98555* 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. 2452 Kennedy Randloph; Pell; Eagleton; Riegle; Metzenbaum; Matsunaga; Dodd A bill to revise and extend programs for the delivery of health services. Labor and Human Resources Referred to Senate Committee Not Enacted 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. 2616 Denton Hatch; Grassley; East; Kennedy; Eagleton A bill to extend the Adolescent Family Life Demonstration Program Labor and Human Resources Presented to the President Enacted P.L. 98512* 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. 2622 Denton Hatch A bill to revise and extend title X of the Public Health Service Act, relating to family planning. Labor and Human Resources Referred to Senate Committee Not Enacted 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th S. 2628 Denton 0 A bill to authorize appropriations for title X of the Public Health Service Act. Labor and Human Resources Referred to Senate Committee Not Enacted 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 5493 Waxman 0 A bill to revise and extend the programs of assistance under title X of the Public Health Service Act. Energy and Commerce Referred to House Committee Not Enacted 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 5560 Waxman 0 A bill to amend the Public Health Service Act to revise and extend the programs of assistance for preventive health programs and the programs of assistance under titles X and XX of that act. Energy and Commerce Referred to House Committee Not Enacted 1984 Ronald W. Reagan (R) D (269)/ R (165) R (54)/ D (46) 98th H.R. 5600 Waxman 0 A bill to revise and extend the programs of assistance under titles X and XX of the Public Health Service Act. Energy and Commerce Amended and passed House; Referred to the Committee on Labor and Human Resources Not Enacted Senate Bills 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th S. 881 Kennedy Weicker; Dodd; Pell; Cranston; Stafford; Packwood; Chafee; Metzenbaum; Kerry; Simon; Cohen; Bradley; Riegle; DeConcini; Levin; Matsunaga; Heinz; Evans; Rpoxmire; A bill to extend title X of the Public Health Service Act for 3 years. Labor and Human Resources Reported with amendments Not Enacted

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326Mitchell; Hart; Inouye; Hollings; Gore; Specter; Lautenberg; Leahy; Bingaman; Glenn; Rockefeler; Eagleton; Bentsen; Wilson; Baucus; Gorton; Sasser; Moynihan 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th S. 1091 Chafee 0 A bill to amend title X of the Public Health Service Act to provide for contraceptive development and evaluation. Labor and Human Resources Referred to Senate Committee Not Enacted 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th S. 1643 Wallop (by request0 0 A bill to extend various health services authorities, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted House Bills 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th H.R. 947 Garcia 0 A bill to define Federal policy on adolescent pregnancy and to assist in making available comprehensive services to prevent unintended adolescent pregnancy and childbearing and to assist pregnant adolescents and adolescent parents and their families. Education and Labor; Ways and Means; Energy and Commerce Referred to House Committees Not Enacted 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th H.R. 2252 Waxman 0 A bill to revise and extend the programs of assistance under title X of the Public Health Service Act. Energy and Commerce Referred to House Committee Not Enacted 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th H.R. 2358 Dennemeyer Bliley A bill to extend various health services authorities, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th H.R. 2369 Waxman Madigan A bill to revise and extend the programs of assistance under title X of the Public Health Service Act. Energy and Commerce Failed of passage under suspension of the rules Not Enacted 1985 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th H.R. 3975 Oakar 0 A bill to amend the Public Health Service Act to provide assistance for counseling of, and preparation and distribution of information for pregnant women. N/A N/A Not Enacted Senate Bills 1986 Ronald W. Reagan (R) D (252)/ R (182) R (53)/ D (47) 99th S. 2905 Hatfield Stafford; Heinz; Cranst on A bill to establish a national population policy, and improve methods for collecting, analyzing, and employing natural resources, Governmental Affairs Referred to Senate Committee Not Enacted

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327environmental, and demographic data. House Bills Senate Bills 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th S. 271 Humphrey 0 A bill to amend section 1001 of the Public Health Service Act to permit family planning projects to offer adoption services. Labor and Human Resources Referred to Senate Committee Not Enacted 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th S. 1171 Hatfield 0 A bill to establish a national population policy and to improve methods for correcting, analyzing, and employing natural resource, environmental, and demographic data. Governmental Affairs Referred to Senate Committee Not Enacted 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th S. 1242 Humphrey Armstrong; Danforth; Garn; Gramm; Hatch; Hecht; McClure; Nicles; Symms A bill to prohibit the use of Federal funds for abortions except where the life of the mother would be endangered, and to prohibit the provisions under title X of the Public Health Service Act of Federal family planning funds to organizations that perform or refer for abortions, except where the life of the mother would be endangered, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th S. 1366 Kennedy Stafford; Weicker; Metzenbaum; Matsunaga; Dodd; Simon; Pell; Mikulski; Cranston; Leahy; Gore; Packwood; Chafee; Kerry A bill to revise and extend the programs of assistance under title X of the Public Health Service Act Labor and Human Resources. Labor and Human Resources Reported with amendments Not Enacted 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th S. 1950 Kennedy Hatch; Bingaman A bill to amend the Public Health Service Act to reauthorize adolescent family life demonstration projects, and for other purposes. Labor and Human Resources Reported with amendments Not Enacted House Bills 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th H.R. 1279 Bliley Boulter; Dreier-CA A bill to amend the Public Health Service Act to authorize, with respect to certain grants to assist voluntary family planning projects, the expenditure of grant funds for the purpose of providing adoption services. Energy and Commerce Referred to House Committee Not Enacted 1987 Ronald W. D (258)/ D (55)/ 100th H.R. Hyde Armey; Barton-TX; Bliley; Boulter; Bunning; Burton-Indiana; Coats; A bill to prohibit the sue of Federal funds for abortions Energy and Commerce Referred to House Not Enacted

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328 Reagan (R) R (177) R (45) 1729 Craig; Daniel; Dannemeyer; Davis-IL; DeLay; DeWine; Dreier-CA; DornanCA; Emerson; Fields; Gingrich; Grandy; Gray-IL; Hastert; Holloway; Hunter; Hutto; Kemp; Kyl; Lagomarsino: Lent: Livingston; Thomas A. Luken; Donald E. Lukens; Lungren; Mazzoli; Molohan: Moorhead; Nielson-UT; Packard; Parris; Petri; Rhodes; Roth; RowlandCT; Sensenbrenner; Shumway; SmithNJ; Smith-NH; Smith-Nebraska: Solomon; Spence; Stangeland; Stenholm; Sweeney; Swindall; Tauzin; Volkmer; Vucanovich; Walker; Weber; Wortly; Young-FL except where the life of the mother would be endangered, and to prohibit the provision under title X of the Public Health Service Act o federal family planning funds to organizations that perform or refer for abortions, except where the life of the mother would be endangered, and for other purposes. Committee 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th H.R. 2212 MacKAY Brown-CA; Fazio A bill to establish a national population policy and to improve methods for collecting, analyzing, and implementing natural resource, environmental, and demographic data. Pot Office and Civil Service Referred to House Committee Not Enacted 1987 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th H.R. 3769 Waxman Madigan A bill to amend the Public Health Service Act to revise and extend the program of assistance for family planning services. Energy and Commerce Referred to House Committee Not Enacted House Bills 1988 Ronald W. Reagan (R) D (258)/ R (177) D (55)/ R (45) 100th H.R. 4270 Atkins Snowe; Levin-MI; Kostmayer; Solarz; Beilenson; Fazio; Roybal; Mrazek; Weiss; Boxer; Leach-Iowa; Schroeder; Porter; Berman; LehmanFL; Moody; Owens-NY; Green; Crockett; Ackerman; Johnson-CT; Gejdenson; Scheuer; Udall; Skaggs; Saiki; Studds; Florio; Dymally; MilerCA; Morrison-CT; Wolpe; Waxman; AuCoin; Hoyer; Scneider; Frenzel; Martin-IL; Smith-FL; MorrisonWashington; Matsui; Durbin; Strak; Rangel; Evans; Frank; Morella; Wilson; Levine-CA; Akaka A bill to provide that restrictions may be applied to family planning programs that receive United States assistance only to the extend that the same restrictions apply to domestic family planning programs funded under title X of the Public Health Service Act. Foreign Affairs Referred to House Committee Not Enacted 1988 Ronald W. Reagan D (258)/ R D (55)/ R 100th H.R. 5020 Hyde Annunzio; Archer; Baker; Ballenger; Barton-TX; Bilbray; Bliley; Boulter; Buechner; Bunning; Coats; Craig; A bill to prohibit the use of Federal funds for abortions except where the life of the Energy and Commerce Referred to House Committee Not Enacted

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329(R) (177) (45) Dannemyer; Davis-IL; Davis-MI; DeWine; Dornan-CA; Dyson; Emerson; Grandy; Gray-IL; Hastert; Hiler; Holloway; Hunter; Hutto; Kemp; Kildee; Kyl; Lagomarsino: Lent; Lipinski; Donald E. Lukens; Manton; Marlenee; Mazzoli; MillerOH; Mollohan; Moorhead; NielsonUT; Packard; Perkins; Petri; Rinaldo; Roth; Rowland-CT; Saxton; Shumway; Skelton; Smith-NH; SmithNJ; Solomon; Stangeland; Sundquist; Swindall; Tauke; Vander Jagt; Volkmer; Vucanovich; Walker; Weber; Wolf; Wortley; YoungAlaska; Boniour-Michigan; SmithNebraska; Traxler; McGrath; McCollum; Lott; Armey; Combest; Parris; Tauzin; Henry; Lungren; McCrery; Herger; McMillan-NC; Denny Smith; Hansen mother would be endangered. Senate Bills 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 23 Sen. Gordon J. Humphrey R-NH 3 FAMILY PLANNING PROJECTS ADOPTION SERVICES ACT: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services. Labor and Human Resources Referred to Senate Committee Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 70 Sen. Jesse Helms RNC 0 AIDS CONTROL ACT OF 1989: A bill to control the spread of AIDS. Labor and Human Resources Referred to Senate Committee Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 71 Sen. Jesse Helms RNC 0 AIDS CONTROL ACT OF 1989: A bill to control the spread of AIDS. Upon introduction, the measure was placed on the Senate calendar. Not Referred to Committee Placed on Senate Calendar Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 108 Sen. Daniel K. Inouye D-HI 0 NATIVE HAWAIIAN HEALTH CENTERS GRANT ACT: A bill to amend the Public Health Service Act to permit the Secretary of Health and Human Services to make certain grants to Native Hawaiian health Select Committee: Indian Affairs Referred to Senate Committee Not Enacted

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330 centers. 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 110 Sen. Edward M. Kennedy, D-MA 48 (D-39, R-9) FAMILY PLANNING AMENDMENTS OF 1989: A bill to revise and extend the programs of assistance under title X of the Public Health Service Act. Labor and Human Resources Numerous amendments; Bill returned to Senate Calendar Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 120 Sen. Edward M. Kennedy, D-MA 12 (7-D, 5-R) ADOLESCENT PREGNANCY PREVENTION, CARE, & RESEARCH GRANT ACT of 1989: A bill to amend the Public Health Service Act to reauthorize adolescent family life demonstration projects, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 1671 Sen. Daniel R. Coats RIN 3 FAMILY PLANNING AMENDMENTS ACT OF 1989: A bill to amend title X of the Public Health Service Act to authorize a program of grants to States for family planning programs, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted House Bills 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 720 Rep. Atkins D-MA 112 RESTRCTIONS ON FAMILY PLANNING PROGRAMS: A bill to provide that restrictions may be applied to family planning programs that receive U.S. assistance only to the extent that the same restrictions apply to domestic family planning programs funded under title X of the Public Health Service Act. Foreign Affairs Referred to House Committee Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 930 Rep. Henry A. Waxman, D-CA 170 (138-D, 32-R) FAMILY PLANNING REAUTHORIZATION ACT OF 1989: A bill to amend the Public Health Service Act to extend the program of voluntary family planning established in title X of such act. Energy and Commerce House Subcommittee on Health and the Environment held a hearing Not Enacted 1989 George H.W. Bush D (259)/ R D (55)/ R 101s t H.R. 1042 Rep. Daniel K. Akaka D-HI 0 PUBLIC HEALTH SERVICE ACT AMENDMENT: HAWAIIAN HEALTH Energy and Commerce Referred to House Committee Not Enacted

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331(R) (174) (45) CENTERS: A bill to amend the Public Health Service Act to authorize the Secretary of Health and Human Services to make certain grants to native Hawaiian health centers. 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 1078 Rep. Claudine Schneider, R-RI 143 GLOBAL WARMING PREVENTION ACT OF 1989: A bill to establish national policies and support and encourage international agreements that implement energy and natural resource conservation strategies appropriate to preventing the overheating of the Earth’s atmosphere, known as the greenhouse effect. Energy and Commerce; Science, Space and Technology; Ways and Means; Foreign Affairs; Public Works and Transportation; Government Operations; Agriculture; Interior and Insular Affairs; Banking, Finance, and urban Affairs; Armed Services; Merchant Marine and Fisheries Referred to House Committees Not Enacted 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 2500 Rep. Ronald V. Dellums D-CA 9 U.S. HEALTH SERVICE ACT: A bill to establish a United States Health Service to provide high quality comprehensive health care for all Americans and to overcome the deficiencies in the present system of health care delivery. Energy and Commerce; Armed Services; District of Columbia; Education and Labor; Judiciary; Post Office and Civil Service; Veterans’ Affairs; Ways and Means; Banking, Finance, and Urban Affairs Referred to House Committees Not Enacted 1989 George H.W. D (259)/ D (55)/ 101s t H. R. Rep. William E. 4 (D-0, R-4) PUBLIC HEALTH RESPONSE TO AIDS ACT OF Energy and Commerce Referred to House Not Enacted

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332Bush (R) R (174) R (45) 3102 Dannemeyer R-CA 1989: A bill to amend the Public Health Service Act to establish certain eligibility requirements in the program of grants to grants to the States for counseling and testing with respect to acquired immune deficiency syndrome, and for other purposes. Committee 1989 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 3143 Rep. Les AuCoin, DOR 38 NATIONAL ENERGY POLICY ACT OF 1989: A bill to establish a national energy policy to reduce global warming, and for other purposes. Energy and Commerce; Science, Space and Technology; Banking, Finance, and Urban Affairs; Foreign Affairs; Small Business; Armed Services; Public Works an d Transportation; Interior and Insular Affairs; Agriculture; Ways and Mans Referred to House Committees Not Enacted Senate Bills 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101st S. 2240 Sen. Edward M. Kennedy D-MA 65 RYAN WHITE COMPREHENSIVE AIDS RESOURCES EMERGENCY ACT OF 1990: A bill to amend the Public Health Service Act to provide grants to improve the quality and availability of care for individuals and families with HIV diseases, and for other purposes. Labor and Human Resources Presented to the President Enacted P.L. 101381* 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 2961 Sen. Barbara Mikulski DMD 15 (D-15, 0-R) WOMEN'S HEALTH EQUITY ACT OF 1990: A bill to amend the Public Health Service Act to promote greater equity in the delivery of health care services to women through expanded research on Labor and Human Resources Referred to Senate Committee Not Enacted

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333 women's health issues, improved access to health care services, and the development of disease prevention activities responsive to the needs of women, and for other purposes. 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 2997 Sen. Rudolph E. Boschwitz R-MN 1 (0-D, 1-R) FAMILY PLANNING AMENDMENTS OF 1990: A bill to revise and extend the programs of assistance under title X of the Public Health Service Act, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t S. 2998 Sen. Rudolph E. Boschwitz R-MN 0 FAMILY PLANNING SERVICES ACT OF 1990: A bill to amend the Public Health Service Act to revise and extend title X, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted House Bills 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 4470 Rep. Henry A. Waxman D-CA 4 (4-D, 0-R) AIDS PREVENTION ACT OF 1990: A bill to amend the Public Health Service Act to establish a program of grants to provide preventive health services with respect to acquired immune deficiency syndrome. Energy and Commerce House Subcommittee on Health and the Environment approved for full Committee action, amended Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 4785 Rep. Henry A. Waxman D-CA 5 (5-D, 0-R) AIDS PREVENTION ACT OF 1990: A bill to amend the Public Health Service Act to establish a program of grants to provide preventive health services with respect to acquired immune deficiency syndrome, and for other purposes. Energy and Commerce House insisted on its amendment and requested a conference with the Senate Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 4874 Rep. Henry A. Waxman D-CA 0 AIDS PREVENTION ACT OF 1990: A bill to amend the Public Health Service Act to establish a program of grants to provide preventive health services with respect to acquired immune deficiency syndrome, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted

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3341990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 5231 Rep. John E. Porter R-IL 86 TITLE X PREGNANCY COUNSELING ACT OF 1990: A bill to amend the Public Health Service Act to provide clarification with respect to the authority of grantees under title X of such act to provide information and counseling regarding family planning. Energy and Commerce Referred to House Committee Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 5246 Rep. Nancy L. Johnson, R-CT 33 MICKEY LELAND ADOLESCENT PREGNANCY PREVENTION AND PARENTHOOD ACT OF 1990: A bill to amend the Public Health Service Act to reauthorize adolescent family life demonstration projects, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 5393 Rep. Constance Morella RMD 20 (17-D, 3-R) WOMEN AND AIDS OUTREACH AND PREVENTION ACT: A bill to amend the Public Health Service Act to establish a program of grants regarding the prevention of acquired immune deficiency syndrome in women. Energy and Commerce Referred to House Committee Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 5397 Rep. Patricia Schroeder D-CO 81 (68-D, 13-R) WOMEN’S HEALTH RESEARCH ACT: A bill to promote greater equity in the delivery of health care services to American women through expanded research on women's health issues, improved access to health care services, and the development of disease prevention activities responsive to the needs of women. Energy and Commerce; Ways and Means; Post Office and Civil Service Referred to House Committee Not Enacted 1990 George H.W. Bush (R) D (259)/ R (174) D (55)/ R (45) 101s t H.R. 5693 Rep. Henry A. Waxman D-CA 1 (0-D, 1-R) FAMILY PLANNING REAUTHORIZATION ACT OF 1990: A bill to amend the Public Health Service Act to extend the program of voluntary family planning established in title X of such act. Energy and Commerce House Committee Ordered Reported Amended; Reported in the House Not Enacted

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335 Senate Bills 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S.112 Sen. Daniel K. Inouye DHI 0 NATIVE HAWAIIAN HEALTH CENTERS ACT OF 1991: A bill to amend the Public Health Service Act to permit the Secretary of Health and Human Services to make certain grants to Native Hawaiian health centers. Select Committee: Indian Affairs Referred to Senate Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 185 Sen. Jesse Helms RNC 0 AIDS CONTROL ACT OF 1991: A bill to control spread of AIDS, and for other purposes. Labor and Human Resources Committee Referred to Senate Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 186 Sen. Jesse Helms RNC 0 FEDERAL ADOPTION SERVICES ACT OF 1991: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 323 Sen. John H. Chafee R-RI 48 (40-D, 8-R) FAMILY PLANNING AMENDMENTS ACT OF 1992: A bill to require the secretary of Health and Human Services to ensure that pregnant women receiving assistance under title X of the Public Health Service Act are provided with information and counseling regarding their pregnancies, and for other purposes. Labor and Human Resources Committee Vetoed by President Senate voted to override President s veto; House voted to sustain President veto 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 514 Sen. Barbara Mikulski D-MD 24 (23-D, 1-R) WOMANS HEALTH EQUITY ACT OF 1991: A bill to amend the Public Health Service Act, the Social Security Act, and other Acts to promote greater equity in the delivery of health care services to women through expanded research on womens issues, improved access to health care services, and the development of disease prevention activities responsive to the needs of women, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted

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3361991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 1177 Sen. John D. Rockefelle r D-WV 0 "PEPPER COMMISSION HEALTH CARE ACCESS AND REFORM ACT OF 1991: A bill to amend the Social Security Act to assure universal access to health insurance for basic health services in the United States through qualified employer health plans and a public health insu rance plan, to contain costs and assure quality in the provision of health insurance to small employers, and for other purposes. Finance Committee Committee resumed hearings Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S. 1197 Sen. Edward M. Kennedy D-MA 44 (38-D, 6-R) FAMILY PLANNING AMENDMENTS OF 1991: A bill to amend the Public Health Service Act concerning family planning and to provide for the availability of information and counseling regarding pregnancies, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd S.1995 Sen. Arlen Specter RPA 0 HEALTH CARE ACCESS AND AFFORDABILITY ACT OF 1991: A bill to provide increased access to and affordability of health care, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted House Bills 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 392 Rep. John Edward Porter, RIL 172 (149-D, 23-R) TITLE X PREGNANCY COUNSELING ACT OF 1990: A bill to amend the Public Health Service Act to provide clarification with respect to the authority of grantees under title X of such act to provide information and counseling regarding family planning. Not Referred to Committee upon Introduction Referred to Committee on Energy and Commerce (from full text of bill) Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 1161 Rep. Patricia Schroeder, D-CO 122 (108-D, 14-R) WOMENS HEALTH EQUITY ACT OF 1991: A bill to promote greater equity in the delivery of health care services to American women through expanded research on Energy and Commerce; Ways and Means; Post Office and Civil Services Referred to House Committees Not Enacted

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337women’s health issues, improved access to health care services, and the development of disease prevention activities responsive to the needs of women. 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 1397 Rep. William E. Dannemey er R-CA 19 (1-D, 18-R) FAMILY PLANNING PARENTAL NOTIFICATION ACT: A bill to amend title X of the Public Health Service Act to establish in the program for family planning projects a requirement relating to parental notifications. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 1398 Rep. Nancy L. Johnson, R-CT 35 (30-D, 5-R) MICKEY LELAND ADOLESCENT PREGANNCY PREVENTION AND PARENTHOOD ACT OF 1991: A bill to amend the Public Health Service Act to authorize adolescent family life demonstration projects, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 1968 Rep. Thomas J. Biley RVA 12 (1-D, 11-R) CONSOLIDATED MATERNAL & CHILD HEALTH SERVICE ACT OF 1991: A bill to amend the Public Health Service Act to establish a program of block grants to the States for the purposes of consolidating Federal programs with respect to maternal and child health. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 2343 Rep. Henry A. Waxman D-CA 8 (8-D, 0-R) FAMILY PLANNING AMENDMENTS ACT OF 1991: A bill to amend the Public Health Service Act to revise and extend the program of assistance for family planning services. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 2585 Rep. Henry A. Waxman, D-CA 0 FAMILY PLANNING AMENDMENTS ACT OF 1991: A bill to amend the Public Health Service Act to revise and extend the program of assistance Energy and Commerce House Subcommittee on Health and the Environment approved for Not Enacted

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338for family planning services. full Committee action amended 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 2611 Rep. Ron Wyden DOR 7 (6-D, 1-R) TITLE X PREGNANCY COUNSELING ACT OF 1991: A bill to amend the Public Health Service Act to require recipients of financial assistance for the provision of family planning methods or services under title X of such act to provide certain nondirective counseling and referral services. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 2612 Rep. Henry A. Waxman D-CA 3 (2-D, 1-R) FAMILY PLANNING AMENDMENTS ACT OF 1991: A bill to amend the Public Health Service Act to revise and extend the program of assistance for family planning services. Energy and Commerce Referred to House Committee Not Enacted 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 2707 Rep. William H. Natcher DKY 0 LABOR, HHS & EDUCATION APPROPRIATIONS FOR FY92: A bill making appropriations for the Departments of Labor, Health, and Human Services, and Education, and related agencies, for the fiscal year ending September 30, 1992, and for other purposes. Referred by Senate Appropriations Committee House failed to override the President's veto of the bill, by a recorded vote of 276 yeas and 156 nays (Roll No. 403), two thirds of those present not voting to override, subsequently, message and bill referred to Committee on Appropriations, subsequently the Committee introduced a new appropriations bill (H.R. 3898); House Appropriations Committee received permission to have until Not Enacted

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339 midnight to file a report; Reported in the House 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 3090 Rep. Henry A. Waxman D-CA 0 FAMILY PLANNING AMENDMENTS ACT OF 1991: A bill to amend the Public Health Service Act to revise and extend the program of assistance for family planning services. Energy and Commerce Numerous amendments; Laid on table in House S. 323 passed in lieu 1991 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 3839 Rep. William H. Nathcher D-KY 0 A bill making appropriations for the Departments of Labor, Health, and Human Services, and Education, and related agencies, for the fiscal year ending September 30, 1992, and for other purposes. Appropriation Enrolled in the House and Senate Enacted P.L. 102170* House Bills 1992 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 4983 Rep. Richard John Santorum, R-PA 27 (5-D, 22-R) A bill to amend the Public Health Service Act to make modifications in the program for adolescent family life demonstration projects. Energy and Commerce Referred to House Committee Not Enacted 1992 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 5193 Rep. G.V. (Sonny) Montgomery, D-MS 13 (9-D, 4-R) VETERANS HEALTH PROGRAMS IMPROVEMENT ACT OF 1992: A bill to improve the delivery of health-care services to eligible veterans and to clarify the authority of the Secretary of Veterans Affairs. House Veterans Affairs Committee; House Armed Services Committee; Senate Veterans Affairs Committee Presented to the President Enacted P.L. 102585* 1992 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 5514 Rep. John D. Dingell D-MI 8 (8-D, 0-R) HEALTH CHOICE ACT OF 1992: A bill to provide for health care for all Americans in an affordable manner. Energy and Commerce; Ways and Means; Education and Labor Referred to House Committees Not Enacted 1992 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H.R. 6083 Rep. E. Clay Shaw, R-FL 2 (0-D, 2-R) WELFARE REFORM DEMONSTRATIONS ACT OF 1992: A bill to authorize States to conduct demonstration projects Ways and means; Energy and Commerce; Education and Labor; Referred to House Committees Not Enacted

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340to test the effectiveness of policies designed to help people leave welfare and increase their financial security, and for other purposes. Agriculture; Banking, Finance and Urban Affairs; Judiciary 1992 George H.W. Bush (R) D (267)/ R (167) D (56)/ R (44) 102nd H. Res. 442 Rep. Louise M. Slaughter D-NY 0 RESOLUTION PROVIDING FOR THE CONSIDERATION OF H.R. 3090: Resolution providing for the consideration of the bill H.R. 3090. Not Referred to Committee upon Introduction Agreed to in the House by voice vote 273 yeas and 146 nays (D 24419; R 29-127) Not Enacted Senate Bills 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 18 Sen. Arlen Specter R-PA 0 COMPREHENSIVE HEALTH CARE ACT of 1993: A bill to provide improved access to health care, enhance informed individual choice regarding health care services, lower health care costs through the use of appropriate providers, improve the quality of health care, improve access to longterm care, and for other purposes. Finance Referred to Senate Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 43 Sen. Jesse Helms R-NC 0 FEDEARL ADOPTION SERVICE ACT OF 1993: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services, and for other purposes. Not Referred to Committee upon Introduction Placed on Senate Calendar Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 61 Sen. Jesse Helms R-NC 0 FEDEARL ADOPTION SERVICE ACT OF 1993: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services, and for other purposes. Labor and Human Resources Committee Referred to Senate Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 631 Sen. Arlen Specter R-PA 1 (0-D, 1-R) COMPREHESIVE ACCESS AND AFFORDABILITY HEALTH CARE ACT OF 1993: A bill to contain health care costs and increase access to affordable health care, and for other purposes. Finance Referred to Senate Committee Not Enacted 1993 William J. D (258)/ D (57)/ 103rd S. Sen. Orrin G. Hatch R-UT 18 (8-D, 10-R) BREAST AND CERVICAL CANCER INFORMATION Not Referred to Committee Placed on Senate Not Enacted

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341Clinton (D) R (176) R (43) 1002 ACT OF 1993: A bill to require each recipient of a grant or contract under section 1001 of the Public Health Service Act to provide information concerning breast and cervical cancer. upon Introduction Calendar 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1317 Sen. Orrin G. Hatch R-UT 4 (3-D, 1-R) BREAST AND CERVICAL CANCER INFORMATION ACT OF 1993: A bill to amend the Public Health Service Act to require that certain entities provide information concerning breast and cervical cancer, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1428 Sen. Paul Simon, D-IL 6 (6-D, 0-R) WOMEN AND HIV OUTREACH AND PREVENTION ACT: A bill to amend the Public Health Service Act to provide for programs regarding women and the human immunodeficiency virus, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1757 Sen. George J. Mitchell, D-ME 28 (27-D, 1-R) HEALTH SECURITY ACT: A bill to ensure individual and family security through health care coverage for all American sin a manner that contains the rate of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care, and to ensure and protect the health care of all Americans. Not Referred to Committee upon Introduction Senate Indian Affairs Committee considered provisions of the bill which fall within the jurisdiction of the Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1770 Sen. John H. Chafee, R-RI 22 (2-D, 20-R) HEALTH EQUITY AND ACCESS REFORM TODAY ACT OF 1993: A bill to provide comprehensive reform of the health care system of the United States, and for other purposes. Not Referred to Committee upon Introduction Placed on Senate calendar Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1775 Sen. Daniel Patrick Moynihan, DNY 0 HEALTH SECURITY ACT: A bill to ensure individual and family security through health care coverage for all Americans in a manner that contains the rate Not Referred to Committee upon Introduction Amendment submitted and ordered to lie on the table Not Enacted

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342of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care, and to ensure and protect the health care for all Americans. 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 1779 Sen. Edward M. Kennedy, D-MA 0 HEALTH SECRUITY ACT: A bill to ensure individual and family security through health care coverage for all Americans in a manner that contains the rate of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care, and to ensure and protect the health care for all Americans. Not Referred to Committee upon Introduction Amendment submitted and ordered to lie on the table Not Enacted House Bills 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 670 Rep. Henry A. Waxman D-CA 0 FAMILY PLANNING AMENDMENTS ACT OF 1993: A bill to require the Secretary of Health and Human Services to ensure that pregnant women receiving assistance under title X of the Public Health Service Act are provided with information and counseling regarding their pregnancies, and for other purposes. Energy and Commerce Committee Reported in the Senate Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 2293 Rep. Jon Kyl R-AZ 14 (7-D, 7-R) BREAST AND CERVICAL CANCER INFORMATION ACT OF 1993: A bill to require each recipient of a grant or contract under section 1001 of the Public Health Service Act to provide information concerning breast and cervical cancer. Energy and Commerce Referred to House Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 2395 Rep. Constance Morella, RMD 92 (79-D, 13-R) WOMEN AND HIV OUTREACH AND PREVENTION ACT: A bill to amend the Public Health Service Act to provide for programs regarding women and the human immunodeficiency virus. Energy and Commerce Referred to House Committee Not Enacted 1993 William D D 103rd Rep. Patricia 95 WOMENS HEALTH EQUITY Armed Referred to Not

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343J. Clinton (D) (258)/ R (176) (57)/ R (43) H.R. 3075 Schroeder, DCO (87-D, 8-R) ACT OF 1993: A bill to promote greater equity in the delivery of health care services to American women through expanded research on womens health issues and through improved access to health care services, including preventive health services. Services; Education and Labor; Energy and Commerce; Foreign Affairs; Judiciary; Veterans Affairs; Ways and means House Committees Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 3561 Rep. Nancy L. Johnson, R-CT 33 (31-D, 2-R) MICKEY LELAND ADOLESCENT PREGNANCY PREVENTION AND PARENTHOOD ACT OF 1993: A bill to amend the Public Health Service Act to reauthorize adolescent family life demonstration projects, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 3600 Rep. Richard A. Gephardt, D-MO 103 (103-D, 0-R) HEALTH SECURITY ACT: A bill to ensure individual and family security through health care coverage for all Americans in a manner that contains the rate of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care and to ensure and protect the health care for all Americans. Armed Services; Education and Labor; Energy and Commerce; Government Operations; Judiciary; Natural Resources; Post Office and Civil Service; Rules; Veterans Affairs; Ways and Means Reported in the House, amended Not Enacted 1993 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 3704 Rep. William M. Thomas, R-CA 8 (0-D, 8-R) HEALTH EQUITY AND ACCESS REFORM TODAY ACT OF 1993: A bill to provide comprehensive reform of the health care system of the United States, and for other purposes. Education and Labor; Energy and Commerce; Judiciary; Rules; Ways and Means; House Subcommittee on Health concluded hearings Not Enacted Senate Bills 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 2009 Sen. Tom Harkin D-IA 3 (0-D, 3-R) WELFARE TO SELFSUFFICIENCY ACT OF 1994: A bill to amend title IV of the Social Security Act by reforming the aid to families with Finance Referred to Senate Committee Not Enacted

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344dependent children program, and for other purposes. 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 2134 Sen. Lauch Faircloth, RNC 20 (0-D, 20-R) WELFARE REFORM ACT OF 1994: A bill to restore the American family, reduce illegitimacy, and reduce welfare dependence. Finance Referred to Senate Committee Not Enacted 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 2296 Sen. Edward M. Kennedy, D-MA 0 HEALTH SECURITY ACT: A bill to ensure individual and family security through health care coverage for all Americans in a manner that contains the rate of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care and to ensure and protect the health care for all Americans. Originated from the Senate Labor and Human Resources Committee Placed on Senate Calendar Not Enacted 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd S. 2351 Sen. Daniel Patrick Moynihan, DNY 0 HEALTH SECURITY ACT: An original bill to achieve universal health coverage, and for other purposes. Originated from the Senate Finance Committee Amendments submitted Not Enacted House Bills 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 4202 Rep. Jim McCrery, RLA 11 (2-D, 9-R) HEALTH SAVINGS AND SECURITY ACT OF 1994: A bill to increase access to high quality, affordable health insurance Education and Labor; Energy and Commerce; Judiciary; Ways and Means Referred to House Committees Not Enacted 1994 William J. Clinton (D) D (258)/ R (176) D (57)/ R (43) 103rd H.R. 4473 Rep. James Talent, R-MO 42 (0-D, 42-R) REAL WELFARE REFORM ACT OF 1994: A bill to restore the American family, reduce illegitimacy, and reduce welfare dependence. Agriculture; Banking, Finance and Urban Affairs; Education and Labor; Energy and Commerce; Government Operations; Judiciary; Natural Resources; Public Work and Transportation; Rules; Ways and Means Referred to House Committees Not Enacted 1994 William J. Clinton D (258)/ R D (57)/ R 103rd H.R. 4566 Rep. James Talent, R-MO 46 (0-D, 46-R) REAL WELFARE REFORM ACT OF 1994: A bill to restore the American Agriculture; Banking, Finance and Referred to House Committees Not Enacted

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345(D) (176) (43) family, reduce illegitimacy, and reduce welfare dependence. Urban Affairs; Education and Labor Committee; Energy and Commerce; Government Operations; Judiciary; Natural Resources; Public Works and Transportation; Rules; Ways and Means Senate Bills 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 18 Sen. Arlen Specter R-PA 1 (1-D, 0-R) HEALTH CARE ASSURANCE ACT OF 1995: A bill to provide improved access to health care, enhance informed individual choice regarding health care services, lower health care costs through the use of appropriate providers, improve the quality of health care, improve access to longterm care, and for other purposes. Finance Referred to Senate Committee Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 29 Sen. Jesse Helms R-NC 0 FEDERAL ADOPTION SERVICES ACT OF 1995: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services, and for other purposes. Not Referred to Committee upon Introduction Read the first time; Placed on Senate Calendar Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 321 Sen. Jesse Helms R-NC 0 FEDERAL ADOPTION SERVICES ACT OF 1995: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 736 Sen. Tom Harkin D-IA 1 (0-D, 1-R) WELFARE TO SELFSUFFICIENCY ACT OF 1995: A bill to amend title IV of the Social Security Act by reforming Finance Referred to Senate Committee Not Enacted

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346the aid to families with dependent children program, and for other purposes. 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 979 Sen. Barbara Boxer D-CA 13 (10-D, 3-R) WOMENS CHOICE AND REPRODUCTIVE HEALTH PROTECTION ACT OF 1995: A bill to protect womens reproductive health and constitutional right to choice, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 1209 Sen. Daniel R. Coats R-IN 0 RESPONSIBLE PARENTHOOD ACT OF 1995: A bill to amend title V of the Social Security Act to promote responsible parenthood and integrated delivery of family planning services by increasing funding for and block granting the family planning program and the adolescent family life program. Not Referred to Committee upon Introduction Introduced in the Senate Not Enacted House Bills 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 759 Rep. Joseph K. Knollenberg R-MI 14 (0-D, 14-R) COMMON SENSE WELFARE REFORM ACT OF 1995: A bill to improve the effectiveness of Federal welfare efforts and increase citizen participation in fighting poverty. Agriculture; Banking and Financial Services; Commerce; Economic and Educational Opportunities; Judiciary; Resources; Rules Referred to House Committees Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 833 Rep. James C. Greenwood R-PA 51 (36-D, 15-R) FAMILY PLANNING AMENDMENTS ACT OF 1995: A bill to require the Secretary of Health and Human Services to ensure that pregnant women receiving assistance under Title X of the Public Health Service Act are provided with information and counseling regarding their pregnancies, and for other purposes. Commerce Referred to House Committee Not Enacted 1995 William J. Clinton R (230)/ D R (53)/ D 104th H.R. 1146 Rep. Richard (Doc) Hastings, R9 (0-D, 9-R) STATE FLEXIBILITY, INDIVIDUAL EMPOWERMENT, AND Agriculture; Banking and Financial Referred to House Committees Not Enacted

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347(D) (204) (47) WA DEPENDENCY REDUCTION ACT: A bill to reduce the Federal welfare bureaucracy and empower States to design and implement efficient welfare programs that promote personal responsibility, work and stable families by replacing certain Federal programs with a program of annual block grants to States, and for other purposes. Services; Commerce; Economic and Educational Opportunities; Judiciary; Resources; Transportation and Infrastructure; Ways and Means 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 1623 Rep. Robert K. Dornan RCA 0 FAMILY PLANNING PROGRAMS REPEAL ACT: A bill to amend the Public Health Service Act to repeal family planning programs under title X of the Act. Commerce Referred to House Committee Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 1952 Rep. Patricia Schroeder DCO 73 (69-D, 3-R) WOMENS CHOICE AND REPRODUCTIVE HEALTH PROTECTION ACT OF 1995: A bill to protect womens reproductive health and constitutional right to choice. Commerce; Judiciary Referred to House Committees Not Enacted 1995 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 2127 Rep. John Edward Porter R-IL 0 DEPARTMENTS OF LABOR, HHS, EDUCATION & RELATED AGENCIES APPROPRIATIONS ACT: A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies, for the FY ending 9/30/96, and for other purposes. Originated from the House Appropriations Committee; Senate Appropriations Committee; Senate Subcommittee on Labor, Health and Human Services, and Education, and Related Agencies Unanimousconsent agreement was reached providing for the scheduled cloture vote on a motion to proceed to the consideration of the bill, to occur at a time to be determined Not Enacted Senate Bills 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 1594 Sen. Mark. O. Hatfield, ROR 0 An original bill making omnibus consolidated rescissions and appropriations for the fiscal year ending September 30, 1996, and for other purposes. Originated form the Senate Appropriations Committee Reported in the Senate Not Enacted 1996 William R R 104th Sen. Olympia 10 WOMENS HEALTH EQUITY Labor and Referred to Not

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348 J. Clinton (D) (230)/ D (204) (53)/ D (47) S. 1799 J. Snowe, RME (9-D, 1-R) ACT OF 1996: A bill to promote greater equity in the delivery of health care services to American women through expanded research on womens health issues and through improved access to health care services, including preventive health services. Human Resources Committee Senate Committee Enacted 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th S. 1904 Sen. Daniel R. Coats R-IN 0 PROJECT FOR AMERICAN RENEWAL ACT: A bill to implement the Project for American Renewal, and for other purposes. Finance Referred to Senate Committee Not Enacted Houes Bills 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 1044h H.R. 3019 Rep. Robert L. Livingston, R-LA 0 OMNIBUS CONSOLIDATED RESCISSIONS AND APPROPRIATIONS ACT OF 1996: A bill making appropriations for fiscal year 1996 to make further down payment toward a balanced budget, and for other purposes. Appropriation s; Budget Presented to the President Enacted P.L. 104134* 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 3174 Rep. Constance Morella, RMD 15 (13-D, 1-R) WOMEN AND HIV OUTREACH AND PREVENTION ACT: A bill to amend the Public Health Service Act to provide for programs regarding women and the human immunodeficiency virus. Commerce Referred to House Committee Not Enacted 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 3178 Rep. Louise M. Slaughter D-NY 43 (36-D, 6-R) WOMENS HEALTH EQUITY ACT OF 1996: A bill to promote greater equity in the delivery of health care services to American women through expanded research on womens health issues and through improved access to health care services, including preventive health services. Agriculture; Banking and Financial Services; Commerce; Economic and Educational Opportunities; International Relations; Judiciary; National Security; Ways and Means Referred to House Committees Not Enacted 1996 William R R 104th Rep. Louise 8 FAIRNESS TO MINORITY Agriculture; Referred to Not

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349J. Clinton (D) (230)/ D (204) (53)/ D (47) H.R. 3179 M. Slaughter D-NY (8-D, 0-R) WOMEN HEALTH ACT: A bill to modify various Federal health programs to make available certain services to women who are members of racial or ethnic minority groups, and for other purposes. Commerce; Economic and Educational Opportunities; Ways and Means House Committees Enacted 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 3716 Rep. John R. Kasich ROH 3 (0-D, 3-R) PROJECT FOR AMERICAN RENEWAL ACT: A bill to implement the project for American renewal, and for other purposes. Agriculture; Banking and Financial Services; Commerce; Economic and Educational Opportunities; Judiciary; Ways and Means Referred to House Committees Not Enacted 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 3755 Rep. John Edward Porter R-IL 0 DEPARTMENTS OF LABOR, HHS, EDUCATION & RELATED AGENCIES APPROPRIATIONS ACT: A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies, for the fiscal year ending September 30, 1997, and for other purposes. Originated from the House Appropriations Committee Senate Appropriations Committee ordered reported, amended Not Enacted 1996 William J. Clinton (D) R (230)/ D (204) R (53)/ D (47) 104th H.R. 4278 Rep. Robert L. Livingston, R-LA 0 A bill making omnibus consolidated appropriations for the fiscal year ending September 30, 1997, and for other purposes. Not Referred to Committee upon Introduction Became part of H.R. 3610 Not Enacted Senate Bills 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 24 Sen. Arlen Specter RPA 0 HEALTH CARE ASSURANCE ACT OF 1997: A bill to provide improved access to health care, enhance informed individual choice regarding health care services, lower health care costs through the use of appropriate providers, improve the quality of health care, improve access to longterm care, and for other purposes. Finance Referred to Senate Committee Not Enacted 1997 William J. R (227)/ R (55)/ 105th S. 45 Sen. Jesse Helms R-NC 0 FEDERAL ADOPTION SERVICES ACT OF 1997: Not Referred to Committee Read twice and placed on Senate Not Enacted

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350Clinton (D) D (207) D (45) A bill to amend title X of the Public Health Service Act to permit family projects to offer adoptions services upon Introduction Calendar 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 187 Sen. Jesse Helms R-NC 0 FEDERAL ADOPTION SERVCIES ACT OF 1997: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services Labor and Human Resources Referred to Senate Committee Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 1061 Sen. Arlen Specter, RPA 0 DEPT. OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES: An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 1998, and for other purposes. Originated form the Senate Committee on Appropriations Passed in Senate; Text inserted in to H.R. 2264, then indefinitely postponed Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 1208 Sen. Barbara Boxer D-CA 3 (3-D, 0-R) FAMILY PLANNING AND CHOICE PROTECTION ACT OF 1997: A bill to protect womens reproductive health constitutional right to choice, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 1318 Sen. Edmond Spencer Abraham, RMI 2 (1-D, 1-R) ADOPTION AWARENESS PROGRAM ACT: A bill to establish an adoption awareness program, and for other purposes. Labor and Human Resources Referred to Senate Committee Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th S. 1364 Sen. John McCain, RAZ 1 (1-D, 0-R) FEDERAL REPORTS ELIMINATION ACT OF 1998: A bill to eliminate unnecessary and wasteful Federal reports. Governmental Affairs; Government Reform and Oversight Passed both chambers, cleared for the President Not Enacted House Bills 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 1219 Rep. Nancy Pelosi, D-CA 121 (107-D, 13-R) WILLIAM A. BAILEY COMPREHENSIVE HIV PREVENTION ACT OF 1997: A bill to amend the Pubic Health Service Act to promote activities for the prevention of additional cases of infection with the virus commonly known as HIV. Commerce Referred to House Committee Not Enacted

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351 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 1374 Rep. Ronald V. Dellums D-CA 0 JOSEPHINE BULTER UNITED STATES HEALTH SERVICE ACT: A bill to establish a U.S. health service to provide high quality comprehensive health care for all Americans to overcome the deficiencies in the present system of health care delivery. Commerce; Judiciary Committee; Ways and Means Referred to House Committees Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 2264 Rep. John Edward Porter R-IL 0 LABOR, HEALTH AND HUMAN SERVCIES, AND EDUCATION APPROPRIATIONS ACT, 1998: A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 1998, and for other purposes. Originated from the House Committee on Appropriation Enrolled in the Senate Enacted P.L. 105-78* 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 2525 Rep. Nita M. Lowey DNY 49 (47-D, 1-R) FAMILY PLANNING AND CHOICE PROTECTION ACT OF 1997: A bill to protect womens reproductive health and constitutional right to choice, and for other purposes. Commerce; Education and the Workforce; Judiciary Referred to House Committees Not Enacted 1997 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 2941 Rep. Kevin Brady R-TX 12 (1-D, 12-R) A bill to permit States to condition use of State funds for purchase of prescription drugs for minors under certain Federal State matching programs upon parental consent. Commerce; Ways and Means Referred to House Committees Not Enacted House Bills 1998 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 3229 Rep. Don Manzullo RIL 34 (1-D; 33-R) TITLE X CHILD ABUSE, RAPE, MOLESTATION AND INCEST REPORTING ACT: A bill to provide for the applicability, to providers of services under title X of the Public Health Service Act, of State reporting requirements for minors who are victims of abuse, rape, molestation, or incest. Commerce Referred to House Committee Not Enacted 1998 William R R 105th Rep. Don 31 TITLE X PARENTAL Commerce Referred to Not

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352J. Clinton (D) (227)/ D (207) (55)/ D (45) H.R. 3230 Manzullo RIL (0-D; 31-R) NOTIFICATION ACT OF 1998: A bill to provide for parental notification of family planning services, and reporting under State law for minors who are victims of abuse, rape, molestation, or incest, under title X of the Public Health Service Act. House Committee Enacted 1998 William J. Clinton (D) R (227)/ D (207) R (55)/ D (45) 105th H.R. 4721 Rep. Ernest James Istook R-OK 18 (1-D; 17-R) PARENTAL NOTIFICATION ACT OF 1998: A bill to establish restrictions on the provisions to minors of contraceptive drugs and devices through family planning projects under title X of the Public Health Service Act, and for other purposes. Commerce Referred to House Committee Not Enacted Senate Bills 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th S. 42 Sen. Jesse Helms R-NC 5 (0-D; 5-R) FEDERAL ADOPTION SERVICES ACT OF 1999: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services. Not Referred to Committee upon Introduction Placed on Senate Calendar Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th S. 290 Sen. Edmond Spencer Abraham, RMI 6 (1-D, 5-R) ADOPTION PROMOTION ACT: A bill to establish an adoption awareness program, and for other purposes. Health, Education, Labor, and pensions Referred to Senate Committee Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th S. 1400 Sen. Barbara Boxer D-CA 7 (7-D; 0-R) FAMILY PLANNING AND CHOICE PROTECTION ACT OF 1999: A bill to protect womens reproductive health and constitutional right to choice, and for other purposes. Health, Education, Labor and Pensions Referred to Senate Committee Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th S. 1650 Sen. Arlen Specter, RPA 0 APPROPRIATIONS FOR THE DEPT. OF LABOR, HHS, AND EDUCATION FOR F/Y 2000: An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending Originated form the Senate Committee on Appropriations Passed in the Senate, as amended Not Enacted

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353September 30, 2000, and for other purposes. House Bills 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th H.R. 2405 Rep. Nancy Pelosi, D-CA 67 (60-D, 6-R) COMPREHENSIVE HIV PRENVTION ACT OF 1999: A bill to amend the Public Health Service Act to promote activities for the prevention of additional cases of infection with the virus commonly known as HIV. Commerce Referred to House Committee Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th H.R. 2485 Rep. Clifford B. Stearns, R-FL 6 (1-D, 5-R) FEDEARL ADOPTION SERVICES ACT OF 1999: A bill to amend title X of the Public Health Service Act to permit family planning projects to offer adoption services. Commerce Referred to House Committee Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th H.R. 2540 Rep. Chris Smith, R-NJ 1 (1-D, 0-R) 1999 OMNIBUS ADOPTION ACT: A bill to establish grant programs and provide other forms of Federal assistance to pregnant women, children in need of adoptive families, and individuals and families adopting children. Education and the Workforce; Ways and Means; Commerce; Judiciary; Banking and Financial Services; Armed Services; Transportation and Infrastructure Referred to House Committees Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th H.R. 3037 Rep. John Edward Porter, R-IL 0 A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2000, and for other purposes. Originated form the House Committee on Appropriations Report filed by House Committee on Appropriations Not Enacted 1999 William J. Clinton (D) R (222)/ D (211) R (55)/ D (45) 106th H.R. 3424 Rep. C.W. (Bill) Young, RFL 0 DEPARTMENTS OF LABOR, HEALTH, AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS ACT, 2000: A bill making appropriations for the Departments of Labor, Health and Human Services, Appropriation Enacted by cross-reference as part of H.R. 3194 (P.L. 106113) Enacted P.L. 106113*

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354 and Education, and related agencies for the fiscal year ending September 30, 2000, and for other purposes. Senate Bills 2000 George W. Bush (R) R (222)/ D (211) R (55)/ D (45) 106th S. 2553 Sen. Arlen Specter, RPA 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and relate agencies for the fiscal year ending September 30, 2001, and for other purposes. Originated from the Senate Committee on Appropriations Report filed by the Senate Committee on Appropriations Not Enacted Senate Bills 2000 George W. Bush (R) R (222)/ D (211) R (55)/ D (45) 106th H.R. 4365 Rep. Michael Bilirakis, RFL 1 (1-D, 0-R) A bill to amend the Public Health Service Act with respect to childrens health. House Committee on Commerce; Senate Committee on Health, Education, Labor, and Pensions Presented to the President Enacted P.L. 106310* 2000 George W. Bush (R) R (222)/ D (211) R (55)/ D (45) 106th H.R. 4577 Rep. John Edward Porter, R-IL 0 A bill making appropriations for the Departments of Labor, Health and Human services, and Education, and related agencies for the fiscal year ending September 30, 2001, and for other purposes. Not Referred to Committee upon Introduction Presented to the President Enacted P.L. 106554* 2000 George W. Bush (R) R (222)/ D (211) R (55)/ D (45) 106th H.R. 5574 Rep. Nick Lampson, D-TX 22 (20-D, 2-R) ADOPTION DOES OFFER POTENTIAL TREAURES ACT OF 2000: A bill to authorize the Secretary of Health and Human Services to establish an adoption awareness program; to establish the Adoption Awareness Commission; and to promote adoptions through increased public awareness and increased tax incentives. Commerce; Education and the Workforce; Ways and Means Referred to House Committees Not Enacted 2000 George W. Bush (R) R (222)/ D (211) R (55)/ D (45) 106th H.R. 5656 Rep. John Edward Porter, R-IL 0 DEPARTMETNS OF LABOR, EHATLH AND HUMAN SERCIES, AND EDUAITON, AND RELATEA GENCIES Not Referred to Committee upon Introduction Incorporated by reference into the conference Not Enacted

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355APPROPRIATIONS ACT, A bill making appropriations for the Departments of Labor, Health and Human services, and Education, and related agencies for the fiscal year ending September 30, 2001, and for other purposes. report of H.R. 4577 Senate Bills 2001 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th S. 24 Sen. Trent Lott, R-MS 0 HEALTH CARE ASSURANCE ACT OF 2001: A bill to provide improved access to health care, enhance informed individual choice regarding health care services, lower health care costs through the use of appropriate providers, improve the quality of health care, improve access to longterm care, and for other purposes. Finance Referred to Senate Committee Not Enacted 2001 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th S. 1536 Sen. Tom Harkin, DIA 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2002, and for other purposes. Originated from the Senate Committee on Appropriations Report filed by the Senate Committee on Appropriations Not Enacted House Bills 2001 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th H.R. 3006 Rep. Jo Ann Davis R-VA 30 (2-D; 28-R) ADOPTION INFORMATION ACT: A bill to require assurances that certain family planning service projects and programs will provide pamphlets containing the contact information of adoption centers. Energy and Commerce Referred to House Committee Not Enacted 2001 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th H.R. 3061 Rep. Ralph S. Regula, R-OH 0 A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2002, Originated from the House Committee on Appropriations Presented to the President Enacted P.L. 107116*

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356 and for other purposes. Senate Bills 2002 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th S. 2766 Sen. Tom Harkin, DIA 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education and relate agencies for the fiscal year ending September 30, 2003, and for other purposes. Originated form the Senate Committee on Appropriations Referred to Senate Committee Not Enacted House Bills 2002 George W. Bush (R) R (221)/ D (212) R (50)/ D (50) 107th H.R. 5320 Rep. C.W. (Bill) Young, RFL 0 A bill making appropriations for the Department of Labor, Health and Human Services, and Education, related agencies for the fiscal year ending September 30, 2003, and for other purposes. Appropriations Referred to House Committee Not Enacted Senate Bills 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th S. 1356 Sen Arlen Specter, RPA 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2004, and for other purposes. Originated from the Senate Committee on Appropriations Report filed by the Senate Committee on Appropriations Not Enacted House Bills 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 246 Rep. Ralph S. Regula ROH 0 A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2003, and for other purposes. Appropriations Referred to House Committee Not Enacted 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 1229 Rep. Jo Ann Davis R-VA 51 (1-D; 50-R) ADOPTION INFORMATION ACT: A bill to require assurances that certain family planning service projects and programs will provide pamphlets containing the contact information of adoption centers Energy and Commerce Referred to House Committee Not Enacted 2003 George R R 108h Rep. Ron 1 FREEEDOM OF Energy and Referred to House Not

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357W. Bush (R) (229)/ D (205) (51)/ D (48) H.R. 1548 Paul R-TX (0-D; 1-R) CONSCIENCE ACT OF 2003: A bill to prohibit any Federal official from expending any Federal funds for any population control or population planning program or any family planning activity. Commerce; International Relations Committees Enacted 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 2444 Rep. Todd Akin R-MO 94 (4-D; 90-R) PARENT’S RIGHT TO KNOW ACT OF 2003: A bill to establish certain requirements relating to the provision of services to minors by family planning projects under title x of the Public Health Service Act. Energy and Commerce Referred to House Committee Not Enacted 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 2618 Rep. David Obey, D-WI 0 DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCAITON, AND RELATE AGENCIES APPROPRIATIONS ACT, 2004: A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2004, and for other purposes. Appropriations Referred to House Committee Not Enacted 2003 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 2660 Rep. Ralph S. Regula, ROH 0 DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATONS ACT, 2004: A bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2004, and for other purposes. Not Referred to Committee upon Introduction Passed in Senate, as amended; Several motions in House Not Enacted 2004 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108t h H.R. 2673 Rep. Henry Bonilla, RTX 0 CONSOLIDATED APPROPRIATIONS ACT, 2004: An original bill making Originated from the House Committee on Presented to the President Enacted P.L. 108199*

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358appropriations for Agriculture, Rural Development, Food and Drug Administration, and Related Agencies for the fiscal year ending September 30, 2004, and for other purposes. Appropriation ; Referred to the U.S. House of Representative Senate Bills 2004 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th S. 2336 Sen. Harry Reid DNV 11 (9-D, 1-R) PUTTING PREVENTION FIRST ACT: A bill to expand access to preventive health care services and education programs that help reduce unintended pregnancy, reduce infection with sexually transmitted disease, and reduce the number of abortions. Health, Education, Labor, and Pensions Referred to Senate Committee Not Enacted House Bills 2004 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 4192 Rep. Louise M. Slaughter D-NY 130 (125-D, R-4) PUTTING PREVENTION FIRST ACT: A bill to expand access to preventive health care services and education programs that help reduce unintended pregnancy, reduce infection with sexually transmitted disease, and reduce the number of abortions. Education and the Workforce; Energy and Commerce; Ways and Means Referred to House Committees Not Enacted 2004 George W. Bush (R) R (229)/ D (205) R (51)/ D (48) 108th H.R. 5006 Rep. Ralph S. Regula, R-OH 0 DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICESW, AND EDUCAITON, AND RELATED AGENCIES APPROPRIATION BILL, 2005 REPORT: An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and relate agencies for the fiscal year ending September 30, 2005, and for other purposes. Originated from the House Committee on Appropriations House passes, as amended Not Enacted Senate Bills 2005 George W. R (232)/ R (55)/ 109th S. Sen. Harry 25 (24-D, 0-R) PREVENTION FIRST ACT: A bill to expand access to Health, Education, Referred to Senate Not Enacted

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359Bush (R) D (202) D (44) 20 Reid DNV preventive health care services that help reduce unintended pregnancy, reduce the number of abortions, and improve access to womens health care. Labor, and Pensions Committee 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th S. 844 Sen. Hillary Clinton D-NY 1 (1-D, 0-R) COMPASSIONATE ASSISTANCE FOR RAPE EMERGENCIES ACT: A bill to expand access to preventive health care services that help reduce unintended pregnancy, reduce the number of abortions, and improve access to womens health care. Not Referred to Committee upon Introduction Introduced in Senate Not Enacted 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th S. 1279 Sen. Tom Coburn ROK 10 (0-D; 10-R) PARENTS RIGHT TO KNOW ACT OF 2005: A bill to establish certain requirements relating to the provision of services to minors by family planning projects under title X of the Public Health Service Act. Health, Education, Labor, and Pensions Referred to Senate Committee Not Enacted 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th S. Res. 162 Sen. Olympia J. Snowe R-ME 11 (10-D, 0-R) A resolution expressing the sense of the Senate concerning Griswold v. Connecticut. Judiciary Referred to Senate Committee Not Enacted House Bills 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 69 Rep. Jo Ann Davis RVA 42 (3-D, 38-R) ADOPTION INFORMATION ACT: A bill to require assurance that certain family planning service projects and programs will provide pamphlets containing the contact information of adoption centers. Energy and Commerce Referred to House Committee Not Enacted 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 777 Rep. Ron Paul RTX 4 (0-D; 4-R) TAXPAYERS FREEDOM OF CONSCIENCE ACT OF 2005: A bill to prohibit any Federal official from expending any Federal funds fro any population control or population planning program or any family planning activity. Energy and Commerce; International Relations Referred to House Committees Not Enacted 2005 George W. Bush R (232)/ D R (55)/ D 109th H.R. 1709 Rep. Louise M. Slaughter 134 (129-D, 4-R) PREVENTION FIRST ACT: A bill to expand access to preventive health care services Education and the Workforce; Energy and Referred to House Committees Not Enacted

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360(R) (202) (44) D-NY that help reduce unintended pregnancy, reduce the number of abortions, and improve access to womens health care. Commerce; Ways and Means 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109t h H.R. 3010 Rep. Ralph S. Regula R-OH 0 DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS ACT, 2006: An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and Related Agencies for the fiscal year ending September 30, 2006. Originated from the House Committee on Appropriation Presented to the President Enacted P.L. 109149* 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 3011 Rep. Todd Akin RMO 85 (2-D, 83-R) PARENTS RIGHT TO KNOW ACT OF 2005 A bill to establish certain requirements relating to the provision of services to minors by family planning projects under Title X of the Public Health Service Act. Energy and Commerce Referred to House Committee Not Enacted 2005 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H. Res. 311 Rep. Rosa L. DeLauro D-CT 59 (53-D, 5-R) A resolution recognizing the importance of the decision of the Supreme Court, Griswold v. Connecticut, which 40 years ago held that married couples have a constitutional right to use contraceptives, thereby recognizing the legal right of women to control their fertility through birth control and providing for vast improvements in maternal and infant health and for significant reductions in the rate of unintended pregnancy, and for other purposes. Judiciary Referred to House Committee Not Enacted Senate Bills 2006 George W. Bush (R) R (232)/ D (202) R (55) / D (44) 109th S. 2206 Sen. David Vitter RLA 4 (0-D, 4-R) TITLE X FAMILY PLANNING ACT: A bill to amend Title X of the Public Health Service Act to prohibit family planning grants Health, Education, Labor and Pensions Referred to Senate Committee Not Enacted

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361 from being awarded to any entity that performs abortions. 2006 George W. Bush (R) R (232)/ D (202) R (55) / D (44) 109th S. 3708 Sen. Arlen Specter, R-PA 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2007, and for other purposes. Not Referred to Committee upon Introduction Report filed by Senate Committee on Appropriations Not Enacted 2006 George W. Bush (R) R (232)/ D (202) R (55) / D (44) 109th S. Res. 485 Sen. Hillary Clinton D-NY 17 (15-D; 1-R) A resolution to express the sense of the Senate concerning the value of family planning for American women. Health, Education, Labor, and Pensions Referred to Senate Committee Not Enacted House Bills 2006 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 5647 Rep. Ralph S. Regula ROH 0 An original bill making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2007. Originated from the House Committee on Appropriations Reported in the House Not Enacted 2006 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 5967 Rep. Jeb Hensarlin g, R-TX 3 (0-D, 3-R) AMERICAS COMMITMENT TO VETERANS ACT: A bill to provide for increased funding for veterans health care for fiscal year 2007, and for other purposes. Energy and Commerce; Judiciary; Veterans Affairs Referred to House Committees Not Enacted 2006 George W. Bush (R) R (232)/ D (202) R (55)/ D (44) 109th H.R. 6067 Rep. Tim Ryan DOH 23 (23-D, 0-R) REDUCING THE NEED FOR ABORTION AND SUPPORTING PARENTS ACT: A bill to provide for programs that reduce the number of unplanned pregnancies, reduce the need for abortion, help women bear healthy children, and support new parents. Education and the Workforce; Energy and Commerce; Ways and Means Referred to House Committees Not Enacted Senate Bills 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th S. 21 Sen. Harry Reid, DNV 34 (32-D, 1-R) PREVENTION FIRST ACT: A bill to expand access to preventive health care services that help reduce unintended pregnancy, reduce abortions, and improve access Health, Education, Labor, and Pensions Referred to Senate Committee Not Enacted

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362to womens health care. 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th S. 351 Sen. David Vitter, RLA 4 (0-D, 4-R) TITLE X FAMILY PLANNING ACT: A bill to amend Title X of the Public Health Service Act to prohibit family planning grants from being awarded to any entity that performs abortions. Health, Education, Labor, and Pensions Referred to Senate Committee Not Enacted House Bills 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 104 Rep. Jo Ann Davis R-VA N/A ADOPTION INFORMATION ACT: A bill to require assurances that certain family planning services projects and programs will provide pamphlets containing the contact information of adoption centers. Energy and Commerce Referred to House Committee Not Enacted 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 819 Rep. Louise M. Slaughter D-NY 159 (157-D, 2-R) PREVENTION FIRST ACT: A bill to expand access to preventive health care services that help reduce unintended pregnancy, reduce abortions, and improve access to womens health care. Energy and Commerce; Ways and Means; Education and Labor Referred to House Committees Not Enacted 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 1074 Rep. Tim Ryan D-OH 39 (39-D, 0-R) REDUCING THE NEED FOR ABORTION AND SUPPORTING PARENTS ACT: A bill to provide for programs that reduce the number of unplanned pregnancies, reduce the need for abortion, help women bear healthy children, and support new parents. Energy and Commerce; Education and Labor; Ways and Means Referred to House Committees Not Enacted 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 1095 Rep. Ron Paul, R-TX 7 (0-D, 7-R) TAXPAYERS FREEDOM OF CONSCIENCE ACT OF 2007: A bill to prohibit any Federal official from expending any Federal funds for any population control or population planning program or any family planning activity. Foreign Affairs; Energy and Commerce Referred to House Committees Not Enacted 2007 George D D 110th Rep. Todd Akin 61 PARENTS RIGHT TO Energy and Referred to Not

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363W. Bush (R) (233)/ R (202) (49)/ R (49) H.R. 2134 R-MO (2-D, 59-R) KNOW ACT OF 2007: A bill to establish certain requirements relating to the provision of services to minors by family planning projects under Title X of the Public Health Service Act. Commerce House Committee Enacted 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 3043 Rep. David Obey, D-WI N/A DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS ACT, 2008: A bill making appropriations for the Department of Labor, Health and Human Services, and Education, and related agencies for the FY ending 9/30/2008, and for other purposes. Not Referred to Committee upon Introduction/ Originated from the House Committee on Appropriations House failed to override Presidents veto (277 yeas to 141 nays) Vetoed by President Sustained 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H. R. 4133 Rep. Michael Pence, R-IN 67 (0-D, 67-R) TITLE X ABORTION PROVIDER PROHIBITION ACT: A bill to amend Title X of the Public Health Service Act to prohibit family planning grants from being awarded to any entity that performs abortions, and for other purposes. Energy and Commerce Referred to House Committee Not Enacted 2007 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H. Con. Res. 232 Rep. Kenny Marchant, T-TX 3 (0-D, 3-R) Concurrent resolution it is the Sense of the Congress that the confidentiality mandates for minors should be removed from family planning service programs operating under Title X of the Public Health Services Act and Medicaid. Energy and Commerce Referred to House Committee Not Enacted Senate Bills 2008 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th S. 3230 Sen. Tom Harkin, D-IDA N/A DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS ACT, Not Referred to Committee upon Introduction Report filed by Senate Committee on Appropriatio ns Not Enacted

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364 Notes: 1. H. Maj./Min. = The majority party that wa s in the House during that Congress Session. 2. S. Maj./Min. = The majority party that wa s in the Senate during that Congress Session. Miscellaneous Notes: Sponsor(s) and Co-Sponsor(s): The Co-Sponsor(s) names and party affiliations were availabl e for most bills but were not available for all bills in LexisNexis Congressional for the 101st 110th Congress Sessions. For bills proposed during 91st 100th Congress Sessions, Sponsor(s) and Co -Sponsor(s) were only identified by name, and not by political party affiliation. The availability of informati on for Co-Sponsor(s) differs between Congre ss Sessions, whereas information on Co-Sp onsor(s) for 92nd 100th Congress Sessions are reported by last name and where as information on Co-Sponsor(s) for 101st 110th Congress Sessions are reported by the number of Co-Sponsor(s) by political party affiliation. Titles for Bills: Titles for bills proposed during 101st 110th Congress sessions reflects the Short Title in the full text of the bill that follows the statement: This act may be cited as _____. If no Short Title was provided in the full text of the bill, the abbreviated titl e as displayed in the Bill Tracking was used. If no abbreviated title is displayed in the B ill Tracking, no title is documented in the above table. Last Legislative Activity: The addition of Co-Sponsors are not included as part of th e Last Legislative Activity column as this column only major represents major legislative actions that facilitate or stop a bill from progressing to the next legislative step in the legisl ative process. 2009: House Bills 2008 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 5968 Rep. Robert Wittman R-VA 0 ADOPTION INFORMATION ACT: A bill to require assurances that certain family planning service projects and programs will provide pamphlets containing the contact information of adoption centers. Energy and Commerce Referred to House Committee Not Enacted 2008 George W. Bush (R) D (233)/ R (202) D (49)/ R (49) 110th H.R. 6712 Rep. Jeb Hensarling, RTX N/A AMERICAS COMMITMENT TO VETERANS ACT OF 2008: A bill to provide for increased funding for veterans health care for fiscal year 2009 by transferring funds from the Legal Services Corporation and certain title X family planning funds, and for other purposes Veterans Affairs; Judiciary Referred to House Committees Not Enacted

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365 Table 13. Amendments enacted into la w affecting Title X (P.L. 91-572): 91st-110th Congress sessions Year Administration Originating House/Senate Bill Number Official Title of Public Law as Enacted Description of Amendment Affect ing Title X Enacted Public Law 1972 Richard M. Nixon (R) 92n d S. 3442 Communicable Disease Control Amendments Act of 1972 To amend the Public Health Service Act to extend and revise the program of assistance under that Act for the control and prevention of communicable diseases. Increased appropriation authorization for FY ending June 30, 1973 from $90,000,000 to $111,500,000. P.L. 92-449 1973 Richard M. Nixon (R) 93r d S. 1136 Health Programs Extension Act of 1973 To extend through fiscal year 1974 certain expiring appropriations authorizations in the Public Health Service Act, the Community Mental Health Centers Act, and the Developmental Disabilities Services and Facilities Construction Act, and for other purposes. Extending appropriations for family planning program (including project grants and contracts, training, research, and in formation and education sections) for FY ending June 30, 1974. P.L. 93-45 1975 Gerald R. Ford (R) 94t h S. 66 Family Planning and Population Research Act of 1975 An Act to amend the Public Health Service Act and related health laws to revise and extend the health revenue sharing program, the family planning programs, the community mental health centers program, the program for migrant health centers and community health centers, the National Health Service Corps program, and the programs for assistance for nurse training, and for other purposes. Authorized appropriations for family planning program, including project grants ($115,000, $115,000), research (55,000,000, $760,000,000), training ($4,000,000, $5,000,000), and information and education ($2,000,000, $2,500,000) for FY 1976 and 1977, respectively. Provided no funds appropriated under any provision of Act (except for research subsection) may be used to conduct/support research. Section 5 (Plans and Reports) is repealed. Plans and Reports is made into new section (Sec. 1009) Report from Secretary to Congress now due before seventh months after close of each FY instead of before sixth month after date of enactment. P.L. 94-631

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366“Family planning projects ” (Sec. 1001a) revised to read “family planning proj ects which shall offer a broad range of acceptable and effective family planning methods (includi ng natural family planning methods).” New sentence after Sec. 1001b: “Local and regional entities shall be assured the right to apply for direct grants and contracts under this section, and the Secretary shall by regulation fully provide for and protect such right.” Amendment that grant unde r any section of title shall be determined by Secretary; no grant after June 30, 1975 may be < 90%, with minor exceptions. Provision to ensure economic status is not a deterrent to participation of program. Sets forth reporting requirements for the Secretary to Congress. 1977 James E. Carter (D) 95t h H.R. 4975 Health Services Extension Act of 1977 An Act to amend the Public Health Service Act to extend through the fiscal year ending September 30, 1978, the assistance programs for health services research; health statistics; comprehensive public health services; hypertension programs; migrant health; community health centers; medical libraries; cancer control programs; the National Cancer Institute; heart, blood vessel, lung, and blood disease prevention and control programs; the National Heart, Lung, and Blood Institute; National Research Service Awards; population research and voluntary family planning programs; sudden infant death syndrome; hemophilia; national health planning and development; and health resources Authorize appropriations fo r family planning project grants ($136,400,000), training (3,000,000), research ($68,000,000), and information and education ($6,000) for FY 1978. Provided no funds appropriated under any provision of Act (except for research subsection) may be used for administration of research section. P.L. 95-83

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367development; to amend the Community Mental Health Centers Act to extend it through the fiscal year ending September 30, 1978; to extend the assistance programs for home health services; and for other purposes. 1978 James E. Carter (D) 95t h S. 2522 Public Health Service Act, amendment An Act to extend the programs of assistance under title X and part B of title XI of the Public Health Service Act. Authorized appropriations for family planning program, including project grants ($200,000,000, 230,000,000, 264,4000,000), training ($3,100,000, $3,600,000. 4,100,000), research (105,000,000, 3,600,000, 138,900,000) and information and education ($700,000, $805,000, 926,000) for FY 1979, 1908, and 1981, respectively. Inserted provisions related to infertility services and services for adolescents. Regulation added that info rmation and educational materials developed will be suitable for the population/community considering education and cultural background and standards. Advisory Committee including individuals broadly representative of population/ community will review and approve materials prior to distribution. P.L. 95-613 1981 Ronald W. Reagan (R) 97t h H.R. 3982 Omnibus Reconciliation Act of 1981 To provide for reconciliation pursuant to section 301 of the first concurrent resolution on the budget for the fiscal year 1982. Authorized appropriations for family planning program, including project grants ($126,510,000, 139,200,000, 158,830,000), training ($2,920,000, $3,200,000. 3,500,000), and information and education ($570,000, $600,000, 670,000) for FY 1982, 1983, and 1984, respectively. Inserted provisions relating to encouraging family participation in projects. Provision for Secretary of HHS to study ways for State delivery of Title X services and willingness and ability of states to administrate activities. Report due 18 months after enactment of present Act. P.L. 97-35 1982 Ronald W. Reagan (R) 97t h H.R. 5238 Orphan Drug Act An Act to amend the Federal Food, Drug, Substituted a semicolon for a comma after “1981” in Sections 1001(c), 1003(b), and 1005(b). P.L. 97-414

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368and Cosmetic Act to facilitate the development of drugs for rare diseases and conditions, and for other purposes. 1984 Ronald W. Reagan (R) 98t h S. 2616 To revise and extend the programs of assistance under title X and XX of the Public Health Service Act Authorized appropriations for project grants and contracts ($158,400,000) for 1985. P.L. 98-512 1984 Ronald W. Reagan (R) 98t h S. 2301 An Act to revise and extend programs for the provision of health services and preventive health services, and for other purposes. Added subsection (c) “The Secretary, at the request of a recipient of a grant under subsection (a), may reduce the amount of such grant by the fair market value of any supplies or equipment furnished the grant recipient by the Secretary. The amount by which any such grant is so reduced shall be available for payment by the Secretary of the costs incurred in furnishing the supplies or equipment on which the reduction of such grant is based. Such amount shall be deemed as part of the grant and shall be deemed to have been paid to the grant recipient”. Re-designated previous s ubsection (c) as subsection (d). P.L. 98-555 1990 George H.W. Bush (R) 101st S. 2240 Ryan White Comprehensive AIDS Resources Emergency Act of 1990 To amend the Public Health Service Act to provide grants to improve the quality and availability of care for individuals and families with HIV disease, and for other purposes. Provides that family planning clinics offer and encourage early intervention services as it relates to HIV/AIDS. Lists Title X as one of the eligible grantees (public and non-profit private entity) are eligible to apply for AIDS grant. P.L. 101-381 1991 George H.W. Bush (R) 102n d H.R. 3839 Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act, 1992 Making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies, for the fiscal year ending September 30, 1992, and for other purposes. Makes appropriations (lump sum) for FY 1992 for the Department of Health and Human Services, which includes Title X of the Public Health Service Act among the lists of acts/programs. Prohibits the use of funds to perform abortions except where the life of the mother would be endangered if the fetus were carried to term. P.L. 102-170 1992 George H.W. Bush (R) 102n d H.R. 5193 Veterans Health Care Act of 1992 Provides for family planning project receiving a grant or contract under sect ion 1001 to be a covered P.L. 102-585

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369An act to amend title 38, United States Code, to revise certain pay authorities that apply to Depart ment of Veterans Affairs nurses, to improve preventive health services for veterans, to improve health-care services for women veterans, and to enable the Department to purchase pharmaceuticals at reasonable prices, and for other purposes. entity for which payment can be made for drugs purchased by the state under the state plan for medical assistance under Title XIX of the Social Security Act. 1996 William J. Clinton (D) 104t h H.R. 3019 Making appropriations for fiscal year 1996 to make a further downpayment toward a balanced budget, and for other purposes. Provides appropriation ($193,349,000) for Title X to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. P.L. 104-134 1997 William J. Clinton (D) 105t h H.R. 2264 Department of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 1998 Making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 1998, and for other purposes. Appropriates $203,452,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. P.L. 105-78 1999 William J. Clinton (D) 106t h H.R. 3424 Making consolidated appropriations for the fiscal year ending September 30, 2000, and for other purposes. Appropriates $238,932,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. 106-113

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370Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. Provides that no Title X provider shall be exempt from any State law requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest. 2000 George W. Bush (R) 106t h H.R. 4365 Children’s Health Act of 2000 To amend the Public Health Service Act with respect to children’s health. Provides for health centers that receive grants under section 1001 (relating to voluntary family planning projects) to be eligible for training regarding providing adoption informa tion and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling to pregnant women. P.L. 106-310 2000 George W. Bush (R) 106t h H.R. 4577 DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS ACT, 2001 Making consolidated appropriations for the fiscal year ending September 30, 2001, and for other purposes. Appropriates $253,932,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it P.L. 106-554

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371encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. Provides that no Title X provider shall be exempt from any State law requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest. 2002 George W. Bush (R) 107t h H.R. 3061 Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Act, 2002 Making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2002, and for other purposes. Appropriates $265,085,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. Provides that no Title X provider shall be exempt form any State law requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest. P.L. 107-116 2003 George W. Bush (R) 108t h H.R. 2673 Consolidated Appropriations Act, 2004 Making appropriations for Agriculture, Rural Development, Food and Drug Administration, and Re lated Agencies for the fiscal year ending September 30, 2004, and for other purposes. Appropriates $280,000,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to P.L. 108-199

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372promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. Provides that no Title X provider shall be exempt from any State law requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest. 2005 George W. Bush (R) 109t h H.R. 3010 Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations, 2006 Making appropriations for the Departments of Labor, Health and Human Services, and Education, Related Agencies for the fiscal year ending September 30, 2006, and for other purposes. Appropriates $285,963,000 for the program under Title X of the Public Health Service Act to provide for voluntary family planning projects. Stipulates that funds should not be expended for abortions; pregnancy counseling shall be nondirective; and amounts shall not be expended for any activity (includi ng the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office. Provides that no funds may be made available to any entities unless applicant certifies to Secretary that it encourages family participation in the decision of minors to seek family planning services and provides counseling to minor s on resisting attempts to coerce minors into engaging into sexual activities. Provides that no Title X provider shall be exempt from any State law requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest. P.L. 109-149

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373 Table 14. Bills included in Title X’s (P.L. 91-572 ) legislative history, classified by theme Administration: Bills affecting the administration of the program such as the following: attempts to extend or repeal the program; administrative and grant requirements; coordination with State activities; use of funds; administration of grants to specific populations; admi nistration of grants related to particular program sections; and data collection and reporting. Bill Administration 92nd H.R. 17053 Richard M. Nixon (R) 93rd S. 1708 Richard M. Nixon (R) 93rd H.R. 3381 Richard M. Nixon (R) 93rd H.R. 5940 Richard M. Nixon (R) 93rd H.R. 6021 Richard M. Nixon (R) 93rd H.R. 6139 Richard M. Nixon (R) 93rd H.R. 6222 Richard M. Nixon (R) 93rd H.R. 6601 Richard M. Nixon (R) 93rd H.R. 6834 Richard M. Nixon (R) 93rd H.R. 7467 Richard M. Nixon (R) 93rd H.R. 7468 Richard M. Nixon (R) 93rd H.R. 7735 Richard M. Nixon (R) 93rd H.R. 8172 Richard M. Nixon (R) 93rd H.R. 11995 Richard M. Nixon (R) 93rd H.R. 12155 Richard M. Nixon (R) 93rd H.R. 12323 Richard M. Nixon (R) 93rd H.R. 13750 Richard M. Nixon (R) 93rd H.R. 14214 Richard M. Nixon (R) 94th S. 66 Gerald R. Ford (R) 94th H.R. 2133 Gerald R. Ford (R) 94th H.R. 2954 Gerald R. Ford (R) 94th H.R. 4235 Gerald R. Ford (R) 94th H.R. 4925 Gerald R. Ford (R) 94th H.R. 5719 Gerald R. Ford (R) 94th H.R. 5720 Gerald R. Ford (R) 95th S. 2614 James E. Carter (D) 95th H.R. 11007 James E. Carter (D) 95th H.R. 11925 James E. Carter (D) 95th H.R. 11926 James E. Carter (D) 95th H.R. 12400 James E. Carter (D) 95th H.R. 12894 James E. Carter (D) 95th H.R. 13111 James E. Carter (D) 95th H.R. 13278 James E. Carter (D) 96th S. 988 James E. Carter (D) 97th S. 288 Ronald W. Reagan (R) 97th H.R. 2446 Ronald W. Reagan (R) 97th H.R. 3982 Ronald W. Reagan (R) 98th S. 2301 Ronald W. Reagan (R) 98th S. 2452 Ronald W. Reagan (R) 98th S. 2622 Ronald W. Reagan (R) 98th H.R. 5493 Ronald W. Reagan (R) 98th S. 881 Ronald W. Reagan (R) 99th S. 1091 Ronald W. Reagan (R) 99th S. 1643 Ronald W. Reagan (R) 99th H.R. 2252 Ronald W. Reagan (R) 99th H.R. 2358 Ronald W. Reagan (R) 99th H.R. 2369 Ronald W. Reagan (R) 100th S. 1366 Ronald W. Reagan (R) 100th H.R. 3769 Ronald W. Reagan (R) 101s t S. 108 George H.W. Bush (R) 101s t S. 110 George H.W. Bush (R) 101s t S. 1671 George H.W. Bush (R) 101s t H.R. 1042 George H.W. Bush (R) 101s t H.R. 2500 George H.W. Bush (R) 101s t S. 2240 George H.W. Bush (R)

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374101s t S. 2997 George H.W. Bush (R) 101s t S. 2998 George H.W. Bush (R) 102nd S. 112 George H.W. Bush (R) 102nd S. 323 George H.W. Bush (R) 102nd S. 1197 George H.W. Bush (R) 102nd H.R. 1968 George H.W. Bush (R) 102nd H.R. 2343 George H.W. Bush (R) 102nd H.R. 5514 George H.W. Bush (R) 103rd H.R. 670 William J. Clinton (D) 103rd S. 2134 William J. Clinton (D) 103rd H.R. 4473 William J. Clinton (D) 103rd H.R. 4566 William J. Clinton (D) 104th S. 1209 William J. Clinton (D) 104th H.R. 759 William J. Clinton (D) 104th H.R. 1146 William J. Clinton (D) 104th H.R. 1623 William J. Clinton (D) 104th S. 1904 William J. Clinton (D) 104th H.R. 3716 William J. Clinton (D) 104th H.R. 3755 William J. Clinton (D) 105th S. 1364 William J. Clinton (D) 105th H.R. 1374 William J. Clinton (D) 105th H.R. 2941 William J. Clinton (D) 108th H.R. 1548 George W. Bush (R) 109th H.R. 777 George W. Bush (R) 109th S. 2206 George W. Bush (R) 109th H.R. 5967 George W. Bush (R) 110th S. 351 George W. Bush (R) 110th H.R. 1095 George W. Bush (R) 110th H.Con. Res. 232 George W. Bush (R) 110th H.R. 6712 George W. Bush (R) Appropriation: Bills with appropriation amendments either originated from Title X bills, or from bills whose focus was not on Title X, but whose focus was on another related legislation or policy. Bill Administration 92nd H.R. 14341 Richard M. Nixon (R) 92nd H.R. 17053 Richard M. Nixon (R) 92nd H.R. 17153 Richard M. Nixon (R) 92nd S. 3442 Richard M. Nixon (R) 93rd S. 1136 Richard M. Nixon (R) 93rd S. 1708 Richard M. Nixon (R) 93rd S. 1723 Richard M. Nixon (R) 93rd H.R. 3381 Richard M. Nixon (R) 93rd H.R. 3621 Richard M. Nixon (R) 93rd H.R. 5940 Richard M. Nixon (R) 93rd H.R. 6021 Richard M. Nixon (R) 93rd H.R. 6139 Richard M. Nixon (R) 93rd H.R. 6222 Richard M. Nixon (R) 93rd H.R. 6601 Richard M. Nixon (R) 93rd H.R. 6834 Richard M. Nixon (R) 93rd H.R. 7467 Richard M. Nixon (R) 93rd H.R. 7468 Richard M. Nixon (R) 93rd H.R. 7735 Richard M. Nixon (R) 93rd H.R. 8172 Richard M. Nixon (R) 93rd H.R. 11995 Richard M. Nixon (R) 93rd H.R. 12155 Richard M. Nixon (R) 93rd H.R. 12323 Richard M. Nixon (R) 93rd H.R. 13750 Richard M. Nixon (R) 93rd H.R. 14214 Richard M. Nixon (R) 94th S. 66 Gerald R. Ford (R) 94th H.R. 2133 Gerald R. Ford (R) 94th H.R. 2954 Gerald R. Ford (R) 94th H.R. 4235 Gerald R. Ford (R) 94th H.R. 4925 Gerald R. Ford (R)

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37594th H.R. 5719 Gerald R. Ford (R) 94th H.R. 5720 Gerald R. Ford (R) 95th H.R. 3598 James E. Carter (D) 95th H.R. 4975 James E. Carter (D) 95th H.R. 4976 James E. Carter (D) 95th S. 2522 James E. Carter (D) 95th H.R. 10553 James E. Carter (D) 95th H.R. 11007 James E. Carter (D) 95th H.R. 11925 James E. Carter (D) 95th H.R. 11926 James E. Carter (D) 95th H.R. 12370 James E. Carter (D) 95th H.R. 12400 James E. Carter (D) 95th H.R. 12894 James E. Carter (D) 95th H.R. 13111 James E. Carter (D) 95th H.R. 13278 James E. Carter (D) 95th H.R. 13852 James E. Carter (D) 96th H.R. 1593 James E. Carter (D) 96th H.R. 5062 James E. Carter (D) 97th S. 288 Ronald W. Reagan (R) 97th S. 1102 Ronald W. Reagan (R) 97th H.R. 907 Ronald W. Reagan (R) 97th H.R. 2807 Ronald W. Reagan (R) 97th H.R. 3982 Ronald W. Reagan (R) 98th S. 2452 Ronald W. Reagan (R) 98th S. 2622 Ronald W. Reagan (R) 98th S. 2628 Ronald W. Reagan (R) 98th H.R. 5493 Ronald W. Reagan (R) 98th H.R. 5560 Ronald W. Reagan (R) 98th H.R. 5600 Ronald W. Reagan (R) 98th S. 881 Ronald W. Reagan (R) 98th S. 1091 Ronald W. Reagan (R) 98th S. 2616 Ronald W. Reagan (R) 99th H.R. 947 Ronald W. Reagan (R) 99th H.R. 2252 Ronald W. Reagan (R) 99th H.R. 2369 Ronald W. Reagan (R) 100th S. 1366 Ronald W. Reagan (R) 100th H.R. 3769 Ronald W. Reagan (R) 101s t S. 110 George H.W. Bus (R) 101s t S. 1671 George H.W. Bus (R) 101s t H.R. 930 George H.W. Bus (R) 101s t H.R. 1078 George H.W. Bus (R) 101s t S. 2997 George H.W. Bus (R) 101s t S. 2998 George H.W. Bus (R) 101s t H.R. 5693 George H.W. Bus (R) 102nd S. 323 George H.W. Bus (R) 102nd S. 1177 George H.W. Bus (R) 102nd S. 1197 George H.W. Bus (R) 102nd S. 1995 George H.W. Bus (R) 102nd H.R. 2343 George H.W. Bus (R) 102nd H.R. 2585 George H.W. Bus (R) 102nd H.R. 2612 George H.W. Bus (R) 102nd H.R. 2707 George H.W. Bus (R) 102nd H.R. 3090 George H.W. Bus (R) 102nd H.R. 3839 George H.W. Bus (R) 103rd S. 18 William J. Clinton (D) 103rd H.R. 670 William J. Clinton (D) 103rd S. 2009 William J. Clinton (D) 104th S. 18 William J. Clinton (D) 104th S. 736 William J. Clinton (D) 104th S. 979 William J. Clinton (D) 104th H.R. 833 William J. Clinton (D) 104th H.R. 1594 William J. Clinton (D) 104th H.R. 1952 William J. Clinton (D) 104th H.R. 2127 William J. Clinton (D) 104th S. 1799 William J. Clinton (D)

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376104th H.R. 3019 William J. Clinton (D) 104th H.R. 3174 William J. Clinton (D) 104th H.R. 3178 William J. Clinton (D) 104th H.R. 3755 William J. Clinton (D) 104th H.R. 4278 William J. Clinton (D) 105th S. 24 William J. Clinton (D) 105th S. 1061 William J. Clinton (D) 105th S. 1208 William J. Clinton (D) 105th H.R. 2264 William J. Clinton (D) 105th H.R. 2525 William J. Clinton (D) 106th S. 1400 William J. Clinton (D) 106th S. 1650 William J. Clinton (D) 106th H.R. 2405 William J. Clinton (D) 106th H.R. 3037 William J. Clinton (D) 106th H.R. 3424 William J. Clinton (D) 106th H.R. 3424 William J. Clinton (D) 106th S. 2553 George W. Bush (R) 106th H.R. 4577 George W. Bush (R) 106th H.R. 5656 George W. Bush (R) 107th S. 24 George W. Bush (R) 107th S. 1536 George W. Bush (R) 107th H.R. 3061 George W. Bush (R) 107th S. 2766 George W. Bush (R) 107th H.R. 5320 George W. Bush (R) 108th S. 1356 George W. Bush (R) 108th H.R. 246 George W. Bush (R) 108th H.R. 2618 George W. Bush (R) 108th H.R. 2660 George W. Bush (R) 108th H.R. 2673 George W. Bush (R) 108th S. 2336 George W. Bush (R) 108th H.R. 4192 George W. Bush (R) 108th H.R. 5006 George W. Bush (R) 109th S. 20 George W. Bush (R) 109th S. 844 George W. Bush (R) 109th H.R. 1709 George W. Bush (R) 109th H.R. 3010 George W. Bush (R) 109th S. 3708 George W. Bush (R) 109th H.R. 5647 George W. Bush (R) 109th H.R. 6067 George W. Bush (R) 110th S. 21 George W. Bush (R) 110th S. 3230 George W. Bush (R) 110th H.R. 819 George W. Bush (R) 110th H.R. 1074 George W. Bush (R) 110th H.R. 3043 George W. Bush (R) Requirements: Bill proposing to amend specific family planning services, information, education and other related activities. Bill Administration 92nd H.R. 17053 Richard M. Nixon (R) 92nd H.R. 17153 Richard M. Nixon (R) 93rd S. 1708 Richard M. Nixon (R) 93rd H.R. 3381 Richard M. Nixon (R) 93rd H.R. 5940 Richard M. Nixon (R) 93rd H.R. 6021 Richard M. Nixon (R) 93rd H.R. 6139 Richard M. Nixon (R) 93rd H.R. 6222 Richard M. Nixon (R) 93rd H.R. 6601 Richard M. Nixon (R) 93rd H.R. 6834 Richard M. Nixon (R) 93rd H.R. 7467 Richard M. Nixon (R) 93rd H.R. 7468 Richard M. Nixon (R) 93rd H.R. 7735 Richard M. Nixon (R) 93rd H.R. 8172 Richard M. Nixon (R) 93rd H.R. 11995 Richard M. Nixon (R)

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37793rd H.R. 12155 Richard M. Nixon (R) 93rd H.R. 13750 Richard M. Nixon (R) 94th S. 66 Gerald R. Ford (R) 94th H.R. 4925 Gerald R. Ford (R) 94th H.R. 5719 Gerald R. Ford (R) 94th H.R. 5720 Gerald R. Ford (R) 95th H.R. 7806 James E. Carter (R) 95th S. 2522 James E. Carter (R) 95th S. 2614 James E. Carter (R) 95th H.R. 11007 James E. Carter (R) 95th H.R. 11925 James E. Carter (R) 95th H.R. 11926 James E. Carter (R) 95th H.R. 12370 James E. Carter (R) 95th H.R. 12400 James E. Carter (R) 95th H.R. 12894 James E. Carter (R) 95th H.R. 13111 James E. Carter (R) 95th H.R. 13278 James E. Carter (R) 96th H.R. 2501 James E. Carter (R) 97th S. 288 Ronald W. Reagan (R) 97th H.R. 2446 Ronald W. Reagan (R) 97th H.R. 2447 Ronald W. Reagan (R) 97th H.R. 2848 Ronald W. Reagan (R) 97th H.R. 3982 Ronald W. Reagan (R) 97th S. 2322 Ronald W. Reagan (R) 98th H.R. 512 Ronald W. Reagan (R) 98th H.R. 513 Ronald W. Reagan (R) 98th S. 2452 Ronald W. Reagan (R) 98th S. 2622 Ronald W. Reagan (R) 98th H.R. 5493 Ronald W. Reagan (R) 98th S. 881 Ronald W. Reagan (R) 99th H.R. 947 Ronald W. Reagan (R) 99th H.R. 2252 Ronald W. Reagan (R) 99th H.R. 2369 Ronald W. Reagan (R) 99th H.R. 3975 Ronald W. Reagan (R) 100th S. 271 Ronald W. Reagan (R) 100th S. 1366 Ronald W. Reagan (R) 100th H.R. 1279 Ronald W. Reagan (R) 100th H.R. 3769 Ronald W. Reagan (R) 101s t S. 23 George H.W. Bush (R) 101s t S. 70 George H.W. Bush (R) 101s t S. 71 George H.W. Bush (R) 101s t S. 110 George H.W. Bush (R) 101s t S. 1671 George H.W. Bush (R) 101s t S. 2240 George H.W. Bush (R) 101s t S. 2997 George H.W. Bush (R) 101s t S. 2998 George H.W. Bush (R) 101s t H.R. 4470 George H.W. Bush (R) 101s t H.R. 4785 George H.W. Bush (R) 101s t H.R. 4874 George H.W. Bush (R) 101s t H.R. 4470 George H.W. Bush (R) 101s t H.R. 5231 George H.W. Bush (R) 102nd S. 185 George H.W. Bush (R) 102nd S. 186 George H.W. Bush (R) 102nd S. 323 George H.W. Bush (R) 102nd S. 1197 George H.W. Bush (R) 102nd H.R. 392 George H.W. Bush (R) 102nd H.R. 1397 George H.W. Bush (R) 102nd H.R. 2343 George H.W. Bush (R) 102nd H.R. 2585 George H.W. Bush (R) 102nd H.R. 2611 George H.W. Bush (R) 102nd H.R. 3090 George H.W. Bush (R) 103rd S. 43 William J. Clinton (D) 103rd S. 631 William J. Clinton (D) 103rd S. 1002 William J. Clinton (D) 103rd S. 1317 William J. Clinton (D)

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378103rd H.R. 670 William J. Clinton (D) 103rd H.R. 2293 William J. Clinton (D) 104th S. 29 William J. Clinton (D) 104th S. 321 William J. Clinton (D) 104th H.R. 833 William J. Clinton (D) 104th H.R. 1594 William J. Clinton (D) 104th H.R. 2127 William J. Clinton (D) 104th S. 1799 William J. Clinton (D) 104th H.R. 3019 William J. Clinton (D) 104th H.R. 3178 William J. Clinton (D) 104th H.R. 3179 William J. Clinton (D) 104th H.R. 3755 William J. Clinton (D) 104th H.R. 4278 William J. Clinton (D) 105th S. 45 William J. Clinton (D) 105th S. 187 William J. Clinton (D) 105th S. 1061 William J. Clinton (D) 105th S. 1318 William J. Clinton (D) 105th H.R. 2264 William J. Clinton (D) 105th H.R. 3229 William J. Clinton (D) 105th H.R. 3230 William J. Clinton (D) 105th H.R. 4721 William J. Clinton (D) 106th S. 42 William J. Clinton (D) 106th H.R. 2485 William J. Clinton (D) 106th S. 290 William J. Clinton (D) 106th S. 1650 William J. Clinton (D) 106th H.R. 2485 William J. Clinton (D) 106th H.R. 2540 William J. Clinton (D) 106th H.R. 3037 William J. Clinton (D) 106th H.R. 3424 William J. Clinton (D) 106th S. 2553 George W. Bush (R) 106th H.R. 4365 George W. Bush (R) 106th H.R. 4577 George W. Bush (R) 106th H.R. 5574 George W. Bush (R) 106th H.R. 5656 George W. Bush (R) 107th S. 1536 George W. Bush (R) 107th H.R. 3006 George W. Bush (R) 107th H.R. 3061 George W. Bush (R) 107th S. 2766 George W. Bush (R) 107th H.R. 5320 George W. Bush (R) 108th S. 1356 George W. Bush (R) 108th H.R. 246 George W. Bush (R) 108th H.R. 1229 George W. Bush (R) 108th H.R. 2444 George W. Bush (R) 108th H.R. 2618 George W. Bush (R) 108th H.R. 2660 George W. Bush (R) 108th H.R. 2673 George W. Bush (R) 108th H.R. 5006 George W. Bush (R) 109th S. 1279 George W. Bush (R) 109th H.R. 69 George W. Bush (R) 109th H.R. 3010 George W. Bush (R) 109th H.R. 3011 George W. Bush (R) 109th S. 2206 George W. Bush (R) 109th S. 3708 George W. Bush (R) 109th H.R. 5647 George W. Bush (R) 110th S. 351 George W. Bush (R) 110th S. 3230 George W. Bush (R) 110th H.R. 104 George W. Bush (R) 110th H.R. 2134 George W. Bush (R) 110th H.R. 3043 George W. Bush (R) 110th H.R. 4133 George W. Bush (R) 110th H.R. 5968 George W. Bush (R) Restrictions: Bill proposing to restrict and/or prohibit specific family planning services, information, education and other

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379related activities. Bill Administration 93 S. 1708 Richard M. Nixon (R) 93rd H.R. 13750 Richard M. Nixon (R) 94th S. 66 Gerald R. Ford (R) 94th S. 318 Gerald R. Ford (R) 94th H.R. 12327 Gerald R. Ford (R) 95th H.R. 4975 James E. Carter (D) 95th H.R. 7912 James E. Carter (D) 95th S. 2614 James E. Carter (D) 95th S. 2697 James E. Carter (D) 98th S. 2622 Ronald W. Reagan (R) 98th H.R. 5493 Ronald W. Reagan (R) 100th S. 1242 Ronald W. Reagan (R) 100th H.R. 1729 Ronald W. Reagan (R) 100th H.R. 5020 Ronald W. Reagan (R) 101s t H.R. 1078 George H.W. Bush (R) 102nd H.R. 3839 George H.W. Bush (R) 103rd S. 2134 William J. Clinton (D) 103rd H.R. 4473 William J. Clinton (D) 103rd H.R. 4566 William J. Clinton (D) 104th H.R. 1594 William J. Clinton (D) 104th H.R. 2127 William J. Clinton (D) 104th H.R. 3019 William J. Clinton (D) 104th H.R. 3755 William J. Clinton (D) 104th H.R. 4278 William J. Clinton (D) 105th S. 1061 William J. Clinton (D) 105th H.R. 2264 William J. Clinton (D) 106th S. 1650 William J. Clinton (D) 106th H.R. 3037 William J. Clinton (D) 106th H.R. 3424 William J. Clinton (D) 106th S. 2553 George W. Bush (R) 106th H.R. 4577 George W. Bush (R) 106th H.R. 5656 George W. Bush (R) 107th S. 1536 George W. Bush (R) 107th H.R. 3061 George W. Bush (R) 107th S. 2766 George W. Bush (R) 107th H.R. 5320 George W. Bush (R) 108th S. 1356 George W. Bush (R) 108th H.R. 246 George W. Bush (R) 108th H.R. 2618 George W. Bush (R) 108th H.R. 2660 George W. Bush (R) 108th H.R. 2673 George W. Bush (R) 108th H.R. 5006 George W. Bush (R) 109th H.R. 3010 George W. Bush (R) 109th S. 2206 George W. Bush (R) 109th S. 3708 George W. Bush (R) 109th H.R. 5647 George W. Bush (R) 110th S. 351 George W. Bush (R) 110th S. 3230 George W. Bush (R) 110th H.R. 3043 George W. Bush (R) 110th H.R. 4133 George W. Bush (R) Related Legislation: Bills that focused on other polices (not Title X-specifi c bills), but which had language with integrated text affecting Title X (i.e., Adolescent Pregnancy Grant; Family Life Education; Women’s and AIDS Outreach and Prevention Act; Mate rnal and Infant Care Coordination, etc.) Bill Administration 97th H.R. 2807 Ronald W. Reagan (R) 99th H.R. 947 Ronald W. Reagan (R) 100th S. 1950 Ronald W. Reagan (R) 100th H.R. 4270 Ronald W. Reagan (R) 101s t S. 120 George H.W. Bush (R)

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380101s t H.R. 720 George H.W. Bush (R) 101s t H.R. 1078 George H.W. Bush (R) 101s t H.R. 3102 George H.W. Bush (R) 101s t H.R. 3143 George H.W. Bush (R) 101s t S. 2240 George H.W. Bush (R) 101s t S. 2961 George H.W. Bush (R) 101s t H.R. 4470 George H.W. Bush (R) 101s t H.R. 4785 George H.W. Bush (R) 101s t H.R. 4874 George H.W. Bush (R) 101s t H.R. 5246 George H.W. Bush (R) 101s t H.R. 5393 George H.W. Bush (R) 101s t H.R. 5397 George H.W. Bush (R) 102nd S. 514 George H.W. Bush (R) 102nd H.R. 1161 George H.W. Bush (R) 102nd H.R. 1398 George H.W. Bush (R) 102nd H.R. 4983 George H.W. Bush (R) 102nd H.R. 5193 George H.W. Bush (R) 102nd H.R. 6083 George H.W. Bush (R) 103rd S. 18 William J. Clinton (D) 103rd S. 1428 William J. Clinton (D) 103rd S. 1757 William J. Clinton (D) 103rd S. 1770 William J. Clinton (D) 103rd S. 1775 William J. Clinton (D) 103rd S. 1779 William J. Clinton (D) 103rd H.R. 2395 William J. Clinton (D) 103rd H.R. 3075 William J. Clinton (D) 103rd H.R. 3561 William J. Clinton (D) 103rd H.R. 3600 William J. Clinton (D) 103rd H.R. 3704 William J. Clinton (D) 103rd S. 2296 William J. Clinton (D) 103rd S. 2351 William J. Clinton (D) 103rd S. 4202 William J. Clinton (D) 104th H.R. 3174 William J. Clinton (D) 105th H.R. 1219 William J. Clinton (D) Related Polices: Bills that proposed to establish global and national institutes, administration and centers, and bills that proposed to respect family planning principles, establish a U.S. family planning and population policy, and upholds rights to privacy. Bill Administration 92nd S.J. Res. 108 Richard M. Nixon (D) 92nd H.R. 16986 Richard M. Nixon (D) 92nd H.R. 17053 Richard M. Nixon (D) 92nd H.R. 17153 Richard M. Nixon (D) 92nd H.R. Res. 789 Richard M. Nixon (D) 92nd H.J. Res. 837 Richard M. Nixon (D) 92nd H.J. Res. 849 Richard M. Nixon (D) 92nd H.J. Res. 853 Richard M. Nixon (D) 92nd H.J. Res. 904 Richard M. Nixon (D) 93rd S. 1708 Richard M. Nixon (D) 93rd H.R. 3381 Richard M. Nixon (D) 93rd H.R. 4767 Richard M. Nixon (D) 93rd H.R. 5940 Richard M. Nixon (D) 93rd H.R. 6021 Richard M. Nixon (D) 93rd H.R. 6139 Richard M. Nixon (D) 93rd H.R. 6222 Richard M. Nixon (D) 93rd H.R. 6601 Richard M. Nixon (D) 93rd H.R. 6834 Richard M. Nixon (D) 93rd H.R. 7467 Richard M. Nixon (D) 93rd H.R. 7468 Richard M. Nixon (D) 93rd H.R. 7735 Richard M. Nixon (D) 93rd H.R. 8172 Richard M. Nixon (D) 93rd H.R. 11995 Richard M. Nixon (D) 93rd H.J. Res. 90 Richard M. Nixon (D)

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38193rd H.R. 12155 Richard M. Nixon (D) 93rd H.R. 13750 Richard M. Nixon (D) 94th H.R. 5719 Gerald R. Ford (R) 94th H.R. 5720 Gerald R. Ford (R) 94th H.J. Res. 125 Gerald R. Ford (R) 94th H.J. Res. 559 Gerald R. Ford (R) 94th H.J. Res. 764 Gerald R. Ford (R) 94th H.J. Res. 769 Gerald R. Ford (R) 95th S.J. Res. 64 James E. Carter (D) 95th H.R. 13852 James E. Carter (D) 95th H.J. Res. 532 James E. Carter (D) 96th H.R. 1593 James E. Carter (D) 96th H.R. 5062 James E. Carter (D) 97th S .1771 Ronald W. Reagan (R) 97th H.R. 907 Ronald W. Reagan (R) 97th H.Con. Res. 206 Ronald W. Reagan (R) 98th S. 1025 Ronald W. Reagan (R) 98th S.Con. Res. 21 Ronald W. Reagan (R) 98th H.R. 2491 Ronald W. Reagan (R) 98th H.Con. Res. 93 Ronald W. Reagan (R) 99th S. 2905 Ronald W. Reagan (R) 100th S. 1171 Ronald W. Reagan (R) 100th H.R. 2212 Ronald W. Reagan (R) 101s t H.R. 1078 George H.W. Bush (R) 109th S.Res. 162 George W. Bush (R) 109th H.Res. 311 George W. Bush (R) 109th S.Res. 485 George W. Bush (R) Technical Amendments: Bills proposing to change the syntax, such as and grammatical changes and the re-numbering of sections. Bill Administration 93rd H.R. 12323 Richard M. Nixon (D) 94th S. 66 Gerald R. Ford (R) 97th H.R. 2807 Ronald W. Reagan (R) 97th H.R. 3982 Ronald W. Reagan (R) 97th H.R. 5238 Ronald W. Reagan (R) 97th H.R. 6355 Ronald W. Reagan (R) 98th S. 2301 Ronald W. Reagan (R) 101s t H.R. 5231 George H.W. Bush (R) 102nd H.R. 392 William J. Clinton (D) 102nd H.Res. 442 William J. Clinton (D) Note: Bills can appear in more than one thematic category.

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382 Appendix J. Figures Figure 1 The 10 HHS regions (location of regional office) are as follows: Region I (Boston, MA) – Connecticut, Maine, Massachusetts, New Hampsh ire, Rhode Island, and Vermont; Region II (New York, NY) – New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands; Region III (Philadelphia, PA) – Delaware, Washington, D.C., Maryland, Pennsylva nia, Virginia, and West Virginia; Region IV (Atlanta, GA) – Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Ca rolina, and Tennessee; Region V (Chicago, IL) – Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; Region VI (Dallas, TX) – Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; Region VII (Kansas City, MO) – Iowa, Kansas, Missouri, and Nebraska; Region VIII (Denver, CO) – Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming; Region IX (San Francisco, CA) – Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Republic of the Mars hall Islands, and Republic of Palau; Region X (Seattle, WA) – Alaska, Idaho, Ore gon, and Washington. RTI International. (November 2006). Family planning annual report: 2005 National summary Exhibit 1. Health and Human Servic es (HHS) Regions (p. 7). Research Triangle Park, NC: RTI. Figure 1. Ten U.S. Department of Health and Human Services ( HHS) regional office

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383 Figure 2 Figure 2. Actual and inflation-adjusted Title X appropriation, 1980-1999 The Alan Guttmacher Institute. (2000). Fulfilling the promise: Public policy and U.S. family planning clinics Table 14. Despite recent increase s, Title X funding has decreased 60% since 1980, when inflation is taken into account (p. 47). New York, NY. Reprinted with permission from the publisher. 0 50,000,000 100,000,000 150,000,000 200,000,000 250,000,00019 8 0 19 8 2 19 8 4 1986 198 8 199 0 19 9 2 1994 1996 199 8 Actual Title X Appropriation Inflation-Adjusted Title X Appropriation

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384 Figure 3 Age (years) Figure 3. Women’s fertility years The Alan Guttmacher In stitute [AGI]. (2000). Fulfilling the promise: Public policy and U.S. family planning clinics (p. 10). New York, NY. Reprinted with permission from the publisher. 10 15 20 25 30 35 40 45 50 55 Menarche 12.6 First Intercourse 17.4 First Pregnancy 22.5 First Marriage 25.1 First Birth 26.0 Intend No More Children 30.9 Menopause 51.3

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385 Figure 4 1960 The Food and Drug Administration (FDA ) approves oral contraceptives and the IUD for use in the U.S. 1961 President Kennedy defines population growth as a “staggering problem,” formally endorses research aimed at making contraceptive methods available.. 1963 The National Institute of Child Health and Human Development is established, in part to support and oversee contraceptive research and development. 1965 The Office of Economic Opportunity funds the first federal family planning grants; the Supreme Court strikes down a state law that prohibits the use of contraceptives by married couples (Gri swold v. Connecticut); the Social Security Act amended to create Medicaid, under which states may claim reimbursement for family planning services. 1966 As part of the War on Poverty, President Johnson names family planning one of four critical health problems in the nation needing special attention. 1967 The Social Security Act is amended to require that at least 6% of funding nationwide under the maternal and chil d health program be earmarked for family planning and that family planning services be provided to public assistance recipients who request them. 1968 Pope Paul VI issues an encyclical affirming the Catholic Church’s opposition to “artificial” methods in contraception. 1969 President Nixon calls for increased federal support for domestic family planning services and appoints the Commission on Population Growth and the American Future to report on U.S. population issues. 1970 Enactment of Title X Family Planning program (Public Law 91-572) by President Nixon 1972 The Supreme Court strikes down a state law prohibiting the distribution of contraceptives to unmarried people (Eisen stadt v. Baird); Medicaid is amended to require coverage of family planning services; U.S. family planning clinics serve 2.6 million people. 1973 The Supreme Court strikes down state laws that prohibit abortion and upholds a woman’s right to choose abortion (Roe v. Wade and Dow v. Bolton). 1977 The Supreme Court strikes down a state law that prohibits the sale of nonprescription contraceptive to minors yo unger than 16 (Carey v. Population Services International). 1978 Congress amends the Title X statue to emphasize the importance of serving teenagers. 1980 The Carter administration issues regulations establishing the sliding-fee scale for Title X services.

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3861981 Congress rejects Reagan administration’s proposal to fold Title X into a block grant; Congress eliminated the 6% earmark for family planning under the maternal and child health program; the fist case of AIDS is reported. 1982 The Reagan administration issues the “squeal rule,” regulations requiring Title X-supported clinics to notify parents befo re dispensing contr aceptives to minors; Title X funding is cut by one-quarter. 1983 The “squeal rule” is struck down in several court cases (National Family Planning and Reproductive Health Association v. U.S. Department of Health and Human Services and others). 1984 HIV is determined to cause AIDS. 1986 The Supreme Court rules that states may give family planning grants to agencies that provide abortions with their own funds or provide abortion counseling or referral (Babbitt v. Planned Parenthood of Central and Northern Arizona). 1987 The Reagan administration proposes the “gag rule,” regulations prohibiting Title X-supported clinics from discussing abortion with women facing unintended pregnancies and requiring clinics to maintain a “wall of separation” between family planning and abortion services. 1988 The FDA approves the cervical cap for use in the United States. 1990 The FDA approves the contraceptive implant for use in the United States. 1991 The Supreme Court finds the “gag rule” constitutional (Rust v. Sullivan). 1992 The FDA approves the contraceptive in jectable for use in the United States; the Supreme Court reaffirms the essential holdings of Roe v. Wade (Planned Parenthood of Southeastern Pennsylvania v. Casey). 1993 President Clinton suspends the “gag rule” during his initial days in office; the FDA approves the female condom for use in the United States. 1996 A law overhauling the nation’s welfare system is enacted. 1997 For the first time, the FDA approves a product marketed as an emergency contraceptive. 1998 Maryland becomes the first state to mandate comprehensive contraceptive coverage in private insurance plans; Congress requires insurance coverage of contraceptives for federal employees. 1999 The Centers for Disease Control and Prevention cites family planning as one of the top public health achievements of the century. Figure 4. Family planning timeline, 1960-1999 Adapted from, The Alan Guttmach er Institute [AGI]. (2000). Fulfilling the promise: Public policy and U.S. family planning clinics New York, NY. Reprinted with permission from the publisher.

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387 Figure 5 Figure 5. Percentage of contraceptiv e users by contraceptive method, 2002 Adapted from, Mosher, W.D., Martinez, G.M., Chandra, A., Abma, J.C., & Wilson, S.J. (2004). Use of contraception and use of family planning servi ces in the United States: 1982-2002. Table 5. Number of women 15-44 y ears of age using contraception, and percent distribution (wit h standard error) by current cont raceptive method: United States, 1982, 1995, and 2002. Vital and Health Statistics No. 350, December 10, 2004. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 27 30.6 1.2 5.3 2 0.3 1.2 0.4 0.9 18 9.2 4 05101520253035Female Sterilization Pill 3-Month Injectable (Depo-Provera) Diaphragm Periodic Abstinence-Calendar Method WithdrawalContraceptive MethodPercent of Contraceptive Users

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388 Figure 6 Figure 6. Reported public expenditures for fa mily planning client services, by funding source, United States, FY 2006 Sonfield, A., Alrich, C., & Gold, R.B. (2008). Public funding for family planning, sterilization and abor tion services, FY1980–2006. Table 3.1. Reported public expenditures for family planning client services, by funding source, FY 2006 (p. 19). New York, NY: Guttmacher Institute, No. 38. Reprinted with permission from the publisher. 70% 2% 13% 3% 12% Medicaid ($1,304,006,000) State Appropriations ($241,149,000) Title X ($215,297,000) Social Security Block Grant/Temporary Aid for Needy Families ($47,652,000) MCH Block Grant ($38,188,000) Other Federal Sources (670,000)

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389 Figure 7 Figure 7. Reported public expenditures for fa mily planning client services, by funding source, Florida, FY 2006 Sonfield, A., Alrich, C., & Gold, R.B. (2008). Public funding for family planning, sterilization and abor tion services, FY1980–2006. Table 3.2. Reported public expenditures for family planning client serv ices (in 000s of dollars), by funding source, according to state, FY 2006 (p. 20). New Yo rk, NY: Guttmacher Institute, No. 38. Reprinted with permission from the publisher. 50% 18% 32% State Appropriations ($31,887,000) Medicaid ($20,656,000) Title X ($11,753,00) MCH Block Grant ($0) Social Security Block Grant/Temporary Aid for Needy Families ($0) Other Federal Sources ($0)

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390 Abstinence Contraception Abortion Figure 8 Figure 8. The reproductive process McFarlane, D.R., & Meier, K.J. (2001). The politics of fertility control (p. 5). Washington, DC: CQ Press. Reprinted with permission from the publisher. Step 1: Sexual Intercourse Step 2: Conception Step 3: Gestation and Parturition Live Birth

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391 Figure 9 Figure 9. The legislative process Adapted from, Reed Elsevier Inc. (2007). How a bill becomes law. Retrieved September 3, 2008, from LexisNexis Congressional database. Adapted from, U.S. House of Representatives. (n.d.). Tying it all together: Learn about the legislative process. Retrieved September 3, 2008, from http://www.house.gov/hous e/Tying_it_all.shtml Bill Introduced in House Bill Referred to Committee Public Hearin g s and Testimon y Marku p s Amendments Votes Re p orte d Law Codifie d Public Law President Si g ns or Vetoes Conference Committee Floor Debate in House N ew Re g ulations Re g ulations Codifie d Bill Introduced in Senate Bill Referred to Committee Public Hearin g s and Testimon y Marku p s Amendments Votes Re p orte d Floor Debate in Senate

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392 Figure 10 Empowering women/ Providing women choices regarding their fertility HIV/AIDS – Information, education and preventative services Social and cultural context – Culturally sensitive information and education Welfare reform Funding (increases/ decreases) Integrating Title X with other policies/programs (including funding and services) Multiple identities (providing services to all individuals) Abortion Family planning methods Abstinence education Administration and politics (“Schizophrenia” in politics; perpetual legislators) Adolescents (maintaining confidentiality; parental notification; emancipation of minors; school-based clinics Technical guidance (requirements /restrictions) Stake-market control (the role of the government) Public health issues (birth spacing, health mothers/babies preventing unintended pregnancy, preventing disease) Figure 10. Synergism of data: Common them es emerging from the thematic analysi s of Title X’s legislative history (Phase I) and oral histories with key Title X stakeholders (Phase II)

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ABOUT THE AUTHOR Cheryl Vamos received a Bachelor’s De gree in Biological Science, Honours, in Nutritional and Nutraceutical Sciences from th e University of Guelph, Guelph, Ontario, Canada. Cheryl then received a Masters of Public Health with a concentration in Maternal and Child Health, and a Graduate Certificate in Women’s Health from the University of South Florida. Following these degrees, Cheryl persued her Ph.D. in Public Health at the University of South Florida. Cheryl has been involved with many re search, teaching and se rvice activities in public health. Research projects that Ch eryl has contributed to have focused on behavioral and psychosocial health issues and include reproductive cancers, HPV in women and men, contraception a nd abortion utilization, chronic diseases in marginalized female populations, state and county-level n eeds assessments in women’s health, and family planning policy. Cher yl has presented her research at professional conferences, has a variety of publications, and is a peer-r eviewer for several journals. In addition, Cheryl has also taught many undergraduate publi c health courses, and has served as the teaching assistant for several graduate courses.