Probably the last thing a high schooler wants to be doing on a Friday afternoon is practicing unrolling a condom onto a styrofoam penis as part of a three-hour sex ed class.

And yet that’s exactly what nine 11th-grade boys were doing on a recent Friday afternoon in early November while attending a sexual health class in downtown Las Vegas put on by a local non-profit organization. There were the requisite bouts of uncomfortable giggles, but also frank conversations about risky behaviors, sexually transmitted infections and birth control methods. The goal: Destigmatize conversations about sexual health, whether or not you are planning to have sex anytime soon.

“Oh, I love that analogy. I’ve never heard that before,” said class instructor Jessi Dorn, praising the way one of the boys framed purchasing condoms. “It's like buying Band-Aids and cotton balls. It should be just part of your routine, and putting on a condom should be like brushing your teeth. It happens every time. You brush your teeth every day. You're preventing cavities.”

Dorn patiently and matter-of-factly answered their questions: Plan B isn’t a routine form of birth control, it’s emergency contraception. STI stands for sexually transmitted infection, the preferred way to talk about what were once known as STDs, or sexually transmitted diseases. Yes, herpes can be transmitted just through skin-to-skin contact. No, you can’t get HIV through French-kissing.

Where kids of generations past might have been subject to decades-old public service announcement videos in their sex ed classes from teachers who adamantly insisted they were representative of teenage interpersonal relationships, Dorn acknowledged the cheesiness of the videos she showed them. As she passed out condoms for the demonstration, Dorn told them, “Shake it out, get the wiggles out, while I pass it out, get your giggles, I mean,” before descending herself into laughter along with the group.

“Half the kids I teach don't know how to put a condom on properly. I watch them struggle,” Dorn said in an interview before the class. “I know that they're learning on their own or they're not learning from anyone. So to watch them struggle and feel embarrassed, I'm almost like, ‘Good, I'm glad you're a little embarrassed so you're more receptive how to do it appropriately or the correct way.’”

That Friday afternoon was Dorn’s first session teaching students from the Core Academy after school program, which provides mentoring, tutoring and character development programs for underserved youth in Clark County. Dorn, an educator with the non-profit SAFY (Specialized Alternatives for Families and Youth), typically teaches sexual health classes to kids in the juvenile detention centers and on probation, as well as to homeless and foster youth.

The work Dorn does educating kids about healthy sexual choices is made possible through a federal grant, administered by the Southern Nevada Health District, aimed at reducing teen pregnancies. But earlier this year, the Trump Administration decided to cut the $214 million in federal grants that pay for Dorn’s classes and other pregnancy prevention efforts and research across the country.

What was supposed to be a five-year grant program will abruptly end after three in June, leaving the local organizations who relied on the federal government for teenage pregnancy prevention funds in a lurch, scrambling to think of creative alternatives and look for private funding sources that might be able to sustain their work. Teen pregnancy rates are on the decline in Nevada as they are nationally, but local health officials worry that cutting the funds means taking a step backwards when the United States still has higher teen pregnancy rates that most other developed nations.

“Although people can say, ‘Well these rates are going down, so there’s not a need,’ that’s exactly why there is a need — because we have proven that by providing these services, it does provide a positive change and a positive impact,” said Southern Nevada Health District health education supervisor Xavier Foster, adding that cutting the funds “will put us in danger of reversing this trend.”

An “evidence-based” approach

The federal Teen Pregnancy Prevention Program, established in 2010, is the result of a congressional mandate to fund medically accurate and age-appropriate programs to prevent teen pregnancies across the United States. (It’s one of six federal evidence-based initiatives aimed at tackling various social issues.)

The Southern Nevada Health District and the 101 other recipients of the first round of funding, which spanned 2010 to 2014, helped reach nearly half a million kids in 39 states and Washington D.C., trained 6,100 program facilitators and created more than 3,800 community partnerships, according to the U.S. Department of Health and Human Services. The program also funded 41 evaluation studies to figure out which sexual health curricula were most effective where, when and with whom.

The second round of funding, from 2015 to 2020, awarded 84 grants to implement evidence-based teen pregnancy prevention programs, build the capacity of existing programs, support technology- and program-based innovations to prevent teen pregnancy that need further development and rigorously evaluate new approaches to reducing teen pregnancy. The goal of the second round of funding was to reach 1.2 million teens in 39 states and the Marshall Islands by 2020.

The Southern Nevada Health District used its first round of funding to gear up its evidence-based teen pregnancy prevention efforts and has been using it’s second round, $750,000 a year award to build capacity in its existing system. The Nevada Primary Care Association, based in Carson City, also received a roughly $572,000 a year award in the second round of funding to implement for the first time a teen pregnancy prevention program in community health centers statewide.

But then, in July, the Department of Health and Human Services abruptly announced that grant funding through program would not be renewed for the fourth or fifth year, citing the “poor evaluation results” from the program.

"The very weak evidence of positive impact of these programs stands in stark contrast to the promised results, jeopardizing the youth who were served, while also proving to be a poor use of more than $800 million in taxpayer dollars," the department said in a statement to CNN.

"The poor evaluation results were the reason that the Trump Administration, in its FY 2018 budget proposal, did not recommend continued funding for the TPP program and HHS hit the pause button on it," the statement said. "This action gives the Department time to continue its review of the program and the evidence, to ensure that should Congress continue it, the program provides positive reinforcement of the healthy decisions being made by a growing majority of teens."

But part of the goal of the Teen Pregnancy Prevention Program was to test the effectiveness of the programs and observe how well different curricula worked in different communities. Advocates for the program say that cutting off funding next year is tantamount to ending a five-year experiment two years early.

“These programs were designed to test programs and strategies. The current round of grants was building off of the success of the first round,” said Lauren Ranalli, director of the Adolescent Health Initiative at the University of Michigan Health System. “Cutting these programs is counterintuitive and flies in the face of good public health data and policy. We need to invest in the scientifically sound ways to help young people make healthy decisions.”

Teen pregnancy rates are at an all-time low. Between 2010 and 2015, Clark County saw a 33 percent decrease in teen birth rates, down to 26.3 births per 1,000 teenage girls. That’s higher than the national teen birth rate of 20.3 per 1,000, but slightly lower than Nevada’s teen birth rate, 27.6 per 1,000.

“Why mess with success? One of the nation’s great success stories over the past two decades has been the historic declines in teen pregnancy and childbearing. Teen pregnancy is down better than 50 percent since peaking in the early 1990s. Teen births are down 67 percent,” said Bill Albert, chief program officer of the National Campaign to Prevent Teen and Unplanned Pregnancy. “There have been declines in all 50 states, that includes Nevada, and among all racial and ethnic groups. Truly historic process on an issue that experts in the field considered intractable."

Albert says the Teen Pregnancy Prevention Program hasn’t been solely responsible for the decline — “not by a long shot.” But he says it would be “folly” to think the program had nothing to do with the historic drop in rates of teen pregnancies.

Changing teen behavior when it comes to sex is “not for the faint of heart,” Albert said. “It’s hard to do. He noted that somewhere close to 40 percent of the programs funded through the grant were successful in changing teen sexual behavior, which is “remarkably successful” when similar public health interventions are typically considered successful at a 10 percent success rate.

“The entire Teen Pregnancy Prevention Program was based on evaluation. What worked among a relatively well-to-do white population in New England is not working with relatively poor black African American kids in Mississippi,” Albert said. “That’s what the Teen Pregnancy Prevention Program has done. It is committed to evaluation. It has expanded the menu of options that communities can choose from.”

Dr. Joseph Iser, chief health officer for the Southern Nevada Health District, wrote a letter in July with 19 other health officials from across the country to then-Health and Human Services Secretary Tom Price voicing concern about the administration’s decision to slash funding to the program.

“Ending what was intended to be five year TPPP grants two years early is highly disruptive to ongoing work in localities across the country,” Iser and the other officials wrote. “These cuts will negatively affect the lives of young people currently participating in these programs, and will mean fewer project jobs, fewer trained professionals, and reduced community partnerships.”

Nevada’s efforts

The Southern Nevada Health District’s goal with the Teen Pregnancy Prevention funding was to target specific zip codes in Las Vegas and North Las Vegas with the highest rates of teen pregnancy, with the goal of reducing teen pregnancy rates in the two cities by 15 percent by 2020.

The grant to the health district currently funds two programs for teens: Be Proud, Be Responsible and Sexual Health and Responsibility Program (SHARP), both which focus on communicating skills to prevent sexually-transmitted infections, HIV and pregnancy. A third program, called Families Talking Together, helps parents talk about sex with their kids.

Much of the focus of the health district’s grant is on reaching kids in the juvenile detention centers and foster homes, as well as homeless youth, though the health district and its community partners will occasionally work with after school programs to teach the curriculum to kids there. It is the responsibility of the community partners, in this case SAFY and Planned Parenthood, to actually teach the programs in the community, while the health district staff ensures the classes are taught appropriately and evaluating how much kids are learning through the classes.

The health district is responsible for community outreach about the program, from handing out condoms outside high schools with a card with a number that kids can text to get sexual health information or ask for the closest clinic where they can go to receive services to putting up advertisements in bus shelters near some of the target high schools. A Youth Leadership Council also funded under the grant to teach high schoolers leadership skills while training them to become peer educators for sex education.

But all that could change starting next year. Foster said that when the health district received the notice from the federal government in July indicating the Teen Pregnancy Prevention program funding for the third year of the grant had been formally approved, they also received notice that it would be the last year of funding.

“I mean there’s always been talk with the election and the new administration that their focus could be something different that would not be as open to what we are doing and the focus might switch from prevention to abstinence,” Foster said.

Unless Congress takes action to specifically fund the Teen Pregnancy Prevention program when it approves its budget in December, the funding for the programs will officially expire at the end of June. That’s why the health district is trying to look at other possible funding sources, such as private foundations, to continue to fund the pregnancy prevention efforts. Foster and other officials involved with the program presented to the Southern Nevada Health District board last month in an effort to raise community awareness about what the program does and what the community stands to lose if it ends.

“The purpose of the presentation to the board of health last week was to kind of like, ‘Let’s use your connections and your leverage to get all these systems and institutions and cities to sit together and let’s find some funding from somewhere where everybody can chip in so we can continue providing these services,’” Foster said.

Up north, the health district’s sister grantee based in Carson City, the Nevada Primary Care Association, is grappling with the possibility of winding down a program that has barely just started. The association, which aids federally qualified health centers and other community health providers across Nevada, received an implementation grant to ramp up their pregnancy prevention efforts in the state’s community health centers in both southern and northern Nevada by 2020.

It took time for the association to ramp up its program. First, it had to reach out to various community health centers across the state to see if they had the time and space to run sexual health programs and pick out which evidence-based curricula they wanted to teach. Once they figured that out, the staff at the health centers had to be trained, and the association had to coordinate outreach to get kids into the programs.

Since the program launched in July 2016, they have reached 390 kids and families in Clark and Washoe counties at eight community health centers. The initial grant included Elko, Lander, Nye and Eureka counties, as well as Carson City, but hasn’t expanded to health centers in those communities yet.

But now, the association is grappling with how to ensure the program is sustainable and low cost so that community health centers can continue to provide sexual health education to the community even after the funding ends in June. All that on top of the fact that federally qualified health centers, nonprofit health centers and clinics that serve medically underserved areas and provide services regardless of a patient's’ ability to pay, have yet to receive funding reauthorization for Congress for the next year.

“So far we’ve been focusing most of our efforts on making the program sustainable because they are set up and people have been trained so they have everything they need to run the evidence-based curriculum,” said Jim Godwin, communications coordinator for the primary care association. “We’re trying to work on ways to have it still be there.”

Godwin emphasized that even though the numbers of teen pregnancies are going down, they’re still “alarmingly high.”

“These programs do work, and it is important to promote safe and supportive sexual and reproductive health education that helps reduce those planned pregnancies and STIs,” Godwin said. “I think now with the way technology is and social media the teen pregnancy prevention programs or adolescent health and wellness programs take on an added urgency.”

What happens next

Albert, from the National Campaign to Prevent Teen and Unplanned Pregnancy, said there is a “very, very small” but “not zero” chance that the Teen Pregnancy Prevention program will be funded, depending on what Congress decides to do with the budget. He said that there are private and regional foundations or local businesses that might be able to step in to help grantees continue operating their teen pregnancy prevention efforts.

“Many will seek private funding, perhaps, some may appeal to state government to replace the lost federal money, and I think some will be successful,” Albert said. But my concern — and I’m not trying to be cynical here — I think the concern is many will not be successful in replacing that money and will subsequently go dark.”

Foster, with the Southern Nevada Health District, said he has had some conversations with the state, which operates two pregnancy prevention programs, about how to hand off the district’s relationships with its community partners should the funding dry up with no viable alternatives in place.

The Nevada Adolescent Health and Wellness Program already works with Planned Parenthood, one of the health district’s community partners, through its State Personal Responsibility Education Program (PREP) program funded through the Department of Health and Human Service’s Administration on Children, Youth and Families. The state also receives a federal grant through the Abstinence Education Grant Program (AEGP). Both programs are under consideration for reauthorization at the federal level, but are funded through 2019 and 2018, respectively.

Through the PREP program, the state has focused on implementing a Spanish-language based program called ¡Cuídate!, which aims to use Latino cultural beliefs to talk about abstinence and condom use. Planned Parenthood has used that curriculum to go out into homes and community centers to educate the community about sexual health, said Vickie Ives, Maternal, Child and Adolescent Health Section manager at the state’s Division of Public and Behavioral Health.

The state’s efforts also include focusing on teen pregnancy prevention education in the rural communities. Through its abstinence-based program, the state works with the Nye Community Coalition in Nye County, and both the AEGP and PREP funds are used to facilitate trainings at the Family Resource Center of Northeastern Nevada in Elko.

“We actively try to serve and create linkages and share best practices with our more urban and more rural sites,” Ives said.

But when it comes to the impact of what eliminating the Teen Pregnancy Prevention Program funding might have on the state’s efforts as a whole, Ives said she couldn’t be sure.

“We try to do outreach to others working in the state to increase capacity and create relationships,” Ives said. “But in terms of just capacity to serve as many youth as possible? That’s always something we’re looking at and concerned about.”

Updated 11/13/17 at 7:01 a.m. to correct the fact that the Adolescent Health Initiative is a part of the University of Michigan Health System, not the school of medicine.