Ms. WAGGONER. I can only speak for myself, but I would think they would give up the title X dollars because you cannot put those restrictions on all physicians within your hospital. It is just not something that you can do.

Also the abortion services often bring in more money than the family planning services do. Title X is not highly funded.

Again, I cannot speak for everyone, but as long as abortions are legal, title X really cannot compete over the rest of the medical system.

Mr. WAXMAN. Dr. Nelson, do you have something to add to that? Ms. NELSON. Yes. I am part of a hospital-based system also. We have gone to a very aggressive antepartum detection for birth defects program. We have required alpha feta protein testing, amniocentesis, all of these things, and looked to abortion as an option for a patient, when she discovers her baby has a life-threatening or incompatible-with-life defect. If we could not offer that in our hospital, we would again face the same question.

I do believe that title X services would be the one that would leave, not the abortion services.

Mr. WAXMAN. So if there are not family planning services available, in a community like Ms. Jarman's, there may not be any available for any one in the community at all if the title X program closes up.

Is that right, Ms. Jarman?

Ms. JARMAN. That is correct.

Mr. WAXMAN. There seems to be a lot of confusion about what is called nondirective pregnancy options counseling.

Could we have some description of how you do such counseling? There seems to be a lot of confusion about pregnant women in family planning clinics and some assumptions that only nonpregnant women come in.

Can you explain the services that you provide, why some pregnant women do come in, what you think about Dr. Windom's suggestion that all pregnant women with health concerns be immediately sent elsewhere? How would that work in practice?

Ms. Jarman.

Ms. JARMAN. I can start off just by saying it would work terribly. It amazes me that someone can suggest that a woman come in for a pregnancy test and receive a pregnancy test and you say, yes, you are pregnant, or, no, you are not pregnant, and dismiss her. Even the medical implications of all of that aside, I think it is inhuman to treat anyone like that.

It is important to know-and I think you referred to this earlier-that there is a lot of information that goes to the patient at the time of that pregnancy testing that isn't directly related even to the options that she has to consider: nutrition information; if she is pregnant, information on the importance of not smoking; a range of medical care issues that must be addressed, if indeed, she decided to continue the pregnancy. In many communities it may be weeks and weeks before she even has an opportunity to get in to see an ob-gyn. So it seems to me it is critical that we must be able to discuss all of the options.

Also, if, indeed, she decides that she wants to terminate her pregnancy, again if she has not received adequate counseling at the

time, she could again go weeks and weeks and weeks into the pregnancy before she has had an opportunity to fully explore this possibility.

Mr. WAXMAN. It strikes me that if a clinic is going to be so nervous about talking to a woman about the possibility of an abortion, should that woman be thinking about an abortion and realize she is not going to get any counseling from them about it, she will go home and, if she is unhappy about being pregnant, maybe sign up for an abortion without having talked it through with someone, when maybe through counseling she would have decided not to have an abortion. But because of the sort of bureaucratic maze that they want to set up for fear that women will know their options and think them through and decide for themselves what they want to do, they may well be pushing people into more abortions.

I certainly think that is the case. I never could understand this: why the people who are against abortion fight against contraception. If you don't have programs for family planning to avoid pregnancy and you have more unwanted pregnancies, there are clearly going to be more abortions.

That always befuddled me, that the anti-abortion forces look at this whole thing from behind blinders that keep them from seeing that reality.

Maybe, Mr. Klausmeier or Ms. Waggoner, either one of you, can you tell me more about how you discuss the option of abortion. The law provides that you have to give nondirective pregnancy option counseling, including information about abortion. These are the guidelines. Suddenly the administration has switched it around and said, in effect, that you can't give even nondirective information about abortion.

How would it be handled if you are giving nondirective abortion counseling?

Mr. KLAUSMEIER. I think the point was made this morning that this is a reversal of what the title X regulations have required; that is, that we give each pregnant woman all three choices, whether she wants to have a child and be referred for prenatal care, the option of adoption or abortion. The point has also been made that we are often advocates for pregnant women who need help in getting into the health care delivery system for delivery services and prenatal care.

It is not unusual for us at Family Health Services to be assisting a woman for a month or two, especially low income women with this entry process, especially if it is the first child. We also have a problem getting these low income women obstetrical care. That is not only a problem in our community, but it is a problem across the country.

What has not been said yet today is that we spend a lot of time doing that. I think that fits title X. I think it is very important, and I also think it is very important that we provide all the options in an unbiased fashion; that we not weigh either one of the options. If a woman chooses to have an abortion, that is a decision between her and her doctor. And it is a legal option in this country.

Ms. WAGGONER. Can I add something? I think we are doing our patients a disservice. They may be poor, but they are not blank slates that walk into us and whatever we say first is what they are

going to do. When you say the word, "abortion," to them, they are going to make their own decisions because they are thinking human beings. It isn't because we give that option as one of the several available to them that they are automatically going to make that decision.

Mr. WAXMAN. The groups opposed to family planning believe that what is happening is that the people are being encouraged, if they are not happy about being pregnant, encouraged to have an abortion.

Ms. WAGGONER. I can assure you that we give them information. We do not encourage them to use one method or another method. We provide them with information. Our whole reason for being there is to educate that consumer and having her participate in her own care and her own decisionmaking, to have her go back to school to stay in school, to get a job, to get off public aid.

She needs to be able to make her own decisions. We try to get her to the point where she can do that.

Mr. WAXMAN. Let me change to another question that is very important. That is the AIDS issue. In your clinics, I am sure you have occasions for the issue of AIDS to be brought up because AIDS is a sexually transmitted disease. Do you support counseling and testing in the family planning clinics for AIDS, and do you believe that a Federal confidentiality and nondiscrimination policy would assist in this effort?

Anybody want to take that on? Mr. Klausmeier.

Mr. KLAUSMEIER. I think a Federal initiative would be helpful. I believe philosophically that HIV testing and counseling should be available in family planning programs. There is then the question of the financing of such a venture. HIV testing and counseling would be one more thing being added to the title X list of services. I believe it should be added and we have begun in our own clinic sites to offer HIV testing and counseling on a confidential basis. It is very important if title X is going to mandate AIDS testing and counseling on a national basis that there be forthcoming an appropriation to allow the clinic to do that.

I think family planning clinics are well-equipped medically to handle the HIV testing and couseling, but they would need financial support as well.

Mr. WAXMAN. If you had the financial support, do you think the Federal Government ought to mandate that every woman that comes into a family planning clinic be tested and counseled?

Mr. KLAUSMEIER. Absolutely not. We believe in voluntary confidential testing for HIV infections.

Mr. WAXMAN. Why do you give them the option?

Mr. KLAUSMEIER. Why do we give them the option of whether they want to be tested or not?

Mr. WAXMAN. Right.

Mr. KLAUSMEIER. I think medicine in this country is based on informed consent and voluntary participation. If we were to move to a practice of medicine that was forced medicine, then I think we would change what the medical system is about and we would change it in a negative way. I also think in this case, if it were changed specifically for this issue, that it would drive the disease

underground and make it more difficult for generations to come to fight this battle against AIDS.

Mr. WAXMAN. Dr. Nelson.

Ms. NELSON. In the short run and I think long run also, a mandatory policy would exactly turn around what we want to have happen. People would avoid coming to family planning clinics as soon as they knew the testing was required. The next step after mandatory testing is going to be contract tracing and you are going to have this whole array of very invasive procedures into the patients' lives.

I think they would walk with their feet and stay away from the clinics.

Mr. WAXMAN. Especially if that information is given out, if confidentiality is not protected, or if it does get out some way or other, people will lose their jobs and be discriminated against simply because they have a positive test. And I understand there is even discrimination against people who ask for the test to be taken, because some insurers are saying if you ask that you be tested for AIDS, there must have been some reason you were worried about it, and therefore they don't want to insure you.

It seems all those become obstacles for people to even come in and be tested. We want to remove the obstacles if we want the test information to get to the individual so counseling can encourage them to change the kind of behavior that would spread the disease to others.

MS. NELSON. The second half of that is if a patient were to get a negative result back, he or she should not be falsely reassured. There is a long latency time and people should-everyone should be practicing safer sex. We should be including this and I am sure we all are, as part of our education efforts with patients.

Please don't think just because your partner has a negative test result today, you oughtn't be using safe sex practices. The false assurance is just as important as the invasion and the ethical issues also.

Mr. WAXMAN. I want to thank you. You have been a very good panel. I appreciate your being with us. Your information will be very helpful.

Appearing on our last panel is Dr. Duane Alexander, Director of the National Institute of Child Health and Human Development, which is part of the National Institutes of Health. NICHD is the primary institute responsible for carrying out federally supported research on issues related to contraceptive technology and development.

Dr. Alexander is here today to discuss our national efforts in this field. We have already received your prepared statement for today's hearing. Dr. Alexander, we will have that as part of the record. We would like to ask you to summarize and make your oral presentation in 5 minutes.

STATEMENT OF DUANE ALEXANDER, DIRECTOR, NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT, NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. ALEXANDER. Thank you, Mr. Chairman.

Mr. Chairman and members of the subcommittee, I am Dr. Duane Alexander, Director of the National Institute of Child Health and Human Development [NICHD], of the National Institutes of Health. I am here to provide you with information on the contraceptive development activities of the NICHD.

Since its establishment in 1962, the NICHD has put emphasis on programs in the reproductive sciences. This research has provided a broad science base in the fields of human fertility, reproductive biology and infertility.

In 1968, the President's health message to Congress directed that the center for Population Research be established within the NICHD. The Center is responsible for grants and contracts in population research and is the focal point in the Federal Government for population research and training.

The goals of the Center are the advancement of fundamental knowledge required for maintenance of the reproductive health of men and women; the identification and development of new leads from basic research for safe, effective and acceptable methods of fertility regulation for use by men and women; and the alleviation of human infertility.

Mr. Chairman, contraceptive development is a major part of NICHD's responsibility for the enhancement of health by improving the ability of couples to regulate the number and spacing of their children, and by assuring the safety and protective effects of current and new contraceptive methods, including their role in preventing sexually transmitted diseases. In view of current social and health problems, the NICHD has undertaken a special initiative to support research leading to the development of new methods of contraception and the improved use of existing methods.

The objectives of this contraceptive development initiative, which was approved by the NICHD National Advisory Council, are: one, the development of an array of contraceptive methods that are safe, effective, reversible, inexpensive, easy to administer and acceptable to various population groups; and, two, the more widespread and effective use of methods that are currently available in the United States or that could be made available with adequate assurances of safety.

The current predicament of older women of childbearing age in the United States provides an example of the need for improvements in the regulation of fertility. Most of these women have had all the children they want and therefore desire totally effective contraceptive. Yet, all intrauterine devices, with one exception, have been removed from sale in the United States; many physicians recommend against the indefinitely extended use of the contraceptive pill; and the remaining methods have higher failure rates than the pill or the IUD.

For this reason, most of these women, or their husbands, become sterilized. Yet, for many, sterilization is not ideal. It virtually