The Trump administration has informed multiple divisions within the Department of Health and Human Services that they should avoid using certain words or phrases in official documents being drafted for next year's budget.

Officials at the Centers for Disease Control and Prevention, which is part of HHS, were given a list of seven prohibited words or phrases during a meeting Thursday with senior CDC officials who oversee the budget. The words to avoid: "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based."

A second HHS agency received similar guidance to avoid using "entitlement," "diversity" and "vulnerable," according to an official who took part in a briefing earlier in the week. Participants at that agency were also told to use "Obamacare" instead of ACA, or the Affordable Care Act, and to use "exchanges" instead of "marketplaces" to describe the venues where people can purchase health insurance.

At the State Department, meanwhile, certain documents now refer to sex education as "sexual risk avoidance."

The colleague who provided the briefing at the second HHS agency relied on a document from the Office of Management and Budget detailing guidance for the fiscal 2019 budget, said the official in an interview Saturday. No explanations were given for the language changes. The HHS official spoke on the condition of anonymity because the language change information was supposed to be "close hold." The person did not want to name the agency to protect the identity of officials involved in the talks.

It's not clear whether other federal agencies have been instructed to avoid certain words, and if so, to what extent, in preparing their budget documents for next year. Officials interviewed at the two HHS agencies said the language restriction was unusual and a departure from previous years.

The OMB oversees the process that culminates in the president's annual budget proposal to Congress. That budget document, usually several volumes, is generally shaped to reflect an administration's priorities. An OMB spokesman did not respond to a request for comment.

News of the directives to stop using these words and phrases drew outcry from scientific groups, researchers and advocacy organizations who took to Twitter and other social media.

Rush Holt, chief executive of the American Association for the Advancement of Science, said: "Among the words forbidden to be used in CDC budget documents are 'evidence-based' and 'science-based.' I suppose one must not think those things either. Here's a word that's still allowed: ridiculous."

Mara Keisling, executive director of the National Center for Transgender Equality, noted that CDC's own research suggests that transgender people face a higher risk of being infected with HIV.

A CDC study published in August, which analyzed 9 million agency-funded HIV tests, determined that transgender women "had the highest percentage of confirmed positive results (2.7%) of any gender category."

"To pretend and insist that transgender people do not exist, and to allow this lie to infect public health research and prevention is irrational and very dangerous, and not just to transgender people," Keisling said in an email.

While HHS staffers were directly notified about how they must change the language they use when preparing budget documents, a shift is happening in other departments as well.

At the State Department, for example, employees received a guidance document on Wednesday that outlined how they should develop country operating plans under the President's Plan for Emergency AIDS Relief (PEPFAR) for 2018. This document repeatedly uses the phrase "sexual risk avoidance," which has been defined in recent congressional funding bills as abstinence-only practices until marriage, as the primary form of sex education.

Jen Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation, said in an interview Saturday that while the document does not specifically change how much money should be spent on abstinence-only programs under PEPFAR, the heavy emphasis on it could shift priorities on how money is spent overseas.

"It's a change, and the language in these documents does matter, because that's what's communicated to the teams in the field," Kates said, adding that it's "too early to tell" how this might translate into funding changes.

According to a database compiled by the Foundation for AIDS Research, or Amfar, the amount of money that has been allotted for "Abstinence/Be Faithful" programs under PEPFAR fell from a high of $258.3 million in 2008 to $20.1 million in 2017. As a share of overall PEPFAR funding, this represented a decline from 7 percent to 1 percent.

The same guidance document includes a line touting the efficacy of abstinence-only programs, referring to "abstinence as a highly effective form of prevention."

Several public health experts questioned that assertion, noting that multiple studies have shown that there is little evidence this form of education either delays sexual activity or reduces the number of sexual partners a person has. A nine-year congressionally mandated study concluded in 2007 that teenagers enrolled in abstinence-only programs were no more likely to refrain from having sex than those who did not enroll. Among those who did have sex, the study found, there was no difference in when they began to engage in this activity or how many partners teens in each group had.

Jesse Boyer, senior policy manager at the Guttmacher Institute, said in an interview Saturday that the "rebranding" of abstinence programs with the term "sexual risk avoidance" would not make them more effective.

"It's the continual promotion of a coercive and ideological agenda over what the science and research tells us what young people need to lead healthy lives," she said.

In a statement, the State Department said Violence Against Children surveys funded by the program in 11 countries "showed that an average of 1 in 3 young women had a first sexual experience that was forced or coerced. In light of this alarming evidence, PEPFAR has placed an even greater emphasis on activities supporting sexual risk avoidance, with a particular focus on girls ages 9-14," in the guidance.

The HHS official who received the briefing on language changes said the reaction among participants was similar to that at the CDC when budget analysts were informed they couldn't use the seven words or phrases in drafting budget materials.

"People were surprised, people were not thrilled," the HHS official said. "We all kind of looked at each other and said, 'Oh, God.' "

At the CDC, budget analysts were told they could use an alternative phrase instead of "evidence-based" or "science-based" in budget documents. That phrase is "CDC bases its recommendations on science in consideration with community standards and wishes," said a budget analyst who took part in the 90-minute briefing.No alternatives were suggested for the other words.

At the CDC, the briefing was led by a senior career civil servant in the office that oversees formulation of the agency's budget. She opened the meeting by telling participants not to use the words "vulnerable," "entitlement" and "diversity" because documents containing those words were being "flagged" by others higher up the chain in the budget process, and documents were being sent back to CDC for corrections.

The civil servant then announced the additional words — "fetus," "transgender," "evidence-based" and "science-based" — that were not to be used. Another senior CDC budget person told the group that agency budget officials conducted a search across the agency's budget documents and found that "evidence-based" and "science-based" were used so frequently that they were essentially meaningless, the analyst recalled.

In a statement, HHS spokesman Matt Lloyd said: "The assertion that HHS has 'banned words' is a complete mischaracterization of discussions regarding the budget formulation process. HHS will continue to use the best scientific evidence available to improve the health of all Americans. HHS also strongly encourages the use of outcome and evidence data in program evaluations and budget decisions."

Lloyd declined to identify any specific inaccuracies in The Washington Post's report about words that are prohibited in CDC budget documents.

CDC Director Brenda Fitzgerald emailed staff late Saturday reassuring them that the agency has a history of making public health and budget decisions based on the best available science and will continue to do so. "I want to assure you that CDC remains committed to our public health mission as a science- and evidence-based institution," she wrote.

The CDC analyst said it was clear to participants that they were to avoid those seven words but only in drafting budget documents.

"What would you call it when you're told not to use those words?" the person said. "If that's not a ban, maybe I need to improve my vocabulary."

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