Gardasil hysteria plays into hands of pediatricians

20110813-221604.jpgCartoon by Ben Lansing – from Age of Autism website

Stories like this one at anti vaccine sites are unfortunately typical in their misinformation and use of hyperbole and sound bites rather than informing the reader in a non-biased manner. What I found amusing is that the specific approach used in this article actually plays into the hands of pediatricians…

Let’s ignore the rhetoric of the “dangerous” HPV vaccine (it is not) or the claim that it has caused “as many as twelve deaths in the US alone” (it has not) and focus on the headline of the piece.

“California mulls giving 12-year-olds STD vaccine Gardasil without parental consent”

While being technically correct that Gardasil does indeed protect against a sexually transmitted virus, the implications here are clear – anything involving 12 years olds and STDs is immoral, and anything where the parents have no say is unethical. Putting the two together is an order of magnitude worse!

Far from implying that 12 year olds are “sexual animals” (their words, not mine) the simple fact is that the 11-12 year old well-child visit is a perfect time to address many aspects of preventative care before the child becomes a teenager. This is why the vaccine is recommended at 11 years even though it is approved down to 9 years of age. Updating the vaccines at that visit is a no-brainer. With any luck the kids are NOT YET “sexual animals”, because ideally you want to protect them before that happens. Getting the HPV shots started 6 months before a teen’s “big night” is, I’m sure, not something they have on the calendar…and having taken care of my share of teenage mothers I can vouch for the fact that planning their sexual activity is clearly not something they are very good at at all.

Sexual health for teens includes proper counseling, education, and access to contraception. Abstinence is the most obvious way to avoid STDs and unwanted pregnancies, but abstinence-only education is associated with HIGHER rates of pregnancy and SIMILAR rates of STDs than more well-rounded education! Over half of abstinence “pledgers” will still go on to have pre-marital sex, the same rate as teens who don’t pledge abstinence (80% in fact denied ever having pledged in the first place…) While there may be an initial delay in the first sexual episode, after that the lack of proper education really does these people a disservice (if they are delaying sex, but their STD rates are similar, then someone is playing catch-up!) Not giving them a vaccine that, if all three shots are given on time, protects against 70% of cervical cancer is simply wrong.

The second part is whether or not parents have a say. In general, parents operate under the assumption that they are responsible for the health and well-being of their child until they are an adult. They get to call the shots (pardon the pun) and have access to all the information. Sadly, as some discover, that simply isn’t true. Parents do have the responsibility to take care of their kids, but if they fail to do so then the authorities can step in and take over that responsibility – most obviously in cases of child abuse or neglect. Effectively the State acts as if it is responsible for the welfare of children and merely delegates that responsibility to the kids’ parents or legal guardians – a delegation they can revoke if need be. But a lesser known area where parents lose their right to control their kid’s healthcare is sexual health.

It is clear that in order for teens to feel safe about coming forward to ask for help with sexual health issues, this MUST be done under strict confidentiality. Having a requirement that parents provide consent to treat (as is needed for every other situation except life-threatening emergencies) is a barrier to effective safe treatment of teens sexual health issues. The laws vary by State but in many places minors are allowed access to confidential sexual healthcare.

Ironically perhaps, by trying to demonize Gardasil as a way in which the medical establishment is sexualizing the youth of today, and labeling it explicitly as a sexual health vaccine, antivax groups are automatically putting it outside the remit of parental oversight. In the same way as a sexually active teen can (and should) get advice, contraception or treatment for STDs without fear of their parents knowing about it, I see no reason why they shouldn’t be allowed to ask for a sexual health vaccine under the same existing laws.

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  1. #1 by Peter English on August 14, 2011 - 11:54

    Thanks for that interesting article, Nick.

    It’s interesting to compare legal frameworks in different countries. There’s some information on the UK position at http://www.ganfyd.org/index.php?title=Minors. Here, the default position is that people are deemed “competent” to consent from the age of 16 – no parental consent is required. (Curiously, from 16 to 18 they are still legally minors, and if they’re not competent – if they “lack capacity” – parents can consent on their behalf; after that age it becomes more complicated.)

    Under the age of 16 the “Gillick” rule applies. Victoria Gillick was a woman with strong religious principles – you know the type, I expect; I get the impression that middle America is full of the type. She had several daughters, and sought confirmation that they would never be prescribed contraception without her prior consent. The courts – sensibly – concluded that if a person under the age of 16 understood the implications of consenting to treatment, they could do so without requiring parental consent.

    This principle has extended to other treatments including vaccination. For vaccines, the “what you need to understand” bit is fairly straightforward for vaccination (they are extremely safe, with only x per 100,000 having a serious side effect, although a greater proportion, y per 100,000 will have minor reactions such as a sore arm, headache, or mild pyrexia; they reduce your chances of getting condition C, [should you be exposed to it] by this much… or in short, they make it much less likely to get C, and are very safe, albeit not entirely without risks…). So in some situations it’s been agreed locally that people over the age of e.g. 14 would normally be able to understand this, and it would only be if somebody thought otherwise (the health care worker doing the vaccination, or perhaps a teacher if done at school) that more effort would be required to test the child’s understanding.

    Interestingly, there’s another legality that arises with young children, too young to understand. What should you do when parents disagree? For most treatments, the consent of only one “person with parental responsibility” is required. Does this also apply to vaccination?

    This has been tested in two cases, about MMR vaccination, at a level of court which can set precedent.[1,2] The parents who didn’t want the child vaccinated called on a precedent regarding circumcision (much less commonly done in the UK than in the USA; and before the research showing a lower risk of various STIs in circumcised men). It had been established in court that where a treatment (like circumcision) was highly controversial, consent of both parents (or rather, “all persons with parental responsibility”) was necessary.

    In the two cases concerned – heard together – the judge concluded that immunisation with MMR was clearly in the children’s best interests medically, and should proceed, against the wishes of one of the parents. Infuriating for future cases, however, the judge added that the judgement had to be made taking everything into consideration – including the possible harm done to the child by damaging the relationship between the parents; and that the judgement should not be used as precedent to presume that vaccination should be given if only one parent consented.

    The judgement was made at the height of fears about MMR vaccination, several years ago: it is possible that, now that MMR fears have been allayed (yes, they should never have been raised in the first place!), if the cases were to be heard now, a far more permissive judgement would be given.

    1. Thorpe, Sedley, Evans A. B (a child) [2003] EWCA Civ 1148, 2003 (30 July); (http://www.quackwatch.org/03HealthPromotion/immu/mmrappeal.html).

    2. English R. RE B (A CHILD) sub nom IN RE VACCINATION/MMR LITIGATION : A v B : D v E sub nom IN RE C (A CHILD) (IMMUNISATION: PARENTAL RIGHTS) : IN RE F (A CHILD) (IMMUNISATION: PARENTAL RIGHTS) (2003) [2003] EWCA Civ 1148. 2003; Updated July 2003; Accessed: 2009 (18 November): Recent Cases (http://www.1cor.com/1198/?form_1155.replyids=277).

    • #2 by Nick Bennett on August 14, 2011 - 12:07

      Thanks for the detailed reply Peter. In the US there is no such thing as “Gillick” competence. This came up recently in a ethics discussion about parents refusing transfusion for their kid – and what would happen if the kid was old enough to understand and wanted to do it… In practice here the case has to go to court (their are fast-track proceedings available for medical decisions like this) so the decision is taken out of everyone’s hands.

      The exception is sexual health issues, as it is the lesser of two evils. In an ideal world the folks would consent or the kid wouldn’t be intimidated in coming forward for treatment, but since the world isn’t ideal the kid’s needs (as the patient) come first.

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