The HPV vaccine mandate controversy

In this editorial we address the controversies surrounding human papillomavirus (HPV) vaccine school-entry mandate legislation, but differentiate between the mandate debate and issues specific to the vaccine itself. Our goal is not to take a stand in favor of or opposed to mandates, but rather to critically examine the issues. We discuss the following arguments against HPV vaccine school-entry requirements: 1. The public health benefit of mandated HPV vaccination is not sufficient to warrant the intrusion on parental autonomy; 2. A vaccine that prevents a non-casually transmitted infection should not be mandated; 3. Opt-out provisions are inherently unfair to parents who oppose HPV vaccination; 4. Limited health care dollars should not be directed toward cervical cancer prevention; and 5. The vaccine is expensive and potential problems with supply suggest that mandates should not be implemented until insurance coverage and supply issues are resolved. Next, we critically evaluate the following critiques of HPV vaccination itself: 1. Giving girls HPV vaccine implies tacit consent to engage in sexual activity; 2. Giving girls this vaccine will confer a false sense of protection from sexually transmitted infections and will lead to sexual disinhibition; 3. Children already have too many vaccinations on the immunization schedule; 4. Long-term side effects of HPV vaccine are unknown; 5. The vaccine's enduring effectiveness is unknown and booster shots may be required; and 6. It is wrong to only target girls with HPV vaccine; boys should be vaccinated as well.     

Participation of Adolescent Girls in a Study of Sexual Behaviors: Balancing Autonomy and Parental Involvement

Study ObjectiveThe process of research with adolescents should balance parental involvement and adolescent autonomy. The attendance of parents and peers at research study visits of girls participating in a 6-month study of topical microbicide acceptability is described, as well as the participants’ conversations with their parents.MethodsGirls, 14 through 21 years, were recruited from previous studies (3%), advertisements (14%), clinics (17%), and recommendations by friends (66%) to participate. Girls under 18 years were required to have parental consent, but parents could provide verbal phone consent as long as a signed consent form was returned before participation.ResultsThe 208 participants were 41% African-American, 30% Hispanic, and 29% Caucasian. Girls averaged 18 years of age, and 95 (46%) were under 18. Seventeen percent of parents attended the first visit; only 1 parent attended with a daughter older than 18 years of age. The mothers of older adolescents were less likely to attend the appointment with them. More Caucasian than African-American girls came with a mother. Parental attendance decreased at follow-up visits. Thirty-seven percent of girls brought a peer to the first visit; there were no age or race/ethnic differences. There was no relationship between attending with a parent or peer and talking to a parent about the study. Some adolescents obtained parental consent to participate in the study while keeping their sexual behaviors private.ConclusionsParental attendance at study visits may not be marker of parental involvement with the study. Creative ways for balancing concerns about confidentiality, promotion of autonomy, and adult involvement should be considered.     

Respecting adolescents' confidentiality and reproductive and sexual choices.

Adolescents, defined as between 10 and 19 years old, present a growing challenge to reproductive health. Adolescent sexual intercourse contributes to worldwide burdens of unplanned pregnancy, abortion, spread of sexually transmitted infections (STIs), including HIV, and maternal mortality and morbidity. A barrier to contraceptive care and termination of adolescent pregnancy is the belief that in law minors intellectually mature enough to give consent also require consent of, or at least prior information to, their parental guardians. Adolescents may avoid parental disclosure by forgoing desirable reproductive health care. Recent judicial decisions, however, give effect to internationally established human rights to confidentiality, for instance under the Convention on the Rights of the Child, which apply without a minimum age. These judgments contribute to modern legal recognition that sufficiently mature adolescents can decide not only to request care for contraception, abortion and STIs, but also whether and when their parents should be informed.     

Fertility control in the under 16 year old

Providing contraception and sexual health to under 16 year olds remains a controversial and emotive issue despite clear guidance and the fact that 20–30% of young people report having had their first experience of sexual intercourse by the age of 16 years old.Competent under 16 year olds have the ability to consent to medical treatment and the duty of confidentiality owed to them is as great as to any other individual. Contraception can be provided to under 16 year olds without parental consent provided certain criteria are met.Health professionals should maximise all opportunities they have to develop a relationship of trust with a young person and explore their contraception and sexual health in an open, non-judgemental and confidential manner.Effective hormonal methods combined with condoms, to prevent sexually transmitted infections, should be promoted and the realities of teenage sexual behaviour acknowledged if the UK high rate of teenage pregnancy is to be reduced.     

Human Papillomavirus Vaccination and Sexual Behavior in Young Women

Study ObjectiveTo compare sexual attitudes and behaviors of young women who have received or declined the HPV vaccine.DesignCross-sectional survey.SettingObstetrics and gynecology and pediatrics clinics at a large, Midwestern, academic health center.Participants223 young women (ages 13-24): 153 who had received HPV vaccination and 70 with no prior HPV vaccination.Main Outcome MeasuresSexual behaviors; attitudes toward sexual activity.ResultsVaccinated young women were slightly but significantly younger than unvaccinated (mean age 19.2 vs 20.0). Both groups showed a large percentage of participants engaging in high-risk sexual behavior (75% vs 77%). The mean age at sexual debut was not significantly different between the groups (16.8 vs 17.0) nor was the average number of sexual partners (6.6 for both). Unvaccinated participants were more likely to have been pregnant (20% vs 8.6%, P = .016), although this difference was not significant in multivariate analysis CI [0.902-5.177]. Specific questions regarding high-risk sexual behaviors and attitudes revealed no significant differences between the groups.ConclusionWe found that sexual behaviors, including high-risk behaviors, were similar between young women who had and had not received HPV vaccination. Our findings provide no support for suggestions that the vaccine is associated with increased sexual activity. Importantly, we found that young women in our population are sexually active at a young age and are engaged in high-risk behaviors, affirming the importance of early vaccination.     

Are women ready for the HPV vaccine?

OBJECTIVE: An HPV (human papillomavirus) vaccine will be available soon. Because vaccination for both boys and girls will be critical to reduce the incidence of this disease, we evaluated the willingness of women to accept the HPV vaccine and to consent to having their children vaccinated. METHODS: A 20-item questionnaire was distributed to women who had children between the ages of 8 and 14 years, the likely age range of the children who will be targeted to receive the vaccine. RESULTS: 200 women completed surveys. The median age for the respondents was 34.4 years (range, 23-53 years). 77% of the women surveyed would be willing to accept an HPV vaccine for themselves. 67% who had a daughter (n = 156) and 66% who had a son (n = 137) would consent to have their child vaccinated. Those not accepting the vaccine cited the risk of unknown adverse effects or their current lack of sexual activity. Women who would not consent to have their children vaccinated cited the risk of unknown adverse effects and their belief that their children are not sexually active. Male children not directly benefiting from the vaccine were also a reason for not considering the vaccine for sons. A history of an abnormal Papanicolaou smear was not associated with willingness to accept the vaccine. CONCLUSIONS: This pilot study demonstrated a willingness of women to accept the HPV vaccine for themselves and their children. Gynecologists and gynecologic oncologists must focus not only on the diagnosis and treatment of cervical cancer but also on its prevention.     

Adolescents and consent to treatment.

Adolescents, defined by WHO as 10 to 19 years old, can give independent consent for reproductive health services if their capacities for understanding have sufficiently evolved. The international Convention on the Rights of the Child, almost universally ratified, limits parental powers, and duties, by adolescents' "evolving capacities" for self-determination. Legal systems may recognize "mature minors" as enjoying adult rights of medical consent, even when consent to sexual relations does not absolve partners of criminal liability; their consent does not make the adolescents offenders. There is usually no chronological "age of consent" for medical care, but a condition of consent, meaning capacity for understanding. Like adults, mature minors enjoy confidentiality and the right to treatment according to their wishes rather than their best interests. Minors incapable of self-determination may grant or deny assent to treatment for which guardians provide consent. Emancipated minors' self-determination may also be recognized, for instance on marriage or default of adults' guardianship.     

Protective and risk factors of early sexual initiation in youth subcultures

Abstract

Objectives To assess the association between subculture affiliation (Hip-hop, Techno-scene, Metal, Punk, Skinheads) and early sexual initiation, and whether gender, family affluence, peer influence, lack of parental bonding and lack of parental monitoring explain this association.

Methods We collected data on 15-year-old primary school pupils who participated in the Health Behaviour in School-aged Children 2009/2010 study. The association of subculture affiliation with early sexual initiation was adjusted for gender, family affluence, peer influence, lack of parental bonding and lack of parental monitoring in five consecutive models using logistic regression.

Results Nearly 50% of the adolescents had a subculture affiliation. These youths were significantly more likely than other adolescents to have had sexual intercourse. Peer influence explained 49% of this association. Adding lack of parental bonding and lack of parental monitoring into the model weakened the association of subculture affiliation with early sexual initiation (20%), but this association remained statistically significant.

Conclusion Youth subculture affiliation is strongly correlated with early sexual initiation. This association is mediated for a large part by peer influence and defective parental monitoring and bonding. Health promotion regarding early sexual initiation should therefore in particular target adolescents under strong influence of peers and with weak parental relationships.     

Adolescent and Parent Willingness to Participate in Microbicide Safety Studies

Study ObjectiveTo understand adolescents' and parents' willingness to participate (WTP) in a hypothetical phase I prevention study of sexually transmitted infections, discordance within adolescent-parent dyads, and expectations of each other during decision-making.Design and SettingAdolescent-parent dyads were recruited to participate in a longitudinal study about research participation attitudes.ParticipantsAdolescents (14-17 years old) and their parents (n = 301 dyads) participated.InterventionsNone.Main Outcome MeasuresIndividual interviews at baseline assessed WTP on a 6-level Likert scale. WTP was dichotomized (willing/unwilling) to assess discordance.ResultsWTP was reported by 60% (182 of 301) of adolescents and 52% (156 of 300) of parents. In bivariate analyses, older adolescent age, sexual experience, and less involvement of parents in research processes were associated with higher level of WTP for adolescents; only sexual experience remained in the multivariable analysis. For parents, older adolescent age, perceived adolescent sexual experience, and conversations about sexual health were significant; only conversations remained. Dyadic discordance (44%, 132 of 300) was more likely in dyads in which the parent reported previous research experience, and less likely when parents reported higher family expressiveness. Adolescents (83%, 248 of 299) and parents (88%, 263 of 300) thought that the other would have similar views, influence their decision (adolescents 66%, 199 of 300; parents 75%, 224 of 300), and listen (adolescents 90%, 270 of 300; parents 96%, 287 of 300). There were no relationships between these perceptions and discordance.ConclusionInclusion of adolescents in phase I clinical trials is necessary to ensure that new methods are safe, effective, and acceptable for them. Because these trials currently require parental consent, strategies that manage adolescent-parent discordance and support adolescent independence and parental guidance are critically needed.     

Reproductive health education and sexual risk among high-risk female adolescents and young adults

STUDY OBJECTIVE: The objective of this study was to explore the associations of sources, content, and timing of reproductive health education with cognitive and behavioral sexual risk in a sample of high-risk female adolescents and young adults. DESIGN: Female adolescents and young adults (n=113, median age 17 years) receiving treatment for a sexually transmitted disease (STD) reported sources of reproductive health education, topics covered, and when first formal education occurred. Dependent variables included sexual risk knowledge; condom attitudes, negotiation skills, and use (consistent and at last sex); and number of sexual partners. RESULTS: Most participants reported receiving reproductive health education from both parental (80%) and formal sources (92%). Parents discussed the menstrual cycle (94%) more frequently than other sex education topics, while formal sources focused most on teaching about STDs (91%). Although median age of first formal instruction was 12 years, 26% of girls received their first formal education during or after the year they initiated coitus. Girls with a parental source of education and those receiving formal instruction on pregnancy reported greater ability to negotiate condom use. Girls who received education later in relation to the onset of sexual activity and those with a parental source of education reported more sexual partners. CONCLUSIONS: Early reproductive health education and education from both parental and formal sources is associated with reduced sexual risk among high-risk adolescent girls. Interestingly, receiving parental education is also associated with more sexual partners, suggesting that parental educational efforts may be reactive to their daughters' increasing sexual risk behavior. Future research should examine multiple sources of reproductive health education and the timing of education from these sources to enhance understanding the dynamic interactions between reproductive health education and adolescent sexual risk.     

Parental factors and sexual risk-taking among young people in Côte d'Ivoire

C?te d'Ivoire is the country worst affected by the HIV epidemic in West Africa, and young people in this country are a particularly vulnerable group. This study examined the relation between parental factors and sexual risk-taking among young people using logistic regression and survival analysis methods. Three parental factors (living in the same household as the father during childhood, perceived parental disapproval of early and premarital pregnancy, and parent-child communication about sexual abstinence) were positively associated with primary sexual abstinence (defined as yet to experience sexual debut), secondary sexual abstinence (defined as sexual abstinence subsequent to sexual debut) and reduced number of sex partners. The findings suggest that parental monitoring and control are important predictors of youth sexual behaviours and underscore the need to target parents and guardians in efforts to promote responsible sexual behaviours among adolescents. It is important to promote parent-child communication about sexual issues and empower parents and guardians to communicate effectively with their children and wards about sexual issues.     

Perinatal mortality: clinical value of postmortem magnetic resonance imaging compared with autopsy in routine obstetric practice

Objective To compare postmortem magnetic resonance imaging (MRI) with autopsy in perinatal deaths. To determine the acceptance and feasibility of postmortem perinatal MRI.
Design Cohort study.
Setting Large teaching hospital.
Population Fetuses and neonates from 16 weeks gestational age until 28 days after birth, stillbirths as well as intrapartum and neonatal deaths.
Methods MRI was performed prior to autopsy in a consecutive cohort of perinatal deaths after full parental consent. Agreement between MRI and autopsy was calculated. The consent rate for both examinations was recorded separately, as well as the time between the perinatal death and the MRI.
Main outcome measure Full agreement between MRI and autopsy.
Results Of 58 cases, 26 parents consented to both examinations (45%). Autopsy showed 18 major malformations, of which 10 were detected with MRI. The positive predictive value of MRI was 80% (4/5) and the negative predictive value was 65% (13/20). Additional consent for MRI was given in eight cases (14%). In 84%, the MRI could be performed within 48 hours.
Conclusions MRI is of value if autopsy is refused, but diagnostic accuracy is insufficient to recommend substitution of full autopsy. The acceptance rate of MRI only is better than that of autopsy.     

Eligibility and willingness of young Icelandic women to participate in a HPV vaccination trial

BACKGROUND AND AIMS: Cervical cancer is an important health problem worldwide, and the incidence of preinvasive cervical cancer is increasing among young sexually active women. The causal association between human papilloma virus (HPV) and cervical cancer makes it theoretically possible to eradicate the disease through vaccination. The aim of this study was to analyze the eligibility and willingness of 18-23-year-old Icelandic women to participate in a vaccination trial to prevent HPV infection and to assess knowledge of HPV. MATERIAL AND METHODS: A questionnaire was formulated with questions on demographics, HPV knowledge, sexual behavior, attitude towards HPV vaccination, and other health-related issues. The questionnaire was tested on a subgroup of women before being mailed to 300 women aged 18-23 years, randomly selected by date of birth from the total population living in the Capital area of Reykjavík. RESULTS: The response rate of the mailed questionnaire was 54%. Of respondents, 96% reported having had sexual debut and 39% were aged 15 years or younger at first intercourse. Knowledge of HPV infections and associated diseases was limited, indicating the need for an educational campaign. Although 60% of the respondents were willing to participate in a HPV vaccination trial, the eligibility rate for the invited women was estimated to be approximately 13% (95% CI: 9-17%) after accounting for various exclusion criteria such as number of sexual partners, abnormal Pap smears, planning a pregnancy, or travelling abroad for more than 6 months. CONCLUSIONS: Icelandic women between 18 and 23 years of age have a sexual behavior profile and lifestyle that may decrease their eligibility in future prophylactic HPV vaccine trials. Improved education about HPV infection and its consequences is needed. Future trials may need to include younger women to improve recruitment.     

Influence of Sources of Information and Parental Attitudes on Human Papillomavirus Vaccine Uptake among Adolescents

Study ObjectiveThe purpose of this study was to: 1) describe parental sources of information about human papillomavirus (HPV) vaccination for adolescents, 2) understand how parental sources of information about HPV vaccine are associated with adolescent HPV vaccine uptake, and 3) understand if the relationship between a greater number of HPV-related information sources and HPV vaccine uptake among adolescents is mediated by parental attitudes.Design, Setting, Participants, and InterventionsWe conducted a 3-arm randomized controlled trial in middle and high schools in eastern Georgia from 2011 to 2013. As part of the trial, we surveyed parents during the final year to understand their sources of information about HPV vaccine for their adolescent. Data were collected from 360 parents via phone and online surveys.Main Outcome MeasuresParents responded to a survey that asked them to identify demographic information, parental HPV attitudes, sources of information about HPV vaccination, and HPV vaccine uptake.ResultsMost of the sample was African American (74%; n = 267) and 53% of parents (n = 192) reported that their adolescent received at least 1 HPV vaccine dose. The top sources of information about HPV vaccine reported by parents were a doctor or medical professional (80%; n = 287) and television (64%; n = 232). A mediation analysis showed sources of information about HPV vaccine are associated with parental attitudes, and parental attitudes about HPV vaccine are associated with vaccine uptake among adolescents.ConclusionThese findings highlight the importance of HPV sources of information on parental attitudes.     

Strategies for Conducting Adolescent Health Research in the Clinical Setting: The Mount Sinai Adolescent Health Center HPV Experience

BackgroundClinical research with adolescents can be challenging due to issues of informed consent, parental involvement, institutional review board requirements, and adolescent psychosocial development. These requirements present a dilemma, particularly in the area of sexual health research, as adolescents are disproportionately affected by sexually transmitted infections such as human papillomavirus (HPV). To successfully conduct adolescent research in the clinical setting, one requires an awareness of state statutes regarding adolescent confidentiality and consent for medical care, and a close partnership with the IRB.Case StudyIn 2007, the Mount Sinai Adolescent Health Center in collaboration with the Albert Einstein College of Medicine developed a longitudinal research study to examine the natural history of oral, cervical, and anal HPV in an adolescent female population engaged in high-risk sexual behaviors. We use this research project as a case study to explore the ethical, methodological, and clinical issues related to conducting adolescent health research.Summary and ConclusionsSeveral strategies were identified to promote adolescent study participation, including: (1) building a research team that is motivated to work with adolescents; (2) combining research and patient care visits to avoid duplication of services; and (3) establishing a personalized communication network with participants. Using these methods, adolescent sexual health research can successfully be integrated into the clinical setting. While retaining a prospective cohort of adolescents has its challenges, a persistent and multi-disciplinary approach can help improve recruitment, sustain participation, and acquire critical data that will lead to improved healthcare knowledge applicable to understudied populations of adolescents.     

New abortion parental involvement laws continue trend toward modified requirements

During 1995, more than 50 bills introduced in state legislatures pertained to parental consent for a minor's abortion. Six of 22 abortion bills enacted in the first nine months of the year contained requirements for parental consent or notification. This represents a sharp increase over the number of such bills enacted in recent years. Currently, 26 states have a parental involvement law in effect (an additional three are under injunction). Most statutes waive the requirement if the minor has been abused by a parent, and the Supreme Court has required that a minor have a confidential alternative to parental involvement. The new laws share only the judicial bypass requirement and the fact that they require the involvement of only one parent. In Delaware, notification is required if the minor is under 16. Illinois requires notification of an adult family member. Louisiana authorizes a judge to personally notify parents of a minor when the court determines said minor is not able to make an abortion decision unaided. This statute is under injunction. A statute in Montana, which requires notification of one parent and contains judicial bypass provisions is also under injunction. In North Carolina, the consent of a parent or custodial grandparent is required with certain exceptions. Tennessee replaced a one-parent notification statute with a one-parent consent law. Anti-abortion groups view mandatory parental involvement as a measure to reduce the number of abortions performed. Opponents of the measures feel that forced communication of this nature may be disastrous for teenagers, that many minors are capable of making such a decision for themselves, and that such laws violate the confidentiality guaranteed to minors seeking medical services.