Challenging Dogma

...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

A Matter of State’s Decision or Parents' Autonomy Over their Daughter’s Sexual Lives? A Critique of Mandatory HPV Vaccination - Isabel Garcia-Fullana

As of March 2007, at least 21 US states are considering laws to mandate vaccination on 9-12 year old girls against a sexually transmitted virus known as Human Papillomavirus Virus (HPV) (4). HPV is the most common sexually transmitted disease in the United States; known to cause 70% of cervical cancer (1). The vaccine assures protection against four types of high-risk HPV, two of which are linked to exacerbate the development of cervical cancer (1). The vaccine is a breakthrough in women’s health, because “we know that cervical cancer is 100% preventable, we know what causes it” (2). Legislators argue that by knowing what causes it, immunization at an early age can help prevent women from getting cervical cancer in the future.

Legislators across the United States are planning on the HPV vaccinations be a required immunization for girls entering middle school. For full protection HPV vaccination needs to be “administered before girls become sexually active”, says the Advisory Committee on Immunization Practices (ACIP)(3). They recommend 9-12 year of age is the appropriate age for vaccination, assuming they have not become sexually active. However, we must argue, are legislators considering all of the options? Is the vaccination the only option girls have to prevent getting infected with HPV? Is there an HPV outbreak, hence the urgency for the mandatory policy? The answer to theses question is no.

HPV vaccination is not the only option to prevent infection. Abstinence, sexual educations about safe-sex and yearly check ups (Pap smear) are. Besides not all HPV stains are harmless, most of them your body gets rid of naturally (5). And if a person is infected with a high-risk HPV, it would take years before it develops into a death threatening disease. The urgency for the compulsory vaccination is unnecessary. More studies should be conducted to value the potential side effects and efficacy.

Yes, sometimes is better to be safe than sorry, but the policy at hand is targeting to mandate young girls to get immune against a sexual disease. Clearly legislators are using the coercive and health belief model to put forward the policies. The policy will not succeed because it disregarding important ethical issues behind: parent’s autonomy, and their cultural belief and values about sex. It’s utilizing the coercive approach to force parents into immunization their child against a disease that has no immediate mortality or morbidity.

The mentality behind the policy
The policy is influenced by parts of the health belief model and the power-coercive approach. The Health Belief model is based on the notion of perceived susceptibility (risk of getting the condition), perceived severity (seriousness of the condition), perceived barriers (influences that promote or discourage a behavior), and perceived benefits (positive consequences of adopting the behavior), which will then determine the person’s intention to change behavior (5).
Research shows that at least 11,150 women will be infected with one type of HPV virus and 3,700 women will be diagnosed with cervical cancer and die this year (6). The perceived susceptibility and severity of girls getting infected with HPV are very high; if they engaged in unprotect sexual intercourse, and if they have several sexual partners (6). The last two steps of the Health Belief model are implied through the use of the coercive approach. The policy mandates an immediate action to take place. Hoping parents, of the young girls, allow their child to be vaccinated against HPV, since there is a 24% prevalence of contracting HPV on 14-19 years of age (5).

Slogans like “Be one less” Gardasil only proven vaccine to prevent cervical cancer (9), helps promote legislators predisposition on the use of a coercive approach to mandate girls of age 9 and older to get vaccinated. They view coercive approach as the only way to assure full immunization and a successful defeat against cervical cancer. Many pro-mandating law supporters claim “it’s just in good, common-sense [to use as] preventive medicine” (10).

A power-coercive approach, in some situations, is a necessary and appropriate. For a coercion effort be successful it most consider the person’s values, attitudes and feelings to efficiently impose a change (8). These are very important aspect that makes coercion work; because it establishes a personal connection and makes it more efficient to cause a direct change on the person’s behavior. These are just basic concepts that allow set norms to work properly. For example, the law states that on a red light you must stop. If you run a red light, you have violated the law and the direct risk of this action could have been the endangerment of a person’s life. These rules are placed for a reason, to be follow and to provide order in the community.

However, it does not make “common sense” to coerce young girls to get vaccinated against a sexually transmitted disease that only affects 24% of them (5). As well as it does not satisfy the basic aspect of making a coercive approach successful. They are disregarding parents-autonomy, attitudes and belief over their child by utilizing the moral-coercive approach. The coercive approach exploits parent’s emotions by creating in their minds the severity of their daughters getting infected with this disease. Hopefully getting their child vaccinated. As the Focus of the family, a parent organization expressed, they “believes in the benefits of a vaccination to prevent cervical cancer; however it does not support the states intervention in making the vaccine obligatory. They deem the attempt of a secular state to force a child to undergo an intervention that may be irreconcilable with her families’ religious values and belief.” (2) For good reason. “God gives children to parents, not to the government” (14). Government should focus on protecting society from terrorism acts and street crime. Let parents create positive bonds with their children, so they can guide them through the right path and allow them to express their feeling about sex.

Difference between Acute Bacterial Vaccination and HPV
The use of power-coercive approach to mandate vaccinations is not a new concept. Mandatory immunization guarantees preventable outbreaks and offer a greater equity of living. Vaccines have proven to be the most cost-effective strategy for preventing outbreaks of infectious diseases (13). By the time children are born they are bombarded with different kinds of shots that will shun them from ever getting life threatening disease. By the age of 12, a child would be immune to: Diphtheria-Tetabus-Pertusis, Hepatitis A & B, HiB, Influenza, Measles-Mumps-Rubella, Polio, Pneumococcal, Rotavirus, Varicella, Meningococcus, among other vaccines (5). These are all common acute bacterial diseases that in one point in time where considered extremely morbid and mortal, but mandatory vaccinations has allowed control over them and has not allowed them to resurface.

Smallpox is a great example of the results a mandating vaccination had on the elimination of smallpox. As the World Health Organization declared a planet free of smallpox because it’s no longer in the environment (13).

The difference between acute bacterial infections and HPV is that HPV is a chronic virus. Chronic virus is harder to detect because it does not provoke the immune system to strike back and attack the virus. It resides within the immune system, mutating and infecting other parts of the body; making HPV a dangerous infection because it can stay in your body, not presenting any symptoms, and then develop into cervical cancer.

However, Gardasil should not be a school required vaccine. Is a virus that can only be spread through sexual activity and skin-on-skin contact with sexual organs (6). The likelihood of getting infected with HPV are high, however the chances of getting infected with a high-risk HPV virus is small. Since the virus is not easily transmittable there shouldn’t be an urgency of getting girls immediately vaccinated against HPV. As discussed above, it’s a chronic virus that takes years to develop into a harmful disease. The vaccine should be available for those that have considered all of their options and what to protect themselves from the possibilities of getting infected, however this decision should be a personal one.

Importance of parents-child autonomy
Parents are the first ones to teach their child how to behave and follow the norms and values forced by society. They play an important role in shaping the psychological growth and development of the child’s sense of self. They conduct all of these shaping techniques through series of activities, role modeling, and reinforcement strategies. Without parents guidance children would not be able to distinguish right from wrong. As the Family Research Council (FRC) states “families are the foundation of civilization, the seedbed of virtue and the well spring of society (5). Children are vulnerable and it’s the parents’ responsibility to protect them and choose the right decision for their health, so they can have a successful life. For this reason parents autonomy over their children is very important role which nobody, not even the government should intervene in.

HPV is a preventable disease. No harsh methods are needed to protect young girls. As long as there is open communication among parent-child, topics like sex can be discussed openly and information can be provided.

Alternative approach
The use of persuasion-economic tactics to lure parents into immunization their daughters can be another option. Take into consideration Australia approach. Without implementing a compulsory vaccination law, 90% of their children population is immune. In 1997 Australia developed a financial incentive for parents and family doctors to comply with the school required vaccinations. This became the Family Assistant Act of 1999. (12) Through the use of persuasive-financial approach, parents and medical practices got federal funding to pay for their medical expenses, providing a 90% immunization goal. The benefits that allowed for the persuasive approach to work in Australia were the maternity allowance, tax benefits and universal child-care, as long as they had vaccination proof (12).

The United States HPV policy can learn a lot from the Australia Act. US legislators can create a program based on sexual education-advocacy and combining it with a persuasive-financial program potentially attracting superior immunization coverage. Information never hurt anyone. Sexual education is an important element in improving adolescent’s sexual health. Financial program can include extra health care, tax benefits, medicine discounts to families after proof of vaccination. Government should not force these incentives, but should persuade parents with the benefits of both giving their children the vaccine and getting extra health care coverage. Financial incentives and education could limit public backlash against HPV vaccination, as well as have a successful immunization percentage.

Social and behavioral initiatives have started to influence many of the Public Health intervention tactics and models because they tend to look beyond the health problems. Governments and agencies are expected to provide a sense of security to society, by developing strategies to stop child-abuse and promote good health. In the case of HPV, using the coercive approach to mandate HPV vaccination as a required school is not appropriate because government is forcing the parents to immune their child against non-tactile transmittable disease, which is prevented through other methods. The vision behind the HPV compulsory vaccination in the United States needs to change. It is great that a vaccine, such as Gardasil, has a promising future in preventing cervical cancer. However, I believe parent-child should make that decision.

(1) Times, An STD Vaccine for all Girls? Jan 17, 2007;
(2)Colgrove, J. The Ethics and Politics of Compulsory HPV Vaccination. The New England Journal of Medicine; Dec 7, 2006, 355:2389-2391.
(3) Press Release. CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination; June 29, 2006.
(4) Scott, A. Lawmakers to take up controversial vaccine. Herald Tribute,
(5) HPV Vaccination, Children Vaccinations lists, Family Research Council,
(6) American Cancer Society, Cervical Cancer Facts.
(7) Kirkey, Sharon, Medical recommended HPV vaccinations stills facing questions. April 15, 2007,
(8) Chin, Robert; Benne, Kenneth.(22-43) General strategies for effecting changes in human systems, The Planning of Change, New York, Holt, Rinehart and Winston, 1976.
(9) Merck,
(10) Cengel, K, Mandatory cervical-cancer vaccine proposed. February 2007.
(11) Siegel, M. Education and persuasion versus coercion as public health approach., May 2006.
(12)Department of Family and Community Services, Commonwealth of Australia, Family Assistant Act 1999, Section 6 (3).
(13)Berzofsky, J; Ahlers, J; Janik, J. Progress on new vaccination strategies against chronic viral infections. J. Clin. Invest, 114:450-462 (2004).

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