Dilemma - A mother refuses the HPV vaccine for her child

The dilemma - A mother brings her 13-year-old daughter into the surgery as she wants your advice.

She has been sent a reminder from the surgery about her daughter's HPV vaccine and she wants your opinion about the vaccine. She has read many conflicting reports about the effectiveness of the HPV vaccine and also about cervical cancer being an STI. She feels that her daughter having the HPV vaccine at such a young age will make her more promiscuous and does not see the need for her to have it. What would you advise her?

A GP's response
Dr Alison Glenesk is a GP trainer in Aberdeen

Parents often have strong views about immunisation, particularly since the MMR debacle. It can be very difficult to persuade them that a proposed treatment is safe, strongly evidence based and in their child's best interest. There is a great deal of difference, however, between immunising a 13-year-old and a pre-school child.

A normal 13-year-old should be able to understand most aspects of the proposed treatment (being Gillick/Fraser competent). Therefore her views, and ultimately her consent, must be sought.

Firstly, addressing both mother and daughter, I would establish a rapport by congratulating them on their good sense in coming to discuss this difficult topic. It is tempting to dive straight in to tackle the unlikely and probably media-fuelled notion about the vaccine encouraging promiscuity, but this is likely to embarrass the child and annoy the mother.

It is better to explore their existing knowledge of the vaccine, discuss safety data, and explain the connection between sex, HPV and cervical cancer, and the long-term protection the vaccine can offer.

If there is still uncertainty, provide some written information, give some web addresses, and offer a return appointment.

If all goes well, you may never have to tackle the mother's stated anxiety about promiscuity, with its unlikely corollary that the fear of developing cancer many years hence will prevent young people having sex.

If this is still a stumbling block, it would be worth looking at the drivers and checks for sexual behaviour in young people, and encouraging an open discussion between mum and daughter.

Finally, you must emphasise that, while you are happy to give advice, the ultimate decision must be theirs.

A medico-legal opinion
Dr Roger Palmer is a medico-legal adviser at the Medical Protection Society

Quite understandably the mother has sought further information regarding a new vaccination that is being offered in the UK.

You should provide her, and her daughter, with as much relevant information about the process, benefits and risks of immunisation as they require to enable them to make an informed decision.

It may be sufficient to answer their questions and provide them with patient information sheets, although they may need further time to consider matters and have another discussion.

During your discussion, you should ascertain whether the daughter, as well as her mother, fully understands the purpose of the vaccination. Ultimately, if the daughter is able to understand the reasons for the vaccination and the potential consequences for her, she will be legally competent to give consent herself (Gillick competency) even though she is a minor. If this is the case and she requests immunisation, you can proceed even if the parents object.

It would be preferable to have the agreement of all parties.

Similarly, should the daughter refuse immunisation and the parent consent, the vaccination could not take place. It is unlikely that a parent could overrule a 'Gillick competent' child in such a circumstance. Where the child is not competent to make the decision the parental views should be respected.

In addition, you should inform individuals on how the data on immunisation is stored and used before vaccination. Consent may be taken in writing, orally or by attendance and co-operation. However, consent may be withdrawn at any time and only remains valid where no additional information becomes available in the interim (e.g. newly identified risks with vaccination).

A patient's response
Elizabeth Brain is a member of the RCGP patient partnership group.

You should tell the mother, on her own, that cervical cancer is not a directly transmitted sexual disease. It is the HPV that is transmitted, and that this can be a precursor to cervical cancer. Also explain that HPV is the most common cause of cervical cancer and genital warts in young women and that the vaccine is highly effective in preventing the strains of HPV relating to cervical cancer, and related diseases.

The vaccine is not effective if a girl has already been exposed to one of the HPV strains relating to cervical cancer. The vaccine does not treat existing HPV infections or the diseases they may cause. It is only preventive.

Your advice should include a mention that even if vaccination increased the risk of her daughter's promiscuity, this may do her less physical harm than the consequential risks of not being immunised.

You should also advise the mother that while the risk of contracting HPV is substantially reduced, there are several other diseases that can still be contracted.

Even if her daughter has no intention of having unprotected sex at present, the vaccine will afford a degree of protection for the future.

Such matters are not entirely medical and there are moral and social overtones. Therefore, it is important you recommend that she discusses these issues with her daughter.

Since such discussions between mother and daughter can be a source of mutual embarrassment and friction, you should advise the mother to have this discussion privately, and with acute sensitivity and empathy.

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