Are we lowering the age of innocence?

A campaign to vaccinate teenage girls against cervical cancer has become a conflict between the rights of children and parents

THE first thing 14-year-old Rachel knew about the vaccinations was a television advert interrupting her summer holiday viewing. Shown constantly in prime-time commercial breaks over the past two weeks, it features dozens of teenage girls speaking calmly and in unison about getting jabs to prevent cervical cancer.

The adverts have worked – Rachel is now aware of the vaccination scheme. But she readily admits she has not really thought much about it, distracted by the pleasures offered by the long holiday break. The moral maze of a mass teenage vaccination programme to prevent a sexually-transmitted disease doesn't really trouble her. What concerns her most is that it will require three injections over the course of six months.

"I know it's just a jag, but my friends are going to have a problem with three needles," she says. "I can see why we need it and I think it's important but I think some people might not want to have it – just because they don't like injections."

Squeamishness about needles is the least of the medical professionals' worries as they try to implement a vaccination programme to combat the human papilloma virus (HPV). They are fighting objections from some quarters on religious, moral and medical grounds. Some worried parents believe the jag could encourage young girls into promiscuity, as it would reduce one of the potential dangers of sleeping around.

"The sex issue makes it different from other jags," admits Rachel, who attends a state secondary school in Edinburgh, "but that doesn't mean they are expecting you to have sex after the injection. HPV is one of the less known infections you are scared about – there are still hundreds of others."

If all children were as clued up as Rachel, and all parents as supportive as her's, Scotland's sexual health experts would have little to worry about. But it is not every household where mum or dad can talk openly about sex to their teenage daughter. A different kind of squeamishness – one caused by embarrassment – could also prove to be a factor when, in the next few weeks, a vaccination consent form is delivered to tens of thousands of homes across the country. Around some family dinner tables it will bring the delicate subject of the birds and bees into the open, perhaps for the first time.

From September 1, forms will arrive at the homes of parents of 12- and 13-year-old girls asking permission to vaccinate them against HPV, a sexually-transmitted disease. According to the Scottish Government strategy, the 30,000 girls who start in S2 that week will be vaccinated against two strains of the virus that cause cervical cancer, which affects thousands of women in the UK every year. Ministers have pledged £64m over three years to ensure all girls from 12 to 17 are immunised, with a catch-up programme this year for 16- and 17-year-olds.

A crucial complication is the issue of a child's rights. Even if the parents give their consent, a daughter has the right to refuse the treatment. And if a parent withholds consent, a daughter can, in theory, insist she gets the vaccination – although this would require a medical professional to confirm she was capable of making such a decision.

Traditionalist groups, including some as members of the Catholic Church, are appalled that the Scottish Government is bringing issues of sexual health into the school lives of pre-teenage girls in this way, and, more pertinently, into the home. Others take a different view – they are glad of the opportunity to protect their daughters from the risk of cervical cancer, and see the sexual aspect as a storm in a teacup.

So will 12-year-old girls really be encouraged into promiscuity by an injection? Or are parents over-sensitive about the sexualisation of their daughters? What advice is being given to teenage girls about what rights they have over what is done – or not done – to their bodies? And will the vaccination policy end up pitching mothers against daughters in homes across Scotland?

No parent wants their child to grow up too fast, but the risk of cervical cancer is one that it is hard to ignore.

Suzanne Fernando, from Kilburn in Artier, knows the importance of the vaccination first hand. She developed cervical cancer while she was pregnant and had the tumour removed after giving birth.

Having survived the four-year ordeal, she is keen for her daughters to be immunised. "My children have practically grown up with me going through cancer, recovering, and then fundraising and campaigning alongside me," she says. "I completely understand parents are going to have doubts about a new vaccine that nobody knows much about but I think people should take their time before making any rash decisions and look up all the information."

Most research says the only side effect of the jabs is soreness around the site of the injection, but long-term effects are not known as the first tests took place only six years ago. American websites report three young women dying after being inoculated, but experts say the link between the deaths and the vaccine is not understood and in any case, they were given the Gardasil vaccine, which was dismissed by the Westminster Government in favour of Cervarix, a decision backed by ministers in Edinburgh.

But should it be parents worrying about all these issues? Is it their decision to make? Under the Age of Legal Capacity (Scotland) Act 1991, if a girl over the age of 12 is deemed competent of making the decision herself she is entitled to do so, even against her parents wishes. This may be a shock to parents who have not come across the law before, but a teenage daughter can make all medical decisions herself – from HPV to going on the pill – without parents knowing.

"As with all medical and health care, it is important that both girls and parents or guardians are aware of their rights," says Children's Commissioner Kathleen Marshall. "The NHS leaflets do indicate what these rights are.

"It is also crucial that girls do not feel pressurised into a decision by either parents or health professionals. I would hope that, should a situation arise, the girl would be fully supported."

The Catholic Church has backed the scheme, telling parents the vaccination does not offer "any sort of encouragement to promiscuity". This flatly contradicts its previous position – Peter Kearney, spokesman for Cardinal Keith O'Brien, in 2005, said the vaccination "could lead to the sexualisation of a generation of 10- to 13-year-olds, the fear being that a vaccination like this could be construed as a green light to any form of sexual activity".

The price of the Catholic Church's change of mind appears to have been the removal of all remarks about artificial contraception from information going out to schools. This assured McGrath that the 'risk' was averted.

Controversially, mention of contraception has been removed from the leaflets for every Scottish school – not just Catholic schools.

Not all Catholics, however, are convinced. Patricia McKeever, editor of the website Catholic Truth Scotland, has received concerns from parents. "It is entirely the wrong signal to send out to young girls in Catholic schools, which are supposed to teach about purity, chastity and modesty," she says. "To go ahead with this mass inoculation of young girls in any school without giving parents the full facts is absolutely scandalous."

For McKeever, the "full facts" include telling parents explicitly that HPV is a sexually-transmitted infection, and highlighting that HPV vaccinations have not been given widely to girls under 16 – although the brand being used in the UK, Cervarix, has been safely tested on children as young as 10.

One Catholic mother, who wishes to remain anonymous, has already withdrawn her 12-year-old daughter from school because of concerns about sexualisation. "I felt the HPV vaccination was too early and I didn't feel I needed to discuss it with my daughter," she says. "She has never brought up the subject of sex with me and I don't want her to lose her innocence. If she stayed in school I thought she would lose her Catholic faith so I am going to school her at home. She is happy with that decision and she can carry on enjoying her childhood."

But if a girl decided to have the inoculation against the wishes of her parents, the school may not cooperate. Heads of Catholic and secular schools, state and independent, have said they do not know how they would respond.

Professor Sheila McLean, head of medical law at Glasgow University, says the fear is of legal action. "Parents could try to sue the school for not following the consent form, but there is no chance of it succeeding if the girl was competent," she said.

"In fact there are questions about involving any third parties in the decision if it is up to the girl. It over-complicates things.

"A 13-year-old girl could go to a GP by herself and ask for the birth control pill. If she was competent, the pill could be given and parents would never know."

Some names have been changed to protect anonymity

At the sharp end: the issues surrounding the HPV vaccination

What is being proposed?

From September 1, all 12 and 13-year-old girls in the UK will be vaccinated against human papillomavirus (HPV) to reduce their chances of contracting cervical cancer. There will also be a catch-up campaign for girls up to 17.

Why are some people objecting?

HPV is a sexually transmitted infection and the vaccination is most effective before a girl has engaged in sexual activity. Some groups believe this suggests to girls that sexual activity is acceptable after the vaccination. Others worry about a possible health risk.

Who chooses whether a girl has the vaccination? All parents will be sent a consent form asking them to confirm in writing whether they want their daughter to have the vaccination. However, by law, a girl under 16 has the right to choose her own treatment if a health professional thinks she understands the consequences.

Is there any health risk?

Fears have been raised that the vaccination has never been given to under-16s before, but Cervarix – the maker of vaccination used in the UK – has been safely tested on children aged 10.

What does the Catholic Church say? In 2005, the Catholic Church in Scotland said the vaccination could give children the "green light" to sexual activity. But this week it will send letters to schools dismissing any moral objections. It is encouraging parents to use the opportunity to discuss chastity with their daughters.

What role are schools playing? Girls will be given the vaccination at school, but it will be administered by health professionals. Schools will send out consent forms and have been consulted by the Scottish Government about the practicalities of the scheme.

What does the Scottish Government say? The Scottish Government is encouraging as many girls as possible to have the vaccination. It recommends parents and guardians talk to girls about the vaccination and about taking responsibility for their health.

THE SCIENCE BIT

HPV will be carried by eight out of 10 people in their lifetime. There are hundreds of strains of the virus and most are harmless and clear up on their own, but 15% of them are 'high risk' and associated with cancer. Two strains – numbered 16 and 18 – cause 70% of the cases of cervical cancer in Scotland every year. The vaccination protects against these two types. In 2004, 282 women were diagnosed with cervical cancer and 102 died from the disease.

HPV is a sexually transmitted infection in that it is passed by skin-to-skin contact during sex, and some strains cause genital warts. However, the vaccination being given in Britain does not protect against genital warts. Clinical tests were started six years ago, so there is only evidence that the vaccination lasts at least six years.