BILL ANALYSIS Ó
AB 499
Page 1
Date of Hearing: April 5, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 499 (Atkins) - As Introduced: February 15, 2011
SUBJECT : Minors: medical care: consent.
SUMMARY : Permits a minor who is 12 years of age or older to
consent to medical care related to the prevention of a sexually
transmitted disease. Makes a technical, conforming change to
existing law.
EXISTING LAW permits a minor who is 12 years of age or older and
who may have come into contact with an infectious, contagious,
or communicable disease to consent to medical care related to
the diagnosis or treatment of the disease, if the disease or
condition is one that is required by law or regulation adopted
pursuant to law to be reported to the local health officer, or
is a related sexually transmitted disease (STD), as may be
determined by the State Director of Health Services (now the
State Public Health Officer).
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, there is a gap
in the law relative to prevention of STDs because existing law
only specifies the ability of minors to consent to diagnosis
and treatment. The author states that the omission of consent
for preventative services creates a barrier to time-critical
preventive services. The author asserts that at the time the
existing law was passed, the preventive options we have today
did not exist and there are now time-critical prevention
services for diseases that are sexually transmitted, such as
prophylactic post-exposure HIV medications (which must be
given within 72 hours of exposure) and the Human
papillomavirus (HPV) vaccine (which, if given before exposure,
can significantly reduce the risk of certain cancers and
abnormal, precancerous cervical cell changes and genital
warts). The author states that these diseases can be
life-long and are only treatable, not curable. The author
further states that while physicians encourage their minor
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patients to involve parents, in the past the Legislature has
recognized, by enacting minor consent laws, that involvement
is not always practical and what is paramount is that teens
receive timely, necessary medical care. The author states
that this bill is needed since some adolescents, from
difficult family situations, will either delay or simply fail
to obtain services if confronted with a legal requirement of
parental consent.
2)STD PREVELANCE . According to the Centers for Disease Control
and Prevention (CDC), compared to older adults,
sexually-active adolescents 15 to 19 years of age and young
adults 20 to 24 years of age are at higher risk for acquiring
STDs for a combination of behavioral, biological, and cultural
reasons. For some STDs, such as Chlamydia, adolescent women
may have a physiologically increased susceptibility to
infection due to increased cervical ectopy (the condition when
certain cells are present on the outer surface of the cervix).
The higher prevalence of STDs among adolescents may also
reflect multiple barriers to accessing quality STD prevention
services, including lack of insurance or other ability to pay,
lack of transportation, discomfort with facilities and
services designed for adults, and concerns about
confidentiality. Estimates suggest that while representing
25% of the sexually experienced population, 15- to
24-year-olds acquire nearly half of all new STDs. According
to a July 2010 report of the California Adolescent Sexual
Health Work Group, in 2008 there were 517 California children
ages 10 through 17 who were infected with HIV/AIDS, 18, 901
who were infected with chlamydia, 2,581 who were infected with
gonorrhea, and 22 who were infected with syphilis. While
adolescent rates are lower than young adult rates, these cases
are of great concern to public health officials because
chlamydia and gonorrhea are the leading causes of preventable
infertility in California, affecting all women, but
particularly women who are just entering their reproductive
years.
3)HPV AND CERVICAL CANCER . According to a 2008 report by the
California Cancer Registry (CCR), cervical cancer is the
eleventh most frequently diagnosed cancer among California
women, with approximately 1,500 cases, including 400 deaths,
per year. CCR reports that cervical cancer incidence has
declined 29% in California since 1988. However, Hispanic
women are more than twice as likely to be diagnosed with
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cervical cancer as non-Hispanic women. Hispanic and
non-Hispanic black women are also more likely to die from
cervical cancer than non-Hispanic white and Asian/Pacific
Islander women. Nearly all cervical cancer is caused by HPV
infection, with two types of HPV accounting for approximately
70% of cervical cancer. HPV also causes 90% of anal cancers;
40% of vulvar, vaginal, and penile cancers; and, smaller
proportions of oral and throat cancers.
In 2006, the federal Food and Drug Administration (FDA) approved
Gardasil, a quadrivalent vaccine (prevents four types of HPV)
manufactured by Merck, for use in females nine through 26
years of age. The vaccine is injected as three separate
doses; the second dose should be administered two months after
the first dose and the third dose six months after the first
dose. The cost of a three-dose vaccination is estimated at
$468, including the cost of administration, for those covered
by private insurance. In October 2009, the FDA approved
Cervarix, a bivalent vaccine (prevents two types of HPV) by
GlaxoSmithKline, for use in females 10 through 25 years of
age. Non-vaccine strategies to prevent HPV infection include
the use of physical barriers, such as condoms, and reducing
the number of sexual partners, including abstinence from
sexual contact.
4)HPV INFECTION IN ADOLESCENTS . According to a 2007 article in
the journal Disease Markers, adolescents who are sexually
active have the highest rates of prevalent and incident HPV
infection rates, with over 50 to 80% having infections within
two to three years of initiating intercourse. According to
the article, most infections are transient in nature and will
clear. However, a small number of adolescents will not clear
the infection, and persistence of HPV is strongly linked to
the development of invasive cancer. The author stated that
association between age of first intercourse and invasive
cancer cannot be ignored. Consequently, initiating screening
at appropriate times in this group is essential. In addition,
HPV vaccination prior to the onset of sexual activity is
critical since most infections occur within a short time frame
post initiation.
5)PREVIOUS LEGISLATION . SB 543 (Leno), Chapter 503, Statutes of
2010, authorizes a minor who is 12 years of age or older to
consent to mental health treatment or counseling, except as
specified, on an outpatient basis, or to residential shelter
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services, if specified conditions are satisfied.
6)DOUBLE REFERRAL . This bill has been double referred, if it
should pass out of this committee, it will be referred to the
Assembly Committee on Judiciary.
7)SUPPORT . According to the California STD Controllers
Association, the California Nurses Association, the California
Family Health Council, and ACT for Women and Girls, the gap in
the law likely stems from the fact that many prevention
methods did not exist when the law was created in 1964.
Supporters state that now we have both vaccines and medicines
which could, if given in a timely fashion, reduce the risk of
serious disease; and, that more developments could occur in
the future. Supporters write that while most teens involve
their parents in medical decisions, even those involving
sensitive subjects, we need to allow for those minors who
can't or won't include their parents. Supporters further
state that the current requirement that minors obtain parental
consent for STD prevention services has resulted in missed and
denied opportunities for minors to receive vital and
timesensitive medical care. The American Congress of
Obstetricians and Gynecologists, District IX, (ACOG), writes
that for prevention in the form of vaccines, the CDCs Advisory
Committee on Immunization Practice recommends these vaccines
be administered befo8)re attainment of teen years. The CDC
panel also recommends "catch up" for those not vaccinated
earlier. Particularly for the HPV vaccine, with its more
recent FDA approval, there is a cohort of teens who would not
have had the opportunity to be vaccinated earlier. ACOG
states that it makes sense for teens, when in a medical
appointment for other confidential medical services, to be
able to simultaneously obtain the vaccine, and that
facilitating timely access to a vaccine would result in
superior, more comprehensive care. The California National
Organization for Women states that we should not deny minors
access to preventative methods when they are available,
especially for viruses that currently cannot be cured. The
California Coalition for Youth writes that while parental
consent is important to obtain, some youth do not have the
advantages of supportive and engaged families. CCY states
that homeless youth are not homeless by choice; their family
environments have been unhealthy and either they have been
kicked out or feel forced out. CCY asserts that these youth
should be able to have access to preventative medical
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services, if needed.
9)OPPOSITION . The California Catholic Conference, Inc. writes
that this bill is dangerous because it expands a faulty law
which assumes that children know better than their parents,
rather than assuming that parents know their children and care
about their health. The California Catholic Conference states
there are occasions when a minor child is mistreated or
abandoned by his or her parents, but it is certainly not the
usual case; and that contingency plans are good when parents
are irresponsible, but should not be standard operating
procedure. Capitol Resource Family Impact writes that medical
care decisions are not a light subject; in fact, most medical
care decisions carry heavy implications and a parent has the
right to be involved in his or her child's medical care. The
California Right to Life Committee, Inc. writes that this bill
would have the citizen, voter, and taxpayer believe that 12
year olds can be their own medical advisors and not their own
parents.
REGISTERED SUPPORT / OPPOSITION :
Support
California STD Controllers Association (sponsor)
ACCESS Women's Health Justice
ACT for Women and Girls
American Association of University Women
American Civil Liberties Union
American Congress of Obstetricians and Gynecologists, District
IX (California)
Asian Communities for Reproductive Justice
California Adolescent Health Collaborative
California Church Impact
California Coalition for Youth
California Communities United Institute
California Family Health Council
California Medical Association
California National Organization for Women
California Nurses Association
Children's Hospital Los Angeles, Division of Adolescent Medicine
Kaiser Permanente
NARAL Pro-Choice California
National Center for Youth Law
National Council of Jewish Women
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Nevada County Citizens for Choice
Reproductive Justice Coalition
Women's Health Specialists
Opposition
California Catholic Conference, Inc.
California Right to Life Committee, Inc.
Capitol Resource Family Impact
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097