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 AB 499 Page 2 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 AB 499 Page 3 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 AB 499 Page 4 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 AB 499 Page 5 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 AB 499 Page 6 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