BILL ANALYSIS Ó
AB 499
Page 1
Date of Hearing: April 26, 2011
ASSEMBLY COMMITTEE ON JUDICIARY
Mike Feuer, Chair
AB 499 (Atkins) - As Introduced: February 15, 2011
SUBJECT : Minors: medical care: consent
KEY ISSUE : Should minors over the age of 12 be allowed to
consent to preventative STD care, CONSISTENT WITH THE FACT THEY
ARE ALREADY PERMITTED TO CONSENT TO THE DIAGNOSIS AND TREATMENT
OF THE DISEASE after THEY CONTRACT IT?
FISCAL EFFECT : As currently in print this bill is keyed
non-fiscal.
SYNOPSIS
When a minor has potentially contracted a sexually transmitted
disease (STD), current law already permits the minor to consent
to the diagnosis and medical treatment for the disease.
Illogically and dangerously, however, current law does not
similarly permit these very same minors to consent to the
medical care needed to prevent exposure to the sexually
transmitted disease in the first place. This bill seeks to mend
this illogical and dangerous disparity by permitting a minor
that is 12 years old or older to consent to medical care to
prevent transmission of STDs just as they already can consent to
receive treatment for STDs after they become infected. In doing
so, the bill will expand young people's access to preventative
medicine that could potentially prevent their contraction and
spread of potentially dangerous, and even life-threatening,
STDs. According to the Center for Disease Control, the risk for
STD infection is highest among adolescents, and preventative
measures are therefore most beneficial and effective before a
minor's first sexual encounter. As the author of the bill
notes, "70% of our young people are exposed to these diseases by
the time they are 19. Even at as young an age as 15, 13% of
teens are at risk. America was able to eliminate polio in the
1950's through vaccination, saving thousands of lives. AB 499
would help us do the same for sexually transmitted diseases."
While many parents do seek HPV and Hepatitis B vaccinations for
their children, the author states that a sense of unease felt by
some parents that these vitally important vaccines might somehow
condone early sexual activity remains a significant barrier
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preventing adolescents from being vaccinated. The author notes
this bill seeks to close this illogical and dangerous public
health gap for minors by allowing them to receive time-critical
preventative medical care for such potentially deadly and
incurable STDs. While every state in the nation permits minors
to consent for the treatment of STDs post-infection, many states
have similarly proactively closed the gap regarding preventative
care for STDs, including Alabama, Arkansas, Idaho, Iowa, Kansas,
Maryland, Montana, North Carolina, South Carolina, South Dakota,
and the District of Columbia. A broad coalition of women's and
public health groups support this legislation, while the
California Catholic Conference, Inc., the California Right to
Life Committee, Inc., and Capitol Resource Family Impact oppose
it.
SUMMARY : Seeks to permit a minor who is 12 years of age or
older to consent to medical care related to the prevention of a
sexually transmitted disease, just as they are already permitted
to consent to the diagnosis and treatment of the disease after
they contract it.
EXISTING LAW :
1)Provides that a minor who is 12 years old or older who might
have come into contact with a contagious, infectious, or
communicable disease can consent to medical care related to
the diagnosis or treatment of that disease if that disease or
condition is one that is required by law to be reported to the
local health officer, or is a sexually transmitted disease as
determined by the State Director of Health Services (now the
State Public Health Officer). (Family Code Section 6926(a).
All further references are to this code unless otherwise
noted.)
2)Provides that the parents of a minor who has consented to
medical treatment under Family Code Section 6926 are not
liable for payment for that care. (Section 6926(b).)
3)Provides that a minor may consent to medical care related to
the prevention or treatment of pregnancy. (Section 6925(a).)
4)Provides that a minor's consent under minor consent statutes
cannot be subject to disaffirmance because of minority.
(Section 6921.)
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5)Provides that a minor that is 12 years old or older that is
alleged to have been raped may consent to diagnosis and
treatment of that condition. (Section 6927.)
6)Allows a minor alleged to have been sexually assaulted to
consent to medical care related to the diagnosis and treatment
of that condition. (Section 6928(b).)
7)Allows a minor to consent to medical care related to the
diagnosis or treatment of a drug or alcohol-related problem.
(Section 6929(b).)
8)Provides that a minor may consent to medical or dental care if
that minor is; over the age of 15, living separate and apart
from his or her parents whether with or without his or her
parents' consent, managing his or her own financial affairs.
(Section 6922(c).)
COMMENTS : When a minor has potentially contracted a sexually
transmitted disease, current law already permits the minor to
consent to the diagnosis and medical treatment for the disease.
Illogically and dangerously, however, current law does not
similarly permit these very same minors to consent to the
medical care needed to prevent exposure to the sexually
transmitted disease in the first place. The author states that
this bill seeks to mend this illogical and dangerous public
health disparity facing our children. In doing so, the author
notes, the bill will expand young people's access to
preventative medicine that could potentially prevent their
contraction and spread of potentially dangerous and even
life-threatening STDs.
The author further states 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 notes that these
diseases can be life-long and are only treatable, not curable.
The author further states that while physicians encourage their
minor patients to involve parents, in the past the Legislature
has recognized, by enacting minor consent laws, that involvement
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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.
According to the author, this bill would save teenage lives by
ensuring that teens have access to vaccines that allow for
prevention of STDs that cannot be cured once they have been
contracted. As the author contends:
70% of our young people are exposed to these diseases by
the time they are 19. Even at as young an age as 15, 13% of
teens are at risk. America was able to eliminate polio in
the 1950's through vaccination, saving thousands of lives.
AB 499 would help us do the same for sexually transmitted
diseases
Background of Minor Consent to Medical Services . Under common
law, minors traditionally lacked the legal capacity to consent
to medical treatment or services. A parent or a guardian's
consent was thus necessary for a doctor to provide medical
services outside of an emergency. ( American Academy of
Pediatrics v. Lungren , 16 Cal.4th 307, 315 (1997).) This
remains the general rule in California and the United States,
although every state provides for exceptions.
In California, there is a significant number of what are called
"limited medical emancipation statutes". These statutes
authorize minors to consent to medical care, without the consent
of their parents, for specific medical conditions. Exceptions
to the general requirement of parental consent are allowed in
certain sensitive situations where a minor in need of medical
care might be reluctant to communicate their medical needs or
concerns to their parents. Because of the reluctance to
communicate with parents in these situations, "?there is a
substantial risk that minors will fail to seek medical care -
'to the detriment of themselves, their families, and society.'"
( American Academy of Pediatrics v. Lungren , supra at 214;
quoting Wadlington, "Medical Decision Making for and by
Children: Tensions between Parent, State and Child (1994) U.Ill.
L. Rev. 311, 323-324.) Limited emancipation statutes currently
extend to: diagnosis and treatment of sexually transmitted
diseases, medical care related to rape and sexual assault, care
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and counseling related to alcohol or drug related problems,
medical care related to the pregnancy of an unmarried minor, and
mental health treatment or counseling on an outpatient basis.
(Family Code Sections 6924-6929.)
STD Prevalence . 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.
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 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
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causes 90% of anal cancers; 40% of vulvar, vaginal, and penile
cancers; and, smaller proportions of oral and throat cancers.
In order to reduce the risk of cervical cancer and HPV, the CDC
recommends that females and males be vaccinated against HPV at
the age of 11 or 12, and up until the age of 26 if not
vaccinated earlier. (The Centers for Disease Control, HPV
Vaccines Offer Disease Protection Pre-teens Can Grow into - Now
for Girls and Boys , (2010) available at
http://www.cdc.gov/media/subtopic/matte/pdf/2010/hpvvaccine_prete
ens.pdf.) 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.
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 states that the 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.
Measures Outside of California : While every state has a measure
allowing for a minor to consent for the treatment of STDs
post-infection, many states have proactively closed the gap
regarding preventative care for STDs including: Alabama,
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Arkansas, Idaho, Iowa, Kansas, Maryland, Montana, North
Carolina, South Carolina, South Dakota, and the District of
Columbia. (See "State Policies in Brief: Minors' Access to STI
Services as of March 1, 2011, Guttmacher Institute,
http://www.guttmacher.org/statecenter/spibs/spib_MASS.pdf .)
Furthermore, recognizing the vital importance of HPV
vaccinations in preventing cancer, several states, including
Colorado, Indiana, Iowa, Louisiana, Maine, Maryland, Michigan,
Minnesota, Missouri, Nevada, New Mexico, New York, North
Carolina, North Dakota, Rhode Island, South Dakota, Texas, Utah,
Virginia and Washington, have enacted statutes requiring HPV
vaccinations for school age children, providing funding for
vaccinations, or providing funding for education about the
merits of HPV vaccination. ("HPV Vaccine", the National
Conference of State Legislatures,
http://www.ncsl.org/default.aspx?tabid=14381 , last updated March
2011.)
ARGUMENTS IN SUPPORT : According to the California STD
Controllers Association, the California Nurses Association, the
California Family Health Council, and ACT for Women and Girls,
the current gap in the law this bill seeks to bridge 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 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 CDC's Advisory Committee on Immunization Practice
recommends these vaccines be administered before 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
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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
generally important, 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 services, if needed.
ARGUMENTS IN OPPOSITION : The California Catholic Conference,
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 not the usual case;
and that though contingency plans are good when parents are
irresponsible, they 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, writes that this bill would have the
citizen, voter, and taxpayer believe that 12 year olds can be
their own medical advisors instead of relying on their own
parents.
Prior Related 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
services, if specified conditions are satisfied.
REGISTERED SUPPORT / OPPOSITION :
Support
California STD Controllers Association (sponsor)
ACCESS Women's Health Justice
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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
Nevada County Citizens for Choice
Planned Parenthood Advocacy Project Los Angeles County
Planned Parenthood Mar Monte
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 : Drew Liebert and Erik Martin / JUD. /
(916) 319-2334