What is the recommended approach for a 15-year-old's Human Papillomavirus (HPV) vaccination when parents disagree?

Parental Disagreement on HPV Vaccination in a 15-Year-Old

When parents disagree about HPV vaccination for a 15-year-old, work with both parents using a "guiding style" approach that emphasizes cancer prevention, addresses specific concerns through motivational interviewing, and strongly recommend vaccination now rather than delaying—while recognizing that at age 15, this adolescent requires 3 doses instead of 2, making immediate vaccination even more critical. 1

Immediate Clinical Approach

Engage Both Parents Separately and Together

• Use a "guiding style" approach that involves: (a) seeking permission to discuss immunization, (b) addressing each parent's specific concerns, (c) providing appropriate evidence-based resources, and (d) determining readiness to change 1
• Apply motivational interviewing techniques to understand the hesitant parent's specific concerns—whether they relate to safety, timing, sexual activity assumptions, or other misconceptions 1
• Build rapport by providing detailed, up-to-date information on both risks and benefits of vaccination 1

Frame the Discussion Around Cancer Prevention

• Emphasize that HPV vaccination prevents cancer—this is the single most powerful message and the major reason parents accept the vaccine 1
• Explain that HPV types 16 and 18 cause approximately 70% of cervical cancers, and the 9-valent vaccine protects against types responsible for 84% of HPV-related cancers 2
• Highlight that the vaccine also prevents penile, anal, vulvar, vaginal, and oropharyngeal cancers in both males and females 1, 2

Address the Critical Timing Issue

At age 15, this patient now requires 3 doses instead of 2 doses, making delay particularly detrimental 1

• Persons who receive the first dose at 15 years of age or older must complete a 3-dose schedule at 0,1-2, and 6 months 1
• Individuals younger than 15 years require only 2 shots, providing added flexibility and incentive for earlier vaccination 1
• Adopt a "now or never" mentality—adolescents are less likely than other patients to follow up, and vaccination negotiated for a later time often never occurs 1

Counter Common Misconceptions

• Clarify that HPV vaccine does not promote promiscuity—this is a common parental concern that should be directly addressed 1
• Explain that attempting to predict when the adolescent will become sexually active is difficult, impractical, and often results in missed vaccination opportunities 1
• Emphasize that younger age elicits a better immune response—geometric mean antibody titers are higher in 9- through 14-year-olds than in 16- through 26-year-olds 1

Provide Strong, Unambiguous Recommendation

• Give a strong recommendation—parents prefer clear, unambiguous recommendations, and offering the vaccine without strongly recommending it confuses and frustrates parents 1
• Health care provider recommendation independently predicts HPV vaccine initiation and completion 1
• Normalize the HPV vaccine by coadministering it with other vaccines (Tdap, meningococcal) using the "same way, same day" approach to avoid singling it out 1

Safety Reassurance

• Emphasize that approximately 200 million doses have been distributed worldwide between 2006 and 2015, with no serious adverse outcomes associated with HPV vaccine 1
• In studies with 97,272 participants, there was little to no difference in serious adverse events between HPV vaccine groups and control groups at up to 72 months follow-up (RR 0.99,95% CI 0.94 to 1.04) 3

Legal and Ethical Considerations

While the Gillick guidelines provide a legal framework for adolescent consent to medical treatment, in practice there is variable and confused interpretation of this guidance, and overriding parents' wishes is perceived as problematic 4

• Work toward parental consensus rather than proceeding with vaccination over parental objection 4
• Schedule follow-up appointments to continue the discussion if immediate consensus cannot be reached 1
• Document all discussions, concerns raised, and education provided 1

Common Pitfalls to Avoid

• Do not delay vaccination waiting for signs of approaching sexual activity—this strategy consistently results in missed opportunities 1
• Do not single out the HPV vaccine for special discussion separate from other adolescent vaccines—this increases parental skepticism 1
• Do not provide weak or ambiguous recommendations—this approach confuses parents and reduces vaccination rates 1
• Do not accept "we'll do it later" without recognizing that the patient has already aged into the 3-dose requirement and adolescents frequently fail to follow up 1