Parent-child communication about sex, particularly communication with daughters, is important because it is associated with decreased sexual risk taking during adolescence and an older age at sexual debut.^{1, 2} Parents need to have these conversations early and often for them to be most effective. Communication ideally begins before children start having sex;² however, many parents underestimate their children’s level of sexual activity, and their timing of communication is often late, occurring after sexual debut, if at all.^3–5 For example, in a recent study of parent-adolescent dyads, 40% of youth had intercourse before their parents talked with them about safer sex.³ Frequency of communication also matters. Discussing sex topics repeatedly, rather than as a single conversation or “big talk,” provides parents with opportunities to reinforce messages, answer questions, and tailor content to their children’s development, potentially increasing the protective benefits of communication.⁶ These findings underscore the need to promote communication about sex between parents and their children during early adolescence.

Many parents rely on situations that arise spontaneously to prompt conversations with their children about sex. These cues can include external events, such as something seen on television or a child’s school providing a sex education class,⁷ but they can also include developmental changes, such as a daughter’s menarche or interest in sex.⁸ Conversations about sex topics may also be part of broader discussions about puberty or topics not directly related to sex.⁹ Understanding whether and how cues are effective in prompting such conversations is important for public health.

One potential cue to talking about sex that has gone largely unexamined is mother-daughter communication about human papillomavirus (HPV) vaccine. U.S. guidelines recommend routine administration of HPV vaccine to 11 or 12 year old girls with catch-up vaccination through age 26.¹⁰ Since HPV is a common sexually transmitted infection (STI), discussions about HPV vaccine may provide an opportunity for parents to talk with their young adolescent daughters about STIs and other sexual health issues. Furthermore, as HPV vaccine is administered in 3 shots over 6 months,¹⁰ discussions about the vaccine may provide multiple opportunities to talk about sex. Many studies, both pre- and post-vaccine licensure, have found that most parents intend to vaccinate their adolescent daughters against HPV,^{11, 12} and just under half have done so now that the vaccine is available.¹³

While recent research suggests that many parents talk with their daughters about HPV vaccine,^{14, 15} little is known about the role of HPV vaccine discussions as a cue to talking about sex. The purpose of the present study was to characterize mothers’ communication with their daughters about HPV vaccine, and assess the potential for HPV vaccine to provide an opportunity for mothers to talk with their early adolescent daughters about sex.

We surveyed a nationally representative sample of mothers of adolescent females aged 11–14 years during December 2009. All mothers were members of an existing panel of U.S. households maintained by the survey company, Knowledge Networks. The survey company recruits members using a dual frame approach, combining list-assisted, random-digit dialing and address-based random sampling.¹⁶ In exchange for completing surveys, panel members accumulate points which can be redeemed for small cash payments. Households without pre-existing internet are provided a laptop computer and internet access.

The survey company invited 1,681 mothers to complete our cross-sectional online survey (Figure 1). Among those mothers, 1,170 (70%) responded to the invitation, and 1,009 were eligible to participate in the study as they had daughters ages 11–14 years. A total of 951 mothers of 11–14 year-old females consented to participate and completed the survey in December 2009 (response rate=66%¹⁷). If a mother reported having more than one daughter in the age range, the daughter with the most recent birthday was selected as the index child for survey questions.

Participants were more likely than non-participants to have a college degree, but they did not differ on other sociodemographic characteristics. In the present analysis, we report data from 900 mothers, having excluded those with missing values for items assessing mother-daughter communication about sex or HPV vaccine, and other potential cues to talking about sex (n=51, 5% of total sample). Mothers in the analytic sample and those whose data we excluded had similar sociodemographic characteristics in bivariate analyses. The Institutional Review Board at the University of North Carolina approved the study.

Our findings indicate that HPV vaccine could provide a new and effective cue to prompt parents to talk with their young adolescent children about sex. In this nationally-representative sample, most mothers reported having talked with their 11–14 year old daughters about HPV vaccine, and many of these mothers included messages about sex in their HPV vaccine discussions, consistent with our previous research on HPV vaccine communication among mothers and daughters in North Carolina.¹⁵ In addition to confirming correlates of mother-daughter communication about sex found in previous studies (e.g., daughter’s menarche,¹⁸ general communication skills,⁶ personal experience talking with their own mother²¹), our study also identifies a novel correlate — mothers’ discussions with their daughters about HPV vaccine were associated with their communication about sex, even controlling for these other factors.

To our knowledge, this study is among the first to compare multiple potential cues to talking about sex. We found that HPV vaccine discussions provide a cue to talking about sex that is as important as some more widely recognized cues (such as menarche),^{2, 24, 25} even though HPV vaccine discussions have not yet been promoted as a possible cue to parent-child communication. Many mothers who included sex topics in their HPV vaccine discussions reported that talking about the vaccine facilitated discussing sex by providing a good reason or by making it easier to start the conversation.

Taken together, these findings suggest that it may be possible to capitalize on HPV vaccine discussions to facilitate parent-child communication about sex. Some mothers may not talk with their daughters about sex because they have difficulty beginning conversations or finding the “right” time to talk.^{22, 26, 27} For mothers who have not yet talked with their daughters about sex, initiating HPV vaccine discussions may provide an avenue to begin talking with their daughters about sex topics. As a substantial proportion of mothers in our sample had low knowledge of HPV and HPV vaccine, previous research suggests that education about the vaccine and health care provider recommendation might promote HPV vaccine communication among more mothers and their daughters,¹⁵ as well as potentially increase vaccine acceptability and uptake. For mothers who are already talking with their daughters about HPV vaccine, more could be encouraged to take advantage of this opportunity to promote sexual health.

Health care providers may be able to use HPV vaccination visits to provide information and guidance to parents about discussing sex topics with their children. Research shows that parents want providers to broach sensitive topics like sex,^{28, 29} and such an approach is aligned with current guidelines for adolescent preventive services suggesting that providers offer guidance to adolescents and their parents about sexual health.³⁰ However, provision of such guidance is low.^31–33 Because HPV vaccine protects against an STI, it may provide a natural segue to talking about sex. As it is recommended for all 11–12 year-old girls and administered over 3 visits,¹⁰ it could be a cue for early and frequent communication about sexual health and an opportunity to integrate preventive counseling and guidance into clinical practice. However, providers may be less likely to recommend HPV vaccine when considering it necessary to discuss sexuality beforehand.³⁴ Research suggests that training and access to materials for parent education may address some of the barriers clinicians have to broaching sensitive topics.³⁵ Further, while parents are largely supportive of HPV vaccine, they are more supportive when it is framed as preventing cancer, as opposed to an STI or genital warts only.³⁶ Thus, it is possible that using HPV vaccine to promote sexuality discussions could negatively affect vaccination rates. The effect of including sexual health promotion messages alongside cancer prevention information on HPV vaccine acceptability should be explored further.

Our study’s strengths include a large nationally-representative sample and extensive controls for variables associated with parent-child communication about sex. The main limitation is reliance on mothers’ reports, which may not fully reflect actual conversations, as parent and adolescent reports of communication about sex can be discrepant.⁴ However, data on parent (as opposed to child) perceptions may be more appropriate for the present study, as it can inform interventions targeting parents. Our study used a single, dichotomous measure of mother-daughter communication; future research should assess the content, timing, and frequency of mothers’ conversations with their daughters about HPV vaccine and sex. The study’s cross-sectional design precludes causal inferences about associations between HPV vaccine-related variables and parent-child communication about sex topics. The generalizability of study findings to other populations is unknown.