CHICAGO - Seven months after the U.S. government recommended that all preteen girls be vaccinated against the virus that causes cervical cancer, at least two dozen are struggling to decide how to make that happen.

One option would be to add the vaccine to the list of shots required for admission to school, which the governor of Texas did on Feb. 2. Proposed legislation in Illinois and 17 other states would mandate immunization; other bills would require the state to pay for the vaccine or force insurance carriers to do so.

The topic is controversial because the virus - human papillomavirus, or HPV - is sexually transmitted. Conservative groups, who concede that the vaccine should be available, vehemently oppose making it mandatory because they believe it implicitly encourages premarital sex.

Some other critics point out that HPV, unlike measles or chicken pox, cannot be transmitted through casual contact. Others note that the HPV vaccine is expensive - $120 for each shot in a required series of three, compared with less than $20 for a flu shot.

Proponents agree that any mandated vaccine should be free to anyone who can't pay. Those with good private insurance are expected to be covered, and Illinois provides free vaccines to uninsured children and those on Medicaid. But about 10 percent of children are thought to have insurance that won't cover the vaccine.

"If we're going to consider requiring it, the more important question is, `Is it so valuable that we collectively are going to put together the resources to make sure the underinsured have an equal opportunity to be protected?'" said Jerry Stermer, president of Voices for Illinois Children.

Members of the Illinois General Assembly are considering two separate bills on the issue. The House legislation, sponsored by Rep. Naomi Jakobsson, D-Urbana, would apply to all girls entering 6th grade and take effect in August 2008.

The bill sponsored by state Senate Majority Leader Debbie Halvorson, D-Crete, would phase in a requirement for all 11- and 12-year-olds entering any grade. The deadline to be vaccinated would be August 2009.

"We're giving it two years to work out the kinks," said Halvorson.

Her bill also would require the state to provide free vaccine to the estimated 18,000 11- and 12-year-olds whose vaccination would not be covered by public or private insurance, which she said would cost up to $4 million a year.

Under both bills, the state would develop a campaign to increase awareness of HPV. And both would allow parents to opt out of the vaccination on medical or religious grounds, but only after being informed of the link between HPV and cancer.

According to a recent study by the National Cancer Institute, only 40 percent of U.S. women have heard of HPV, and less than half of those were aware of the virus' connection to cervical cancer.

Stacie Geller, who chairs the state's Cervical Cancer Elimination Task Force, said the panel had hoped education would be enough to achieve a high level of vaccination coverage, or "herd immunity." But the committee is rethinking its position.

"Mandating the vaccine for school-age children is probably the ideal long-term strategy" to achieve broad immunity and guarantee universal access, Geller said.

The committee has yet to submit its recommendations to the Illinois Department of Public Health, where a department official said the state has no position on mandating the HPV vaccine.

Geller said she favors phasing in the mandate over a couple of years.

"It needs to be explained that in many ways this is a vaccine like other vaccines that we give to healthy children. You want to protect against cervical cancer and not get caught up in the mode of transmission," she said. "If we told people you get HPV by coughing, they'd be in the doctor's office in a minute. But nobody wants to think about their daughter having sex."

Kathy Gossard, a paralegal with three daughters, said she was "creeped out" when she thought about her 9-year-old getting the vaccine.

"We haven't even had the birds-and-bees talk," said Gossard. "She still believes in Santa Claus."

But on second thought, she said, it would be better to vaccinate girls before they start thinking about sex. "If I give it to her when she's 9, I'm protecting her health. If I do it when she's a teenager, she might think I'm condoning premarital sex."

While Gossard said she initially didn't like the idea of the government telling her she has to vaccinate her daughter, later she realized it might make it easier to explain the shot to the child: "If she wants to know why, it's because the state mandates it."

The vaccine, Gardasil, protects against four common strains of HPV that cause 70 percent of all cases of cervical cancer. It was approved by the Food and Drug Administration in June. A few weeks later, the Centers for Disease Control and Prevention recommended the vaccine be given to all girls ages 11 and 12 and said it could be given as early as 9. A vaccine for boys is not yet available.

HPV is the most common sexually transmitted disease in the U.S., infecting about 20 million people. It is responsible for virtually all cases of cervical cancer, which kills 3,700 American women a year.

Mainstream pediatricians are cautiously in favor of a vaccine requirement.

"We are supportive of a mandate, but we're concerned it has to be executed properly," said Dr. Eddie Pont, president of the Illinois chapter of the American Academy of Pediatrics.

The chapter, which represents the majority of pediatricians in the state, wants to see the mandate start in 2009 and to make sure the state will cover the cost for the underinsured. "It's unreasonable to say to a parent, `Cough up $360 or we won't let your daughter into school,'" Pont said.

"Pro-family" groups, however, point to the position of the American College of Pediatricians, a smaller group that opposes abortion and favors abstinence until marriage.

"Excluding children from school for refusal to be vaccinated for a (sexually transmitted) disease . . . is a serious, precedent-setting action that trespasses on the right of parents to make medical decisions for their children," the college says.

Adding to the unease over government meddling in family decisions is the fact that Merck & Co., the makers of Gardasil, has been lobbying state lawmakers to make it mandatory.

For now, the company has a monopoly on the HPV vaccine market. Another vaccine, Cervarix, is being developed by GlaxoSmithKline and could be approved later this year.

Merck would not say how much it spends on lobbying. But the company spent nearly $14 million in the first month of its national consumer advertising campaign for Gardasil, according to Nielsen Media Research.

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