Preventing disease, not sex, with the HPV vaccine

Go figure – people just keep having sex no matter how many bad things it can cause. Fortunately, there is a new vaccine against one of those things – the sexually transmitted virus that causes cervical cancer, Human Papilloma Virus (HPV). That should have American girls happily lining up to get the HPV vaccine; HPV is why women need to get Pap smears, it causes 3,000-plus cervical cancer deaths each year and infects more than 20 million Americans.

Fighting about sex, however, is America’s favorite national pastime (after sex itself, and baseball), and everything about sex in this country is controversial. In the case of the HPV vaccine, the controversy stems primarily from two concerns; expert recommendations that we start vaccinating girls (the vaccine has not yet been approved for males) against HPV at the age of 12, and the old argument that protecting teenagers against the repercussions of sex makes them more likely to have sex.

Now, most of us don’t like to talk about 12-year-old girls and sex in the same breath, so vaccinating them against a sexually transmitted disease makes a lot of people uncomfortable. Some would rather HPV vaccinations be given at age 16 or 18, when more women are closer to the onset of sexual activity (the average age of onset of sexual activity is about 19.) Some would also prefer to stand with their fingers in their ears saying “La la la la – I can’t hear you!” whenever anyone says anything about teenagers having sex.

There are problems with the delayed vaccination approach, however. Many young women, unfortunately, become sexually active before 16 and would therefore be exposed to HPV before the vaccination could protect them. In addition, many teenagers stay as far away from shot-happy health professionals as they possibly can. The result; vaccination rates of 16 year-olds would likely be much lower than vaccination rates of 12-year olds, which means more HPV that is now preventable would go “unprevented.” That, in turn, means more HPV infections, more abnormal Pap smears, and ultimately, more women dying from cervical cancer who could have been saved by vaccinations at 12.

Some of the discomfort no doubt comes from wondering what the heck it is we tell a 12-year-old about why she is getting the three-part HPV vaccine. Girls this age are pretty nosey, pretty smart, and pretty mouthy; it is not like vaccinating your toddler, who you can still wrestle into submission and two minutes after the shot will be focused on the post-shot Winnie-the-Pooh stickers. You could just tell your daughter the vaccine is protection against infections, which is also true of the 25 other vaccinations she has had in the previous 12 years, and leave out the HPV-sex part. However, 4.2 seconds after she gets home she will be on the Internet or the cell phone to her best friend finding out exactly what HPV is all about, so ignorance may only be brief parental bliss.

That means the best approach might be to use the HPV vaccine as a way to start talking about sexuality to 12-year-old girls. The heavens will not implode, and many experts recommend starting conversations about sexuality at that age because otherwise those girls get their information from boys and other friends, which is a bad idea. These are the people who come into my office and tell me girls could get pregnant from toilet seats, could not get pregnant if they had sex standing up, and

that the frustration of abstinence was bad for your boyfriend’s prostate, the poor guy.

But talking about sex to young girls leads to the real controversy of the HPV vaccine, which is the fear that if we vaccinate girls at 12 against HPV, and talk to them at that age about sex, they will be less likely to abstain from sex until they are older and-or married. This fear is at least as old as sex education, and probably older than sex itself; as a bucket, it does not hold water. It also ignores the fact that the average American woman does not get married until age 26, and is therefore unlikely to postpone sex until marriage.

There is little evidence that parents and healthcare professionals talking to teenagers about sex makes them more likely to have sex, if for no other reason than that the whole world already talks to them about sex anyway. In that context, parents and healthcare professionals are probably the only people talking thoughtfully and (hopefully) intelligently to teenagers about sex.

More reassuring may be the fact that we already vaccinate our children against another sexually transmitted disease, and the world has not reversed orbit or gone into sexual overdrive as a result. Hepatitis B is (primarily) a sexually transmitted disease against which we have been giving infants the three-part Hep B vaccine series for many years. There is no evidence that the current generation of teenagers is wandering out in the sexual rain and having sex at an earlier age because they now have an immunological raincoat against Hepatitis B. “We’ve got Hep B protection – let’s have sex” remains a pickup line that has probably not been used successfully among American teens.

The way past this sexual thicket of controversy is to forget the sex for once, and to focus instead on HPV as a disease that infects 6 million Americans each year, requires millions of women to miserably and annually “assume the Pap smear position,” causes many thousands of cases of cervical cancer that must be treated, and kills more than 3,000 American women tragically and unnecessarily each year.

If the price for beating back that preventable plague on women is three anti-HPV shots and some potentially uncomfortable conversations with 12-year-old girls, it seems cheap. As the controversy about it swirls we would all do well to remember those numbers and this; disease is preventable and sex largely is not, and the HPV vaccine is about preventable disease, not about preventable sex.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.