Read more from Slate's Sex Issue.
In recent months, you may have seen a TV ad featuring striking young women skateboarding and drumming as a voice-over intones, "Every year, thousands of women die from cervical cancer. I want to be one less woman who will battle cancer." The women represented are self-confident, accomplished, artistic, and independent. Only one boy shows up in the ad—in a still photo. But what is most striking about the ad is that it is just one part of a much larger cultural and political battle about young women and sex.
America declared a "war on cancer" 30 years ago, and yet few cures or vaccines have been discovered since. So when Merck announced that it had a created a drug that could prevent some 70 percent of cervical cancers from developing, you would think Americans would rejoice. Instead, there was a backlash. Last February, Republican Gov. Rick Perry signed an executive order that would have made Texas the first state to mandate the vaccination of schoolgirls against HPV, the sexually transmitted virus that is a frequent cause of cervical cancer. He promptly came under fierce attack. The Texas Legislature expressed its deep reservations about the vaccine, and the media reported that Perry had received a campaign contribution from Merck prior to signing the order. Ultimately, the order was vetoed by the legislature. Earlier this year, 24 states were contemplating making Gardasil—as the cervical-cancer vaccine is known—a mandatory vaccination for young women. Today, only one state, Virginia, has such a law, and it leaves a loophole for parents to opt out.
In one sense, this reluctance seems understandable. Merck is the same company that made headlines in 2004 for failing to disclose that its painkiller Vioxx raised the risk of cardiac arrest and stroke in patients. Gardasil is a brand-new drug, and the company has conducted only limited testing on it. Though the pre-release studies suggest it is highly efficacious, the vaccine's long-term side effects are not fully known. What's more, the vaccination comprises three painful shots, at an estimated cost of $360. Given all this, it is hard to blame parents who resist putting their daughters on the drug's front line, preferring to wait until more is known about it.
Much less understandable, though, is the position taken by many opponents: namely, that a cervical-cancer vaccination would "promote promiscuity" among teenage girls. Implicit in this argument is the assumption that good girls don't get cervical cancer; only "loose" ones do—and they may get what they deserve. Earlier this year, State Sen. George Runner of California told the Los Angeles Times that American money would be much better spent on other types of vaccines, since cervical cancer is a result of lifestyle choices, rather than bad genetic luck.
This view involves a hefty dose of ignorance, as well as a dollop of old-fashioned magical thinking. As any doctor can tell you, it takes only one sexual contact to contract a strain of HPV that can lead to cervical cancer. The CDC reports that at least 50 percent of Americans are infected with HPV over the course of their lives, and a whopping 80 percent of American women are infected by age 50. Admittedly, the chances are slim that HPV would lead to cervical cancer: Only a small portion of HPV infections become cancerous. Still, according to the National Cancer Institute, roughly 11,000 women will be diagnosed with cervical cancer this year in the United States. Nearly 3,700 women will die. If you are one of those 3,700 women, you might feel that a vaccine could have changed everything. And—contrary to Runner's insinuations—you needn't be a slut to be among them: You could have married a guy who slept with just one other girl. Or, of course, you could be one of the approximately 13 percent of American women who, according to a 2003 study, are or will be a victim of rape over the course of their lives.
Meanwhile, the idea that a mere vaccination could "promote promiscuity" is bizarrely simplistic—as if the prick of a needle in the arm of a pre-adolescent girl stands in for a, well, prick of another kind. For one thing, no evidence suggests a connection between a decrease in HPV and an increase in sexual activity, nor is it likely to: HPV is hardly a major deterrent to kids who might be squeamish about STDs, since it has few short-term effects and cervical cancer usually takes years to develop. Adolescents have a hard enough time thinking about next week, let alone a decade from now. They're more likely to be worried about the immediate effects of herpes, gonorrhea, or syphilis, or even AIDS, which is still more prevalent than cervical cancer. For another thing, there's already a vaccine out there designed to prevent a sexually transmitted disease—and it's not being protested by anyone on the grounds that it might encourage promiscuity. That vaccine is for hepatitis B, and it is given to approximately 88 percent of all American children by the time they are 19 months old. Finally, it's not as if adolescents are incredibly rationalabout their sexual calculations, as the vaccine-promiscuity argument would have Americans believe.
On the contrary, the reason so many legislators and parents have conjured up a tie between vaccination and sex clearly has less to do with objective reality than with the age at which girls are supposed to receive the vaccine. Gov. Perry's executive order would have mandated that girls receive the vaccine as they go into sixth grade, at age 11 or 12—precisely the juncture between childhood and adulthood we're the most uncertain about how to conceptualize. According to Sydney Spiesel, a pediatrician and a Slate writer, parents often complain that 11 is too early for a Gardasil shot, because their daughters aren't sexually active yet. But that's not the point; the point is that these pre-adolescents need to receive the vaccine well before they are sexually active.
It may be that Merck miscalculated in not finding a way for vaccinations to begin in childhood rather than in pre-adolescence, even if it meant patients needing a booster series. The later age encourages parents and politicians to make a categorical error, associating Gardasil with the pill or with the sex talk, when it needn't be associated at all (just as hep-B shots aren't). Merck may also have miscalculated by recommending that the vaccine be administered only to girls, though boys are carriers of HPV, too—and in fact, scientists believe that the virus plays a role in head and neck cancers as well as anal cancer. Merck is currently testing the drug for boys, but by now the debate has fully catalyzed pre-existing latent anxieties about young women and sex.
Indeed, one of the most fascinating elements of the Gardasil debate is that the hysteria appears to have been internalized by some of the constituents themselves—a twist Freud might appreciate. Rumors abound about significant negative side effects, although pre-release statistics show nothing out of the ordinary. (To be sure, early studies may not capture the full range of drug-related risks.) At one school in Australia, 26 girls injected with Gardasil went to the campus medical office complaining of adverse effects; a couple were hospitalized. Since then, additional reports of group dizziness and fainting have been posted in the comments section of various Internet sites. Since many patients now know the vaccine is controversial, one has to wonder whether some of these instances have more to do with sublimated anxiety about sex and with sociogenic effects than with the drug itself. (Spiesel said that none of his patients had reacted adversely, though he had heard of one case where a patient had.)
And so liberal parents who distrust Big Pharma are also highly suspicious of Gardasil. But as Darshak Sanghavi, a pediatric cardiologist and a Slate writer, told me, speaking by phone from his office, "Looking at the science, I think it's highly unlikely that there is any significant side effect that hasn't been caught. For sure, there could be something rare. But there is no suggestion of anything masked." He stressed the importance of contextualizing the vaccine, pointing out that it takes a lot of research money to create vaccines, and it is not always a profitable enterprise. Given the very real dangers of cervical cancer, Sanghavi said, "I don't believe that they have pushed [Gardasil] in an unethical manner. They have a product that is almost certainly going to save lives." In the meantime, fears about the health risks of Gardasil have obscured the hidden moral calculus of the conservative opposition to Gardasil: that in the end, it may be worth it for several thousand women to die from cervical cancer every year as collateral damage in the war against premarital teen sex. Because, of course, even if the vaccination did encourage promiscuity, it's not clear that it's OK for women to die as a result.
Protesters in all camps of the anti-vaccine coalition are chafing at what they see as the paternalism inherent in making vaccines mandatory. But if anyone in the government is being paternalistically intrusive, it's not the Gov. Perrys of the world. It's the legislators who are pursuing the war against premarital teen sex when they could seize the chance to eradicate the HPV virus and its associated cancers from the lives of young Americans. On second thought, this isn't really paternalistic at all. To pretend for a little longer that their daughters will never grow up, and that we all can protect them by hiding our heads in the sand for another few years—actually, that's just childish.
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