Why don’t we talk about how the HPV vaccine can prevent anal cancers?

Why Don’t Doctors Tell Patients the HPV Vaccine Can Prevent Anal Cancer?

Why Don’t Doctors Tell Patients the HPV Vaccine Can Prevent Anal Cancer?

Outward
Expanding the LGBTQ Conversation
Nov. 30 2016 8:30 AM

Why Don’t Doctors Tell Patients the HPV Vaccine Can Prevent Anal Cancer?

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All boys need to hear about all the benefits of the HPV vaccine.

Brainsil/Thinkstock

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A widely available vaccine can substantially lower the risk of various cancers for those who receive it. For men who have sex with men, the benefits may extend even further. But those potential benefits for gay and bisexual men are often left out of the conversation.

Whether they should be, and how to raise them, are more complicated issues than one might think.

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The vaccine in question prevents infection against several strains of the human papillomavirus, known as HPV. The most common sexually transmitted infection, HPV can both cause genital warts and increase the risk of several different kinds of cancer, though the strains that cause warts are different from those that raise cancer risk. Almost all cases of cervical cancer are caused by infection with HPV, and in 2006 a vaccine was licensed in the United States for administration to girls to lower their risk of that disease. The vaccine has been found to be so effective that the Centers for Disease Control recently lowered the number of shots recommended from three to two if they are first administered before age 15. (Three shots are still recommended for those starting later.)

It’s not only girls who should get the vaccine, though. Boys should receive it, too, in order to lower their own risk of genital warts and cancer. When it comes to the cancer-preventing benefits for boys and men, much attention has been given to the association between the virus and cancers of the mouth and throat. But there are other HPV-related cancers that men can get.

Of men with cancers caused by HPV, about 14 percent are anal cancers, according to Dr. Stephen Goldstone, a New York City surgeon and assistant clinical professor in surgery at Mount Sinai’s Icahn School of Medicine, who specializes in the treatment of cellular changes related to HPV. In a recent conversation, Dr. Goldstone stressed that men who have never had sex with other men can still get anal warts or cancer, but the substantial preponderance of HPV-related anal cancers occur in gay or bisexual men.

Often, however, the discussion about HPV and cancer risk in men stops at the neck or fails to include the vaccine’s broader protective benefits for men who have sex with other men.

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In a segment for NPR, 29-year-old Jake Harper pondered whether he should get the vaccine, despite being well above the age when most young men get it. Harper mentioned that the CDC recommends vaccination up to age 26 “for some high-risk groups” of men, but he neglected to specify that those groups include gays and bisexuals. (Those with immune deficiencies are also included.) An article in the Wall Street Journal about how medical providers discuss the vaccine with parents notes that HPV causes “cervical, penile, throat and other cancers” without mentioning anal cancers at all. (My Slate colleague Christina Cauterucci managed to include both a mention of anal cancer and the expanded vaccine recommendations for men who have sex with men in her coverage of HPV-related cancers in men. It can be done.)

As much as I would like to throw stones about these omissions, I’m not really in a position to do so. I am one of the many people who have elided any acknowledgment of HPV-related anal cancers, both as a writer and a physician.

I’m an ardent proponent of vaccination in general, and against HPV in particular. I’ve written before about the unfortunate reluctance many medical providers have to recommend the HPV vaccine routinely to all their patients, male and female. In that article, I noted the risk of tongue and throat cancers and remarked that all my patients have tongues. It’s a fact I bring up routinely when discussing the vaccine and its benefits to my male patients.

All my patients also have anuses. But somehow that fact never comes up.

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Instead, whenever I talk about the vaccine to parents in my office, the spin doctor in my head hopscotches right over any implication that my male patients could grow up to have sexual relationships with other men. On some level, I’m afraid that any suggestion of potential same-sex intercourse will be offensive, and I habitually fail to mention anal cancer.

Pondering this pattern of omission on my part, I was ready to chalk it up to internalized homophobia, which is at odds with my overall self-impression as a physician.  It felt like an embarrassing thing to realize about myself.

However, Dr. Goldstone shares these reservations.

“I don’t want pediatricians mentioning [HPV-related anal cancer risk] to the mother of a young boy, because it’s still a very homophobic world,” he told me. “You don’t want this to be perceived as ‘the gay men’s vaccine.’ I want it discussed as a vaccine for all girls and all boys, irrespective of who they’re going to end up having sex with. I want everyone to get it.”

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Given that Dr. Goldstone authored a book called The Ins and Outs of Gay Sex: A Medical Handbook for Men the same year I graduated medical school, I’m not going to diagnose his reluctance as internalized homophobia. But I do wonder if pediatricians need to be so averse to describing the full benefits of the HPV vaccination.

I reached out to colleagues on social media to conduct an informal survey of how they discuss the vaccine with parents in their practice. All the people I heard back from described thorough, thoughtful recommendations about lowered risk of warts and various cancers, but only two mentioned anal cancer.

Somewhat ironically, the only one who told me he specifically notes the reduced risk of HPV-related anal cancer for gay men is a doctor I know to be very active in a relatively conservative Christian church. (He was someone I had in mind when I expressed reservations about LGBTQ patients using medical providers’ political affiliations as a filter for where to seek medical care, though given how frightened many of us feel after the recent election that filter is understandable.) If a conservative Christian physician in middle America can mention this potential benefit to patients in his efforts to sincerely recommend the vaccine, how much caution do we truly need to exercise?

Just as I don’t pre-emptively debunk as implausible a parent’s expectation that their daughter will be perfectly abstinent until marriage and wed someone similarly chaste, I don’t necessarily have to note that the protection from anal cancer will be of greater benefit to boys who might grow up to have same-sex relationships. I’ve made an effort lately to matter-of-factly include anal cancers on the list of those the vaccine may help prevent, and thus far nobody has gasped and asked just what I’m implying.

Like so many potentially fraught topics in medical care, balancing the reality of persistent homophobia with the need to fully educate parents about the benefits of a cancer-preventing vaccine requires nuance and a willingness to tolerate potentially awkward conversations. Even if the potential benefit is greater for those who may grow up to be gay or bisexual, the protective effect against anal cancer applies to all boys, and it should be included as part of the reasons to recommend it. And any discussion about the vaccine for older patients that doesn’t specifically mention queer men does a disservice to those who need the information most.

Daniel Summers is a pediatrician in New England. He writes about medicine and LGBTQ issues.