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Sexually Transmitted InjectionWhy vaccinate girls but not boys against HPV?

By William SaletanPosted Thursday, Oct. 15, 2009, at 10:10 AM ET

GardasilShould boys be vaccinated against the human papillomavirus?

You've probably heard about girls being vaccinated everywhere for HPV. The virus has been implicated in cervical, vulvar, and vaginal cancers. But it can also cause diseases that affect men and boys: oral, anal, and throat cancers, not to mention genital warts and juvenile onset recurrent respiratory papillomatosis, an infant respiratory condition that may result from maternal HPV infection. "Recent data on the use of the HPV vaccine in males suggest high efficacy against vaccine type infections and external genital lesions," says a study published last week in the British Medical Journal.

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So, should boys be vaccinated?

No, say the authors. "Our results suggest that if vaccine coverage and efficacy are high among preadolescent girls (12 years), then including boys in an HPV vaccination programme is unlikely to provide good value for resources compared with vaccinating girls only. … [O]ur analysis favours HPV vaccination of preadolescent girls (with continued screening in adulthood) as a valuable intervention for its cost. … Including boys in the vaccination programme, however, generally exceeded conventional thresholds of good value for money."

Why vaccinate girls but not boys? The authors cite several factors. First, HPV is more likely to harm girls. Second, the vaccine is more effective in girls. Third, the rate of viral transmission depends on the virus's prevalence "in the opposite sex at any given time." If girls are routinely vaccinated, there's nothing for boys to catch or transmit.

In other words, boys don't have to get vaccinated for the same reason they don't have to wash dishes, do laundry, buy birth control, or think about other people in general: Girls will do it for them.

Why do HPV vaccines work better in girls than in boys? Because they were designed for and tested in girls. It's true that HPV affects girls more than boys, but the same can be said of pregnancy. There's still a male in the equation somewhere. Boys certainly share the pleasure. Why not share the responsibility? And what about that infant respiratory condition? Shouldn't men do their part to prevent it?

If you want to see a world where men wash dishes and do laundry, it isn't hard to find. It's a world where men live, have sex, and share household responsibilities with other men. They don't have wives or girlfriends to think about and take care of everything for them. They have to do it themselves.

The same is true of protection from sexually transmitted viruses. The authors of the BMJ paper concede that they "only represented heterosexual partnerships and therefore did not reflect HPV transmission among men who have sex with men, who face a high risk of anal cancer and may realise a greater benefit from HPV vaccination." But the argument for vaccinating gay men isn't just that they might benefit. It's that vaccinating women won't help them. They can't count on somebody else to take care of the problem.

What would happen to straight men if women weren't vaccinated? The authors played out that scenario in their mathematical models. "If coverage in girls ends up being low, then vaccinating boys became much more attractive," the lead author concedes.

Maybe routine vaccination of both sexes is overkill. But in that case, perhaps we should ask why the partner who takes care of the birth control should get the vaccination, too.

(Now playing at the Human Nature blog: 1) Polanski and airing ugly truths. 2) Polanski and pedophilia. 3) The beauty of artificial virginity.)

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William Saletan is Slate's national correspondent and author of Bearing Right: How Conservatives Won the Abortion War. Follow him on Twitter here.

Photograph of Gardasil by Russell Kirk/Merck & Co. via Getty Images.

COMMENTS

When the HPV vaccine was being promoted there were promises that it would be tested against boys as well as girls and that the eventual vaccination program would encompass both sexes. As the vaccine mandates started rolling out, however, the vaccine for boys was nowhere to be seen. I would suspect the vaccine makers would rather milk the cash cow of mandatory vaccines for girls rather than doing the additional testing required to tune and ensure the safety of the vaccine in boys. Overall it feels like a broken promise.

-- fletc3her
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I disagree. Give it time. No business would chose to leave out 50% of its clientele. The pharmaceutical industry didn't get rich by being stupid. The studies are coming, but it takes time to determine if the vaccine works. It only makes sense that girls were targeted first because they are by far at the most risk.

-- FeTuS
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The policy of only recommending the HPV vaccine for girls is, perhaps, a cost-saving measure to get good value for dollars spent. But, if the recent healthcare debates have taught us anything, I think it would be that maximizing value is not the same as maximizing health (or, for that matter, justice). Saletan points to two of the main assumptions underlying the "vaccinate girls" strategy.

First, it assumes that women, more so than men, can be counted on to take responsibility for their bodily health and that of their partners. This happens in other ways relating to sex, such as the lack of funding and research on male hormonal contraceptives relative to women's hormonal contraceptives (even though some women, with family histories of heart disease or certain cancers, may be advised not to take hormonal birth control, and they'd benefit from their partners doing so instead). A dependence on women's responsibility also happens in other realms, as Saletan points out - obviously there are exceptions, but today it is still the case that straight men heavily rely on women to do housework, make doctors' appointments, plan healthy meals, etc, much more than the other way around.

The second assumption here is heteronormativity - that everyone is straight, and, if sexually active, is having hetero sex. If that were true, then a policy of vaccinating only men or only women would make a lot of sense, since either they or their partners would be vaccinated. The current policy, however, basically only ensures protection to women, and to men who have sex with women. In some sense - whether intentional or not - the policy penalizes men who have sex with men, by (1) obscuring the fact that HPV can cause ill health in men (it's not all about cervical cancer!), and (2) further obscuring the possibility that such men COULD benefit from getting the vaccine. I wouldn't be surprised if health insurance companies don't cover the HPV vaccine for men, which further penalizes (i.e., discriminates against) those men who have sex with other men. In short, while vaccinating women against HPV may be a cost-saving measure, it's certainly not ensuring the greatest health for the greatest number of people - and certain people will bear that cost much more than others.

-- Berkolate
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