Further thoughts about HPV

I don’t know if it’s worth cluttering up the space over on the main page, but I wanted to make a couple of small points about HPV that may help clarify my stance on mandatory vaccination (which I oppose).  My post yesterday generated a lot of commentary over at the main page, and I’ve also been following the comment stream over at Burt’s post as well.

Some commenters have taken exception to the distinction I draw between passive transmission of disease between people simply sharing a space, such as on a bus, and those who actively choose to participate in an activity that carries risk of transmission, such as sexual activity.  I draw the distinction not because I think that sexual activity has some kind of moral pall on it that puts it into its own category.  However, I believe that keeping our shared civic and educational spaces as free of serious infectious disease as possible is a compelling enough reason to justify governmental intrusion on parental prerogatives to accept or refuse treatment (such as vaccinations), whereas obviating the risks faced by two people who choose to engage in sexual intercourse is not.  People should be able to send their kids to school, use public transportation, etc. with as minimal fear of exposure to infectious disease as possible, and guaranteeing that public security warrants mandatory vaccination against illnesses that could easily be passed within those public spaces.  The risk of transmission is far more circumscribed for HPV, such that I no longer believe a government mandate is supportable.

At least one commenter has noted that HPV is a very prevalent infection, and cites a statistic that ~80% of women may be exposed within their lifetime.  This is true; HPV is the most common sexually-transmitted infection.  It is very important, however, to keep in mind that all HPV infections are not equal.  Certain strains of the virus are much more likely to increase risk of anogenital cancer than others, two of which (16 and 18) together account for ~70% of cervical cancer cases and are included in the four strains Gardasil protects against.  However, to quote from the 2009 Red Book “[m]ost infections are transient and clear spontaneously.”  It is important to avoid conflating the number of women exposed to HPV and the number who are at increased risk of cervical cancer.  Preventing the roughly 3,700 deaths from cervical cancer every year is a very important goal (which is why I would want all appropriate patients to be vaccinated against HPV), but that number is far lower than 80% of the female population in the United States.

Just to be clear one last time, I think every appropriately-aged patient should be vaccinated against HPV.  I think parents who refuse the vaccine are making the wrong choice for their children.  I strongly urge them to reconsider.  I find any attitude that views cervical cancer as a meet consequence of disapproved sexual activity to be morally repugnant.  I simply do not believe the state’s interests in preventing this particular infectious disease are sufficient to override my deference to parental prerogative, no matter how misguided.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. More than any stance by a poster on any topic lately, I am surprised by the degree of pushback on this opinion. Even a dissenting voice has to be saying to themselves “I disagree because of X, but still, that would be a totally reasonable policy.”


  2. This is an extremely tough issue for me. I can’t get on board with the extremes of any side, either saying that vaccination requirements for sexually transmitted diseases shouldn’t exist, or saying that the public health really trumps all else in the case of STDs because, well, they really get around!

    I think right now my view is wait-and-see. Let’s see what voluntary (“opt-in”) vaccination does before setting it up as a requirement. If enough people vaccinate, the risks don’t go away, but can be reduced (by blocking transmissions) to the point that a mandate would only save a fraction of the number of people we’re looking at now. On the other hand, if nobody gets the vaccination, I’m not opposed to a greater amount of nudging.

    One of the things I’ve heard a lot of mixed things about was how complicated the opt-out in Texas was. I’ve heard that it’s relatively simple and I’ve heard that it’s intentionally made difficult so that parents will resign themselves to just getting it if they’re anything less than hot-blooded passionate on the issue.

    One really, really good point you make is how rarely HPV actually becomes cervical cancer. Were this not the case, I would much more enthusiastically support a mandate whether transmitted by sex or air.

    • This comment describes my default views pretty well, and yes, many thanks for clarifying the statistics on HPV vs. cancer incidence. I was thinking about that last night myself, and was hoping to find the answer today and lo and behold, here it is.

      Sadly, I believe that many who oppose vaccinating girls for HPV do so for precisely the reason Dr. Saunders (and I) find morally repugnant:

      I find any attitude that views cervical cancer as a meet consequence of disapproved sexual activity to be morally repugnant.

  3. Actually, HPVirus is much more nasty than you seem to know. Not only are our daughters at risk, but so are our sons. HPV is also a leading cause of throat cancers of the tonsil and tongue. And while most of our sons and daughters will clear the infection, the HPV-related incidence of cancer in men is growing very quickly. So while our daughters will have a pap smear and often find medical treatment, our sons will (after a gestation period of as much as 3 decades) find themselves facing radiation, chemotherapy, and surgery, accompanied by multiple PET/CAT scans.
    So, the need to corral this disease by preventing infection is very important. It’s epidemic, even if we don’t yet know it.

    • While there is indeed a growing body of research regarding the link between HPV and oropharyngeal cancers (of which I am quite aware, thanks), the degree to which the incidence of these cancers is rising and to what extent HPV is responsible are far from settled questions.

      This does not change my viewpoint, in any case.

      • Well, if you were aware, you might have mentioned it. And the incidence and frequency of increase of such cancers isn’t quite as unsettled as you seem to think.

        In conversation last week with one specialist in the field, I learned that in five years, these HOV-related cancers will be among the most common, life threatening cancers in men 50 to 65 years old.

        • Please feel free to link to citations that support your assertions. I respectfully consider your conversation with the specialist in the field to be highly speculative.

          And, as the Internet is ever so very vast a space, you are always welcome to hold forth in your own forum on whatever topic you choose, to whatever degree you choose, including whatever information you choose. As the connection between HPV and oropharyngeal cancers has no bearing on my opinion about mandatory vaccination, I see no reason why I should be obliged to include a discussion of it.

          • I would think that readers here might be interested to know that HPV-related cancers aren’t just problems for “little girls”. That it’s probably a bigger problem for older men who were infected four decades before their cancers presented itself. And that that information is quite relevant to the question of the whether HPV vaccination should be manditory.

            As you correctly infer, I’m no specialist, just an informed, very interested party. As to whether my source’s opinion is “highly speculative”, I don’t think so, not at all. The data is in process of accumulation. And so are the incidences of these HPV-related cancers in men.

          • Wherever have I come anywhere close to saying that HPV-related cancers are just problems for “little girls”?

            Thank you for taking on the heavy burden of fleshing out what readers here “might be interested” in knowing. I find the task of providing all the information they might find interesting impossibly wearying, so your contributions are much appreciated.

            As for whether HPV-related head and neck cancers will make a leap to the top of the most common causes of cancer morbidity in the US, it would take quite a leap to surpass the prostate, lung, colon, bladder and skin. I call it speculative to posit such a leap, you don’t. Welcome to Impasseville.

          • I would think that readers here might be interested to know that HPV-related cancers aren’t just problems for “little girls”. That it’s probably a bigger problem for older men who were infected four decades before their cancers presented itself. And that that information is quite relevant to the question of the whether HPV vaccination should be manditory.

            It’s certainly relevant to the question of whether people should vaccinate their daughters, but then nobody here has suggested they shouldn’t. Whether it’s relevant to the question of whether HPV vaccinations should be mandatory is less certain.

  4. Your position is almost identical to the position I took at Burt’s post. So obviously I quite agree with you. I also appreciate the further information on the different strains of HPV, which I had not known.

  5. I think the reason I disagree comes down to the fact that condoms aren’t entirely effective at preventing HPV. I would say that “sex using protection” is riskier than riding a public bus or sending a child to day care, but that all three should fall on the “list of things you should expect to do without getting sick” (as differentiated from unprotected sex). That’s why I was firm about drawing the distinction.

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