Human Papillomavirus (HPV) Vaccine: A Gendered Innovation

Abstract

As a medical student, Leana Wen visited her student health center for an annual check-up and Pap test. Four weeks later, her Pap results came back positive for cervical cancer. After undergoing several excisional procedures,[i] Wen was declared cancer-free. At age 27, her cervical cancer re-emerged, and Wen underwent a more invasive procedure called cervical conization, which involved removing a portion of her cervix along with the cancerous tissue. Today, Dr. Leana Wen, a cervical cancer survivor, activist, and proponent of preventative medicine, serves as the President of Planned Parenthood.[ii]

Around the same time that Dr. Wen was fighting her second battle with cervical cancer, Academy award-winning actor Michael Douglas was diagnosed with Stage 4 oropharyngeal cancer.[iii] He received an aggressive eight-week course of chemotherapy and radiation therapy, during which he lost 45 pounds. Although physicians declared him cancer-free, he recognizes that the cancer may return. Wen has been vocal and transparent about her journey against cervical cancer; however, Douglas kept his condition hidden from the public for three years.[iv] In 2013, he decided to share his story to raise awareness about his cancer.

Both Wen and Douglas fought cancers caused by human papilloma virus (HPV), a ruthless virus that affects more than 79 million people in the United States.[v] HPV, the most common sexually transmitted infection worldwide, infects up to 85% of women and 91% of men with sexual partners.[vi] All sexes can transmit the virus to people of the same or different sex. HPV causes a variety of cancers including cervical, oropharyngeal, urethral, bladder, anal, penile, vaginal, and vulvar cancers as well as genital warts; therefore, HPV-associated cancers can affect people of all sexes.[vii]^,[viii] The virus infects squamous cells lining the inner surface of the organs listed above and interferes with cell signaling, causing the uncontrolled proliferation of infected cells.[ix] The Centers for Disease Control and Prevention (CDC) estimates on average 31,500 people—19,400 females and 12,100 males—are diagnosed with HPV-attributable cancers each year.[x] Often times, HPV-associated cancers manifest decades after viral exposure, making early detection difficult. Because traditional viral diagnostic measures such as electron microscopy, immunological tests, and cell culture are not suitable for HPV,[xi] current diagnostic methods primarily depend on abnormal Pap test results or presence of genital warts.[xii]

Because HPV, a predominantly silent infection, is not readily detected using traditional viral diagnostic tests, vaccination is key. As one of two licensed vaccines[xiii] that protect against virally-induced cancers, [xiv] the HPV vaccine immunizes individuals against up to seven high-risk viral strains known to cause cancers in all sexes and two low-risk strains responsible for most genital warts.[xv]^,[xvi] The CDC has identified six reasons why people should receive the vaccine (Figure 1);[xvii] more than 100 million doses of HPV vaccines have been safely administered, and extensive clinical studies show that the vaccine confers "safe, effective, and long-lasting protection."[xviii]

Despite these profound results, recommendations for HPV vaccine administration remain unclear. The CDC recommends the vaccine for pre-teen girls and boys around the ages of 11 or 12, but it can be administered as early as 9 years of age. Women under the age of 26 and men under the age of 21 also qualify for the vaccine.[xix] On October 5^th, 2018, the Food and Drug Administration (FDA) approved the vaccine for men and women ages 9-45; however, the CDC recommendations remain unchanged.[xx]^,[xxi] Without standardized guidelines, decisions about who receives the vaccine may differ based on patient-physician interactions and insurance. Dr. Robyn Tepper, Medical Director of Stanford University Vaden Health Center, states that physicians at Vaden "are happy to give HPV vaccines to anyone who wants it, up to the FDA approved age of 45. However, insurance [including Stanford's Cardinal Care] typically covers vaccines once they are recommended by the Advisory Committee on Immunization Practices (ACIP)," which has yet to extend the age range.[xxii] Although men older than 21 may want the vaccine, current policies limit access.

Although HPV vaccines prevent cancers in people of all sexes, vaccination rates, especially in non-female sexes, remain low.[xxiii] Based on survey data collected by the CDC, 1 dose vaccine coverage in 2016 for females ages 19-26 was 48.5% compared to 13.5% of males in the same age group.[xxiv] Only a few countries outside of the U.S. recommend the vaccine to males due to false assumptions about the vaccine's cost effectiveness, and most countries do not have recommendations for transgender individuals.[xxv] Disparity of vaccine administration rates between female and non-female sexes may also arise due to limited health and biomedical research on the impacts of the HPV vaccine on male, transgender, and intersex individuals.

This paper will address gendered gaps in HPV vaccination rates by analyzing the lack of "Health and Biomedical Research" on non-female cells, animal models, and individuals as well as economic and political "Factors Intersecting with Sex and Gender" that restrict vaccine access to non-female individuals. Additionally, this paper will address the female-oriented "Language and Visual Representation" surrounding the vaccine and conclude with innovations that promote a de-gendered HPV vaccine that is accessible to people of all sexes.

[i] Leana Wen's cervical cancer excisional procedure is called Loop Electrosurgical Excision Procedure (LEEPs), which are "short procedures which use a small electrical wire loop to remove the abnormal cells." 

[ii] Wen, Leana, "Before I Was President of Planned Parenthood, I Was Diagnosed with Cervical Cancer at a Routine Screening," Self, January 28^th, 2019: https://www.self.com/story/leana-wen-cervical-cancer

[iii] Christensen, J., "Michael Douglas: 'Throat Cancer' Was Really Tongue Cancer," CNN, October 15^th, 2013: https://www.cnn.com/2013/10/14/health/michael-douglas-tongue-cancer/index.html

[iv] Shoard, C., "Michael Douglas: Oral Sex Caused My Cancer," The Guardian, June 2^nd, 2014: https://www.theguardian.com/film/2013/jun/02/michael-douglas-oral-sex-cancer

[v] "Genital HPV Infection-Fact Sheet," Centers for Disease Control and Prevention, November 16^th, 2017: https://www.cdc.gov/std/hpv/stdfact-hpv.htm

[vi] Chesson, Harrell W., et al. "The estimated lifetime probability of acquiring human papillomavirus in the United States." Sexually transmitted diseases 41.11 (2014): 660-664: https://ovidsp.tx.ovid.com/sp-3.32.2a/ovidweb.cgi?WebLinkFrameset=1&S=AICAFPJMANDDLHLFNCDKFHDCNBFLAA00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.32.33%257c0%257c00007435-201411000-00004%26S%3dAICAFPJMANDDLHLFNCDKFHDCNBFLAA00&directlink=https%3a%2f%2fovidsp.tx.ovid.com%2fovftpdfs%2fFPDDNCDCFHLFAN00%2ffs046%2fovft%2flive%2fgv023%2f00007435%2f00007435-201411000-00004.pdf&filename=The+Estimated+Lifetime+Probability+of+Acquiring+Human+Papillomavirus+in+the+United+States.&pdf_key=FPDDNCDCFHLFAN00&pdf_index=/fs046/ovft/live/gv023/00007435/00007435-201411000-00004

[vii] Burd, Eileen M., "Human papillomavirus and cervical cancer," Clinical microbiology reviews vol. 16,1 (2003): 1-17: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC145302/

[viii] "What is HPV?" Centers for Disease Control and Prevention, December 13^th, 2016: https://www.cdc.gov/hpv/parents/whatishpv.html

[ix] "HPV and Cancer," National Cancer Institute, March 1^st, 2019: https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer?redirect=true 

[x] Gargano, J., Meites, E., Watson, M., Unger, E., and Markowitz, L., "Chapter 5: Human Papillomavirus (HPV) Manual for the Surveillance of Vaccine-Preventable Diseases," Centers for Disease Control and Prevention, November 10^th, 2017: https://www.cdc.gov/vaccines/pubs/surv-manual/chpt05-hpv.html

[xi] Dixit, Rahul et al. "Laboratory diagnosis of human papillomavirus virus infection in female genital tract" Indian journal of sexually transmitted diseases and AIDSvol. 32,1 (2011): 50-2.: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139291/

[xii] "Genital HPV Infection-Fact Sheet," Centers for Disease Control and Prevention, November 16^th, 2017: https://www.cdc.gov/std/hpv/stdfact-hpv.htm

[xiii] The Hepatitis B vaccine protects against virally-induced liver cancers (hepatocellular carcinomas). 

[xiv] "Cancer Prevention and Control Vaccines (Shots)," Centers for Disease Control and Prevention, May 2^nd, 2018: https://www.cdc.gov/cancer/dcpc/prevention/vaccination.htm

[xv] "Human Papillomavirus (HPV) Questions and Answers," Centers for Disease Control and Prevention, August 23^rd, 2018: https://www.cdc.gov/hpv/parents/questions-answers.html

[xvi] "Gardasil 9," Merck Vaccines, December 2018: https://www.merckvaccines.com/Products/Gardasil9

[xvii] More than 100 million doses of HPV vaccines have been safely administered, and extensive clinical studies show that the vaccine confers long-lasting immunity.

[xviii] "6 Reasons to Get HPV Vaccine for Your Child," Centers for Disease Control and Prevention, May 1^st, 2018: https://www.cdc.gov/hpv/infographics/vacc-six-reasons.html

[xix] "HPV Vaccines: Vaccinating Your Preteen or Teen," Centers for Disease Control and Prevention, August 23^rd, 2018: https://www.cdc.gov/hpv/parents/vaccine.html

[xx] Denise Grady & Jan Hoffman, "HPV Vaccine Expanded for People Ages 27 to 45," New York Times, October 5^th, 2018: https://www.nytimes.com/2018/10/05/health/hpv-virus-vaccine-cancer.html

[xxi] "Gardasil 9," Food and Drug Administration, October 10^th, 2018: https://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm426445.htm

[xxii] Tepper, Robyn. Personal Interview. March 13^th, 2019.

[xxiii] Lewis, Rayleen M., and Lauri E. Markowitz. "Human papillomavirus vaccination coverage among females and males, National Health and Nutrition Examination Survey, United States, 2007–2016." Vaccine 36.19 (2018): 2567-2573: https://www.sciencedirect.com/science/article/pii/S0264410X18304614?via%3Dihub

[xxiv] Lewis, Rayleen M., and Lauri E. Markowitz. "Human papillomavirus vaccination coverage among females and males, National Health and Nutrition Examination Survey, United States, 2007–2016." Vaccine 36.19 (2018): 2567-2573.: https://www.sciencedirect.com/science/article/pii/S0264410X18304614

[xxv] Margaret Stanley (2014) HPV vaccination in boys and men, Human Vaccines & Immunotherapeutics, 10:7, 2109-2111, DOI: 10.4161/hv.29137: https://www.tandfonline.com/doi/pdf/10.4161/hv.29137?needAccess=true