Bedside Manners

I dedicate this month’s column to parents who are in the midst of crises which are well-articulated on the website A Heartbreaking Choice:

Pregnancy does not end happily for everyone. Sadly, some parents receive grim prenatal news that something is seriously or fatally wrong with their loved and wanted unborn baby. They have to make a decision about continuing or ending pregnancy. We realize that all parents make a loving choice, one they feel is better for their baby. Regardless of the fetal anomaly found, the decision to end a pregnancy is always a difficult one.

Although it is estimated that between 80 and 95 percent of parents receiving a severe prenatal diagnosis choose to end the pregnancy, those who face this nightmare often feel alone. There is very little in the way of support programs for them. With this site and the dedication of courageous parents willing to reach out, we hope to create a safe haven of encouragement, validation, hope and healing.

How many of us have thought about all that is involved with therapeutic abortions?  Parents in these situations have to navigate a medical system which is under the influence of a legal system which (in my humble opinion) has succumbed to a failure of the separation between church and state. It saddens and infuriates me that these mothers — especially those in their third trimesters — may be denied access to medical options which could best protect their physical and mental health. In this day and age of U.S. abortion policies, should we be grateful that any states allow any options at all?  Gratefulness is hard to come by in the face of so much suffering.  My prayers and love go out to all parents who face these heartbreaking choices.

Coco Chanel has often been quoted as saying, “A woman who doesn’t wear perfume has no future.” If perfume staves off doom, then perhaps that’s what inspired this otherwise-inexplicable new ad by GlaxoSmithKline for its HPV vaccine:

As you can see, it leads with a blue-eyed, fair-skinned, made-up (and apparently affluent) young woman lounging on an antique sofa on the first floor of a mansion. But softly shimmering lights and fairy-like chimes distract the waif from her book. She dreamily follows the golden twinkling lights up an impressive staircase, where she gazes with a beatific smile upon a champagne-colored perfume bottle magically floating in mid-air. As the bottle rotates to reveal the words “CERVICAL CANCER“, the young woman’s expression switches from bliss to frowning concern. Enter the narrator’s voice:

Maybe it’s unfair to get your attention this way, but nothing’s fair about cervical cancer. Every 47 minutes, another woman in the U.S. is diagnosed. But, there are ways to prevent it. Talk to your doctor.

Unfair? I would have said “insulting.” As in, maybe it’s insulting to assume that the best way to attract a young woman’s attention to a serious health issue is to dupe her into thinking she’s watching a perfume commercial? But, if you want to talk ‘unfair’…Maybe it’s unfair that there hasn’t been a public health campaign to educate teens, women and men about sexually-transmitted HPV (human papillomavirus), which can cause not only cervical cancer but also other serious cancers in men and women? Maybe it’s unfair that the only public “education” about the HPV epidemic has come in the form of pharmaceutical ads that continue to narrowly brand and market HPV vaccines as “cervical cancer” vaccines?

The ad finishes by presenting a GlaxoSmithKline website — which troubles me, as a sexual health researcher, because it does not offer visitors a comprehensive HPV education. But that may have been too much to hope for, given that their HPV vaccine (Cervarix) received FDA approval for use in girls and women (ages 9 to 26) just this past October.

So, skip this ad and website if you’re looking for a more neutral source of information about HPV vaccine options, and visit the CDC instead. And those who’d like a more thorough STD/STI education should check out the American Social Health Association and other website resources which are not funding by pharmaceutical companies.

Note: while GSK has disabled adding comments to their series of new ads, you may rate not only this ‘perfume’ ad but also their ‘front porch‘ and ‘night out‘ ads with the start-ratings you feel they deserve. And, for more on the mis-marketing of HPV vaccines, read my article, “Why Men’s Health is a Feminist Issue,” in the Winter issue of Ms., on newsstands now.

(Originally posted on Ms. blog, cross-posted at Sociological Images and AdinaNack.com)

Last week, the NYT reported “Merck: Studies Boost Gardasil for New Uses“; this week the CDC’s Advisory Committee on Immunization Practices (ACIP) met to discuss these new results. It will be interesting to see what, if any, changes result from new clinical evidence that (1) the vaccine is effective in preventing anal precancers in males and (2) the vaccine is effective in women 27-45 years old.

Those who’ve followed HPV research for the past decade were not surprised by the findings of either study. What has surprised me is how little attention ‘male’ Gardasil has attracted since receiving FDA approval last October. Writing a feature article for the Winter 2010 Ms. magazine gave me the opportunity to more deeply explore this topic and hopefully raise awareness — not only about Gardasil, a.k.a. the “cervical cancer” vaccine, but also about the full range of male HPV-related cancers that it might also prevent. 

So, this month’s column is inspired by my desire to respond to some of the interesting questions, comments and accusations that I’ve received via the blogosphere (like WashingtonCityPaper and HugoSchwyzer) in these first days following the publication of my article. I’ll start by acknowledging that my article’s title seems to have pushed more than a few buttons: apparently not everyone wants to know “Why Men’s Health is a Feminist Issue.” One comment asked “Why does the burden for sexual health need to fall, yet again, to women?” My response: It’s a burden for only girls/women to be responsible for sexual health, so prioritizing equal access to STI/STD vaccines results in a more fair sharing of this ‘burden.’ From the opposite side, a comment criticized this angle as being self-interested: “…when feminists speak of male health issues, it is usually in the context of the way they affect women.” To that, I reply: if you read the full article, you’ll see that boys/men have plenty of reasons to care about having access to this vaccine that have to do with protecting their own health, regardless of whether or not they ever have a female sexual partner.

This leads to another trend in responses: What’s in it for men?  Or, as one comment put it, “The only reason for males to get the vaccine would be to prevent HPV in women.” Really? How about the variety of serious HPV-related male cancers (oral, penile, anal, and others) that are (1) on the rise, (2) often fatal due to lack of accurate testing/screening, and (3) in the U.S. likely result in more combined deaths in men than cervical cancers in women? (See my Ms. article for an overview of these stat’s or, if you love charts check out p. 4 of the American Cancer Society’s 2009 report).

And, media coverage of Gardasil would not be complete without questions/concerns focused on whether or not Gardasil does more harm than good. For the record: I have not taken a pro-vaccine or anti-vaccine stance on Gardasil or any other vaccine. But, I speak in favor of equal access to vaccines, support the conducting and media coverage of medical studies that reveal the full range of potential health costs and health benefits of any vaccine,  and argue for funding public health campaigns about HPV and other sexually transmitted epidemics. And, though some blog comments reveal confusion over the possibility of being “required” to get the Gardasil vaccine, I’m not aware of any current U.S. vaccination policy that does not allow for ‘opting out.’ (Note: as of December 14, 2009 Gardasil was no longer required for female green card applicants.)

A less popular theme, though one that intrigues me, came from those who took the angle of “What’s in it for big pharma?” One comment hypothesized, “…you can’t help but suspect Merck’s money motive is playing a role in the push for expansion to men.”  And, I reply, what PUSH? If money was their motive, then wouldn’t they have updated the Gardasil.com website to encourage male consumers? Visit that site prior to March 1, and you’d think that it was still only approved for girls/women.

I’ll end this post by expressing my thanks to all of the journalists and blog authors who are raising awareness about this topic, including Ms.‘s own Executive Editor Katherine Spillar on the Huffington Post. I also send out my gratitude to blog readers who add insightful, thoughtful, sociological, and truly feminist comments like Annie‘s. In my opinion, to be feminist is not to be pro-women, it is to be pro-equality and pro-justice (not to mention anti-sexism, anti-racism, anti-homophobia, anti-ageism…you get my drift). I don’t know if the pro- and anti-vaccine folks will ever see eye to eye, but there’s absolutely nothing to lose and everything to gain by being pro-HPV-education.

January is Cervical Health Awareness Month, making it the perfect time to post a follow-up to Part I which featured my concerns about potential unintended consequences of new Pap test guidelines (from ACOG, the American College of Obstetricians and Gynecologists). To recap, it is vital that we do not confuse a recommendation of less frequent Pap tests with the unchanged recommendation of annual pelvic/sexual health exams (see the National Cancer Institute for explanations of both).

So, let’s look back at a letter dated November 20, 2009, in which the President of ACOG clarified:

Cervical cancer screening should begin at age 21 years (regardless of sexual history). Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

Medically speaking, why should this recommendation disregard an individual woman’s sexual history? His letter continues on to state:

Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Evidence shows that screening women every year has little benefit over screening every other year.

Doesn’t this depend on how many new sexual partners a woman has in a given year? Are the revised guidelines assuming monogamy (or at least long-term, serial monogamous relationships) which decrease odds of a woman contracting a new cancer-causing strain of HPV in less than a 2-year period? Where are the conclusive findings of large-scale sexual-behavior surveys to support this assumption?

ACOG’s November 2009 press release featured these quotes from Alan Waxman, M.D.:

Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix. Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.

I agree with GWP reader anniegirl1138 who commented on my previous post that over-treatment is no joke. However, we have not been presented with data that a Pap test — the test, itself, not over-treatment based on test findings — is directly linked to significant increases of any negative health outcome.

Cervical HPV infections can be detected by Pap tests: ACOG acknowledges that, “the rate of HPV infection is high among sexually active adolescents, but counters with, “the large majority of cervical dysplasias in adolescents resolve on their own without treatment.”

Why should that smaller group of girls and young women (whose pre-cancerous lesions do not resolve without treatment) miss the annual opportunity to receive an early diagnosis? Early-stages of cervical HPV infection can often be resolved with less-invasive treatment options.

More-invasive treatment options, such as the “excisional procedures for dysplasia” that have been linked to increased risk of premature births, are one of several medical treatments for cervical HPV.

And, what about the possibility that an increased risk of premature births may not be the paramount concern for every female patient? Not all women want to or can biologically become mothers. What if an individual female patient would rather seek medical treatment for a HPV infection that has resulted in cervical dysplasia so that she has greater peace of mind in knowing that she has reduced her risk of cervical cancer and reduced the likelihood of transmitting HPV to her sexual partner(s) and/or future babies?

Call me a feminist, but I still believe that knowledge is power and that every sexually-active girl and woman should be encouraged to consider the benefits of annual Pap tests. When Pap smear results show “abnormal” cellular changs, then healthcare practitioners should explain the potential for false-positives and discuss the pro’s and con’s of moving forward with different diagnostic and treatment options.  

ACOG acknowledges that, “HPV also causes genital and anal warts, as well as oral and anal cancer.” A Pap test may be a girl/woman’s first chance to learn of a cervical HPV infection, which can result in her having a colposcopy exam. This procedure helps a practitioner find HPV-infected cells not only on the cervix but also in other anogenital areas (the vaginal canal, the labia, the perineum). Beyond the cervix, a Pap test that is positive for HPV may be a wake-up call to get a thorough oral screening for serious oral cancers which have been linked to sexually transmitted HPV.

In addition, my research and others’ studies have found that STI diagnoses can lead to attitudinal and behavioral changes which can decrease risks of contracting other STIs, including HIV. For all of these reasons, a Pap test that leads to a diagnosis of a sexually transmitted cervical HPV infection can bring unintended positive consequences.

In light of the new Pap smear guidelines, I hope that U.S. girls and women who get less frequent Pap tests will more frequently ask their healthcare practitioners to educate them about cervical cancer, about the full range of STIs, and about FDA-approved vaccines against viruses that can be sexually transmitted (HPV and Hepatitis B).

For the medical facts about HPV and HPV vaccines, check out the book The HPV Vaccine Controversy by Shobha Krishnan, M.D., a member of the Medical Advisory Board of the National Cervical Cancer Coalition. 

The Bottom Line: a recommendation for less frequent Pap tests does not mean you should forgo your annual pelvic exam. In our busy lives, e-reminders can make the difference:  PromiseToMe.com allows you to schedule an annual email reminder. [Note for boys/men: make sure to get an annual sexual health exam, too!]

Recently, I had the pleasure of corresponding with sociologists Chloe Bird and Pat Rieker about their book Gender and Health: Constrained Choices and Social Policies (Cambridge University Press, 2008), credited as the “first book to examine how men’s and women’s lives and their physiology contribute to differences in their health.” I was curious how the authors see their research relating to some of the health topics that have made headlines in recent months.

Nack: Starting off with the topic of mental, health, you’ve written about sex-based differences.  Reflecting on recent articles, like NYT’s In Anxious Times, Medical Help for the Mind as Well as the Body, how does your book add to our understanding of and concern for policies like the Mental Health Parity Act?

Rieker:  Our book provides concrete data for why the Mental Health Parity Act is such a strategic and critical addition to general health care policy.  We focus on gender differences in mental health, particularly depression and substance abuse disorders.  Although the overall rates of mental illness are similar between men and women, if you look at it by specific disease, then you see large gender differences.  Women’s depression and anxiety rates are double that of men’s; while men’s rates of substance abuse and impulse control disorders are double that of women’s. Available research shows that individuals with serious mental health problems also have more physical health issues, including a lower life span. Both social and medical interventions are needed to prevent and treat these socially and financially costly conditions which create enormous health burdens on individuals, who may become unable to perform work and other social roles, and their families, Employers and society, as a whole, bear additional costs. 

Bird:  Also, differences in men’s and women’s lives can affect their utilization of mental health care and the effectiveness of specific interventions. We need systematic assessments of the effectiveness of treatments/approaches for both men and women, which can ultimately lead to better physical and mental health outcomes. The US has fallen behind Canada and other countries which require this approach in federally-funded research. 

Nack: How are the differences between men’s and women’s mental health problems particularly relevant as we consider the impact of the economic downturn, in general, and, with regard to healthcare coverage, the rising numbers of uninsured and underinsured Americans?

Rieker:  In the current poor economic climate, many men and women are experiencing increased stress/anxiety when losing jobs which may have provided dependable incomes and health insurance. Constant worry, itself, leads to ill health and exacerbates existing underlying conditions (e.g., cardiovascular and respiratory conditions).  Our framework of constrained choice illustrates how social and economic policy can reduce or enhance the options and opportunities for individuals to engage in healthy behaviors such as not smoking, not drinking to excess, eating well, and exercising.  While some individuals respond to economic downturns by temporarily limiting costly habits of smoking or drinking, we argue that more could be done at different policy levels to encourage positive health behaviors and coping strategies that improve physical and mental health. more...

On this national day of gratitude, I find myself giving thanks for many things — including my family, my friends, and my health. I owe my sexual health to the now outdated norm of getting annual gynecological exams, with Pap smears, from the time I became sexually active. As a 20-year-old, in the mid-1990’s, I benefited from U.S. medical guidelines that supported my gynecologist in recommending cryosurgery (application of liquid nitrogen) to kill/remove the HPV-infected cells on my cervix. Early detection and early treatment afforded me a quick recovery from a potentially cancer-causing and highly contagious sexually transmitted infection. Following that treatment, I never had another abnormal Pap test result, got pregnant the first time I tried, and gave birth to a healthy baby. For all of those outcomes, I give thanks.

Today, many teen girls and women may not benefit from the level of medical care that I received. Last week, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines for pap smear and cervical cancer screening, and this may prove to have unintended, negative consequences for sexually-active Americans.

Until 2008, ACOG had recommended annual screening for women under 30. This month, ACOG summed up their revised recommendations:

…women should have their first cancer screening at age 21 and can be rescreened less frequently than previously recommended. 

Media coverage of this latest revision has not done as good a job distinguishing that a Pap test is just one aspect of a pelvic/sexual health exam. How many girls and women will interpret the new guideline of “No need for an annual pap tes,” as, “No need to get an annual pelvic exam”?

ACOG admits that the Pap test has been the reason for falling rates of cervical cancer in the U.S.

Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all.

So, why revise the guidelines such that we are likely to see an increase in the number of U.S. women “who are screened infrequently or not at all”?

And, it’s not just teen girls and young women that are the focus of these revisions. ACOG also recommends that older women stop being screened for cervical cancer:

It is reasonable to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and no abnormal test results in the past 10 years.

How much of this rationale depends upon women over 65 years old being sexually inactive or monogamous? This argument seems predicated upon ageist assumptions about older women’s sex drives and sexual behaviors (or lack thereof).

As the tryptophan from my Thanksgiving feast begins to dampen my ire, I’ll bring this post to a close. These are just a few of the problematic aspects of this new policy recommendation — stay tuned for “Part II” of this post in the near future.

Some would say this has been true since 2006, when the FDA approved Gardasil for exclusive use in girls/women, and finally the FDA agrees. Last week Merck received FDA approval for Gardasil to be used as a genital warts vaccine in boys/men (ages 9 to 26 years old). However, yesterday, the CDC Advisory Committee on Immunization Practices voted for only “permisive” use in boys, rather than voting for the stronger recommendation of “routine use,” as they had for Gardasil’s use in girls/women.

As reported in Bloomberg.com, this decision had been predicted by some experts:

William Schaffner, chairman of the department of preventive medicine at Vanderbilt University in Nashville, Tennessee, said the panel will be asking itself “if we vaccinate all the girls, how much additional benefit will we get by vaccinating the boys?”

The Atlanta Journal-Constitution cited a similar argument from a different expert:

Debbie Saslow, director of breast and gynecologic cancer at the American Cancer Society, agreed with the findings. “If we can vaccinate a high enough proportion of young girls, then vaccinating boys is not cost-effective,” she said.

This line of reasoning and the ACIP’s conclusion are problematic on two levels. First, there seems to be a privileging of female health over male health. There are compelling reasons “ other than the prevention of cervical cancer” for the ACIP to recommend “routine use” of a safe and effective male HPV vaccine. Second, there seems to be a heterosexist assumption in the ACIP’s decisions — that all boys/men are sexually attracted to (and sexually active with) girls/women and vice versa.

Maggie Fox of Reuters offered a more complete assessment in her article published yesterday:

The main reason the vaccine was approved was to prevent cervical cancer, which kills 4,000 women a year in the United States alone. But various strains of HPV also cause disfiguring genital warts, anal and penile cancers and head and neck cancers. “We know that the later the cancer is discovered, the lower the chance of survival is,” David Hastings of the Oral Cancer Foundation told the committee, asking for a recommendation to add the vaccine to the standard schedule for boys. However, ACIP decided only to consider its use based on its ability to prevent genital warts.

Did the ACIP adequately factor in the clinically proven causal links between certain strains of HPV and potentially life-threatening oral cancers — which do not discriminate on the basis of sex? This seems important, particularly if, “The death rate for oral cancer is higher than that of cancers which we hear about routinely such as cervical cancer” (Oral Cancer Facts)?

A recent New York Times article reports that the committee will “take up the issue of the vaccine’s effectiveness in preventing HPV-related male cancers at its next session in February, when more data should be available.”  But data has been available since 2007, when results of clinical studies were reported and the Oral Cancer Foundation issued a press release urging male HPV vaccination?

If the FDA believes Gardasil is safe and effective, then we deserve a more thorough explanation of why the vaccine’s potential to protect against oral cancers — in both men and women — is not reason enough for the federal advisory group to issue as strong a recommendation for male vaccination as for female vaccination.

Welcome to the first official post for Bedside Manners. As a sexual health researcher and book author, I receive a lot of emails from women and men who are dealing with sexually transmitted diseases. Yesterday, I replied to Liza, a 25 year-old married, monogamous woman who had just been diagnosed with a serious cervical HPV infection and treated via LEEP. She could not understand how this had happened, since she had been getting pap smears during her annual gynecological exams for the past 10 years, and her husband had never been diagnosed with genital warts. Her doctor told her it was “bad luck,” and now she is worried about the possibility of having an oral HPV infection, wondering whether her cervical infection is cured, and trying to figure out how to this will affect her marriage.

By getting annual pap smear exams, Liza has been doing the right thing. Unfortunately, most medical practitioners don’t explain that pap smears only sample a small area of a woman’s cervix. So, it is possible to receive a “normal” pap smear result when there are HPV-infected/abnormal cell changes in other portions of the cervix.

With Liza’s husband as her only sexual partner, it’s key for him to get thoroughly examined for HPV/genital warts. If HPV-infected cells are found, then he should have them removed via one of several treatment options. Once both of their bodies have healed from treatments, the couple should strongly consider using condoms during sex (note: condoms reduce but do not eliminate the risk of HPV transmission).

Given Liza’s concern about oral HPV, a ‘HPV test’ can determine the specific strain of the virus. HPV 16 has been linked to cervical cancer and to oral/head/neck cancers. So, an important follow-up exam after receiving a genital HPV diagnosis is to see a dentist: I encouraged her to share that she’s been exposed to HPV orally and request a thorough exam.

As I concluded my reply to Liza, I realized that I needed to address the stress that she was clearly experiencing. Medical sociologists have often written about how disease can cause dis-ease, an illness often causes a patient to lose her sense of wellbeing. In the case of socially stigmatizing and medically incurable infections, like HPV, stress is almost unavoidable for newly diagnosed patients. In my book, Damaged Goods?, I detail specific strategies for handling the variety of stressors that come with a genital HPV or herpes infection, but I’ve decided to wrap up today’s post with a general note about stress.

I was fortunate to attend a talk last night by the authors of a new book, The Inner Game of Stress. Tim Gallwey has teamed up with two physicians, who practice a patient-centered approach to integrative medicine, to combine medical research with his executive coaching techniques. The result is a thoughtful self-help approach to stress management that encourages readers to be assertive patients. As a medical sociologist, I have written about the health impacts of practitioner-patient interactions and was familiar with the body of research showing how stress can weaken a person’s immune system.

For people, like Liza, who are battling a virus, it is important to not only empower yourself with knowledge about your particular illness but also to strategize how to strengthen your immune system. In addition to the obvious recommendations of decreasing unhealthy behaviors and increasing healthy ones, I encouraged her to find sources of emotional and social support. Some who are facing a stigmatizing illness may find comfort by talking with trusted friends, while others may prefer the neutrality of a therapist, and many may find empowerment in a book.