HPV

Having written about sexually transmitted HPV (human papillomavirus) for 13 years, I’ve been waiting for the day when  celebrity would lend his or her fame to spotlight the realities of HPV infection, especially of HPV-related oral cancers. My hopes were that big news could bring about big change.  Today is that day, but it remains to be seen if it can be long-needed catalyst for change.

When news first broke, about three years ago, that Michael Douglas had oral cancer, my gut instinct was that it had been caused by HPV, likely one of the same types of HPV that has been causally linked to cervical cancer. The mucus membrane tissue of mouth and throat are similar to those of genital skin, so researchers have known for some time that, like herpes, HPV could be transmitted oral to genital, as well as genital to oral.

Back in 2009, the research findings were already clear: oral transmission of cancer-causing HPV means that almost all of us are more likely at risk than we are safe from risk.  For my 2010 feature article in Ms. Magazine, I focused on the importance of not only educating the public about HPV-related cancers in men but also about the HPV-oral cancer link. In addition, I advocated for the need to destigmatize all STDs: my research and book have shown that STD stigma makes it more likely for at-risk/infected  individuals to put off getting tested and treated. STD stigma also makes it less likely for individuals to disclose their sexual health status to partners, placing those partners at greater risk for infection.  In addition, negative stereotypes about the ‘types’ of women and men likely to be infected distort our ideas of who is at risk.

I’ll wrap up this post with a call: for us to come together, to learn the facts and not be swayed by incomplete media coverage and confusing pharmaceutical claims.  We must support significant funding increases to investigate exactly how we can prevent HPV-related oral/throat cancers, which research shows to be steadily on the rise and more fatal than cervical cancers in the U.S.

Update (6/3/13): I was not surprised to read reports which broke today — that the actor’s rep is correcting one aspect of yesterday’s breaking news: “He did not say cunnilingus was the cause of his cancer.” All any cancer survivor probably knows is that his/her cancer was caused by HPV (viral tests and typing can be done in lab tests of biopsied tissue samples). Researchers have found that cancer-causing HPV can be transmitted to oral/throat area via oral sex. The point remains: Michael Douglas did a good deed by helping raise awareness that serious (often fatal) oral cancers can be caused by sexually-transmitted HPV which is likely contracted by oral sex….

On this historic day, the US Supreme Court’s ruling on health care is being hailed as “a victory for all Americans” – but will all Americans benefit equally from the new health care law signed into law by President Barack Obama? No, not those, like Obama, who are male.

The ACA’s list of “Covered Preventive Services for Adults” includes screenings for only two sexually transmitted infections (STIs): “HIV screening for all adults at higher risk” and “Syphilis screening for all adults at higher risk.” They do include “Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk,” and “Immunization” for the STIs Hepatitis B, Herpes and Human Papillomavirus (HPV). All sexually active boys and men are potentially at risk for contracting a wide range of STIs, including HIV: the interpretation of “higher risk” could keep many from receiving necessary care.

If you scroll down this page, you’ll find the longer list of “Covered Preventive Services for Women” which includes additional sexual and reproductive health care screenings related to breast cancer, cervical cancer, chlamydia, contraception, gonorrhea, plus extra screenings HIV and HPV.  This laudable list is capped off by “Well-woman visits” described as, “preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate….” Why would a man not benefit from these types of services?

A google search for “well-man visits” turns up nothing on U.S. government websites and only one company’s description of their “Well Man Examination” policy: it includes only “Digital rectal exam; and Screening PSA test (age 40 or older).” Younger men could benefit from an examination for testicular cancer, “the most common cancer in American males between the ages of 15 and 34.” None of these tests are mandated under the ACA.

Looking again at government resources, the inequity jarring. In addition to having a website devoted to National Women’s Health Week in May, the U.S. Department of Health and Human Services also sponsors an Office on Women’s Health website.  If you’re on the homepage of the U.S. Department of Health and Human Services and search for “men’s health” you will not find a men’s health website.  However, their Office on Women’s Health website (somewhat ironically) features the U.S. government’s only resource webpage for men’s health, including a link to men’s sexual health. On this page, it focuses more on aging and sexual dysfunction, with only one small link to sexually transmitted infections. This “sexual health” page seems to patronize and condescend to men, doubting their abilities to care about and seek sexual health care:

“Sexual health is a source of concern for many men. Yet some men are not comfortable talking to their doctors about sex.” And, later on, “Remember that problems with sexual health are medical problems, and your doctor can help.”

If you live in King County, WA, then you might be in luck: their Public Health website features a fairly detailed description of “physical examinations for men.”  If you don’t feel comfortable seeking these examinations from your regular doctor, then check out Planned Parenthood: a national organization that provides men’s sexual health exams. While I’m not sure how many U.S. teen boys and men would think of Planned Parenthood clinics as their home base for sexual health care, U.S. health policymakers should look to them for guidance. Depending on the specific PP clinic, their services might include:

• checkups for reproductive or sexual health problems
• colon cancer screening
• erectile dysfunction services, including education, exams, treatment, and referral
• jock itch exam and treatment
• male infertility screening and referral
• premature ejaculation services, including education, exams, treatment, and referral
• routine physical exams
• testicular cancer screenings
• prostate cancer screenings
• urinary tract infections testing and treatment
• vasectomy

U.S. men, where is your outrage? Where are the protests demanding equality in sexual and reproductive health services? Why is there no U.S. Office on Men’s Health? A little digging online unearthed the failed “Men’s Health Act of 2001” which articulated the need for an Office of Men’s Health. If this act is not a priority for today’s politicians, then I encourage you to do your part to raise awareness about the need for accessible, affordable and comprehensive men’s sexual and reproductive health care. All of us — men, women and children — will benefit from better men’s sexual health.

As a sexual health researcher, I have followed the saga of HPV (human papillomavirus) vaccination since the early 2000s. I’m posting this month’s column early to address three news stories that recently caught my attention – both for what they reported and also for what they left out:

March 26, 2012: PRNewswire report on Harold zur Hausen’s remarks at the annual meeting of the Society of Gynecologic Oncology. Having won the 2008 Nobel Prize in Medicine for discovering the link between HPV and cervical cancer, zur Hausen kept the spotlight on cervical cancer when he advocated for HPV vaccination of young females and males in order to “eradicate cervical cancer.” While I advocated for non-sexist HPV vaccination policies back in a 2010 Ms. Magazine article, I was surprised by reports that zur Hausen favored male vaccination: “…if society were to vaccinate just one gender to prevent the spread of cervical-cancer causing HPV, it would be more effective to vaccinate just males.”  I found myself asking two questions: (1) Why base medical recommendations on heterosexist assumptions that girls/women only contract cancer-causing strains of HPV from male partners? (2) Why continue to narrowly focus on HPV as a cause of cervical cancer, when a growing body of research documents its role in a range of genital cancers as well as often fatal oral-throat cancers?

April 2, 2012: The New York Times offers a summary of a study published in the March issue of the British Medical Journal: the findings suggest that HPV vaccination “can significantly cut the likelihood of virus-related disease even among women who have had surgery for cervical cancer caused by HPV.” The strongest prevention effect – 64% reduction in risk – was for women who had the most serious kinds of cervical cancer. The article quotes Dr. Elmar A. Joura, associate professor of gynecology at the Medical University of Vienna: “Regardless of your age or your history, a vaccination can prevent new disease.” Key question not addressed by this article: why does the CDC have an upper-age limit of 26 years old for HPV vaccination? Last year, Canada raised their upper-age limit to 45 – how much longer will ‘older’ Americans have to wait?

April 4, 2012: Forbes article on “The Gardasil Problem” fails to address the full scope of HPV vaccination ‘problems.’ First, the author misleads readers into thinking that HPV-related oral-throat cancers are “a new form” – again, see not only the 2010 Ms. Magazine article but also the Oral Cancer Foundation’s thorough summary of the decades of research linking sexually-transmitted HPV to serious oral cancers.

The author also misstates the focus/bias of Merck’s original years of marketing Gardasil: “When it was introduced in 2006…Merck began an advertising push to raise awareness of the risks of HPV.” What ads did he see? I and other consumers of mainstream media were exposed to a series of commercials that referred to Gardasil as “the cervical cancer vaccine” and strategically obscured message about “HPV-related diseases”, never clarifying for viewers that HPV was, in fact, sexually transmitted.  While I offered a feminist critique of the branding and marketing of Gardasil in my 2008 book and several blog posts – trying to get the public to understand that “You don’t need to have a cervix to benefit from the cervical cancer vaccine” – Merck did not change to a focus on Gardasil as a STD vaccine until it received FDA approval for male vaccination…until profits depended upon bursting the bubble of the mythical cervical cancer vaccine.

Next, the author not only makes a heterosexist assumption but also unnecessarily demonizes oral sex on women as the ‘usual’ mode of transmission: “Usually transmitted when men perform oral sex on women, it can also spread through other forms of contact, perhaps even just kissing.”  If kissing can transmit the virus, the why is he so sure that most of men with HPV-related oral-throat cancers skipped ‘first base’ and went straight to ‘third base’? If, and this is a big ‘if’, clinical studies can verify unprotected oral sex as the primary mode of transmission, then why not offer readers a brief education on the vaccine-free ways to practice safer oral sex? 

Finally, the author unnecessarily dashes readers’ hopes for the near future: “tests that might well prove that [Gardasil] can prevent the new throat cancer strain would take at least 20 years, until the boys sampled actually became sexually active and then contracted the disease.” Why would these tests take 20 years? Does this author think that a boy who is vaccinated at age 12 will not perform oral sex until he’s 20+ years old? Where is the data to show it would take another ten years for HPV-related oral and throat cancers to develop?  In addition, the author fails to point readers towards the likely source of delay: a lack of interest by the makers of the two FDA-approved HPV vaccines.   

A 2010 article in the Journal of the National Cancer Institute not only clarifies the challenges of developing effective screening for oral HPV infections but also reports the truth about Merck’s failure to move forward with testing HPV vaccination as prevention of oral and throat cancers. Maura Gillison, M.D., Ph.D., a leading researcher on HPV-related head and neck cancers at Ohio State University in Columbus, explained why clinical trial plans were derailed in 2010: “We were 6 weeks from enrolling the first patient when I got an e-mail saying it was no longer in the interest of Merck to conduct the trial.” The article also quotes Pam Eisele, a Merck spokeswoman:

“The link between HPV infection and head and neck cancers continues to be an area of scientific interest for Merck; however, we currently do not have any plans to study the potential of Gardasil to prevent HPV-related oropharyngeal cancers. In 2008, we did conduct a small pilot study to assess our ability to obtain adequate and valid oropharyngeal samples. While the results of the pilot study were promising, due to competing research and business priorities we ultimately decided not to move ahead with an efficacy study at this time.”

Why is Forbes not asking for a more complete explanation of those “competing research and business priorities”?  We, the American public, should demand more funding find out how to prevent cancers which research shows to be on the rise and more fatal than cervical cancer in the U.S.

The one section of this Forbes article that some readers might find valuable is its summary of the data on the safety record of HPV vaccination.  However, as I’ve said before, I am not advocating that vaccination is the only way to reduce one’s risk of contracting cancer-causing strains of HPV.  Those who decide not to vaccinate themselves and/or their children need to learn the facts about HPV prevention, testing, diagnosis, and treatment: check out the American Social Health Association’s online HPV and Cervical Cancer Prevention Resource Center.

In honor of April being STD Awareness Month, I devote this month’s column to a topic that remains near and dear to my heart (and my cervix): HPV, human papillomavirus.  So, it’s a great time to get yourself tested at your local STD testing location, or send an e-card to a loved one who could use a friendly reminder:

This month might have inspired some of you to consider vaccines that offer some protection against HPV: like Gardasil or Cervarix.*  However, don’t get too excited about Gardasil if you happen to be 27 years old (or older) and live in the U.S.  Earlier this month, the FDA decided against expanded the vaccine’s label use for ‘older’ women:

…the Limitations of Use and Effectiveness for GARDASIL was updated to state that GARDASIL has not been demonstrated to prevent HPV-related CIN 2/3 or worse in women older than 26 years of age.

However, as of Tuesday, ‘older’ Canadian women now have more options than their U.S. counterparts:

Merck announced that Health Canada has extended the indication of GARDASIL^® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Recombinant Vaccine] in women up to the age of 45. Merck’s HPV vaccine is now approved for girls and women nine through 45 years of age for the prevention of cervical cancer, vulvar and vaginal cancers, precancerous lesions and genital warts caused by the Human Papillomavirus (HPV) types 6, 11, 16, 18.

So, what’s the deal?  According to a Canadian women’s health expert, this is a good decision:

Whatever the reason, there’s a tendency for women to remain at risk of acquiring new HPV infections as they get older. Whether they are changing their social status or not, women should talk to their doctors about the HPV protection provided by the quadrivalent vaccine,” said Dr. Alex Ferenczy, Professor of Pathology and Obstetrics & Gynecology at McGill University.

If I’m correct in inferring that Dr. Ferenczy’s use of the phrase “social status” refers to a woman’s sexual partner/sexual relationship status, then are we to assume that U.S. women between the ages of 27 and 45 are in more stable sexual relationships than their Canadian counterparts?  I’ve yet to read a study that would support this conclusion.

So, as a U.S. woman who happens to be in this age group, I feel it only right to encourage my peers to ask their doctor about Gardasil, especially if they’re “changing their social status.”

For the boys and men out there, remember that the FDA approved Gardasil in October 2009 for protection against two types of HPV which cause genital warts in males ages 9-26.  Then, last December, the FDA approved of GARDASIL for the prevention of anal cancers caused by two different types of HPV in females and males 9-26 years old. 

However, once again, there appears to be possible age-discrimination: men over 26 years old, consider whether Gardasil might offer health benefits for you.

*Note to readers: I respect that many will decide that a vaccine is not right/healthy/safe for themselves or for their family members.  I highlighted the recent news about Gardasil because I believe that everyone deserves access to vaccine updates.  I’ll conclude by quoting myself:

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.

This interview originally appeared in the Ms. Magazine Blog and is re-posted with permission.

In Part I of my interview with Gail Dines, the self-described anti-porn feminist discussed sexual freedom, coercion, safety and harm. Part II continues the conversation. And this time, porn actors respond.

Shira Tarrant: Your new book, PORNLAND: How Porn Has Hijacked our Sexuality (Beacon Press), is out this month. When readers pick up this book, what do you want them to know by the time they put it down?

Gail Dines: I want people to understand that porn is a business with considerable political clout and the capacity to lobby politicians, engage in expensive legal battles and use public relations to influence public debate. Like the tobacco industry, this is not a simple matter of consumer choice; rather, the business is increasingly able to deploy a sophisticated and well-resourced marketing machine, not just to push its wares but also to cast the industry’s image in a positive light.

These are not fun, creative, playful images that feed our sexual imaginations but instead are industrial products that depict a type of sex that is formulaic, generic and plasticized.

ST: I know you’re concerned about harm to women. In Pornland you describe on-the-job injuries sustained by some porn actors–for example, HPV, genital bruising and HIV. All forms of work involve exploitation and risk, whether it’s dying on an oil rig, developing carpal tunnel syndrome or being exposed to asbestos–what makes risks in porn any worse than other workplace dangers?

GD: HPV or genital bruising are generally not listed as job hazards. Women who do porn talk about anal prolapse and surgery [for repair]. The injuries in porn leave long-lasting emotional impacts. The level of abuse and violence to women in porn stands out. There is the psychological trauma of having one’s body treated in this way. It is a very intimate form of abuse. Articles from the porn industry press reveal how difficult and demanding the job is and that women can’t last that long in the industry because of injury.

*****

I asked folks in the porn industry for their responses to Gail Dines’ claim that porn physically traumatizes women. Beth Brigham disagrees. (Brigham was formerly Dines’ research assistant and worked in porn.) She reports:

There’s no emotional trauma from a sex act that you’re prepared for. If you know in advance what you’re going to be doing, you are ready. If I have a day where I’m doing seven penetrations, I know what to do to insure that my body remains healthy. Sex acts don’t happen by accident in porn and you know how to deal with them in advance.

April Flores, a BBW adult actress, adds:

“There is no doubt porn is a very physical job. However, it is also a very individualized profession. Each performer is responsible for their own physical health. A performer always has the choice of not doing something they are not comfortable with. All of my peers are doing work they feel proud of and that enhances and expands on their own sexuality. Gail Dines thinks all performers are victims and this couldn’t be further from the truth.

I also need to point out that many people outside the industry are having rough sex by choice. I’ve heard quite a few stories of people [in the general population] going a little too hard and hurting themselves.

Dines worries about increasing rates of anal sex caused by men who watch gonzo and convince women to bend over–never mind the missing data, non-het sex or women’s sexual agency. It’s unclear that porn is behind this alleged trend, and the tone implies there’s something wrong with human proclivity.

Then there’s the matter of spanking, teasing, topping or switching. Here’s what Dines says:

Pornographers are controlling sexuality. Sexuality is coming out of an industry not imagination. Porn contributes to more BDSM because [it] appeals to bored and desensitized porn users. This isn’t about sex but about corporatizating desire. It’s not an accident that there’s more BDSM activity now.

Again, there’s the question of evidence. And didn’t Dines say that private sex is a personal matter?

By phone, Dines tells me that what people do sexually is none of her business. “I’m not talking about constraining sexuality, but creating sexuality that is based on respect and equality. I’m not against sex,” Dines says. Her concern is about “the business of porn, not the practice of private pleasure.” But perhaps that line is blurry.

To be continued in Part III …

Above image: “Three Nudes and Reclining Man” (1934) by Ernst Kirchner, public domain. From Wikimedia Commons.

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!]

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.