A committee from the Centers for Disease Control and Prevention recently made headlines by recommending human papillomavirus (HPV) vaccinations for boys and young men. Previously, vaccination, which also protects women from cervical and other cancers, was recommended for girls only. I commend the committee’s decision: Vaccination can all but eliminate HPV-related cancers. Almost all instances of anal cancer are caused by HPV, which is sexually transmitted. HPV also causes many oral and other so-called head and neck cancers.
HPV is a gay men’s health issue. Anal cancer affects about two in 100,000 people in the U.S., but the rate of anal cancer among gay and bisexual men is as much as 44 times higher. Although vaccination is an important step, this recommendation is not enough. Prejudice and stigma continue to hinder an adequate public health response to HPV. As with HIV/AIDS, for HPV and anal cancer silence equals death.
Even though the HPV vaccine, called Gardasil or Silgard, was approved and recommended for use in girls since 2006, it has been hard to get girls vaccinated. The exchange about HPV in a recent debate among Republican presidential contenders sheds light on Americans’ reluctance: As former senator Rick Santorum charged, “this disease is spread through sexual contact... unless 11- and 12-year-olds in the state of Texas are somehow encouraged to participate in that activity, this is not something that the state or federal government should be doing.” The argument is that vaccinating girls encourages them to engage in sex. This is a ludicrous suggestion because Gardasil protects against infection at any time over a lifetime — it is not specific to sex in youth. Other arguments — concerning the safety of the vaccine, for example — have been repudiated repeatedly by medical authorities.
If it has been so hard to get girls vaccinated, for fear of encouraging heterosexual sex, it is no surprise that public health authorities in the U.S. have been reluctant to recommend HPV vaccination to protect boys who, when they become sexually active, may engage in same-sex anal sex.
Moralistic attitudes are perhaps not the only reason for the five-year delay in recommending HPV vaccination for boys. Other reasons included the claim that there was insufficient research evidence on the effect of the vaccine in boys. But the very same evidence that had been available to American authorities in 2006 led the European Union authorities to recommend vaccination to all — girls and boys. I have no doubt that discomfort with sexuality in general, and homophobia in particular, have played a key role.
The new recommendations for HPV vaccine — if they would be taken up at all — would help the next generations of gay men, but the vaccine will not help today’s gay and bisexual men. To be maximally effective, the vaccine needs to be taken at an early age, before initiation of any sexual activity (age 9 is recommended). For most gay and bisexual men, national guidelines for early detection through screening, and treatment of pre-cancerous cells, are necessary.
Screening and early detection of cervical cancer — through Pap smear and later HPV typing — is responsible for it being one of the most treatable cancers. Similarly, early detection and treatment of HPV-related morbidities could significantly reduce the incidence and increase survival of anal cancer in gay and bisexual men. The necessary technologies are available now — Pap smear was first described in the late 1920s — but they have not been implemented in gay and bisexual men nationally. Both physicians and gay or bisexual men lack knowledge about HPV screening and early detection. It is likely that most physicians would not know, nor have the capacity, to treat HPV-related pre-cancerous conditions even if detected.
The barriers of social stigma and widespread lack of awareness are significant, but not insurmountable. As with HIV/AIDS, effectively combating HPV and anal cancer will require the LGBT community, public health officials, and medical providers to work together. And as with HIV/AIDS, the LGBT community cannot afford to wait for a comprehensive public health response to come from others. It must take the lead to create one now.
Dr. Ilan H. Meyer is a senior scholar for public policy at The Williams Institute, UCLA School of Law.
For more information on gay men's health issues, visit the Gay & Lesbian Medical Association's online resource, Ten Things Gay Men Should Discuss with Their Healthcare Provider.