National Partnership for Women & Families

Monthly Women's Health Research Review

Editorial calls for addressing the 'feminization' of HPV

Summary of: "The feminization of HPV: Reversing gender bias in human papillomavirus vaccine policy," Daley et al., American Journal of Public Health, June 2016.

The recent introduction of an improved human papilloma virus (HPV) vaccine "affords the opportunity to undo an unintentional gender bias that has harmed US vaccine efforts," according to Ellen Daley of the University of South Florida's Department of Community and Family Health and colleagues.

Compared with the older vaccine, which prevents HPV types 6, 11, 16 and 18, the latest HPV vaccine "protects against five additional oncogenic HPV types," the authors explained.

The authors noted that HPV's "causal association with cervical cancer" meant that the "original vaccine trials focused on females, and consequently, the vaccine was approved for females aged nine to 26." While the authors said the approach "was perfectly reasonable, given what was known at the time," it "also fit within an existing cultural narrative that HPV was a woman's problem." The authors stated that they "have come to refer to this overidentification of HPV with females, and its subsequent impact on primary prevention efforts as the 'feminization of HPV.'"

According to the authors, "The feminization process was, in some sense, the result of an accidental synergy between the known science and our long history of sexism." They wrote, "The decision to license the vaccine only for females was a 'perfect storm' of science, politics, economics, and socially constructed beliefs regarding gender roles." However, citing a "forthcoming shift from the quadrivalent to the nonavalent [HPV] vaccine," the authors wrote that "new approaches could correct gender disparities in vaccine delivery." In turn, the authors "call for a three-part strategy to address the feminization of HPV, which [they] hope will foster equity in the prevention of HPV-related diseases."

"HPV is not gender-specific," the authors wrote. They touched on the role of sexual transmission in the feminization of HPV, noting that before "the approval of the HPV vaccine, the association of HPV with females has contributed to a reduction in morbidity and mortality, largely because of achievements in the Papanicolau test screening." However, according to the researchers, "the conflation of HPV and female cancers has limited the discussion of the prevention of other HPV-related cancers, such as anal and oropharyngeal cancers, which do not benefit from routine screenings."

Further, the researchers noted that the "delay in the scientific evidence connecting males, cancer, and HPV resulted in both the postponement of HPV vaccine recommendations for males and in separate guidelines." Citing the "confusing [HPV vaccination] recommendations by gender and age," the authors pointed to the "markedly lower uptake" of the HPV vaccine among males than among females. For instance, the vaccination rate in 2014 among 13- to 17-year-olds was about 60 percent among females compared with only 42 percent of males, the authors wrote. "The rates are much lower among the 'catch-up vaccine groups,'" the researchers continued, noting that the rate in 2012 was 34 percent among females ages 18 to 26 and only 5.5 percent among males in 2011-2012.

According to the researchers, "The deeper concern is that the feminization of HPV results in males not benefiting from this vaccine." The researchers noted that "initial vaccine discussions" suggesting that "having adequate HPV vaccination rates among females would ultimately protect males ... have been plagued by low vaccine rates among females in the United States, as well as heteronormative conventions."

They continued, "Indeed, the initial licensure of the vaccine for females only actually created a gender-biased, cost-effectiveness question that has not been asked for any other vaccine. That is, the question gets framed as, 'is it cost-effective to add male vaccination to existing female vaccination?,' rather than, 'is it cost-effective to vaccinate both males and females compared to not vaccinating anyone?'" Citing the "lag between female and male licensure," the researchers wrote that "current cost-effectiveness evaluations for males continue to create an unequal approach to vaccine policy."

Moreover, the authors noted that "males tend to receive fewer recommendations for the HPV vaccine from health care providers." They explained that this discrepancy "is especially worrisome in the United States, which does not routinely vaccinate via a school-based system, making health care provider recommendations critical." In turn, "[t]he resulting low uptake of the HPV vaccine among males ... has resulted in significant HPV vaccine benefit differentials," the authors wrote. They stated, "Consequently, females historically bear the burden for prevention of HPV, while males fail to perceive the risk and obtain the protection they need."

Three-step plan to address feminization of HPV

Citing the "disappointingly slow progress of HPV vaccine rates" among men and women, the researchers outline a three-step plan "[t]o achieve gender balance for the HPV vaccine and reverse the consequences of feminizing HPV."

First, the authors suggest "the creation of identical age and gender guidelines for the vaccine," which would "remove much of the misperception about who will receive the vaccine and at what age." They acknowledged the difficulty of implementing this step, but noted, "We would argue that the failure to harmonize gender recommendations and the resulting confusion constitute unrecognized costs from the resulting undervaccination."

Secondly, the researchers recommend "[c]reating a new national dialogue" around the vaccine "that dispels myths and supports an environment of vaccine acceptance." They wrote, "This requires the collaboration of social, political, professional, and scholarly stakeholders to speak in one voice to create clear and simple messages to promote the vaccine for both males and females."

Third, the researchers noted that "the most effective approach to neutralizing the feminization of the HPV vaccine is to require middle-school entry vaccination for boys and girls," which "will normalize the HPV vaccine." The researchers contended, "The reality is that if the vaccine is not required, it will not be perceived as necessary." To ensure the vaccine is required, and to sidestep possible backlash, the researchers advised the creation of "a state-by-state 'policy window'" that "requires the recognition of HPV and HPV-related cancer prevention as a public health priority." Calling for a partnership between policymakers and providers, the authors wrote, "Policymakers must overcome barriers to universal vaccination, such as HPV's connection to sexuality and the antivaccination movement, by mobilizing HPV vaccine proponents and communicating evidence-informed messages."

Noting that there has been "nearly a decade of strong evidence of safety and efficacy" of the HPV vaccine, the authors noted, "now is the time to frame the vaccine in a different light, to fashion new dialogues about protecting all of our children and young adults equally, to create consistent recommendations for both males and females by both age and by routine or catch-up indications, and to enact new polices that require the vaccine to be part of school entry."