A century after syphilis first appeared in London, William Shakespeare knew the risk of trusting your sexual partner. Neither abstinence nor the marriage bed was a space safe from such diseases. Honesty, as Shakespeare observes in As You Like It, is rarely found in human sexual relations:

�As horns are odious, they are necessary. It is said, �many a man knows no end of his goods:� right; many a man has good horns, and knows no end of them. Well, that is the dowry of his wife; 'tis none of his own getting. Horns? Even so. Poor men alone? No, no; the noblest deer hath them as huge as the rascal. Is the single man therefore blessed? No: as a walled town is more worthier than a village, so is the forehead of a married man more honourable than the bare brow of a bachelor; and by how much defence is better than no skill, by so much is a horn more precious than to want.�
(As You Like It, act III, scene iii)

Trust not even the marriage bed, Shakespeare knows, if your health and honour are at stake. His was the first age of sexually transmitted diseases (STDs) in Europe. His work is full of references to the symptoms (in Othello), treatments (Measure for Measure), and implications of the �infinite malady� (Timon of Athens). In As You Like It the �sad� Jacques, with his melancholic disposition and prior life as a rake, most probably is meant to suffer from syphilis. Shakespeare and his world knew all too well that trusting your lover or even believing in abstinence, so contaminated in his post-Reformation world by its association with the Roman clergy, was often a fatal decision. Even with this admonition, trust and abstinence became an oft-repeated prophylactic for syphilis in the 19th century and then, in the late 20th century, for HIV/AIDS, advocated by public health authorities as well as the clergy.

When Merck in November, 2004, announced that a vaccine called Gardasil helped prevent certain strains of human papillomavirus (HPV) infection, the response was quick. Ironically, given the strong association between HPV and the genital lesions that lead to cervical cancer, the response was not all positive. Some stated publicly that such a vaccine was really just a means of shielding women from the results of their promiscuous sexual activity before marriage. With nearly a third of women in the USA aged 18�22 years testing positive for HPV 1 year after becoming sexually active with only one male partner, some religious groups still opposed broad-scale vaccination believing that vaccinating prepubescent girls would encourage sexual activity by reducing risk. �Abstinence is the best way to prevent HPV�, stated Bridget Maher of the Family Research Council, a leading Christian lobby group. Initially, the campaign broadened to one against the very idea of vaccination, as an intrusion of the government into the rights of parents. Segments of the population saw vaccination in general not only as a government plot in what was a moral crusade, but also an intervention that resulted in unforeseen medical disasters, such as the discredited belief that an increase in rates of autism was the result of the measles, mumps, and rubella vaccine. That such a claim was repeatedly proven to be false lent little comfort to those who were convinced of the causal relation between vaccination and negative outcomes.

To offset this opposition, when the vaccine was approved for general use by the US Food and Drug Administration (FDA) in the spring of 2006, it was marketed in the USA and UK media as a �cancer vaccine� with little or no mention of sexual transmission of the virus in advertisements. Yet the attacks on the vaccine on the grounds of encouraging immoral behaviour in young women continued. In February, 2007, the Republican Governor of Texas, Rick Perry, mandated the vaccine in his state. Opposition was swift. He argued that �The HPV vaccine does not promote sex, it protects women's health. In the past, young women who have abstained from sex until marriage have contracted HPV from their husbands and faced the difficult task of defeating cervical cancer. This vaccine prevents that from happening� (The New York Times, Feb 3, 2007). Governor Perry noted that even faithful, monogamous women can get infected. The Texas State Legislature, however, seemed to disagree with Governor Perry, opposing in March, 2007, the use of the vaccine based on the rights of parents to control the health of their children, since the vaccine was recommended to girls as young as 11 years old. Indeed, in Canada, at least in Newfoundland and Labrador, female grade 6 pupils receive the vaccine free at school-based clinics. In the autumn of 2008, Gardasil was further approved by the FDA to protect against cancers of the vagina and vulva. The focus was only on young women, seen as vulnerable or seen as endangered.

Opponents of the vaccine argued vehemently that the only protection against HPV infection for young women was abstinence before marriage. The old claim about abstinence or the marriage bed as the sole protection against STDs, already ironically dismissed by Shakespeare in the 16th century, became the anti-vaccination groups' answer as the way to assuredly prevent HPV. Yet, some research has shown that many adolescents who have taken a �virginity pledge� have gone on to contract HPV at similar or slightly higher rates than those who did not. Like the Women's Christian Temperance Union pledge not to drink alcohol adopted in 1894, �True-Love-Waits� and other such programmes that promote abstinence and the marriage bed only provide a public acknowledgment of a specific definition of immoral behaviour. Like prohibition, the result has been catastrophic: adolescents who took the pledge were likely to engage in unprotected oral and anal sex. They came to see this sexual behaviour as not �real� (ie, genital) sex. Thus, they have contracted HPV, chlamydia, gonorrhoea, and trichomoniasis at the same rate as �non-pledgers�. The assumption is that not being �real� sex these adolescents did not use condoms or oral dams. Those so infected may also be more likely to go untreated. As the British Royal Commission Report on Venereal Disease stated in 1916, the �fear of disgrace and the consequent desire for concealment� was one of the foremost dangers attendant to the diseases. It still is. And the consequences remain devastating.

In the general American population the fear of cancer seems to have trumped the debate about chastity or vaccination among young women. As of October, 2008, 25�1% of the teen girls involved in a recent CDC survey had received at least one dose of Gardasil. It seems that the idea of a �cancer� vaccine has taken hold to protect what is often described as a �vulnerable� population, despite the protests of those who oppose vaccination or premarital sex. This extraordinary success has meant that Gardasil, the only cervical cancer vaccine on the market, has made US$1�5 billion in sales since 2006. Other �anti-cancer� vaccines, such as Cervarix, manufactured by GlaxoSmithKline, will only be marketed later this year.

Now who is affected by HPV? The population targeted by Gardasil was and remains young women and the outcry about abstinence or the marriage bed was in response to �protecting� this population. The two most carcinogenic types of HPV, HPV16 and HPV18, are associated with about 70% of cervical cancers. In the USA during 2006, there were about 10 000 new cases of cervical cancer and 3710 deaths from the disease. But it is also the case that in the population that has HPV infections about one in 400 deliveries result in the infection being spread to the newborn baby who can develop recurrent respiratory papillomatosis; there are about 2000 new cases of recurrent respiratory papillomatosis a year in the USA. So the HPV vaccine also prevents damage to children born to women who may have no idea that they are infected with the virus or that they are placing their child at risk of life-long, chronic illness. Women and children are thus traditionally seen as the most vulnerable populations. In this model men are assumed to be the source of infection not its victim.

But even Shakespeare knew that everyone was at risk from STDs. It turns out that men too are a vulnerable population at risk from the deadly results of HPV infections. Recently, the steep increase in oral cancers among men has been traced to an increase in HPV infections stemming from the increased practice of oral sex; from 1973 to 2004 oral cancers associated with HPV infections became about as common as those from tobacco and alcohol. Perhaps we should begin advocating Gardasil for young men who are also at risk from catastrophic illnesses resulting from HPV infection? �Abstinence only� is in reality a danger to everyone�men, women, and their children�since the violation of the marriage bed is too common and the claims of individual abstinence are too fraught with ambiguity.

There are also social costs to the claims about abstinence. Treatments for oral and cervical cancer as well as recurrent respiratory papillomatosis drive health-care costs higher in an age when the judicious application of public health measures could reduce these costs as well as ameliorate human suffering. It seems self-evident that our public health structures should be keyed to the prevention of illness and death. If we cannot protect our population by setting realistic policy concerning all infectious diseases we are all at risk. It is not that children are �more innocent� than adults, but that assuming abstinence will eliminate the risk for HPV infections of all types is more than foolish. It is dangerous and destructive to trust the consistency of human actions. Even in those who are abstinent.

Brian, I couldn't agree more with this. In December, 2004, I was diagnosed with SCC, BOT. I was 62. My wife, who I later discovered had HPV, was 35. After six months at Methodist Hospital in Houston (37 rounds of radiation, Cisplatin, 5Fu, etc.) I came home. The four years since have been plagued with fatigue, lack of energy, depression and anger. My wife divorced me in November, 2007 (I suspect she felt some guilt).
I have always believed in the old axiom, "an ounce of prevention is worth a pound of cure". The state of medical care in this country is abysmal. Insurance companies control the care that one receives, and they will gladly avoid paying a few hundred dollars for Gardisil even though potential cancer treatments for an individual may cost hundreds of thousands of dollars (obviously they are betting on the patients demise). I was fortunate to have excellent insurance and can't imagine what it is like for someone that has none.
Anyway, thanks again for OCF for the information it provides, the community it sponsors and the hope that it gives all of us.
Harry

Brian,

As everyone one knows I have been the most outspoken person on this site about HPV and Gardasil and it still is an uphill battle preaching to the wall. HPV awareness has come a long way in the last 3 years but it still has a long way to go.

Good Post.

As a species, we have not come very far since the 17th century, have we?
Wishful thinking is alive an well despite all the facts to the contrary.
..... I will not even start with recent AIDS/Africa atrocity .....


M

I find the discussion at most of the symposiums I attend that involve the public or members of conservative groups, rather depressing. Of course many of these people have no direct personal contact with any disease, but they are absolutely sure that the adoption of conservative behaviors, prohibition in tobacco, drugs, and more, or abstinence and maintenance of virginity in diseases that have a sexual connection is the path of the righteous, and ultimately the healthy. Prohibition has never worked, our war on drugs is an utter failure but we still pursue it, and as a species we still look for simplistic solutions to complex problems. Sexuality is a biological imperative, and not to be changed, dictated behaviors will never be complied with, and in the end education - which the previous 8 years of our government's policy just about wiped out in this arena - has had overwhelming negative impact. It seems less easy it is to understand a subject, the more it has to be a moral issue. Part of my world of dealing with oral cancer and its paradigm in the US is dealing with all this. Logic does not work, science does not suffice, and in the end I have concluded that policy will not save people from ignorance. It's a sad conclusion to come to.

I probably have more in common with Markus than meets the eye. While I spend everyday, all day and evening working on oral cancer issues, my experience and thoughts venture to other human failings too much. His mention of the AIDS/Africa fiasco tells me this.

My Vietnam experience taught me much about human beings. I will not detail any of it here, but suffice it to say that I have a pretty intimate understanding of the horrors that one human can inflict upon another, having been on both sides of that equation. Besides Uncle Sam's guided tour of Southeast Asia, I have spent part of my life in some other third world human disasters, mostly man made, such as the killing fields of Cambodia, and a few years ago a visit to Rwanda. I actually remember Beirut when it was as modern and cosmopolitan as Paris. I have seen it since. Rubble, hate, poverty, ignorance, prejudice, have replaced an environment that once embraced the arts, education, extraordinary food, and intellectual pursuit. The commonality in all this is a pursuit of absolutes.

Ignorance, prejudice, xenophobia, religious absolutes, the list of human failings is far too long to catalog. The human suffering as a result is beyond cataloguing. I often think that by wrapping myself in one problem to the exclusion of all others, that I might find solace in science, and progress tilting against a windmill of my own choosing. But in the end it is not possible. The more things change the more they stay the same. Indeed we have not come far from the 17th century. Hell, make that the 13th century and the age of darkness.

But if there is a life saved, a burden lifted, a glimmer of progress, then there is always hope.

When I testified before the Florida House in favor of a Gardasil vaccination Bill that would have allowed free shots to those that couldn't afford them; was to be covered by all insurance carriers in Florida and was to be given to all girls entering the 6th grade UNLESS THEIR PARENTS SAID NO WITHOUT HAVING TO STATE A REASON (Opt Out feature added the night before the vote), I was appalled to call myself a Republican as the vote went 100% along party lines with every Democrat voting in favor of it and every Republican voting with the Republican Speaker voting against it. The bill was defeated because the Republicans held the majority. The same conservation comments were advanced by the Speaker even though other STD bills had passed years before mandating, without an Opt Out feature, shots for Hep before attendance to Fl public schools is allowed. BTW not one person spoke in objection to the Bill and 12 of us spoke in favor of it including the American Cancer Society; a past President of the Florida GYN Society and the Chairman of the Florida Dept of Health. Give me a break.

One of my graduate students and I conducted a study on college women's attitudes toward getting the Gardasil vaccine (just before it came out) and their intentions to do so and reasons why and why not. Many who did not plan to get it believed they would have just one sexual partner and marry that person. All the points made above point to the fallacy of that approach as a protection against HPV. First, intentions do not perfectly predict behavior, next, if you are a virgin (and many are "technical" virgins only) and your partner is not, you need to factor in the sexual histories of your partner's partners and all of his/her partners which could exponentially increase your partner's and hence your exposure to dozens or hundreds of people rather than to one), most experts do not believe that condoms protect (or completely protect) against transmission of HPV and modes of transmission have been debated on this board and elsewhere, and of course the age-old issue of fidelity.

[quote=davidcpa]When I testified before the Florida House in favor of a Gardasil vaccination Bill that would have allowed free shots to those that couldn't afford them; was to be covered by all insurance carriers in Florida and was to be given to all girls entering the 6th grade UNLESS THEIR PARENTS SAID NO WITHOUT HAVING TO STATE A REASON (Opt Out feature added the night before the vote), I was appalled to call myself a Republican as the vote went 100% along party lines with every Democrat voting in favor of it and every Republican voting with the Republican Speaker voting against it. The bill was defeated because the Republicans held the majority. The same conservation comments were advanced by the Speaker even though other STD bills had passed years before mandating, without an Opt Out feature, shots for Hep before attendance to Fl public schools is allowed. BTW not one person spoke in objection to the Bill and 12 of us spoke in favor of it including the American Cancer Society; a past President of the Florida GYN Society and the Chairman of the Florida Dept of Health. Give me a break. [/quote]

Politicians apparently don�t know squat about science and apparently are proud of it. I am not a hard core liberal by any stretch of the imagination, but this extremist attitude really gets me going. If you are even a teensy little bit into reason and rationality, then you are likely to wince every time you open a newspaper, surf the web or watch television. I try to prepare myself for the usual denial mixed with narrow-minded statements that proliferate the media. There is absolutely no excuse for this level of ignorance by prominent elected officials. It is of course natural to disagree on political issues; it is even ok to be skeptical of a scientific consensus on the basis of one�s own honest understanding of the situation, the Republican Party has become guilty of flagrant unethical and willful ignorance not just on this issue but many others as well.

/Stepping off soapbox

Thank you all for your enlightened perspectives. We are small voices in a large concert hall, but yours will help us to be heard.

Marlene