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.