“All Adventurous Women Do”

HBO's GirlsOn the third episode of HBO’s new series, Girls, the protagonist Hannah (played by creator Lena Dunham) is diagnosed with human papilloma virus (HPV). Distraught, she tells her best friend, who replies with the most revolutionary phrase ever uttered on television regarding STI stigma: “All adventurous women do.”

STI stigma is not difficult to understand. Since STIs are sexually transmitted, they’re easy to interpret as punishment for promiscuity. People with STIs are often characterized as slutty, dirty, trashy, or stupid and reckless. And when someone is diagnosed with HPV–no matter how confident she is in her choices, no matter how careful she is–she’s faced with the crushing weight of this stigma. She must try her darndest not to internalize it–not to believe that she is being punished for her sexuality, not to believe that she brought this upon herself, or that this viral infection is indicative of poor moral character. This is extremely difficult because no one has prepared her for this, and she will almost certainly go through it alone.

Since HPV and STIs are treated as a shameful secret, we don’t ever talk about what the process of diagnosis and its aftermath is like, and as a result, we never hear what it was like for someone else. We each have to figure out how to cope on our own, in silence, without the comfort or guidance of those who have been there and can understand. There are no celebrity spokespeople for HPV. No star athlete role models. And so very few narratives in television, film, or literature.

It’s rare to see STIs on television. Rather, it’s rare to see STIs on television outside of medical and crime dramas where STIs are used as a “who done it” plot device to reveal some unexpected twist regarding infidelity or some otherwise inappropriate sexual behavior. It’s rare to see a character simply living with an STI–getting diagnosed, experiencing treatment, navigating relationships, and dealing with shame and stigma in every day life. It’s rare, but it shouldn’t be.

HPV is the most common STI in the United States. The CDC approximates that 20 million Americans currently have HPV, with six million new infections occurring each year. (For reference, 20 million people is roughly the population of Beijing, New York state, and the entire country of Australia.) The CDC estimates that 50% of sexually active Americans (men and women) will contract HPV at some point in their lives, although the American Social Health Association thinks it’s closer to 75-80%. For women, the rates are even higher: the CDC estimates that, by the age of 50, at least 80% of women will have acquired sexually transmitted HPV.

So, if at least 50% of Americans will one day have the experience of being diagnosed with HPV, shouldn’t we be doing something to prepare them for that moment so that the bottom doesn’t drop out from under them? Shouldn’t we let them know that this is a shared experience and that they don’t have to feel so alone? Shouldn’t we be working to combat stigma at the social level so that we can reduce the emotional damage it inflicts?

Writing HPV and other STIs into television narratives is a great way to challenge and combat stigma. Especially when the character is able to make peace with the diagnosis, providing a model for the rest of us.

“All adventurous women do.”

In that one glorious sentence, Girls let us know that HPV is common and that instead of a being a sign of poor character, it’s a mark of an adventurous spirit. This one line erases the stigma and reframes HPV as something normal, even positive. “All adventurous women do” allows Lena Dunham’s character Hannah to own the diagnosis, to embrace it, to wear it as a badge of honor. And it teaches the rest of us–all of us girls who have felt the waves of shame and guilt crashing on top of us, suffocating us–that we are okay. That HPV, much like traveler’s diarrhea, is just another part of the experience of being an adventurous woman in the 21st Century.

We’re coming to vaccinate your children: the moral case for compulsory HPV vaccination

Are there moral grounds for compulsory HPV vaccination? Joseph E. Balog, PhD, MSHYG, certainly thinks so. In an article in the April 2009 issue of the American Journal of Public Health, Balog concludes that compulsory HPV vaccination is not only morally justified, it’s a social justice issue.

Some are opposed to compulsory HPV vaccination because they are concerned that vaccinating teens for an STI could be seen as condoning or encouraging sexual activity, undermining abstinence messages and providing a false sense of security about protection from STIs. The scientific community is also skeptical of compulsory vaccination, arguing that the mortality rates of cervical cancer are too low to be considered an “imminent harm” and that the benefits might not outweigh the financial costs, as well as the costs to individual liberty.

Balog argues the “rightness” or “wrongness” of compulsory HPV vaccination should be determined by key ethical principles: whether vaccination would reduce harm to individuals and society, and whether vaccination would produce benefits that are at least as good as the alternatives for prevention of death and disease.

HPV meets the standards for compulsory vaccination
In addressing the concern that mortality rates of cervical cancer are too low to be considered an “imminent harm,” Balog argues that HPV still meets the precedent set by other diseases for which we mandate vaccination, such as polio and measles.  The risk of a fatal outcome from HPV is relatively low, but it is still comprable to that of polio or measles.  The HPV vaccine fits comfortably within the precedent already set for compulsory vaccination.

Eradicating disease trumps the preservation of social ideas
Balog rightly points out that the conservative folks who oppose HPV vaccination because they believe it might promote sexual behavior are more concerned with upholding moral values than they are with preventing real, physical harm. From a public health perspective, prevention of harm is the first priority, especially considering the fact that the types of prevention offered as alternatives to vaccination (abstinence) have been been studied and proven to be ineffective. As Balog argues, it would be wrong to deny teens a real solution in order to uphold a symbolic ideal.

A child’s human rights override parental rights
The law generally respects and protects parental rights over their children. But when it comes to the health and safety of the child, the state may sometimes step in. When it comes to child vaccinations, the state generally upholds the child’s right to healthcare. Since the health threat of HPV affects the child directly and the parent only indirectly, the right of the child to receive the vaccine outweighs parental autonomy. We don’t often think of it this way, but from Balog’s point of view, access to preventative healthcare, like vaccination, is a human right. Of course, any compulsory vaccination program must follow the legal precedent that includes the right of states to allow individuals with medical, religious, and philosophical objections to opt-out. A compulsory HPV vaccine would, of course, include these exceptions.

Compulsory vaccination is a social justice issue
I’m not sure if you’ve seen the ads for Gardasil (the first HPV vaccine on the market), but they are clearly directed to white, middle class women. The reality is, however, that there are huge racial and economic inequalities in rates of cervical cancer and cervical cancer screenings. In the US, incidence of cervical cancer is 50% higher among African American women and 66% higher in Latina women than in white women. While they have the greatest risk, these groups are the least likely to receive cervical cancer screenings (PAP smears) and are also the least likely to get vaccinated. A voluntary vaccination program does not guarantee universal access; the vaccine is prohibitively expensive without health insurance coverage. Public health professionals understand that mandates are not only the most effective way to ensure that the disadvantaged women have access to the vaccine, but also the most effective means of protecting these women from cervical cancer.

Just like children faced the threat of polio in the 1950s, our adolescents are in need of protection against HPV and the array of cancers it can cause. Withholding that protection is unethical, and supporting abstinence as an alternative is both unrealistic and ineffective. But making the HPV vaccine available on a voluntary basis is not enough. It is only with a compulsory vaccination program that all adolescents, regardless of their parent’s values, race, socio-economic background or insurance status, will have real access to the vaccine. Then, and only then, will cervical cancer prevention reach the groups that really need it.