The debate over plans to vaccinate girls and young women against the common sexually transmitted disease HPV has, to date, focused on the ability of such a plan to prevent cervical cancer and on the wisdom of investing in a $400-a-dose vaccine with no proven track record.
But now a new issue has arisen to further enliven debate among supporters and detractors alike: Why not boys?
"If the vaccine is being given to young women, then it should be given to young men," said Gail Beck, president of the Federation of Medical Women of Canada.
The group supports a universal vaccine program but wants it to be truly universal, not gender specific.
Of course, men cannot get cervical cancer, but they do, the same as women, get infected in large numbers by human papillomavirus, and pass it on to their sexual partners. HPV can also cause penile, anal and throat and mouth cancers in men.
The argument, put simply, is that HPV is a sexually transmitted disease and, as the expression goes, it takes two to tango.
Yet, when Health Canada approved Gardasil, the vaccine's brand name, in July, 2006, it did so only for use in girls and women aged 9 to 26. And the National Advisory Committee on Immunization is, so far, recommending the vaccine's use only in females. (It should be noted, though, that despite the recommendations, doctors can prescribe the vaccine "off-label" to men, and many gay men have opted to be vaccinated.)
However, the recommendations target only younger females because, to date, they have been the focus of clinical trials. The vaccine prompts an immune response in boys as well as girls, but tests to see whether it was effective in preventing disease were conducted only on young women.
Michael Fung Kee Fung, director of the gynecological oncology program at the University of Ottawa, said decisions on whom to vaccinate should be guided by research findings, not wishful thinking.
"This can't be done based on the perception of gender equality. It needs to be driven by science."
Science does indeed offer a cautionary tale. Attempts to develop a vaccine for genital herpes have shown a lot of promise in women and utter failure in men, and the gender difference is difficult to explain.
On the other hand, for years, vaccination for rubella (German measles) targeted only girls and pregnant women because they had much higher rates of the disease, and suffered more harm. But rubella was brought under control only after boys were immunized, too.
In an editorial, the British medical journal The Lancet used the example to argue that HPV vaccination should not be restricted to girls.
"For effective and long-term eradication of HPV, all adolescents must be immunized," the journal maintained.
At least two countries, Australia and Austria, have opted to vaccinate both girls and boys.
In Canada, the federal government announced last week that it would provide funding of $300-million to the provinces for the HPV vaccine, but it is up to individual provinces to decide how they will proceed.
Regardless of what approach governments adopt, vaccination needs to be accompanied by an education campaign, and that campaign should target boys in addition to girls, said Michel Roy, a professor of gynecology at Laval University in Quebec City.
"Women know about HPV, but men do not," he said. "Men, young men, need to be educated about their role in spreading cervical cancer."
Linda Capperauld, executive director of the Canadian Federation for Sexual Health, agreed. While stressing that the group does not have a position on Gardasil, aside from its general view that safe, effective prevention measures should be widely available, she noted that, for too long, boys and men have not taken adequate responsibility for the spread of infections such as HPV.
"When it comes to birth control, prevention of sexually transmitted infections and sexual health in general, all the responsibility seems to fall to girls and women," Ms. Capperauld said. "Boys and men have to do their part."
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