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Thursday, March 08, 2007

Another question about HPV Vaccines: Are they only for girls?

The recent proposals in several states to mandate the newly-approved HPV vaccine for 11- and 12-year-old girls have garnered no shortage of controversy, and might have partly inspired this very interesting recent post by Glenn Cohen. Just last month, Governor Rick Perry of Texas surprised us all by issuing an executive order mandating that all girls entering the sixth grade beginning in September 2008 receive an HPV vaccine. And Merck, the manufacturer of the HPV vaccine Gardasil, recently agreed to stop lobbying for mandatory vaccination requirements in the states, in light of the perception that it was perhaps too soon to be mandating this still relatively untested, not to mention controversial, drug.

Most of the controversy has been swirling around whether the drug, which is aimed at two strains of the human papilloma virus (HPV) that are sexually transmitted, will encourage promiscuity among the teenage girls who receive it (Hepatitis B vaccination is also mandatory in many states, and that, too, is sexually transmitted, but it is also transmitted in other ways.) Some amount of controversy has centered on whether the vaccine is truly safe, whether we have enough information yet about long-term risks, and whether parents should ever be forced to vaccinate their children (some of which arise every time a new vaccine is introduced).

Yet, very little has been said about the fact that the proposed measures uniformly target only girls.

The rationale for this is presumably that only girls and women are capable of getting cervical cancer, the most serious condition caused by HPV, as well as that Merck has so far obtained approval of the drug only for women and girls. Yet, while the data are somewhat uncertain on its usefulness for boys, there might be some benefit for boys receiving the vaccine as well – such as protection against genital warts and penile and anal cancer. These latter two conditions are admittedly extremely rare, but cervical cancer is also rare (though much less so). In addition, it stands to reason that immunizing boys who can carry and transmit the HPV virus will further protect girls against HPV and cervical cancer, because it will increase the “herd immunity” effects of mandatory vaccination. If only girls are required to be vaccinated, it is likely that a larger percentage of those girls will nonetheless get the virus, as reported by a recent London Times article, which said that, according to one study, if boys are vaccinated “more than 90 per cent of cases of the disease caused by the four commonest strains of human papilloma virus (HPV) could be eliminated, instead of just over three quarters if only girls were vaccinated.” (Note: The study assumed that only 70% of girls would be vaccinated.) A similar argument was made here. (Thanks to the Reproductive Rights Prof Blog for the informative posts on this.) Of course, even if all girls are required to be vaccinated, some will not be, due to their own or their parents’ noncompliance, or due to religious or conscientious or health exemptions; in addition, for some subset of those who are vaccinated, the vaccine will not be effective. This is why it makes sense to require boys to be vaccinated as well.

So, I’m wondering whether there are any legal (constitutional, Title IX, etc.) implications to vaccinating only girls. It seems to me that there are, but I have heard so little on this issue that it makes me think I am missing something. Laws that would require only girls to be vaccinated would be gender discriminatory on their face; is this discrimination justified simply by the fact that the drug is only approved for girls at present? Or by the fact that girls are most likely to suffer the most serious consequences about HPV? And if the latter, don’t we at least have a narrow tailoring problem, since the law would be even more protective of girls if it required boys to be vaccinated as well, assuming the vaccine would not be harmful and would probably be beneficial to those boys as well?

Posted by Jessie Hill on March 8, 2007 at 11:43 AM | Permalink


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