In the wake of a United States decision, Western governments are approving use of Gardasil — a vaccine against some strains of the human papillomavirus (HPV) leading to cancer of the cervix — for girls as young as nine, to the consternation of many parents. The ethical problem is that HPV is a sexually transmitted infection, and vaccinating pre-adolescents against it looks like a vote of no confidence in young people — or even an invitation to them to experiment with sex.
MercatorNet asked London GP Trevor Stammers — a tireless advocate of abstinence education for young people — for a factual and ethical perspective on the new vaccine. Dr Stammers is senior tutor at St George’s Hospital Medical School, a writer and broadcaster on sexual health. He is the author of Saving Sex: Answers to Teenagers’ Questions About Sex and Relationships.
MercatorNet: First of all, can we establish the facts? Gardasil is touted in news bulletins as "a cure for cervical cancer" and "100 per cent effective". What can we actually expect from this vaccine in terms of cancer prevention? Will current screening programmes remain necessary?
Dr Stammers: So far, and the passage of time may alter this, we know the vaccine is 100 per cent effective in preventing cancerous changes in the cervix developing from the specific strains of HPV that the vaccine targets, that is, strains 16 and 18. The other two strains Gardasil targets give rise to warts, not cancer. Approximately 70 per cent of cancer of the cervix is caused by these two viruses, so at best, prevention will be 70 per cent. This means current screening programmes will need to remain in place indefinitely. The London Times was in error in its famous headline proclaiming the end of screening. It is so easy for hype to take over in the field of new treatments.
MercatorNet: Current approaches seem to be doing a good job of preventing deaths from cervical cancer. In the USA numbers have been dropping for decades and are now only about 1 per cent of cancer deaths among women. Why is a vaccine so important for this disease? Is it more of an issue for developing countries?
Dr Stammers: Yes, in part. Cervical cancer is a major cause of death in women worldwide with over 450,000 new cases each year and tens of thousands of deaths — 80 per cent of them in developing countries where there is no screening. So this vaccine could save the lives of many women. But, of course, it is expensive so how much will reach the third world is very debatable. If we have not cracked malaria and leprosy worldwide with cures known for decades, what hope for this?
As for the developed countries, there are about 1000 deaths each year from cervical cancer in the UK, and about 3700 in the USA. These deaths, though comparatively few, are certainly worth preventing, and if you have lost a loved one from the disease or know someone who has, who could argue against that?
MercatorNet: This vaccine can prevent only a few among more than 20 STIs, and, while its life-saving property might compensate for some of the emotional damage of sexual promiscuity, it can’t prevent the moral harm at all. It could, however, give people a false sense of security about their sexual behaviour and make everything worse. What do you think?
Dr Stammers: In talking about the ethical issues raised by the vaccine let’s be clear first that prevention of a deadly disease is a good thing in itself, no matter how people got the disease. You only have to think of a vaccine for HIV/AIDS to see this.
Secondly, not everyone who contracts cervical cancer does so through her own fault, so to speak. There are women who are raped, women who do not know their husband has had lots of sexual partners, women who know their husband is unfaithful (and this applies particularly in non-Western cultures) but are powerless to do anything about it. Shouldn’t we be offering these women protection against cervical cancer? And if them, why not all women?
Having said that, it is certainly true that if we do nothing but promote prevention and cures for the consequences of sexual promiscuity, things will get worse. Those who have sex with even one partner, let alone more than one, whose sexual history they do not know are still at considerable risk of acquiring an infection even if using condoms and even if they are vaccinated.
There are many unhelpful pressures on young people to engage in premature sex and it would be tragic if the introduction of this vaccine simply added to that pressure. For this reason we must redouble our efforts to get the "saved sex" message to the young.
MercatorNet: Moral objections to the vaccine would not be so strong if it weren’t for the fact that it is recommended for girls as young as 9. This seems to confront conscientious parents with a dilemma: they can eliminate the possibility that their daughter might one day get cervical cancer and even die from it, but only at the risk of undermining all their efforts to teach chastity — "We are not totally confident that you can do this." Is this a real dilemma, for doctors as well, in your view?
Dr Stammers: Oh yes, and the promoters are aware of this but some of them do have real difficulty in seeing it as an ethical issue. They say it is no different from the rubella vaccination – the intention is to prevent future harm, not to encourage current promiscuity. The optimal age for giving the vaccine is before puberty, they say, in order to promote the best immune response. However, since the research that shows it is 100 per cent effective was carried out with older women, I don’t see quite how this holds water.
MercatorNet: There is talk of mandatory vaccination at some point — is there an ethical case for this?
Dr Stammers: No-one is considering, at present, compulsory vaccination, but in the United States I gather that school places are only given to those vaccinated for other diseases and a similar thing could happen with this vaccine. I can see no ethical case for this kind of pressure, however, and parental consent should be as essential for this vaccine as for any other given in childhood.
MercatorNet: Boys and men also contract HPV. Are any STIs implicated in male cancers? Should boys be vaccinated?
Dr Stammers: Yes indeed they should. HPV is implicated in anal and penile cancer to name just two, and anal cancer has a higher incidence in men who have sex with men, than cervical cancer has in women. Gardasil will also reduce the chances of genital warts in both sexes (but not its competitor vaccine from Glaxo). If vaccination is introduced at whatever age I would say that to give it to girls only would be sex discrimination of the most perverse kind.
MercatorNet: Professor Ian Frazer, who developed the vaccine, has suggested that moral objections might be overcome "if we remove the idea that it’s to do with sexually transmitted infection". Is that a good idea?
Dr Stammers: No. We should tell the whole truth about a disease, especially when it is one, like cervical cancer, that can be prevented by behavioural change.
MercatorNet: The British and other governments are constantly pouring money into "prevention" of pregnancies and STIs among young people, with little or nothing to show for it — except in the USA where the federal government has thrown its weight behind abstinence education. When are we likely to see some real prevention programmes like this in the UK?
Dr Stammers: I and others have testified to government committees and MPS of all political persuasions on the effectiveness of abstinence education but there is no public money for such programmes here, presumably because they believe there are no votes in this issue. However, charities such as Love for Life, Challenge Teams UK, Lovewise, Evaluate, Esteem and Romance Academy are spreading the message and the response is very good. Young people here, as in America or Uganda, are perfectly able to appreciate the wisdom of saving sex for marriage.
Carolyn Moynihan is Deputy Editor of MercatorNet.