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HPV Immunization and Risky Personal Choices:

I've heard some argue that HPV is different, and a less proper candidate for a government-mandated (or even government-strongly-pressured) immunization, because HPV is acquired through risky, and usually personally chosen, behavior. This, though, strikes me as mistaken.

Though having multiple sexual partners increases one's risk of getting HPV, all it takes is one sexual partner. Nearly every woman will have sex at some point in her life. Even if she is a virgin bride, she can get HPV from her husband on her wedding night. True, if she marries a virgin, and her husband never cheats on her, then she's not at risk (setting aside the possibility of rape). But even the most moral behavior on her part, under any definition of morality short of lifelong abstinence from sex (including marital sex), won't protect her. The vaccine, on the other hand, likely will protect her.

There's also a very different kind of risky behavior argument: I'm told that regular pap smears, and the medical procedures used when the pap smears show a dangerous result, are very reliable in preventing even HPV-infected women (about 50% of the population, I have read) from developing cervical cancer. In a sense, then, actually getting cervical cancer may be said to be the woman's "fault" not because of her sexual behavior but because of her medical laxness. (That sounds harsh, but I take it that we do say that in some measure, though not without sympathy, in other contexts: If someone dies of untreated pneumonia -- consider, for instance, Jim Henson -- we might think that this death was in some measure his fault.)

Yet that seems to me to be a not very good argument against immunization. Many women don't get pap smears because they're fairly poor. Even those that could easily get them but don't seem to deserve some protection. And even for those who get them and thus don't get cervical cancer, the treatment used to avoid death from cervical cancer is expensive, unpleasant, and emotionally distressing -- and it can lead to infertility.

Of course, all this then raises the broader libertarian objection: Why should some people be forced to be immunized (assuming the Texas law mandated immunization, which this one seems not to, given its broad exemption for parents with conscientious or religious objections) in order to protect others? I'll turn to that in the next post.

JB:
Can't it be passed in childbirth? So two virgins, one of whose parents was a carrier, could both become infected.
2.5.2007 6:52pm
Zoe1 (mail):
Your post seems to assume that HPV is sexually transmitted in the sense of tranmsitted through sexual intercourse. My understanding is that it is easily transmitted through any skin-to-vagina contact as well, whether by mouth or finger or something else. Further, my understanding is that something like 90% of adult women in the U.S. have HPV. (Although that may be the number that has had it at some point; I understand the immune system often clears it up over time.)
2.5.2007 6:54pm
Eugene Volokh (www):
The CDC reports that "At least 50% of sexually active people will get HPV at some time in their lives."
2.5.2007 7:00pm
e:
Remember too that these vaccines protect against the 2-4 of many strains of HPV which are the primary cause of cervical cancer.
2.5.2007 7:26pm
Eugene Volokh (www):
JB: Such transmission is possible, but my sense was that it's not clear how frequent it is, so I didn't want to rely on it.
2.5.2007 8:01pm
Respondent (mail):
Marital sex provides almost no risk of the disease, if both partners never have sex with a non-spouse. In the next post's example, Betty almost surely would not have gotten HPV from Alan if Alan hadn't had sex before, so while Betty's virginity alone won't protect her and Denise, if all four kept to a strict rule of no sex outside of marriage, all of them would be safe (assuming no rapes, et al.)
2.5.2007 9:25pm
BobNSF (mail):

Marital sex provides almost no risk of the disease, if both partners never have sex with a non-spouse.


Never have AND never had. And that includes contact less "involved" than intercourse. Not a large number of marriages, I would guess.
2.5.2007 9:46pm
Norseman:
I guess I see this argument in a similar vein to the Massachusetts mandatory seatbelt law debates of the 1990s. Libertarian objections to these mandatory "do good" laws can generally take pretty good pot shots at the gov't supposed cost benefit analysis. HPV and related cervical cancers don't kill as many people as obesity. Obesity has externalities - my taxes, medicare, medicaid, other insurance, etc. is far higher as a result of obesity of others.

I'm not convinced cervical cancer is more " expensive, unpleasant, and emotionally distressing -- and it can lead to infertility" than CHF, diabetes or a host of other problems caused by obesity. Fight that battle before trying to convince me of a libertarian argument for HPV. Otherwise, I'm not convinced this isn't just rent seeking by pharmaceuticals supported by a group of "public" health experts who have a certain slant on sex that is not shared by a significant percentage of the population.
2.5.2007 9:58pm
Laurie Lynn:
So, all girls should get the vaccine because some women won't go get their annual pap smear?

Also, why do you assume that people won't choose to get the vaccine for their daughters if they are not mandated?

The chicken pox vaccine was not mandated for our school, and yet most of the parents I know choose to immunize their children anyway (including me)

Most parents do act in the best interest of their children. We are ultimately more concerned for our childrens' welfare than the state.
2.5.2007 11:37pm
Elliot123 (mail):
Norseman,

This may very well be rent seeking. So what? The medicine and immunity remain the same regardless of motivation.

We don't need a slant on sex; all we have to do is read the stats on how many folks have engaged in intercourse with more than one partner. Then figure the percentage of virgins that marry virgins.
2.6.2007 12:14am
guest1:
I asked this in a previous post, but this might be the better thread to put the question out there:

If the vaccine has only been tested on 9-26-year-olds, and presumably has a "100% success rate" (even if that's true), does this mean it protects 9-26-year-olds at 100% but then leaves those 27 and older with a new risk?

How long is this vaccine good for? If a 9-year-old gets it, will the protection wear off by the time she's 14 or 15?

And, just out of curiosity, aren't there laws against 9-year-olds having sex???
2.6.2007 12:20am
Eugene Volokh (www):
Respondent: Actually, marital sex provides almost no risk of the disease under your model, if both partners never have sex with a non-spouse and never remarry after divorce or death of the other partner. So, yes, if you're willing not to have sex until marriage; and you're willing to reject the love of your life on the grounds that he or she has had sex with someone beforehand (even if he's now repented and your religion urges you to forgive people's transgressions); and your spouse never cheats on you; and if, when your spouse leaves you or dies, you never remarry someone who has been married before (unless you can be sure that he or she married a virgin who was always faithful) -- then you can be sure that you won't acquire HPV except through rape or transmission at birth.
2.6.2007 2:07am
Lev:

Yet that seems to me to be a not very good argument against immunization. Many women don't get pap smears because they're fairly poor.


And these women who will not get the pap smear because they are too poor will ante up the $360 for the Gardisal three shot series?

Perhaps the state should also mandate annual pap smears.
2.6.2007 3:26am
plunge (mail):
"Many women don't get pap smears because they're fairly poor."

They CHOOSE to be poor, remember.
2.6.2007 9:44am
Respondent (mail):
Eugene,
In your "repentance" example, I assume most religions that require forgiveness would still allow an insistence on the part of the virgin that the non-virgin get tested for any and all STD's. As far as second marriages are concerned, as you noted in parentheses, my model would permit someone to marry a person who married as a virgin, to a virgin, when you can be sure that both of them were faithful. I happen to know a number of divorced people whom I have no doubt fit that description. It all depends on one's social upbringing and religious outlook. In quite a number of non-Catholic Christian denominations, and in many Orthodox Jewish circles, the risk is next to nothing that a person whose very cursory backround check reveals nothing out of the ordinary had sex that put him or her at risk for HPV. I'm sure that there are many other communities that I don;t know of in which the membership overwhelmingly adheres to the precepts it is taught.
2.6.2007 10:00am
Gary McGath (www):
The methods of disease transmission which you describe all require a positive action. It doesn't matter that it's a very common one; no one is going to catch HPV just from being around other people.

If there is a justification for compulsory vaccination at all, it is that a person who has a disease may cause others to be involuntarily infected. The only way a person can involuntarily infect others with HPV is by sexual assault, and there are already laws against that.

An action does not become involuntary through being common.
2.6.2007 10:19am
MDJD2B (mail):
Prof. Volokk,

Cervical cancer is the tip of the iceberg. In the United States, the majority of women have clinical manifesttions of HPV at some point in their lives. This usually is manifest by an asymptomatic pre-cancerous condition detected by abnormal Pap smear. The diagnosis is confirmed by biopsy (a somewhat painful and stressful procedure). Millions of these are done in the US each year.

Those women whose lesions are relatively advanced, or whose mild lesions do not regress require a LEEP or cold knife cone biopsy. These are minor operations usually done under anesthesia. They require a few days off work and several weeks of sexual abstinence following the procedure. Perhaps 5% of reproductive age women who have these done have fertility problems afterwards.

On the other hand, the Merck vaccine only is effective agianst strains accounting for 70% of cervical cancer. It is said that another company is working an a vaccine that immunizes against additional strains.

Finally, the Merck vaccine immunizes against the two strains of HPV that, while not associated with cancer, produce all genital warts. This provides a rationale for immunizing males. Oncogenic strains of HPV are associated with penile cancer, which is extremely rare. They are also associated with anal cance. This is an uncommon cancer with virus transmission probably being through homosexual sexual activity most of the time. But significant numbers of men get genital warts.

I hope this helps.
2.6.2007 10:42am
markm (mail):

It all depends on one's social upbringing and religious outlook. In quite a number of non-Catholic Christian denominations, and in many Orthodox Jewish circles, the risk is next to nothing that a person whose very cursory backround check reveals nothing out of the ordinary had sex that put him or her at risk for HPV.

My gut reaction to that is, "Boy are you naive." In my experience, there are American subcultures where promiscuity before marriage is admittedly common and adultery is admittedly not rare, and there are American subcultures where lying about these matters is endemic. If a married couple tells me that neither has ever had sex with anyone else, I think it's probable that at least one of them is lying. You also have to consider that some activities that Baptists like Bill Clinton, among others, don't consider to be "sex" will still spread HPV.
2.6.2007 12:53pm
Respondent (mail):
Naive? Not in the slightest. Sure there are plenty of "American subcultures where lying about those matters is endemic", but I've seen quite a few where the rules are actually adhered to by almost everyone. There are many factors that determine what percentage of the poulation adheres to these rules, but one thing that all abiding communities seem to have in common is a moral-centric focus on life, where a member spends much of his time talking about religious or moral values. I know hundreds of married couples whom, while I can't swear on any particular one that both spouses have never had non marital sex, I can be sure that 98% of them fit that description. When you consider for example, that many Orthodox Jews won't even shake hands with the opposite sex because it involves touching an opposite-sex member, it's not difficult to understand why there is almost none of these concerns in many of there communities. In sum, I think there are plenty of subcultures out there whose members do overwhelmingly adhere to bans on non-marital sexual contact, and would never dream of allowing anyone other than a spouse or doctor to make contact with there genitals. I suspect that ther are many Muslim communities with almost universal adherence as well, but I don't have enough knowledege of them to be absolutely certain.
2.6.2007 1:17pm
Elliot Reed:
I know hundreds of married couples whom, while I can't swear on any particular one that both spouses have never had non marital sex, I can be sure that 98% of them fit that description.
How do you know? Have you asked them?
2.6.2007 2:27pm
Eugene Volokh (www):
Lev: No, the poor women might be unable to get the immunizations, either (though it may be that free immunizations are more broadly available than free annual pap smears). But that's the point: Some women will remain unimmunized, because they're poor, recent immigrants, too old, and so on. Other women who refuse to get immunized, and therefore get and transmit HPV, might unwittingly put those women's lives in jeopardy.

So that's an argument for the propriety of mandating immunization: If you can afford immunization, you should get immunized, to prevent harm to others (harm that might be avoided if all the others were immunized or got regular pap smears, but in fact not all the others are immunized and get regular pap smears).
2.6.2007 2:28pm
Respondent (mail):
Elliot:
I know the social climate in which they live very well. If any one of those people received as little as a small affectionate tap by a member of the opposite sex (other than by a spouse or close relative), he or she would be horrified. And yes, this includes an affectionate tap by a fiancé. Trust me, I'm not kidding.
2.6.2007 6:22pm
Seamus (mail):
I guess I see this argument in a similar vein to the Massachusetts mandatory seatbelt law debates of the 1990s.

Given the issue of cost, I'd say the more appropriate analogy is the debate in the 70s and 80s about requiring that all cars be equipped with front-seat airbags, because of the assumption that people couldn't be trusted to use seat belts regularly.
2.7.2007 10:32am