The HPV Vaccine

Sixteen year-old Alaina Reyes sits on the gynecologist's exam table under a poster of girls with different body types that reads, "What's normal supposed to look like anyway?" Accompanied by her mother, Christine, Alaina is here for her first visit with Dr. Dianne Foley, an adolescent gynecologist, as she transitions from pediatric care.

"I don't know how much you've heard about this, but there's a new vaccine available for teens that immunizes against the human papillomavirus, HPV," Dr. Foley tells Alaina. "HPV is a sexually transmitted disease that causes cervical cancer." When Alaina communicates she's chosen to remain abstinent until marriage, Dr. Foley replies, "HPV isn't as big a concern for you as for someone who's had multiple sexual partners. That's where we see the highest risk."

However, Dr. Foley tells Alaina that even though she doesn't fit this risk category, one argument for getting the vaccine is the unknown of her future spouse's sexual choices. It's possible to get HPV from only one sexual partner if that partner was infected through previous sexual activity. Another potential risk is sexual assault.

Many Christian women and their daughters, like Christine and Alaina, are trying to make an informed decision about this controversial new vaccine. Here are some important facts and issues worth considering.

The Virus and the Vaccine

HPV is the most common sexually transmitted infection in the U.S. According to the Centers for Disease Control and Prevention, some 6.2 million people are infected each year, and at any given time about 20 million people have it. It's now known to cause almost 100 percent of cervical cancer, although most HPV infections clear up on their own before becoming precancerous. Ten thousand women get cervical cancer and 3,700 die from it each year, according to the National Cancer Institute. Currently there's no test to determine if men have HPV.

Gardasil, the HPV vaccine, is a three-shot immunization given over six months. It protects against four strains of HPV that cause 70 percent of all cervical cancers and 90 percent of all genital warts. To be fully effective, Gardasil needs to be administered at least seven months before a girl becomes sexually active. The Advisory Council for Immunization Practices (ACIP), the group that advises the CDC on immunization practices primarily for physicians and health departments, universally recommends the vaccine for 11- and 12-year-olds and has approved it for ages 9-26. This is our first vaccine for a cancer.

Research continues on its efficacy and whether a booster will be needed, but for the five years studies have been conducted, the vaccine remained effective for up to four and a half years. The FDA, which says it's safe, continues to monitor safety and effectiveness. However, some people are concerned about the usage of such a new vaccine.

Mixed Messages?

Many conservatives worry that giving our daughters the vaccine undermines abstinence teaching. They feel it could encourage promiscuity by disinhibiting them from having sex. Lots of teens aren't having sex, they say, so why indi cate we think they will by giving them the vaccine? This argument is similar to that used against school-based sex education programs and condom distribution.

In addition, many people fear vaccination could give girls a false sense of security. Gardasil doesn't protect against the remaining 30 percent of HPV strains, other sexually transmitted infections, or the emotional and spiritual consequences of premarital sex. This is Dr. Foley's biggest concern, which she makes clear to her clinical patients and those in her public-school abstinence program. However, she still supports the vaccine. "To me, the vaccine and abstinence go hand in hand," she says.

Is it possible to promote the vaccine without sabotaging chastity? That all depends on how the message is presented. According to Dr. Reginald Finger, a Christian physician who served on the ACIP, "If we say or imply that they're getting it now because they could become sexually active at any time or because half their friends are having sex, then that could undermine the teaching of abstinence." Instead, he recommends emphasizing long-term protection "and hopefully lifelong protection from risks that could be encountered in young adulthood, in marriage, and from a potential sexual assault."

As to disinhibition, something the CDC measures, Dr. Finger says it's not a major factor in this debate "because very few teenagers will make a sexual decision based in any way on HPV."

The Mandate Controversy

The vaccine started as a voluntary immunization, but many state legislatures are debating bills to mandate it, adding it to the immunizations required for school and daycare entrance. The debate centers around ensuring girls' public health, its cost effectiveness, and individual and parental choice in healthcare.

Most Christian organizations are adamantly opposed to mandates, since unlike viruses such as measles, there are other ways to prevent HPV (such as abstinence). If mandated, most states allow parents to opt out by applying for an exemption, varying by state, for medical, religious, or philosophical rea sons. Others argue that without a mandate, too few people will opt in and less privileged girls who might need protection most may not be served.

That's because each dose retails for $120, making the full series of shots $360 (sometimes more with practitioner overhead). Lack of insurance, private money, or public health department funding might keep those who need the vaccine or want it from getting it. This is a key argument for many who support mandates. However, others oppose the mandates but wrestle with how that squares with the biblical directive to care for the poor.

Merck—Gardasil's manufacturer —and the Vaccines for Children Program offer applications for free vaccines. And in developing countries, where cervical cancer rates are much higher than in the U.S., efforts are underway to introduce and fund the vaccine at much lower costs.

Parental Consent

What if an underage daughter wants the vaccine but her mom doesn't want her to get it? What if the daughter goes to a physician alone? As it stands now, parents still have the say for their underage daughters. However, some want to abandon the parental consent requirement for the HPV vaccine so teens who confide in their healthcare provider that they plan to become sexually active can get HPV protection. Many Christians strongly support continued parental consent requirements.

Due to these sorts of ethical concerns, many people think Christians are anti-vaccine. On the contrary, many Christian organizations issued policy statements supporting it—with caveats. Dr. Finger sums up this position: "that the HPV vaccine is a good thing, that we believe it does not replace the abstinence message, that we believe it's a matter of individual choice, but that it should be universally recommended in the appropriate age groups so long as that recommendation doesn't translate into a legal mandate."

Different Conclusions

In Dr. Foley's exam room, Alaina and Christine ask questions about the vaccine. "Since Alaina's decided not to become sexually active, would it harm her to wait until she thinks about getting married? I mean, you don't have to have it at this age, right?" Christine asks.

"No, you don't," Dr. Foley replies. She tells Christine and Alaina the young age recommendations are to ensure it's in a girl's system before she becomes sexually active and is potentially exposed to HPV.

Christine asks Alaina if she has any more questions, then says, "I think once she decides to get married, if her future spouse isn't a virgin, that's the time to talk about things like this." Alaina agrees.

Dr. Foley says she'd never fault someone who vetoes the vaccine because of her trust in her child's lifestyle choices, but she adds, "Given the number of circumstances we cannot control in our children's lives, I think the vaccine is a good idea." Some choose to vaccinate, even if their child has pledged chastity until marriage and monogamy afterwards, because of what they can't guarantee:

• That their child won't be forced into a sexual situation.

• That their child's marriage will be lifelong and mutually monogamous.

• That their daughter won't be sexually active.

Eva Marie Everson, coauthor of Sex, Lies, and High School, says for kids who make mistakes, passion trumps planning. "Most Christian teenagers who are sworn to purity but who wind up having sex don't make that decision before they leave the house. They make that decision on the spur of the moment."

Everson adds, "This isn't something you want to be wrong about."

Julie Lippert, a mother of two college-age sons and a 16-year-old daughter, opted to have her daughter, Millie, get the vaccine. She explains, "I was diagnosed with breast cancer and underwent many surgeries, and Millie lived through that with me. I don't think she had any qualms about having a vaccine that can prevent one type of female cancer."

Even though the vaccine is intended to be given before sexual activity of any kind occurs, women 26 and younger who have had previous partners, and even those who test positive for HPV, still can get the vaccine and receive benefit. They simply won't receive full immunity from the four strains the vaccine protects against. And what about a twentysomething married woman who's a virgin when she marries but her husband had even one previous partner? Dr. Foley says, "I'd suggest she get vaccinated." If the vaccine is approved for ages above 26 (it's currently being tested for that demographic), women who marry later in life may find themselves considering whether to vaccinate for some of the same reasons it's recommended for younger women and girls now.

An Open Door

Whether we chose to vaccinate or not, this issue can inspire important communication with our daughters. "This provides you with the perfect opportunity to talk about all the aspects of sexual purity with your teenagers," Dr. Foley says.

Dr. Foley cites a study where kids said those who held the most influence over their decisions about sexual health are their parents. Eighty percent of these children said it would be easier to make healthy choices about sex if they could have an open conversation about it with their parents. We need to tell them if they enter marriage without genital contact with anyone (not just intercourse), they won't get HPV. We can discuss STDs, how to set boundaries, and the physical, mental, emotional, and spiritual aspects of sexual activity. We can use this medical news to tell them why we want them to remain chaste until marriage—and faithful afterwards.

Christian women can come to differing yet God-honoring conclusions about this vaccine with thoughtful consideration, research, conversations with one's physician, and prayer.

Lindsey O'Connor is a freelance journalist, former anchor for USA Radio Network News, and author of If Mama Goes South, We're All Going With Her (Revell).

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