The rabbit hole to HPV

Anytime a Catholic or pro-life website posts something regarding medicine, I take a deep breath and brace for the worst. Why? Despite our brilliant history of “fides et ratio”, there’s nothing like the intersection of medical science and human sexuality to send Catholics into a tizzy. We wind up going down a rabbit hole, furiously digging to uncover some nefarious, anti-life plot, seeing its specter at every turn. So, I was not surprised (though incredibly disappointed) to see the National Catholic Register link to what could only be charitably described as a pablum of unmitigated, anti-vaccine misinformation regarding Gardasil, the vaccine for human papillomavirus (HPV).

NCR-Gardasil

I think it’s time for us— Catholic to Catholic— to have an honest conversation about this vaccine. It’s time for us to be honest about our biases that are putting far too many of us on the same side as people who deny that germs cause disease, that are putting far too many of us on the wrong side of reality.

To be clear, my intention here is to offer perspective and facts, not to condemn our credulity on these matters. And I do say “our” credulity because I was an HPV vaccine refuser, too. By the time I had my “conversion”, which I wrote about for Voices for Vaccines, I was aged out of being vaccinated. Looking back, I couldn’t see that my refusal was based primarily on irrational, misplaced fears and pride because it had been dressed up with the veneer of objective reason and “science.”

Let’s scrape off that veneer and see the rot that lies beneath, starting with the misinformation perpetuated in that awful anti-Gardasil post.

Many people, including Ms. Wills, take refuge in what I dub the Pap Panacea Fallacy. The argument goes that even if the vaccine were safe and effective, even if they accept that people can acquire HPV through no fault of their own (such as from assault or a spouse), the girls can still get their routine pap test. No need for a vaccination, right? Unfortunately, we really need to think about the limitations and implications of this so-called “alternative.”

The first problem is one of pap limitations. Persistent HPV infection can cause more than just cervical cancer. HPV is also responsible for types of vaginal, vulvar, penile, anal, and oropharyngeal (throat) cancers, yet the pap test can only potentially detect abnormal or cancerous cervical cells (thus, completely ignoring the threat HPV presents to our sons). Yes, I did say “potentially.” Like all tests, the pap smear has a false-negative rate, meaning we expect some tests to say that women are fine when, in fact, they have abnormal cells. This rate is often cited around 10-20%, and if a woman is deemed low-risk, she could be laboring under this delusion for 3 to 5 years until her next pap. And, like all cancers, cervical cancer can metastasize, spreading to the pelvic area or lymph nodes.

Even if the pap does successfully detect abnormal or cancerous cells, there’s still a problem: You have to treat them. The treatments for an abnormal pap range from the uncomfortable to the catastrophic. Consider the very common LEEP procedure, where “portions of your cervix are removed with a burning electric wire under local anesthetic, and the foul smoking remains of your cells are sucked up into the smoke shark…. After LEEP, side effects may include infection, hemorrhage and possibly cervical incompetence.”

A picture is worth a thousand (very, very disquieting) words.
A picture is worth a thousand (very, very disquieting) words.

If the woman is pregnant at the time, the risk of cervical incompetence brings an additional threat to her unborn child, as it is a significant cause of second-trimester miscarriage and preterm birth. If such procedures do not work, to save her life, the woman may require a hysterectomy. For many women who want to bear more children, this is an incredibly painful prospect, but when “you are reduced to death from cancer or losing your womb… most women choose to live and suffer the emotional pain.” Are we really so heartless as to think this kind of suffering would not be “worth it” to prevent?

“It’s not until your little girl sits in your lap later and asks you, ‘But, Mommy, why don’t I have brothers or sisters?’ that’s when it really kind of sinks into you.”
“It’s not until your little girl sits in your lap later and asks you, ‘But, Mommy, why don’t I have brothers or sisters?’ that’s when it really kind of sinks into you.”

The next barrier to HPV vaccination seems to be the Nirvana Fallacy, the idea that because the HPV vaccine is not sheer perfection, it is worthless. You will see this a lot when people say that Gardasil “only” protects against 4 strains—6, 11, 16, 18— of HPV. Why even bother? What good is protection from only four of about 100 strains? A lot of good, actually. Serotypes 16 and 18 are responsible for 70% of cervical cancers. Serotypes 6 and 11 cause 90% of genital warts. How much higher do these numbers need to be than the 0% protection afforded by eschewing vaccination to be worthwhile?

But even if we can acknowledge the vaccine would be worthwhile, we arrive at the bubble-of-myths, where half-truths and misinformation just bounce back and forth between people in the bubble, protected from the outside world of reality. Here you’ll see a lot of “scary” misinformation, a lot of “experts” who shine up that veneer of scientific credibility with the average layman never realizing that they are the darlings of the anti-vaccine movement, not because they have credibility and evidence, but because they further anti-vaccine mythology.

“The HPV vaccine is too new.”

While HPV vaccination is definitely newer than, say, polio vaccination, it is not that new. Research into vaccine development began in the early 1990s and human trials in the early 2000s. I know. I’m one of those people who tend to think that 1990 was ten years ago, not twenty-four (!), so it’s hard to recognize how much time has passed. Gardasil was licensed, meaning it passed through the pre-licensure phases of testing, in 2006, over eight years ago. For comparison, the very profitable and infamous Vioxx drug was licensed in 1999 and withdrawn in 2004. In just over five years, the fraud and (statistically low but catastrophic) risks were exposed and “Big Pharma” was riddled with federal charges and class action lawsuits. Why would Gardasil be exempt from such scrutiny for years longer?

“The HPV vaccine is understudied, ineffective, and unsafe”

The HPV vaccine continues to be very well studied for post-licensure safety and effectiveness (remember, we have over 8 years of data). Yet despite demonstrating in large studies that the vaccine has reduced HPV prevalence and the risk of cervical lesions, the vaccine continues to be disparaged. And despite Ms. Wills extensively quoting Dr. Diane Harper, Harper’s own work shows the “Gardasil only lasts 5 years” trope to be patently false, even if one ignores the evidence that the vaccine lasts a minimum of 8 years with sustained antibody response indicating that it will prove to be far longer.

And what of the safety studies? Does the HPV vaccine cause blood clots? No. Guillan-Barré syndrome? No. Problems with fertility, such as ovarian failure? No. So how is it that so many people believe that “evidence” says otherwise? Here is where our biases can give too much power to the unsubstantiated anecdote.

There is an adage in medicine that says ”when you hear hoofbeats behind you, think horses, not zebras.” But when it comes to stories about alleged vaccine injuries from Gardasil, we’re suddenly on African safari. Ms. Wills opened her piece with an anecdote about the tragic death of Meredith Prohaska, a preteen who died within six hours of receiving her HPV vaccination. In the anti-Gardasil narrative, nothing was different except the shot, but reality tells a different tale. Meredith went to the doctor because of a sore throat (not a “slight cough” as Ms. Wills editorialized). Suppose she had a strep infection. While very rare, the complications of strep do include life-threatening conditions such as toxic shock syndrome. Additionally, her rapid decline, but not so rapid as to make anaphylaxis the likely culprit, coupled with her reported malaise, excessive drowsiness, and vomiting is a red flag for possible septicemia or meningitis. Having recently had her lip pierced without her parents’ knowledge (making it less likely to have been done safely) would put her at increased risk. But without any corroborating evidence, Ms. Wills like so many others sees a zebra, a Gardasil-induced death, and jumps on the post-hoc-ergo-propter-hoc train to warn Christendom. And you will find that with so many Gardasil horror stories, the cycle of missing information, more probable causes, more plausible causes are completely ignored by those who are “sure it was the vaccine.”

I am sure that Ms. Wills, like other men and women of goodwill who reject HPV vaccination, truly believes that the “evidence” of Gardasil vaccine injuries and deaths supports her position. But this “evidence” rests significantly on a fundamental misrepresentation of VAERS, the vaccine adverse event reporting system. Put simply, VAERS is a collection of unsubstantiated anecdotes. The system helps detect unexpected adverse events, which can then be evaluated to see whether they were coincidental or causal. Anyone can report anything; you can even report that a vaccine turned you into the Incredible Hulk. (I’ve contemplated submitting that Tdap turned me into a newt, but I got better.) While Ms. Wills pays lip-service to the limitations of VAERS, she continues on as if these unsubstantiated reports by themselves mean anything. They don’t, especially in the face of overwhelming evidence that deaths are not associated with the 67 million doses of Gardasil distributed thus far.

But it’s not just the brigade of ardent anti-vaccinationists who jump on anti-Gardasil anecdotes and misinformation. Sadly, Catholics and pro-lifers are the often the originators of the misinformation! Consider the case of alleged Gardasil-induced ovarian failure that quickly spread through Catholic/pro-life media like a plague. Despite the fact that the girl didn’t experience the cessation of menses until a year after her last Gardasil dose, despite the fact that premature ovarian failure has a quantifiable background incidence and the cause is unknown in up to 90% of those cases, the reporting doctor placed the blame squarely on Gardasil. Who was this doctor? A member of the board of advisors for Family Life International, an Australian Catholic pro-life organization.

Family Life International (FLI) makes some very dishonest and illegitimate claims when discussing Gardasil, such as fabricating a quote from the National Cancer Institute (NCI) that “direct causation has not been demonstrated” between HPV and cancer. To the contrary, NCI proudly states, “Researchers supported by the National Cancer Institute (NCI) helped establish that human papilloma virus (HPV) is a major cause of cervical cancer, carried out studies to determine how HPV causes cancer, and developed the technology used to create the first HPV vaccines.” FLI unscrupulously voices support for the anti-vaccine propaganda film, “The Greater Good”. They quote the Orwellian-named National Vaccine Information Center. They perpetuate unsubstantiated fear-mongering by misusing the VAERS system. They have not updated any of their outdated or incorrect information, but instead promote it years later.

And why would a Catholic organization (and the dozens of others who can be relied on to swiftly regurgitate the same misinformation) have so little regard for the truth? The clue lies in FLI’s own words. Human papillomavirus is, according to them, “often associated with promiscuity.” And… here we are again. The intersection of science and sex. The rabbit hole of nonsense. Honestly, I wish we could just stop talking about sex. Multiple studies have shown that HPV vaccination has no bearing on the sexual behavior of young people. (It still baffles me how it could with herpes, HIV, and antibiotic resistant gonorrhea out there.) I wish we could change the paradigm to what it ought to be: prevention of a potentially devastating, epidemic virus that can cause cancer with a safe, effective vaccine. But since we can’t seem to separate the conversation of one without the other, here’s what I know.

Deep down, if we’re honest with ourselves, a lot of us fear that our position is too weak. The rational, moral argument for the Catholic understanding of human sexuality is not enough. The separation from God by sin is not enough. No, there must be terrible, material consequences for straying from virtue. Therefore, if something might lessen the probability of the sinner experiencing those consequences— even something as morally licit as a vaccination— there must be some terrible physical risk with it such that no one with full knowledge would take the chance. We couldn’t really be expected to make a convincing moral argument without some physical detriment to scare people—even our own children— back to virtue, right?

John 8:11
John 8:11

But this is not our faith. This is not the religion of the cross. The entire premise of Christianity is that we are all sinners who, thanks be to God, do not get what we deserve. “Neither do I condemn you; go, and do not sin again.” I don’t think that Christ would addend that to say, “but if you contract some debilitating or deadly consequence from your past sin, you totally deserved it and should be made an example so no other women follow your ungodly ways.” I’m pretty sure on both fronts, letting the woman be stoned to death would have been a lot more effective.

Here are some other things I know. I know that being an intelligent, physically capable, devoted Catholic trained from age eleven on “how guys think” did not give me the clairvoyance to foresee that I would have my hands pinned behind my back and forced over a table while a man simulated sex with me as a “joke.” (So, if you are laboring under the delusion that your child could never be the victim of unwanted physical contact, STOP.) I know that it doesn’t take promiscuity to contract HPV; in the time it takes to kiss or say, “wait, wait, this is going too far” the disease can spread. I know that many of the most faithful, active Catholics I am privileged to know have a “past.” I know that my children are not boxes of Shake’N Bake—passive, under my control— where all I have to do is add the right “ingredients” and shake for things to turn out right. I know that they are people who will need to freely and perpetually respond to grace, and they will sometimes fail. And I know that it is no place for my pride to place presumptions on my children.

For me, I refuse to condemn my son, daughter, and (by God’s providence) future children to the possibility of acquiring a preventable infection of human papillomavirus. Even if they were to acquire it through sin, even if they were to acquire it by their own volition, I want to be able to turn to them as my Savior turns to me. For any pain they experience in their lives, my hope is that they only will ever need to turn to the Divine Physician for healing. I feel no need to add a preventable detour to a medical physician along the way.


Update: The medical examiner in the case of Meredith Prohaska has issued a statement that Prohaska died of diphenhydramine intoxication, an antihistamine used in several over-the-counter cold and allergy products.

Please remember Meredith Prohaska and her family in your prayers.

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14 thoughts on “The rabbit hole to HPV

  1. Thank you for the very educational article. I do have a question about the effectiveness lasting eight years. What triggers the immune system reaction? If I get the vaccine for my eleven year old and it wears off in eight years…..shouldn’t I wait?

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    • No — the reason it is recommended so early is so that children can get the vaccine before they are potentially exposed to HPV. At 19, there is a very good chance they’ve been exposed to it already, thus rendering the vaccine useless.

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    • Another thing to consider is that the completion of the series takes 6 months, so your child won’t be considered among the 99+% of adolescents who’ve responded to the vaccine until they are at least 7 months older (assuming you can schedule it right on time.)

      I, personally, am uncomfortable with the idea of sending out a 13-year-old unprotected when, for instance, “[only] a few studies have looked at how people get oral HPV, and some of these studies show conflicting results. Some studies suggest that oral HPV may be passed on during… open-mouthed (“French”) kissing, others have not. The likelihood of getting HPV from kissing or having oral sex with someone who has HPV is not known.” (http://www.cdc.gov/std/hpv/stdfact-hpvandoropharyngealcancer.htm) What preteen/early teen girl hasn’t day dreamed of kissing her crush while doodling her “married name” where she should have been taking algebra notes? I can’t take much comfort in “statistically low/unknown” that this could be a child’s first exposure to HPV.

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    • The length of effectiveness of 8 years is the *minimum* length of time immunity has been shown to last, and that is only because that is as long as the vaccine has been widely used. The immunity at 8 years is still extremely high, so we can assume that it persists much longer. I will look for the article I just read about this–it may have been Dr. Offit’s recent piece?– but because of the high rate of antibodies at 8 years and the fact that this vaccine is made similarly to the hep b vaccine which has been studied long-term, it is very likely that the hpv vaccine is effective for at least 30 years.

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  2. Thank you! I was unsure about the vaccine, but this helps put it into the appropriate (science-based) light. I was unaware of all the other ways of contracting hpv, so I thought a vaccine was at best, a guard against the low-risk of involuntary exposure (rape) or at worst, the green-light for promiscuous behavior (and at such young ages!). I think we need more attention drawn to the innocent ways of contracting it (birth canal, diaper changes, etc) so we stop thinking of HPV as strictly a ‘sexual’ STI/STD. I think it’s that term that throws people off.

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  3. how interesting and thought provoking (I am neither Catholic nor Christian, and am a big believer in vaccination). I was especially delighted in explaining how you view your decision in light of your faith. Thank you so much for sharing.

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  4. Thank you for this! I love it. Though I’m not Catholic, much of my family is, and I am so grateful that they are also Rational Catholics. 😀 Mind you, in the Protestant circles that I’m involved with, there is a great deal of Not-Rational going on too, especially with regard to this vaccine.

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  5. Thank you for this! My goddaughter/niece is only three years old now, so I’d appreciate an update on this story in 7 or 8 years, please! 🙂 I intend to be the “cool” aunt who she can trust to discuss any problem or fear with and get a compassionate, faithful response–so I have to prepare for “the talk” and I want to have all my facts straight.

    This particular topic is also on my radar because I had “stage 0” cervical cancer, detected on a Pap smear, and did not know until after the surgery to remove it whether it had spread. Thankfully things have been going well since then, and the surgery did not seem to have any side effects (though, similar to the LEEP procedure mentioned above, it potentially could have weakened the cervix, with potential implications for the outcomes of future pregnancies). There was a small time window after the HPV vaccine came out when I could have benefited from it, and I wish that I had gotten it. But I was an adult on my parents’ health plan at the time, and they never mentioned it, and I didn’t want to have any sex-related talk with them if I could help it, let alone that I was barely thinking about HPV.

    And, as noted above, there is still not much scientific certainty about what can and cannot transmit HPV; it can potentially be transmitted and cause cancers in places other than the cervix–generally mucosal tissues, but other particularly sensitive tissue, like the fingertips, have upon very rare occasion had cancers from HPV. My general sense is that at the extreme HPV could spread in the same situations as herpes, including kissing or drinking from the same glass as someone who’s infected, if disease cells happen to be “shedding” at that unlucky time. (This shouldn’t be a cause for panic: it is apparently very possible to have been infected with a cancer-causing strain of HPV without developing cancer from it. But this small risk of casual infection would be a nice one to eliminate through the vaccine, even on top of the reduced risk of sexual infection.) (I try to follow these studies because I definitely do not want to risk exposing anyone else; I only know that I contracted a cancer-causing strain of HPV at my cervix, but I potentially could have an infection in my mouth or throat, too, that could potentially shed cells that could infect others.)

    This vaccine can help keep my niece safer from one form of cancer, and I want to stay up to date and make sure her parents have it on their radar when she’s a pre-teen. Thank you again for providing this thoughtful blog!

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    • I’m sorry I missed this comment! Anyway, the answer is, NO, there have been clinical trials done on the targeted age range (e.g. In a Phase III clinical trial
      (107477/012) involving 773 participants (girls, 10–14 years of
      age) the AS04-adjuvanted cervical cancer vaccine was found to
      be highly immunogenic with GMTs at Month 7 approximately
      twice as high as those observed in young women aged 15–
      25 years in the same study [52]” (http://www.hu.ufsc.br/projeto_hpv/Immune%20response%20to%20human%20papillomavirus%20after%20prophylactic%20vaccination.pdf)

      The thing that is confusing is that many of the Phase III trials were not complete before the approval of Gardasil. Basically, because these trials were nearing completion and were indicating positive results, the FDA approved “fast-tracking” Gardasil because of the HPV epidemic. (I was in a little bubble of chaste monogamy in the mid-2000s so I was oblivious as to how much it had been spreading by leaps and bounds.)

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  6. Thank you again for the informational article. I am pro most vaccines, but whether or not I choose to vaccinate my children with Gardasil, I appreciate hearing a devoted and informed mother provide rational reasons to use it. To be truly unbiased in the heated vaccine debate, we should all consider all angles! Would that more of my well-intentioned peers considered merely researching a pro-vaccine stance, before writing off ALL vaccines.

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