The British Columbia Ministry of Health recently announced that it plans to include “vulnerable,” “at-risk” males in its free HPV (human papillomavirus) school-based vaccine program. This means that the province will now provide the cancer-preventing vaccine to girls, gay young men and “street-involved” boys. But this policy will likely have many unintended consequences. BC should instead follow the lead of three other provinces by offering the HPV vaccine to all girls and all boys.
The HPV vaccine protects against persistent, sexually transmitted strains of the virus that are associated with cancer. After initial research demonstrated the HPV vaccine’s effectiveness in preventing cervical cancer, Canada’s National Advisory Committee on Immunization (NACI) recommended in 2007 that the vaccine be offered to all Canadian girls. Since then, the increasing number of head and neck cancers in men has been well documented, as has research that shows that the HPV vaccine prevents cancers in both females and males. The rising cancer incidence and the research led to NACI’s 2010 recommendation that both girls and boys (ages 9 to 26) receive the HPV vaccine. The safety and efficacy of the HPV vaccine have been demonstrated by a robust body of evidence.
Because of the HPV vaccine’s demonstrated effectiveness in reducing the incidence of infection that leads to many HPV-related cancers, the Canadian Cancer Society has called the HPV vaccine a “game changer” in cancer prevention. Clearly all children should benefit. The expansion of HPV vaccine programs to include boys has the capacity to affect the health of many Canadians in a positive manner by preventing infection that leads to cancer.
The Canadian Constitution grants provinces and territories jurisdiction in health matters, so they have authority to implement the federal government’s HPV vaccine recommendation and to design HPV vaccination programs. All Canadian provinces and territories have implemented free, school-based, publicly funded HPV vaccine programs for girls. But including boys in such vaccine programs has proved challenging despite NACI’s recommendation and the endorsement of well respected scientific and medical organizations.
BC’s decision to vaccinate gay and “at-risk” boys appears well-intentioned. At approximately $150 per dose, the HPV vaccine is expensive, and multiple doses are recommended. Accepting that cost is a significant factor, some will argue that when there are limited health care dollars, vaccinating some boys against HPV is better than vaccinating none, and that the new policy could be a promising first step to vaccinating all boys. However, British Columbia’s decision to vaccinate only “vulnerable” boys sets a dangerous precedent for many reasons.
First, British Columbia’s school-based HPV vaccination program currently offers the vaccine to children who are 11 years old. The new policy would therefore require an 11-year-old boy to identify as gay to receive a preventive health care measure that offers benefit to all children. Some boys of that age might not be aware of their sexual preferences or might be hesitant to disclose their sexual identity to their classmates, parents and health care providers. To require people to disclose their sexual identity to receive health services at any point in their lives is egregious. Given that parents may not welcome the knowledge that their son is gay or “at-risk,” the required disclosure could be particularly harmful to children, especially because the health care measure requires parental consent.
Second, requiring boys to declare themselves as gay could mean that they will delay accessing the vaccine until they come out. Such delay in being vaccinated could mean that they become infected before vaccination. Moreover, a vaccination administered later in life is less likely to produce the same immune response as one administered at a young age.
Third, the “at-risk” label might cause young BC boys to internalize stigma about being gay when, in fact, most people who engage in sexual touching or sexual intercourse are at risk for the sexually transmitted HPV infection.
Fourth, this policy may be politically divisive and have serious implications for other policy priorities. For example, it is possible that other jurisdictions will follow this policy approach, which not only is discriminatory but could undermine policies that seek to prevent bullying of LGBTQ youth. This policy might also stigmatize the HPV vaccine as the “gay vaccine” and thereby affect vaccine uptake rates.
Fifth, this new policy is unjustly discriminatory. We know that subsets of girls (e.g., Aboriginal, Inuit, Black and Hispanic) are more at risk for HPV-associated cancers than other girls. Government vaccine programs have not discriminated on grounds of ethnicity and should not discriminate on grounds of sexual orientation.
Sixth, the new vaccine-for-only-some-boys policy might be subverted. Parents of heterosexual boys might proclaim their sons “gay for a day” to qualify them for the vaccine. Given the fluidity and incontestability of sexual identity, policing the policy will be difficult.
Seventh, heterosexual males are unfairly excluded from this cancer prevention program. Heterosexual males are not fully protected against the virus when governments offer the HPV vaccine to girls. In many Canadian communities, the number of girls receiving the HPV vaccine is insufficient to ensure herd protection. Moreover, BC men who have sex with people from countries with no HPV vaccine program or, as in Japan, very low rates of HPV vaccine uptake are at risk.
To date, Prince Edward Island, Alberta and Nova Scotia offer free HPV vaccination to boys in schools. These provinces do not discriminate on the basis of gender or sexual orientation. The decision of the British Columbia government deviates from these nondiscriminatory programs by creating a new precedent in HPV vaccine program design. Like Australia and Austria, Canada has been an international leader in free HPV vaccination for boys. The precedent of BC’s discriminatory vaccine policy is unwise in itself and also creates the possibility that other populous provinces (e.g., Quebec and Ontario) and other nations might follow this unwise strategy.
BC’s new HPV vaccine policy commendably extends HPV vaccination to more of its children. But the cost-saving policy is short-sighted. Recent research on a cohort of 192,940 Canadian boys suggests that HPV vaccination could save between $8 million and $28 million over their lifetimes. Further, BC’s HPV vaccine program is not as costly as those of other provinces because it offers two, not three, doses of the HPV vaccine. This decision is based on good evidence that two doses may be sufficient, and this cost saving would help include all boys in the vaccine program.
Though young gay men and street-involved youth in British Columbia can now receive the HPV vaccine free, this discriminatory vaccine policy challenges our values of nondiscrimination and our goal of preventing cancer. A more equitable and effective policy would be to offer vaccination to all children irrespective of their gender and sexual identity.
All Canadian children should be given the opportunity to receive the HPV vaccine.