HPV, the public health, and sexual choices

HPV, the public health, and sexual choices

• Health Care
So, Mary Elizabeth Williams has called me hysterical and claimed I’m ruining feminism with my supposed irrationality because, on Twitter, I criticized a piece she wrote about her pediatrician accidentally giving her daughter the first dose of HPV instead of the scheduled meningitis shot.  When a cascade of people attacked me, I defended my point of view, both that the heavy drama surrounding this was unnecessary and, far more importantly, that Williams’ choice to treat the HPV shot as somehow separate and more fraught than every other vaccine fed a very dangerous narrative about this vaccine, and she should have been more responsible.  Her response minimized and distorted her original piece, and overplayed my reaction, in my opinion.  But let’s take my objections one at a time, for clarity’s sake.

Objection #1: Dramatics

This one’s on me.  I accused Williams of being overdramatic by turning a minor mistake into a big deal that upset her daughter so much that she was, in Williams’ words “scared and sobbing and, on a very primal level, angry and betrayed.”  Even though Williams swears she was calm and acknowledges mistakes happen, she describes wanting to “throttle” the nurse, and claimed her daughter was “robbed” not just of a childhood so far free of minor medical errors, but of her right to make choices about her own sexuality.

I was raised in a “suck it up” culture, and my first inclination in situations like this would be to remember that medical errors are incredibly common, and be grateful that when my number came up, the worst thing that would happen to me is that I have a significantly reduced chance of dying of cervical cancer.  But I fully admit this is a personal choice.  There are good and bad sides to the chilled-out approach and good and bad sides to making a big deal out of stuff.  My irritation at the dramatics was unfair; I should apply the “suck it up” mentality to other people’s dramatics and say, “No big deal. That’s just how they are.”

Objection #2: Toxic narratives about the HPV vaccine

In fact, sucking it up when someone else’s dramatics irritate me is usually what I do, with a side dose of reminding myself that dramatic people often stand up against everyday injustices to the betterment of us all.  But the reason this pissed me off was that Williams juiced up her story by invoking a toxic narrative about the HPV vaccine, that it’s the “sex shot” and therefore is unique amongst all other vaccinations, requiring a lot of hand-wringing about personal choice.  My problem with this narrative is that it feeds the notion that sexual health is separate from other kinds of health, and that continues the politicization of it and feeds right wing narratives that sexual health care is morally corrupt in a way that other health care isn’t.

I think that responsible journalists should not add to the pile.  STIs are not different than other diseases; the only difference is political, not biological.  HPV in particular is ridiculous to politicize, since it’s so common that it’s wise to treat getting it as an inevitability if you don’t get the vaccination. Indeed, the most important difference between the HPV vaccination and other vaccination isn’t the sex stuff, but the fact that you probably get more individual protection from the HPV vaccination.  Most people have measles and whooping cough vaccines, offering the unvaccinated herd immunity.  But with the HPV vaccine, there’s only 11% compliance, meaning that your unvaccinated kid’s chance of getting HPV as an adult should still be treated as an inevitability.  Sadly, we’ll be seeing 4,000 deaths and 12,000 cases of cervical cancer a year for some time yet.

If you read that link, you’ll see that there are many reasons for the low vaccination rate, including cost and ignorance.  However, the perception that this is the “sex shot” has a lot to do with it.  The belief that getitng the vaccination has some sort of sexual implications for your child makes people uncomfortable and unwilling to engage; Williams added to the pile by using the sex aspects of the shot to turn up the interest in her story.

This particular criticism stung, I’m guessing, since Williams objected to it on Twitter and engaged in a little retcon about the sex stuff, claiming that this is solely about the fact that the HPV vaccine is “optional”.  She minimized the way that she treated the HPV vaccine as somehow fundamentally different than other vaccines, and in her follow-up piece, continued to minimize and imply that she treats all “optional” medical decisions as belonging to an 11-year-old and not her parents.

But that is  not how the original story read.  Let’s start with Williams’ attitude towards vaccinations that prevent non-sexual infections.

Meanwhile, she still needs to get that meningitis shot, and I’m going to make damn sure that’s the shot she gets.

Light, fluffy, no big deal, right?   Vaccinations are something responsible parents make “damn sure” that their kids get, because responsible parents understand not just the importance of preventive health care, but also that their kids are members of a large community and owe it to that community to do their part in providing herd immunity.  You, as a responsible parent, would never consider skipping the MMR or the meningitis shot, because duh, vaccinations are a private and public good.

Interestingly, this common sense approach was in the same paragraph as this language about the HPV vaccination:

While my daughter and I are not ruling out changing pediatricians, she has decided to proceed with the course of vaccination. She didn’t come to it lightly; she slept on it and shyly told me her wishes the next day. She is a serious girl, and treated this is a serious choice.

I’m sure Williams was completely consistent and also had her daughter sleep on the serious decision of whether or not to take her chances with meningitis.

Williams’ claim was that she treated these shots differently because the HPV vaccine is optional and meningitis is not.  On Twitter I pointed out that the HPV vaccine should be mandatory, and the only reason it’s not is sex hysteria.  When things aren’t mandated because of political bullshit, but should be mandated, it’s different than something that can be considered truly optional.  When I was a kid, it was legal to ride in a car without a seatbelt, but my parents didn’t believe it was optional in our house, because they believed it should be the law.  I imagine if  conservatives get their way and public schooling stops being mandatory, Williams would also keep sending her kids to school.

In a sense, all this is irrelevant, because in the original story, the fact that HPV is the “sex shot” loomed large as to why it had to be a big deal.  A telling quote:

And though I believe in the logic of getting the HPV vaccine, I have also long felt strongly that any decision involving their future sexual lives should be theirs to make.

That’s the major problem. The choice of whether or  not to get HPV as an adult is more about your future health than your future sex life.  (And that’s setting aside the logic of giving an 11-year-old the right to decide for her 20-year-old self whether or not to invite the possibility genital warts, cervical scrapings, infertility and even cancer into her life.)  Government officials and drug developers designed and regulated the vaccine to minimize the psychological association between the shot and having sex.  Part of that is scheduling the first vaccination years before the average girl starts having sex, in part to get complete coverage, but also so that it’s not fraught like the conversation of whether or not to put a girl on birth control.  You just start getting the shots at 12; if you have sex at 14 or 21, it doesn’t matter.  The choice to have sex and choice not to get HPV are decoupled.  And this is how it should be, since virginity is politically loaded, but that women shouldn’t die or lose their fertility to cervical cancer should be completely apolitical.

To be fair, I don’t know if Williams treats all vaccinations with this gravity.  As I noted, perhaps her daughter was also expected to sleep on the decision of getting the meningitis shot, in order to make sure she knows that she could always have the option not to spend time around people who are sneezing or wiping their mouths.  Perhaps the tetanus shot was only administered after her daughter spent a day thinking about her future life around rusty metal and biting insects; after all, we don’t want to presume for her that she wouldn’t consider simply avoiding the easily identifiable situations where you can get tetanus (rusty objects, hiking, tubing, outdoor barbeques).

To be clear, the emphasis on the “sex” aspect of the shot was heavy in this story.  It wasn’t just the one strange sentence about her future sex life.

And then I’d had to, with all the calm I could muster, have a lengthy conversation about how the doctor had made a mistake, but it was OK, and everything was fine, and now we were going to talk about sexually transmitted diseases.

My daughters know the facts of life. They know where babies come from, and how people can get AIDS. Often, their knowledge hasn’t come from carefully planned birds-and-bees heart-to-hearts but from spontaneous opportunities — a confusing scene in a movie, a rumor a kid spread on the playground. Life does not always keep children in a bubble until both you and they are at your optimum moment of emotional preparedness. Stuff happens, and being a parent means being there to talk about it. It wasn’t the conversation I minded having. It was the harrowing realization of how easily a sloppy mistake, from someone we trusted implicitly, could have meant something far more serious than what we’d just experienced. It was being robbed of choice. Not mine. Hers.

Look, I get that talking about sex with kids is a big deal.  I really do.  I’m 100% sure Williams is responsible and tries to be natural about this stuff.  I think the HPV vaccine is just as good a time as any to have this discussion.

But this isn’t about child-rearing practices.  This is about responsible journalism about important public health issues.  Williams did more than link sex and this shot with her daughter—which again, I can see arguments for it—but she reinforced the link the public mind.  That’s another ball of wax.  When discussing the HPV vaccine, we have two frames to work with: “sexual choices” or “routine health care”.  The first is a loaded frame that allows right wing narratives about choice to seep in.  If you’re working with the “sexual choices” framework, it’s easy for people to say that X isn’t really health care, because the proper choice is to abstain from sex, and there should be consequences for those who make the “wrong” choice.  In fact, as I pointed out over and over again on Twitter, the fact that the vaccine is characterized as a sexual choice is a major reason it’s not mandatory.  People are looking at it with the same nervous eye that they look at putting their kids on birth control with.  The sexual choice frame allows people to think that withholding the shot signals sexual values.

I prefer the “routine health care” frame, which is incidentally the typical frame used in handling the effects of how widespread HPV is.  When you get a Pap smear, for instance, it’s not really treated like a matter of sexual choice-making, but more like getting your oil changed, just part of being female.  Once you characterize a form of health care as being about sexual choice-making, you start to have people not get the routine care they should, because they perceive that care as being something that’s only necessary if you’re a “slut”.  Which is, incidentally, a big reason that a lot of women lose their fertility to chlamydia, because they don’t get care in a timely fashion due to unwillingness to believe STDs can happen to good girls like themselves.

And that is, above all other things, my main concern.  Whatever private decision-making looks like in the Williams’ household is certainly not my business.  But once you write something and publish it, it’s a matter of public concern.  Endorsing the “sexual choices” frame of HPV over the “routine health care” frame is a highly political choice.  You personally may not weigh one sexual choice more heavily than another, but that’s simply not true of most of the public, where the belief that women should avoid “sluttiness” is still the strongly-held majority opinion, as is the belief that STDs are indicative of immoral sexual choice-making.

In addition, in both of Williams’ pieces, she didn’t do a scrap of reporting on the actual safety and efficacy of the vaccination, just noting that there are “pros and cons”, without noting something important, such as the pros way outweighing the cons (with the cons mainly being it’s expensive and it hurts to get a shot).  She mentions that she’s been “following” its evolution, but doesn’t mention that both the FDA and the CDC report that the vaccine is very safe, and that the only verifiable side effects of the vaccine are common to all vaccines—basically a reaction to getting a shot, like when squeamish adolescents faint in the doctor’s office.  She didn’t note the widespread medical opinion that vaccinations are very safe, and in fact, invoked negative reactions to penicillin, as if the two were comparable, even though in terms of risk, penicillin is much more dangerous than vaccines.   If we care about the health of the next generation, we should be more thoughtful than this.  While most people who get HPV are fine and the infection clears up on its own, there are enough adverse effects that we shouldn’t be cavalier about this: 4,000 deaths a year from cervical cancer, 12,000 cases of cervical cancer.  And that’s on top of all the various miseries women have to endure so they don’t become a statistic, including having to endure cervical biopsies and having cervical scrapings of pre-cancerous cells.  Incidentally, those scrapings sometimes also cause infertility in cases where aggressive treatment to prevent cancer is the only real option. A woman who has to choose between not getting cancer and not having babies in the future is someone whose choice has truly been robbed from her—and all because she didn’t get to have the HPV vaccine when she was a kid as part of her routine medical care.