A few weeks ago, we had a celebrate-the-onset-of-summer party for the kids and parents from Josie’s flute class. We like these folks a lot. They are smart, funny, progressive East Village types, with plenty of Jewy representation. Our kids play Bach together. That afternoon, as our spawn ran around with squirt guns and we noshed on orzo salad, the conversation turned to vaccination for HPV, the human papilloma virus. And I discovered I was the only parent definitively planning to get her daughters the vaccine. And I was shocked.
The Centers for Disease Control and Prevention recommends this vaccine for all 11- and 12-year-old girls. Starting in 2010, the CDC began recommending it for all 11- and 12-year-old boys, too. Why? Because the vaccine protects against two particularly virulent strains of HPV: serotypes 16 and 18, the ones that cause most kinds of cervical cancer. Type 16 also causes half the cases of oropharyngeal cancer (cancer of the mid-throat, palate, tongue, and tonsils). And a recent study in the Journal of Clinical Oncology found that by 2020, HPV is actually likely to cause more oropharyngeal cancers than cervical cancers in the United States.
I was surprised at my flute friends’ vaccine resistance. They’re not homeschooling uber-hippie types, and they’re not insular ultra-Orthodox Jews—two groups who have been known for opting out of childhood vaccines. My friends’ kids got the little-kid vaccines that protect against measles, mumps, rubella, diphtheria, hepatitis, whooping cough, tetanus, and more. The only vaccine they oppose is this one. And their reasons dovetail with those of other friends who responded to my Facebook query about whether they were planning to get the HPV vaccine for their kids. (Most of my opting-out friends emailed me privately rather than responding publicly on Facebook. Talking about vaccines on Facebook is like lobbing a cheeseburger into a vegan convention. There will be ugly fallout.)
Here are all the reasons my friends are saying no to this vaccine, presented in one convenient (real) email:
From the research I’ve done, the benefits from the vaccine do not outweigh the potential risks, which could be substantial. To be clear: I am not anti-vaccine. At all. But I think like anything, you have to be a smart vaccine consumer. I am all for vaccines when I think there is real, tangible benefit to be had: polio, MMR, chicken pox, meningitis—all great! But the HPV vaccine seems to me a big pharma marketing exercise. I feel that the protection/reduction of risks from cancer, etc., are small and the potential risks of an untested vaccine on my kids are huge. Just my feeling. But I know lots of others, including doctor friends of mine, who feel the same way.
Vaccine safety and the evil influence of pharmaceutical companies were the two issues that came up again and again. Two friends also said they felt the vaccine was a way of slut-shaming girls (who are still the primary recipients of the vaccine; not many parents know that it’s now recommended for boys as well), trying to make them fear sex. My East Village peeps are proud Planned Parenthood supporters and Rachel-Maddow-watching liberals; they don’t fit the profile of parents who say they’re opposed to sex education and access to contraception because those things send a message that encourages sexual activity.
Further, this crew as a whole felt that HPV infection is no biggie; practically everyone we know has had it, and it usually goes away by itself. (True. Ninety percent of HPV infections do disappear within two years.) They said that as long as you get regular Pap smears, you’ll be fine … and you won’t be exposed to an under-tested new drug that can have terrible side effects, as detailed on scaremongering websites. After the flute party, even I, a vociferous vaccine booster, was waffling about whether I wanted Josie and Maxie to have this vaccine. Our pediatrician’s office starts the 3-shot process when kids are 12. Josie is 11. I’d have to decide fast.
Then, the week after the party, a new federal study came out showing that the presence of HPV serotypes 16 and 18—the scary ones—has dropped by half among teenage girls since 2006. That’s pretty huge … especially since only 35 percent of girls ages 13-17 have had all three doses of the vaccine.
Yet despite the evidence that the vaccine works well, compliance rates are dropping drastically. A national study by Paul M. Darden, a pediatrics professor at the University of Oklahoma, that was published in March in the journal Pediatrics found that in 2008, 44 percent of parents intended to vaccinate; by 2010, that number had fallen to 40 percent. In 2008, 4.5 percent of parents said that safety worries kept them away from the vaccine; in 2010, more than 16 percent said that. That’s a fourfold increase in only two years.
But why? In her New York Times Motherlode column, my friend K.J. Dell’Antonia blamed the messaging that’s getting to parents. Promoting the vaccine as protection against sexually transmitted diseases is freaking people out, she argued, in a piece called “Will Parents Still Turn Down an Anti-Cancer Vaccine?”
And white, educated, upper-middle-class parents (you can substitute the word “Jews” there if it helps you to visualize) seem most likely to distrust vaccine recommendations in general. A recent Israeli study found that the more highly educated the parents, the more likely they were to create their own infant vaccine schedules, ignore official governmental recommendations, and decide on their own which vaccines they wanted administered. The Israeli Health Ministry is trying to figure out what to do about these well-off, stubborn, independent, suspicious-of-authority parents. And here in the good ol’ USA, white families are far more likely than others to opt out. Only 48 percent of white girls got the first HPV vaccine dose, compared to 56 percent of black girls and 65 percent of Latinas. In general in this country, white people have better health outcomes than people of color, but that’s not looking to be true with HPV. “I can’t remember a vaccine where I saw a pattern like this,” said Walter A. Orenstein, director of Emory University’s Program for Vaccine Policy and Development, in an interview with the Times.
Part of me suspects that Jews have more reason than most people to be suspicious of secular authority. We know from our history of getting accused of drinking Christian baby blood and charged with treason and being told our devious Hebraic genes are inferior that governments lie. But another part of me is surprised that parents aren’t being driven by Jewish values, which consider the needs of the community as highly as the needs of the individual: Al tifrosh min ha’tzibur: Do not separate yourself from the community. Seen in this light, this “do whatever you want” perspective on vaccines seems awfully libertarian—and goyish. And Jewish sexual ethics involve respect for one’s partner and protecting oneself.
I chatted with Paul Darden, author of the Pediatrics study, about his theories on why educated parents shy away from the HPV vaccine. I was delighted to find him sympathetic and nonjudgmental about parents’ concerns. (And he wears spiffy bowties.) He understands that telling people they’re stupid for having the beliefs they do is not a way to increase compliance and improve public health. “I do think there’s more anxiety about this vaccine than about other vaccines,” he told me. “Less than 1 percent of parents in our study said they had safety concerns about the vaccine for tetanus, diphtheria, and whooping cough and the vaccine for bacterial meningitis. But 15 percent say they have safety concerns about the HPV vaccine.”
He was refreshingly open in responding to parents’ concern that this vaccine is a pure money-grab by drug companies. “Oh, the pharmaceutical industry operates in a free-enterprise system, and they want to make money, no question,” he said cheerily. “I’m sure they jack up the price on us as much as they can, because that’s what everyone does in this country. But I’ve actually found vaccine developers to be pretty altruistic. They’re like the redheaded stepchild of the industry, because if you want to make money in pharmaceuticals, you don’t go into vaccines. You don’t want a vaccine someone gets a few times. You want a prescription they’ll have to fill every month for 20 years!”
His response to the scary information floating around the Internet about the safety of this vaccine is to tell parents they need to understand correlation versus causation. Yes, bad things can happen after someone gets a shot. “But they can be temporally associated and have nothing to do with causation,” he said. “You could say, ‘Cereal consumption kills adolescents!’ Because some kids had cereal the morning they got the vaccine, and later that day THEY DIED.”
“The one thing [the HPV vaccine] does cause is fainting,” Darden continued. “It is a painful shot. But syncope [fainting] occurs to a degree with every vaccine we give. Back in the measles epidemics of ’89 to ’91, I went out to schools to help vaccinate, and the boys would faint and girls would have hysterics. It’s infectious. Once a guy fell down, they all fell down. I think you’re trying to be brave and you lock your knees and it’s a fear response and you have a little pass-out spell.” And if girls tell other girls they’re going to faint when they get the vaccine, they’re more likely to faint.
This collective response happens to parents as well as kids. Vaccine refusal tends to occur in clusters. “The people you really trust are your friends and social networks, not just doctors,” Darden said. “If your friends have concerns, that will influence what you want to do.” (I can testify to that from my own visceral response to the flute party, which made me go from 100 percent sure my kids would get the vaccine to, let’s say, 45 percent sure by the time the last cupcake was eaten.) But this tendency is “bad from an infectious-disease point of view,” Darden said. “You’re out there hanging around with a group that’s not protected, so you’re really not protected! We know for whooping cough that there are much higher rates [of infection] in those clusters, and measles clusters happen in people who are not vaccinated coming over to the United States on planes.” (And in ultra-Orthodox non-vaccinating communities, too.)
And despite my friends’ fierce pro-women’s-sexual-empowerment, anti-slut-shaming worldviews, I do wonder whether they’re being honest with themselves about their ability to see their own daughters as sexual beings. “When you look at the reasons given for not getting the vaccine in 2010, ‘not sexually active’ was only given by 11 percent of the people responding,” Darden said. “The most frequent response, at 17 percent, was ‘not necessary,’ and another 4 percent answered ‘not appropriate age.’ ” All those answers could actually be related anxiety about daughters’ sexuality. After all, the vaccine is most effective at age 11 or 12, before kids are having sex, so “not sexually active,” is an illogical reason for refusing the vaccine.
As for “not necessary,” that perspective jibes with my hipster community’s general lack of fear of HPV. You can’t Reefer Madness us about it, because we’ve seen how little damage it can do. But put down that metaphorical HPV joint, urges my friend Lena Antimonova Cerbone, a midwife who runs a family-planning clinic in West Virginia, in one of the poorest counties in the nation (and who also works in a hospital that serves a far more affluent and educated population—and yes, she says, her wealthier clients are far likelier to opt out of the HPV vaccine than her poor ones). First of all, just because most of us had HPV that was a minor inconvenience doesn’t mean our kids will be as lucky. If they’re infected with those nasty serotypes 16 and 18, their prognosis isn’t necessarily as sunny. And Cerbone points out that we shouldn’t be cavalier in assuming that Pap smears will make everything A-OK, regardless. “Think about this,” she told me in an interview. “Yes, your daughter will get Pap smears when she’s living in your house and in college, but she’s way less likely to get them in her 20s. And the 20s tend to be when people are having stupid sex. Yes, there are cervical-cancer screening and prevention programs, and yes, Pap smears are the best tool we have, but cervical cancer is still the third most common killer among gynecological cancers in this country.” Besides, there are long-term concerns besides cancer. “Think about your daughter’s future fertility,” she urged. “Having a LEEP or cone biopsy—that is not a cervix that likes to stay pregnant. You don’t want your daughter to have miscarriages and pre-term babies.”
Cerbone is a Russian Jew who understands the skeptical-of-authority worldview. “I would say to parents, ‘I really understand your suspicions! I am a home-birther!’ But the science on this is really good. Are you waiting to find out in 10 years that the science is really good, and by then your kid will have pre-cancer? Are you secretly afraid of your little daughter having sex? Look, a lot of parenting decisions and health-care decisions are not based in science. They’re emotional: One part doing what our moms did and one part doing exactly the opposite of what our moms did; one part who we’re hanging around with and one part what our deepest fears are.”
And if our deepest fears really are of seeing our daughters as sexual creatures at an earlier age than we’d like (or, uh, at all), rest assured that studies repeatedly show that getting the vaccine isn’t associated with promiscuity. “One study looked at girls who got the vaccine and at later markers of sexual activity: birth control, pregnancy, and STD testing,” Darden told me. “There was no relation. Another study found that girls who’d had the vaccine had no earlier initiation of sexual activity and the same number of partners as girls who didn’t have the vaccine … but girls who’d had the vaccine were more likely to use condoms.” Come on, fellow groovy parents! Don’t we want to raise girls who are self-protective and confident enough to make boys put a sleeve on it?
I’d be curious to know what happens with the new(ish) recommendation that boys get the vaccine, too. (Interestingly, for boys the pitch is that the vaccine will prevent penile warts. Which sound really gross. But if I had a son, I’d rather tell him that women’s sexual health is a man’s issue, too, and part of being a mensch is protecting his partner’s health. Even if he’s asymptomatic, does he want to spread a virus to the person he’s shtupping?)
But I wonder, as time passes and more pediatricians get the message that the vaccine is for boys, too, whether boys will be more likely to get the vaccine because adults more comfortable with the notion of boys having sex. Or will the new guidelines mean increased compliance for boys and girls, because it won’t seem as if we’re obsessing solely about girls’ sexual behavior? “We are trying to do a study to find out whether recommending the vaccine for both boys and girls will mean increased uptake for girls,” Darden told me. “I’m hopeful, but I don’t know the answer.”
One final point: If your kid is older than 11 and you’ve opted out of the vaccine, or if you’re in your early 20s and haven’t gotten it, it’s not too late. Research shows that the vaccine still works—though perhaps not quite as well—for women up to age 26 and guys up to age 21. And it’s quite possible your pediatrician never sold you or your parents on it. “We pediatricians are uncomfortable talking about sex,” sighed Darden. “That makes us uncomfortable talking about the vaccine, and parents hear or sense our discomfort, so we’re not as effective as we could be [when it comes to promoting the vaccine]. We pediatricians like babies! We just don’t want to talk about how we get them!” Darden’s two daughters, now 25 and 27, were vaccinated as soon as the vaccine was available, and Cerbone plans to vaccinate her three kids as well. (Her oldest is needle-phobic, so she’s going to wait an extra year.)
So, my crunchy-granola friends: Look for actual, credible sources about vaccine safety, as opposed to anecdotal ones and ones that don’t distinguish between correlation and causation. Consider the reliability of the evidence indicating that this vaccine is more cynical and money-grubby than other vaccines. Think about the long-term health of your kid. And my frum friends: Know that even if your daughter has just one sexual partner in her life, she’s still at risk from HPV.
Doing this story strengthened my resolve to get the vaccine for my kids. When I talked about my concerns with Josie, her response was instantaneous: “I hate shots! They hurt! But why would I not want a shot that keeps me from having cancer a long time from now if now is the best time to get the shot?” Out of the mouths of babes. So, as I’ve said before: Do the Jewish thing and have your kid vaccinated.
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Marjorie Ingall is a columnist for Tablet Magazine, and author of Mamaleh Knows Best: What Jewish Mothers Do to Raise Successful, Creative, Empathetic, Independent Children.
Marjorie Ingall is the author of Mamaleh Knows Best: What Jewish Mothers Do to Raise Successful, Creative, Empathetic, Independent Children.