Human papillomavirus (HPV) vaccination historically has been framed as a women’s health topic, but a gender-neutral approach to prevention may boost health benefits for both females and males.
While HPV is best known as the causative agent of cervical cancer, certain strains also cause oropharyngeal (throat), anal and penile cancers. It is also linked to other low-risk infections such as genital warts.
“We know that single-sex vaccine programs just never work,” says Vinita Dubey, associate Medical Officer of Health at Toronto Public Health. “We’ve tried it with rubella … those programs did not work when they were just focused on women. Having a vaccination that’s just for one sex, for a variety of different reasons, is problematic.”
When the school-based HPV vaccine program first rolled out in Ontario in 2007, only girls were eligible. Since then, the vaccine has been recommended for both females and males. But the messaging remains focused on girls – and many experts say that is wrong.
HPV vaccination in both sexes reduces HPV at the population level by enhancing herd immunity, says Joanne Kearon, associate Medical Officer of Health at the Middlesex London Health Unit. “Even though with boys we’re not concerned specifically about cervical cancer, by vaccinating boys they will not become infected, and they will not spread HPV to their sexual partners.”
Cases of head and neck cancers have risen sharply in recent years, and a great majority of these are caused by strains of HPV. The highest incidence of HPV-related head and neck cancers in the United States is in younger white men.
In Ontario, all students in Grade 7 are eligible to receive the HPV vaccine through school-based programs. They continue to be eligible for the vaccine until they graduate from high school through the publicly funded program.
Men who have sex with men, who are at higher risk for genital and oropharyngeal cancers, are also eligible for the HPV vaccine through age 26 through a program primarily delivered by primary care and sexual health clinics.
The national coverage goal in Canada is 90 per cent for 14-year-old boys and girls. Ontario is not meeting this goal for either gender. But because the HPV vaccine is not included in the Immunization of School Pupils Act, vaccine records for HPV are likely an underestimate of true coverage rates, says Kearon.
Slightly more than half of 12-year-olds in Ontario in the 2023-24 school year had a full series of HPV immunization, says Christine Navarro, public health physician at Public Health Ontario. While gender-based data have yet to be released, Navarro says it’s likely that there are small gender differences, with girls having higher immunization rates.
In the Middlesex-London region, HPV was the most commonly declined vaccine, with an equal breakdown between boys and girls.
“We certainly would like to see higher rates for our HPV vaccination, and we would like to see less people decline the HPV vaccine,” Kearon says.
While the benefits of HPV vaccination are multifaceted, its biggest boon is the prevention of cervical cancer in individuals with a cervix.
“Our support targets girls that are ages 9-14 because we know that’s the age group where the vaccine has the highest protective effect, especially against cervical cancer, which is the most common HPV-induced cancer,” says Emily Kobayashi, head of the HPV vaccines program at Gavi.
Kobayashi says increasing coverage in 9 to14-year-old girls would be the best way to maximize impact and cost-effectiveness of the HPV vaccine program. Of nine studies with economic analyses of HPV vaccination included in a 2021 systematic review, four supported gender-neutral programs, while four demonstrated their cost-effectiveness only in alternative scenarios, such as the inclusion of oropharyngeal and penile cancers.
But cost-effectiveness is only one dimension to consider when designing vaccine programs. The National Advisory Committee on Immunization (NACI) also incorporates EEFA considerations (equity, ethics, feasibility and acceptability) into its vaccine recommendations.
The contrasting stigma surrounding HPV vaccines between girls and boys is one factor that may shape cultural attitudes.
“For boys, the trajectory of the HPV vaccine in the U.S. is called the feminization of the vaccine.”
“We find that in the literature that stigma around HPV vaccines for boys and girls, the content is a little bit different,” says Stephen Foster, Assistant Professor of Social Psychology at Pennsylvania State University. “For girls, it has to do with content regarding sexual purity, not wanting to promote sexual promiscuity … for boys, the kind of trajectory of the HPV vaccine in the U.S. is called the feminization of the vaccine.”
Foster, who studies the social acceptability of the HPV vaccine in honour cultures, and his team found that honour norms, including reputation for strength, virility and self-defence, were linked to decreased support for male HPV vaccinations.
“Boys who grew up in honour cultures might be less likely to get this vaccine because it’s viewed as a feminine vaccine, as something intended for girls,” says Foster. “Essentially, masculinity is very fragile and it’s very easy to threaten – so, from a broader social perspective, it’s about mitigating those sorts of fragile masculinity components.”
The type of messaging required to best promote HPV vaccine uptake among males is a topic of investigation. Messages like “the HPV vaccines keep your community safe” seem to be less effective than those that remind individuals that choosing to vaccinate is an act of self-determination.
“We’re playing around more with the idea of autonomy … targeting a way for honour endorsers to feel like I’m making decisions for myself,” says Foster.
For parents, this means emphasizing that the choice to vaccinate their sons with the HPV vaccine is theirs. Targeting fears and misconceptions held by parents is a logical step forward to reframing the messaging.
“ ‘I don’t want my kid to be made fun of’ – these are very real ideas that most parents have, wanting to protect their kids, wanting to make sure they’re not getting bullied,” says Foster.
“The marketing aspect, I think, is ultimately going to be geared toward parents, and mitigating the stigma will hopefully make honour endorsers less reactive to the vaccine, more likely to then engage in uptake.”
Removing gendered language and highlighting its key role as a cancer prevention measure may also help increase uptake.
“What we’re really trying to do is to actually remove the gender stigma and just make it a routine vaccine to prevent cancer for everyone,” says Dubey. “Everyone has a head and neck, everyone has genitals … in some ways, this is a men’s health issue just as much as it is a women’s health issue.”
Even as HPV vaccine eligibility has opened up for males and females in various jurisdictions around the world, the gap between policy and practice still exists.
“Just having the policy sort of opens the door, but you still have to do all the programmatic work to make sure that individuals actually walk through that door,” says Heather White, executive director at TogetHER for Health, a global advocacy forum for cervical cancer elimination.
“This means [ensuring] health-care practitioners have effective means of communication around it at the community, individual and family level, bringing parents on board, and understanding who are the gatekeepers for both genders.”
