Sex differences, free ridership and the HPV vaccine

It it wrong to require boys to be vaccinated against a disease that does almost all of its damage to women? I can’t see why.

Kenneth Anderson argues that it’s appropriate to require girls to be vaccinated against HPV, because those who aren’t vaccinated are in effect free-riding on those who are.  That’s the usual argument for vaccination, and correct so far as it goes.

But, he continues, it would be wrong to require vaccination for boys, because they are only trivially at risk from HPV:   a small number might get non-life-threatening genital warts, but the risk of cervical cancer, obviously, applies only to girls.  Thus a vaccination requirement that applied to boys would invade their bodily integrity for the benefit of others.  Anderson claims  “a very, very strong presumption that you can’t do things to one group of people’s bodies in order to benefit another group.”   Ergo, he says, parents should have their male children vaccinated on ethical grounds, but it would be wrong to require vaccination.

It seems to me that argument is (1) coherent and (2) obviously wrong in at least two different ways.

First, the power to quarantine carriers of infectious disease – the “Typhoid Mary” case – is well established in law.  Note that Typhoid Mary was not herself sick; she was merely the cause of illness in others.  And yet she was not merely required to take a fairly harmless vaccination; she was deprived of her liberty.   Yes, the threat she posed was more acute and more immediate than the threat created by any one unvaccinated boy, but correspondingly the demands on the boy are orders of magnitude smaller than the burdens on Mary.

If it turned out that an identifiable half of all girls were not personally at risk of cervical cancer from HPV, but could still spread the infection, would there be an argument for exempting them from the requirement to be vaccinated?   I don’t think so.

Second, the notion that HPV infection is harmless to males assumes that infection will not interfere with the male’s sex life.  But knowingly exposing a sex partner to the risk of a sexually transmitted disease is a tort, and at least in some states a crime.   That issue doesn’t generally arise because most men never bother to find out whether they are carrying HPV.  But insofar as HPV infection doesn’t create a social disability, it’s only because of that ignorance.

To be in a position where every time you have sex you put your partner’s life at risk seems to me to be a genuine injury.   If so, then it’s not the case that vaccination has no value for the male, even ignoring –  as Anderson proposes to do – any emotional interest the male might have in his partners’ well-being.

The technical details of the HPV vaccination question are above my pay-grade.  But it seems to me that the legal and moral principles involved aren’t really very hard.

If a vaccination of modest cost and trivial inconvenience and risk can prevent a substantial number of horrible deaths, then requiring everyone to be vaccinated, even people not themselves at risk of dying any of those horrible deaths, is a perfectly unobjectionable public-health measure.   I doubt that the debate would have found much of an audience outside professional circles if it didn’t involve acknowledging the frequency of sex among minors.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact:

11 thoughts on “Sex differences, free ridership and the HPV vaccine”

  1. We will get Gardasil for our two early-adolescent sons (and for our daughter). We think it's good for them: 1. you get HPV, you marry some girl without it, you give it to her, she gets cancer. Not good, you lose the love of your life. 2. you give some older man a blow job, you get HPV in your throat, forty years later you get esophageal cancer – this can happen to boys just as it can to girls. So we think it's in their individual interest.

    On the 'free rider' and 'require' issue – well, there is some real value to my guys in HPV not being widely present in the girls in their middle school (even if they are exclusively hets going forward, and I really have very little idea what they will do, adolescence is long and lust is pretty strong) – a lower chance that the girls they do marry carry a cancer time bomb within them. Lower chance that they will get it from some 9th grade episode and carry it forward to their wives, see above. There is a public health value, as you point out, to getting Typhoid Mary (and Tuberculosis Tom, and Gaetan Dugas) out of the transmission business. If you can do it by vaccination, instead of by jail, it's a good thing.

  2. HPV is also a leading cause of anal cancer in gay men, a problem that seems to be growing. The type of the virus that causes anal cancer seems, as far as I can tell, to be the same as that which causes cervical cancer. So, at least boys will face a direct risk of cancer from HPV. This is a smaller risk than girls face, of course, but still real, and given the other advantages of having boys vaccinated mentioned above, the case for it seems fairly strong to me, especially given that the risks of the vaccine seem pretty small.

  3. It seems to me that the case for vaccinating somebody for their own sake, without their consent, is fairly weak; The idea that the need for consent goes out the window if you're doing something for somebody's own good is one of the more pernicious excuses for evildoing around, because it's so effective at removing moral scruples.

    The defense for mandatory vaccination in order to protect others is much stronger, and it's where the real basis for the practice has always been found.

  4. A suggestion for a thought experiment: suppose that the vulnerable populations are divided between blood types O and AB on one side and A and B on the other, a near even split. Also, as to Brett Bellmore's point, if we are in fact moving in the direction of health care being more of a public responsibility, an obligation to society to take reasonable steps to keep oneself healthy must be taken more seriously.

  5. We vaccinate everyone against rubella even though that disease is dangerous only to sexually active women [more specifically, to prospective children of pregnant women]. HPV vaccination has much less restricted benefits.

    There is a concern as to whether Gardasil will work in the medium to long term: it provides immunity against specific strains of HPV, and while those strains are the only ones currently circulating that cause cervical cancer, it isn't clear what will happen to the distribution of virus strains if vaccination becomes common. This doesn't seem to be relevant to the question of who should be offered vaccination, but it is relevant to whether it should be added to the list of mandatory vaccinations.

  6. "Also, as to Brett Bellmore’s point, if we are in fact moving in the direction of health care being more of a public responsibility, an obligation to society to take reasonable steps to keep oneself healthy must be taken more seriously."

    The classic objection to making health care a public responsibility: That, once the government is paying for it, the government will have a plausible excuse to compel you to do anything the government thinks is good for your health. Thanks for demonstrating the objection is well founded.

  7. What Dave S. said. There is clear emerging evidence on the incidence of ENT cancers and certain sexually transmitted HP viruses. See:

    Since I have both daughters and a son, I don't see my daughters as free riders on the male population at large, anymore than I see the elderly or HIV+ as free riders on my willingness to get a flu shot. As Brett said above, the whole point of vaccines is to protect others who are particularly vulnerable to the disease and who can't get or benefit themselves from the vaccine (immunologically suppressed people can't benefit froma vaccine, that's why they need the rest of us to get vaccinated).

    If the vaccine posed significant risks, I might change my mind. My girls have already been vaccinated.

  8. A few thoughts on this:

    –The power to quarantine is well-established in law, and generally states have the power to quarantine under their police power. But a state's police power is subject to constitutional due process limits, so it isn't enough to say that historically a state has had a power.

    –We don't generally have a compulsory vaccination system in the US. There aren't, for example, any vaccines that any adult is required to receive. We do have compulsory vaccination for school attendance, but historically those have been for diseases communicable at school, and justified by the need to protect the school and those working in or attending it.

    –The case of Typhoid Mary is distinguishable because Typhoid Mary poses a threat by her mere presence. That isn't the case with HPV. And it isn't clear that there is or should be a balancing of the interests in each case, as Mark would have it, where the benefit of the vaccination is weighed automatically against the interests of each individual. Why not require a demonstration of a compelling interest before advancing to a weighing of the burdens?

    –Query: what does Mark's suggestion that we look to the quarantine example suggest about other alternatives for containing the spread of STDs? I think it suggests that he doesn't mean us to take the example seriously.

    –We shouldn't pretend that the burdens of compulsory vaccination are just the risks presented by the vaccination itself. Rather, the law recognizes a right to bodily integrity, and it is that right that is burdened. If it were just a matter of benefits and burdens, well, abortion law would look much different, wouldn't it? (Dawn Johnsen would certainly have something to add on the lack of individual benefits question, and may even escalate matters by bringing in the 13th amendment.)

    –Mark says that "To be in a position where every time you have sex you put your partner’s life at risk seems to me to be a genuine injury." But this is just hyperbole. I mean, it isn't the case that "every time" someone with HPV has sex they risk the life of their partner. After all, at some point you will actually transmit the virus, and thereafter there's no additional risk. But more concretely, it just isn't the sort of thing that anyone cares about. It's the sort of sentiment that everyone endorses, but no one acts on. If they did care, they would know their HPV status, wouldn't they? And they'd insist on knowing their partner's HPV status as well.

    –If the state thought that HPV were a significant issue–a compelling interest–wouldn't the state take other, less invasive steps to limit the transmission of HPV? And yet states don't typically even recommmend to people that they limit their number of sex partners, despite the fact that that is, other than vaccination, the single easiest step to reduce infection.

    –Shouldn't a compelling interest be the sort of thing that is reflected in state policies, and in individual behaviors? If someone thinks, HPV is a serious and compelling matter, so significant that it overrides someone's right to bodily integrity, shouldn't it be reflected in their own behavior?

    –It seems to me that it is perfectly fine to encourage people to vaccinate their children, and it may even be the case that parents have an ethical duty to vaccinate their children. But it doesn't seem to me that the state should require HPV vaccination for school attendance, and, further, I am not persuaded that it's clear that a state may constitutionally require HPV vaccination, for school attendance or otherwise.

  9. Sort of tangential to the point in the post, but I always feel the need to mention this every time the HPV vaccine comes up. HPV is not the only cause of cervical cancer and does not remove the need for annual screenings for women. The vaccine is a huge win in preventing this cancer but it is not a silver bullet. I'm just reminding everyone to make sure their daughters still go for their annual check ups once they are of age even if they are vaccinated.

  10. What I find creepy about the argument that we can't require that boys be vaccinated is that it's thinking of boys and girls as separate groups, when the legal issue is our duties as citizens and the public health issue is that there's lots of sex, even where it's illegal, let alone in the free countries.

    If it's OK to require that Lucy Lucky get vaccinated to protect Cathy Cancerprone, then Lafcadio Lucky has to be required to be vaccinated too. Lafcadio is more likely to be the direct transmitter to Cathy. If Lafcadio's bodily integrity overrides Cathy's risk, so does Lucy's. The original argument isn't internally consistent unless you think women don't have the same moral status that men do.

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