News Sexual Health

New Research on HPV: Some Good News, Some Bad News

Martha Kempner

The bad news is that neck and throat cancers are rising, and this common sexually transmitted infection seems to be the cause. The good news: The vaccines that are available to prevent infection seem to protect against these kinds of cancers as well.

Last month, actor Michael Douglas made headlines (and made TV anchors giggle) when he suggested that the throat cancer he battled a few years ago was caused not by cigarettes but by cunnilingus. His announcement helped bring to light the rising number of throat and neck cancers that have shown to be caused by the human papillomavirus (HPV)—a sexually transmitted infection that also causes genital warts and cervical cancer. The publicity also gave public health experts a chance to discuss vaccines that are available to prevent infection with those strains of HPV that are most likely to cause cervical cancer. Now, two new studies show just how timely and important Douglas’ announcement really was. The first finds that up to one-third of throat cancers are caused by HPV, while the other suggests that the vaccines can protect against those kind of cancers as well.

Released in the Journal of Clinical Oncology, the first study looked at plasma samples from participants in the European Prospective Investigation Into Cancer and Nutrition study who had been followed for many years. Specifically, the researchers compared 638 participants who had oropharyngeal cancer (cancer of the mouth, oropharynx, or larynx), 300 who had cancer of the esophagus, and 1,599 who did not have cancer. The tested samples were taken from participants before they had been diagnosed with cancer (on average, six years before diagnosis).

The researchers found that HPV 16, one of the strains also responsible for cervical cancer, was found in 34.8 percent of patients with oropharyngeal cancer and only 0.6 percent of patients in the control group. HPV was not correlated with cancers in other locations. Some participants had evidence of HPV 16 in their throats in samples taken as many as ten years before their cancer diagnosis. Dr. Ruth Travis, an Oxford cancer researcher and one of the study’s authors, said in a statement, “These striking results provide some evidence that HPV 16 infection may be a significant cause of oropharyngeal cancer.”

In fact, the findings suggest that about 7 percent of non-smoking women and 23 percent of non-smoking men who contract HPV of the throat will develop cancer over ten years. It is thought that men who perform oral sex on women have a higher risk of contracting HPV than either women or men who have sex with men because vaginal fluids have a higher concentration of the virus than the surface of the penis. Smokers and those who drink excessive amounts of alcohol also are at increased risk.

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The second study, which was supported by the National Cancer Institutes and published in the journal PLOS One, looked at whether one of two HPV vaccines on the market could provide protection against cancers of the neck and throat. Researchers tested cells from the throats of 5,840 women in Costa Rica for presence of HPV strains 16 or 18. The women were part of a larger study on the vaccines that had begun four years earlier. Some were vaccinated with Cervarix, while others received a placebo. (The other vaccine on the market, Gardasil, was not used in this study, but researchers believe the results will apply to both.) Of the women who had been vaccinated, only one was infected, compared to 15 of the woman who had received placebo shots.

Researchers were very pleased with these results. Dr. Rolando Herrero, the study’s lead author as well as head of prevention for the World Health Organization’s International Agency for Research on Cancer, told the New York Times, “We were surprised at how big the effect was. It’s a very powerful vaccine.”

Herrero cautions, however, that the study does have a number of limitations. First, when it began it was designed only to test the vaccine’s efficacy in preventing cervical cancer. While all women were tested to be sure they did not already have a cervical infection at the start of the study, they were not tested to see if they had HPV in their throats. This means that some of the infections found either in the placebo or the vaccine group could have been present before the study started.

Another challenge in testing the vaccine’s ability to prevent cancer is how slow cancers of the neck and throat tend to grow. Cancers caused by HPV would not have grown during the four-year study, and, if the women were studied longer, it would not be ethical to ask those who had lesions that looked like they might become cancer to forgo treatment for the sake of the study. Moreover, it’s likely that the women who tested positive for HPV would never develop cancer even without intervention, because in many cases the body can clear itself of the virus before it becomes a problem.

Despite such limitations, researchers believe the study shows the potential of the vaccine. As Dr. Marshall Posner, medical director for head and neck cancer at Mount Sinai Medical Center in New York, told the New York Times, “We expected this—that’s why we want everyone to vaccinate both boys and girls. But there’s been no proof.”

Together, these studies seem to create a bad news-good news situation. The bad news is that head and neck cancers are on the rise, and HPV appears to be the culprit. The good news is that we have a way to prevent HPV infection. As with most developments in science around HPV, these studies provide more good reasons to get both girls and boys vaccinated before they become sexually active.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary LGBTQ

Trans? Good Luck Accessing Reproductive Health Care

s.e. smith

Trans patients now stand to access health care more easily, but enacting policies against discrimination isn't quite the same as actually eliminating it.

Dominick, a disabled transgender man, started making the arrangements for a hysterectomy at age 30. The experience turned out to be a living nightmare—and not just because being disabled had previously presented obstacles to medical care, like being unable to access his gynecologist’s office.

“The doctor,” he says, “sent me home while internally bleeding after the surgery because he needed more beds. He ignored my concerns and dismissed my symptoms as overblown.” He says he almost died when he started hemorrhaging at home.

The horrors of that experience led Dominick to shy away from follow-up care and had profound psychological consequences. “I was afraid to leave my house, for fear I’d start bleeding out. I remember being on a bus to school, completely alone, and having a complete meltdown. I called my girlfriend and was crying and shaking and begging her to come get me.”

While he survived the experience, the trauma lingers to this day—and he’s not alone. For many trans men, dismissive treatment in the gynecologist’s office is part of a larger framework of harmful health-care practices that include verbal and physical abuse and denial of care. Thanks to the finalization of an Affordable Care Act (ACA) rule banning discrimination on the basis of gender, trans patients now stand to access care more easily, but enacting policies against discrimination isn’t quite the same as actually eliminating it. Trans people often face obstacles to care in health-care fields, unless they’re lucky enough to live in a region with a well-organized and structured clinic. Doctors who are ignorant about trans needs, like the imperative of surgical transition for some transgender people, can become dangerous roadblocks. And self-advocacy—including standing up for one’s immediate needs or asking for additional support in cases like Dominick’s—can be exhausting or impossible when continuously faced with such experiences.

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Reproductive health care in particular cuts to the heart of bodily autonomy, something trans people are often already denied in other settings. Yet trans men are frequently left out of the discussion when it comes to accessing services, even as the Women’s Health Network and other organizations, like the American Congress of Obstetricians and Gynecologists (ACOG), argue that the health needs of people who are assigned female at birth, no matter their gender, are indeed matters for reproductive rights conversations.

When it comes to seeking medical care in general, trans people say they often face ignorance or outright prejudice from medical professionals. A 2011 study conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 20 percent of survey respondents were denied health care due to their transgender or gender-nonconforming identity—and people of color experienced even more profound disparities. Twenty-eight percent of all respondents said they had been harassed in physicians’ offices, and 2 percent experienced physical violence.

Chillingly, when care providers discovered that their patients were transgender, the incidence of discriminatory attitudes increased. Many didn’t understand the needs of the transgender community, forcing half of the respondents to provide basic education about managing transgender patients. While proactive self-advocacy—being educated about your own health, self-assured at the doctor’s office, and ready to speak up for yourself—can help everyone achieve better health-care outcomes, this goes far beyond advocacy. In a medical culture where people may have difficulty obtaining providers, trans patients can be forced to repeatedly discuss sensitive medical information that can trigger dysphoria and frustration. And gender dysphoria is fatal if untreated: A staggering 41 percent of the trans community has attempted suicide.

While all aspects of medical care are important, reproductive health care sits at the axis of many important oppressions: It determines whether people are able to have families, whether they receive treatment after rape and sexual assault, if potentially serious sexually transmitted infections (STIs) are treated in a timely fashion, or if they can obtain compassionate and appropriate abortion care. And here, too, trans people have reported difficulty when it comes to requesting and receiving breast and cervical cancer screenings, STI testing and treatment, fertility care, contraception, abortion and pregnancy care, and other reproductive health needs. When such care is provided, it may come with detrimental comments and practices like misgendering patients or making assumptions about their personal lives.

These are especially important issues for trans people: While transgender women are far and away the most likely to have HIV, with skyrocketing incidence rates thanks to poverty and other social factors, transgender men are also more at risk than the general population. They also have difficulty accessing pregnancy care. Approximately 50 percent of transgender people experience sexual violence, and insensitive care providers managing rape survivors can cause further trauma at a time when patients are particularly vulnerable. Denial of services ties into much larger human rights issues for the transgender community: We are in a climate, after all, where trans women risk bladder infections because they cannot use public restrooms.

But whether people are transgender men, along the nonbinary spectrum, agender, or along other axes of gender and experience, if they aren’t cisgender women, they say their reproductive health needs are often dangerously ignored.

“My first gyno, who was an older woman with all kinds of vocalized homophobic, transphobic, racist, and HIV-ignorant ideas,” says K., “left me so uncomfortable I wouldn’t let anyone touch me between my legs with their hands for a good ten years!” K., who is nonbinary, had a traumatic experience when seeking abortion care, and, like Dominick, wasn’t provided with counseling on the subject of egg storage before starting hormone therapy. “I personally never want to be pregnant again,” K. says, but the very option of freezing eggs and using a surrogate in the future was denied.

And this has real consequences: Trauma in reproductive health services, like that Dominick experienced, can drive transgender people into fearing the health-care system as a whole. Between discrimination and the fear that keeps people out of doctors’ offices, trans people are less likely to get preventive care—like HIV counseling and screening—and more likely to develop complications from delayed care. That includes vitally needed reproductive health services.

Discriminatory practices in gynecological care take place within the framework of another problem for trans people: Even with the ACA’s theoretical increased access to health care, substantial barriers to health-care access remain. Transgender people—particularly women and people of color, but also men to a lesser extent—are four times more likely to live in poverty, thus driving a disproportionate use of Medicaid coverage. As Rewire has reported, 16 states explicitly deny transition-related services under Medicaid coverage. Although the ACA explicitly bans discrimination on the basis of sex and gender, with additional protections for gender-nonconforming individuals now that the Department of Health and Human Services (HHS) has finalized its ruling on Section 1557, that doesn’t always work out in practice. Coverage of transition-related treatment, including hormones and surgery, may be denied as “elective” or “aesthetic” under insurance exclusions. For example, a hysterectomy may be deemed “not medically necessary.” Trans people can be instead forced to sue for their care, as in 2014, when Illinois woman Naya Taylor demanded access to hormones. This is especially true in cases where people have successfully changed the gender markers on their identifications, thereby creating a situation where Medicaid may deny coverage for activities like Pap tests for men or prostate cancer screening for women.

“I’ve got many stories about things that have gone wrong in my interactions with medical professionals,” remarks Everett Maroon, a transgender man who lives in the Pacific Northwest with his wife and family. “I’ve gotten inappropriate medical advice, incorrect therapies, seen medical and cultural incompetence, dealt with shitty care, not been provided options I should have gotten.” His issues are the health-care system’s issues, and they are a subject that should be of critical concern to everyone fighting for reproductive rights.

Fortunately, that’s growing to be the case more and more. As OB-GYN Cheryl Chastine wrote for Rewire last year, “How can providers or activists dare to presume that every patient we can’t ‘read’ as trans is cis?,” she said, adding “When those in the reproductive justice movement prioritize trans inclusivity, more trans individuals feel comfortable publicly identifying as such.”

Her commentary was just one example of the growing chorus of support from the reproductive rights and justice community as people come to understand that reproductive health needs are complex, and some populations have historically been left out of the equation.

Combating that oversight includes taking on challenges like providing competency training to health-care providers in medical school and beyond—including the recommendations ACOG is putting forward. Trans-competent health training should allow clinicians to put their patients at ease. At minimum, it should include discussions about gender identity and presentation, how to handle medical issues that may trigger dysphoria, how hormones might affect other prescriptions and the patient’s general health, and why trans patients may feel distrustful and uncertain around health-care providers.

It also includes passing comprehensive legislation to affirm that transition care and related medical treatments are covered by private insurance, Medicaid, and Medicare. And it includes robust third-party investigation—regulated by the HHS, whose Office of Civil Rights is responsible for enforcing the ACA’s nondiscrimination protections—of grievance complaints filed by trans patients, such as those made directly at clinics and hospitals in addition to those filed with state licensing boards.

It’s time to take trans health care seriously. Doing so will create a world of radical inclusion where people can feel safe seeking health care wherever they go.

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