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30 October 2019

What Gareth’s bottom lump says about the need for gender-neutral immunisation

From 2015, there were mounting calls for the HPV vaccine to be administered to all children irrespective of gender, as is the case in Australia and the US.

By Phil Whitaker

Gareth began by telling me he was embarrassed. I gave an encouraging nod, trying to convey that, whatever he was about to say, I had probably heard it before and certainly wouldn’t be judging him over it.

“I’ve noticed this lump,” he said. “By my bottom.”

It had been there four or five months, he said, and he’d been hoping it would go away by itself. No, it wasn’t painful or itchy and it had never bled. It was just there.

By far the commonest perianal lumps are related to piles – either the haemorrhoid itself or an associated skin tag. But that was not what I found when I examined Gareth. Instead, there was a thickened firm mass in the skin.

“I’m worried,” I told him, once he’d retaken his seat. “I’m going to refer you urgently to the hospital. We need to make sure that isn’t a form of cancer.”

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Infection with human papillomavirus (HPV), which is transmitted during sex, generally results in nothing more serious than warts, but there are a few of strains that have the capacity to cause malignancy. HPV underlies virtually all cases of cervical cancer, and people of either sex can develop HPV-related malignancy on the genitalia, in the mouth, or – as I feared in Gareth’s case – the anus.

Cervical cancer is the most common HPV-related tumour, and in an initiative to prevent the disease, immunisation was introduced in 2008. HPV vaccination works best if administered before the onset of sexual activity – and hence potential exposure to HPV – so the programme was offered to girls aged 12 and 13. By 2015, however, there were mounting calls for the UK to follow the example of countries like Australia and the US, and immunise all children irrespective of gender.

The Joint Committee on Vaccination and Immunisation (JCVI) examined the issue in 2017, and was initially reluctant to extend the programme to boys. Uptake among girls was high, and the resultant herd immunity will have the effect of reducing most boys’ exposure to HPV once they became sexually active. The glaring flaw in this approach, of course, is that only heterosexual males benefit from this vicarious protection. But the JCVI’s analysis suggested that it would not be cost-effective to extend the programme to all schoolchildren in order to cover those who would later become men who have sex with men (MSM). Instead, the JCVI recommended that MSM up to the age of 45 should be offered immunisation on an ad hoc basis – even though, by definition, this would be a sexually active population in whom HPV exposure may already have occurred.

The JCVI’s recommendation provoked a backlash, with the Terrence Higgins Trust, a leading campaigner for gender-neutral vaccination, describing it as “deeply disappointing”. Too narrow a focus on cost-effectiveness had left the JCVI open to accusations of discrimination on the basis of sexual orientation. Alternative modelling of cost-benefit was swiftly commissioned, which – I imagine to everyone’s relief – supported extending the programme. Gender-neutral HPV immunisation was rolled out in England this September, with the other home nations soon to follow suit.

Biopsy confirmed my suspicions about Gareth’s lump. Fortunately his anal cancer showed no signs of having spread. Most cases require chemotherapy and radiotherapy, but Gareth’s should hopefully have been cured by surgical excision.

Thanks to gender-neutral vaccination, the next generation should see far fewer men like Gareth developing HPV-related malignancy. There is one sour note, though – the refusal of the government (which in the case of jabs such as MMR appears passionate about improving uptake) to fund a “catch-up” programme to immunise those boys who missed out when only girls were eligible. Otherwise, in 20-30 years time there will be a cohort of male patients left wondering if their cancers might actually have been prevented had they been treated equally to their peers. 

This article appears in the 30 Oct 2019 issue of the New Statesman, Britain alone