Out of the more than 100 strains of the human papillomavirus (HPV) that have been discovered, approximately 40 affect the genital tracts of men and women. HPV is extremely common: By age 50, 80 percent of women would have been exposed to it and at least 50 percent of sexually active men and women will contract genital HPV at some point in their lives.

Each strain of HPV has the potential to cause an abnormal growth on a particular part of the human body—warts or lesions on or near the genitals, anus, hands, feet, mouth, and upper respiratory tract. Most HPV infections go undetected because they do not cause warts or lesions, and most HPV infections in women younger than 30 clear up without treatment. However, even if you don’t exhibit symptoms of HPV, you may transmit it to another person and symptoms may emerge as long as weeks or months after exposure.

Transmission of HPV

Genital HPV is transmitted primarily through skin-to-skin contact of the genital and surrounding regions, including the vulva, vagina, cervix, penis, scrotum, anus, groin, and thighs. Some HPV infections are contracted through oral sex and result in oral or upper respiratory tract infections. Infection occurs when the virus enters your body through a cut, abrasion, or microscopic lesion in the outer layer of your skin. People who have compromised immune systems, as a result of HIV or immune-suppressing drugs, are at higher risk for contracting HPV. Using condoms significantly reduces the risk of contracting genital HPV, but it does not eliminate the risk entirely as condoms do not cover the vulva, base of the penis, scrotum, anus, groin, and thighs.

Types of HPV

Although most people with HPV do not develop symptoms or health problems, certain strains of HPV can lead to genital warts and others can lead to cellular changes that put you at increased risk for developing cancer of the cervix, vulva, vagina, anus, and penis. HPV types are referred to as “low risk” (wart causing) and “high risk” (cancer causing). In both low-risk and high-risk HPV cases, 90 percent of the time, the body’s immune system naturally clears the infection within two years.

HPV types 6 and 11 cause 90 percent of genital warts. These strains of HPV are considered “low risk” as they are not associated with cancer. “Low grade” cellular abnormalities usually resolve without treatment. HPV types 16 and 18 cause 70 percent of cervical cancer—the most common type of cancer associated with HPV. These strains are considered “high risk” and “high grade” cellular abnormalities are less likely to resolve themselves. Almost all cases of cervical cancer are caused by HPV infections and cervical cancer is far less common in the United States than it is worldwide because we have access to cervical screening tests.

Detection and Prevention

HPV can be detected with a Pap smear or an HPV test, both of which analyze a sample of cells taken from a woman’s cervix during a gynecological exam. While a Pap smear checks for changes in cervical cells, an HPV test checks for the DNA of human papillomavirus. The HPV test is only ordered as a second method of evaluation after a suspicious Pap smear result or if a woman is over 30 and considered to be at high risk for cervical cancer. Although the HPV test was found to be 40 percent better at detecting precancerous lesions than the Pap smear, it also turned up more false positives.

In 2006, the FDA approved Gardasil—a vaccination that protects against HPV types 6, 11, 16, and 18—for women ages nine through 26. More than 74 percent of HPV occurs between the ages of 15 and 24. The vaccination has not been around for long enough for us to know its duration of effectiveness. So far, we know it is effective for at least eight years; boosters may be needed thereafter. Gardasil can still provide protection for someone who has already had an abnormal pap; it is unlikely that she has been exposed to all four virus types that the vaccination protects against. For maximum effectiveness, Gardasil should be administered before the onset of sexual activity. The CDC advises vaccinating all females between the ages of 13 and 26—although injections can start as early as age nine—regardless of sexual activity. The vaccination series includes three injections over the period of six months, the second and third injections given two and six months after the first injection.

Cervical cancer rates have been reduced substantially since routine cervical screening became the standard of care. If Gardasil were administered to every girl before the onset of sexual activity, cervical cancer rates could be reduced by an additional 70 percent. In other words, seven out of 10 cases of cervical cancer would fail to develop and numerous lives would be saved. Despite its proven benefits and lack of serious side effects (the only common side effect is irritation at injection site), Gardasil has undergone substantial political controversy.

The Forgotten Group

Among the gay population, there exists a serious health issue that has been ignored by the healthcare system and media alike. Gay and bisexual men—who are among those systematically denied access to Gardasil—suffer direct consequences of “high-risk” HPV at alarming rates. Anal cancer, like cervical cancer, results from the human papillomavirus. Although anal cancer is uncommon in the general population, men who have sex with men are 17 times more likely to develop it than heterosexual men. The incidence rate of anal cancer in gay and bisexual men is 35 out of every 100,000—a rate that matches that of cervical cancer before Pap smears were routinely used to screen women. Although cervical cancer rates have decreased significantly since the 1970s, anal cancer rates in men who have sex with men continue to rise.

Those who have compromised immune systems are even more susceptible to contracting HPV. While 60 percent of HIV negative gay men have anal HPV, this statistic rises to an astonishing 90 percent in HIV positive gay men. Most people eliminate HPV from their bodies naturally, but those with compromised immune systems are at greater risk. Although antiretroviral drugs prevent opportunistic infections, they do not ward off anal cancer. HIV positive gay men develop anal cancer at twice the rate as HIV negative gay men, and the rate continues to rise as antiretroviral medications are increasing life spans.

According to Dr. Joel Palefsky of UC San Francisco’s Anal Neoplasia Research and Treatment Group, “we should be mounting all-out campaigns to educate people around these issues and immediately implement screening and treatment programs to prevent anal cancer, modeled after the highly successful programs to prevent cervical cancer.” The CDC expresses its awareness of the anal cancer epidemic in men who have sex with men: “Certain populations may be at higher risk for HPV-related cancers, such as gay and bisexual men, and individuals with weak immune systems (including those who have HIV/AIDS).” However, implementing screening and treatment programs is not among the CDC’s priorities.

“There is also no approved screening test to find early signs of penile or anal cancer,” claims the CDC. Jeff Huyett—nurse practitioner, gay activist, and consummate writer—dispels this lie: “The anal cytology test that screens for tissue changes can detect HPV-related cancers in the anal canal and is approved by the Food and Drug Administration. The test to screen for the HPV virus itself, while approved to screen a woman’s cervix is not approved to screen the anal canal for HPV.” The cytological test, or Pap smear—which is considered the first method of evaluation for cervical cells—is effective for evaluating cellular changes indicating cancerous or precancerous changes. It is FDA approved and can be used to evaluate the cells of any mucous membrane, including the bronchial tubes, esophagus, and anus. The HPV DNA test—which is considered the second method of evaluation for cervical cells—is not FDA approved for evaluation of anal HPV, although some studies indicate that it might be helpful for diagnostic purposes.

By failing to recommend routine screening of men who have sex with men, despite their acknowledgment of the population’s increased risk, the CDC enforces notions of poor preventative care. Furthermore, the CDC implicitly condones the application of a sub-par standard of care for gay men, despite their being at higher risk for HPV-related cancer than women. In the words of Jeff Huyett: “It would be considered malpractice if a woman developed cervical cancer due to her provider’s negligence to screen her cervix with a Pap smear. The same kind of clinical responsibility should be given clinicians to screen high-risk men...”

The United States and Canada are behind other countries in terms of preventative care pertaining to HPV. Gardasil is already in use for men in over 40 countries, including Argentina, Australia, Finland, France, Germany, Indonesia, Korea, Latvia, Mexico, Peru, Philippines, Slovakia and the United Kingdom. Dr. Harald zur Hausen—a German scientist who was awarded the 2008 Nobel Prize in medicine for discovering the link between HPV and cervical cancer—argues that because men are susceptible to developing HPV-related cancers, it is important for them to get vaccinated too.

Studies are currently underway in the United States and Canada to test the efficacy of Gardasil in men, but the vaccination will not be approved until testing is completed, which will take an estimated three or four years. “From a perspective of burden of disease it made sense to start with women,” said Sheila Murphy, a spokesperson for Merck Frost Canada.

Others are suspicious that the delay in testing is politically motivated. As of yet, there has been little advocacy pushing for the approval of the vaccination for men, nor for the implementation of routine anal Pap smears for gay men. Wilfred Steinberg, an obstetrician and gynecologist in Canada, offers an explanation: “With the negative reaction in the gay community against the idea of AIDS as a gay disease, perhaps gay people think it is politically incorrect to link HPV and anal cancer with gay men.”