While clicking through Snapchat the other day, an ad for Merck’s new Versed campaign for Gardasil, its vaccine against the human papillomavirus (HPV), stopped my thumb in its tracks. As a researcher interested in how gender and science interact in the realm of health policy, I knew what a controversial blunder its earlier marketing had been.
I clicked with caution, was directed to the campaign’s website, and was surprised: a diverse, coolly confident group of 20-year-olds — female and male — dressed in beanies, snapbacks, neutrals, and raw denim were telling me “to get versed about HPV.” Although it was clearly trying very hard to be hip, perhaps overcompensating for Merck’s previously unpopular marketing, the website did highlight important facts about HPV and also mentioned that the virus could be transmitted by sex.
The Versed effort helps debunk two common misperceptions that Merck’s earlier campaign had stoked: that Gardasil is a female-specific vaccine for cervical cancer, and that sexual transmission isn’t important, or at least isn’t worth talking about.
More than 100 different strains of the human papillomavirus have been identified. They infect 80 percent of women and 66 percent of men at least once over the course of their lives. While the majority of HPV infections disappear without treatment, prolonged infection with high-risk strains can develop into a variety of cancers: cancer of the mouth, throat, cervix, and genitals, including anal, penile, and vaginal cancer.
The FDA approved Merck’s HPV vaccine, Gardasil, for female use in 2007 and two years later approved GlaxoSmithKline’s (GSK) version, Cervarix.
Because Merck included only females in its efficacy trials for the vaccine — even though researchers knew that males could transmit the virus and could also be harmed by it — the initial approval and promotion of Gardasil turned vaccination into a health issue for young women only. Pharmaceutical companies marketed it to this population and physician and public dialogue socially constructed it as “the girls’ vaccine.”
This completely jeopardized herd immunity, the form of immunity that occurs when the vaccination of a significant portion of a population (the herd) provides a measure of protection for individuals who have not developed immunity. It ignored that 50 percent of those carrying the virus in heterosexual interactions are male. As a result, females who were unable to access the vaccine weren’t protected from male HPV transmission. Merck’s powerful female-specific narratives didn’t end when the FDA approved Gardasil for males in 2009.
Merck’s powerful female-specific narratives didn’t end when the FDA approved Gardasil for males in 2009.
The fallout of this focus on females is reflected in vaccination rates. In 2014, 60 percent of females and 42 percent of males aged 13 to 17 years had received at least one dose of the vaccine, while 40 percent of females and 22 percent of males completed all three shots in the vaccine series. Although 2016 data suggests that the gap may be narrowing, there is still a lack of gender parity. While Merck may argue that it was using the foot-in-the-door principle, its later attempt to introduce male HPV vaccination came at a cost — society’s misperception of HPV had already been solidified.
The Versed campaign directly mentions that HPV is a sexually transmitted virus, another important step in the right direction. The original Gardasil campaigns did not talk about sex, using gender stereotyping in a way that disempowered women. Merck’s ads depicted mothers and daughters expressing shock at the connection between HPV and cervical cancer. Marketing a narrative that included females as naïve victims worked because it affirmed the mainstream media portrayal of women as without knowledge or power and in need of protection.
Failing to address the sexual nature of HPV transmission solidified harmful gender stereotypes about sex — females as passive, receiving, and denying; males as sexual initiators. That is evident in Gardasil’s 2008 “I Chose” campaign. It shows a series of females giving their reasons for choosing to get vaccinated. The women’s reasons range from “I will do everything I can to protect myself against cervical cancer” to “I chose to get vaccinated because my dreams don’t include cervical cancer.”
At face value, the focus on choice in Merck’s commercials elicits feelings of empowerment. Yet presenting a woman’s choice as between vaccination and cervical cancer implies that initiating safe sex is not an element she has control over.
Kudos to Merck for finally addressing these points of misperception, as they have undermined the HPV vaccine’s ability to promote health for all. But it shouldn’t have taken more than a decade and a changing social climate around female sexuality for the company to reevaluate its marketing tactics.
Pharmaceutical companies shouldn’t wait for things to become “acceptable” in society before they choose to embrace them. The strategy of backing things only after they become socially acceptable is highlighted in the one thing missing from the Versed educational campaign: the heightened risk of HPV-related anal cancer among men who have sex with men. The American Cancer Society has released numerous statements identifying HPV as the cause of the majority of anal cancer — much of which is preventable — in men who have sex with men. The link between HPV and anal cancer was well-known among scientists before the development of Gardasil.
Yet men who have sex with men were consciously left out of the original trials and now, a decade later, when this is socially accepted behavior, the Versed campaign is still silent about it. I believe this is largely because the sexual behavior of the LGBTQ community is still heavily stigmatized.
HPV can affect anyone, regardless of sex, gender, or sexuality. Marketing to a certain demographic, or not including all the facts, can exclude individuals from the reaping the health benefits of a product. The pharmaceutical industry has an important stake in public health, and so has a responsibility to consider what strategy promotes health for as many people as possible when it comes to the development and marketing of any drug or device.
Going forward, how can pharmaceutical companies avoid reifying societal biases and, as a result, undermining the public health effectiveness of their products?
It isn’t uncommon for moral politics to play a role in the FDA approval process, and pharmaceutical companies may cater to them. That’s why people working at the FDA need to set a new precedent: keep societal norms separate from science. In particular, the FDA must be vigilant in addressing sexual and gender stereotypes in the development, approval, and marketing of pharmaceuticals. For instance, it is simply not OK that women still have a high cost imposed on them for being sexually active — the FDA hasn’t approved making oral contraceptives for women available over the counter — while men don’t.
Biases about gender and sexuality do nothing but hinder a product’s ability to promote health. While the pharmaceutical industry and FDA are waiting for certain health issues to become de-stigmatized, people are developing eminently preventable cancers and dying from them.
Ashley Andreou is working toward a master’s in public health at the Yale School of Public Health and is a research and advocacy fellow at Yale Law School.