12/02/2015 § Leave a comment
Marge Berer, RHM Editor, presentation at: Divided we stand? Universal health coverage and the unfinished agenda of the health MDGs, Institute of Tropical Medicine, Antwerp, February 2014
If you click on the forward arrow after the final slide it will take you to Slideshare pages which are not part of the powerpoint presentation. Please ignore these.
10/02/2015 § Leave a comment
Marge Berer – Editor, Reproductive Health Matters
10th February 2015
This was a case that should never have been allowed to happen. While female genital mutilation (FGM) is a harmful practice and needs to stop, the UK government, politicians from David Cameron on down, and especially the Crown Prosecution Service (CPS), the Director of Public Prosecutions Alison Saunders, the police and the General Medical Council all need to take a giant step backwards and reconsider their position.
The CPS were desperate to find a case with enough evidence that could end in a conviction; the political pressure on them was enormous. By their own admission, however, they spent several years having great difficulty finding a suitable case with enough evidence. They found a case, all right. But on 4 February 2015 at Southwark Crown Court, they had mud on their faces, because the case they had chosen hadn’t got a chance of succeeding, even if they won’t admit it.
It is hard to imagine how women with FGM, in whose name this case was pursued, were in the least helped by it. I sat in the courtroom listening to what was said for over two weeks. I believe it is crucial to share the details with those who weren’t there, to ensure that no one walks away from this thinking ‒ even for a second ‒ that a conviction would have been justified. Everything I report here was given in evidence in court.
The history: an emergency delivery
An exemplary registrar (Dr D) was called into the labour ward of the Whittington Hospital on 24 November 2012, a busy Saturday morning, to deal with an unbooked emergency delivery. It was the woman’s first baby (the court called her AB). She was 9 cm dilated upon arrival, the umbilical cord was wrapped around the baby’s neck and his heartbeat was falling rapidly. An emergency, instrumental delivery was required. The midwife called for a doctor, and Dr D and a junior doctor came in. AB had to be catheterised to empty her bladder. Neither the junior doctor not Dr D were able to access her urethra. AB had had female genital mutilation (FGM) aged 6 in her home country. She had come to the UK as a refugee and been granted asylum. She married in 2010. However, she had difficulty having sex because of the FGM, as the opening to her vagina was too small to penetrate. She went to her GP for help, and was referred to a specialist FGM surgeon, who deinfibulated her in 2011. She healed without problems, and was then able to have sex without difficulty, and got pregnant not long afterwards. However, it seems that during the healing process, she must have developed some scar tissue on her labia that became a problem during her delivery.
With the baby’s head coming down, Dr D and the junior doctor examined AB and discovered that she had previously had FGM. It was later agreed in court with expert witnesses that scar tissue from the deinfibulation was covering her urethra. To open it, Dr D made an incision of 1.5-2cm, which exposed the urethra, and he successfully emptied her bladder. Because of the size of the baby’s head, an episiotomy was also done. Dr D tried forceps first, which didn’t succeed, and then used a suction cap. The baby was born safe and sound. Everyone agreed that Dr D had saved his life. The episiotomy was bleeding quite a lot and was stitched by the junior doctor under Dr D’s supervision. It was her first perineal repair and took about 20 minutes. She was informed she was needed elsewhere and left. As the scar tissue was also bleeding, even though not very much, he did one figure-8 stitch at the apex of the incision, and the bleeding stopped. He then left to do an emergency c-section.
That one stitch − clinically justified, according to several senior physicians’ expert testimony − became a central focus of the case: Dr D was accused of reinfibulating AB, which is illegal.
Dr D had never seen the genitals of a woman with FGM before. He had never received any training or information on how to deal with FGM at a delivery, let alone an emergency delivery. He had only been at the hospital for about a month. He had come to the UK as a child from a country in which FGM is not practised. Although AB comes from a culture that widely practises FGM, she wanted her labia to be opened surgically in 2011 ‒ to have intercourse and children. Why would she want to be closed up again a year later? There was no evidence that she did. She resumed sexual relations after she healed from the first delivery and had a second baby in 2013 ‒ with no incisions and only a small perineal tear.
While Dr D was doing the c-section, he thought about the stitch he had made in AB. He had no doubts it was clinically necessary, but he wasn’t sure it had been the best stitch to use in the circumstances. After completing the c-section, he sought out his consultant and asked for her views. She confirmed that a stitch was necessary to stop the bleeding, but that she would personally have used a different stitch to ensure that the scar tissue would not reseal. However, she decided that it would be humiliating for AB to be approached by her on the post-natal ward to be examined, and she advised Dr D to let it be. Expert witnesses confirmed that Dr D behaved properly in talking to her after the fact, rather than delaying completing his care of AB to seek advice.
Midwife J did not see AB antenatally nor during the delivery. She was sent to AB’s home six days after AB had left the hospital, to examine the alleged reinfibulation. She gave evidence that she examined AB on her bed (a soft surface and without the aid of the sort of bright lamp that would normally be used to examine a woman with FGM), and she thought AB’s labia were almost completely closed. In contrast, AB described her own genitals at the time as swollen and sore, but not closed. Midwife J did not mention seeing any swelling herself, but because the notes in AB’s green book had been “lost” (torn out, in fact), she was working from memory. Who should be believed if not the “victim”, however? Surely, having her labia stitched together again would have been the last thing AB wanted − she had been “opened” in 2011 by her own choice and considers herself still open today.
The prosecution’s case
Having no idea of what was to come, Dr D was promoted by the hospital in April 2013 to senior registrar. Yet someone must have reported the “incident” to the Trust, because Dr D was unexpectedly subjected to an investigation − and then someone brought the police in. Who? We weren’t told. However, it was public knowledge that the Crown Prosecution Service was looking for cases, and the issue of FGM was all over the news by 2013. The police investigation led to charges in 2014, which led to the trial − two years and two months after the delivery of AB’s first baby.
In the interim, by order of the General Medical Council, who seem to work from the assumption that you are guilty until proven innocent, and then may subject you to their own brand of investigation even if you are proven innocent in court, Dr D was not able to complete his training or work as a doctor for two years. He has, however, thanks to the support of senior hospital staff, participated in research on urogynaecological problems in older women, and he received glowing professional and personal character references from senior medical experts who were witnesses for the defence in court. These witnesses confirmed in court that even though Dr D had had no experience of FGM, he behaved properly in talking to the consultant after the fact, rather than delaying completing his care of AB to seek advice. The prosecution, on the other hand, tried to make it look as if Dr D had behaved wrongly, irresponsibly, ignorantly ‒ for not knowing about FGM, for not having read the hospital’s policy and guidance on the subject, for not knowing which stitch was best to make, and for not interrupting his care of AB to find the consultant and ask for advice before he acted to stop the bleeding.
The prosecution’s case rested on evidence from several midwives and the junior doctor, which was inconsistent and full of gaps due to their witnesses not being able to remember a lot of what happened. With the absence of the green book notes, the lack of memory of details on the midwives’ parts was understandable; after all, they see hundreds of pregnant women every year and can’t possibly keep all the details in their heads. But that made the prosecution’s case incredibly weak.
Creating case law and a legal precedent
The defence requested more than once that the judge dismiss the case without the jury having to deliberate. Alison Saunders, the DPP, was quoted in the Guardian (6 February 2015) as implying that his decision not to do so meant there had been a strong case to answer. I disagree. The judge did decline, but the closing arguments and his instruction to the jury of the legal questions they had to answer to reach a verdict, based on the evidence, made it clear beyond any doubt how weak the evidence was. I believe he recognised, wisely, that had he dismissed the charges without going to the very end, the verdict and the legal precedent set would have been far less powerful in regard to future cases.
Given that it was the first criminal trial on FGM in the UK, he had to be sure that justice was done ‒ and seen to be done. And it was.
One of the most complicated aspects of this trial was that the law against FGM itself was being tested for the first time. In my opinion, the law was found sorely wanting, and more needs to be done to prevent weak cases from being brought against innocent people again, and particularly innocent medical professionals. A courtroom is not the best place to debate the rights and wrongs of complex clinical treatment. As it happened, both defence barristers and the judge dealt with the evidence brilliantly, so it should have been no surprise that the jury took less than half an hour to reach a “not guilty” verdict.
But what would have happened if Dr D had been found guilty? In deciding to bring this particular case, as opposed to bringing a case against someone who had actually done an infibulation, particularly on a child, I have to ask whether DPP Alison Saunders lost sight of the fact that the criminal law against FGM expressly mentions the importance of not creating barriers that would prevent necessary surgery, including during labour and delivery, which are specifically mentioned in the law in this regard. Yet the creation of barriers was likely to have been one of the main consequences of this trial had Dr D been found guilty.
Why was it these two men who were on trial?
In my opinion, it is not an accident that the first two people in the UK to be tried for FGM were people of colour and immigrants from Asia and Africa, albeit the doctor was educated, middle class and a health professional.
It is mainly African and to a lesser extent Asian women in the UK who have had FGM themselves. As activists in the cause of stopping FGM, they and others have been campaigning with passion, commitment, integrity and the best of intentions to have FGM recognised as a harmful practice ‒ here, as elsewhere. Nonetheless, I believe this issue has been used politically by people in power, particularly senior Tories, who are seeking to gain credibility as champions of women but only because they can present them as victims of their own cultures.
I am concerned that anti-immigrant politics is their motivation, and is why FGM is in the headlines 40 years after campaigns against the practice first began. Bona fide doctors and their patients, and their patients’ partners and families − most from Africa or Asia − are being demonised, investigated and prosecuted not only for the “crime” of FGM but also the “crime” of sex selective abortion. The connection is visible in the Serious Crime bill currently before Parliament, where all these “crimes” are clustered together to be further criminalised. Pick up any newspaper, any report from Parliament, any statement by a vote-seeking politician or the Director of Public Prosecutions, to see words such as “evil”, “abhorrent” and “barbaric” applied to the practices of people of colour, who are implicated for having brought them to these shores as immigrants.
The responsibility of the hospital
No one suggested putting the hospital on trial, though it may yet come to that. It might easily be said that Dr D was a scapegoat for the hospital’s many failings in this case, and Dr D’s barrister and the judge were articulate about this point on the last day of the trial. AB had had three antenatal visits and had acknowledged having had FGM as a child at the first visit (where she also said clearly that she had been “opened”). Yet AB was not referred to a specialist FGM midwife, as she should have been, which would have avoided everything that happened subsequently. No one ensured that she had an interpreter at any of her antenatal or post-natal visits, and there was no time to find an interpreter during the delivery. Nor did she have a birthing plan. She arrived at the hospital at the last minute, an ambulance having refused to take her there when called several hours earlier. So it was convenient to focus only on Dr D.
However, it would be as much of a mistake now to lay blame on the hospital and the midwives as it was to lay blame on Dr D. Clinicians make mistakes, things are missed out in their training. In an NHS starved of cash by a government trying to bring the whole system to its knees (and also trying to close this particular hospital), they would have little spare time to find and digest the endless policy and guidance documents that now exist in the middle of seeing patients, let alone while handling emergencies, as happened in this case.
Turning a clinical judgement call into a criminal act: the consequences for medical professionals
Maternal deaths are rare in Britain, and one of the most important reasons why has been the historic role of confidential enquiries into every maternal death. The purpose of those enquiries is neither to punish nor to identify who did something wrong, but to identify, analyse and learn from what happened, including any mistakes made and how they could have been avoided or addressed differently. Because Dr D and almost all the witnesses in this trial were medical people, something akin to such an enquiry took place − in the Crown Court. But it was not confidential, it was not anonymous, and it was wholly intended to blame and to punish. In my opinion, this is the crux of the injustice of this case, and I believe it would be a serious error on the part of the medical profession to sit back and allow what happened there to happen again.
I hope it is clear that the legal issues in this case as regards Dr D were in fact clinical ones, and I hope from my description of the evidence that it is clear the law had not been broken. The law against FGM says that FGM, including infibulation (or reinfibulation), is illegal unless it is done on the grounds of the woman’s health and/or in relation to labour and birth. The case against Dr D rose and fell on the question of whether the single suture he did was necessary for AB’s health and was done in relation to labour and birth ‒ or whether it was clinically unnecessary and intended to reinfibulate her.
The violation of AB’s privacy and bodily integrity
I believe this prosecution was a gross violation of the privacy of a woman who had had FGM as a child, which was done in the name of protecting her. Not stating her name and not bringing her into court to give evidence were to protect her privacy. Her privacy was actually violated, however, because her most “private parts” were the main subject of attention throughout the trial, where she was talked about as if she were a piece of meat being dissected, with an unrelenting focus on the most minute aspects of her genitalia. In the end, although this might have been necessary, it almost felt like voyeurism.
The intended outcome of this trial was to open a door to further prosecutions, and indeed a new one was announced on 6 February. The CPS and the police are apparently not stopping to reconsider their position, nor apparently are FGM activists. I hope against hope that the medical profession does. The conviction of Dr D would have threatened the entire medical community, who are increasingly being subjected to criticism, opprobrium ‒ and the threat of criminal sanctions − by demagogic politicians, aided by sting operations against doctors carried out by media such as the Daily Telegraph. Several years ago, the Telegraph succeeded in demonising three South Asian doctors over their alleged willingness to authorise fictitious abortions on the grounds of sex selection. None of the doctors was criminally prosecuted by the DPP, who decided it was not in the public interest, but abortion providers have felt threatened, which was in fact always the intention.
I believe an analysis of the wording of the 2003 law against FGM is needed and would reveal major flaws. I believe this case raises questions about whether there should be a criminal law against FGM at all, and if so, what it should be covering. So if someone should be criminalised, who should it be? Do we really want to put grandparents and mothers and aunties in jail? Do we really want small children to be picked up by the police at the airport and taken into care? And little girls’ genitals examined in school? Should everyone getting into an airplane be treated as a suspected FGM criminal, in addition to being seen as a potential terrorist? The conclusion of most of the experts on this issue internationally has been that criminalisation is not the answer. These are questions I plan to take up next.
Lastly, and I think it cannot be said often enough, serious consideration is needed on the part of Parliamentarians, the Ministry of Justice, the police and the legal profession, as well as the medical profession and medical bodies like the Royal College of Obstetric and Gynaecology and especially the General Medical Council, of the negative and destructive consequences of criminalising medical care to do with women’s bodies and sexuality ‒ especially when it is linked to ethnic and racial profiling ‒ which is the bottom line of the many the ethical issues involved in this case.
Read RHM journal papers on FGM here.
18/12/2014 § Leave a comment
Marge Berer, RHM Editor; Lisa Hallgarten, RHM Online Editor
Reproductive Health Matters, member of HPV Action
This paper, sent to the UK Joint Committee on Vaccination and Immunisation (JCVI) is in support of universal vaccination of all boys aged 12-13 against human papillomavirus (HPV) as a cause of genital warts and HPV-linked cancers that affect men regardless of their sexual orientation
The UK has had a universal policy of vaccinating all girls aged 12-13 with a bivalent vaccine since 2008, and with the quadrivalent vaccine Gardasil since 2012 which, in addition to protection against HPV types 16 and 18, offers protection against two strains of HPV that are responsible for 90% of genital warts, types 6 and 11. According to the Royal Society for Public Health’s September 2014 newsletter, Gardasil also protects against most anal cancers, and while there is currently no data on the efficacy of the vaccine to prevent cancers of the penis, most HPV-related cancers of the penis are also caused by the HPV types prevented by Gardasil. 
From September 2014 the vaccine schedule was changed from three to two doses for 12-13 year-old girls in the UK. Costs will fall concomitantly, freeing up resources. Another vaccine, which has just completed clinical trials, has been found to offer even further protection against the four original HPV types in Gardasil (6, 11, 16, 18), plus five additional variants linked to cervical and vaginal cancers. If it is approved, costs will be altered.
Overall uptake by girls for the vaccination programme has been reported as good.  Data for 2012-13 suggest that around 86% of girls had received all three doses of the vaccine in England, and 82% in Scotland. Prevalence of HPV types 16 & 18 in girls has significantly fallen since the introduction of the programme. However, some groups have shown disproportionally low uptake. Research suggests that there is lower knowledge of HPV and lower acceptability of the HPV vaccine in non-white ethnic groups, which may also be linked to religion. High levels of deprivation have also been linked to low HPV uptake. Other research suggests that poor school attenders or those not in school at all, for example those from travelling communities, are at risk of missing vaccination, particularly where schools do not have systems in place to stop girls falling through the net. 
Another issue with uptake appears to be the setting in which vaccination is offered. School-led vaccination programmes appear to be more successful than those offered through GP surgeries. Health services in Cornwall, where uptake has been particularly poor, are now moving their vaccination programme into the school setting. 
All of this information, before even looking at HPV in men, has implications for extending protection to boys and men. First and most immediately, it shows that opting for a more limited policy ‒ i.e. choosing in 2008 the bivalent vaccine over the quadrivalent one, presumably on grounds of cost, in spite of evidence supporting the wider protection offered by the quadrivalent vaccine[*] ‒ can end up causing a long delay in increasing the level of public health protection available. Four years were lost in this instance, and it took action such as an online survey of members of the British Association for Sexual Health and HIV to convince the government to change its policy. That survey collected responses from 407 doctors and 113 nurses and other health staff in January-February 2011 regarding the two types of vaccines. 93% of respondents said they would advise patients to pay privately for the quadrivalent vaccine, rather than accept the government-funded bivalent vaccine. Of those surveyed who had daughters in the school vaccination programme, 61% had actually paid themselves for their daughters to be vaccinated with the quadrivalent vaccine, and some had given their daughters the quadrivalent vaccine after they had had the bivalent one. 
Secondly, gender-specific immunisation programmes have been demonstrably less effective historically than gender-neutral immunisation programmes. This was exemplified by the UK’s rubella immunisation programme, which began in 1970. An initial decline in the incidence of rubella was followed by a resurgence of the disease in young men and pregnant women, who had not been vaccinated. Yet it was only in 1995 that the programme was modified to include boys as well as girls, a delay of 25 years. 
The evidence from Denmark (where the national HPV vaccination programme is for girls only) on the impact of HPV vaccination on the incidence of genital warts shows that incidence has fallen in women but not in men. The authors believe this is almost certainly because men are having sex with unvaccinated women from Denmark and/or other countries.  Or they may be having sex with other men, or both.
Thirdly, since GP- and other non-school venues for vaccination are leading to lower uptake rates than school-based programmes, and the uptake among some girls is better than among others, policy on vaccinating boys needs to take both these limitations into account. Focusing only on boys over 16 years old means school-based programmes have far less chance of reaching boys from a young age. Secondly, focusing only on men who have sex with men (MSM) aged 16-40 raises issues of how to reach them effectively as a “group” and whether focusing only on MSM who attend a GUM clinic will achieve too little, too late as regards near-universal protection.
Given that there are many communities where coverage rates among girls are much lower, vaccinating boys would help to protect unprotected girls/women. Boys/men would also be protected from acquiring HPV infection from non-vaccinated girls/women both from the UK and from other countries, and as well as from non-vaccinated boys/men.
Perhaps most importantly from the point of view of sexual health information, particularly addressed to children under 16 and young men and women in school, excluding boys sends absolutely the wrong message ‒ that girls and women alone are responsible for sexually transmitted infections and sexual health.
What is known about the effects of HPV and the HPV vaccine in boys and men
HPV is the cause of nearly all cervical cancer cases and also causes cancer of the vagina, vulva, anus, penis and the head and neck. It is estimated to be the causal agent in 5% of all human cancers and is heavily implicated in the recent rapid rise in anal and head and neck cancers. HPV is also the cause of genital warts, the commonest sexually transmitted viral disease.  These diseases affect males as well as females; indeed, it has been estimated that in the UK more than 2,000 cases of cancer in men are caused each year by HPV as are some 48,000 cases of genital warts. 
The risk of acquiring HPV infection is linked primarily to sexual behaviour, including having more than one lifetime sexual partner. No one would ever consider treating only women for sexually transmitted infections (STIs) when they are also transmitted by and to men. Surely the same holds true with vaccination against HPV. The National Survey of Sexual Attitudes and Lifestyles 2000 found that 34.6% of men in Britain aged 16–44 had had ten or more lifetime sexual partners compared with 19.4% of women. British men are therefore at even greater risk of being exposed to, contracting and transmitting HPV infection than women. Each man who is vaccinated would therefore reduce the infection risk for more than one woman. 
HIV infection is strongly associated with increased persistence of HPV infection and the re-activation of latent HPV infection. While much of the research on the increased risk of anal and other HPV-related cancers in men has been in MSM, due to the increased risk of HIV in that population, the incidence of anal carcinomas and anal intraepithelial neoplasia is currently rising in the UK and the USA among both homosexual men, and heterosexual men and women. Number of partners is the issue here, not sexual orientation.
A study recruited 1,159 men aged 18–70 years residing in Brazil, Mexico and the USA who were HIV negative and reported no history of cancer; they were recruited from the general population, universities and health care facilities. The incidence of a new genital HPV infection among them was 38.4 per 1,000 person-months. Oncogenic HPV infection was significantly associated with having a high number of lifetime female sexual partners, and a high number of male anal sexual partners.  Thus, the problem of HPV, including oncogenic HPV, is an issue for men who have sex with women too. The data seem to suggest that there are high infection rates and low disease rates in men, while in women there are low infection and high disease rates. 
The rapid increase in the incidence of HPV-related head and neck cancers over the past 20 years is also an issue for all men. 
A large, national cohort study of Danish men and women examined national patient register data for long-term health outcomes, and specifically the risk of cancer in people with genital warts. The study was among 16,155 men and 32,933 women who had been diagnosed with genital warts from 1978 to 2008. These findings were compared to the general population cancer registry for the relative risk of specific cancers/cancer sites. The total number of cancers observed in the study population was 2,362, compared to an estimated 1,807 cancers in the general population. Overall, patients with genital warts were 30% more likely to develop a cancer compared to those without genital warts. A diagnosis of genital warts was strongly related to anal, vulvar, vaginal, cervical, penile, and head and neck cancer, including sub-sites of head and neck cancer with confirmed HPV association. The risks remained elevated for more than ten years following a genital warts diagnosis. In addition, there were moderately increased relative risk estimates for non-melanoma skin cancer, smoking-related cancers, and Hodgkin’s and non-Hodgkin’s lymphoma. Many of these cancers were also associated with high-risk strains of HPV. 
Thus, the risks from HPV for men as well as women are incontestable.
Data on age at vaccination
A systematic review of data in 64 studies, which reported age-specific HPV prevalence, among more than 14,800 men in 23 countries, generally limited to men >18 years old, found that HPV prevalence was high among the sexually active men in all regions but with considerable variation, depending on age, country and region, ranging from 1% to 84% among low-risk men and from 2% to 93% among high-risk men. Peak HPV prevalence spanned a wide range of ages and, compared with that in women, seemed to peak at slightly older ages and remained constant or slightly decreased with increasing age, suggesting longer-term persistence of high-risk HPV infection in men or a higher rate of re-infection. 
In every year that passes, over 400,000 boys miss out on the opportunity to be protected against a virus that causes 5% of all cancers.
Immunity against HPV is greater if the vaccine is administered before age 16. The US Centers for Disease Control and Prevention say:
“Data on immunogenicity in males are available from the phase III trial conducted among males aged 16 through 26 years and from bridging immunogenicity studies conducted among males aged 9 through 15 years. Seroconversion was high for all four HPV vaccine types and post-vaccination antibody titers were significantly higher in males aged 9 through 15 years compared with males aged 16 through 26 years.” 
MSM are at risk of HPV infection immediately after sexual debut. A study of young MSM in Australia found that early and high per partner transmission of HPV occurred between men soon after their first sexual experiences. It therefore recommended that HPV vaccination should commence early for maximal prevention of HPV among MSM.  
Why vaccinating only MSM is not good enough
The reason the term “men who have sex with men” was coined was because many MSM may not identify as “homosexual” or “bisexual” and because they may have sex with girls/women and boys/men over the years. We repeat ‒ because it is the sexual activity that puts them at risk, services need to focus on attracting the people whose sexual activities put them at risk. Moreover, expecting boys and young men (who may not be sexually active yet or sure of their sexual identity) to have to identify whether they have had or will have sex with other boys/men presents both practical and ethical difficulties.
How would policymakers propose to find boys who say they are, or might in the future be MSM, in order to single them out from other boys in order to vaccinate them? What if boys do not identify themselves as MSM publicly, or even in their own minds, given the stigma that still exists? Would a leaflet be enough to bring them in to be immunised in herd-protective numbers? Would talking to their parents, to whom they may have said nothing about their sexuality?
UK data suggest that GUM clinics will not see young MSM before they become infected with HPV.  The median age of MSM at first attendance at a Southampton GUM clinic was 32; thus, most MSM would have had multiple sexual partners with high risk of HPV acquisition before they had attended any clinic. Also, many gay and bisexual men do not use GUM clinics. The 2011 Stonewall Gay and Bisexual Men’s Health Survey, with 6,861 respondents, found that one in four had never been tested for any sexually transmitted infection and 44% had never discussed STIs with a health care professional. One in ten had had sex with women as well as with men in the previous five years. 
Given the data summarised above, GUM clinics would therefore not be an effective place to vaccinate sufficient numbers of still uninfected MSM. In fact, the evidence suggests that vaccinating MSM aged 16-25 and those who attend GUM clinics is not the best way to protect even the MSM population as a whole, let alone their sexual partners.
The issue of discrimination under the Equality Act 2010
Lastly, there is the question of discrimination under the Equality Act 2010, which lists the following as some of the relevant characteristics protected in law against discrimination: age, sex, and sexual orientation.  Given the substantial evidence of the protective effect of HPV vaccination for all boys and men as well as all girls and women, the failure to ensure that HPV vaccination policy is aimed at universal protection could be construed as discriminatory under the Equality Act 2010, and a case could be taken against the government for withholding the vaccine from boys who identify as MSM aged 12-15 and all boys and men who identify as heterosexual.
We believe the JCVI recommendation is discriminatory under the Equality Act 2010. We also think it is not the best policy from a public health perspective either. We question why further information is required before making a recommendation for a universal vaccination programme.
Growing support for vaccination of all boys against HPV
The US Advisory Committee on Immunization Practices of the US Centers for Disease Control & Prevention has recommended that adolescent boys and young men aged 11–21 should be vaccinated against HPV, and that all gay and bisexual men and HIV-positive men aged 26 and under should be vaccinated. 
A number of countries, including Australia, Austria and some parts of Canada, have already extended the vaccine to boys as well.
An editorial introducing a group of articles about HPV in the Journal of Adolescent Health in 2010 argued that the most acceptable way to achieve high uptake of HPV vaccine was to offer voluntary school-based vaccination, supported by effective consent processes, training, and best practice guidelines for those providing the vaccination, and education for parents, adolescents, and teachers. School delivery programmes, it argued, were also the most feasible for vaccinating both boys and girls, with new data suggesting that older adolescent boys’ health care practices were exceptionally low. 
Conclusions and recommendation
In conclusion, we believe the case for universal vaccination of all adolescents aged 12-13 is strong. In September 2014, in a letter to the BMJ, the All-Party Parliamentary Group on Cancer called for vaccination of all boys in the UK.  This approach is supported by the 35 organisations that make up HPV Action, of which we are one. Cancer Research UK also believes that “vaccinating boys would be beneficial for public health”.
HPV Action estimates that the additional cost of extending the HPV vaccination programme to boys in the UK would be in the region of £20–22 million a year. This relatively small cost has to be set against the economic impact of HPV-related disease. The cost of treating genital warts in England alone is estimated to be over £52 million a year.
Gardasil, the quadrivalent vaccine, is already licensed in the UK for use in boys aged 9–15.
We therefore call on the JCVI to adopt and put forward to the UK government the following recommendation: that the most effective way to eliminate HPV and HPV-related diseases is through a gender-neutral, universal vaccination programme for all children aged 12‒13.
Anything else is discriminatory, inequitable, less effective, and difficult to explain or justify.
- Royal Society for Public Health. September 2014 newsletter.
- Doctors bypass NHS for their daughters’ HPV vaccination. British Association for Sexual Health and HIV (BASHH) press release, 15 February 2011. http://www.thefreelibrary.com/British+doctors+recommend+bypassing+free+National+Health+Service…-a0259077137
- Kubba T. Human papillomavirus vaccination in the United Kingdom: what about boys? Reproductive Health Matters 2008;16(32):97–103. http://www.rhm-elsevier.com/article/S0968-8080(08)32413-6/fulltext
- Baandrup L, Blomberg M, Dehlendorff C, et al. Significant decrease in the incidence of genital warts in young Danish women after implementation of a national human papillomavirus vaccination program. Sexually Transmitted Diseases2013 40(2):130-5. http://www.ncbi.nlm.nih.gov/pubmed/23324976
- Baker P. Going gender-neutral with the HPV vaccine. British Journal of Nursing 2014;23(11):550. http://www.theswallows.org.uk/wp-content/uploads/BJ-Nursing-HPV-june-2014.pdf
- Johnson AM, Mercer CH, Erens, B et al. Sexual behaviour in Britain: partnerships, practices and HIV risk behaviours.Lancet2001;358:1835–42. http://www.sciencedirect.com/science/article/pii/S0140673601068830# Cited in Kubba .
- Giuliano AR, Lee J-H, Fulp W, et al. Incidence and clearance of genital human papillomavirus infection in men (HIM): a cohort study. Lancet 2011;377:932–40. http://www.sciencedirect.com/science/article/pii/S0140673613608090
- Monsonego J. Genital infection with HPV in men: research into practice. Lancet 2011;377:881–83. http://www.sciencedirect.com/science/article/pii/S0140673611602778
- Potentially HPV-related head and neck cancers. National Cancer Intelligence Network (NCIN) http://www.ncin.org.uk/publications/data_briefings/potentially_hpv_related_head_and_neck_cancers
- Blomberg M, Friis S, Munk C, et al. Genital warts and risk of cancer – a Danish study of nearly 50,000 patients with genital warts. Journal of Infectious Diseases 2012;205(10):1544‒53. http://www.ncbi.nlm.nih.gov/pubmed/22427679
- 12.Smith JS, Gilbert PA, Melendy A, et al. Age-specific prevalence of human papillomavirus infection in males: a global review. Journal of Adolescent Health 2011;48(6):540–52. http://www.ncbi.nlm.nih.gov/pubmed/21575812
- Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males — Advisory Committee on Immunization Practices (ACIP)Centers for Disease Control and Prevention 2011; 60(50);1705-1708 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm.
- Zou H, Tabrizi SN, Grulich AE, et al. Early acquisition of anogenital human papillomavirus among teenage men who have sex with men. Journal of Infectious Diseases 2014;209(5):642‒51. http://www.ncbi.nlm.nih.gov/pubmed/24265440
- Zou H, Tabrizi SN, Grulich AE, et al. Site-specific human papillomavirus infection in adolescent men who have sex with men (HYPER): an observational cohort study. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2814%2970994-6/fulltext
- Clarke E, Board C, Patel N. Why are anogenital warts diagnoses decreasing in the UK: bivalent human papillomavirus (HPV) vaccine cross-protection or failure to examine? Sexually Transmitted Infections 2014;90(8):587. http://www.ncbi.nlm.nih.gov/pubmed/25398729
- Stonewall Gay and Bisexual Men’s Health Survey. http://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final.pdf.
- Equality Act 2010. http://www.equalityhumanrights.com/legal-and-policy/legislation/equality-act-2010
- Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule: United States, 2012. Annals of Internal Medicine 2012;156(3):211–17. http://www.ncbi.nlm.nih.gov/pubmed/22298576
- Skinner SR, Cooper Robbins SC. Voluntary school-based human papillomavirus vaccination: an efficient and acceptable model for achieving high vaccine coverage in adolescents. Journal of Adolescent Health 2010;47(3):215–18. Doi: http://www.sciencedirect.com/science/article/pii/S1054139X10003186
- John Baron MP and chair, All Party Parliamentary Group on Cancer, et al. Time to vaccinate boys against HPV infection and cancer, say parliamentarians with special interest in public health [letter]. BMJ 2014;349:g5789. Doi: 10.1136/bmj.g5789. http://www.bmj.com/content/349/bmj.g5789
[*] By 2008, worldwide the quadrivalent vaccine was already considered the vaccine of choice and had been selected by health authorities in the United States, Australia, New Zealand, Canada, Switzerland, Italy, Spain and Sweden for regional and national immunisation programmes.
12/11/2014 § Leave a comment
Marge Berer, RHM Editor
The Joint Committee on Vaccination and Immunisation (JCVI) advises the UK Department of Health on its vaccination programme and has been considering the question of whether to vaccinate boys against the Human Papillomavirus (HPV). Today it published its interim recommendations, which do not address a universal programme of vaccination for boys as well as girls.
The UK currently has a programme of HPV vaccination for girls to prevent cervical cancer which is most commonly caused by infection with HPV. Because it is important to vaccinate before they become sexually active and come into contact with the virus, the vaccination is offered to all girls aged 12-13 years old.
In addition to cervical cancer, HPV is a factor in many other cancers including anal cancer, penile cancer, mouth cancer and oropharyngeal cancer, all of which affect men as well as women. People living with HIV are at higher risk of all these cancers. Under the current regime, there is no HPV vaccination programme for boys. Assuming men in the UK only have sex with women who have been vaccinated, they should be protected from HPV. However it is safe to assume that men in the UK may also have sex with:
- women who missed out on vaccination because of their age (vaccination for girls was only introduced in 2008) or parental withdrawal from the scheme,
- women from countries where there is no vaccination programme,
- and other men
Recognising the range and seriousness of diseases that can be prevented, the Australian government introduced HPV vaccination for teenage boys in 2013. HPV action, a UK coalition of 35 health-related organisations, has been lobbying for the same ‘gender-neutral’ vaccination in the UK.
The interim decision of the JCVI, published today, is to advise that “a programme for the vaccination of MSM aged 16 to 40 years of age should be implemented in GUM and HIV clinics in the UK using the quadrivalent HPV vaccine, subject to the programme being provided at a cost-effective price”. This suggestion is shortsighted beyond comprehension.
The whole point of talking about the sexual health needs of MSM (men who have sex with men) as opposed to homosexual or gay men in the first place is because men who have sex with men don’t all only ever have sex with other men. As both men and boys, they also sometimes have sex with women. Given that universal vaccination of girls to prevent human papillomavirus (HPV) and genital warts has been accepted as a public health priority globally, surely universal vaccination of boys is equally a priority – since boys and men are at risk of an equally serious range of cancers and other diseases from HPV (especially if they have HIV), and they have genital warts as often as girls and women.
How could anyone have suggested, let alone seriously considered, vaccinating only MSM in the male population in the first place. What did they expect to do as regards adolescent boys – walk into schools and say “Which boys are having sex with other boys here? Raise your hands − and please come to the school clinic now.”?? Or even more absurd, how can they advise waiting until a boy or man attends an STI clinic in order to recognise they are at risk of HPV, and offer them a vaccination after the fact, when it may be too late! It also seems transgender people aren’t on the radar at all, in spite of findings from 15 countries in the Lancet Infectious Diseases in 20131 that 19% of transgender women have HIV(1), and transgender men also have a high HIV prevalence, which puts them at increased risk of HPV infection and HPV-related diseases.
Moreover, studies have shown that a female-specific vaccination approach would be only 60–75% as efficient at reducing HPV prevalence in women as a gender-neutral vaccination(2).
The only sensible policy is universal vaccination, from the same age as girls of 13, and with the same catch-up provisions for those who are older.
(1) Baral SD et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis, 13: 214-22, 2013.
(2) Kubba T. Human papillomavirus vaccination in the UK: what about boys? RHM 16(32) 97-103
All RHM papers and research round ups on HPV are available to download here
06/10/2014 § Leave a comment
On September 25th RHM Editor, Marge Berer, participated in an evening meeting held to mark September 28th, International Day of Action for the Decriminalisation of Abortion. Delegates at the meeting held at Amnesty International heard from the Central American Women’s Network (CAWN) and Amnesty about the work both organisations are doing in El Salvador to draw attention to the impact of the total criminalisation of abortion on women’s health and human rights. Amnesty launched this report and CAWN screened Life at Any Price.
Marge Berer then did a presentation capturing latest developments in abortion law and policy in Ireland, Spain and the UK.
The future as envisioned by WHO for the post-2015 agenda: a serious regression from its long-standing commitments on sexual and reproductive health and rights
08/07/2014 § Leave a comment
Editor, Reproductive Health Matters
What has gone wrong at WHO? The Lancet’s Offline report (31 May) of what they call “WHO’s definitive statement about the future it envisions for the post-2015 era of sustainable development” signals a serious regression by WHO away from championing its own policies of many years, and makes for a distressing read. Among the policies WHO should be promoting for the post-2015 agenda setting must surely be:
i) the right to the highest attainable standard of health, as one of the fundamental rights of every human being, a goal which has underpinned WHO’s work since it was founded in 1948,
ii) universal access to sexual and reproductive health and rights, and
iii) strengthening of health systems, taking into account the social and economic determinants of health.
“Universal access to sexual and reproductive health and rights” is in line with WHO’s 2004
Reproductive Health Strategy, approved by the 57th World Health Assembly and reflects more than four decades of work by the Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based at WHO, and most recently a resolution at the 67th World Health Assembly.
The most important international bodies and leaders currently support the inclusion of universal access to sexual and reproductive health as a crucial goal in its own right under the overarching health goal in the post-2015 agenda, and add reproductive rights to this also under gender equality. The Stockholm Statement of Commitment agreed by 260 Parliamentarians from 134 countries at the Sixth IPCI/ICPD Conference in April 2014 states that access to sexual and reproductive health and rights is an ‘indispensable component’ of the post-2015 development framework. On July 4th a letter from Parliamentarians around the world addressed to Dr Margaret Chan, Director General of the WHO, expressed their concern about the omission of reproductive health and ‘strongly’ support for the Stockholm statement.
Moreover, in consultation after consultation, numerous national and international civil society organisations have called for the inclusion of reproductive and sexual health and rights as an integrated whole as well.
It is a serious mistake on WHO’s part to try to bury this issue under Universal Health Coverage, where it will get lost in a sea of competing finance-oriented interests. To do so discounts the consistent support for these goals by the World Health Assembly as well as the work of countless WHO staff and expert advisors.
There are other indications of a systematic pushback and regression away from work on sexual and reproductive health and rights at WHO as well. It is not reflected as a priority in the 12th WHO Global Programme of Work, nor in the just published Health for the World’s Adolescents, an unprecedented omission. This cannot be taken lightly.
Friends of WHO must do everything they can to ensure WHO assumes its leadership role on these issues again and does not fall back on its longstanding commitments.
14/04/2014 § Leave a comment
Marge Berer, RHM Editor
Last month an obstetrician-gynaecologist and the husband of a patient at the Whittington Hospital in London were charged with the crime of female genital mutilation (FGM) because of a procedure carried out on a woman, following childbirth, who had previously experienced FGM.
This is the first prosecution for FGM in the UK since it was criminalised in 1985 and the law further amended in 2003. This fact may suggest that the Crown Prosecution Service (CPS) have been too circumspect before now in bringing a prosecution. On the other hand, do they think the current case is watertight, given that the woman will have needed some kind of repair following delivery of her baby? Part of the problem is that the lack of previous prosecutions and recent highly emotional and effective campaigning by a new generation of anti-FGM activists may have put pressure on them to bring the only case they felt had a chance of success, even one which may not stand up to legal or clinical scrutiny further down the line.
The decision to make the arrests was celebrated by veteran anti-FGM campaigner Efua Dorkenoo, who was reported on the website of the International Federation of Gynecologists and Obstetricians to have “welcomed news of the first prosecution relating to the procedure in the UK”. At the same time, an article by Sarah Ditum in the New Statesman on 24 March, asked why the first prosecution took 30 years since the law was first passed. Neither woman addressed the details of the actual case, which were unknown, nor whether it was the right place to start.
However, a letter from a group of distinguished, senior obstetrician-gynaecologists, published in the Guardian soon after the arrests, said that for pregnant women whose external genitals had been cut and stitched together, leaving only a small hole for urination and menstruation, defibulation (that is, opening the stitching), is required for them to give birth, and then after the birth, some form of repair is also required. The Crown Prosecution Service are well aware of this, and that the law exempts such repair from prosecution. Indeed, its website with legal guidance on FGM states:
“No offence is committed by a registered medical practitioner who performs a surgical operation necessary for a girl’s physical or mental health… but only if the operation is on a girl who is in any stage of labour, or has just given birth, and is for purposes connected with the labour or birth.”
While it is also “an offence under the Act for any medical professional (or anyone, for that matter) to reinfibulate or close a woman after she has been defibulated during labour for childbirth” this is diffferent from needing to repair the tissue itself. According to this, obstetricians and midwives should have nothing to fear from providing necessary treatment to a woman who has been deinfibulated before or during labour and needs some kind of suturing afterwards. The signatories to the Guardian letter believe that this prosecution, which may be about this very kind of repair, will create a climate of fear for obstetricians and tie their hands when it comes to providing necessary (and sometimes life-saving) care to women who have had FGM in the past.
This case may hinge on whether the procedure carried out was in fact necessary clinical care or actually went further, in particular, by reinfibulating the woman (i.e. sewing her labia together again, effectively reinstating the FGM, which is against the law). This uncertainty suggests that the guidelines (or their interpretation by the CPS) may not sufficiently distinguish between suturing intended to result in reinfibulation, and suturing to prevent bleeding and accelerate healing for a woman whose infibulated vulva has been cut open to make childbirth possible.
The last thing we need in the UK is to obstruct the very medical professionals who have the skills to help pregnant women with the more severe forms of FGM to have their babies safely without resorting to a caesarean section.
For answers, we must await further details of the case. In the meantime, the conflicting reactions of people who are in fact united in their concern for women’s health and their opposition to FGM itself, serve to demonstrate what a blunt instrument the law may be when dealing with a practice such as FGM.
Action against FGM has been taking place in almost every country where it is practised for up to 20-30 years now. According to a comprehensive review by UNICEF, published in 2013, signs of change – reduced prevalence, more local opposition, especially among younger people, less damaging forms of FGM being used, including symbolic pricks and nicks in the clitoris − are finally appearing in a growing number of countries. But change has been slow because girls and women who do not have FGM have simply not been marriageable. Prosecution has rarely been tried in spite of laws against FGM in many places, both in Africa and Europe, because it is believed by many that far from stopping the practice, this would only push it underground. A recent RHM article from Tanzania (1) corroborates this, reporting on the claim by several ethnic groups that FGM has had to be continued in spite of the law to prevent a new form of genital infection, not for its own sake.
Prosecution or doing nothing are not the only two options. Calling for mandatory information in sex education classes is a bit difficult when sex education itself is not mandatory, thanks to government fears of conservative criticism. How to educate ourselves more needs to be debated and discussed, and needs to reflect the knowledge and expertise of those within the communities where FGM is practised. For example, the call from activists from those communities to designate FGM as “child abuse” instead of a cultural practice was extremely powerful.
Those activists believe that prosecution is a necessary part of the package of actions to stop FGM. However, it is important that prosecutions do not push the practice further underground or inadvertently have a negative impact on those health professionals whose practice supports women with FGM to come through childbirth safely, or to restore genital health and sexual pleasure in spite of the previous mutilation (2).
Post Script (16th April 2014)
This case was heard at Westminster Magistrate’s Court on 15th April 2014 and was referred to Southwark Crown Court to be heard on the 2nd May.
(1) Ali C, Strømb A. ‘It is important to know that before, there was no lawalawa.’ Working to stop female genital mutilation in Tanzania. Reproductive Health Matters 2012; 20 (40):69-75 Doi: 10.1016/S0968-8080(12)40664-4).1.
(2) Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012 Jul 14;380(9837):134-41. doi: 10.1016/S0140-6736(12)60400-0. Epub 2012 Jun 12.
A selection of RHM articles on FGM, labial surgery and cosmetic surgery:
These topics have been covered extensively in RHM. All RHM papers older than one year are now free to download from RHM-Elsevier.