In No Hurry to Give It a Shot
Many College Students Hesitant About Vaccine Offering Protection Against Cervical Cancer

By Laura Sessions Stepp
Washington Post Staff Writer
Tuesday, April 3, 2007

The four women are lounging in the Sigma Kappa living room at George Washington University, discussing the new vaccine that may keep them from dying of cervical cancer. Bryttava Olson, a sophomore, has had two of the series of three injections "because my mom picked me up the first time and said, 'You're going to have a shot.' " Her three sorority sisters, however -- a sophomore and two seniors -- are waiting.

"I need someone to tell me I have to do it," says Sierra Strattner, the other sophomore.

Since the cervical cancer vaccine Gardasil came on the market in June, health authorities and student leaders at colleges and universities have been waging a campaign to inform young people about the vaccine and the human papillomavirus, or HPV, that it attacks. At GWU, freshman Emily Brooks and her fellow campus Democrats worked information tables on campus for a week in February, and health professionals have given more than 300 injections. "I've never seen women so excited about shots," says Cindi Spinelli, a nurse at GWU's student health center.

But there are about 5,000 female undergraduates at GWU. While some of them may have started the shots in their home town, many more, obviously, are holding off. One reason is cost, which can range from $360 to $500. (Some health insurance plans do not cover the vaccination, or cover only part of it.) But they give other reasons as well: The virus is transmitted through sexual activity, and they're not having sex right now. Or they are having sex but are uncertain about how effective Gardasil is or what its long-term consequences might be. Some assume that hookup partners who can afford popped-collar shirts and expensive jeans are not the kind of guys who would be infected. And some admit they think that cervical cancer won't happen to them -- even when, like Strattner, they know someone their age who was diagnosed at an early stage of the disease.

Although the vaccine is most effective in individuals who haven't yet had sex -- a profile that most college students don't fit -- medical authorities are closely following the progress of the vaccine on campus because students, male as well as female, are at such a high risk of acquiring the virus. A recent study by the Centers for Disease Control and Prevention found that women between ages 20 and 24 had the highest infection rate: nearly 45 percent, though only 2 percent of those were infected with cervical cancer strains.

What authorities are finding is some acceptance, but also ambivalence and confusion. Truth is, information doesn't drive behavior in adolescents and young adults, particularly social behaviors like sex, according to specialists such as Michael Cohen, professor emeritus of pediatrics at Albert Einstein College of Medicine in New York. "Teens don't plan their Saturday night that way," he says.

What they learn only in a brochure or class won't make them run to the health clinic for a shot. It won't make them have less sex or, if they get a shot, more sex, as some vaccine critics contend. Other factors are involved in such decisions: sexual maturation, the advice of parents and educators, what they see on YouTube or at the cineplex, what their friends are doing and saying -- particularly a friend they've ended up in bed with.

Condom use is a good example. Most young people know that condoms provide some protection against sexually transmitted diseases, including HPV. But those who are sexually active report using a condom only about half the time, according to the 2006 American College Health Survey.

Male partners are one reason protection is not more common, says GWU senior Adrian Tworecke from her perch in a wing chair at the Sigma Kappa sorority. "They'll ask if you're on birth control, and if you are, they'll say they're not going to use a condom."

And if a woman brings up the fact that a man can be infected with HPV and pass the virus to her?

"You're going to offend him," Strattner says. Or, senior Mallory Kirsh says, "He'll say, 'Do I look like someone who would have an STI?' It's so hard. It makes it look like you don't trust him."

A Too-Distant Future

Many young people tell researchers that they use condoms the first time they have sex, particularly if they don't know the partner well. If they and their partner get tested for STDs and the results are negative, or if they go out with the person several times, they're less likely to continue using protection because condoms lessen the sensations that come with sex.

Four male GWU students interviewed together in a university dining hall say they rely on their partners to enforce condom use. Three of the four say they're more worried about pregnancy than disease. If a date says she's on birth control and doesn't ask her partner to use a condom, "that's a green light," senior Brian Levey says. It's a matter of knowing her well enough to trust that she would tell you if she were infected, he adds.

The young men admit they don't know much about HPV or the new vaccine. Three are surprised to learn that condoms don't provide 100 percent protection against the virus. (Under the best conditions, it's about 70 percent.) They don't know that at least half of all sexually active people will get HPV at some point in their lives or that for most of them, it will clear up by itself.

What they do know is that HPV has more serious health implications for girls and women than for them, that males can't be tested for it yet nor vaccinated against it. "It's hard for guys to take responsibility for condoms or a vaccine when they don't know a lot about the virus and don't think it really affects them," says Jake Tworecke, Adrian's younger brother.

This is a generation that has been vaccinated against more than a half-dozen diseases in their lives, starting in infancy. You might think taking a new series of shots would be a no-brainer for young women. But some sound war-weary.

"There will always be something else out there, some other disease discovered, or a drug that doesn't work anymore," Kirsh says. "We're always hearing about STDs becoming more prevalent. This is the time of our lives when we're supposed to be carefree. Now there's always some danger hovering above."

Some students prefer to focus on the dangers right in front of them, like the friend passed out after a party. Says Levey: "You see someone who's wasted on alcohol or stoned on your couch. Viruses like HPV can seem minor by comparison."

Across the city, at Howard University, many male students are similarly blase, according to Robaer Washington, a senior. "Some guys I know use condoms; some don't," he says, "but a lot of them don't care. All they say is, 'Right now, I'm going to enjoy myself.' "

Howard senior Dominique Scott isn't willing to give young women a free pass, however, saying, "For every guy who's nonchalant about negative conseqences [of sex], I've met a female who doesn't care."

More to Learn

Scott and Washington argue that if the students they know had better information about STDs, they might pay more attention to what they do. Renee Jenkins, president-elect of the American Academy of Pediatrics, agrees.

Behavior may not change quickly with information, says Jenkins, an adolescent medicine specialist at Howard University Hospital, but it won't change at all if you don't have the information.

In a recent national survey of mostly white university students, two out of three said they knew little or nothing about HPV. Jenkins says the proportion is also high among the low-income adolescents she serves.

Pediatricians, who are the primary caregivers for this group, don't have a lot of experience with STDs and are often not well-informed on the subject, Jenkins says.

Additionally, the educational material that physicians and clinics receive from government sources are "pretty dense, not something a lot of people will want to read. We're trying to educate our patients, but I don't get a lot of requests for the vaccine."

At Howard, junior Jennifer Ransome is taking a health class this semester that includes instruction on HPV and other STDs. The class is for women only, and many of the students are afraid to go to a gynecologist, she says. When the teacher told students that condoms, even correctly used, didn't protect completely against HPV, "everyone gasped," she says.

Still, "a lot of them were not for the vaccine." But she is. She says she plans to get her first shot at her upcoming annual visit to the doctor. Scott, too, says she'll get the vaccine, but only if a friend goes with her.

"It's not something I like to do by myself," she says. "I don't need a doc or some commercial telling me. I need my friend's support." ยท

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