The authors respond to “Supporting the call for a gender-neutral human papillomavirus vaccination in Canada”
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* Gilla K. Shapiro
* Samara Perez
* Zeev Rosberger

We thank Patel and Macartney for their recent letter and for providing evidence of Australia’s experience.1 It is particularly interesting that, since males were incorporated into Australia’s funded human papillomavirus (HPV) vaccination program, not only have male vaccination rates in Australia increased, but female vaccination rates have also been positively influenced and have increased as well.2 This is unexpected, and it would be helpful to isolate the mechanisms that may have influenced this increase in female vaccination rates. Could a gender-neutral communication strategy about HPV and the HPV vaccine be more convincing and acceptable to parents of girls and their daughters? Are parents less skeptical of a vaccine that is provided to males and females?

We are optimistic that the recent change of policy to provide access to free HPV vaccination for males in some Canadian provinces will also increase HPV uptake rates in both males and females. Notably, since September 2016, three additional Canadian provinces (Manitoba, Ontario, and Quebec) have joined three provinces (Alberta, Nova Scotia and Prince Edward Island) in providing HPV vaccination for both males and females.3

We are very encouraged by the descriptive findings showing that, since Australia funded males, vaccination rates in both males and females have improved. Nevertheless, we wonder whether these results can be extrapolated to other countries like Canada. With additional data in the future, this trend can be statistically investigated and verified. To do so, it will be important for HPV vaccination rates in Canadian provinces to be closely monitored and evaluated over time.

We also agree with Patel and Macartney that vaccinating children regardless of gender is the most equitable policy approach.1 Indeed, since publishing our article in April, British Columbia (BC) — a province that vaccinates females and only a subset of males (including men who have sex with men and street youth)4 — has faced a human rights complaint from twin brothers in grade six who argue that BC’s policy is discriminatory.5 This complaint is under review and a decision is expected in the near future.

As findings published in a recent special report on HPV-associated cancers from the Canadian Cancer Society have shown, HPV-associated cancers in males are becoming a serious health concern.6 The proportion of HPV-associated oropharyngeal cancers in males (i.e., 28%) surpasses oropharyngeal cancers in females (i.e., 7%) and is approaching the proportion of cervical cancers (i.e., 35%, 2012 statistics).6 The Canadian Cancer Society predicts that, if the incidence trends continue, oropharyngeal cancer rates in males will soon exceed the incidence of cervical cancers in females.6,7 An increasing need for HPV vaccination for males will further exacerbate the inequity of programs that only provide the HPV vaccine to females.7

A gender-neutral HPV vaccination program across Canada may increase HPV vaccination rates in females, as was found in Australia, but this will only be confirmed in time. Nevertheless, we now know that vaccinating males will help prevent a growing number of HPV-associated oropharyngeal and anal cancers in males, and it is certainly a more equitable and consistent policy approach.

## References

1.  Patel C, Macartney K. Supporting the call for a gender-neutral human papillomavirus vaccination in Canada [letter]. CMAJ 2017 January 23;189:E118. doi:10.1503/cmaj.732446.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTg5LzMvRTExOCI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xODkvMy9FMTE5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Coverage data 2016. Melbourne (AU): National HPV vaccination program register; 2016. Available: [www.hpvregister.org.au/research/coverage-data](http://www.hpvregister.org.au/research/coverage-data) (accessed 2016 Dec. 15).
    
    

3.  Shapiro GK, Perez S, Rosberger Z. Including males in Canadian human papillomavirus vaccination programs: a policy analysis. CMAJ 2016; 188: 881–6.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTg4LzEyLzg4MSI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xODkvMy9FMTE5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Immunize BC. Diseases and vaccinations: HPV (human papillomavirus). Vancouver: BC Centre for Disease Control. Available: [www.immunizebc.ca/diseases-vaccinations/hpv](http://www.immunizebc.ca/diseases-vaccinations/hpv) (accessed 2016 Dec. 15).
    
    

5.  Talmazan Y. WATCH: 13-year-old boy pushes BC government to expand HPV vaccine program. Global News; 2016 Sept. 12. Available: [http://globalnews.ca/news/2935057/watch-13-year-old-boy-pushes-bc-government-to-expand-hpv-vaccine-program/](http://globalnews.ca/news/2935057/watch-13-year-old-boy-pushes-bc-government-to-expand-hpv-vaccine-program/) (accessed 2016 Dec. 19).
    
    

6.  Canadian cancer statistics. Toronto: Canadian Cancer Society; 2016.
    
    

7.  Guichon J, Shapiro GK. Opinion: Give HPV vaccine to prevent mouth and throat cancers. Vancouver Sun 2016 Oct. 28.