In a survey of physicians conducted in 2008, before human papillomavirus (HPV) vaccination of young males received federal approval, more than nine in 10 respondents said that if vaccination were recommended and covered by health insurance for males, they would recommend it for those aged 13–26; considerably lower proportions would offer it to 9–12-year-olds.1 Respondents—all of whom had vaccinated young females—generally agreed that vaccinating males would be important not only because it would prevent disease in males, but also as a strategy for protecting females from the risk of HPV infection and its consequences. The notion that the vaccination of females obviates the need to vaccinate males garnered little support. The vaccine was approved for use in males in 2009; the Centers for Disease Control and Prevention has provided “guidance” for its use to reduce the likelihood of genital warts among males aged 9–26, but does not recommend it for routine use in this population.2

For the physician survey, investigators used claims data from a managed care plan to identify a sample of pediatricians and family practitioners who had given the HPV vaccine to at least five female patients and had treated at least 20 patients younger than 20 in the first half of 2008. Eligible physicians were sent mailed questionnaires that covered personal and practice characteristics, knowledge of HPV, and attitudes toward and perceptions of the HPV vaccine. Responses from the 1,094 physicians who returned completed surveys were tabulated, and differences among subgroups were assessed in chi-square analyses.

The sample was equally divided between males and females; 54% were pediatricians, and 46% family practitioners. Pediatricians had been in practice longer than family practitioners and typically saw more 11–18-year-olds. Nine in 10 respondents said that they rarely or never saw patients with anal, penile or cervical cancer, and six in 10 rarely or never saw patients with genital or anal warts; family practitioners saw patients with these conditions more frequently than did pediatricians. Close to three-quarters of physicians said that they discussed sexual health with young males during school physicals or routine exams; smaller proportions did so in other situations.

Most respondents agreed (either somewhat or strongly) that males are at risk for HPV infection (99%), that HPV infection is common among males (85%), that genital and anal warts can have serious consequences for men (93%) and that HPV infection can lead to a variety of cancers in men (86%). Nearly all would recommend vaccination to males aged 13–18 and 19–26 (93% for each), but only 64% would recommend it to 11–12-year-olds and 24% to 9–10-year-olds. A similar pattern was evident in the proportion who recommend HPV vaccination to females; however, significantly greater proportions recommend it to 11–12-year-old and 13–18-year-old females than would recommend it to males of those ages, and a significantly lower proportion recommend it to 9–10-year-old females than would do so to males that young. Although pediatricians were more likely than family practitioners to say that they recommend vaccination to females aged 11–12 and 13–18, the two groups were equally likely to say that they would recommend it to males aged 11 and older.

Physicians generally recognized both direct and indirect benefits of HPV vaccination of males. Eighty-nine percent agreed that vaccination would prevent anal and genital warts in males, and 83% believed that it would prevent anal and penile cancers. Furthermore, 96% thought that males should be vaccinated as a means of preventing cervical cancer and other consequences of HPV in their female partners, and 94% as a way of preventing HPV infection in females. Respondents mainly disagreed (somewhat or strongly) that vaccinating males is not worthwhile because genital and anal warts can be “managed in other ways” (87%), is not effective for sexually experienced males (86%) and is not necessary because females are being vaccinated (92%).

More than half of physicians strongly agreed that a gender-neutral HPV vaccination recommendation “is appropriate based on the concept that vaccines are a public health benefit” and that vaccinating only females “is an incomplete way of preventing HPV disease.” The most common response to the statements that a gender-neutral recommendation would interest parents of male patients and would improve acceptance among female patients and their parents was “somewhat agree” (45% and 42%, respectively); the most common response to the statement that such a recommendation would make it easier to recommend HPV vaccination to females was “neither disagree nor agree” (26%). Pediatricians’ and family practitioners’ views of the effects of a gender-neutral recommendation were statistically indistinguishable.

The investigators note that their study was limited by a low response rate and the selection of physicians who have vaccinated females against HPV. Furthermore, they point out, now that the vaccine is approved for males, physicians’ provision of it may differ from their anticipated provision before approval. They encourage future research to “address actual male HPV vaccination practice in the context of a permissive…recommendation.”—D. Hollander