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Published:November 10th, 2009 07:21 EST
The HPV Vaccine Controversy: Sex, Cancer, God, and Politics

The HPV Vaccine Controversy: Sex, Cancer, God, and Politics

By SOP newswire2

By Shobha S. Krishnan
248 pp
Santa Barbara, CA, Praeger Publishing, 2008

Shobha Krishnan`s The HPV Vaccine Controversy is a welcome and much-needed book authored at a critical time. The literature on human papillomavirus (HPV) has increased to enormous proportions since Harald zur Hausen`s publications in the early 1980s establishing the link between the HPV virus and cancer of the cervix. Krishnan`s book does a masterful job of organizing the complex and expansive HPV literature into well-organized chapters discussing different aspects of the HPV field. The references provided for each chapter are an invaluable source for any student of HPV who wants to delve further into the literature. More than 300 total references are provided. The index is thorough and well organized.

The beginning chapters are each dedicated to the requisite fundamentals of the HPV field: "HPV Transmission and Natural History," "Risk Factors and Testing," "Cancer, Warts and HPV," "Emotional Aspects and Prevention of HPV," and "The New HPV Vaccines." Each chapter begins with a bold-faced 1-line "myth" that grabs the reader`s attention. Immediately below the "myth" is a counterbalancing "fact," with a 1- or 2-sentence clarifying explanation. The end of each chapter has a section entitled "Key Facts" that includes 6 to 8 bulleted sentence summarizations of the pertinent facts in each chapter. This formatting makes for an enjoyable read, which induces the reader to skim through the book just for fun to get repeated overviews of the highlights.

The "HPV Vaccine" chapter provides a thorough analysis of the Females United to Unilaterally Reduce Endo/Ectocervical Disease (FUTURE) studies I and II, published in 2007, which studied the efficacy of an HPV quadrivalent vaccine in preventing anogenital warts and high-grade precancerous lesions, respectively. Proper attention is directed toward important topics such as the usefulness of the vaccine for prevention but not treatment. A valuable review of the timeline of the scientific advances that made the development of the vaccine possible is presented. A more in-depth discussion of the issue of the duration of immunity could have addressed the question of why the vaccine was rushed to market before it was known whether booster shots would be needed and what the relative cost-effectiveness of the vaccine would be. This critical health policy issue may preclude the cost-effectiveness of introducing the vaccine into developing countries.

The chapter on risk factors is valuable for health care professionals who need to acquire more information about how to counsel their patients as well as for individuals who want to independently learn how to minimize the chances of future exposure. The "Cancer, Warts and HPV" chapter describes several of the diseases that have been linked to HPV and offers an explanation for the layperson of the often confusing cervical intraepithelial neoplasia terminology. The "HPV Transmission and Natural History" section provides a short overview of the basic science of the HPV virus as well as an introductory overview of this condition.

The "Emotional Aspects and Prevention of HPV: Shame, Blame, an Absence of Cure" chapter will be valuable to clinicians, patients, and health care educators. Krishnan discusses that one frequently cannot effectively deliver sound medical advice without first addressing the emotional status of the patient. The patient is often confronted with varying degrees of anxiety, depression, guilt, and fear of rejection, and the single most important factor to prevent HPV and to calm the concerns of the patient is education. The importance of the recent history of the consequences of the avoidance of public discussion of health care issues related to sex becomes apparent when one considers the countless number of individuals who acquired human immunodeficiency virus that might have been prevented if only there had been an earlier concerted effort to educate the public. The author likewise emphasizes that many cases of HPV can be prevented with the combination of educational efforts, logical screening programs, and vaccination.

The book has several unique chapters. The FAQs (Frequently Asked Questions) are invaluable for any clinician or educator who wants to be able to answer pointed and focused questions from anxious and concerned patients. The "HPV Vaccines for Males: The Unsolved Half of the Equation" section is an excellent clinical review of the available data on the importance of the elusive male factor in causing cancer of the cervix. The importance of the male factor has for the most part been ignored in the mainly gynecology-dominant literature. The usefulness of the vaccine for the gay population as well as the increasing incidence of oropharyngeal cancer is also addressed. I was encouraged to see the responsible inclusion of a chapter on the role of HPV vaccination in developing countries, a region in which the HPV vaccine could potentially bring enormous benefit to an impoverished population. Cervical cancer is the second most common cancer in the world, and more than 80% of the cases are in developing countries in Africa, Asia, and Latin America. The text reviews why the continued expansion of screening programs is critical and why the cost-effectiveness of any vaccination program can be achieved only through seamless cooperation between pharmaceutical companies, foundations, the World Bank, and government organizations.

The HPV Vaccine Controversy is a superb book for any person who wants to be introduced to this fascinating field as well as for the more experienced clinician or health educator who wants to get a fresh and renewed perspective. This book is a much-needed reference source for parents who want more written information and explanations before making the decision as to whether to give the vaccine to their children as well as for concerned patients who have pressing questions and want full and detailed answers. This book is a terrific contribution, and individuals involved in the HPV field should be grateful for its publication. 
 Canadian Medical Association Journal, Oct 26th 2009 
One of the great strengths of the book is the author`s use of pedagogical techniques, such as Myths and Facts " and Key Facts " sections in each chapter "..The subtitle includes A Guide for Parents, Women, Men, and Teenagers. However, this book is also an excellent resource for health professionals; it is a fact-based and balanced approach to the HPV vaccine controversy and achieves her aim of having the reader become well-informed and educated with the disease manifestations of HPV and the roles of the new vaccines. " 
Doody Reviews-Excerpt: 07/03/2009:

Reviewer: Yvonne Collins, MD (Christ Hospital and Medical Center)

With its expanded look at the human papillomavirus that includes etiology, transmission, diagnosis, ramifications, vaccination, and controversies, this book attempts to answer questions and concerns of patients, parents, and providers.

The goal of this book is to better inform readers on the disease manifestations of HPV and the role of vaccine therapy. The author also wishes to address issues that have been raised in an attempt to empower women.

This is intended to be a resource for healthcare providers,  parents, and patients (both young and the more mature).. ...

The book covers HPV in good detail, including natural history, risk of regression, transmission and the importance of behavior modification, risk factors for transmission... She also addresses the disease burden of HPV beyond the cervix. She discusses vaccine therapy, taking a thorough look at other vaccines throughout history. With vaccine therapy, she explores treatment, prevention, side effects, risks, and the possibility of vaccinating other non-FDA approved populations. Lastly, she also addresses the global need for intervention for cervical cancer. The book is impressive in the vast area covered, the questions answered, and the controversies raised. The author provides an unbiased view and is honest about what we don`t know. The key facts at the end of each chapter help identify the take-home points, and the glossary and figures help emphasize pertinent information ".
 It attempts to provide a complete source of information without directing patients and parents to multiple sources and sites. It covers just about everything patients and parents want to know
Journal of American College Health...Vol 57, No. 5 / March - April 2009 / March - April 2009. Dr Ted Grace, MD, MPH, executive editor Copyright © 2009 Heldref Publications
Excerpt " ". Shobha Krishnan, MD, author of The HPV Vaccine Controversy, has a great background for tackling a subject as complex as human papillomavirus (HPV), reportedly the most common sexually transmitted disease. " "strength of the book is that each chapter begins with a common myth, followed by a fact, about HPV infections or vaccines. Every chapter similarly concludes with a bulleted list of key facts " that have been discussed within that chapter, and the author has identified the key points within each chapter in highlighted boxes throughout.  The vaccine controversy " portion of the title is well covered in several chapters of the book " the author is empathetic to the parents` and patients` dilemmas surrounding these difficult decisions, presents adequate details on both sides of an issue, and does not try to use guilt to sway the readers either way.

Health educators purchasing this book will probably dog-ear the chapter on Frequently Asked Questions on HPV and the Vaccines " " Many college health practitioners will also find useful the patient questionnaire that gauges a person`s emotional impact after being diagnosed with HPV disease ". it is a great resource for college health professionals facing these types of questions on a regular basis.

Finally, the author`s background in epidemiology is clearly evident in her professional use of incidence and prevalence rates, sensitivity versus specificity of tests, and analysis of current research.And the final chapter presents an outstanding global view of the issues associated with diagnosing and preventing cervical cancer in parts of the world with socioeconomic inequalities. Prathibha`s Story " about the difficulties of one woman`s experience in India (the author`s native country) to screened and treated for cervical cancer adds a nice personal touch to the text. In summary, this is a great book for anyone dealing with sexuality issues, as well as who wants to know more detailed information about HPV and its vaccine. "
Krishnan, Shobha S.  The HPV vaccine controversy: sex, cancer, God, and politics: a guide for parents, women, men, and teenagers.  Praeger, 2008.  230p bibl index afp; ISBN 9780313350115, $39.95. Reviewed in 2009mar CHOICE-a division of the American Library Association- Krishnan (Columbia Univ./Barnard) offers a well-written, easy-to-understand book that does a superb job of providing timely, relevant information regarding human papilloma virus (HPV). Chapters treat transmission, effects on the human body, prevention, and how the virus causes cancer. The author, both a gynecologist and family practice physician, does an outstanding job of explaining the controversy surrounding the vaccine, and has brought to light a rarely discussed issue: why males/boys are not mentioned in the vaccination plans, when according to the data cited HPV causes almost as many cancers in men as in women. The book also offers frank discussion of the HPV-related disease risks of homosexual behavior....this volume will be a very valuable acquisition for public, two-year community college, four-year university/college, and consumer health libraries. Summing Up: Highly recommended. Lower-level undergraduates and general readers. -- L. M. McMain, Sam Houston State University
A gynecologist, family physician and mother, Dr. Krishnan delves into the pros, cons, misconceptions and legislative controversy surrounding the HPV vaccine in her new book. This up-to-date guide provides a wealth of information for readers who are unsure about the vaccine -2008 Women`s Cancer Handbook Resource Guide ,September 2008
Recommended for academic/medical libraries and comprehensive collections at public libraries....Gynecologist Krishnan (Barnard Coll. Heath Svcs., Columbia Univ.) provides admirable and balanced coverage of the controversy and science involved. She discusses her own decision to have her daughter vaccinated and whether or not she believes it promotes promiscuity.
"Library Journal Xpress online reviews September 9, 2008
This book is packed full of information. It should be a tool for parents and for health classes in high school, as to teach all teenagers the dangers of sexually transmitted diseases / infections and to also encourage both parents and teenagers to be open and honest in regards to their sexual activity. This book contains so much needed information, from the cause to the treatment, and also the vaccine itself. If I had a teenager, or a child in puberty I would definitely use this book as a learning tool. As a nurse, of course I find any writing related to Health care very beneficial, but that said, shouldn`t all parents be informing their children not only the importance of abstinence but also some of the consequences that accompany their sexual urges? This book also delves into the vaccine aspects for both males and females. This book contains much needed information and also gives references and Internet resources. This book is easy for the layman to understand, and also contains a glossary. September 11, 2008.

Story Circle Book Reviews-by Susan Andrus: (excerpt):
If you care about your health, you must read this book. The HPV Vaccine Controversy: Sex, Cancer, God, and Politics. Shobha S. Krishnan, M.D. gives you practical, jargon-free information about one of the most widely spread sexually transmitted diseases--Human Papilloma Virus (HPV). Rather than frighten the reader with facts and statistics, Krishnan uses a conversational tone that provides information to make decisions about having an annual gynecological exam, gives parents assistance in deciding whether or not to have their daughters immunized, and leaves the reader feeling confidently informed of the nature of this virus and how she can protect herself from its effects. Men also need to read this book. Krishnan shows how in different cultures, men`s sexual behavior predicts the incidence of women`s cervical cancer better than the women`s sexual behavior. To protect women from contracting HPV from men who often have no symptoms, Krishnan wants the reader to make an informed decision about the HPV vaccine. Only 230 pages long, this book includes information on topics including sex, cancer, religious beliefs, politics, and the emotional impact of the HPV diagnosis. Krishnan also addresses the lack of testing and vaccinating in poorer countries and includes a glossary, references, notes, and a comprehensive index.  
HPV Book Release- Nurse Practioners` in Women`s Health-Shobha S. Krishnan, MD, is releasing a book titled, "The HPV Vaccine Controversy." To get some of the most up-to-date information on the HPV and how it relates to Sex, Cancer, God and Politics, be sure to check the book out. The book can be purchased at the end of August from, and Nurse Practioners in Women`s health. 
Dr. Krishnan provides the reader with a frank and honest presentation of the facts about HPV, the consequences and the choices for preventative health care. Good health care is about making informed decisions. Before taking a side on the HPV Vaccine issue, get the facts; read The HPV Vaccine Controversy. It is an excellent, informative resource for laymen and health care professionals -Public Healthcare Issues,, September 30, 2008.
Finally, there is a book that covers the often contentious debate surrounding HPV vaccinations for teenagers in a thorough and objective way. Leaving no stone unturned, The HPV Vaccine Controversy: Sex, Cancer, God, and Politics: A Guide for Parents, Women, Men, and Teenagers makes a compelling case for why preteens and teens should be vaccinated against one of the most widespread STIs in the population, and the only one that can cause cancer. Dr. Shobha S. Krishnan writes in an understanding way that addresses the concerns of reluctant parents and even politicians alike. Kudos for a job well done.-
Toni Weschler, MPA, Author of Taking Charge of your Fertility and Cycle Savvy: The Smart Teen`s Guide to the Mysteries of Her Body
Book Review: The HPV Controversy- Posted by SureWoman on November 16, 2008 at 2:00pm ---Dawn G. Prince (excerpt) ".The HPV vaccine has sparked a debate over sex, religion, politics and parental rights, which makes the astonishingly well-researched and well-presented, THE HPV VACCINE CONTROVERSY: Sex, Cancer, God and Politics, " A Guide to Parents, Women, Men and Teenagers - aptly titled. Written by gynecologist and family-physician Shobha S. Krishnan, it`s a very thorough, insightful and informative book on the subject of HPV and cancer, while taking into account the questions and fears of parents surrounding the drug Gardasil. Krishnan, in layman`s terms, lays out the benefits as well as the risks and why the introduction of Gardasil is timely. Charts are used to further breakdown the subject into bite-sized bits that don`t overwhelm. There is a question and answer section taken from a clinic she held for college students.

To date, THE HPV VACCINE CONTROVERSY is the most comprehensive guide that I have seen on the subject. Krishnan addresses all the controversies, making this book one of those valuable tools that could help in understanding the overwhelming tug-of-war concerning the vaccine. Krishnan`s method of filtering out the vast amount of information can help young women and their parents learn about the HPV virus, and hopefully make informed decisions.
·S. Krishnan, author of The HPV Vaccine Controversy: Sex, Cancer, God, and Politics speaks to the subject of this exciting and groundbreaking work ...She took it upon herself to compile an accurate and intensive report of all the research we have so far. She includes tables on the current legislation in each state, information on the progression of vaccines in other countries, and extensive FAQs. It is currently the only book available on the subject, but Dr. Krishnan pulls more than enough weight for an entire library. Her expertise is invaluable on the weighty subject of HPV vaccines, and she holds nothing back in her
Dr. Shobha S. Krishnan`s speaks to us more than as a gynecologist and family physician; she is the mother of a young daughter. She wants to educate and inform us and hopefully prepare us for the next round of discussion when we are faced with vaccines for other sexually transmitted diseases.
Will The HPV Vaccine Controversy give you enough information to make an informed decision? That is entirely up to you and would say this is one book that shouldn`t be passed up. I would say read it and learn all you can to make a better informed decision one way or the other on whether or not to vaccinate your daughter for HPV. BellaOnline`s Daughters Editor-Violette DeSantis-

Excerpt-A comprehensive new book, The HPV Vaccine Controversy, by Shobha S. Krishnan, M.D., provides a well-documented, readable guidebook to HPV that covers everything from sex to science to politics and religion. One particularly compelling section details the author`s own deliberations as mother to a young daughter, reviewing factors that any parent should consider before vaccinating a daughter-By Edward C. Geehr, M.D., LifeScript Chief Medical Officer 
Excellent reading with much needed information for parents to navigate and make up their own minds. The book covers crucial areas that typically confuse parents- it was quite clear to me that the vaccine would do more good than bad after reading the book. The author maintains an objective stance throughout the book while dissecting the issues very well.
October 17, 2008 | CHowell
An interesting book that I specifically read to help me decide whether or not this vaccine is something that I should consider for my 12 year old daughter.  After reading the various pro`s and con`s, which is portrayed in this well written book, I now feel like I have enough of an understanding to be able to talk with my daughter`s primary care physician and not get lost in the doctor-speak that I might not have understood prior to reading Dr. Shobha`s book. I seriously recommend this book for all parents considering whether or not your child may benefit from this relatively `new` immunization. ~ VW
Book Review: Krishnan, Shobha S. The HPV Vaccine Controversy: Sex, Cancer, God, and Politics: A Guide for Parents, Women, Men, and Teenagers. Westport, 2008. Greenwood eBooks.

In The HPV Vaccine Controversy, Shobha Krishnan covers quite a bit of ground. At the very beginning, she reminds the reader that this book is a reference guide for Parents, Doctors and Teenagers. It`s a dense read; one that is well-researched, well-presented and well-covered. The book covers three main areas: What HPV is, who it`s for and what should be done about it.

In the first area, What HPV is, Shobha Krishnan devotes quite some time to discussing what the HPV virus is, what it isn`t, its forms and what parents should be concerned about. The HPV virus, says Shobha, is widely and readily passes from person to person, in its many different forms, via sexual or nonsexual means. It may cause simple warts to cervical and anal cancer, and may come and go on its own or require surgical excision and therapy. Since some strains of HPV may cause cervical cancer, an outline of what cancers they may cause is vastly discussed and may be beyond the reach of the lay reader who is not familiar with medical terminology or issuance.

The second area, who the HPV vaccine is for goes into quite a `sell`. What that means, is that an extraordinarily amount of the book is spent trying to persuade the reader (parents) why the vaccine is needed (and before their daughters are sexually active) in order for the vaccine to work properly. Since the main purpose of the book is to prevent cervical cancer via HPV vaccinations, there must be an explanation why parents need to vaccinate their young daughters when the outcome will not be seen for many decades. A point is brought up that boys should be vaccinated, as there is early proof that men infect others with the more serious strains of HPV virus that cause cervical and anal cancer. (So far, in the US, only Gardisil is approved for HPV vaccinations and only for girls and women up to age 26).
The last area, what should be done about the HPV vaccine, is, more or less, a reiteration of the first parts of the book. International, developing and underdeveloped countries are touched upon, as cervical cancer rates are much higher than in developed countries. Doctors and health care workers `in the field` ask that the vaccine cover more than just those HPV strains that lead to cervical and anal cancer and to bring the cost down to a dollar a shot, compared to the three-shot requirement of over $120 per shot.
The book is a good resource and recommended for those parents and caregivers of young girls (and boys) who are concerned about HPV. Brick O Neal

Nine out of ten people will want to pick up a book that has the words `Sex`, `Cancer`, `God`, `Politics` and `Controversy` on its front wrapper. But these aren`t terms of enticement fo r this 230-page hardcover. Dr. Shobha S.Krishnan`s book is about the Human Papillomavirus (HPV) vaccine and the questions surrounding it. To every Indian engaging in sex (hey, we`re a nation of one billion!) the book is necessary education.

New York-based Dr. Shobha, Board-certified in Obstetrics-Gynecology and Primary Care simply had to write it. "Having been educated in Chennai and the U.S., I`ve had the best of both worlds," she said recently in Chennai. "The vaccine has been in use for the last two-and-a-half years (now in India) and I have the research tools to assess the response. I was already writing on South Asian women`s health issues. The controversy about the vaccine was a natural choice of subject."

Alarming statistics

The connection between the virus and Indian women`s health borders on the alarming. Nearly 75, 000 women die annually of HPV-gifted cervical cancer. Lack of education, inhibitions and our hesitation to go for regular Pap tests push us into the high risk area. Dr. Shobha`s book brings us those "simple, essential things" that we don`t know and will never ask " prevention, symptoms and treatment.
"The HPV virus is sexually (some forms non-sexually) transmitted," she said. "We know the cause. It is preventable. Both men and women ought to be immunised. It`s a cancer of the young, it devastates the family."

Look at it this way. Here is a sexually transmitted virus that causes cervical cancer. A pharmaceutical company markets a vaccine that claims to prevent it in women. The vaccine has to be administered to girls as young as 12 (anti-bodies are high in this age group). It is expensive. The government may/may not make it compulsory.

We have questions. Do we really need the vaccine? Aren`t Pap tests enough to prevent the cancer? Will the vaccine make girls promiscuous? Will abstinence prior to start of sexual activity and commitment to sex with one partner guarantee life-long protection? If there`s a reasonable chance my daughter will indulge in pre-marital sex, shouldn`t I consider prevention? But how do I trust a vaccine promoted by a pharmaceutical company? Again, should governments handle immunisation for a sexually-transmitted cancer virus?

Dr. Shobha answers these and other questions with facts and guidelines that might bring clarity to the parent`s dilemma. Aside of clinical data on who, when, how and what side effects, the book touches on religious beliefs, politics, and the emotional impact of the HPV diagnosis. Gratifyingly, Dr. Shobha addresses the why-not-a-male-vaccine question as well. "The vaccine does not prevent pregnancy or HIV, so how will it promote promiscuity?" she asked. "It is like having an airbag or automatic brakes in the car. It is a tool to protect you." The book, she said, is to know what best we can do as parents.
Clearly it is for a U.S. audience. The legislative information and medical statistics are U.S. focused. But a discussion on this vaccine is meant for all mothers of young daughters. In a rapidly changing society with nil public debate on new vaccines, an independent, up-to-date, non-pharma evaluation of a vaccine is a fortunate happening. If parents and paediatricians make a medical choice, shouldn`t they be sure it is an informed one? Dr. Shobha`s reader-friendly book, with its wide index, could be the first important step towards it. "The idea is to expose the reader to everything about the vaccine," she said.