The Lancet
Nov 14, 2015 Volume 386 Number 10007 p1917-2028 e36-e44
http://www.thelancet.com/journals/lancet/issue/current

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Comment
HPV vaccination for victims of childhood sexual abuse
Suzanne M Garland, Asvini K Subasinghe, Yasmin L Jayasinghe, John D Wark, Anna-Barbara Moscicki, Albert Singer, Xavier Bosch, Karen Cusack, Margaret Stanley
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00757-6

Health authorities around the world, including WHO, recommend starting cervical screening at age 25 years or older, thus excluding young women from population screening.1 This guidance was developed on the basis of numerous investigations documenting high rates of human papillomavirus infection in the general population of young women, with very low rates of cervical cancer.2 Although human papillomavirus infection is common, occurring shortly after sexual debut, it is largely transient and asymptomatic. Cervical cancer has decreased greatly owing to cervical cytology screening for and treatment of precursor lesions.3 However, the data from cervical cytology screening are from birth cohorts whose age of sexual debut was 5–10 years later than that of the present generation. An earlier age of sexual debut creates a wider gap between initial contact with human papillomavirus and the present recommendations for age of onset for screening.4 This generational change in sexual behaviour has the potential to increase the population risk for cervical cancer, an outcome that can be offset by human papillomavirus vaccination before sexual debut.

Less than 2% of women worldwide receive human papillomavirus vaccination, despite vaccines being licenced in 129 countries, with 64 countries having such vaccines in their national immunisation programmes.5 Few countries achieve wide vaccine coverage, although even in those with low coverage—such as the USA—the prevalence of vaccine-targeted human papillomavirus genotypes is low. Although delayed screening will not pose a risk to the vast majority of women, it could lead to otherwise preventable cervical cancers among high-risk women younger than 25 years of age in countries with poor vaccine coverage. Young women who have experienced childhood sexual abuse might fall into this category.

According to WHO, childhood sexual abuse is defined as the involvement in sexual activity of a child under the age of 18 years who did not give informed consent or is not developmentally prepared.6 The global prevalence of childhood sexual abuse is estimated to be 8–31% for girls and 3–17% for boys.7 According to a review published in 2004, parents were the perpetrators of about 45% of cases of childhood sexual abuse in the USA, and other relatives were responsible for 19%.8 Additionally, perpetrators can be trusted authority figures in society such as priests and teachers.8 Consequently, survivors of such abuse are often hesitant to report such incidents because of shame and fear of retribution. Thus, the incidence and prevalence of childhood sexual abuse is almost certainly underestimated.

Results of a study in Australia9 suggest unwanted sexual experiences with genital contact in adolescence increase the risk of cervical cancer. Moreover, early onset of sexual activity is a strong risk factor for cervical cancer. This effect could be due to the greater risk of prolonged carriage of high-risk human papillomavirus as a result of earlier genital contact in these young women, or a specific vulnerability of the cervical epithelium during a critical developmental period. Globally, around 5–10% of girls and 1–5% of boys are exposed to penetrative childhood sexual abuse.10 Preliminary data from questionnaires from 398 women aged 16–25 years in Victoria, Australia, who had experienced childhood sexual abuse showed that penile–genital contact at the time of the abuse was common (32%)—the mean age at time of abuse was 12 years.11 Certainly, cervical or vaginal trauma resulting from forced intercourse places these women at high risk of infection. In addition, the epithelial vulnerability of immature cervixes could accelerate human papillomavirus acquisition and persistent human papillomavirus carriage.12
People who have experienced childhood sexual abuse are more likely to engage in risky behaviours associated with cervical cancer, such as an increased number of sexual partners, sex work, and cigarette smoking.13 Drug and alcohol use and depression are also more common in victims of childhood sexual abuse.14 Most childhood sexual abuse (70%) occurs at a mean age of 10–11 years, which is younger than the age at which human papillomavirus vaccinations are administered.15 Early virus exposure thus reduces later human papillomavirus vaccine efficacy. Hence, it would be intuitive to administer human papillomavirus vaccine as soon as childhood sexual abuse is reported because of the risk of ongoing exposures due to maladaptive coping, including potential disengagement with mainstream education and health services.

We believe that male and female victims of childhood sexual abuse should not only be screened for sexually transmitted infections (and offered appropriate treatment), but also be offered human papillomavirus vaccination. Moreover, although cervical cancer screening from age 25 years is appropriate for the general female population, policy makers should consider options for screening from 18 years when clinicians are concerned about individual risk. Early human papillomavirus vaccination, and cervical screening for women younger than 25 years who have experienced childhood sexual abuse, should help to reduce the burden of human papillomavirus-related disease in this high-risk population.

Women treated for cervical cancer are at increased risk of developing human papillomavirus-related anogenital cancers16 and need lifelong surveillance.17
[References at title link]

SMG has received research funding from Merck, GlaxoSmithKline, and bioCSL; non-financial support from Merck; and speaking fees from Merck Sharp & Dohme and Sanofi Pasteur MSD. YLJ has received the Novartis Scholarship from the Royal Australasian College of Physicians. AS has received personal fees from IBC Medical Services. XB has received research funding and personal fees from Merck Sharp & Dohme, GlaxoSmithKline, Sanofi Pasteur MSD, and Qiagen; and personal fees from Roche Molecular Systems. MS has received personal fees from GlaxoSmithKline Biologicals, MSD Merck, and Sanofi Pasteur MSD. A-BM has received personal fees from Merck. AKS, JDW, and KC declare no competing interests.

The Lancet Commissions
The Rockefeller Foundation–Lancet Commission on planetary health
Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health
Sarah Whitmee, Andy Haines, Chris Beyrer, Frederick Boltz, Anthony G Capon, Braulio Ferreira de Souza Dias, Alex Ezeh, Howard Frumkin, Peng Gong, Peter Head, Richard Horton, Georgina M Mace, Robert Marten, Samuel S Myers, Sania Nishtar, Steven A Osofsky, Subhrendu K Pattanayak, Montira J Pongsiri, Cristina Romanelli, Agnes Soucat, Jeanette Vega, Derek Yach
Summary
Far-reaching changes to the structure and function of the Earth’s natural systems represent a growing threat to human health. And yet, global health has mainly improved as these changes have gathered pace. What is the explanation? As a Commission, we are deeply concerned that the explanation is straightforward and sobering: we have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting nature’s resources, human civilisation has flourished but now risks substantial health effects from the degradation of nature’s life support systems in the future.