Sex and the Pediatrician’s Office: Using the HPV Vaccine to Explore How Sexuality Shapes Healthcare Experiences and Medical Decision Making

Abstract

The human papillomavirus (HPV) vaccine is projected to significantly lower HPV-related cancer rates via vaccination during early adolescence. Because HPV is primarily transmitted sexually and widespread, children must be vaccinated before sexual onset to prevent infection and reduce their risk of cancer. Yet U.S. vaccination rates remain low compared to other adolescent vaccines. I argue that the stigma of adolescent sexuality shapes medical staff and parents’ interactions and thus vaccine decision making processes in ways that discourage uptake and ultimately affects children’s healthcare experiences and HPV-related cancers risk. By analyzing medical staff, parents, and adolescent patients’ HPV vaccine clinical encounter discussions, I explore how staff’s and parents’ medical decision making is shaped by broader conceptions of adolescent sexuality, childhood, parenting, and patient-provider relationships along with processes of stigma, biomedicalization, medical authority, and surveillance. Based on a rare data set of audio-recordings of pediatric clinical encounters and parent surveys, ethnographic observations in four medical offices, and interviews with medical staff, I examine how medical staff’s and parents’ understanding of and engagement with the concept of adolescent sexuality shape healthcare processes and decisions regarding children’s care in three studies. Chapter 2 investigates whether and in what circumstances medical staff defer their medical authority when recommending the HPV vaccine to parents and patients. I find that medical staff use less authority when at risk of stigmatizing patients: they are less authoritative when recommending HPV vaccination versus other adolescent vaccines, particularly when addressing the need to vaccinate before sexual onset due to concerns of labeling the child as sexually active. Medical staff abandon authority in ways that potentially discourage HPV vaccine uptake: they encourage HPV vaccination less than other vaccines and infrequently challenge parents’ sex-related reasons for vaccine refusal. In Chapter 3, I explore how providers decide when to push parents to vaccinate. I find that the shift towards power-sharing in patient-provider relationships encourages providers to conceptualize relational harm as a potential health risk. In the case at hand, providers fear harming their relationship with parents if they push an unwanted treatment, jeopardizing their ability to effectively treat patients, and thus posing a risk to patients’ health. Combined with providers’ concerns about stigmatizing parent and patient with early sexual activity, providers estimate parents’ HPV vaccination preference and the patient’s risk of imminent sex to decide whether the vaccine’s benefits to the patient are worth pushing vaccination and risking relational harm. Providers’ assumptions about parents’ HPV vaccination intentions are frequently incorrect, however: providers weakly advocated or did not mention the vaccine to half of the parents who intended to vaccinate their child against HPV. Chapter 4 examines whether and how HPV vaccine discussions generate broader messages about adolescent sexuality. I find that the HPV vaccine becomes a site of multi-surveillance. The vaccine’s primary surveillance purpose – the monitoring and prevention of cancer risk – acts as a genesis for parents and providers to surveil adolescent patients’ sexuality, effectively creating two surveillance projects. Within HPV vaccine discussions, providers and parents surveil patients’ sexuality by monitoring and conveying standards regarding the patient’s sexual development, thoughts, and behaviors while clearly presenting adolescent sexual activity as dangerous and undesirable. Together, these findings can inform medical education efforts to raise HPV vaccination rates. It is important to make medical staff aware of how their concerns about adolescent sexuality’s stigma and how they navigate these concerns during vaccine discussions can hinder their ability to educate and guide parents’ HPV vaccination decisions, potentially increasing the child’s risk of HPV-related cancers.