HPV—the human papillomavirus—is one of the most common sexually transmitted infections (STIs) in the world. Absent vaccination, over 75 percent of Canadians will acquire HPV in their lifetime. It’s so common, in fact, that most clinics won’t test for it—most HPV infections don’t cause symptoms, and the body clears most infections on its own within a few years. Sounds like no big deal, right?
It is simultaneously true that a few key strains are responsible for the vast majority of anal, cervical and throat cancers. Strains that cause cancer are called high-risk.
A recent meta-analysis of anal HPV prevalence in men who have sex with men (MSM) found that 41 percent of HIV-negative MSM and 74 percent of HIV-positive MSM have a high-risk strain of HPV. HIV-positive MSM are also 80 times more likely to develop anal cancer compared to HIV-negative MSW.
There is a vaccine to protect against seven high-risk HPV strains (16, 18, 31, 33, 45, 52 and 58). Queer and trans men should get this vaccine to reduce the risk of anal cancer—along with the related risks of cervical and throat cancers.
The vaccine also protects against two key HPV strains (6 and 11) that cause warts anywhere on the body—your ass, your dick, your front hole, anywhere on your skin. These strains don’t cause cancer, so clinicians call them low-risk, but warts are annoying, so preventing them is a nice bonus.
To better understand the clinical ins and outs of the HPV vaccine for queer and trans men, we spoke to Derek Blechinger, MD, MPH, an internal and preventative physician and HIV specialist who does LGBTQ2S+ primary care and gender-affirming care at Kaiser Permanente San Francisco. Dr. Blechinger’s comments are representative of his views and clinical practice; he is not speaking on behalf of Kaiser Permanente.
For the broader community and public health communication on the HPV vaccine for queer and trans men, we spoke with Nova Scotia-based sex educator Abbey Ferguson, executive director of the Halifax Sexual Health Centre, which provides HPV vaccination in tandem with a wide range of sexual health and gender-affirming care services.
What is the HPV vaccine?
“This is the way we [essentially] ‘cure’ cancer—in advance instead of waiting until you get sick. I highly recommend it for all ages,” Dr. Blechinger says.
The first HPV vaccines were approved in the U.S. and Canada in 2006 and protected against four cancer-causing HPV strains. In 2015, Health Canada approved the nine-strain version. Collectively, these nine strains are responsible for most anal, cervical and throat cancer, as well as warts anywhere on the body.
For example, “over 90 percent of anal cancers are linked to the high-risk HPV viruses like 16 and 18,” which the vaccine protects against, says Blechinger.
Have I already gotten this shot?
Maybe. If you were born in the early 1990s or later, there’s a good chance you got the HPV vaccine as a kid. Most jurisdictions in Canada and the U.S. recommend or require HPV vaccination for youth between the ages of nine and 13.
Who is it recommended for and why?
Everyone who is sexually active.
In short, if you haven’t gotten the HPV vaccine and you’re sexually active or planning to be, you should ask for it. If it’s not funded by public or private health insurance, ask your healthcare provider to refer you to programs that offer free or low-cost doses.
It’s never too late to provide yourself with a vaccine. “It’s been my practice for over 10 years to offer HPV vaccination to any queer folks who are still sexually active later in life,” says Blechinger. “I have a lot of folks who are very sexual into their 50s, 60s, 70s and 80s.”
Even if you’re monogamous, the HPV vaccine still helps protect you and your partner.
Wait, why does my insurance say this just for young people?
Health Canada recommends the HPV vaccine for ages nine to 26, and then for people over 27 if they have higher-risk factors under shared clinical decision-making.
Translation: talk to your doctor about your specific situation, and your doctor can advise if the vaccine is required based on your risk factors. If you are a queer and/or trans man— especially if you are HIV-positive—you are at a higher risk for HPV and thus have a higher need for the vaccine.
Individual insurers vary in which populations they cover and why. Insurers reference vaccine guidelines, but they also look at what your doctor has specifically concluded in conversation with you. If your doctor recommends the HPV vaccine under shared clinical decision-making, your insurance is more likely to cover it.
Why don’t more guidelines recommend the vaccine for older adults?
Two reasons.
First, the vaccine will only protect you against strains you haven’t been exposed to. The longer you’ve been sexually active and the more partners you’ve had, the more likely it is that you’ve been exposed to the strains of HPV in the vaccine.
That said, given that HPV testing is not widely available, it’s not possible to know which strains you’ve been exposed to, no matter your age.
Second, for vaccine guidelines to change, we need large-scale randomized controlled trials, and it is difficult to obtain funding for such studies in queer and trans populations. As a result, doctors who work in queer and trans medicine and HIV care have to share clinical knowledge with each other and follow the smaller scale studies that exist.
How does HPV spread?
“The thing with HPV is that it’s not fluid-based. It is skin-to-skin cell contact,” says Ferguson. Condoms and dental dams protect us from fluid-based STIs, but leave most of our skin uncovered. Absent covering ourselves from head to toe with latex, we’re exposing ourselves to skin-based transmission when we rub our skin against our lover’s.
“All of us, if we’re sexual creatures, we’re putting our bodies together skin to skin, an unspoken social contract we all have is that we are at risk for things that are skin-to-skin spread, even without ejaculation [such as HPV or herpes],” says Blechinger.
Your eyes are your friend, Ferguson says. While many infections don’t carry symptoms, it’s always a good idea to look closely at your partner’s crotch, ass and other intimate areas. Do you see any lesions, bumps, warts? If so, gently check in.
Similarly, if you’re sharing sex toys with a partner, especially if you’re both inserting those toys, use toys made of non-porous materials like silicone, and before you take out the toy and fuck your partner with it, either change the condom on it or sterilize it.
Why are queer men specifically at higher risk for HPV and anal cancer?
First and foremost, because queer men have more frequent anal sex. “Because the anus is not a self-lubricating body part, it often stretches and has these micro tears, which means it’s just easier to transmit STIs. When we talk about high-risk, that’s why,” says Ferguson.
Men who engage in casual sex and cruising culture with multiple or anonymous partners regularly can also face a higher risk, Ferguson says.
Biologically speaking, cervical cancer and anal cancer develop in similar tissue with the same cellular mechanisms. But the research and infrastructure to prevent, screen for and treat cervical cancer is decades ahead of the equivalent infrastructure needed for anal cancer—which created a frustrating systemic disparity.
In that sense, we could just as well say queer men are at higher risk for HPV and anal cancer because we have not invested in the public health infrastructure to prevent, screen for and treat anal cancer the way we have for cervical cancer. After all, we don’t say that straight cis women are at higher risk for HPV and cervical cancer because they have more frequent vaginal sex—we understand that vaginal sex is part of life and we arrange our public health infrastructure to prevent cancer anyway.
What do HIV-positive people specifically need to know?
If you’re HIV-positive, you’re at a higher risk of developing cancers caused by the HPV strains the vaccine protects against, even if your health is well-managed and you have an undetectable viral load. So getting your HPV vaccine is even more important, says Blechinger.
We don’t yet know why the risk of cancer is elevated for HIV-positive folks with undetectable viral loads. It’s possible, says Blechinger, that the initial immune-system shock from HIV infection creates elevated risk even after the immune system is functioning again, much like how a fully healed broken bone is never quite the same as it was before the break. That said, this is an active area of research.
Beyond vaccination status and HIV status, are there any other major risk factors we should know about?
“Smoking. That’s a big one,” says Blechinger.
Smoking is a well-established risk factor for cervical cancer. Smokers clear HPV infections more slowly than non-smokers, and smokers with HPV are twice as likely to develop precancerous cervical lesions than people with HPV who don't smoke.
Smoking works with HPV to cause cancer in five ways:
- Smoking speeds up the replication of HPV.
- Smoking boosts the cancer-causing proteins of high-risk HPV strains.
- Smoking suppresses key components of the immune system in the cervix.
- Smoking causes damage to cervical cell DNA, including the protein p53, which normally detects cell damage and calls for repair.
- Smoking and HPV activate many of the same pathways, amplifying each other’s effects.
Getting vaccinated and quitting smoking drastically reduces your cancer risk.
Who should get tested for HPV and why?
We need to distinguish between the low-risk HPV strains that cause warts, and the high-risk HPV strains that cause cancer.
“If you have warts, you have HPV. You don’t need to get tested,” says Blechinger. You can see your provider to treat the warts.
Most strains of HPV are low-risk—meaning they don’t cause cancer.
The purpose of the vaccine is to prevent infection with the strains that do cause cancer. Testing is thus a tool to identify high-risk strains, and catch precancerous lesions before they develop into cancer.
Schedule your cancer screenings based on the body parts you have: cervical screening if you have a cervix, anal screening if you have an anus.
We have strong infrastructure for cervical cancer screening, including testing for both HPV and the precancerous cell changes that can follow.
Checking cervical cells for precancerous lesions is part of a regular Pap. A traditional Pap identifies precancerous lesions, but doesn’t specifically test for what caused those lesions. Some jurisdictions, including Ontario, are starting to test for high-risk HPV strains directly, since HPV arrives before cells start to change, which offers an earlier opportunity for intervention.
We do not yet have this robust infrastructure for anal cancer screening, despite the elevated risks for anal cancer in queer and trans men and the 2024 release of consensus guidelines on anal cancer screening among high-risk groups.
Access to anal cancer screening remains severely limited. In Canada, CATIE offers an overview of screening procedures; in Toronto, HQ offers self-administered anal Pap tests via walk-in, with follow-ups with clinicians as needed.
Colonoscopies, while vital for preventing colorectal cancer, don’t actually look at your anal canal—the first few inches where anal cancer develops. Anal cancer is more similar to cervical cancer, and the screening needed is thus more of a Pap or HPV test.
The ANCHOR Study, an NIH-funded randomized clinical trial, confirmed that actually identifying and treating precancerous anal lesions prevents progression to anal cancer in men who have sex with men, especially HIV-positive men. You can bring this study to your doctor if you’re having trouble accessing anal cancer screening.
What if I don’t remember if I’m vaccinated, and I don’t have my records?
In Canada, you can get your vaccine records from each province, says Ferguson.
How much does the HPV vaccine cost? How can I get it for free or cheap in the U.S. and Canada?
The cost varies by region. In Toronto, for example, the cost without insurance is about $215 per dose, for a total of $645 for three doses.
If insurance won’t cover you and you can’t afford to pay out of pocket, look into public health departments and STI clinics, says Blechinger.
In Canada, Ferguson recommends looking up clinics that may offer the HPV vaccine for free or at a reduced cost through Action Canada for Sexual Health & Rights.
The vaccine offers lifetime protection. If it helps, think of it as an investment: once you’re done with the shots, you’re protected for life. It may be worth saving up for, or travelling a bit of a distance to a free or reduced-cost clinic, if you can find one.
At the end of the day, why is vaccination important?
“In this age where we have an administration that is hostile toward vaccination and preventive care and queer health in general, it is an act of defiance to stand up and get your vaccination and say, ‘No, I’m going to protect my health.’ So go do it,” says Blechinger.
