‍In this research deep dive, we reframe how to understand Human Papillomavirus (HPV) risk. HPV is common and transmitted through sexual interactions. Delving into the social determinants of health, we uncover a more complex and comprehensive reasoning behind why certain high-risk HPV infections may progress to cervical precancer or cancer while others do not. As researchers continue working toward a more nuanced framework around HPV risk, it is crucial that the stigmatizing narrative around this virus and cervical cancer transforms with it. 

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Contents: 

1. Although HPV is Common, it Remains Stigmatized
2. A Shift Away from Stigma
3. Chronic Stress and Related Lifestyle Coping Practices 
4. Poverty and Healthcare 
5. Experiences of Trauma and Violence (note: we discuss sexual violence and trauma in this section, which may not be suitable for some readers)
6. Toward Structural Health Transformations

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Although HPV is Common, it Remains Stigmatized 

Almost all cervical cancers are caused by persistent and untreated high-risk Human Papillomavirus (HPV) infections. According to the Centers for Disease Control, nearly all sexually active adults will get HPV at some point in their lives, making it the most common sexually transmitted infection. The following statistics illustrate just how widespread HPV is in the United States:

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Despite its prevalence, HPV remains a stigmatized health issue. Guidance around HPV prevention has typically focused on managing one’s sexual practices (e.g., monogamy, protected sex). While safe and consensual sex is important for many reasons, over the years, this emphasis on individuals’ sexual habits as the main risk-reduction mechanism for HPV has created a sense of stigma around HPV and blame toward women who test positive for this virus. 

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This stigma around HPV is consequential. It can constrain equitable and compassionate care for those diagnosed with HPV, and can put survivors in a place where they face continued harms. Stigma can obscure the information and awareness needed to provide adequate healthcare access to patients. For instance, some survivors describe that insurance does not always cover ongoing hormone replacement medications or fertility supports, which can be critical for those whose treatments involve full hysterectomies (including removal of ovaries). Stigma can also mean that survivors are continually marginalized, making recovery an isolating journey and limiting visible advocacy. The resulting shame can also discourage women from engaging in life-saving routine screening and follow-up interventions. 

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Given that we have the tools (i.e., HPV vaccination and routine screening) to eliminate cervical cancer as a public health concern, it is critical to shift the culture around HPV and cervical cancer from one of shame to awareness and mitigation. It is especially important that providers take a stigma-reduction approach to HPV-related diagnoses and treatment, underscoring how common HPV is and de-centering individual blame, to build a culture of greater awareness and equity. 

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A Shift Away from Stigma

While not all HPV infections progress into cervical precancer or cancer, routine preventative screening remains critical to identify and monitor infections. For 90% of women, HPV clears up on its own within 2 years. But in some cases, HPV infections can persist, and if left untreated may progress into possibly cancerous cell changes. Per the American Cancer Society, factors that can influence how HPV persists and progresses include: 

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• Certain genetic predispositions (specific HLA haplotypes and genome-wide specific variants)
• In-utero exposure to Diethylstilbestrol, a pregnancy-supporting drug commonly used in the 1940s-1970s (‘DES daughters’)
• Smoking tobacco, which can lead to DNA damage of cervix cells and immune system compromise
• A weakened immune system resulting from other co-infections or conditions (e.g., HIV, chlamydia, autoimmune conditions, immunosuppressant drugs). 

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Further, emerging research illuminates how the likelihood that HPV persists is also intertwined with one’s socioeconomic context and life experiences (and resulting physiological effects). Moving away from an over-emphasis on sexual practices, this growing body of research suggests that social determinants partly explain why the immune system may be less able to overcome HPV infections in certain cases. In what follows, we explore three of these interlinked social determinants:  

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1. The effects of dealing with chronic stress and depression on the immune system’s response to HPV
2. The impacts of living in poverty on one’s healthcare outcomes 
3. And, the continual challenges that a personal history of sexual trauma or violence has on one’s body and health. 

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Recognizing social determinants behind HPV and cervical cancer risk illuminates a fuller framework of how to address this common virus and eliminate a highly preventable cancer. 

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Chronic Stress and Related Lifestyle Coping Practices 

Structural health inequities translate to physiological outcomes. Chronic stress and depression have been shown to suppress one’s immune functions, which compromises the body's ability to clear HPV infections.

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In part, researchers find that the increased cortisol levels related to chronic stress contribute to a higher risk of HPV persisting and progressing. 

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A study published in the Journal of Immunology Research found stress leads the body to develop an inflammatory response, which in turn intensifies stress. This creates a harmful cycle that continually suppresses one’s immune response, contributes to DNA damage, and increases the possibility of HPV-related carcinogenesis. In women with cervical dysplasia, data has shown that higher levels of perceived stress compromise the body’s ability to respond to high-risk HPV 16 infections. Similarly, research illuminates that women who reported more severe symptoms of depression were also more susceptible to active HPV infections persisting. 

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Further, lifestyle coping behaviors are also closely tied to how HPV may progress into cervical cancer. For example, smoking tobacco (which often goes hand in hand with managing stressors) can elevate cervical cancer risk by about twofold. Similarly, other high-risk coping strategies for stress and mental health – such as substance abuse – also increase the chances that an HPV infection progresses into potentially cancerous cell changes. Both these lifestyle practices damage DNA and weaken one’s immune response. 

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Poverty and Healthcare 

In the United States, living in poverty – which is often connected to residential segregation that limits other life opportunities – is a key structural determinant of one’s health outcomes. Those who are low-income, especially if they also live in residentially segregated spaces, often face barriers to critical healthcare, including limited healthcare recommendations and resources, healthcare provider shortages, and less access to preventative care. As a result, they often experience additional healthcare challenges and poorer outcomes. These health disparities are particularly stark for those of color. 

Cervical cancer is no exception. Cervical cancer incidence has been steadily increasing, including among those who are low-income.

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In particular, research finds an association between cervical cancer incidence, lower levels of education, and higher poverty. While studies show that cervical cancer incidence is higher in rural areas (often due to limited access to the HPV vaccine and routine screening), in urban areas research finds that those living in impoverished neighborhoods face much higher cervical cancer incidence.

Circumstances of poverty can bring overlapping challenges that compound the effects of chronic stress, and therefore make one’s immune system more vulnerable to persistent HPV. These challenges may include:

• Longer working hours and irregular shift work
• Inconsistent paychecks
• Immigration hurdles
• Lack of reliable access to healthcare and childcare
• Unsteady housing situations
• Racial and ethnic discrimination

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The resulting chronic stress not only hurts one’s immune response but may also influence risky coping strategies and mental health challenges, illustrating how circumstances of poverty can entrench people in systems of health inequity. 

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As such, while HPV is widespread, individuals from low-income communities can experience circumstances leading to a higher likelihood that the infection persists and progresses. 

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Experiences of Trauma and Violence

Note: we discuss sexual violence and trauma in this section, which may not be suitable for some readers

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There is a significant link between experiences of violence or trauma and increased risk of contracting HPV with the infection progressing into cervical cancer. Some reasons behind this association are tied to the physiological repercussions this brings, namely the ongoing stressors related to processing trauma that compromise long-term immune responses. 

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Those who have survived sexual violence and trauma continually process these experiences psychologically and physically. This makes them more vulnerable to persistent HPV infection and cervical cancer, given how chronic stress and depression impact one’s immune system’s ability to fight off HPV infections. 

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Experiences of sexual violence and trauma are prevalent among women. In the United States, over half of all women have experienced sexual violence. Relatedly, those who are low income are significantly more likely to experience sexual trauma and violence; some reports suggest a 12 times higher probability. In particular, women and children living in poverty are at much higher risk of being victimized, often by intimate partners, as they lack the financial resources to change their living situations. 

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The risk of developing cervical cancer and precancerous lesions from HPV is thus notably higher among women who have experienced sexual abuse, intimate partner violence, or forced sexual experiences. These personal experiences of sexual violence and abuse represent extreme stress and trauma, which hurts one’s long-term immune response while also increasing vulnerability to social circumstances and behaviors that escalate the risk for persistent HPV infections. 

For the LGBTQ+ community, their increased risks around HPV and cervical cancer reflect an intersection of negative healthcare experiences as well as heightened experiences around trauma and violence. LGBTQ+ individuals also face higher rates of sexual trauma and violence. Half of all trans individuals in the United States have been sexually assaulted. And, when it comes to cervical cancer, these communities are often underscreened and therefore at higher risk: a study found that only 56% of trans men were engaged in routine cervical cancer screening, compared to 72% of cisgender women. 

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Their lower screening participation often stems from systematic healthcare biases (in one study, 87% of LGBTQ+ patients reported receiving disrespectful and biased healthcare), as well as gender dysphoria related to the traditional provider-collected speculum exam (a study found that over 90% of trans male patients preferred self-collecting over provider-collection). Pairing traumatic and stressful personal histories with inequities around healthcare delivery, these communities can face higher risks of HPV infections persisting and progressing into cancer or precancer. 

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Toward Structural Health Transformations

This research deep dive introduces an emerging understanding of HPV risk and cervical cancer that goes beyond managing one’s sexual practices and stigmatizing sexual behavior. Individuals across socioeconomic and personal backgrounds experience HPV and cervical cancer. However, a basis in the social determinants of health reveals that (i) chronic stress, (ii) socioeconomic status, and (iii) personal histories of trauma and violence are among key social cofactors that can increase the likelihood that an HPV infection persists and progresses into possibly cancerous cell changes. 

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While more research is required into social determinants associated with persistent HPV infections, it is clear from emerging studies that these factors play a role in the persistence and carcinogenesis of HPV. To be sure, the systemic issues around cervical cancer in the United States are not limited to particular social groups. Substantial data tells us that under-screening for cervical cancer as well as incidence of cervical precancer and cancer are widespread issues, across racial, ethnic, and income groups. 

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Public health systems must continue to develop comprehensive strategies – addressing not only individual behaviors but also broader social and structural interventions – to engage more people in routine cervical cancer screening. These could include: 

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• More accessible options to complete routine HPV screenings (e.g., mobile clinics, self-collection, at-home screenings)
• Reliable clinic access for follow-up care
• Family-centered education around the HPV vaccine
• Awareness-building resources and advocacy that transform the narrative of stigma 

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Efforts to reduce HPV and cervical cancer prevalence need to be attentive to individuals’ socioeconomic contexts and co-factors possibly influencing their health risks, with practices that are trauma-informed, culturally sensitive, and rooted in an awareness of how one’s social position impacts their health outcomes. 

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We hope this research can bring to light how we can begin to rethink HPV risk and better support those facing cervical cancer. To share your thoughts, please reach out to us. To stay up-to-date on when you may be able to use the Teal Wand^TM for your at-home cervical cancer screening, please join our waitlist.*

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*The Teal Wand has been designated as a Breakthrough Device and is currently under review by the FDA.

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