Dear Dr G,

I am a 57-year-old man with a younger partner who is nearly 50.

I often assume having a younger partner can fulfil my healthy sexual appetite.

Since passing my milestone birthday seven years ago, my partner assumes we are approaching the sunset years and that sexual frequency would dwindle.

On the contrary, I continue to enjoy an active sex life, as often as during my youth.

My partner sadly finds such frequency unacceptable, and reckons frequent sexual intercourse should be a distant memory, with the focus shifting to non-sexual forms of intimacy in our later years.

I often find the disparity in our sexual desire a real frustration.

This is clearly having a significant adverse impact on our relationship.

I take this opportunity to put you on the spot for evidence and real-life data on sexual activity among older Malaysians.

I understand Malaysia is a conservative country. However, is there any study highlighting the normal frequency of sexual activity in Malaysia?

Is there a significant drop in the frequency of sexual intercourse in ageing populations?

Incidentally, what influences the frequency of sexual intimacy?

I look forward to your response.

Yours truly,

Frequent Frederick

Malaysia-specific data on sexual activity among married and partnered adults are relatively limited, because large-scale national surveys tend to focus on reproductive health, adolescent behaviour, or sexual health issues rather than the frequency of sexual intercourse among couples.

Nevertheless, available Malaysian studies provide some insights into sexual activity, satisfaction and wellbeing. The Asia Pacific Sexual Health and Overall Wellness (APSHOW) survey, published in 2011 in the Journal of Impotence Research, involved 4,000 participants across 13 countries, including both male and female participants from Malaysia.

It offers a glimpse of sexual health in Malaysia a decade ago and outlines how older Malaysians view sexual health. Research on older Malaysian adults aged 60 and above found that 57.3% had engaged in sexual intercourse within the previous 12 months. The prevalence was higher among men (61.6%) than women (50.6%).

Significant ethnic differences were also observed, with sexual activity reported by 68.8% of older Indians, 62.4% of Malays, and 51.7% of Chinese respondents. The study concluded that sexual activity remained an important aspect of quality of life in later years, and was associated with better physical health, marital relationships and overall wellbeing.

Among older Malaysians, another study examining sexual desire and satisfaction found many participants continued to value intimacy and regarded sexual relations as an important component of marriage. Although the frequency of sexual activity declined with age, emotional closeness, companionship and mutual support became increasingly important determinants.

There may be a decline in average frequency of sexual intercourse among couples from eight times a month to six times a month between under- and over-40 age groups. The frequency of intercourse remained relatively high in both age groups. Studies examining sexual health among Malaysians indicate sexual concerns are common but often underreported.

Research involving older adults found women reported more sexual difficulties than men. About 72.5% of women reported a lack of interest in sex, 55.1% reported difficulty achieving orgasm, and 34.8% described sex as unpleasant.

These findings suggest sexual satisfaction is influenced not only by frequency of intercourse, but also by physiological, psychological and relationship factors. Malaysia’s multicultural and religiously diverse society shapes sexual attitudes and behaviours. Marriage remains the socially accepted context for sexual activity.

Consequently, discussions about sexual health often occur less openly than in many Western countries. This conservatism can discourage couples from seeking professional help for sexual problems, despite evidence that sexual wellbeing contributes substantially to overall health and relationship satisfaction. Studies consistently show Malaysians place a high value on marital harmony, emotional intimacy and family stability, all of which are closely linked to sexual satisfaction.

Economic and lifestyle factors also influence sexual activity among Malaysian couples. Rapid urbanisation, long working hours, traffic congestion, financial pressures and the increasing prevalence of dual-income households can reduce opportunities for intimacy. In urban centres such as Kuala Lumpur, Petaling Jaya, Johor Baru and Penang, couples frequently report work-related stress as a major challenge affecting relationship quality and sexual desire.

While comprehensive national statistics on sexual frequency are unavailable, health researchers generally recognise stress, fatigue, chronic illness and mental health concerns as important determinants of sexual wellbeing among Malaysian adults.

Overall, the evidence suggests sexual wellbeing among Malaysians is strongly associated with physical health, emotional connection, communication between partners and relationship satisfaction.

Malaysian experience indicates the quality of intimacy and emotional closeness often has a greater impact on sexual satisfaction than the frequency of sexual intercourse alone. Couples who maintain strong communication, mutual respect and good health generally report higher levels of overall wellbeing and relationship fulfilment.

In conclusion, while comprehensive national data on the frequency of sexual activity among Malaysian couples remain limited, existing research suggests frequency of intercourse can be a barometer of relationship wellbeing. Sexual wellbeing is also a key component of overall quality of life.

Factors such as physical health, emotional intimacy, cultural values, communication and lifestyle pressures all play significant roles in shaping sexual satisfaction. The evidence suggests that for many Malaysians, sexual frequency remains important in maintaining healthy and fulfilling partnerships. The American sex researcher Emily Nagoski once said: “Sex strengthens the bonds between partners.”

When Dr G is questioned by people who feel deprived by less frequent sex, his view is: “The more frequent, the stronger the bond!”

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Dear Dr G,

I read with interest the articles highlighting the various adversities of sexual and reproductive health.

I think it is time for me to be open about my status as an individual living with HIV.

I am a 33-year-old man who contracted HIV in my late 20s through ignorance and carelessness.

Although guilt and shame initially drove me to despair, I am living proof there is a fulfilling life after being infected with HIV.

My world crumbled when I learned I had tested positive during routine blood donation screening, as HIV was always three letters associated with imminent death.

Now living with the virus with the right treatment, I feel compelled to spread the word that HIV no longer has the haunting past it once did.

Although I am living healthily on an antiretroviral regimen, I still cannot help doubting how treatment, or living with HIV, might affect me sexually.

As I start a new life with my wife, I would like to put you on the spot for clarification on the sexual and reproductive impact of living with HIV.

First, how does HIV affect men’s reproductive health?

Can the virus or its treatment cause sexual dysfunction in any way?

How can I prevent HIV transmission to my loved ones, including the next generation?

Lastly, my biggest fear is stigma. How do we stop stigma from consuming us?

Yours truly,

HIV-Howard

Living with HIV can affect sexual and reproductive health in physical, emotional and social ways. Since HIV was identified in the 1980s, medical advances have transformed it from a life-threatening illness into a manageable chronic condition. Today, antiretroviral therapy (ART) allows many people living with HIV to live long, healthy lives.

However, HIV and its treatment can still influence fertility, sexual wellbeing, mental health and long-term physical health. HIV can affect sexual and reproductive health in several ways. In the early stages of infection, the virus weakens immune function and may contribute to fatigue, weight loss, hormonal imbalance and increased vulnerability to other sexually transmitted infections.

In men, HIV may be associated with reduced sperm quality, lower testosterone levels and erectile dysfunction, particularly if infection is untreated or treatment is interrupted. Women living with HIV may experience menstrual irregularities, pelvic infections and pregnancy-related complications if proper care is not available.

The emotional and social impact of HIV is also significant. Many people living with HIV experience anxiety, depression, fear of rejection and stigma that affects relationships and sexuality. Concerns about transmitting the virus to partners or future children can affect intimacy and family planning decisions.

In some societies, stigma and discrimination still create barriers to healthcare and emotional support, even though medical understanding of HIV has improved greatly. One of the greatest breakthroughs in HIV care has been antiretroviral therapy. ART works by reducing the amount of virus in the body to extremely low levels.

When taken consistently, treatment can make the virus “undetectable”, meaning it cannot be sexually transmitted to others. This is the basis of “Undetectable = Untransmittable” (U=U) and has expanded the reproductive choices of people living with HIV.

In the short term, ART can cause side effects such as nausea, headache, fatigue, diarrhoea, and sleep disturbance, particularly when treatment is first started. Some people may also notice changes in mood or appetite. These symptoms often improve as the body adjusts.

The long-term effects of ART are more complex. While modern medications are far safer than earlier HIV drugs, long-term treatment may still be associated with weight gain, higher cholesterol, liver or kidney problems and reduced bone density in some patients.

Long-term HIV infection and chronic inflammation may also increase the risk of cardiovascular disease and diabetes as people age. Despite these challenges, ART has dramatically improved reproductive outcomes.

With proper treatment and medical follow-up, women living with HIV can become pregnant and give birth with a very low risk of mother-to-child transmission. Couples affected by HIV can also pursue parenthood with medical guidance, including timed conception and assisted reproductive technologies where appropriate.

Living with HIV today is very different from what it was decades ago. Many individuals can maintain healthy relationships, active sex lives and successful pregnancies. However, HIV still carries physical, emotional and social challenges that require ongoing healthcare, education and support.

Reducing stigma remains essential. “Stigma is more harmful than the disease itself” is a widely used mental health advocacy quote. In the 21st century, with the right treatment and disease awareness, living with HIV can be much like living with other chronic conditions.

Dr G is often put on the spot about how to minimise stigma.

His view is: “Only disease awareness and open communication can sway the shame and stigma against the disease itself!”

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Dear Dr G,

I can see that you are discussing various preventable viral infections in May.

I am a bit surprised that the elephant in the room, Covid-19, is not being highlighted, as it should still be fresh in our minds.

I am in my early twenties and, unfortunately, like many other people, my wife and I contracted Covid-19 during the pandemic. My wife was very lucky, as her symptoms were relatively mild, but I unfortunately ended up in the ICU due to severe respiratory distress.

Our biggest worry at the time was that my wife was also pregnant with our first child. We were very concerned about how the virus or the vaccine could adversely affect our baby.

Thankfully, our daughter is now three years old. She has achieved all her normal developmental milestones and is flourishing.

Despite life returning to normal, I cannot help but wonder what impact the virus and the Covid vaccine may have had on my family and me.

I would like to take this opportunity to put Dr G on the spot for his wisdom!

Five years down the line, what data are there on children born during the Covid pandemic?

What are the adverse reproductive consequences of Covid and the vaccine on both men and women?

Lastly, I have also read about men suffering from Covid-induced sexual dysfunction. Should I be worried that this might come back to haunt me?

Regards,

Covid-Christopher

Five years after the Covid-19 pandemic changed the world, its impact on sexual and reproductive health is still being felt. What began as a respiratory illness quickly affected many other areas of life, including fertility, pregnancy, mental health, relationships, and access to healthcare. Both the virus and the vaccines became major topics of concern, especially when questions about infertility and pregnancy safety began spreading online. Many researchers are still analysing the physical and psychological effects associated with both the virus and the vaccine.

Research over the years has shown that Covid-19 infection itself can affect reproductive health in several ways. In men, severe infection has been linked to temporary reductions in sperm quality and hormonal changes caused by fever, inflammation, and overall stress on the body. Women have also reported menstrual irregularities after infection, including delayed or heavier periods. Most of these effects appear to be temporary, but they clearly demonstrate that the virus can influence the reproductive system. Although most men and women recover completely without long-term reproductive impairment, a small proportion of individuals may experience irreversible infertility following more severe Covid-19 infection.

Pregnancy was another major concern during the pandemic. Studies found that pregnant individuals who contracted Covid-19 faced higher risks of severe illness, hospitalisation, and complications such as preterm birth. Hospitals and healthcare systems were also overwhelmed, making access to prenatal care and reproductive services more difficult in many countries. Fertility treatments, contraception services, and sexual health clinics were often delayed or interrupted during lockdowns. Encouringly, data collected during the peak of the pandemic did not show an increase in stillbirths or major birth abnormalities. The vaccines have been shown to be safe for both mother and fetus during pregnancy and after birth.

Covid-19 vaccines soon became surrounded by controversy and misinformation. Many people feared that the vaccines could cause infertility, but years of scientific studies have found no evidence to support these claims. Research involving millions of vaccinated individuals has shown that the vaccines do not reduce fertility in men or women. Some women experienced temporary changes in their menstrual cycles after vaccination, but these effects were generally mild and short-lived. Health experts have consistently concluded that vaccination is far safer than the risks associated with Covid-19 infection, especially for pregnant individuals. There is no evidence that the vaccines reduce sperm quality, and no association has been found between Covid-19 vaccination and sexual dysfunction.

The pandemic also affected sexual health emotionally and socially. Lockdowns, stress, anxiety, loneliness, and financial difficulties placed considerable pressure on relationships and mental well-being. Many people experienced depression, isolation, or reduced intimacy during this period. At the same time, telemedicine became more common, allowing people to access reproductive and sexual healthcare online when in-person visits were difficult. Although mental health issues were highlighted during the pandemic, most individuals who experienced stress and depression have demonstrated resilience and largely returned to their usual level of mental well-being. Post-infection depression and sexual dysfunction are well-documented, but they are also highly treatable with counselling and appropriate medical care.

Five years later, the evidence suggests that Covid-19 infection posed far greater risks to sexual and reproductive health than the vaccines developed to prevent severe illness. The pandemic also revealed the importance of resilient healthcare systems, robust scientific research, and clear public communication. Although scientists continue to study the long-term effects of Covid-19, the pandemic has permanently changed how society views reproductive health, public health, and medical trust. The Lebanese-American poet Khalil Gibran once said, “Out of suffering have emerged the strongest souls.” Five years after the beginning of the Covid-19 pandemic, Dr George is still being challenged by doubtful patients about the aftermath of the virus on their sexual, reproductive, and overall health. His view is: “Despite emerging as stronger souls with minimal lasting harm, our sufferings should serve as a reminder to live more mindfully and pursue a healthier life.”

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Dear Dr G,

I understand that you are outlining various viral infections that can be prevented by vaccination during the month of May.

Personally, as a Hepatitis B carrier, I am somewhat confused about the ABC of viral hepatitis and their impact on my sexual health.

I contracted hepatitis as a child from my mother.

All my life, I have been told to be cautious about my liver function and to take precautions when engaging in sexual activity.

After I got married, I became paranoid about transmitting the virus sexually to my wife.

I often tried to read up more about other forms of hepatitis and the role I play in preventing transmission of the virus to my wife and children.

Apart from vaccination and the use of barrier protection during intercourse, I often worry about other ways I can prevent transmission of my disease.

I wish to put Dr G on the spot to outline the ABC of hepatitis and how they impact sexual health.

What exactly are hepatitis viruses, and how are they transmitted?

Are hepatitis A, B, and C all different, or are they just different strains of the same virus?

How do these viruses affect sexual and reproductive health?

Looking forward to your answers.

Yours truly,

Hepatitis Howard

Viral hepatitis is a major public health problem worldwide and is responsible for significant illness, liver failure, and death. The three most important forms are hepatitis A, hepatitis B, and hepatitis C. These viral infections primarily target the liver, causing inflammation. Although they share similar effects on the liver, they differ in their modes of transmission, disease progression, and long-term complications. Viral hepatitis is also closely linked to sexual and reproductive health because some forms are transmitted through sexual contact, can affect fertility and pregnancy, and may be passed from mother to child.

Hepatitis A is caused by an RNA virus that spreads mainly via the faecal–oral route, often through contaminated food or water or poor sanitation. After entering the body through the digestive tract, the virus travels through the bloodstream to the liver. The pathogenesis of hepatitis A is mainly immune-mediated, meaning that liver damage occurs when the immune system attacks infected liver cells. This inflammatory response leads to symptoms such as fever, fatigue, nausea, abdominal pain, loss of appetite, dark urine, and jaundice. Unlike hepatitis B and C, hepatitis A does not usually become chronic because the immune system can generally clear the infection completely. Although hepatitis A is not commonly considered a sexually transmitted infection, it can spread through sexual practices involving oral–anal contact. Poor hygiene and close physical contact during sexual activity may increase the risk of transmission.

Hepatitis B is caused by a DNA virus that is transmitted through blood and body fluids, including semen and vaginal secretions. It spreads through unprotected sexual intercourse, contaminated needles, blood transfusions, and from mother to child during childbirth. After entering the body, the virus infects liver cells and replicates within them. The virus itself causes little direct damage, but the immune system attacks infected hepatocytes, resulting in inflammation and liver injury. In some individuals, especially infants infected at birth, the immune response fails to eliminate the virus completely, leading to chronic infection. Chronic hepatitis B can progress to fibrosis, cirrhosis, liver failure, and hepatocellular carcinoma.

Hepatitis B has major implications for sexual and reproductive health because it is highly infectious through sexual contact. Individuals with multiple sexual partners or those who do not use protection are at greater risk of acquiring the infection. The virus may also coexist with other sexually transmitted infections, increasing transmission rates. One of the most serious reproductive health concerns is vertical transmission from mother to baby during delivery. Infants infected at birth are much more likely to develop chronic hepatitis B, which can later lead to severe liver disease. Chronic HBV infection may also interfere with reproductive hormones and contribute to infertility and sexual dysfunction.

Hepatitis C is caused by an RNA virus that spreads mainly through blood exposure, particularly through shared needles, unsafe injections, and contaminated blood products. Sexual transmission is less common than with hepatitis B, but it can occur, especially among individuals with multiple sexual partners, HIV coinfection, or traumatic sexual practices. After infecting hepatocytes, the virus mutates rapidly, allowing it to escape immune detection and persist in the body. The continuous immune response against infected cells causes chronic inflammation and progressive liver damage. Over time, this can result in fibrosis, cirrhosis, and liver cancer.

The reproductive and sexual health effects of hepatitis C are also important. Pregnant individuals with HCV can transmit the virus to their infants, especially if they have high viral loads or coinfection with HIV. Chronic liver disease associated with HCV may affect hormone production and lead to menstrual disturbances, infertility, reduced libido, and complications during pregnancy. In the past, some antiviral treatments for hepatitis C were unsafe during pregnancy, although newer therapies are more effective and safer when given before conception.

In conclusion, hepatitis A, B, and C are serious viral infections that affect the liver through immune-mediated inflammation and hepatocyte injury. Hepatitis A usually causes an acute, self-limiting illness, while hepatitis B and C can become chronic and lead to cirrhosis and liver cancer. These infections are strongly connected to sexual and reproductive health because they may spread through sexual contact, affect fertility and pregnancy outcomes, and be transmitted from mother to child. Effective prevention through vaccination, safe sexual practices, antenatal screening, and early treatment remains essential in reducing the burden of viral hepatitis and protecting reproductive health. WHO Director-General Tedros Ghebreyesus once said, “Viruses know no borders.” When Dr G is put on the spot to outline the sexual health implications of hepatitis A, B, and C, his response is always: “Knowledge creates borders for these viruses!”

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Dear Dr G,

I read with interest your explanation of how German measles affects women and how the disease itself has minimal effect in men.

I am somewhat surprised you did not outline the risks associated with another dangerous virus, mumps, which can have a more detrimental impact on young adult males.

As a child, I contracted mumps after missing vaccination at school.

I was horrified when I learned mumps may sometimes lead to infertility, and this information has caused me concern.

Many people tend to think of mumps as only a childhood illness, but I understand complications can occur when adults are infected.

As I am venturing into adulthood, I worry the aftermath of mumps may cause havoc to both my sexual and reproductive health.

I would like to put you on the spot so you can address how mumps may affect sexual and reproductive health in young men.

What exactly is mumps and how is the infection transmitted?

How common are complications such as inflammation of the testicles, reduced fertility, or other long-term effects?

Are these risks rare, or should young adults be more cautious?

I also hope you can explain whether vaccination still provides good protection in adulthood and what steps people can take to reduce their risk of infection.

I believe this is an important public health topic that many readers, especially young adults and parents, would benefit from understanding better.

Yours sincerely,

Mumps Matthew

For many people, mumps is remembered as a common childhood illness marked by swollen cheeks, fever and a few days away from school. However, beneath this seemingly harmless infection lies a virus that can sometimes lead to serious complications, especially among adolescents and young adults.

Although vaccination has dramatically reduced the number of cases worldwide, mumps remains an important public health concern because outbreaks still occur and complications can affect long-term health and fertility. Mumps is a contagious disease caused by the mumps virus, which belongs to the Paramyxovirus family.

The illness mainly affects the salivary glands, particularly the parotid glands near the ears, producing the characteristic swelling of the face and jaw. The disease has been recognised since ancient times. The Greek physician Hippocrates described symptoms resembling mumps as early as the fifth century BCE.

However, it was not until 1934 that scientists Claude Johnson and Ernest Goodpasture proved mumps was caused by a virus spread through saliva and respiratory droplets. Before the development of vaccines, large epidemics occurred every few years, especially among schoolchildren.

Most people contracted the infection during childhood, and outbreaks spread rapidly in crowded communities. The introduction of the measles-mumps-rubella (MMR) vaccine changed the situation dramatically. In countries with strong immunisation programmes, the incidence of mumps dropped by more than 90%.

Nevertheless, the disease has not disappeared. Thousands of cases continue to be reported globally every year, particularly in places where vaccination rates have declined, or where young adults live in close-contact environments such as universities, dormitories and military camps.

The virus spreads easily through coughing, sneezing, talking, or sharing utensils and drinks. Once it enters the body through the nose or mouth, it multiplies in the respiratory tract before spreading through the bloodstream to other organs. Children infected with mumps often develop fever, headache, tiredness, muscle aches and swelling of the salivary glands.

In many cases, the illness resolves within 1–2 weeks without lasting problems. However, complications become more common and more severe in adolescents and adults. One of the most worrying complications among post-pubertal males is orchitis, which is inflammation of the testicles.

This condition can develop several days after the onset of facial swelling and may cause severe pain, swelling, tenderness and fever. Although most men recover fully, some may experience shrinkage of the affected testicle. In rare cases, particularly when both testicles are involved, fertility may be reduced. Complete infertility is uncommon, but the possibility has caused understandable concern among many young men.

Mumps may also affect other organs, including the pancreas, brain and inner ear, sometimes leading to meningitis, encephalitis or hearing loss. Vaccination has proven to be one of the greatest achievements in modern medicine.

The MMR vaccine provides strong protection against mumps and significantly reduces the risk of serious complications. High vaccination coverage also contributes to herd immunity, protecting vulnerable members of society who cannot be vaccinated.

Unfortunately, misinformation and vaccine hesitancy in some communities have allowed outbreaks to re-emerge in recent years. Public education therefore remains essential in reminding people that diseases once considered “mild childhood illnesses” can still produce serious consequences. Scientists believe mumps can potentially be controlled to very low levels through widespread vaccination, strong public health systems and rapid outbreak response.

Although complete global elimination remains difficult because immunity may decrease over time and vaccination coverage differs between countries, the dramatic decline in cases over recent decades demonstrates prevention works.

The story of mumps reminds us medical progress should never be taken for granted. Infectious diseases that once caused widespread suffering can return if societies become complacent. Continued scientific research, vaccination programmes and public awareness are necessary to protect future generations from preventable illnesses.

American astronomer Carl Sagan once said: “The consequence of today is determined by actions of the past”

Dr G is often put on the spot by infertile men questioning whether the aftermath of mumps results in irreversible damage to fertility.

His view is: “We will definitely prevent the consequence of today, when we are determined in the actions of vaccination tomorrow!”

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Dear Dr G,

I read with interest your point that HPV vaccination should be given to both boys and girls to help eliminate cervical cancer and other HPV-related malignancies.

Although I’m a bit too old to take the HPV vaccine, I can’t help recalling a similar situation with German measles.

As a boy, I remember rubella vaccination being recommended only for girls, on the basis that rubella could damage female fertility.

Yet the virus also affected males, and it was apparently deemed less serious, so boys were not routinely vaccinated.

My understanding is that rubella infection remained widespread until boys were included in vaccination programmes as well.

May I take this opportunity to put you on the spot about the similarities between HPV and rubella vaccination?

First, what exactly is German measles, or rubella?

Does the virus affect fertility in both men and women?

Can you explain how girl-only vaccination failed to eliminate the disease?

And has gender-neutral vaccination now eliminated the virus?

I look forward to your answers.

Yours truly,

Curious Chris

Rubella, also known as German measles, is a viral infection that is generally mild in children and adults, but has profound implications for reproductive health and public health. While the illness itself rarely causes severe disease, infection during pregnancy can be devastating.

It can lead to miscarriage, foetal death or a range of serious birth defects collectively known as congenital rubella syndrome (CRS). Over the past few decades, vaccination has dramatically reduced the global burden of rubella. However, how well a programme works depends heavily on whether it targets only females or adopts a gender-neutral approach.

Rubella does not directly cause infertility in either males or females, but it can seriously affect reproductive outcomes, particularly in women. If a woman becomes infected during early pregnancy, especially in the first trimester, the virus can cross the placenta and infect the developing foetus.

This can result in miscarriage or stillbirth, or lifelong disabilities such as hearing impairment, congenital heart defects, visual problems and neurological damage. In men, rubella has minimal long-term effects on fertility. Although infection may occasionally cause a mild, temporary illness that could affect general health, there is no strong evidence it leads to permanent impairment of sperm production.

Globally, rubella has declined dramatically since the introduction of vaccination programmes. At the start of the 21st century, hundreds of thousands of cases were reported annually. By the early 2020s, that number had dropped by about 97%. Despite this progress, rubella has not been eliminated everywhere.

Thousands of cases are still reported each year, and an estimated 100,000 infants are born annually with CRS. This is particularly so in regions with lower vaccination coverage such as parts of Africa and South-East Asia. By contrast, regions such as the Americas have eliminated rubella transmission through sustained, high vaccination coverage.

Early vaccination strategies in some countries focused on immunising adolescent girls, with the goal of protecting future pregnancies. While this may have seemed logical, it proved insufficient and, in some cases, counterproductive.

Vaccinating only girls does not stop the circulation of the virus. Gender-neutral vaccination programmes, which immunise both boys and girls, have been far more effective in controlling and eliminating rubella. By vaccinating all children, these programmes reduce overall virus circulation and lower the risk of exposure for everyone, including pregnant women. This supports herd immunity, in which a sufficiently high proportion of the population is immune.

When herd immunity reaches the necessary threshold, typically around 85% to 90% coverage, rubella can be effectively eliminated from a community. Countries that implemented universal vaccination, often through combined vaccines such as the measles-mumps-rubella (MMR) vaccine, saw dramatic reductions.

The global success of rubella vaccination underscores the importance of inclusive, population-wide strategies. Today, most countries have incorporated rubella vaccination into their national immunisation schedules. The vaccine is highly effective, providing long-lasting immunity in more than 95% of recipients.

These efforts have prevented millions of cases of CRS and reduced the global burden of disease. However, gaps in coverage remain, and sustained work is needed to ensure equitable access in all regions. Rubella is not a direct cause of infertility, but it poses a serious threat to reproductive health through its effects on pregnancy and foetal development.

The history of rubella control shows vaccination strategies must extend beyond a single group to be truly effective. Programmes that target only girls fail to interrupt transmission and may even increase risks under certain conditions. Gender-neutral vaccination provides broader protection by reducing circulation and establishing herd immunity.

Bill Gates famously said: “Vaccines are miracles of modern medicine!”

Dr G is often put on the spot about whether HPV and rubella have demonstrated the same miracle.

His view is simple: the miracle is only possible if everyone is protected, and that clearly includes boys.

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Dear Dr G,

I am a mother of two teenagers who are just starting secondary school.

I received paperwork from the school health department asking for consent for HPV vaccinations for both children.

Of course, I completely agree my 13-year-old daughter should be protected against cervical cancer.

I also see the benefit of my 12-year-old son receiving the vaccine for protection against rare HPV-related male cancers.

I am more intrigued by the leaflet highlighting the role of vaccination in boys helping to build herd immunity in the overall elimination of cervical cancer.

I understand achieving high vaccination coverage is not always possible.

Therefore, I am curious about the current overall protection a girls-only vaccination programme provides in achieving cervical cancer elimination goals.

Therefore, I would like to put Dr G on the spot for clarification on gender-neutral vaccination.

Can you give me some idea of protection against cervical cancer when vaccination coverage is low in a girls-only programme?

Furthermore, can you outline the differences in coverage and herd immunity when coverage is higher?

Lastly, can high vaccination coverage really result in complete elimination of HPV-related cancers in both genders?

Yours truly,

Protective Pamela

Human papillomavirus (HPV) is responsible for nearly all cases of cervical cancer and contributes to a growing number of other cancers affecting both women and men. The introduction of HPV vaccines has transformed the landscape of cancer prevention, offering the possibility of dramatically reducing and potentially eliminating these diseases.

Early vaccination programmes focused primarily on girls, with the rationale that protecting females directly would reduce cervical cancer and indirectly protect the wider population through herd immunity. While this approach has produced meaningful reductions in HPV prevalence and disease, it has become increasingly clear that relying on girls-only vaccination is not sufficient to achieve long-term elimination of HPV-related cancers.

The effectiveness of HPV vaccines at the individual level is well established. When administered before exposure to the virus, they can greatly reduce the risk of cervical cancer. In a girls-only vaccination programme, the overall reduction in cervical cancer depends on both vaccine efficacy and the proportion of girls vaccinated.

If coverage reaches 80%, then direct protection alone would be expected to reduce cervical cancer incidence by about 93%. At this level of uptake, herd immunity begins to play a role, as fewer infections circulate within the population.

Although this level of reduction is substantial, it falls short of elimination. More importantly, the virus continues to circulate among males, who are not protected in a girls-only programme and can transmit HPV back to women.

This ongoing transmission limits the extent of herd immunity and prevents the complete interruption of the virus’s spread. The limitations of girls-only vaccination become even more apparent when coverage is lower.

At 40% coverage, direct protection reduces cervical cancer risk by approximately 53%. Herd immunity at this level is weaker because a larger proportion of the population remains susceptible, and transmission chains are less disrupted. In this scenario, nearly half of cervical cancer cases would still occur, and HPV would continue to circulate widely within the population.

These figures highlight a central problem with relying on herd immunity in girls-only vaccination strategies. Herd immunity is highly sensitive to vaccination coverage and population structure. It assumes relatively uniform uptake and stable transmission patterns. Gender-neutral vaccination offers a more comprehensive solution to these challenges.

By vaccinating both girls and boys, the programme provides direct protection to all individuals, rather than relying heavily on indirect effects. This approach reduces the overall circulation of HPV because it targets both sides of the transmission pathway.

If coverage reaches 80% in both boys and girls, complete elimination of HPV-related cancers is expected in both genders, including cervical cancers. In addition to strengthening herd immunity, gender-neutral vaccination addresses important issues of equity and disease burden.

HPV is not solely a women’s health issue; it also causes cancers in men, including oropharyngeal, anal and penile cancers. A girls-only approach leaves men largely unprotected and fails to address these growing cancer burdens. Furthermore, gender-neutral vaccination reduces the programme’s dependence on uniformly high uptake among girls.

In practice, achieving and maintaining coverage above 80% is challenging, particularly in settings with limited healthcare access or vaccine hesitancy. When both sexes are vaccinated, the system becomes more resilient to gaps in coverage, as immunity is distributed more broadly across the population.

This resilience is critical for sustaining long-term reductions in HPV transmission and for progressing towards elimination. The ultimate aim of HPV vaccination programmes is not merely to reduce disease but to eliminate HPV-related cancers as a public health problem. While girls-only vaccination has laid an important foundation, its limitations mean it cannot achieve this goal on its own. Even at relatively high coverage levels, significant transmission persists, and substantial numbers of cancers continue to occur.

Gender-neutral vaccination, by contrast, offers a more robust and effective pathway to elimination by directly protecting all individuals, reducing transmission more comprehensively, and addressing inequalities in both risk and access to prevention. Gender-neutral vaccination overcomes limitations by strengthening population immunity, protecting both sexes, and accelerating progress towards the elimination of HPV-related cancers.

Benjamin Franklin famously said: “One ounce of protection is worth a pound of cure!”

Dr G is often put on the spot for his view of how protecting boys against HPV will help to eliminate cervical cancer in girls. His view is: “Every ounce of protection in both genders will definitely be worth the cure of this horrible cancer!”

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Dear Dr G,

I read with interest your argument that men are the weaker sex when it comes to immunity against HPV infection.

I am a woman in my late twenties, well protected against HPV through early vaccination.

However, as a woman, I cannot help but point out that HPV-related cancers affect more than half a million women globally every year.

Although you argue that men also suffer from HPV-induced cancers, the number of male-related cancers is significantly lower than in women.

I would imagine that women suffer more from HPV-related cancers largely because men constantly infect women with the disease.

Am I wrong to assume that transmission of HPV from men to women is higher?

I chose this opportunity to put Dr G on the spot for some clarification.

Is it true that HPV is a sexually transmitted disease?

Do men transmit HPV to women more than women transmit it to men?

Is it also true that men have a higher risk of promiscuity, which puts women at risk?

Lastly, am I also wrong in assuming that men have a higher disease burden of HPV and put more women at risk of cancers?

I look forward to your rebuttal.

Regards

Finger-pointing Florence

Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide, and a complex interaction of biological, anatomical, and behavioural factors shapes its transmission dynamics. Although HPV spreads efficiently in both directions between sexual partners, research has explored whether transmission from female to male differs in likelihood compared to male to female transmission.

Transmission of HPV occurs primarily through direct skin-to-skin or mucosa-to-skin contact during sexual activity. In female-to-male transmission, the virus is typically shed from infected mucosal surfaces of the cervix and vaginal lining. These tissues are composed of non-keratinised epithelium, which supports viral replication and can release viral particles into genital secretions. During intercourse, the penile epithelium comes into contact with these secretions, allowing the virus to access susceptible cells, particularly through microscopic abrasions that occur naturally during sexual activity. This continuous shedding from a relatively large mucosal surface area may increase the likelihood that a male partner is exposed to an infectious dose of the virus.

In contrast, male-to-female transmission involves viral presence on the penile shaft, glans, foreskin, or surrounding genital skin. These areas are more keratinised, meaning the outer layer of cells is thicker and less conducive to viral shedding compared to mucosal tissue. However, transmission remains highly efficient because the virus can be transferred to the cervix, especially to the transformation zone, a region where two types of epithelial cells meet and which is particularly vulnerable to HPV infection. Even a relatively small viral inoculum can establish infection in this biologically susceptible area, which helps explain why male-to-female transmission is also clinically significant.

Differences in observed transmission rates between the two directions may partly reflect variations in viral load and shedding patterns. Women with active HPV infection can exhibit higher short-term viral loads in the cervix, leading to increased shedding and potentially a higher probability of transmitting the virus to male partners during that period. Men, on the other hand, often exhibit lower peak viral loads but may carry the virus for longer durations. This persistence may not always produce symptoms, allowing HPV to remain undetected and transmissible over extended periods. As a result, while men may not always transmit the virus as efficiently with a single exposure, their longer infectious period can sustain transmission within a population.

Immune response differences also contribute to these dynamics. Women tend to mount stronger localised immune responses in the cervix and are more likely to clear HPV infections within one to two years. In men, immune responses in penile tissue appear to be less robust or less durable, which may allow the virus to persist longer. This difference does not mean that men inevitably carry high viral loads throughout life, but it does suggest that persistent, low-level infection is more common in men than in women. The absence of routine screening programs for men, comparable to cervical screening in women, further contributes to the perception of prolonged infection, as many cases go undiagnosed.

Behavioural and environmental factors further influence transmission in both directions. Frequency of sexual contact, number of partners, and condom use all play significant roles in determining risk. Circumcision status has also been associated with differences in acquisition and persistence, with uncircumcised men showing higher rates in some studies, possibly due to the microenvironment under the foreskin. Additionally, the presence of microabrasions, coexisting infections, and individual immune status can modify susceptibility.

It is important to emphasise that HPV transmission is fundamentally bidirectional and highly efficient regardless of direction. While certain studies suggest that female-to-male transmission may occur more readily in some contexts due to higher viral shedding from mucosal surfaces, male-to-female transmission is equally important, particularly because of the higher likelihood of persistent infection and serious outcomes such as cervical cancer in women. Therefore, differences in transmission should not be interpreted as a simple imbalance but rather as variations influenced by timing, biology, and context.

Women exhibit higher viral shedding during active infection, increasing short-term transmission risk to men, while men may experience longer persistence of infection, sustaining transmission over time. Both directions of transmission are efficient, and both contribute significantly to the global burden of HPV. Preventive strategies such as vaccination, safe sexual practices, and appropriate screening remain essential for reducing transmission and its associated health consequences. Albert Einstein famously said, “You cannot blame gravity for falling in love!” Dr G is often put on the spot by finger-pointing spouses demanding to find out who should take the blame for the higher risk of HPV transmission. His view is: “It’s definitely not helpful to blame this virus of Love!”

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Dear Dr G,

I read with interest how you highlighted the possibility of men having of cancer following human papillomavirus (HPV) infection.

You did note HPV-related cancers are far more common in women and fully agree that raising public awareness is important.

However, I am concerned by the suggestion that men, as what some refer to as the “stronger” sex, may need less protection than women.

I read a study that found there was a higher HPV prevalence in men and lower rates of lasting immune response after natural infection.

If this is the case, is it true HPV infect men and women equally?

Do men carry the virus more than women as they age?

Lastly, is there evidence that men develop stronger natural immunity to HPV than women?

Yours truly,
Weaker William

HPV is one of the most common sexually transmitted infections worldwide, affecting both men and women across all age groups.

Despite this shared exposure, important differences exist in terms of immunological response.

While HPV has traditionally been framed as a major women’s health issue due to its association with cervical cancer, growing evidence shows that men have weaker natural immunity to HPV.

This reduced immune response contributes to persistent infection, repeated exposure and a significant burden of HPV-related disease throughout life.

The burden of HPV infection in men is substantial and remains relatively constant across the lifespan – unlike women, whose HPV prevalence typically peaks in early adulthood and declines with age.

Men continue to acquire new infections throughout life, indicating a lack of effective protective immunity. As a result, men serve as both reservoirs and transmitters of the virus.

Clinically, HPV infection in men can manifest as genital warts caused by low-risk HPV types, as well as more serious conditions such as penile, anal and oropharyngeal cancers linked to high-risk types. Notably, the incidence of HPV-related oropharyngeal cancers has been increasing in men and often presents later in life, reflecting the long-term consequences of persistent infection.

A key explanation for this sustained disease burden lies in the differences in immune response between men and women following natural HPV infection.

Women are more likely to undergo seroconversion, meaning they develop detectable antibodies against HPV, particularly high-risk types such as HPV16 and HPV18.

These antibodies can provide partial protection against reinfection, suggesting the development of some level of immune memory.

In contrast, men exhibit lower rates of seroconversion and produce lower levels of antibodies. Even when antibodies are present, they do not appear to offer significant protection against subsequent infections, indicating a weaker and less durable immune response.

The reasons for this disparity are both anatomical and biological. The female genital tract is primarily composed of mucosal epithelium, which allows for greater exposure of viral antigens to the immune system and promotes stronger immune activation.

In contrast, much of the male genital epithelium is keratinised, limiting antigen presentation and reducing the effectiveness of immune recognition.

Additionally, broader immunological differences between sexes play a role, as females generally mount stronger innate and adaptive immune responses. Hormonal influences such as estrogen enhance immune activity, while testosterone in males has been associated with relatively immunosuppressive effects, further contributing to weaker immunity in men.

As a consequence of these factors, men often clear individual HPV infections without developing lasting immune protection. This leads to a cycle of infection, clearance and reinfection rather than the development of durable immunity.

Over time, repeated exposure increases the likelihood of persistent infection with high-risk HPV types, which is a critical factor in carcinogenesis. The inability to effectively eliminate the virus or prevent reinfection places men at a higher cumulative risk of developing HPV-related cancers.

The implications for cancer are significant, particularly given the absence of routine screening programs for men. While women benefit from cervical screening that allows for early detection and intervention, men typically lack comparable preventive measures. This often results in HPV-related cancers being diagnosed at later stages, when treatment is more challenging and outcomes are poorer. The rising incidence of oropharyngeal cancers in men highlights the growing importance of addressing HPV as a men’s health issue.

In conclusion, men can be considered the weaker gender in terms of natural immunity to HPV infection due to their lower rates of seroconversion, weaker antibody responses and lack of effective immune memory.

These immunological disadvantages, combined with anatomical and hormonal factors, lead to persistent susceptibility, repeated infections and an increased lifetime burden of disease. Recognising this disparity is essential for informing public health strategies, particularly the promotion of vaccination and awareness, to reduce the impact of HPV-related diseases in men and the broader population.

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Dear Dr G,

I am a father of two boys who is keen to highlight the lack of awareness for cancers in men induced by HPV.

I have two teenage boys who are 13 and 14 years old. Both of them recently came home with HPV vaccination consent forms.

Initially, I found it amusing as I thought the boys had brought back the consent forms by mistake, since I assumed HPV only affects women.

As the boys explained to me that HPV-induced cancer is a serious condition that affects both boys and girls, I began to pay attention.

I realized HPV is so serious that it causes many types of cancers, including cancers that can affect men too.

I am not sure what I read is true and hope to put Dr G on the spot for clarification.

Can you tell me what HPV is and how it is transmitted?

What is the scale of HPV induced cancers affecting both men and women?

What sorts of cancers can HPV cause in men?

Can HPV affect different races differently?

Look forward to your valuable responses.

Yours truly,

Worried William

Human papillomavirus (HPV) is one of the most prevalent sexually transmitted infections globally and a well-established cause of multiple malignancies. It plays a significant role in the global cancer burden, contributing to approximately 690,000 cancer cases each year and accounting for about 4.5–5% of all cancers worldwide. HPV is unique among infectious carcinogens because of its widespread transmission and its ability to cause cancers in both women and men.

Cervical cancer represents the most significant manifestation of HPV-related disease and remains the cornerstone of its global impact. It is the fourth most common cancer among women worldwide, with an estimated 660,000 new cases and approximately 350,000 deaths annually.

More than 90% of cervical cancer cases are attributable to HPV infection, particularly high-risk types such as HPV 16 and HPV-18, which together account for about 70% of cases. The disease disproportionately affects women in low- and middle-income countries, where nearly 90% of deaths occur. The geographical distribution of cervical cancer reflects broader global health disparities. Regions such as sub-Saharan Africa, South Asia, and parts of Latin America bear the highest burden

This stark inequality is largely due to limited access to preventive measures such as HPV vaccination, regular screening through Pap smears or HPV testing, and treatment. In men, HPV-related cancers present a different epidemiological profile. Unlike women, men do not experience a single dominant cancer equivalent to cervical cancer. Instead, HPV contributes to cancers of the oropharynx, anus, and penis, with oropharyngeal cancer emerging as the most common HPV-related malignancy in men.

Although the overall number of HPV-related cancers in men is lower than in women, the incidence of certain cancers, particularly oropharyngeal cancer, has been increasing in many parts of the world. In some high-income countries, the incidence of HPV-related oropharyngeal cancer in men now surpasses that of cervical cancer in women.

The rising burden of HPV-related cancers in men can be attributed to several factors. Unlike cervical cancer, there are no widely implemented screening programs for HPV-related cancers in men, resulting in later detection and poorer outcomes. Additionally, HPV vaccination programs initially focused on girls, leading to lower vaccination coverage among males, particularly in older cohorts.

Behavioral factors, including changes in sexual practices, have also contributed to increased transmission of oral HPV infections. Studies indicate that approximately one in three men worldwide is infected with genital HPV, highlighting the widespread nature of the virus in the male population.

A comparison between HPV-related cancers in women and men reveals important differences in disease burden, prevention, and trends. Women bear a significantly higher overall burden due to the predominance of cervical cancer, but benefit from established screening programs that enable early detection and treatment. In contrast, men experience a lower overall burden but face increasing incidence rates of certain cancers, particularly oropharyngeal cancer, and lack comparable screening strategies.

As a result, while cervical cancer incidence is declining in many high-income settings, HPV-related cancers in men are rising, suggesting a potential convergence in disease burden between genders in the future.

Looking ahead, the global trajectory of HPV-related cancers will depend heavily on the implementation of effective prevention strategies. HPV vaccination has the potential to prevent more than 90% of HPV-related cancers caused by vaccine covered strains and represents a cornerstone of cancer prevention efforts. The World Health Organisation has set ambitious targets for the elimination of cervical cancer as a public health problem, emphasizing widespread vaccination, screening, and treatment.

However, achieving these goals will require addressing disparities in vaccine access and healthcare infrastructure, particularly in low and middle-income countries. Expanding vaccination programmes to include boys and improving awareness of HPV-related risks in men will also be critical in reducing the overall burden of disease.

HPV has a profound and multifaceted impact on global cancer epidemiology. Cervical cancer remains the dominant HPV-related malignancy, particularly affecting women in low-resource settings, while other HPV-related cancers, especially oropharyngeal cancers in men, are increasing in incidence. Without significant global efforts, the burden of HPV-related cancers is likely to rise, particularly in underserved populations.

Conversely, with comprehensive vaccination and screening strategies, there is a realistic opportunity to substantially reduce the most devastating consequences of HPV infection.

Malala Yousafzai famously said: “We cannot succeed when half of us are held back.”

Admittedly, this is in reference to discrimination against women. However, when HPV-induced malignancy indiscriminately affects both genders, awareness is crucial to ensure equity.

Men surprised by the fact HPV can cause cancer in them often put Dr G on the spot. His opinion is: “We cannot succeed in fighting cancer when anyone is held back by lack of knowledge!”

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