Examensarbete för Master
i sociologi med samhällsanalytisk inriktning, 30 hp
Producing “Healthy” Girl Subjectivities –
Pharmaceutical Advertising of the HPV Vaccine in
Sweden
Lisa Lindén
Supervisor: Mark Elam
Semester: VT- 11
1
Contents
Introduction
1
Transforming and Governing the Bodies of Adolescent girls
in an Era of Biomedicalization
2
A Feminist Situational Visual Discourse Analysis
6
The Cultural Imaginary of the Swedish Public Health Landscape
9
“What do Eva and Anna have to do with Cervical Cancer?”
– The Visual Production of the Ideal Swedish HPV Vaccine User
9
“A Message to you who have a Teenage Daughter”: “Remember Gardasil!”
– Swedish Mothers as Ideal Consumers of the HPV Vaccine
15
Direct to Consumer Letters Filled with a Moral Imperative to Get Vaccinated
17
Activating Adolescent Swedish Girls at Risk for Genital Warts
18
Discussion: HPV Vaccine in a Vaccination Landscape under Transformation
20
References
23
Producing “Healthy” Girl Subjectivities – Pharmaceutical
Advertising of the HPV Vaccine in Sweden
Lisa Lindén, Department of Sociology, Gothenburg University
Abstract. This article investigates direct to consumer advertising in Sweden of a contemporary gendered
technology of the adolescent female body: the HPV vaccine. The aim is to explore how advertising campaigns
encourage adolescent girls to vaccinate themselves by producing new girl subjectivities as the ideal users of the
vaccines Gardasil and Cervarix. Making use of visual discourse analysis the article examines how new
“healthy” girl subjectivities are constructed through advertising and presented as “fit for” the HPV vaccine. It is
shown how Swedish adolescent girls in an era of biomedicalization are encouraged to assume responsibility for
managing the risks of cervical cancer in order to help optimize their (future) health. It is argued that as a
preventive technology, HPV vaccine is addressed to individual members of the population by means of which
the advertising serves to rearticulate simultaneously “nationalized” and “globalized” notions of girlhood,
heterosexuality as well as individual empowerment, risk and responsibility transforming and regulating the
bodies of adolescent girls in Sweden.
Key words: HPV vaccine, direct to consumer advertising, biomedicalization, biopolitics, governmentality,
adolescent girls
2
Introduction
The vaccines Gardasil and Cervarix are used to prevent type 16 and 18 of the sexual
transmitted disease (STD) human papillomavirus (HPV) which together are estimated to
cause 70% of cervical cancer (CC) cases per year (MPA, 2010b). 1 After their approval in the
US in 2006, due to their status as the world’s first “cancer vaccines”, these two vaccines have
been hailed by physicians, public health practitioners and the popular press as constituting a
major advance in public health (Braun & Phoun, 2010:39). Both vaccines have been widely
marketed in Sweden after their approval by the Swedish Medical Products Agency
(Läkemedelsverket) – Gardasil in 2006 and Cervarix in 2007 (MPA, 2010b).
In the US, pharmaceutical companies have extensively marketed and advertised the HPV
vaccine directly to the American citizen (Mamo et al, 2010, Braun & Proun, 2010). As
previous studies have pointed out, this has not been possible in Europe or Canada due to
legislation that forbids direct to consumer advertising (DTCA) for prescription
pharmaceuticals (Stöckl, 2010, Löwy, 2010, Connell & Hunt, 2010). In Sweden, however, the
HPV vaccine makes an interesting case as advertising for prescription pharmaceuticals
directed to the consumer is allowed when it comes to vaccines against infectious diseases
such as HPV (MPA, 2010a). This makes it possible for the pharmaceutical companies behind
Gardasil and Cervarix, Sanofi Pasteur and GlaxoSmithKline, to launch HPV vaccine
campaigns aimed directly at the Swedish citizen. This has brought about extensive HPV
vaccine advertising targeting the individual consumer and her life presenting HPV vaccine as
similar to other consumer products of the body (cf. Mamo & Fishman, 2001). As the HPV
vaccine in Sweden is subsidized for adolescent girls aged 13 to 17, the pharmaceutical
companies have essentially targeted this group with their advertising.
Because the Swedish HPV vaccine advertisements are directed at adolescent girls as a
category, I intend to study the discourses produced in the advertisements addressing the girls
as “ideal users” of the technology (see Clarke & Montini, 1993). Therefore, I will examine
how the advertising campaigns frame Swedish adolescent girls as “fit for” HPV vaccine use. I
will investigate some of the social, political and cultural implications following from the
marketing of the HPV vaccine in relation to the novel subjectivities that are enacted in the
HPV vaccine campaigns encouraging girls in Sweden to get vaccinated.
The aim of this study is to explore how Swedish HPV vaccine advertising campaigns serve to
produce Swedish adolescent girl subjectivities as the ideal users of HPV vaccine and how
adolescent girls are addressed encouraging them to identify with the new “healthy girl”
subjectivities.
I ask the following two questions:
1) How are “healthy” adolescent girl subjectivities discursively produced, framed and
promoted in the Swedish HPV vaccine advertisement campaigns?
2) How are adolescent girls addressed by Swedish HPV vaccine advertising in ways
encouraging them to identify with the new “healthy girl” subjectivities?
1
There exist over 100 different types of HPV. 14 types are proved to cause severe cytological abnormalities,
precancerous lesions and cervical cancer (NBH, 2008a: 14). HPV is transmitted through genital skin to skin
contact. Both men and women transmit the virus (ibid.: 71).
3
Transforming and Governing the Bodies of Adolescent girls in an Era of
Biomedicalization
Previous studies about vaccines and vaccination have argued that a growing tension between
vaccination as a collective population good and as an individual consumer choice have
brought about a changed vaccination landscape (Blume & Geesink, 2000, Rose & Blume,
2003, Leach & Fairhead, 2007).2 In this article, I investigate these changes in the light of
political and social transformations towards an individualization of health in Western
societies (e.g. Lupton, 1995). This helps me understand the contemporary political and social
context enabling and constraining the marketing of the HPV vaccine to Swedish citizens.
Studies of vaccines, I assert, can tell us something who qualifies as a “good citizen” in
increasingly individualized consumer societies where the role of the state crucially is
transformed (Rose & Blume, 2003). Following masculinity theorist Graham Dawson (1994), I
discuss the specific Swedish context and history of governmental concern with “people’s
health” (Folkhälsa) vaccination intervention (Johannisson, 1994b, Porter, 1999) as a cultural
imaginary that consists of ‘‘vast networks of interlinking discursive themes, images, motifs,
and narrative forms that are publicly available within a culture at any one time, and articulate
its psychic and social dimensions’’ (Dawson, 1994:48, see also Johnson & Åsberg, 2009). In
a non-essentialistic way, this concept enables me to analyze discursive articulations of, for
example, “Swedishness” in the HPV vaccination advertising. Importantly, due to
transnational movements and/or transformations of technologies, bodies, identities and states,
I also discuss the cultural imaginaries interlinked with the HPV vaccine discourse as a hybrid
of global, national and local imaginaries (cf. Casper & Carpenter, 2009a).
I consider HPV vaccine as a technology of the gendered body (Balsamo, 1996) that cannot be
separated from social categories of sex/gender (Casper & Carpenter, 2008). Importantly, I
explore how cultural imaginaries and gendered assumptions along with the HPV vaccine coproduce (Jasanoff, 2004:2-3) Swedish adolescent girls as ideal users (Oudshoorn & Pinch,
2003) of the HPV vaccine. The co-production at stake implies that the HPV vaccine as a
technology along with social and cultural norms about girlhoods, sexuality, health and
medicine are produced together by mutual human- and nonhuman interactions (Clarke et al,
2010:163) which simultaneously co-constitute the discourses of HPV vaccine advertising
(ibid.:166). Crucially, this involves an understanding of the Swedish society and the HPV
vaccine as entangled and mutually produced in the context of HPV vaccine advertisements.
I adopt the biomedicalization framework for my analysis, developed by Adele Clarke and
colleagues (2003, 2010). Whilst medicalization theorists often emphasize how individuals are
put under medical control due to medicalization3 processes (Conrad, 1992, 2007), the
biomedicalization framework stresses broader technoscientific transformations, connected to
an “emergent biopolitical economy of health, illness, life, death, and medicine” (Clarke et al:
2010:22).4 In line with this, it traces a shift from “enhanced control over external nature”
2
I discuss previous research along with a discussion of the theory framework of my study due to the fact that my
theoretical approach to a high degree coincides with that found in other sociological and/or Science and
Technology Studies (STS) research about the HPV vaccine. I believe this approach to the theoretical field
enables me to summarize and review the “state of the art” and, at the same time, introduce my theoretical
approach.
3
Medicalization is a process when “a problem is defined in medical terms, described using medical language,
understood through the adoption of a medical framework, or 'treated' with a medical intervention” (Conrad,
2007:5).
4
See Riska (2010) for a detailed discussion of the contrasts between Conrad and Clarke et al.
4
(medicalization) to “the harnessing and transformation of internal nature, often transforming
'life itself'” (biomedicalization) (ibid.: 2005:164). Biomedicine itself, Clarke et al argue
(2003, 2010), has coalesced into biomedicalization which has expanded the “territory” of
biomedicine. In this study I will apply the biomedicalization framework to conceptualize how
the Swedish vaccination campaigns both rely on, and produce new, discourses about girls,
their bodies and subjectivities in an era of rapid biomedical technoscientific transformations.5
Whilst several studies discuss the HPV vaccine in terms of medicalization or
biomedicalization (see e.g. Mara, 2010), I especially draw upon the work of Laura Mamo,
Amber Nelson and Aleia Clark (2010) as they discuss in detail HPV vaccine campaigns
within a biomedicalization framework.
I connect the Swedish HPV vaccine to a biomedicalization of health and risk. The HPV
vaccine, I argue, depends on a construction of adolescent girls as being “at risk” or “becoming
ill” and, in turn, the technology HPV vaccine as the “right tool for the job” of risk
management (cf. Fosket, 2010, Clarke & Fujimura, 1992). This is a transformation of
adolescent girls’ bodies and subjectivities as belonging to a biomedical risk group that is a
crucial part of a biomedicalization shift from “restoring health” to “preserving health” which
implicates a new focus upon health itself (Clarke et al, 2003, 2010).6 Health is according to
this discourse seen as a matter of individual responsibility and an ongoing moral selftransformation (Lupton, 1995, Lupton & Petersen, 1996, Bunton, Nettleton & Burrows,
1995). In line with this, previous research links HPV vaccination and/or HPV vaccination
campaigns to a moralization of the health imperative that exhorts adolescent girls to assume
(future) cervical cancer risk and, therefore, use and consume the HPV vaccine “in the name of
health” (Mamo et al, 2010, see also Polzer & Knabe, 2009, Connell & Hunt, 2010).
The HPV vaccine acts upon “life itself” (Rose, 2007) in relation to gendered norms. As a
result it “places life at the center of political order” (Lemke, 2011a: 1) through gendered
interventions towards the body and the (future) life of the adolescent girl. As a preventive
technology, HPV vaccine then serves to control future risk through an intervention in the
present (Stöckl, 2010, Casper and Carpenter, 2008). Due to this, HPV vaccine treats risk of
disease – not the disease itself (Aronowitz, 2010, see also Castel, 1991, Dean, 1999, Lupton,
1999). This is essential since it distinguishes vaccines from other forms of pharmaceuticals
while interlinking them with screening technologies for disease prevention and risk
management such as mammography and the Pap smear (see Fosket, 2010, Casper & Clarke,
1998).
The HPV vaccine can in one respect be identified as an epidemiological risk technology that
has “the health outcomes of the population” (Dean, 1997:218) as its subject and target.
However, as Aronowitz (2010) I investigate how the vaccine is framed as a drug that
promises control over the experience of individual risk by asserting an “individual-byindividual population level” (34). Thus the HPV vaccine does not first and foremost produce
a message about what is “good for the nation” but, instead, it entails assumptions about what
is good for the individual girl and her life. I investigate how an individualized risk discourse
5
Even though Clarke et al (2003, 2010) link biomedicalization to the transformations of the American society I
believe that, due to an ongoing marketization and privatization of Swedish biomedicine, the biomedicalization
approach is applicable to contemporary Sweden. Clarke (2010) herself asserts that there is a need for
biomedicalization studies outside the American context (381ff).
6
Public health has always had a focus upon health issues, therefore the conceptualization of this as a new form
of focus upon health itself. This new focus is often conceptualized as a moral imperative of health or a healthist
imperative (see Crawford, 1980, Lupton, 1995).
5
is merging with, and reformulating, collectivistic vaccination practices that still primarily
target the health of the Swedish population.
I connect the biomedicalization thesis to a governmentality and biopolitics framework which
investigates “particular mentalities, arts and regimes of government and administration”
(Dean, 2010:2). I regard the HPV vaccine to be a biopolitical technique that categorically
targets and regulates girls for prevention purposes (Casper & Carpenter, 2009a). Importantly,
as Connell & Hunt (2010) state, I consider the HPV vaccination campaigns to be converging
upon “the regulatory discourses of moralization and medicalization”7 (63) since they utilize
discourses about health, morals, risk and responsibility as regulating practices (67).
Since biomedicalization processes create new, and transform old, identities and subjectivities
my study focuses upon the relation between the government of others and government of the
self (Connell & Hunt, 2010). I examine how adolescent girls’ subjectivities in a biopolitical
mode are governed, transformed and produced through, and in relation to, the HPV
vaccination campaigns in the biomedicalization era (cf. Dean, 2010). In contrast to Michel
Foucault (1990), who primarily conceptualized biopolitics as power and technologies of the
self employed by the state to preserve the health of the population, I consider contemporary
biopolitics as a government of life at the population and the individual level, executed by a
range of interconnected actors such as economic corporations, human and nonhuman actors
and the state. In line with Thomas Lemke (2011a, 2011b) and Nikolas Rose (2007) I thus
consider that contemporary biopolitics must take into consideration a new form of
“molecular-politics” that implicates a new level of intervention beyond the classical
biopolitical poles of “individual” and “population” (cf. Aronowitz, 2010).
In contemporary Western societies, governing takes place through appeals to the freedom of
the individual. This takes place through practices of self government; to regulate oneself is
considered to be self-reflective and thus to be free (Rose & Miller, 2008, Dean, 1997).
Choice could in this context be identified as “a calculable element within the optimizing
behavior of individuals” (Dean, 1997:216, my emphasis). Individuals are therefore expected
to handle a form of regulated freedom in the name of optimizing one’s life/fulfilling one’s
potential due to which they are more or less compelled to choose particular consumer
products and technologies. In an era of biomedicalization adolescent girls are asked to choose
on the assumption that they want to be healthy and that the HPV vaccine is the way to go to
optimize their quality of life through a maximization of health (Polzer & Knabe, 2009, Mamo
et al, 2010).
In line with Nikolas Rose and Peter Miller (2008) I consider the mobilizing of the consumer
requires an idea of who this particular consumer is. This is a way of making the consumer of
the HPV vaccine knowable and calculable and, hence, possible to address. Therefore a notion
of what it is to be a contemporary adolescent girl in Sweden must be shaped and put forward
as an ideal user of the HPV vaccine in the Swedish HPV vaccination advertisements (cf.
Mamo & Fishman, 2001). Notably this implies that technologies such as the HPV vaccine are
created for someone, they have intended audiences and users which are a result of the
producers’ assumptions about whom the audience is and what it wants (Rose & Miller, 2008).
7
Connell and Hunt (2010) intentionally or unintentionally take part of a discussion started by Conrad (1992).
Conrad argues that there is a difference between medicalization processes and what he entitles ”healthization”.
Whilst the first refers to the emergence of medical definitions for previously nonmedical problems, the second
refers to a moralization of previously biomedical defined events (223). However, as Connell’s and Hunt’s (2010)
argumentation show, contemporary processes of biomedicalization and healthism are converging on each other.
6
Therefore, “technologies and users are mutually shaped in practice” (Casper & Carpenter,
2009a:82) and users are “inscribed” into technologies (Rose & Blume, 2003). I consider this
production of ideal users of the HPV vaccine as the creation of new, transformed and
rearticulated girl subjectivities. These new ideal user subjectivities are in the promotion and
marketing of the HPV vaccine employed as modes of addressing and interpellating the
Swedish adolescent girls through processes of identification and consumption (Sturken &
Cartwright, 2000). Utilizing the interpellation concept, I investigate the subject creation
capacities of the HPV vaccine. I explore how discourses of the HPV vaccine advertisements
“call out to” Swedish adolescent girl and tell them to “install themselves” in specific
biomedicalized subject positions (Sturken and Cartwright, 2000:358) and, thus, identify with
a biomedical cervical cancer risk group. This especially takes place by referring to cultural
signs, references and imaginaries that adolescent girls are intended to identify themselves
with (Clarke, 2005:240, Sturken & Cartwright, 2000:48,203).
For an understanding of which contemporary girl subjectivities the vaccination campaigns
simultaneously rely on, address and produce, I, drawing upon Mamo et al (2010), frame my
analysis using theoretical work deriving from the field of girlhood studies (Harris et al, 2004,
Aapola et al, 2005, Frih & Söderberg, 2010). I, therefore, link the contemporary hegemonic
Western girl to a postfeminist, Girl Power discourse which takes gender equality as a given
(Griffin, 2004). This discourse positions the Western adolescent girl as “standing at the corner
of feminism and neoliberalism” (Harris, 2004:xvii-xviii).8 This contemporary Western Girl
Power girl is framed as someone who has learned the lessons from earlier feminist struggles
and therefore sees herself as a free, autonomous, empowered “can do” girl.9 This discursive
production of empowered girl subjectivity is interlinked with consumer based agendas for
girls; a “commodification of girl power” (Aapola et al, 2005:30) is considerable at stake.
Intertwined with the moralization of health discourse, a discourse that asserts that to be a
“good” girl is to be a fully responsible and a freely choosing individual is possible to produce
in the HPV vaccine campaigns (Mamo et al., 2010, Polzer & Knabe, 2009). To be responsible
is to be free and to consume right (i.e. to get vaccinated). Hence, the HPV vaccination
campaigns can make use of a postfeminist climate due to which adolescent girls are governed,
framed and addressed as “the new consumer citizens” (Harris, 2004:164).
A Feminist Situational Visual Discourse Analysis
To be able to analyze the subject production capacity of the HPV vaccine as it appears in
advertising material produced by the pharmaceutical companies Sanofi Pasteur and
GlaxoSmithKline10 I utilize a discourse analysis drawing upon culture studies rather than a
8
This postfeminist discourse is perhaps especially evident in Sweden due to a prominent gender equality
discourse in the Swedish society that entails a cultural imaginary of “the equal Sweden” (see Melby et al, 2008).
9
The adolescent boy is never talked about in terms of “boy power” which arguably relies on normative
assumptions about boys as autonomous subjects as a given, something not needing to be articulated and,
therefore, not in need of confirmation. There is no need of performing the “can do” boy, as apparently is the case
of the girl (cf. Butler, 1990).
10
My research material consists of advertising material produced by the pharmaceutical companies Sanofi
Pasteur and GlaxoSmithKline. This includes letters sent to Swedish households, educational pamphlets and print,
internet as well as TV advertisements. I have analyzed all the material I have been able to find and/or get access
to. I have accessed the advertisements campaigns from the Swedish Pharmaceutical Industry Organization
(Läkemedelsindustriföreningen, LIF). Altogether my material consists of 40 ads. Since Gardasil is more
extensively marketed than Cervarix my analysis entail more Gardasil ads than Cervarix ones. However, since I
have not found differences regarding how the adolescent girl and the HPV vaccine are framed by the different
pharmaceutical companies, my study does not compare Cervarix ads with Gardasil ones.
7
linguistic tradition (Mills, 2004). I derive my analytic and methodological framework from
Clarke’s (2005) situational analysis and her guidelines for carrying out a visual discourse
analysis. She positions this as a materialist social contructionism approach (Clarke, 2005:7).
Since I use Clarke et al (2003, 2010) as my basic theoretical framework, choosing situational
analysis appears appropriate as a “theory-methods package” (Clarke, 2005, Clarke et al.:
2010). When performing a discourse analysis this mixture of theoretical assumptions and
methodological devices is of the essence as theoretical assumptions of non essentialism,
performativity and the deconstruction of binaries often come “with the package” (see Winter
Jørgensen & Phillips, 2000).
Drawing upon Clarke (2005) I consider a discourse as not limited to language but also
including visual images, nonhuman things/material cultural objects and other modes of
communication. The concept of discourse can therefore be considered as “communication of
any kind around/about/on a particular socially or culturally recognizable theme –
contemporary and/or historical” (ibid.:148). Discourses are enacted within a social context
and determined by that social context and, in turn, they contribute to the way that social
context continues to exist (Mills, 2004:10). By utilizing a discourse analysis, I can investigate
how language and pictures produce and transform statements – i.e. utterances and texts which
have some institutional force and make some truth-claims – of gendered girlhoods and health
(ibid.). Hence, I analyze visual images and texts as discursive cultural products of particular
worlds and not as authentic mirrorings or representations of the material world (Clarke,
2005:219).
In my analysis I investigate how discursive productions of subjectivities attempt to fixate the
meaning of who the ideal user and consumer of the HPV vaccine is (Winter Jørgensen &
Phillips, 2000) that takes place by means of specific modes of addressing or interpellation.11 I
consider the created subjectivities used for interpellation as produced through gendered
binaries that facilitate the attempts to fixate the possible meanings about adolescent girls in
Sweden (ibid.: 2000:102-6). This implies that the adolescent Swedish girl is positioned in
contrast to invisible, but yet implicated actors (Clarke, 2005). This is essential for my
analysis; discourses and subjectivities are produced relationally and do not exist in isolation
since there is a set of structures which construct them to make sense and, thus, give them a
coherent meaning (Mills, 2004:45). As implicated actors/invisible others are positioned as the
difference that the ideal user can be defined as distinct from, the binary meaning/difference is
essential for the production of ideal HPV vaccine users. Therefore to look for “the invisible
others” enables me to deconstruct binaries and disclose the arbitrary and contradictory
elements of the discourses the HPV vaccination campaigns produce, and are produced by. To
make the “invisible others” visible is then crucial for my analysis.
Expanding upon the social interactionist and grounded theory framework entitled “social
worlds/arena theory” Clarke argues for a new form of “grounded theory after the postmodern
turn”, enabled by “pushing grounded theory around” through infusing it with
postmodern/poststructuralist theory.12 Following Donna Haraway’s concept of situated
11
This is perhaps especially important when analyzing advertisements since the addressing of the consumer is
the central goal of advertising. This often takes place through encouragements to think of commodities as ways
of expressing identity (Sturken & Cartwright, 2000:198).
12
Clarke (2005) argues that her work can be seen as a toolbox and she directs her readers to be free to make use
of particular parts of that toolbox. In this vein I use Clarke’s assertions about discourses and nonhuman actors. I
further utilize her way of organizing the analysis by performing an ordered situational map. However,
8
knowledge Clarke asserts that knowledge and scientific practice are “produced and consumed
by particular groups of people, historically and geographically locatable” (Clarke, 2005: xxv,
cf. Haraway, 1991). Essentially, this is a turn away from an humanist imaginary of theories,
methods and practices which at its center puts the (imagination of) the scientific (hu)man who
simply enables and assists the release of universal truths. Clarke argues that the conditions of
the situation are in the situation (Clarke, 2005:71).
The decentralization of the human subject is a necessity for a satisfactory “theory-methods
package” when carrying out a discursive analysis that tries to take a whole situation in
consideration (Clarke, 2005). Essential for my study, the decentralization of the human
subject makes a focus upon “discourses as elements of practices that are constitutive of
subjectivities” (ibid.:53) possible. However, deriving from Clarke and feminist technoscience
studies13, I believe that a decentralization of the human subject also needs to widen its scope
and include the capacity of nonhuman elements to transform “life itself”. I consider humans
and nonhuman actors (such as discourses, consumer products and technologies) as coconstitutive (ibid.:63).
When carrying out my visual discourse analysis I have utilized Clarke’s guidelines for how to
write memos and perform coding and mapping. The first step of my analysis was to write
analytical memos by means of which narratives about each visual could be produced. This
required that I could “put into words” what I saw and thought when scrutinizing the
advertisement images. This made it possible to make my visual material more like other
material while at the same time retaining its distinctiveness as visual and, therefore, retaining
the capacity to interpret and analyze it as visual (Clarke, 2005:224-6). Guided by Clarke I did
three types of memos: locating memos that helped me to connect the HPV vaccination to a
political, social and economic context, big picture memos that enabled me to describe the
visual fully and, finally, specification memos that made it possible to “break the frame” of the
visual material so that I could see the images in multiple ways and, hence, destruct the
attempts to fixate meanings. Instead of seeing the images in the intended way I therefore tried
to “go outside the frame” (ibid.:227). The specification memos were written on the basis of
questions suggested by Clarke such as how the subject of the image is framed, who the
intended and unintended audiences of the image are and the performative work of the image
(ibid.:227-8). On basis of the written memos I then constructed codes through a use of what
Clarke, drawing from grounded theory, conceptualizes as sensitizing concepts. Since they are
not to be considered as monolithic or deterministic theoretical assumptions these concepts
open up for the incorporation of unexpected empirical findings (ibid.:157). In accordance with
the situational analysis approach, the codes constructed for my analysis are theoretically
grounded, but moderated to suit the empirical material at hand. For instance, I constructed the
code “sex frame” on the basis of my empirical findings. In contrast, the code “cancer frame”
is adopted from previous research. Originating from the result of my coding I then did an
ordered situational map as a strategy “for articulating the elements in the situation and
examining relations among them” (ibid.:86). This was a tool from Clarke’s toolbox that made
it possible for me to sketch out human and nonhuman individuals, collective and implicated
actors, and the discursive constructions of all these actors, as well as political and economic
elements as part of the HPV vaccine advertisements (ibid.:243).
theoretically my focus is upon her attention to Haraway, Foucault, biomedicalization and technoscience studies
and not on her remaking of grounded theory and symbolic interactionism.
13
See Åsberg and Lykke (2010) for a review of this expanding theoretical field.
9
Since I am carrying out a discourse analysis, ethical considerations of my study are not
concerns about confidentiality and information requirements about the rationale of my study
to e.g. interview respondents. Since I am analyzing public materials I do not moreover need
consent from the pharmaceutical companies when analyzing the advertisements. Instead my
considerations concern first and foremost my position as a researcher, how I relate to my
research material and the interpretations I make.
As a discourse analyst my goal is not to get “behind” the discourse and tell the world the truth
about my field of research as it really is and, hence, separate the correct information from the
incorrect. Instead, my aim is to analyze what is actually written and visualized in my material
– and to sketch its discursive productions and effects. When doing this, I have no intention of
occupying the correct interpretation (Winther Jørgensen & Phillips, 2000:28-9). Just as I
consider the material I am analyzing as connected to a specific social, political and cultural
context, so are the interpretations I am making and the story I am telling. I am not writing and
analyzing “from nowhere” – instead the knowledge I produce is in a very concrete sense
located in time and space (cf. Haraway, 1991). This is not only a question about a
“confession” concerning my position as a young, white, middleclass women and feminist
from a big Swedish city. I consider it as important to reflexively argue for, and legitimize, the
value of my interpretations as linked to a theoretical and methodological field since my choice
of framework allows and directs me to see the world in specific ways (Winther Jørgensen &
Phillips, 2000:30).
The utilizing of the biomedicalization and situational analysis “theory-methods package” has
enabled me to see situations appearing as given and natural in my material as constructed,
produced and intertwined with other situations. It has made it possible for me to “ask” my
research material questions about ideal users and consumers, biomedicalization and
biopolitics – and about how to situate what I find. If I had chosen other theories and another
method I most definitely would have seen the ads differently when scrutinizing the material –
and I would have drawn slightly different conclusions. For instance, if a qualitative text
analysis would had been chosen I would have primarily concentrated my analysis to how
reality is represented – not articulated and performed – in the advertisements. Due to my
framework’s capacity to point at transformations and productions of bodies and subjectivities
I however consider it well-suited to an analysis concerned with how advertisements in fact
aim to transform targeted groups into consumers.
The Cultural Imaginary of the Swedish Vaccination Landscape
Even though my analysis to a large extent draws upon previous research about the HPV
vaccine in first and foremost the US and Canada, due to the findings of my discourse analysis
I argue that the Swedish HPV vaccination advertisements differ somewhat from their North
American relatives. I conceptualize these differences as due to a Swedish cultural imaginary
that partly is intertwined with regulatory regimes and policies of the Swedish government.
Cultural imaginaries are not detached from state polices and regulatory regimes exercised by
health authorities since the marketing of prescription pharmaceuticals is regulated by medical
legislation. When analyzing the pharmaceutical companies’ marketing of Gardasil and
Cervarix this is evident since the ads first and foremost convey HPV vaccine as intended for
girls aged 13 to 17, i.e. that age-group which in Sweden is covered by the high-cost protection
for prescription pharmaceuticals (Högkostnadsskyddet) when getting vaccinated against HPV
(Dental and Pharmaceutical Benefits Agency, 2011). Therefore, the task of the
10
pharmaceutical companies is turned into promoting this age-group as the ideal user of HPV
vaccine.
To be able to discuss the Swedish cultural imaginaries surrounding the HPV vaccine I sketch
two different vaccination practices: a collectivized and an individualized. Whereas I consider a
collectivized vaccination practice as a biopolitics of the population in which vaccination is
seen as first and foremost a civic responsibility, I link the individualized vaccination practice
to the shift towards biomedicalization that entails biopolitics at the individual and the
population level. However, I do not see this shift from collectivized towards individualized
vaccination practices as “clear cut”; the possible overlaps between the practices are of
considerable interest – especially in Sweden with its long history of collective public health
and vaccination interventions.
“What do Eva and Anna have to do with Cervical Cancer?” – The Visual
Production of the Ideal Swedish HPV Vaccine User
I consider the rationale of the first Gardasil advertisements, launched just after the NBH
(Socialstyrelsen) decided to include HPV vaccine in the Swedish national vaccination
program in February 2008 (NBH, 2008b), is to make the Swedish citizen knowledgeable of
the connection, not only between the HPV virus and cervical cancer, but significantly
between Gardasil and the Swedish adolescent girl. The viewer of the ads is encouraged to
contemplate exactly how and why the Swedish adolescents pictured in the ads, named in one
ad as “Eva and Anna” and in another as “Lisa and Simon”, “have something to do with
cervical cancer” 14 and why HPV vaccine is “the right tool for the job” (Clarke & Fujimura,
1992) to treat cervical cancer (fig. 1-2). To manage to inform Swedish citizens about this link
I believe an ideal user of the HPV vaccine is produced and put forward to counsel the
Swedish adolescent girl. I regard this to be an attempt to foster a “will to knowledge”, and a
related “will to health” (Mamo et al, 2010:139, see also, Foucault, 1990) that facilitates use
and consumption of HPV vaccine.
14
Since the text of the advertisement is written in Swedish I have translated it into English. See fig. 1-19 for the
Swedish original.
11
Fig. 1. Gardasil advertisement, 2008
Fig. 2. Gardasil advertisement, 2008
In the “Eva and Anna” and “Lisa and Simon” campaign a framing of HPV vaccination as
something that “just over 10 million young women around the world” have chosen, the
adolescent girl is welcomed to join a worldwide “collective of women” that together is
“fighting against cervical cancer” (cf. Casper & Carpenter, 2009a). Thus a biomedical risk
group potentially including all women is imagined through which the Swedish adolescent girl
is addressed on the basis of being a woman and therefore at risk for cervical cancer (Mamo et
al, 2010). This “worldwide women” risk group invitation legitimizes and frames the HPV
vaccine as a “technology of the gendered body” (Balsamo, 1996) that only concerns women.
The girls are encouraged to identify themselves with an imagined biosociety of women and,
therefore, to understand their bodies and selves on the basis of a gendered biological risk
deposition for cervical cancer (cf. Lemke, 2011b:96, see also Rabinow, 1992). Through a use
of statistical and scientific language, the adolescent girl is exhorted to calculate the risk of
cancer and weigh it against the financial cost of getting vaccinated. In this sense, formulations
such as “around 450 women are afflicted by cervical cancer each year and 68% survive” are
implicitly contrasted with the money the consumer is encouraged to spend on the HPV
vaccine. Naturally, the right choice to make, and the choice the constructed ideal user of the
HPV vaccine is positioned as capable of making, is to get vaccinated.
12
Fig. 3. Cervarix advertisement, patient folder, 2009
Fig. 4. Cervarix advertisement, patient folder, 2009
The assumption that the Swedish adolescent girl identifies herself with an imagined “global
world of women” supports an assumption of womenhood as the most important basis for
identification in the context of HPV vaccine (cf. Mohanty, 2003). Since HPV vaccination
targets girls on the basis of the female category the advertising focus upon women as a group
is enabled and employed (cf. Carpenter & Casper, 2009b:95-6). This enables a discursive
production of the HPV vaccine as intended solely for the adolescent girl’s body – and an
exclusion of the fact that the HPV is contagious even for boys and men and thus in fact could
be considered a “boy issue”. This framing of the vaccine as solely a women’s issue does not
only reveal and entail cultural assumptions of (an imagined global) femininity, at the same
time, it entails imaginaries about the Swedish adolescent girl and her femininity. A production
of Swedish girl subjectivity fit for HPV vaccine is based on assumptions of femininity and
national as well as global belonging. I consider this girl subjectivity to be nothing less than a
white, heterosexual girl. She is part of the Girl Power discourse as discussed in contemporary
girlhood studies since she is empowered and “active”; all by herself she is skateboarding,
playing basketball, bicycling and playing the guitar (fig. 5, 6, 8, 13). Since she is empowered,
she is also capable of shouldering the individualized responsibility of making the right
decisions to enable a preservation and optimization of her future healthy life.
13
Fig. 5. Gardasil advertisement, 2009
Fig. 6. Gardasil advertisement, 2009
However, she differs in the sense that she is a little bit more “down to earth” then the girls in
for example the US campaigns (cf. Mamo et al, 2010). Through a visual framing, her
femininity is in the ads naturalized in, I argue, a very concrete sense. The discursive effect of
the images is a girl that does not need to “actively” perform femininity since it is a natural
part of her. The effect is performative: the images of a “natural looking girl”, entailing for
example “natural looking” makeup and clothes, co-produce naturalized girl subjectivity. In
this respect, the naturalizing effects of the images conceal the gendered, globalized and
nationalized effects of this framing since the girl pictured is framed as the (normal and
general) Swedish girl. I argue that this framing embodies a cultural imaginary of Swedishness
as closely related with “naturalness” and “down to earth”-ness (see Jansson, Wendt & Åse,
2010, cf. Johnson & Åsberg, 2009) and the typical Swedish girl as natural and feminine – but
not too feminine since that would make her “unnaturally” feminine (fig. 7-8).
Fig. 7. Gardasil advertisement pamphlet, 2009
Fig. 8. Gardasil advertisement pamphlet, 2009
In the making of the ideal user of the HPV vaccine as a Swedish adolescent girl, discourses of
heteronormativity are involved. Even though it is not always clear whether the girls in the ads
are sexually active they are most definitely heterosexual and their future is in the hands of
14
heteronormativity. In the “Lisa and Simon” ad the viewer is told that the reason why Lisa and
Simon have something to do with cervical cancer is because “cervical cancer is caused by a
sexual transmitted virus” that “most people are infected by already when they young” (fig. 1).
Since “Lisa” and “Simon” are portrayed with a red heart in between them, and due to the fact
that they are not explicitly imaged as engaged in sexual activity, the viewer is left to presume
that they do have, or will soon begin, having sex, and that “Lisa” therefore is at risk for
cervical cancer. Due to the fact that the viewer has to presume heterosexuality, this framing of
the ideal user as heterosexual is a subtle, but therefore also pervasive, part of the naturalizing
of the ideal HPV vaccine user and the production of a girl subjectivity fit for this technology.
The girl at stake is not articulated as sexually active but, at the same time, she does have a
pre-defined sexuality and a will to, at least in the future, engage in heterosexual activities.
Crucially, “Simon” is a part of the ad to confirm the heterosexuality of the Swedish
adolescent girl. In the HPV vaccine ads he is therefore not under biomedical regulation or
exhorted to engage in calculations of cancer risk; he is primarily placed as the binary other
that is a necessary part of the performance of compulsory heterosexuality (Butler, 1990) and,
by extension, the biomedicalization of adolescent girl bodies (Mamo et al, 2010).
Interestingly, “Simon” is also performing and legitimizing another imaginary discourse in the
situation, namely the multicultural adolescent in Sweden that, in practice, first and foremost
tends to legitimize Swedishness as the norm and center in the Swedish society (see for
example de los Reyes, Molina & Mulinari, 2006). Since “Simon” is one of the very few boys
and non-whites imaged in the HPV vaccination campaigns he fulfills the position of a binary
other “perfectly”.
Fig. 9. TV Gardasil advertisement, 2008
The heteronormativity of the Swedish Gardasil campaigns recalls the analysis dealing with
the US HPV campaigns (Mamo et al, 2010). However, in the US campaigns a cancer frame is
used to avert a sexual moral panic (e.g. ibid., Aronowitz, 2010) This does not seem to be as
urgent in Sweden. Even though a “cancer frame” is most evidently a part of the Swedish
vaccinations campaigns – the HPV vaccine is throughout the campaigns entitled “a cervical
cancer vaccine” or a “vaccine that can prevent cervical cancer” – I would argue that there also
is somewhat of a “sex frame”. Although the sex part is not as prominent as the cancer one –
“cervical cancer” is almost all the time mentioned before something about sex is mentioned –
it is most definitely a part of the vaccination campaigns. As in the “Lisa and Simon” ad
heterosexuality is often framed as something “to come” – as the “the normal next stage of
life” for the adolescent Swedish girl (fig. 1). For instance, in one Gardasil TV ad a girl is
looking secretively and longingly after a boy. In the next the fingers of boy and girl are
touching (fig. 9). As in the “Lisa and Simon” ad, the viewer is encouraged to presume
heterosexuality – and future sexual activity between boy and girl (cf. Mamo et al, 2010).
15
Importantly this “sex as the normal next stage of life” discourse is not a “sexual panic” call
taking place – sexual activity is in contrast naturalized.
In line with several studies concerning the HPV vaccine in the US and in Canada, I therefore
argue that the vaccination advertising in Sweden is an example of the moralization of health
at stake in the contemporary biomedicalization era (Cornell & Hunt, 2010, Mamo et al, 2010,
Polzer & Knabe, 2009). The girls are not regulated on sexual abstinence grounds or exhorted
to calculate sexual risk. Instead a healthist prescription is prescribed: get vaccinated and, thus,
preserve and optimize health and “the normal path of life”. Therefore, to get vaccinated is
discursively framed as something the adolescent Swedish girl ought to do for her own sake.
Her future life is at stake and HPV vaccine is “the right tool for the job” (Clarke & Fujimura,
1992) to optimize her life (Rose, 2007).
Nonetheless, since HPV vaccine paradoxically simultaneously is framed as an optimal health
technology and a consumer good for all Swedish girl citizens aged 13 to 17, the ideal user of
HPV vaccine is both individualized and collectivized. This facilities a production of the HPV
vaccine as a gendered technology operating on an individual-by-individual population level
(Aronowitz, 2010); the adolescent girl is implicitly framed as both a unique individual and as
a part of the Swedish population. This is a biopolitical practice operating at the population and
the individual level at the same time. Since the individual as belonging to a collective
biological risk group is addressed, so too is the molecular level of the girl’s body the target of
the biopolitical technique (Lemke, 2011b, Rose, 2007).
Fig. 10. Gardasil advertisement, 2010
As the adolescent Swedish girl is positioned as capable of making the right decision, she is
also positioned as responsible for doing so. This is an articulation of HPV vaccine as a
consumer responsibility that neutralizes vaccination as something that is not free of charge for
children and brings about a reformulation of in what way children’s rights to get vaccinated
are considered. I suggest that a strategic discursive move is undertaken by Sanofi Pasteur, and
partly also GlaxoSmithKline, since a focus upon Gardasil and Cervarix as parts of the
pharmaceutical privilege system (Läkemedelsförmånen) and the high cost protection
(Högkostnadsskyddet) for girls aged 13 to 17 facilitates a framing of the HPV vaccine as a
part of the Swedish state’s responsibility for its citizen that neutralizes it as a consumer
responsibility. I suggest that a transformed social contract for vaccination therefore is
performed in the ads; the state subsidizes, the citizen consumes (fig. 10, 12). Due to this a
16
dressing of the individualized risk HPV vaccine as a collective vaccination practice is made
possible (Aronowitz, 2010).
“A Message to you who have a Teenage Daughter”: “Remember Gardasil!” –
Swedish Mothers as Ideal Consumers of the HPV Vaccine
Whilst the adolescent girl is interpellated as an ideal user of the HPV vaccine her mother is
hailed as an ideal consumer of the vaccine. When it comes to men and possible fathers the
Swedish HPV vaccine advertising is a story of silence; there seem to be no pictures including
adult men and, therefore, possible fathers of the girls. The father thus becomes nothing more
than an implicated actor in the gendered drama performed by the HPV vaccination
campaigns. This leaves the, in contemporary Sweden frequently imagined, equal father figure
as a silent actor that has no right to a place in the women oriented community of HPV
vaccination (cf. Melby et al, 2008). Instead the silent, but yet implicated, father leaves the
mother primarily responsible for her daughter’s health, and by extension, makes her the ideal
consumer of HPV vaccine.
As Mamo et al (2010) argue this discourse of mother’s responsibility is an old one that
embodies cultural assumptions about ideal womenhood as well as ideal motherhood. The
mother has for ages been seen as responsible for not only the health of the family but,
additionally, the health of the nation (Yuval-Davis, 1997). This “women’s burden of disease”
(Thompson, 2010) has moreover legitimized health interventions and has often implied
medicalization processes of women in Sweden and elsewhere (Johannisson, 1994a). In
Sweden, the Mother Svea figure has often embodied this “mother of the nation” imaginary
that literally reproduces the Swedish nation (Eduards, 2007). In the Swedish Gardasil ads this
figure is evoked and reformulated; to be able to maintain the healthy Swedish population
Mother Svea needs technological assistance in the form of the HPV vaccine.
The production of a Swedish mother subjectivity is enabled by, and embodies, a cultural
imaginary of who the Swedish mother is. The cultural imaginaries evoked in the ads are
reminiscent of the subjectivity created for the adolescent girl. The mother is visualized as the
white, “natural looking”, “down to earth” and responsible mother of the Swedish daughter.
Crucially, this builds upon the assumption of the good mother as care giving and, by nature,
prepared to take responsibility for others’ health. In practice the subjectivity created is utilized
to interpellate the mother as a HPV vaccine consumer on the basis of her being a good
Swedish mother. As her opposite, naturally, figures the moralization imaginary of the bad,
irresponsible mother as a silent, but still implicated, actor that is haunting the mother of the
HPV vaccine girl. In one ad, for example, a young girl and, one can suppose, her mother are
pictured along with this text: “To you who are considering vaccinating your daughter against
cervical cancer: you do know Gardasil is discounted for girls aged 11 to 17, don’t you?” (fig.
13 see also fig. 11). If the viewer chooses to read further, Gardasil is in the same ad later on
described as the right technology to “protect your daughter”. In this case the text and image
work together to address the mother of the daughter; the ad renders equivalent “you” with
“mothers”. In another image, a mother and her two daughters are joined by the moral
exhortation “Remember Gardasil!” (fig. 12). In both these examples the mother is seen as
morally responsible for the health of her daughters.
In the Swedish Gardasil ads a discourse that positions the Swedes as close to the environment
is also evoked. Even if it is not the actual intent of the pharmaceutical company this is a part
of the HPV vaccine situation as a surrounding discourse that functions as a cultural imaginary
17
available for the audience to take up to “make sense” of the HPV vaccine ads. The mother
and/or her daughter are, to be precise, often visualized in an idealized and naturalized
Swedish environment with green meadows, sea cliffs, “Falun red” farmhouses and fir and
pine trees. The Swedish girl is visualized as bicycling and rollerblading in the Swedish
landscape and camping with her mother in the Swedish forest (fig. 1-2, 5-8, 11-12). This
imaging, I consider, is a part of the co-constitution of the ideal Swedish user and consumer of
the HPV vaccine as embodying a “natural looking”, “down to earth” and “healthy”
subjectivity that is utilized to interpellate Swedish citizens to consume Gardasil. Thus, the
production of Swedish adolescent girl and mother subjectivities fit for HPV vaccine
technology relies on an imaging of the natural women and girl in natural Swedish landscapes
(cf. Jansson, Wendt & Åse, 2010). This, I argue, makes a discursive production of the HPV
vaccine as a vaccine that enables the natural Swedish adult life of heteronormativity and
healthiness possible (cf. Åsberg & Johnson, 2009).
Fig. 11. Gardasil advertisement, 2009
Fig. 12. Gardasil advertisement, 2009
The discourse of the good mother involves daughters as in need of mother’s protection.
Therefore, the Swedish adolescent girl framed in the HPV vaccine ads is not only an
empowered and free one, at the same time she is highly dependent on, and governed by, her
mother. This is seemingly arbitrary and contradictory since the girl is framed as both capable
of shouldering a moral responsibility to get vaccinated and as highly dependent on her
mother’s capacity to do exactly the same thing. However, I have found these two
subjectivities to co-exist fairly smoothly in the HPV vaccine campaigns. Since the mother is
part of the situation due to her role as consumer of HPV vaccine, and thus guarantor of the
healthiness of the adolescent girl, she mainly facilitates her daughter’s journey towards a
normal adulthood of heteronormative activities. The freedom and autonomy of the Swedish
girl is often discursively produced as dependent on the mother’s capacity of making the right
choice for her. The mother’s job is thus to enable and preserve the freedom of the girl through
HPV vaccine consumption. In one TV ad (fig. 13), for example, a young girl playing
basketball is encouraged by her mother to get vaccinated and shoot the ball in the basket. As
the ad ends as the girls successfully shoots the basket the message of the ad could be
considered to be that the Gardasil user at stake is an empowered “can do” girl capable of
fulfilling her wishes for a life of freedom; she can not only play basketball successfully, she
can get all she want from her life as she is capable of making the “right choice”. However,
since her capacity for freedom is dependent on her mother’s goodness and, therefore, wish to
see her daughter vaccinated, she is at the same time framed as dependent on the wisdom of
her mother and, in addition, HPV vaccination technology.
18
Fig. 13. TV Gardasil advertisement, 2008
Direct to Consumer Letters Filled with a Moral Imperative to Get Vaccinated
The framing of the good mother in the HPV vaccination campaigns often uses the logics of
risk to exhort the mother to make the right decision to get vaccinated. It is implicated in the
ads that, if the mother does not choose to get her daughter vaccinated, the daughter is at risk
for cervical cancer and her wishes for her future life are endangered. This is perhaps most
evident in the letters that Sanofi Pasteur in 2008 to 2010 sent to Swedish households with
teenage daughters (fig. 14-16). These letters are a very concrete example of how a form of
DTC advertising is made possible and performed in Sweden due to regulatory regimes of
government that enable advertising that addresses Swedish citizens individually when it
comes to vaccination against infectious diseases. The message about HPV vaccine is literally
transported to the letter box or door of the Swedish citizen.15
In the letters the pharmaceutical company uses a mixture of scientific and familiar vocabulary
to encourage “you who have a teenage daughter” to consume HPV vaccine. Through this
choice of words Sanofi Pasteur positions themselves as both a friend of the parents and as an
HPV vaccine expert. As in the “Lisa and Simon” and “Eva and Anna” ads, Sanofi Pasteur use
statistics of death and survival rates as a way to exhort the parent of the adolescent girl to
consume the HPV vaccine. This brings about a statistically calculable binary risk situation for
the parents to handle: to endanger your daughter’s future life or to choose to consume the
HPV vaccine. The letters are thus a performance of individualized responsibility and
moralization of health through exhortations to the parents to adopt risk calculation practices.
In this way, the letters use anxiety to sell their product by implicitly suggesting that the
daughters of the family are at risk for cervical cancer if Gardasil is not consumed (cf. Sturken
& Cartwright, 2001:216). The friendly and familiar, and yet, informed and expert oriented,
vocabulary serves the pharmaceutical company’s rationale of consumption and, by extension,
legitimizes the biomedical regulation and transformation of Swedish adolescent girl bodies.
Through this combination the letters produce a neutralization of the fact that the vaccine is not
free of charge and that it is the responsibility of the parents/guardians of the daughter to
consume the vaccine. Instead, the letters emphasize that the high cost protection is “the state’s
way of subsidizing pharmaceuticals so that all Swedish people can afford good and effective
medicines”. As earlier argued, due to this, a framing of HPV vaccination practice as a
15
This DTC letter advertising strategy caused a big controversy in Sweden in which both politicians and medical
professionals were involved (see Linnersten, 2008, Nihlén, 2008).
19
“vaccination as public good” is enabled and performed. The result is a transformation of the
logics of vaccination in Swedish society (and its “people’s health” imaginary) as a vaccine
directed towards the individual is dressed in a collective garment. This is illustrative of the
growing tension between the vaccine as a collective good at the population level and as an
individual (consumer) choice, as discussed in previous research (Rose & Blume, 2003).
Fig. 14, 15, 16. Envelopes to DTC-letters, 2008-2010
Activating Adolescent Swedish Girls at Risk for Genital Warts
In 2010 the decision about whether Gardasil or Cervarix should be purchased by the Swedish
government for distribution to Swedish 11 year old girls through the Swedish national
vaccination program was under discussion. At this time, Sanofi Pasteur started to actively
launch Gardasil as not only a “cervical cancer vaccine” but also as a “genital warts vaccine”.
As Gardasil, in contrast to Cervarix, has been proved to be able to prevent HPV virus types
that cause genital warts (NBH, 2008b: 10), Sanofi Pasteur evidently played their “genital
warts card” when promoting Gardasil in 2010. In contrast to the cervical cancer ads, these ads
directly and solely address the adolescent, and not the mother, as ideal users and consumers.
In these ads, the Swedish girl is exhorted to calculate the risk of genital warts on the basis that
genital warts are “not dangerous” but “uncomfortable” and can “affect your self esteem
negatively” and bring about “shame and disgust for your own body” (fig. 17-19). In one ad,
for instance, one can read that “Genital warts are nothing one dies of. But they can be deadly
embarrassing”. Since the viewer in the same ad is told that to have had sex, or to want to have
sex, is to be “how most people are”, “the sex frame” enables the discourse about sexual
activeness as “the normal next stage” for the adolescent girl to be foregrounded. But to be
able to have sex without embarrassment, genital warts must be avoided and a healthy
subjectivity to be chosen. In these Gardasil ads the HPV vaccine is thus not framed as a literal
“life saver” but normatively, as a life enhancer, enabling the life every girl is presumed to
want; that is a life lived with self esteem and spared of embarrassments. This mode of
address, I believe, relies on a normative assumption of the adolescent girl as embodying a
lack of self esteem when it comes to bodily looks. This is a binary from contemporary
20
girlhood studies that is revealed: the empowered “can do” girl is contrasted with the low self
esteem “in crisis” girl (see for example, Harris et al, 2004). Significantly, the genital warts ads
embody both of these possible girls’ subjectivities. If the addressed “you” does the right thing,
i.e. gets vaccinated, she can escape the destiny of the “in crisis” girl, the ad articulates.
Fig. 17. Genital warts Gardasil advertisement, 2010
The Gardasil’s genital warts ads use interactive technology to mobilize the adolescent girl as
their ideal consumers. Using for example Facebook banner loops the Swedish adolescent is
hailed as an up to date user of Internet technology and, thus, as an active citizen, capable of
empowerment (cf. Barry, 2001) (fig. 18-19). In one ad the viewer is faced with the following
question and exhortation: “Are you at risk for genital warts? Check here!” (fig. 18). This, I
consider, is regulated freedom performed; the adolescent girl’s will to freedom and autonomy
is worked upon to encourage the girl to calculate genital warts risk so that she can enable a
life free from shame and embarrassment. Interestingly, these ads tend to frame the HPV
vaccine as a life-style drug that promises to prevent a life of embarrassment and preserve a
life of health and happiness for the Swedish girl. This framing foregrounds individualized
responsibility and HPV vaccine as a life-style choice of the empowered adolescent girl when
it comes to genital warts prevention. The biological life of the Swedish adolescent girl is not
at stake, her individual experience of normality and hopes for a normal future life are.
21
Fig. 18. Facebook Genital warts Gardasil advertisement, 2010
Fig. 19. Facebook Genital warts Gardasil advertisement, 2010
Nonetheless, a slightly different and challenging interpretation is possible to make since it in
fact is not absolutely certain that the intended audience actually solely is the adolescent
Swedish girl. At first glance, nothing that explicitly addresses only girls and not boys is
evident in the genital warts ads. And genital warts, in contrast to cervical cancer, are
commonly seen both as a female and male issue. This opens up for a new potential user and
HPV vaccination actor: the adolescent boy or young man. Although a use of the gendered
framing “cervical cancer vaccine” later on potentially averts unintended audiences the first
impression nonetheless makes a different user of the HPV vaccine imaginable. This is of
importance as it potentially reveals the inessential status of the adolescent girl as the natural
user of the HPV vaccine.
Discussion: HPV Vaccine in a Vaccination Landscape under
Transformation
In this article, I have connected the HPV vaccine to an era of biomedicalization (Clarke et al,
2003, 2010). I have shown that the Swedish HPV vaccine campaigns put forward
22
biomedicalized transformations of adolescent girl identities and subjectivities since they
frame the HPV vaccine as acting upon the bodies and (future) lives of adolescent girls. In line
with theories about the contemporary moralization of health (see Lupton, 1995) I have found
that “healthy” Swedish adolescent subjectivities are promoted in the Swedish HPV vaccine
ads through a framing of an empowered adolescent girl capable of shouldering an
individualized responsibility to optimize health and manage risk. Due to this I do not consider
a “medicalization” framework (Conrad, 1992, 2007) as adequate to conceptualize the current
changes taking place in the Swedish HPV vaccination landscape. Instead of first and foremost
legitimizing and enhancing control over adolescent girls’ bodies, I have found that the HPV
vaccine ads serve to transform the body and life of adolescent girls through a moral
imperative to get vaccinated.
The “healthy” girl subjectivities produced recall the framing of adolescent girls in the US
(Mamo et al, 2010) and in Canada (Polzer & Knape, 2009) in the sense that she is a
heterosexual Western “Girl Power” “good girl” that is framed as an “active” and self-aware
“can do” girl. This girl knows how to calculate cancer risk to get the future that she wants and
that she knows is healthy for her. At the same time she differs from her North American
relatives as her healthiness is highly interlinked with her status as “natural looking” and
“down to earth”. The assumptions about “naturalness” in the productions of Swedish girl
subjectivities are thus co-produced with notions of “healthiness” and “empowerment”. To be
healthy is to be empowered and natural. This intertwining between empowerment, healthiness
and naturalness is significantly performative; the effect is a framing of an ideal HPV vaccine
user for the Swedish pharmaceutical market that, on the basis of a presumed will to health, is
used to encourage adolescent Swedish girls to choose to get vaccinated. This brings about a
crucially limited choice for the girls at stake: to get vaccinated or not. In addition, since
(future) heteronormative activity is the only presented possible alternative, a no choice
situation when it comes to sex and sexuality is evident which brings about a reduction of
girl’s own sexual agency.
The framing of the adolescent girl as the ideal HPV vaccine user co-produces a discourse
about a specific performed femininity as global and national which, in fact, relies on
gendered, sexualized and racialized assumptions that legitimize a discourse of hegemonic
femininity and girlhood (see de los Reyes & Mulinari, 2007, cf. Mamo et al, 2010). This
discursive production can have significant material effects as legitimizing and rearticulating
heteronormative practices and gendered lives as they take shape in the everyday world. This,
naturally, brings about rearticulations of non-whites, non-heterosexual girls as deviant and
unnatural. Most crucially, these invisiblized “other” girls are due to this left with an imaginary
of an ideal girlhood that they due to economic, social and cultural aspects most likely cannot,
and possibly do not want to, identify with and embody. Furthermore, confronted with the
binary choice of consuming HPV vaccine or to be at risk for cervical cancer, these “other”
girls are paradoxically, since they according to this discourse do not exist, not even positioned
as capable of making the significantly limited choice of getting vaccinated or not. Since their
agency thus is negated, they are located in the invisible, but yet implicated, “in crisis” subject
position or exhorted to “get empowered” and, thus, join the biosociety of cervical cancer
fighting women. This is a call for self regulation: the “in crisis” girl is regulated to make her
body and life suitable for the girl subjectivity created as “fit for” HPV vaccine use. This is a
homogenizing discursive production that, on the basis of them being the same, mobilizes
Swedish adolescent girls as a group and neglects factual diversity regarding categories such as
sexuality, gender, class and “race”.
23
I have moreover argued that the production of the simultaneously individualized and
collectivized girl subjectivity fit for vaccination is co-produced with the HPV vaccine as a
biopolitical technology operating at an individual-by-individual population level that first and
foremost manages and treats individualized risk for disease. Framed as a general citizen good,
a consumer vaccine is in the Swedish HPV vaccine campaigns put forward as a state´s
responsibility for the health of its citizens – with a naturalization of the consumption part as
an effect (cf. Aronowitz, 2010:34-5). This is a discourse that is well suited for the Swedish
society since a combination of neoliberal consumer citizenship is interlinked with a Swedish
history of “people’s health” interventions that legitimize vaccination as a self-evident citizen
good. Therefore I consider the tension between a collectivized and an individualized
vaccination practice as particularly evident in the Swedish HPV vaccine campaigns.
Since the state’s position in the Swedish HPV vaccination campaigns tends to be reformulated
as a responsibility to enable the individual citizen to optimize her own life and health – in
contrast to vaccination as an act of civic responsibility towards fellow Swedish citizens – the
collectivized vaccination practice tends to primarily function as a well looking garment to
dress the consumer products Gardasil and Cervarix in. The framing of the boy (and the man)
as invisible, yet implicated, is due to this not only a strategy that makes him invisible as an
actor who’s own (future) life can be addressed directly; it also neglects him as an actor who
potentially can have a will to get vaccinated as a responsibility for the sake of other’s health.
To open up for other potential users could in contrast potentially foster HPV vaccination as
something one not only does for the sake of one’s own future health but also to enable the
health of others.
24
References
Aapola, Sinikka, Gonick, Marnina & Harris, Anita (2005). Young Femininity: Girlhood,
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