Producing “Healthy” Girl Subjectivities –Pharmaceutical Advertising of the HPVVaccine in SwedenLisa Lindén

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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

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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

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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?

1There 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).

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2) How are adolescent girls addressed by Swedish HPV vaccine advertising in ways encouraging them to identify with the new “healthy girl” subjectivities?

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 co- produce (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:

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).

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2010:22).⁴ In line with this, it traces a shift from “enhanced control over external nature”

(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 self- transformation (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-by- individual 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

4 See Riska (2010) for a detailed discussion of the contrasts between Conrad and Clarke et al.

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).

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is good for the individual girl and her life. I investigate how an individualized risk discourse 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.

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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 linguistic tradition (Mills, 2004). I derive my analytic and methodological framework from

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.

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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, 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.

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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 co- constitutive (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).

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

13 See Åsberg and Lykke (2010) for a review of this expanding theoretical field.

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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 pharmaceutical companies is turned into promoting this age-group as the ideal user of HPV vaccine.

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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.

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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.

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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.

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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

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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).

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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

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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

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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).

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.

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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).

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“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 girlhood

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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.

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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

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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”.