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Cervical screening is no exception to the discomfort and distress that a survivor of sexual violence may experience. It is likely that experiences of sexual violence contribute significantly to the already low attendance rates.
In a survey conducted by Jo's Cervical Cancer Trust in partnership with Rape Crisis, almost half of survivors said they had not attended cervical screening because of their experience of sexual violence. A quarter said they had put off the test for the same reason, while just 14.5% of respondents said they attend screening when invited.
For a survivor, attending a routine smear test can be a source of intense anxiety. They may feel forced or pressured to disclose their experiences, or the examination itself could trigger a whole host of distressing physical and emotional responses.
Previous research has identified a number of common barriers to cervical screening amongst women with experience of sexual violence. A 2012 research analysis by the National Association for People Abused in Childhood (NAPAC) concluded that:
"Common feelings among survivors of sexual abuse include shame, guilt, self-blame and feeling unclean, contaminated or dirty. These feelings can be compounded during the experience of a smear test. The physical position in which smear tests are taken is generally with the woman lying on her back with legs bent and knees parted. NAPAC hears from many women that this position is too similar to the physical positions they were forced into during the abusive acts against them."
Understanding these triggers, and the effect this may have on patients, is crucial to smear takers' ability to support survivors of sexual violence.
Likewise, certain words or phrases – like telling the patient to "relax" – may be reminiscent of the coercive language used by their attacker.
Besides the actual physical experience of screening, the prospect of pain or tension, and the thought of being unwillingly 'penetrated' by a clinical object, many survivors' concerns are related to control and victimisation.
Indeed, previous research found that:
"There is a clear power differential between the smear taker and the woman undergoing the rest. [Women] made remarks about feeling vulnerable, and someone having control over them being 'similar to the control that is suffered during abuse'... They commented on the intrusive and invasive nature of the test and how they did not like to be 'lying down exposed… having somebody touch me in that area' or 'having a stranger standing there'."
We know that embarrassment and self-consciousness are common barriers to cervical screening amongst women in general, and this can be particularly pronounced in survivors of sexual violence.
They may be concerned about visible scarring or signs of abuse; have feelings of guilt, shame, and low self-worth; or even feel that they are no longer entitled to good treatment.
6 out of 10 respondents in our survey said there was nothing to help prepare them for cervical screening, and they did not know where to go for support.
86% of respondents said that cervical screening information written specifically for women who have experienced sexual violence would be helpful, while many felt that more signposting to support was necessary.
Many survivors also worry about having to disclose experiences of sexual violence to their smear taker, and whether they will be adequately supported if they do so. Women with these experiences want to feel safe and able to trust their smear taker, including that they will respond compassionately, calmly, and with an understanding of the issues.
Concerns around going for cervical screening are not simply about bringing up feelings or memories of a past event. If not done properly and with the right sensitivity, the test could traumatise a survivor again as an unwanted act of penetration (due to the use of the speculum). It is important to let any survivor know they are in control of the use and respect their wishes around language, positioning and time taken.
Avoidance is a key component of the post-traumatic stress response and, as our survey shows, around half of survivors react to these barriers by simply not attending cervical screening appointments when invited.
In a 2012 study, a small minority of women said they would "rather die of something that screening would pick up than be in that position again."
For those who do attend, it may take many months or years of putting it off before they feel able to book their smear test.
Once in the appointment, survivors may become emotional or distressed. They may want to disclose their past experiences, or talk through what the procedure will involve. They may need more time and patience than other patients to prepare for the screening itself.
Other common reactions by survivors to cervical screening include:
These may be similar to the stress responses that kicked in during their experiences of violence and, either way, can be incredibly distressing.
If the survivor regularly suffers from one of these symptoms, they may come into the appointment already feeling anxious about their mind or body responding in this way, and that anxiety can itself present a further barrier.