Author: Erin Pallott
This post contains mention and discussion of sexual trauma and intimate medical examinations, which some readers may find distressing. I have linked several resources at the very end.
23rd – 29th of January marked Cervical Cancer Prevention Week. Cervical cancer is the 4th most common cancer in women, and over 95% of these cases are caused by the human papilloma virus (HPV).
There are 2 major tools applied to prevent cervical cancer. The first is the HPV vaccine. In the UK, it is now recommended for all children at 12/13 years old, preventing infection and transmission of the virus which is spread through sexual activity. The second prevention tool is cervical screening, also referred to as the smear test.
For those unfamiliar with this screening, women are invited from 6 months before their 25th birthday, and then every 3 years to attend a smear test. This test involves an examination of the cervix, and collection of cervical cells to test for HPV, aiming to identify infection and pre-cancerous lesions to allow treatment before cancer develops. Currently, this screening test involves women attending an appointment with a nurse, who will insert a speculum into the vagina to get visual access to the cervix. A brush is used to collect cells for clinical testing. There is no doubt that screening saves lives. Cancer screening services offered by the NHS save an estimated 9,000 lives yearly in the UK alone, thanks to pre-cancerous or early detection.
This leaves the question: Why do 1 in 3 women not respond to their cervical screening invitation?
There was a focus during the recent awareness week on screening uptake. In 2021, only 68% of women aged 25-49 had been screened in the last 3.5 years, which is approximately 5% lower than 10 years ago. Several campaigns have been launched in recent years to encourage women to attend their appointments, which have shown some marginal success. Commonly cited reasons why women don’t attend these screenings is they are embarrassed, worried it might hurt or that they forget to book it.
Mind if I address a few of the elephants in the room?
Most campaigns by charities and the NHS acknowledge that it’s not a pleasant experience to lay on a table for a pelvic exam. However, I noticed a trend in language used that I found concerning. Several campaigns informed that smear tests “shouldn’t hurt” or “do not hurt”. I attended my very first cervical screening a few months ago. I was reassured by the nurse and people I know that it won’t be painful. Actually, it did hurt quite a bit, and in the moment, I was scared something had gone horribly wrong.
In a survey of young women by the cervical cancer charity Jo Trust, over a third of women reported they found the procedure painful, and not just uncomfortable. 14.7% of women aged 60-64 also reported the procedure was more painful after menopause. If they’re worried about women feeling embarrassed about getting undressed, they should imagine how it feels to have an experience you were outright told would not happen.
Several studies have also identified a need for trauma-informed approaches to cervical screening, as survivors of sexual assault and trauma are less likely to attend, and more likely to stop attending after their first screening.
Emma Szewczak, who is currently researching for and writing a book on medical misogyny, expressed similar feelings about the ongoing campaigns on Twitter. She mentioned how painful experiences and past trauma are seldom discussed barriers to screening uptake. The responses to this discussion inspired me to get this post written, and one of the first words I saw was “fearmongering”. Some people responded that talking about pain and trauma would scare women away from attending.
Another aspect that is often missing from surveys is negative experiences with the medical practitioner, which is a common discussion point with women sharing their experiences. Over 30% of women in the Jo’s Trust survey disagreed that their practitioner made them feel at ease, but it does not go into detail about what made women uncomfortable. Reading through personal experiences, women discussed being yelled at, gaslit about their pain and having their requests for lubrication or a smaller speculum ignored. Emma’s upcoming book will be discussing violence across gynaecological healthcare and will be published next year.
If we need to lie to women to get them to attend a medical appointment, it tells me that something urgently needs to change. It is not fair to ask women to be silent about negative experiences for “the greater good”. Fortunately, there are promising new research developments that could completely change the nature of screening.
Self-Swabbing and Urine Testing
The good news is there are promising alternatives to the speculum examination being researched. Emma Crosbie is a professor of gynaecological oncology at The University of Manchester and a gynaecological surgeon. Prof Crosbie’s research is directly addressing and tackling barriers to cervical screening. In her recent review, it is discussed that non-speculum screening shows the greatest promise in tackling poor uptake, especially in lower socioeconomic groups.
Home tests are currently being piloted, where women take vaginal swabs in their own home, and have shown to be as equally sensitive as a full exam and are as equally accurate in detecting high-risk HPV. Surveys showed women would be far more willing to partake in screening. Hopefully, once ongoing pilot studies are completed, we can begin implementing these tests nationally, which has already been done in some countries.
There are also promising results for a self-sampled urine test to detect pre-cancerous abnormalities and high-risk HPV strains. Prof Crosbie and colleagues have been investigating optimal processing and sensitivity for this test and their recent data showed good sensitivity compared to vaginal sampling. This non-invasive strategy would be a game-changer in improving uptake in cervical screening. I hope we see these tests trialled on a larger scale in the very near future.
There is no mistake in that cancer screenings are incredibly important and life-saving services. It is vital that women attend cervical screening where possible. However, we need to keep in mind when sharing “don’t fear the smear”, that women are not concerned about a medical boogeyman, these are real lived experiences of a medical exam that can and must be improved.
Resources and important information:
- ALL people with a cervix should attend screening if they are able. People with a cervix registered as male with their GP may not receive the automatic invitations. You can still contact your GP to arrange an appointment.
- It helps to be familiar with the process before you attend. You can ask for a chaperone, a smaller speculum and lubrication. Most importantly, you can stop the exam at any time.
- There are several charities who offer cervical screening appointments specifically for people who have suffered sexual trauma and/or do not identify as women. They can support you with longer appointments and trauma-informed healthcare. Examples include The My Body Back Project and Clinic T. More information here.
Discover more from Research Hive
Subscribe to get the latest posts to your email.
Research Hive 