The National Health Service Cervical Screening Programme (NHSCSP) is a national, government-funded cervical screening programme using a call–recall system. It has been estimated that the NHSCSP saves up to 5000 lives per year.1
All women registered with a general practitioner (GP) in the UK are sent regular invitations for free cervical screening. The routine screening interval is 3 or 5 years, depending on age. The age at which women are first invited is either 20 or 25 years and ceases at 60 or 64 years, varying between the different countries of the UK. The majority of cervical cancer cases in the UK are in under-screened women.2
A recent audit of invasive cervical cancer in England confirmed that only 29% of these cancers occurred in those who had adhered to screening interval guidelines.3
Therefore non-attendance for cervical screening must be seen as a major risk factor for cervical cancer. The NHSCSP reported that on 31 March 2011, 78.6% of eligible women had been screened at least once in the previous 5 years.4
This means that approximately one in five women had not been screened within the past 5 years and could be regarded as non-attenders.
Statistics on the prevalence of sexual abuse perpetrated against women and children vary widely5–9
but the most comprehensive UK data from the National Society for the Prevention of Cruelty to Children reported in 2000 that 21% of girls aged under 16 years experience sexual abuse.10
It has also been stated that almost one in five women will be the victim of sexual assault in their lifetime. However, only approximately 40% of rapes are reported and 31% of children who have experienced abuse reach adulthood without disclosing this,11
indicating that these estimates could be conservative.
Evidence suggests that there are higher levels of gynaecological problems and cervical neoplasia in women who have been abused than those who have not.12–18
Sexual abuse can reasonably be considered to put a woman at increased risk of cervical neoplasia. This may be attributable to a number of factors other than non-attendance for screening, including early exposure to high-risk human papillomavirus (HPV), the main risk factor for cervical cancer.19–22
In addition, it has been shown that women who have been sexually abused are more likely to engage in behaviours associated with health risk such as smoking, drug and alcohol misuse and high-risk sexual behaviour.23–25
There are many reported barriers to attendance for screening in the general population. These include practical obstacles such as time constraints and lack of childcare but also emotional and psychological barriers including embarrassment and fear of pain.26
It has been suggested that among the non-attenders for screening are women who have been sexually abused.28–32
There are many potential responses to the trauma of sexual abuse. Some of the more damaging behavioural responses have already been outlined but reaction to the experience has been likened to post-traumatic stress disorder.32–34
One way of coping with the trauma of sexual abuse is to control or avoid the triggers of trauma responses. This may mean not attending for cervical screening.
Intimate gynaecological examinations can be particularly stressful for women who have been abused because of the parallels with the abuse situation, for example perceived loss of control, the power disparity and the physical sensation of the examination.33
It is not everyday practice for a clinician to ask directly about sexual abuse and many women find disclosing abuse difficult.33
There is little empirical evidence about the specific barriers to cervical screening in this hard-to-identify group of women, or about measures that might be taken to facilitate screening in this at-risk group.
This exploratory study was designed to use mixed methodology: an online survey followed by discussion groups, with the aims to:
- Explore self-reported cervical screening history among women who have been sexually abused;
- Explore barriers to attendance for cervical screening in a population of women who have experienced sexual abuse;
- Identify measures to improve the experience of screening for women who have been sexually abused.
It was hoped that by seeking this information directly from the women themselves the findings could be assimilated into the body of research on this topic and used to help to inform areas where future research could be directed, and in particular where clinicians could effect changes in their practice.