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Why Some Sexual Abuse Survivors Avoid Pap Smears

Summary and Comment |
November 8, 2012

Why Some Sexual Abuse Survivors Avoid Pap Smears

  1. Diane E. Judge, APN/CNP

Barriers include concerns about power, trust, safety, comfort, and examiner communication.

  1. Diane E. Judge, APN/CNP

Some data suggest that survivors of sexual abuse are underscreened for cervical cancer. In an exploratory study of why this might be so, investigators surveyed 135 British users of a support website for abuse survivors about their experiences with cervical cancer screening.

Of the respondents aged ≥25 who lived in England — where women are invited for free screening starting at age 25 and then every 3 to 5 years until age 64 — 78% reported ever being screened and 48% reported being screened within the past 5 years. Open-ended responses about barriers included concerns about power, trust, and safety (including vulnerability to a stranger that triggered memories of abuse). Additional concerns were discomfort or pain, fear and anxiety, poor examiner communication and sensitivity, and triggering of poor coping responses. Participants' suggestions for improvement included allowing the time and means for abuse disclosure, knowing the examiner, choosing the examiner's sex, bringing an advocate, being allowed to terminate the exam at any time, speculum self-insertion, sample self-collection, respectful examiner communication, and choice of position (e.g., side-lying, in which the woman lies on her side with one or both legs flexed so that the speculum can be inserted from behind).

Comment

This small group of website users might not be representative, but they do provide useful insights about how to ease the gynecologic examination experience for abuse survivors. Some suggestions are already in use or are easily implemented. For example, (1) for women who identify themselves as survivors of sexual abuse during the history, offering the opportunity to schedule the exam on another day and to bring an advocate if they choose; (2) allowing each woman who seems unusually apprehensive to sit up instead of remaining in the lithotomy position while the clinician and she discuss her concerns; (3) raising the back of the examination table for eye contact; (4) identifying a word or signal for immediate termination of the examination; (5) offering self-insertion of the speculum and alternative examination positions. Self-collected samples are also possible (JW Womens Health Dec 30 2003 and JW Womens Health Apr 15 2010). These measures alone will not increase the number of abuse survivors who seek screening, but publicizing their availability might do so.

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