Written by Amanda Pisciotta
Edited by Raheem Sheikh
Introduction:
Sexual violence affects one in three women in their lifetime [1]. However, imagine surviving the trauma of sexual assault, only to face another silent threat—cervical cancer—because the fear and anxiety of gynecological exams prevent you from getting screened. Cervical cancer is globally the fourth most common cancer, with 660,000 new cases and around 350,000 deaths in 2022 [2]. Although screening has decreased the incidence and mortality rates of cervical cancer by over 50 percent in the past 40 years, largely due to the widespread uptake of screening with the Pap test, a vastly vulnerable group is often forgotten: sexual assault survivors [3].
HPV and Cervical Cancer Risk in Sexual Assault Survivors:
HPV Overview:
HPV (Human Papillomavirus) is a group of more than 200 related viruses, some of which are spread through vaginal, anal, or oral sex[4]. Sexually transmitted HPV types fall into two groups: low risk and high risk[4]. Nearly all sexually active people, regardless of their sex, gender identity, or sexual orientation, become infected with HPV within months to a few years of becoming sexually active[4]. Around half of these infections are with a high-risk HPV type[4]. Sometimes, HPV infections are not successfully controlled by the immune system[4]. When a high-risk HPV infection persists for many years, it can lead to cell changes that, if untreated, may worsen over time and become precancerous and then cancerous[4]. HPV can cause up to six different types of cancer, including cervical cancer[4]. Virtually all cervical cancer is caused by HPV[4]. Routine screening with an HPV test or Pap test can prevent most cervical cancer by allowing healthcare providers to find and remove precancerous cells before they develop into cervical cancer[4]. Cervical cancer is most common in women who are rarely or never screened[4].
Increased Risk in Sexual Assault Survivors:
After a sexual assault, individuals often face heightened concerns about the risk of sexually transmitted infections (STIs), including HPV. The World Health Organization (WHO) describes a 50%–80% increased risk of STIs, including HPV, among women exposed to sexual violence [5]. Screening for and managing STIs are well-established procedures after sexual assault. However, for sexual assault survivors, accessing screenings and undergoing specific procedures to manage STIs may not be as readily accessible as it is for the general population.
Barriers to Screenings and Gaps in Current Practices:
Sexual assault (SA) survivors face numerous barriers and gaps in current practices that prevent them from seeking cervical cancer screenings. These barriers and gaps contribute to a lack of safety and comfort, leaving survivors vulnerable to cervical cancer due to their reluctance to undergo necessary procedures like Pap smears.
Lack of Safe Disclosure Environment:
One major reason SA survivors avoid gynecological care is the discomfort and fear associated with disclosing their assault history. Many doctors excuse their inadequate care by claiming they were not informed about the patient's history. However, expecting survivors to trust and openly communicate about their traumatic experiences with a stranger is unrealistic. It is the doctor's responsibility to initiate this dialogue sensitively during the patient history intake, reassuring the patient that they are in a safe space and are not alone in their struggle. Despite the prevalence of sexual violence (affecting 1 in 3 women), only 0.5% of women report being asked about their experiences by their gynecologist, whereas over 30% are too afraid to mention it and 55% think it is not relevant[8].
Feelings of Guilt, Shame, or Embarrassment:
SA survivors often experience feelings of guilt, shame, or embarrassment related to their trauma[6]. In one study, it was estimated that at least 75% of sexual assault victims have experienced victim blaming, and this number can be even higher[14]. Our modern society has adapted to a world where rape culture is prevalent. Although many groups, like the Me Too movement, try to combat it, many people have internalized harmful dialogue. Society glamorizes sexual assault and dismisses the safety of women with phrases like “Boys will be boys” and “She asked for it,” while inflating false rape report statistics and scrutinizing a victim’s dress, mental state, motives, and history[15]. This shifts the responsibility to the victim rather than acknowledging that rape is an crime committed by the abuser.
This harmful tone can come from various sources: strangers, family, friends, law enforcement, religious leaders, campus faculty, professional colleagues, lawyers, doctors, or even the survivors themselves. It contributes to feelings of guilt, self-blame, and shame, hindering the processing of trauma and preventing individuals from seeking the medical help they deserve[14]. Some survivors may feel embarrassed about visible scarring or signs of abuse[6]. Feelings of shame or low self-worth, coupled with a sense of guilt, can lead survivors to believe they are not entitled to proper treatment[6]. Consequently, these emotions create significant psychological barriers to seeking medical care.
Fear of Disclosure:
Survivors often fear having to disclose their experiences of sexual violence during their examination. The worry about whether they will be adequately supported if they do disclose can be a major deterrent[6]. This fear of disclosure can prevent survivors from scheduling or attending cervical screenings, as they may prefer to avoid the emotional stress associated with discussing their trauma.
Lack of Choice in Health Care Provider:
Another significant gap is the limited choice SA survivors have in selecting their health care provider for cervical screenings. Although some women can choose their gynecologist, many cannot due to office policies that involve doctor rotations, preventing continuity of care. Furthermore, gynecologists are often not the ones who perform the smearing; it is done by other medical personnel such as nurses or physician assistants. Patients are rarely given the option to choose who performs the smear. Even when making an appointment, doctors typically do not offer this choice, assuming that providing a female smearer is sufficient. However, this assumption can be problematic, as some survivors have been abused by women. One survivor remarked, “My abuser had been a woman, and the assumption that if a woman does the test that will make it OK is not true”[7]. Allowing individuals to choose their smearer, including their gender, can make the environment feel safer and more comfortable for them, avoiding decisions based on assumptions.
Poor Communication During Procedures:
Effective communication during procedures is often lacking. Doctors frequently fail to walk patients through the steps of the procedure, leaving them unaware of what to expect[9]. This lack of communication can make SA survivors feel disconnected, forgotten, and vulnerable, mirroring their traumatic experiences. Consequently, the fear of undergoing an unknown and potentially painful procedure without adequate explanation can discourage survivors from seeking care.
Fear of Being Triggered or Retraumatized:
The fear of being triggered or retraumatized by the gynecological examination is a substantial barrier. Cervical exams like Pap smears can have numerous similarities to the original sexual violence, such as being asked to undress, lying still with feet in stirrups, and being touched and/or penetrated (with a speculum) by a stranger or authority figure[6]. These parallels can make the procedure feel like a re-enactment of the trauma, causing intense fear and anxiety. Some patients even describe the cervical examination as “legalized rape” due to the similarities[7]. During appointments, many SA survivors may become emotional or distressed. They may experience panic attacks, dissociate, or disconnect from reality, and freeze during the examination[6]. These intense emotional reactions are part of the post-traumatic stress response and lead many survivors to avoid cervical examinations altogether[6]. Nearly half of SA survivors react to these fears by not showing up to their cervical examination appointments, further increasing their risk of cervical cancer[6].
Unawareness of Patient Rights:
Many patients are unaware of their right to have a support person present during their procedure. This can be particularly beneficial for SA survivors, providing additional comfort and reassurance. The lack of awareness of this right means that survivors may feel they have to face the procedure alone, increasing their anxiety and reluctance to attend screenings.
Insufficient Pain Management:
Pain management during gynecological procedures is often inadequate. Many women report that procedures like Pap smears are painful or uncomfortable, yet they do not receive appropriate pain relief[7]. SA survivors, who may already be tense and unable to relax, can find these procedures particularly excruciating[7]. The anticipation of severe pain without sufficient pain management options can be a significant deterrent for survivors.
Ignoring Withdrawal of Consent:
Another critical gap is the failure of some clinicians to respect a patient's withdrawal of consent[9]. Instances where clinicians continue the procedure despite the patient’s request to stop due to pain or discomfort are unacceptable[9]. Such experiences can retraumatize survivors, reinforcing their reluctance to seek necessary medical care. Fear of having their consent ignored can lead survivors to avoid appointments altogether.
Blame in Result Communication:
Even after undergoing the examination, the manner in which results are communicated can be problematic. Some doctors may convey positive test results in a blaming tone, implying the patient is at fault for their sexual activity. This is particularly troubling in the case of HPV, which is common even among those who practice safe sex. The fear of being judged or blamed for their results can discourage survivors from seeking follow-up care or attending future screenings.
These barriers and gaps in current practices create an environment that feels unsafe and unwelcoming for SA survivors, leading to their avoidance of essential gynecological care and increasing their risk of cervical cancer.
Creating Safe Cervical Screening Environments:
Healthcare providers play a crucial role in making Pap smears accessible and comfortable for sexual assault (SA) survivors. Integrating screening for sexual assault into routine check-ups is imperative[10]. Providers must emphasize the importance of this knowledge before directly addressing the patient's history of sexual violence.
Options for survivors to disclose their experiences should be readily available, such as through written forms or electronic surveys[10]. During medical exams, providers must prioritize creating nurturing and safe spaces by offering clear communication, respecting privacy, and allowing survivors to have a support person present.
Providers should welcome companions and advocates, provide flexible scheduling options and the ability to extend appointment time for SV survivors to recover after their procedure and offer alternative screening methods, like self-administered HPV tests[11]. Additionally, they must respond with validating and empowering statements, refrain from pressuring survivors for details, and provide comprehensive education and counseling resources about sexual violence and health issues as part of follow-up care.
Although not all healthcare facilities may have a background in providing trauma-informed care, by implementing these changes and offering specific training to all physicians in this specialty, healthcare providers can ensure that SA survivors receive necessary screenings and significantly reduce their risk of cervical cancer by increasing their accessibility to Pap smears. This proactive approach not only addresses the unique needs of survivors but also strengthens patient-centered care and improves overall healthcare outcomes.
Conclusion:
Every 98 seconds, another individual experiences the trauma of sexual assault. Yet, in the realm of medicine, we allow preventable obstacles to stand in the way of proper gynecological care for these survivors. Cervical cancer, a largely preventable disease with a 98% prevention rate through regular screening, should not loom as a threat to those who have already endured the horrors of sexual violence[12]. With early detection methods like the loop electrosurgical excision procedure (LEEP), abnormal cells can be effectively managed[13]. We must not subject survivors to the possibility of becoming victims of cancer on top of the trauma they have already endured. By dismantling barriers and ensuring equal access to screenings and treatments, we can shield survivors from unnecessary suffering and safeguard their health and well-being.
References:
UN Women. “Facts and Figures: Ending Violence Against Women”. UN Women Website:https://www.unwomen.org/en/what-we-do/ending-violence-against-women/facts-and-figures#:
World Health Organization. “Cervical Cancer”. WHO: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer#:.
American Cancer Society. “Screening Leads to Cervical Cancer Decline in the United States”. Cancer Action Network: https://www.fightcancer.org/sites/default/files/FINAL%20-%20Cervical%20Cancer%20General%20Factsheet%2001.08.20.pdf
National Cancer Institute. “ HPV and Cancer”. NIH: https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer#:.
Skjælaaen, Katarina; Et al. “Sexually transmitted infections among patients attending a sexual assault centre: a cohort study from Oslo, Norway”. NIH– National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9716778/
Jo’s Cervical Cancer Trust. “Understanding Sexual Violence and Cancer Screenings”. Rape Crisis & Jo’s Cervical Cancer Trust Website: https://www.jostrust.org.uk/professionals/health-professionals/nurse-gp/supporting-survivors-sexual-violence/how-survivor-may-feel#:
Cadman, Louise; Et al. “Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study”. NIH– National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470431/
Peschers, Ursula.M; Et al. “Prevalence of sexual abuse among women seeking gynecologic care in Germany”. NIH– National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/12517653/
“Communicating With Patients About Cervical Smear Tests”. The MDU: https://www.themdu.com/guidance-and-advice/latest-updates-and-advice/communicating-with-patients-about-cervical-smear-tests
Onyejiaka,Tiffany. “A Guide to Navigating Your Next Pelvic Exam After Sexual Assault”. Healthline: https://www.healthline.com/health/navigating-medical-exams-after-sexual-assault#Information-for-caregivers,-parents,-and-partners
“Women in the U.S. Can Now Collect Their Own Sample for Cervical Cancer Screening”. SOURCE BD (Becton, Dickinson and Company): https://news.bd.com/2024-05-15-Women-in-U-S-Can-Now-Collect-Their-Own-Sample-for-Cervical-Cancer-Screening#:.
Centers for Disease Control and Prevention.“Cervical Cancer is Preventable”. CDC: https://www.cdc.gov/vitalsigns/cervical-cancer/index.html#:~:text=Up%20to%2093%25%20of%20cervical,that%20cause%20most%20cervical%20cancers.
Perlmutter Cancer Center. “Treatments for Precancerous Conditions of the Cervix”. NYU Langone:https://nyulangone.org/conditions/cervical-cancer/treatments/treatment-for-precancerous-conditions-of-the-cervix#:~:text=Your%20doctor%20may%20use%20a,wire%20loop%20into%20the%20vagina.
Van Gestel, Myrthe. “What is the Impact of Victim Blaming and Why Do People Do It”. Fair Space: https://fairspace.co/what-is-the-impact-of-victim-blaming-why-do-people-do-it/#:~:text=Of%20all%20victims%20who%20experience,than%20by%20the%20event%20itself.
Southern Connecticut State University. “Rape Culture, Victim Blaming, and the Facts”. Inside Southern: https://inside.southernct.edu/sexual-misconduct/facts
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