We asked three women why they missed their smear test

Row of chairs in a waiting room

A white envelope with an NHS letter inside inviting you to book your first cervical screening will usually be the first thing that gets you thinking about smear tests.

Many women will then call their local GP to schedule an appointment and when it arrives, they’ll be in and out in less than 15 minutes. They may have experienced some very mild discomfort during the screening. But it’s not that simple for all of us.

Existing health issues, sexual trauma, painful conditions like vaginismus, or just general anxiety about the procedure or its outcome can be so overwhelming for some women that it feels easier to put the process off entirely.1 A previous bad experience with a cervical screening, including receiving a worrisome result, can feed the same sort of feelings of anxiety, dread, and fear, which may bring women to skip their next appointment.2 Other reasons, like simply not getting round to it are less common, but still a factor.3

Women from Black or Asian communities are also less likely to attend cervical screenings, because of misconceptions to do with the process, stigma attached to the need for the test, and perceived promiscuity and sex outside marriage.4 A study found that emotional barriers to cervical screenings were more prominently experienced among Asian women, while negative experiences were a key factor for non-attendance across women from all ethnic backgrounds.5

What does a cervical screening look for?

A cervical screening examination involves inserting a speculum — a long, usually plastic device shaped a bit like a duck bill — into the vaginal canal and then opening it to give the nurse or doctor a clear view of the cervix. They check for any visual abnormalities and swab the area to test for cancerous cells, or abnormal cells that have the potential to turn cancerous if left untreated, as well as the presence of human papillomavirus (HPV), a sexually transmitted infection that can cause genital warts and cancer.

According to Cancer Research UK, cervical cancer rates are highest among 25 to 29-year-old women, and there are around 3,200 new cases in the UK every year. Smear tests are given to all women from the age of 25 by the NHS, every three years as a diagnostic and preventative measure, so that risk factors — like abnormal cells — can be treated or monitored. This also enables new cases of cervical cancer to be diagnosed in the early stages.

Most people will get HPV at some point in their sexually active lives. HPV is not routinely checked for outside of cervical cancer screenings, and the body usually clears the infection itself.6 But some types of HPV — there are more than 150 strains, with 12 considered high risk — are more aggressive than others, and some women may be more genetically likely to develop cervical cancer, especially if they have a family history of the disease.

“I lied and said I thought I could be pregnant, because I knew they would deny me the smear test because of that”

A cervical screening can literally save your life, and yet, the rate of those attending their smear tests in the UK is falling. In 2018, Public Health England expressed concern about the millions of women that were skipping smear tests, with 72% of 25-64 year old women having attended theirs last year, compared to 75% in 2017.

So what’s stopping some women from going through the screening process?

Fear and family history

The experiences of family members and those close to us can have a long-lasting effect on the way we view our own health, and the health services that are there to help us. Amanda* missed her first smear test that she had booked two months after her 25th birthday. But when the day finally arrived, she got to her GP’s practice and “completely froze”.

“I was initially super keen to have it done,” she says. “But when I got to the doctors, I was nervous about having someone see down below, but also, when my mum was my age, they found cancer cells during her smear and had to remove some of her uterus or cervix.”

Amanda began to panic once inside the room her smear was about to take place in. She remembers beginning to physically shake, and quickly came up with an excuse to avoid the smear test once the nurse began the pre-questionnaire.

“I lied and said I thought I could be pregnant, because I knew they would deny me the smear test because of that,” she says. “So I walked out without one, relieved in the moment, but I always regretted it.

“I don’t know what came over me. I would always encourage [women to get smear tests] despite my own fears. It’s taken me ages to get around to booking one again.”

Amanda’s response is not unusual. Jo’s Cancer Trust says that 35% of young women were too embarrassed to attend smear tests because of worries about the appearance of their vulva, while 38% felt conscious of the smell, and 34% felt ashamed of their body shape.

“Cervical screenings are so important, but women need to feel mentally supported through the process, which can be traumatic for a number of reasons, like previous sexual abuse or a prior negative experience”

GP Dr Sophie Carr says that the negative or former cervical cancer experience of a close friend or family member can elicit panic and cause women to start catastrophising about worst-case scenarios.

“This is perfectly understandable,” she says. “As doctors, we need to offer support in these cases, helping women to feel at ease and letting them know that we are here to discuss and listen to their concerns surrounding their cervical screening, including not feeling mentally able to go ahead with it.

“Cervical screenings are so important, but women need to feel mentally supported through the process, which can be traumatic for a number of reasons, like previous sexual abuse or a prior negative experience. Drilling home the dangers of skipping a smear test in an abrasive way can actually worsen aversion and fear in those that are already finding it difficult, which serves no one.”

Trauma and bad experiences with past smears

Diana* was the victim of both childhood sexual abuse and a sexual assault as an adult during her time in care at a mental health facility. She says she finds the entire cervical screening process deeply invasive, from the pre-questionnaire to the examination itself. While she has attended cervical screenings in the past, she has missed her last few, because she felt she was treated aggressively and without sensitivity during her smear tests.

“I find the process really uncomfortable,” she says. “It’s like being a piece of meat, I wasn’t treated with regards, and doctors and nurses have become frustrated with me in the past because I was finding the process uncomfortable, as if I was being dramatic, or unnecessarily difficult.”

“Until we address the trauma and fear that drives this type of response to cervical screenings, we are doing both a disservice to women, and ourselves”

A lack of sensitivity from nurses and doctors carrying out cervical screenings has been flagged by both the public, charities, and healthcare professionals as an issue that’s detrimental to increasing the uptake of smear tests,7 especially for those who are a victims of physical or sexual abuse. In partnership with Rape Crisis, Jo’s Cervical Cancer Trust has put together a series of sensitivity guidlines for healthcare professionals carrying out smears on women who have experienced sexual violence.

The Trust also carried out a survey that found half of female sexual violence survivors avoided cervical screenings because of trauma related to their abuse.8 The process of women exposing their vulvas, and having a device inserted into their vagina can trigger flashbacks, or even physical stress responses, like panic attacks, dissociation, or completely freezing.9

Sexual abuse survivors also might feel deeply distressed about or unable to reveal their experience of sexual violence to the healthcare professional carrying out their examination,10 creating an additional barrier between them.

Worry about previous abnormal result

Louise* received an abnormal result at her last smear test, and was advised about the next steps, which included close monitoring and more frequent smear tests to track any potentially dangerous changes in her cervix cells. But, she hasn’t been for a cervical screening since, feeling terrified about what could be found. She finds some relief in putting it to the back of her mind: avoiding speaking, thinking, or being proactive about it.

“There’s a part of me that feels too busy to attend regular smear tests, which aren’t exactly a happy experience for me anyway,” she says. “But I know that’s probably part of the problem, thinking that way, it’s an excuse, I think I might be a bit worried about what will happen or what the result will be, especially because I’ve already had one abnormal result.

“It’s temporarily comforting to just put it all out of my mind.”

As a casual smoker, this habit also intensifies Louise’s worry about cervical screenings and all the negative possibilities when it comes to a second, or even third set of results. Smoking is considered a risk factor for cervical cancer, though more research is needed to fully understand the relationship between smoking and HPV.11

But the same study found that it could impact the way HPV progresses inside the body, possibly suppressing lymphocyte and immunoglobulin activity, weakening immune responses which could make the body less able to halt the progression of a HPV infection and cancer growth.12

“Encouragement in a sensitive, understanding and patient manner is key,” says Dr Carr. “Some women feel a great sense of shame and guilt around not attending cervical screenings, because they genuinely do understand how important they are and what the consequences could be, but just feel completely unable to go through with one emotionally, mentally, or physically.”

“Until we address the trauma and fear that drives this type of response to cervical screenings, we are doing both a disservice to women, and ourselves — we have to help them help themselves so that we can help them, and that can only be done with a deeply understanding approach. On the other hand, there is also a huge issue around health literacy — many women also don’t understand why cervical screenings are so important, and therefore don’t attend. This is an issue that needs to be addressed urgently too.”

For support with difficulty going through with smear tests, please visit jostrust.org.uk or rapecrisis.org.uk

Featured image is of a row of chairs in a doctor’s waiting room. They have been faded from left-right, moving closer to greyscale as they approach the right

Page last updated September 2019

References

  1. Cadman, L., et al., Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study, BMJ Sexual and Reproductive Health, 2019, vol 38, issue 4, [online], https://srh.bmj.com/content/38/4/214.full (accessed 11 September 2019) 
  2. Waller, Jo., et al., Barriers to cervical screening attendance in England: a population-based survey, Journal of Medical Screening, December 2009, vol 16, issue 4, pp 199-204
  3. Ibid
  4. Marlow, L.A.V., et al., Barriers to cervical cancer screening among ethnic minority women: a qualitative study, BMJ Sexual and Reproductive Health, January 2015, vol 41, issue 4, [online], https://srh.bmj.com/content/41/4/248 (accessed 11 September 2019)
  5. Ibid
  6.  NHS, Human papillomavirus (HPV), March 2019, [online], https://www.nhs.uk/conditions/human-papilloma-virus-hpv/ (accessed 9 September 2019)
  7. Cadman, L., et al., Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study, BMJ Sexual and Reproductive Health, 2019, vol 38, issue 4, [online], https://srh.bmj.com/content/38/4/214.full (accessed 11 September 2019) 
  8. Jo’s Cancer Trust and Rape Crisis, ‘The information and support needs of survivors of sexual violence around cervical screening’, survey, 2018, [online], https://www.jostrust.org.uk/sites/default/files/jcct_rc_information_and_support_needs_-_survivors_of_sexual_violence.pdf (accessed 11 September 2019)
  9. Jo’s Cancer Trust, ‘Cervical screening after sexual violence’, January 2019, [website], https://www.jostrust.org.uk/information/cervical-screening/cervical-screening-after-sexual-violence (accessed 11 September 2019)
  10. Cadman, L., et al., Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study, BMJ Sexual and Reproductive Health, 2019, vol 38, issue 4, [online], https://srh.bmj.com/content/38/4/214.full (accessed 11 September 2019) 
  11. Fonesca-Moutinho, J.A., Smoking and Cervical Cancer, ISRN Obstetrics and Gynecology, April 2011, pp 1-6, article ID: 847684 [online], https://www.hindawi.com/journals/isrn/2011/847684/cta/ (accessed 11 September 2019)
  12. Ibid

Rachel Mantock

Deputy Editor, The Femedic

A feature writer who started out in lifestyle and wellness, Rachel joined The Femedic after becoming frustrated with the way women’s bodies and intimate health were being reported on. She wanted to talk about the good, the bad, the ‘ugly’ and the ‘really ugly’, with no topic too taboo to investigate. From conversations with the women she meets everyday to speaking with doctors, she’s constantly surprised by the amount of misinformation and lack of research around women’s health issues. She’s determined to raise awareness of the female health issues that are prominent in minority groups and to get more women talking shamelessly about their bodies and experiences.

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