KEY POINTS FOR CLINICIANS
- Women who had not had recommended cervical cancer screening were more likely to have been sexually abused in childhood.
- Women who were sexually abused in childhood may be at higher risk than other women for HPV and cervical cancer; therefore, screening is particularly important for these women.
- Not having cervical cancer screening may be a marker for childhood sexual abuse. Therefore, health care providers should consider investigating these issues with women who do not adhere to guidelines for routine Pap smears.
Unfortunately, 15% to 24% of US women do not receive recommended cervical cancer screening.1-3 Barriers to Pap screening include low income, low education, minority status;4 lack of cancer knowledge, attitudes, beliefs, low perceived cancer susceptibility, pain, embarrassment;5-7 language, and certain cultural beliefs.7-9 Sexual trauma has received little research attention as a factor contributing to lowered rates of Pap screening. Sexual trauma is reliably associated with subsequent poor health, which may be partially accounted for by poor preventive care.10-16 Childhood sexual abuse is strongly associated with negative health behaviors such as physical inactivity and smoking.13,17 Sexual violence is associated with lower rates of breast cancer screening18 and increased risk of posttraumatic stress disorder (PTSD).19-21 Avoidant coping styles (an aspect of PTSD) are associated with decreased health promotion behaviors such as screening.22-25
Gynecologic procedures may feel threatening to women with a history of sexual assault, and may be experienced as re-traumatizing.14,26-29 Women who had suffered childhood sexual abuse reported more anxiety, shame, and fear during a gynecologic examination than other women.28 Springs and Friedrich16 found a lower frequency of screening for cervical cancer among adult survivors of childhood sexual abuse, but did not assess the impact of other traumatic events in childhood or adulthood on Pap screening. Because previous research on correlates of sexual trauma has been criticized on the grounds that third variables could account for the observed associations,30 we evaluated associations of any traumatic event with low rates of Pap screening.
We hypothesized that having experienced traumatic events, in particular childhood sexual trauma, would function as barriers to Pap screening. We predicted that women who had not had medically appropriate Pap screening would report a greater number of traumatic events, especially sexual abuse trauma in this ethnically diverse random sample of women. We also expected that sexually traumatized women would express more negative attitudes toward Pap screening, and would be more likely to meet criteria for PTSD, both of which might contribute to lower levels of Pap screening.
Methods
Kaiser Permanente (KP), a pre-paid maintenance organization, offers cervical cancer screening at no cost to patients. KP’s clinical guidelines recommend Pap screening every 2 years for women over age 20 with average risk for cervical cancer. Self-report questionnaires were mailed to an age-stratified random sample of women 21–64 years old who were KP members at 3 locations. Women who had had a total hysterectomy were excluded. We compared women who had and who had not obtained Pap screening in the previous 2 years. In previous research18 we found that women who had not obtained mammography had a lower response rate to mailed questionnaires than women who had been screened. We therefore oversampled women who had not had Pap screening. We mailed questionnaires to 1314 women who had obtained Pap screening and 2897 who had not. The final sample included 364 women who had received screening in the past two years (28% response rate) and 372 who had not (13% response rate). Repeated sampling or telephoning of non-respondents was not allowed by KP policy.
Trauma history was measured in 2 ways. The Trauma History Questionnaire31,32 assesses a range of lifetime traumatic events. The Childhood Trauma Questionnaire33 assesses childhood physical abuse, physical neglect, sexual abuse, emotional abuse, and emotional neglect. PTSD was assessed with the Posttraumatic Stress Disorder Checklist.34 We inquired about attitudes toward Pap screening based on previous findings.
Data were analyzed using SAS.35 Contingency tables were analyzed to estimate the prevalence of traumatic events and their bivariate associations with Pap screening. Chi square analysis was used to evaluate the statistical significance of these associations. Hierarchical logistic regression was used to evaluate associations of traumatic events with screening, independent of clinic location, demographic characteristics, attitudes about screening, and PTSD.
Results
Sample demographics
Women who had been screened for cervical cancer and unscreened women were similar in age and education (Table 1). Unscreened women were more likely to be Asian American, to have incomes of $20,000 per year or less, and to have never been married.