Is a history of trauma associated with a reduced likelihood of cervical cancer screening?

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Original Research

Is a history of trauma associated with a reduced likelihood of cervical cancer screening?

J Fam Pract. 2002 October;51(10):827-831

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References

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TABLE 1

Demographic characteristics of women with and without Pap screening

	No Pap (%) n = 372^a	Pap (%) n = 364^a	P
Ethnicity			.001
African American	10.1	11.6
Asian American	20.1	8.0
European American	60.6	71.8
Other	9.2	8.6
Age			.076
Mean (standard deviation)	43.8 (12.8)	45.5 (12.4)
Education			.187
Elementary school	2.7	1.4
High school	39.6	34.8
College	41.5	43.2
Post-college	16.9	20.6
Family income			.002
$20,000/year or less	12.4	5.8
$20,001–$50,000	41.3	38.2
More than $50,000	46.2	56.0
Marital status			.012
Never married	34.3	24.8
Married	47.0	59.1
Separated	1.6	0.6
Divorced	13.8	13.1
Widowed	3.2	2.5
^aSample sizes vary slightly because of missing data on individual demographic items.

Prevalence of trauma

Commonly reported events during childhood included natural disaster (reported by 13% of the women), sexual assault other than rape (11%), and news of a death or injury (10%). Childhood sexual abuse or sexual assault was reported by 18.4% of the respondents. The most common traumas in adulthood were receiving news of a death or serious injury (46%), natural disasters (33%), actual or attempted robbery (27%), and serious accidents (14%). Of the respondents, 8.3% reported sexual abuse or sexual assault in adulthood. Their overall rate of childhood and adult sexual assault was 26.7%.

Associations of trauma history with pap screening

We investigated the association of trauma with screening using chi square analyses. Women who had been raped before age 18 (36% vs. 50%, n = 713, P = .050) and women who had been subjected to other sexual assaults before age 18 (35% vs. 51%, n = 694, P = .009) were less likely to have been screened. Nonsexual childhood abuse and neglect were not related to screening. Women who experienced a natural disaster during childhood (36% vs. 52%, n = 571, P = .009) and those who experienced terrorist acts during adulthood (20% vs. 49%, n = 715, P = .024) were less likely to have been screened. (Although the association with a terrorist act was significant, exposures were reported by only 3% of unscreened women and 0.9% of screened women.) Women who reported a household break-in during adulthood were slightly more likely to have been screened (53% vs. 47%, n = 656, P = .032).

In a hierarchical logistic regression model (Table 2), childhood sexual abuse, but not other traumatic events, was associated with lower odds of screening when clinic location, demographic characteristics, attitudes, and PTSD were controlled. The logistic regression model was repeated using CTQ subscales to assess trauma, with similar results. Unmarried women were less likely than currently married women to have been screened, and Latina, Native American, Asian/Pacific, or multicultural women were less likely than European American women to have been screened. Women who endorsed the statement, “I have no symptoms so I do not need a Pap test” and those who anticipated embarrassment during screening were less likely than others to have been screened; women who believed that testing would ease their mind were more likely to have been screened.

TABLE 2

Hierarchical logistic regression model of sexual trauma and attitudes as predictors of pap screening

Predictor	Adjusted odds ratio (95% CI)
Traumatic events
Break-in (adult)	1.14 (0.77, 1.70)
Natural disaster (child)	0.78 (0.45, 1.38)
Terrorist act (adult)	0.28 (0.07, 1.07)
Childhood sexual trauma	0.56 (0.34, 0.91) *
Site
Santa Rosa	0.68 (0.44, 1.04)
San Francisco	1.0 (referent)
Oakland	1.27 (0.80, 2.02)
Education
Less than college	1.09 (0.71, 1.69)
College	1.0 (referent)
More than college	1.01 (0.65, 1.57)
Ethnicity
European-American	1.0 (referent)
African American	0.59 (0.33, 1.06)
Other than African
American or European
American	0.46 (0.29, 0.71) **
Unmarried (compared with married)	0.67 (0.48, 0.94) *
Attitudes toward Pap screening
“I have no symptoms so I do not need a Pap test”	0.66 (0.51, 0.85) **
“I’ve had negative experiences with my health care provider”	0.90 (0.73, 1.10)
“Getting a Pap test would ease my mind”	1.54 (1.25, 1.89) ***
“There is danger of infection from a Pap test”	1.09 (0.83, 1.43)
“I do not trust the health care system”	1.06 (0.81, 1.39)
“I would be embarrassed to have a Pap test”	0.67 (0.52, 0.84) ***
“Women who have many sexual
partners are more likely to have cervical cancer”	0.88 (0.73, 1.06)
“Pap would cause sexual assault flashbacks, or health care provider looks at me in a sexual way”	1.05 (0.77, 1.45)
PTSD diagnosis	1.62 (0.91, 2.90)
Missing data	0.96 (0.80, 1.13)
*P

Discussion

Childhood sexual abuse is reliably associated with a decreased likelihood of cervical cancer screening. This association persisted despite controlling for demographic characteristics, attitudes about Pap screening, and PTSD symptoms. These findings are strengthened by the consistency with which childhood sexual abuse is associated with low rates of Pap screening using 2 measures of trauma in 3 clinics. Although cost has been a major barrier to access in previous studies of cervical cancer screening, it is not a barrier for women who are members of a pre-paid health plan. It was therefore possible for us to investigate known and suspected barriers to cervical cancer screening with fewer confounding co-variables.

This study clarifies the role of childhood sexual assault in Pap screening. Sexual assault, but not other traumatic events or other types of childhood abuse, is associated with lower rates of cervical cancer screening. Furthermore, sexual assault during childhood, but not during adulthood, is strongly associated with decreased Pap screening.