Is a history of trauma associated with a reduced likelihood of cervical cancer screening?
- OBJECTIVE: We tested the hypothesis that a history of trauma (especially sexual trauma) was associated with a reduced likelihood of having had medically appropriate cervical cancer screening.
- STUDY DESIGN: A case-control study using mailed self-report questionnaires.
- POPULATION: The questionnaires were completed by an age-stratified random sample of adult women members of a large health maintenance organization. The sample included 364 women who had received medically appropriate cervical cancer screening and 372 who had not.
- OUTCOMES MEASURED: We defined cases as women who, according to their medical record, had not had cervical cancer screening within 2 years before the study. Controls were defined as women who had been screened. We evaluated exposures to trauma that we hypothesized to be associated with the case/control state.
- RESULTS: Women who had been sexually abused in childhood were less likely to have had a Pap smear within the past 2 years (36.0% vs. 50.4%, P = .050). Other traumatic events were associated with Pap testing in bivariate analyses but not when demographic characteristics and clinic location were controlled. Childhood sexual abuse remained associated with reduced odds of Pap screening in logistic regression analyses that controlled for clinic location, demographics, attitudes about Pap screening, and posttraumatic stress disorder symptoms (adjusted OR = 0.56, 95% CI 0.34 to 0.91).
- CONCLUSIONS: These findings suggest that childhood sexual abuse may lead to decreased probability of screening for cervical cancer, potentially contributing to the poorer health seen in other studies of women who have been sexually abused.
The relationship between childhood sexual abuse and Pap screening is particularly disturbing because women who were sexually assaulted as children are more likely to develop cervical dysplasia.36 Women who were sexually assaulted in childhood also tend to begin sexual activity at a young age and have more sexual partners.15,16,36 These are among the primary risk factors for human papillomavirus (HPV),37 an important cause of cervical cancer,38,39 and for cervical cancer.7 Women who were sexually abused in childhood are at increased risk of sexually transmitted disease,15,40 and HPV is the most common sexually transmitted viral disease.38 Therefore, women at higher risk for cervical cancer may be the same women who are least likely to be screened. Childhood sexual abuse may increase cervical cancer morbidity by reducing the probability of Pap screening, and by increasing the probability of disease. It may also decrease the likelihood that these women visit their physician for other routine health maintenance needs.
The low response rate in this study may have resulted from the questionnaire’s being sent to KP members once, without follow-up. Our response rate was comparable to a similar study of HMO members.16 Use of a mailed questionnaire probably resulted in underestimation of childhood sexual abuse prevalence.41 The relationship of sexual abuse to preventive health behaviors is comparable to that reported in studies with higher response rates.13,17
There is some evidence that the interpersonal climate between patient and clinician affects health outcomes,42 and we suspect it is a critical factor in increasing women’s comfort with Pap screening. One of our respondents commented: “I’ve always been treated professionally by my gynecologist and yet I still feel the need for the reassuring presence of a nurse during this procedure. I have asked the nurse to hold my hand during the test to calm me down. I find the hand holding or even her hand on my arm comforting.”
The most consistent predictor of cancer screening among women aged 40 and over was a health maintenance visit or regular source of care.43,44 Not having cervical cancer screening may be a marker for childhood sexual abuse. Therefore, health care providers should consider inquiring about a history of sexual abuse with women who do not follow guidelines for routine Pap screening. It is crucial to develop interventions that will lead to routine medical visits for women who have experienced sexual violence. As part of this process, we recommend education for physicians and other health care providers regarding sexual violence against women.
· Acknowledgments ·
Larry Walter, MA, and Sujaya Parthasarathy, PhD, of the Kaiser Permanente Division of Research in Oakland, California, contributed to our obtaining the random sample of women health plan members in this study. Howard Barkan, DrPH, helped design this project and participated in the data collection. We thank him for his insight and expertise.
