Cervical cancer history

* 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.

* KEYWORDS Child abuse, sexual; rape; mass screening; vaginal smears. (J Fam Pract 2002; 51:827-831)

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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 screening (18) 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 Friedrich (16) 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 research (18) 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 Questionnaire (31,32) assesses a range of lifetime traumatic events. The Childhood Trauma Questionnaire (33) 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.

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).