Trauma informed approaches in Health Care: Cervical Screening Dr Hame Lata, Consultant Reproductive and Sexual Health, Highland Sexual Health Jane Chandler, Health Improvement Specialist, NHS Highland

Overview Summary of cervical screening Introduction to sexual violence Trauma informed Care

Summary of Cervical Screening All women aged 25 to 64 in Scotland are routinely invited for cervical screening. Women aged 25 to 49 are invited every three years Women aged 50 to 64 are invited every five years Transgender men in this age range may be eligible The test can pick up changes to the cells in the cervix which if left untreated could develop into cervical cancer.   .

What Cervical Screening involves Intimate genital examination which involves the insertion of a speculum into the vagina to view the cervix. Cells, gently brushed from the cervix, are then sent to the lab for testing

Uptake In Highland Uptake for Cervical Screening for NHS Highland and age group – 1st April 2017 to 31st March 2018 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 25-64 25-49 50-64 SIMD1 Most deprived 66% 71% 75% 76% 79% 77% 72% 73% ISD: 2018

Barriers to Screening

Defaulters Somebody who does not attend for cervical screening after an invitation and subsequent reminders

Sexual violence Evidence suggests acceptance of cervical screening is significantly lower in women who have been sexually abused. Fear that the experience will trigger flashbacks resulting in “freezing” and “physical tension” which can lead to increased physical discomfort during the procedure. Low self esteem A negative body image

Introduction to Sexual Violence Film – “Its more common than you think”

One Out of Four One in Four women have experienced either childhood sexual abuse or some form of sexual violence as adults. Experience of sexual violence leads to low self esteem which can lead to lack of self care and engagement with health services Eg non attendance for cervical screening

Kelly’s story Kelly, a single 26 year old woman living with her father and younger brother, attends her local doctor’s surgery for a routine annual check for her long term condition, epilepsy. Kelly tells us about her visit and how it makes her feel and think. She sees a general practice nurse who invites Kelly to have an opportunistic sample taken for cervical cytology screening. This is because, according to Kelly’s records, she had not responded to letters inviting her to attend for this routine procedure.

Kelly’s Story Film clip and activity

Activity As a group consider the following questions – we will take feedback from each group Q1.Why might the NHS ask about sexual history prior to undertaking cervical screening and what is the best way to do it?  Q2.What was there about the consultation that might have led the practitioner to consider sexual abuse in Kelly’s case? Q3. In your service, what indicators might lead you to think that someone might have experienced sexual violence? How might you manage this? And, what changes could you make?  

Polly's Story Polly and her husband are attending for her first antenatal appointment in their first pregnancy. The staff caring for her initially do not know that Polly was raped by her ex-boyfriend and his friends some years ago. She requests a planned caesarean section as she cannot see how she can go through labour due to the intimate procedures which may be involved. Polly tells us how she feels about the care she received and the impact on her.

Polly’s Story Film clip and activity

Activity As a group consider the following questions – we will take feedback from each group Q1. What were the possible indications in Polly’s story that she had a history of sexual violence? For other women what indications might there be? Q2. What were the negative behaviours by health professionals in Polly’s story and what were the more positive behaviours?  Q3. What would you do or say if a woman discloses a history of sexual violence to you?  

Your role Be aware – and approach each interaction or procedure as if the woman is a survivor of sexual violence. Recognise the signs Initiate discussion – sensitive curiosity Find out what the woman needs from you Provide care as required – explain all procedures Stop procedure/discussion if she needs or asks you to Assess current safety Document findings (with awareness of issues of privacy and safety if hand-held notes)

Care for Yourself Suspecting abuse or listening to disclosure by women can be stressful.  You/colleagues may be a survivor yourself and need support to cope with handling certain consultations. Know who to approach for assistance in your workplace. A number of the supports available to survivors are also there for workers supporting survivors including the Rape Crisis National Helpline – 08088 01 03 02. 

Our Work In Highland Cervical Screening Referral Pathway established between RASASH and Highland Sexual Health supporting women and trans men who have experienced sexual violence to access cervical screening enable survivors of sexual violence to ultimately return to main stream services.

Resources One Out of Four (NES on line training) www.knowledge.scot.nhs.uk/maternalhealth/learning/one-out-of-four.aspx Highland Policies http://intranet.nhsh.scot.nhs.uk/Staff/GenderBasedViolenceresources/Pages/Default.aspx

Any Questions?