1. 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

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

3. 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.   .

4. 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

5. 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

6. Barriers to Screening

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

8. 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

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

11. 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

12. 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.

13. Kelly’s Story
Film clip and activity

15. 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?

16. 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.

17. Polly’s Story
Film clip and activity

19. 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?

20. 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)

21. 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 –  

22. 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.

23. Resources One Out of Four (NES on line training)
Highland Policies

24. Any Questions?