<p> Judith Walker</p><p>The Impact of Childhood Sexual Abuse on Cervical Screening: are clinical staff trained to recognise the effect this has on their patients?</p><p>Abstract</p><p>The national target for cervical screening coverage is set at 80%. This is not always achieved and although institutional and cultural barriers to screening attendance have been researched, little is known about the other underlying or hidden reasons why women do not attend for the test. Considering the extent of</p><p>Childhood Sexual Abuse (CSA), the intimate nature of the examination and the potential difficulties for adult CSA survivors in undergoing a screening test, this project aimed to assess, from a service evaluation perspective, whether there were unmet training needs in this area of clinical practice among staff who regularly take cervical screening samples.</p><p>The findings indicate that current training does not equip clinical staff adequately and there is a need for further training and support. This needs addressing not only during basic cervical screening training programmes, but also afterwards when nurses and doctors start uncovering the effects of sexual abuse on their patients in their everyday work. They need to understand how to provide appropriate, sensitive care, when and where to refer for more specialist help and how to increase their skills and confidence in their care of CSA survivors. </p><p>1 Introduction</p><p>It has been estimated that between 10% to 20% of women have experienced sexual abuse before the age of sixteen (Cawson P et al 2000). This can have serious and long term effects on their physical and mental health. The NHS</p><p>Cervical Screening Programme (NHSCSP) invites all women between the ages of 25 and 65 for routine testing. This has the potential to cause distress for the survivors of CSA and can re – traumatise women if not managed sensitively</p><p>(Leeners et al, 2007) & (Havig K 2008). Little is known about the patient experience of having a cervical screening test, but a history of CSA has been linked with avoiding cervical screening and feelings of fear and distress (Harsanyi</p><p>A et al 2003).</p><p>Aim of project</p><p>This project aimed to assess awareness and training needs of CSA among clinical staff undertaking cervical screening within Westminster Primary Care</p><p>Trust.</p><p>Method</p><p>In order to address these aims and objectives, the study was designed to consist of three stages:</p><p>2 Stage1: Literature review.</p><p>The aim of the literature review was to scrutinise work that has been undertaken in the area of the relationship between CSA and cervical screening. </p><p>Stage 2: Questionnaire.</p><p>The questionnaire was designed to ascertain knowledge, professional experience and training experience and needs of cervical screening sample takers. This included asking both quantitative and qualitative questions as well as providing opportunities to add comments. This method was chosen to gain information and to gauge themes requiring further exploration at a focus group. </p><p>Stage 3: Small focus group.</p><p>This was the chosen method of further exploring themes raised by the questionnaire.</p><p>Given the sensitive nature of the subject matter, an attempt was also made to elicit feelings among healthcare professionals when faced with the issue of disclosed or suspected CSA with women in their clinical practice. The NHS</p><p>Cervical Screening Programme training programme guidelines include the recommendation that sample takers are required to be competent in picking up verbal and non–verbal cues from women undergoing screening tests, but do not explicitly mention the needs of CSA survivors. The question remained as to whether sample takers are trained to be able to provide sensitive care to survivors. While it could be argued that only survivors are able to answer that</p><p>3 question, the project was interested in finding out whether clinical staff felt adequately trained. </p><p>Background to the project</p><p>The project arose out of discussions between the project worker (a cancer screening nurse) and the London Quality Assurance Reference Centre (QARC).</p><p>The project worker has a particular interest in psychosexual nursing and her clinical supervision is provided by the Association of Psychosexual Nursing. She has experience of the difficulties faced by both patients and professionals when an apparently routine cervical screening test turns out to be traumatic as a result of sexual violence. The purpose of the project was to find out the following from clinical staff undertaking cervical screening;</p><p> Levels of knowledge of the incidence of CSA.</p><p> Awareness of the impact of CSA on cervical screening.</p><p> Whether they had already attended any training on the subject.</p><p> Whether they still felt they had unmet training needs in this area of</p><p> practice.</p><p>The participating staff were all nurses or doctors working in the following settings;</p><p> GP surgeries</p><p> Walk In Centres</p><p> Colposcopy clinics</p><p> Sexual and Reproductive health clinics (both Genito Urinary Medicine and</p><p>Family Planning). </p><p>4 The numbers of women potentially affected are high, so staff who carry out the tests should have an understanding of the issue and be trained to recognise and address the needs of this group of women who are at risk of being re– traumatised by care which does not meet their needs. The project worker, as well as being a sample taker, also provides cervical screening training to clinical staff and was interested in this aspect of service provision and training. Sample takers who are trained to recognise the effects of CSA and to provide sensitive care have the potential to increase the uptake of cervical screening and to improve the patient experience. A sample taker can also enable a woman to make an informed choice to decline testing if she still feels unable to participate after being offered a service which has taken her particular needs into account.</p><p>User involvement</p><p>The views and opinions of a CSA survivor’s organisation, the National</p><p>Association for People Abused as Children (NAPAC) were sought and their approval was given. </p><p>Background to cervical screening</p><p>Cervical screening started in the mid 1960s and in 1988 the NHS Cervical</p><p>Screening Programme (NHSCSP) was established to ensure that the screening programme was made available nationally to all women in the UK through computerised call and recall systems. National standards were set for all aspects of the programme, including training, and the uptake target was set at 80%. This</p><p>5 is the number required to achieve a 95% reduction in the death rate long-term.</p><p>Financial incentives for General Practitioners (GPs) were introduced at the same time and were very successful in improving uptake rates. Nationally, the uptake achieved reached 82.5% in 1998, but that was never reached in some inner - city areas, including Westminster, where the uptake rate is currently 67%. The national rate has declined to 78.6% in 2008 (NHS Information Centre, 2010).</p><p>Cervical screening can prevent cervical cancer from developing by detecting early abnormal cell changes which have the potential to become cancerous. The affected cells can then be removed and the risk of cervical cancer virtually eliminated. Women are screened every three years between the ages of 25 and</p><p>49 and every five years between 50 and 65. The NHSCSP invites women who are registered with a GP to participate; all women with a cervix are included and they are sent two letters from the local screening recall department, usually followed by at least one from their GP. The system generates invitations without any prior warning and excludes no-one.</p><p>In addition to those who respond to their invitation, about a third of women are screened on an opportunistic basis; that is, when they consult a doctor or nurse on another health matter. </p><p>The test itself is intimate and invasive; the women has to lie on a couch and have a speculum inserted into her vagina so that the nurse or doctor can see her cervix and take a sample of cells from the surface of it. This can be uncomfortable and even painful for some women. The sample is then processed at a local cytopathology laboratory and the woman receives a letter with the</p><p>6 result approximately two weeks later. When abnormal cells are found, the woman is referred to a colposcopy clinic where further investigations are carried out to ascertain the nature and extent of the abnormality. Treatment decisions are based on the results of these investigations. For the woman undergoing colposcopic examination, this entails more invasive and intimate examinations and more frequent cervical screening tests as a result. </p><p>Background to Childhood Sexual Abuse (CSA)</p><p>The National Society for the Prevention of Cruelty to Children (the NSPCC) defines CSA in the following terms;</p><p>“Sexual abuse is when a child or young person is pressurised, forced or</p><p> tricked into taking part in any kind of sexual activity with an adult or young</p><p> person. This can include kissing, touching the young person’s genitals or</p><p> breasts, intercourse or oral sex. Encouraging a child to look at</p><p> pornographic magazines, videos or sexual acts is also sexual abuse.</p><p>Child sex abusers can come from any professional, racial or religious</p><p> background, and can be male or female. They are not always adults –</p><p> children and young people can also behave in a sexually abusive way.</p><p>Usually the abuser is a family member or someone known to the child,</p><p> such as a family friend.</p><p>Abusers may act alone or as part of an organised group. They sometimes</p><p> prefer children of a particular age, sex, physical type or ethnic</p><p> background. After the abuse, they will put the child under great pressure</p><p>7 not to tell anyone about it. They will go to great lengths to get close to</p><p> children and win their trust. For example, by choosing employment that</p><p> brings them into contact with children, or by pretending to be children in</p><p> internet chat rooms run for children and young people.</p><p>Child sex abusers are sometimes referred to as “paedophiles” or “sex</p><p> offenders”, especially when they are not family members.” (NSPCC</p><p> website).</p><p>The abuse can have happened on only one occasion or repeatedly. </p><p>It has been estimated that between 10-20% of women have experienced sexual abuse before the age of 16 (Cawson P et al 2000). This can have serious and long-term effects on their physical and mental health. The process of cervical screening has the potential to cause distress to survivors by triggering memories of abuse. Given the nature of the test, during which women are exposed and vulnerable and the perceived unequal power relationship between them and the sample taker, it is hardly surprising that a survivor could experience distress at some stage of the process. Most clinical staff taking samples are female, but some are male; for some women, this will further aggravate their feelings of vulnerability. </p><p>8 Results</p><p>Stage 1: Literature review findings</p><p>The aim of the literature review was to examine work undertaken in the area of cervical screening and childhood sexual abuse. The themes that emerged from the literature review fell broadly into the following categories;</p><p>1. The prevalence of CSA</p><p>2. The long-term health effects of CSA</p><p>3. The health - seeking behaviour of CSA survivors</p><p>4. Reasons for low uptake of/non - attendance for cervical screening</p><p>5. Survivor’s experiences of healthcare professionals</p><p>6. Disclosure</p><p>7. Safe and sensitive practice</p><p>8. Healthcare staff knowledge and awareness</p><p>9. Healthcare staff training</p><p>Prevalence</p><p>The NSPCC reported a figure of 16% of women having experienced contact sexual abuse by the time they were 16 (Cawson, P et al 2000). The abuse may have been on one occasion or more and may have been committed by a family member or other adult. </p><p>9 Long-term effects</p><p>The adverse mental and physical health effects of CSA can be long-term and wide–ranging and include the following; depression, eating disorders, gastro– intestinal and gynaecological problems, unwanted pregnancies and risk-taking behaviour such as smoking, excessive use of alcohol and engaging in high risk sexual behaviour. Women may also be more likely to experience sexual dysfunction. (Catherine Itzin 2006). The extent and nature of health problems will depend on a variety of reasons, but if the abuse is perpetrated by someone known to the child or if it is frequent, prolonged or penetrative, the more likely it is that health problems will be serious and long term. There is evidence that women who experienced CSA are more likely to start having sexual relationships earlier and to have more sexual partners (Springs, FE and Friedrich, WN1992) which may make them more likely to pick up a Human Papilloma Virus (HPV) (the virus directly linked with at least 95% of cervical cancers) earlier.</p><p>Trust</p><p>When children are abused by a trusted adult, their ability to trust is impaired and can be further damaged by not being believed if they do attempt to disclose. Dole</p><p>(1999) noticed that women CSA survivors struggled with issues of trust, control and authority in medical care and were very fearful of medical and gynaecological examinations. The cervical screening test is a procedure which requires a high degree of trust to be established very quickly, often with a health professional unknown to the woman. </p><p>10 Health–seeking behaviour</p><p>Cervical screening invitations are sent to women from the age of 25 to 64 who are registered with a GP. The reasons for non-attendance for screening have been examined, but have often focused on socio-demographic variables and administrative processes in Primary Care. Despite the evidence supporting the long-term effects of sexual violence on both mental and physical health, screening uptake studies rarely mention the issue. However, there is a small body of evidence linking CSA with a reduced likelihood of cervical screening;</p><p>Farley et al (2002) found that women with a history of CSA were less likely to have had a smear test in the past 2 years (36.0% vs. 50.4%). Dole (1999) also suggests a link. Fears associated with gynaecological examinations are a barrier to accessing screening and a history of trauma was associated with a reduced likelihood of cervical cancer screening (Farley et al, 2002).</p><p>A higher uptake in the general population has been associated with a good relationship between the woman and her Primary Care Team (O’Malley et al,</p><p>2002). </p><p>A Department of Health report on the needs of women using mental health services (Women’s Mental Health, into the mainstream, 2002) highlights the incidence of CSA and the effect it has on women’s mental health, including a reluctance to attend for screening. It is documented that CSA often underlies mental illness in women, which in turn, militates against attending for screening. </p><p>11 Survivor’s experience of healthcare professionals</p><p>It has been demonstrated that over 40% of women with a history of CSA have experienced memories of the abuse during a gynaecological examination, brought on by triggers such as being told “it won’t hurt” and lying on a table, together with a feeling of helplessness and pain (Leeners et al, 2007).</p><p>A significant percentage of CSA survivors experience anxiety and distress associated with gynaecological care (Leeners et al, 2007) and unfortunately, many also have had negative reactions when attempting to discuss their history of abuse and have been met with reactions of embarrassment, repulsion, pity, disinterest and avoidance from healthcare professionals (Havig K 2008).</p><p>The Home Office and Department of Health published a report in 2006 “Tackling the Health and Mental Health Effects of Domestic and Sexual Violence and</p><p>Abuse” which recommended integrating the recognition of abuse into mainstream</p><p>NHS services, yet it failed to mention screening services. A recent literature review from the USA (Havig K 2008) looked at the difficulties and barriers that healthcare professionals face with CSA; a lack of understanding of the consequences of CSA, not knowing how to respond to disclosure, fear, embarrassment and an avoidance of the issue because of personal experience of CSA. These findings have been echoed in other studies of healthcare professionals (Abrahamson 1998), as have the findings that awareness on the health professional’s part can improve the health and the health–seeking behaviour of CSA survivors. </p><p>12 Disclosure</p><p>There is a general consensus about the factors that enable disclosure and the potential benefits of doing so (Weiner 1995). However, there is also evidence that disclosure is not always handled sensitively and can actually cause more harm. One study revealed that only 25% of women felt that disclosing their CSA history to their gynaecologist would be helpful. That may well be because 46% of the women in the study group who had already tried to discuss their history had received a negative reaction (Leeners 2007).</p><p>Sensitive practice</p><p>Sensitive practice that meets the needs of adult CSA survivors can improve access to healthcare (Friedman et al 1992). Some aspects of clinical care which foster a feeling of safety and compliance are; </p><p> Respect</p><p> The ability to establish a safe rapport</p><p> Respecting physical end emotional boundaries</p><p> Sharing control </p><p> Establishing and checking consent to medical interventions/care</p><p> An indication from the professional that they are aware of the issue of</p><p>CSA</p><p>There is debate around whether disclosure is necessary or desirable and also about how and when to ask. Teram et al (2006) found that survivors felt that a</p><p>13 sensitive reaction to their disclosure enabled the healthcare provider to understand their physical pain. </p><p>There is a lack of consensus on the value of routinely asking patients about a history of CSA; some welcome the opportunity while others find it threatening.</p><p>There is, however, consensus around the qualities and skills of professionals who foster a relationship in which women feel safe enough to disclose, as outlined in the Scottish sensitive practice guidelines (Hampson and Nelson</p><p>2008). Although the Scottish guidelines focus more on mental health services, it was noted that the personality traits of people who are judged trustworthy and safe include personal qualities of warmth, willingness to form a relationship, even a brief one, and an ability to persevere even when the client is behaving in a challenging way. </p><p>Stage 2: Questionnaire</p><p>The questionnaire was piloted with practice nurses who regularly carry out cervical screening tests. It was interesting to note the following reactions of the nurses in the pilot;</p><p> the issue of CSA had not been considered a problem </p><p> the omission of female genital mutilation (FGM)</p><p> adult sexual assault/rape was a significant issue</p><p> training need to address not only speculum examinations, but also how to</p><p> talk with women who have experienced sexual abuse or assault.</p><p>14 As a result of the pilot, the questionnaire was amended and a question about sexual assault as an adult was added before the final version was sent. The decision to omit FGM was made on the grounds of that the numbers of women affected are much smaller and the subject was felt to be outside the scope of this project. </p><p>The questionnaire was designed to elicit quantitative and qualitative data using</p><p>Likert scores. Additional comments were also sought to enable participants to expand on some answers. The questions emerged from the literature review themes and fell into the following categories;</p><p>1. Prevalence; knowledge of the incidence of sexual abuse and what might</p><p> alert clinical staff to a woman having experienced it.</p><p>2. Experience of undertaking cervical screening and managing survivors; this</p><p> included experience of disclosure, care pathways and levels of confidence</p><p> and competence in undertaking cervical screening with survivors. A</p><p> question about the feelings engendered in the nurse/doctor was included</p><p> in an attempt to find out the effect of disclosure on clinical staff. Nurses</p><p> and doctors are often faced with distress and it can make them feel</p><p> uncomfortable and out of their depth; avoidance can be used as a defence</p><p> mechanism to distance them from painful feelings. Selby (2000) describes</p><p> this process;</p><p>“ Practitioners working in the caring professions are usually</p><p> compassionate people, but this can lead them to avoid patient’s pain,</p><p> fearful that if this is acknowledged, the patient may break down.</p><p>15 Trying to be kind and reassuring to avoid the pain may be the</p><p> practitioner’s defence against the knowing of this pain” </p><p>(Selby 2000:251-2). </p><p>This can result in the patient being unable to express their distress and to</p><p> access appropriate care. </p><p>3. Training; participants were asked if they had received any training on CSA</p><p> either at cervical screening or any other training programmes. They were</p><p> also asked whether it would be useful to have training on sexual</p><p> abuse/assault and providing sensitive care to survivors and if so, what</p><p> kind of training would enable them to feel more confident and competent</p><p> to meet the needs of women who have been sexually abused or</p><p> assaulted.</p><p>Staff were asked on the questionnaire to indicate whether they would be willing to take part in a focus group to discuss issues raised by the questionnaire.</p><p>The questionnaire was sent in two ways; in an electronic format via a web-based survey tool and in paper format for staff in clinics where there was little available</p><p>IT software. </p><p>The electronic version was sent to the following;</p><p> all GPs and practice nurses currently on Westminster Primary Care</p><p>Trust’s group emails</p><p> nurses at the local Walk In Centre who run a nurse led smear clinic</p><p>16  the cervical screening lead nurse at the local Genito-Urinary Medicine</p><p>(GUM) clinic, who was asked to distribute it to clinical staff involved with</p><p> cervical screening</p><p> nurse colposcopists and the consultant colposcopist at the local service.</p><p>Paper versions were sent to the following;</p><p> family planning nurses in the local service</p><p>62 replies were received out of approximately 250 sent. It is not possible to assess an exact response rate as the GP and practice nurse email lists are not kept up to date. It was, however, the most expedient way of ensuring that as many staff as possible received it. </p><p>Questionnaire results</p><p>The 62 questionnaires were received from the following staff groups or departments;</p><p>Practice nurse/nurse practitioner/GP 38</p><p>Family planning nurse/doctor 11</p><p>GUM clinic nurse/doctor 8</p><p>Walk in Centre 2</p><p>Colposcopy 2</p><p>HIV clinical nurse specialist 1</p><p>17 Prevalence of CSA (60 answers)</p><p>Less than 1% 7 (11.7%) Between 1% and 5% 14 (23.3%) Between 5% and 10% 23 (38.3) More than 10% 16 (26.7%)</p><p>Just over a quarter of health professionals answered this correctly. This indicates a significant lack of awareness of the prevalence, but it also suggests that there might be an unwillingness to acknowledge the extent of CSA and the high numbers of women affected. Comments included the following;</p><p>“I hope it’s not more than this” i.e., less than 1%</p><p>“ Depends on how you define it. If you include all inadvertent touching,</p><p> remarks and glances, then 100%”.</p><p>Prevalence of sexual assault; (58 answers)</p><p>Less than 1% 2 (3.4%) Between 1% and 5% 20 (34.5%) Between 5% and 10% 10 (17.2%) More than 10% 26 (44.8%)</p><p>Comments included the following;</p><p>“Universal I should think over a lifetime”</p><p>“Including sexual assault in a relationship”</p><p>“Increased rate in pregnancy”</p><p>“Related to domestic violence”</p><p>18 It was interesting to note that the prevalence of adult assault was estimated as being higher than rates of CSA. There are possible explanations for this; staff may have more experience of dealing with it (see below) and the issue is raised in relation to domestic violence and other training programmes. However, it is also worth asking whether childhood sexual abuse is more hidden and under– reported. Clinical staff are trained to deal with situations about which they can do something and there are clearer care pathways for adult sexual assault than there are for adult CSA survivors.</p><p>What might a patient do or say to make you consider that she has experienced sexual abuse as an adult or a child?</p><p>There were many comments covering a wide range of issues and experiences.</p><p>The following themes emerged;</p><p>1. Symptoms; dysuria, continence problems, sexually transmitted infections</p><p>(STIs), sexual dysfunction, painful sex, vaginismus, abdominal pain.</p><p>2. Refusal or avoidance of cervical screening test and reluctance to be</p><p> examined. </p><p>3. Risky sexual behaviour and inconsistent use of contraception.</p><p>4. Body language; disinhibition, that is, an unusual lack of embarrassment</p><p> and a possible detachment form an intimate examination, looking anxious,</p><p> shaking, tearful/crying, silence when being examined.</p><p>5. Refuses male doctor or insists on female.</p><p>6. Feelings from the patient; anxiety, fear, anger, lack of trust, impatience.</p><p>19 7. Emotional/mental health issues, for example, eating disorders, low self–</p><p> esteem, relationship problems.</p><p>A sense of what it felt like to be with the patient emerged from the comments;</p><p> they gave an indication that clinical staff are encountering women who have</p><p> experienced some form of abuse and who articulate their distress, sometimes</p><p> obliquely, when they are faced with a vaginal examination. A few mentioned</p><p> disclosure and one participant indicated that they ask questions about consent in</p><p> sexual relationships in order to facilitate disclosure. A few also mentioned that</p><p> some patients do disclose. </p><p>Comments that patients made were added by some and these again clearly</p><p> indicate distress with an intimate examination;</p><p>“Get it over and done with”</p><p>“I hate anyone touching me there”</p><p>“What a horrible job for you”. </p><p>One clinician person stated that it never occurred to them that a patient might</p><p> have experienced CSA. </p><p>Experience of CSA disclosure</p><p>60 responses:</p><p>Yes 37 (62%) No 23 (38%)</p><p>20 Experience of sexual assault/rape disclosure</p><p>55 responses:</p><p>Yes 38 (69%) No 17 (31%)</p><p>What do you think you would do if you encountered a woman with this</p><p> issue?</p><p>There were some detailed responses to this question. The broad themes were as</p><p> follows;</p><p>1. Listening, allowing her time, asking what she wants and how can I help.</p><p>2. Support/reassurance.</p><p>3. Dealing with medical/forensic aspects, for example, STI screening, post-</p><p> coital contraception, post-exposure prophylaxis (for the prevention of HIV).</p><p>4. Recognition of limitations and professional boundaries indicated by</p><p> referral or signposting to appropriate agencies.</p><p>5. Discussing with colleague.</p><p>6. Information giving; police/law, Haven (specialist centre for people who</p><p> have been raped or sexually assaulted), other agencies.</p><p>7. Indicating that you believe her.</p><p>Some comments were interesting as they indicated the professional’s personal</p><p> discomfort;</p><p>“Main thing, don’t flinch”</p><p>“ Initially I would internally panic when someone disclosed such</p><p> information, but having had to go through such discussions on a number</p><p>21 of occasions, has made me more comfortable….I no longer see it as my</p><p> role to ‘heal’ these women”</p><p>“Struggle”.</p><p>Feelings about disclosure</p><p>This responses and feelings evoked by this question were;</p><p>1. Anger</p><p>2. Sadness</p><p>3. Upset, some very upset, NB this was a frequent response. </p><p>4. Protectiveness</p><p>5. Anxiety</p><p>6. Pleased to be trusted with the disclosure.</p><p>7. Sympathy/empathy/caring.</p><p>Comments included the following;</p><p>“Difficult to answer unless incident had happened to me”</p><p>“ Anxious she wouldn’t receive the care she needed due to long waiting</p><p> lists”</p><p>“I would like to think I would stay very professional about the matter”</p><p>“Upset for her”</p><p>The responses indicate the distress felt by the professional when faced with sexual abuse/assault, the desire to provide an appropriate, caring response and an anxiety that women may not get enough care or get it quickly enough. The anxiety could indicate that these issues lie outside their scope and competence.</p><p>22 Referral agencies for psychological/emotional support</p><p>A wide range of agencies was mentioned; </p><p>1. Havens (specialist centres for people who have been raped or sexually</p><p> assaulted)</p><p>2. GP</p><p>3. Counsellor; in–house and other</p><p>4. Psychologist/psychotherapist</p><p>5. Family planning clinic</p><p>6. Charity/voluntary sector</p><p>7. Support groups</p><p>8. Psychiatrist</p><p>9. Sexual Assault Management Team</p><p>From the responses it would appear that the issue of adult sexual assault rather than CSA was foremost in people’s minds. </p><p>Assessment of levels of confidence and competence in undertaking cervical screening for women with a history of sexual abuse/assault</p><p>These questions were attempting to elicit feelings about carrying out intimate examinations on women; it was felt that confidence indicates an emotional readiness, that is, an internal feeling, whereas competence is an action which can be externally validated. There is significant cross-over between these two aspects, but proxy measures of training and experience were being sought as</p><p>23 well as levels of personal readiness. It was felt that being able to do something is not the same as feeling comfortable in doing it. </p><p>I feel confident I feel competent Strongly disagree 7.7% Strongly disagree 3.8% Disagree 13.5% Disagree 9.6% Undecided 25% Undecided 21.3% Agree 42.3% Agree 53.8% Strongly agree 11.5% Strongly agree 11.5% It was interesting to note the discrepancies between the two and it might be reasonable to expect clinicians to express a lack of confidence, especially in such a sensitive area of practice. It could be argued that extremely high levels of confidence might indicate a lack of awareness of and sensitivity to potential difficulties and that a certain level of uncertainty is preferable. </p><p>The next section of the questionnaire was concerned with ascertaining whether any training had been undertaken in the areas of sexual abuse and assault. The results of the literature review had indicated that despite the scale of the problem, there was a lack of literature on the subject. This is in sharp contrast with another important, but often overlooked group of women, i.e., those with a learning disability, for whom there are clear guidelines and supporting material available. </p><p>Raised in smear taker training Raised in other training Yes 57.7% Yes 82.3% No 42.3% No` 17.7%</p><p>Comments included;</p><p>“It is important to tackle this problem”</p><p>“No formal training, possible informal conversation”</p><p>“On other sexual health training”</p><p>24 “Very well covered at smear update”</p><p>“Highlighted in every training I have attended”</p><p>Some referred to other training programmes, for example in genito-urinary medicine and domestic violence and included training undertaken while working as health visitors, midwifes and school nurses, but this is more likely to have been training associated with dealing with children, not adult survivors.</p><p>It is interesting to note that a similar percentage of smear takers who have had some training also feel confident and competent. However, on closer inspection, the relationship was not straightforward; </p><p> 23 out of 39 who had training felt confident and 28 out of those 39 felt</p><p> competent</p><p> Of 9 respondents who had no training, 4 felt confident and the same</p><p> number felt competent. </p><p>For some respondents, an absence of training appears not to affect levels of confidence and competence. One particular respondent added that it was her professional experience (she works with particularly vulnerable women who are much more likely than the average population to have experienced sexual violence as a child and/or an adult) which has allowed her to feel able to manage. It was also apparent that training undertaken does not appear to be meeting some clinician’s needs; a few respondents who had received training still felt that they were not confident or competent. </p><p>Another consideration is that whereas a discrete training session meets a need for information and awareness raising, it is a different situation when a nurse or</p><p>25 doctor is faced with a patient in their consulting room and they feel the need to know what to do or say. There is an implicit assumption that a different way of working is required for survivors of abuse. However, while these women do have particular needs, there are universal principles and guidelines on sensitive practice which are designed to meet the needs of all patients undergoing physical and intimate examinations to enable them to feel safe.</p><p>Would it be helpful for smear taker training to include the issue of abuse/assault and best practice for providing safe and sensitive care to survivors?</p><p>54 responses:</p><p>Yes 51 (94%) No 1 (2%) Unsure 2 (4%)</p><p>The one respondent who answered ‘no’ had estimated the level of CSA at less than 1% of the population and had also indicated a lack of confidence and competence in undertaking cervical screening on women previously abused/assaulted. </p><p>Comments included;</p><p>“Absolutely, invaluable to clinicians and service users”</p><p>“Useful as such an emotive and sensitive issue”</p><p>26 “ Yes, definitely – after attending a training session and hearing a</p><p> woman’s account of attending for a smear who had suffered sexual abuse</p><p>– should be mandatory – it really made me think”</p><p>”Encourage uptake”</p><p>“I’m very surprised it isn’t mentioned”</p><p>It was interesting to note that clinicians were linking sensitive practice with cervical screening uptake, recognising that providing sensitive cervical screening testing is important not just for an improved patient experience, but that it contributes to the prevention of morbidity and mortality from cervical cancer. </p><p>What kind of training would be useful?</p><p>The responses were divided into the following categories;</p><p>1. Forensics i.e., the collection of samples to use as evidence of recent</p><p> sexual assault.</p><p>2. Communication skills; how to approach patients, what to ask, what to say,</p><p> counselling skills, picking up cues, how to identify survivors. </p><p>3. Services and patient pathways into appropriate services.</p><p>4. Information about abuse, i.e., facts and figures.</p><p>5. Cultural and ethnic issues, for example, what sexual practice is normal in</p><p> other cultures. </p><p>6. Legal issues.</p><p>7. Survivor’s views and experiences.</p><p>27 8. Cervical screening testing issues, for example, how to persuade women to</p><p> have the smear test, how to help them relax, how to give women more</p><p> control and how to decide whether the smear test is appropriate. </p><p>9. Understanding the long term effects on women.</p><p>Comments included;</p><p>“Anything available!” </p><p>“Tips on making the woman feel comfortable and not violated”</p><p>There were indications that getting it wrong is potentially harmful and there was anxiety that harm could be done by insensitive care. </p><p>Summary of questionnaire results</p><p> There was a lack of awareness and an underestimation of the prevalence</p><p> of CSA.</p><p> There was an awareness of verbal and non–verbal cues indicating</p><p> difficulties with and reluctance to undergo a vaginal speculum</p><p> examination.</p><p> The majority of respondents had experienced disclosure of CSA and adult</p><p> sexual assault.</p><p> Disclosure of sexual abuse and violence aroused difficult feelings in</p><p> clinical staff.</p><p> There was knowledge of sexual assault and rape services.</p><p> Just over half of respondents felt confident and two thirds felt competent to</p><p> undertake cervical screening testing for CSA survivors. </p><p>28  94% of respondents thought that training in safe and sensitive practice</p><p> when taking cervical screening samples for abuse survivors would be</p><p> helpful.</p><p>Stage 3: Focus group</p><p>The aim of the focus group was to explore further the issues arising from the analysis of the questionnaire. The questions that emerged from the analysis were as follows;</p><p>1. The perceived differences between the long-term effects of CSA and</p><p> sexual assault on adults.</p><p>2. The gaps in training; why do clinical staff not feel confident and competent</p><p> to meet survivor’s needs after training has been provided? What further</p><p> training or support is required?</p><p>3. How do clinical staff judge their competence?</p><p>This method was chosen because it allows the participants to interact with each other and even to disagree. The focus group lasted for two hours and was facilitated by the project worker and her supervisor, who took notes. The participants were four female nurses working in local GP surgeries (where 75% of cervical screening tests locally are carried out) and were all sample takers; two</p><p>29 for at least ten years, one for at least five years and the other for just over a year.</p><p>They had all sent in a questionnaire and expressed an interest in taking part in this stage of the project and they volunteered to take part on a weekday evening.</p><p>They had a wide variety of professional experience between them, but they all had a particular interest in women’s health. That might suggest that they are not truly representative of smear takers; nurses working in GP surgeries need to acquire knowledge and skills in a wide variety of clinical areas including cervical screening, but they do not necessarily need to preference the area of women’s health as this group did.</p><p>After the introductions, the nurses were given a few minutes to look at and think about the following comments before starting the discussion;</p><p> Your understanding of the prevalence of sexual abuse/assault and how </p><p> it affects a woman’s feelings about speculum examinations</p><p> How you recognise a woman’s reluctance to be tested/examined</p><p> Your experiences of dealing with disclosure of abuse/assault</p><p> Support/supervision for clinical staff</p><p> Care pathways and local services</p><p> Your experiences and ideas about training</p><p> Any other relevant issues not mentioned above</p><p>The discussion was audio taped and then transcribed. What became clear early on was that these nurses brought a rich mixture of experiences and opinions and</p><p>30 generously shared them with colleagues they had not previously met. The only person known to them all was the project worker.</p><p>The themes fell broadly into four categories;</p><p>1. Describing CSA and the differences between CSA and adult sexual</p><p> abuse.</p><p>2. The impact of CSA and how it emerges in a nurse/patient consultation;</p><p> related to that is the secrecy surrounding it, how hidden it is and</p><p> whether disclosure is beneficial. </p><p>3. Nurse’s feelings when faced with the aftermath of sexual abuse and</p><p> violence.</p><p>4. Training.</p><p>Describing CSA</p><p>There was a consensus on what is considered CSA. There was agreement that it involves children under the age of 16 and that it includes contact or non– contact abuse. Watching children inappropriately and the internet were also mentioned, as was FGM. No one quantified the incidence, but all agreed that it is higher than supposed because it is so well hidden. </p><p>When asked about the possible differences for the woman who comes in for a smear test between having been sexually abused as a child or as an adult, i.e., whether the aftermath is different, a less clear answer emerged. It appeared that the experience of having a smear test induced the same feelings of distress for women irrespective of the nature of their abuse. It was suggested that women</p><p>31 may respond differently if they have had counselling and “dealt with it”, but it was acknowledged that the smear test provokes huge anxiety for these women and can induce flashbacks. The project focussed on cervical screening, but it seemed reasonable to assume that there would be similarities for women when they undergo gynaecological examinations for other reasons.</p><p>The impact of sexual violence </p><p>It was apparent that all four nurses had experienced levels of distress in women who came to them for smear tests and that some of the distress was known to be associated with sexual violence. There was discussion about the verbal and non</p><p>–verbal cues which indicate a woman’s distress. Women asking the nurse to “get it over and done with” and appearing to be in a hurry/urgency was a familiar scenario, as was a discrepancy between verbal consent and body language, for example, telling the nurse to carry on while displaying signs of physical pain. </p><p>One nurse mentioned disinhibition;</p><p>“I think it’s the same when you get a woman that comes in and she starts</p><p> almost stripping off before you….you know you haven’t even said hello”. </p><p>It was later acknowledged by another nurse that there may be other (perfectly simple) reasons for a woman wanting to get her clothes off quickly however.</p><p>32 There was disagreement about the value of disclosure in providing holistic care; one nurse strongly advocated that disclosure is essential whereas another nurse was equally certain that it is not. Discussion followed about the invasive nature of asking for information about sexual violence which mirrors the physically invasive nature of the smear test. Interestingly, the nurse who argued strongly for the patient’s benefits of disclosure is the one nurse who routinely offers speculum self-insertion as a way of enabling a woman to take some control of her smear test. Issues of control between the nurse and the patient were mirrored with regard to disclosure. Anxiety was expressed about “opening up” memories by encouraging disclosure. Implicit was the question about whether sensitive care can be delivered without disclosure. </p><p>The issue of how nurses learn to pick up non-verbal cues, i.e., what training they had, arose out of the discussion about those cues. Some attributed it to being a life skill, suggesting that it was acquired rather than studied/learned, but as they explored this further, it emerged that observing other nurses working with patients was influential in enabling them to judge what constituted sensitive care;</p><p>“Observing someone else do the procedure…what they say to the patient</p><p> and how they react and you think oh such and such does it a lot nicer</p><p> than…you’re the bystander that can watch the whole scene unfold so you</p><p> can pick up certain cues there and learn from that”. </p><p>33 Empathy and the ability to put yourself in the patient’s shoes were also mentioned so that you;</p><p>“Treat others how you would like to be treated”.</p><p>Nurse’s feelings about examining women who have been sexually abused</p><p>It was interesting to note how soon the focus group participants spontaneously started to talk about their own feelings alerting them to the patient’s distress. The discomfort felt by nurses was expressed as a wish not to have to put the speculum in;</p><p>“ … at one level you don’t want to do it because it’s so invasive</p><p> again”.</p><p>One of the nurses stated;</p><p>“I don’t have any feelings” yet she talked about how she judges whether women are ready to disclose or not and respects their decision to keep quiet so although she denied having feelings, it seemed as if she was using them in her daily work with patients and students.</p><p>Their sadness and helplessness at hearing about sexual abuse were also apparent. It seemed as if listening and believing weren’t enough. This was coupled with an anxiety that that they cannot provide any more. The nurses were asked who supported them and there were various responses from no–one to talking with colleagues. It was clear that there were no formal structures in place to support these nurses and not even any informal ones for others. The patient’s</p><p>34 experience of finding someone to trust and listen seemed to be mirrored by the nurses wish to be listened to. It was acknowledged that the job can feel lonely.</p><p>Not everyone shared the feeling of helplessness; there was recognition that for some patients, being able to talk about their abuse was therapeutic in itself.</p><p>General training issues</p><p>It transpired that mentors act as role models; they are in a position to teach by example the skills that cannot be taught in a classroom. The anxiety of learning how to do smears was agreed – “daunting”. There was debate about whether learning how to do vaginal examinations on anaesthetised women is acceptable; </p><p>“I don’t think the bottom end is the place to start”! </p><p>The same nurse spoke movingly about how she mentors nurses;</p><p>“I guide them through it, I hold their hand…until they feel comfortable and</p><p> if they can’t find the cervix I’m always nearby. I think it’s important that</p><p> you’re there behind them or with them”. </p><p>It was suggested that after learning how to be a competent sampler taker, nurses would benefit from an “MOT” 6 or 12 months later. In that time, they could keep a diary of case studies to discuss with their mentor.</p><p>35 Boundaries and limitations were also mentioned as requiring clarification. Nurses had talked about not being counsellors or therapists, but their role in relation to sexual abuse needed clarification. </p><p>No one had seen any guidelines for sensitive practice and it was agreed that it would be useful.</p><p>Information about patient pathways and relevant services would also enable nurses to feel that they had provided appropriate care. </p><p>Summary of focus group findings</p><p> CSA levels are high and the issue is hidden.</p><p> There was knowledge and awareness of the long term distress that</p><p> women experience as a result of sexual abuse or assault.</p><p> The nurses had experience of women’s anxiety and flashbacks while</p><p> undergoing cervical screening testing.</p><p> There was disagreement about the need for disclosure.</p><p> There was anxiety about the test causing harm by re–awakening</p><p> memories.</p><p> There was anxiety that the nurses sometimes wished they could provide</p><p> more help than listening.</p><p> There were feelings of sadness and helplessness towards CSA survivors.</p><p> Practitioners act as role models for sensitive practice.</p><p> There is a need for information about referral pathways.</p><p>36  There is a need for further support and supervision after initial cervical</p><p> screening training has been completed.</p><p>Limitations of the project</p><p>The scope of the project was limited by the time available so the decision was made to focus on unmet training needs as a service evaluation project. This decision meant that there is an absence of user involvement and that patient experience feedback acquired through the project worker’s clinical work and involvement with NAPAC (National Association for People Abused in Childhood) could not be incorporated.</p><p>The number of responses was small and local and therefore it may not be representative of the views of sample takers nationally. </p><p>There remains a lack of clarity about the differences between CSA and adult sexual assault; dividing the questions into two distinct sections to cover each might have given rise to different answers, particularly in relation to services for</p><p>CSA survivors. </p><p>The questionnaire responses came mainly from nurses and the focus group participants were all nurses. Training for cervical screening sample taking is mainly taken up by nurses, leaving doctors with less training and no mandate to attend any either. </p><p>Conclusion</p><p>37 The NHSCSP needs to be inclusive if it to be accessible to all women. Women should not feel marginalised by the service because it does not meet their needs, but if the service has not considered their needs women will be denied equality of access to screening.</p><p>There are unmet training needs for clinical staff (mostly nurses) who, in the course of their everyday work with patients, encounter women who have experienced childhood sexual abuse. Although there is little literature available on the subject, there is a consensus that women with a history of abuse are less likely to attend for screening and that they risk re-traumatisation by the test itself, especially if the healthcare professional is not sensitive to their particular needs. </p><p>Sample takers need knowledge and skills to enable them to feel more confident and competent to meet those needs. Moreover, they could benefit from clinical supervision which supported them to use the feelings that can arise when CSA survivors express their difficulties verbally or non–verbally; they do not need to be counsellors and women do not always need to disclose, but the issue needs attention if these women are not to be further disadvantaged by a system which doesn’t take their needs into account.</p><p>There is a need for more work in the following areas;</p><p> The effects of CSA on women’s ability to participate in the NHSCSP</p><p> User involvement, which is, asking CSA survivors what they need from</p><p> clinical staff to enable them to undertake cervical screening. Do they think</p><p> staff are trained to provide the care they require?</p><p>38  What kind of training/supervision works best and how can that training be</p><p> provided?</p><p> The potential need for specialist clinics in Primary Care to provide cervical</p><p> screening for women who have experienced sexual violence.</p><p>One participant in a study on the impact of CSA on primary care made the following statement;</p><p>“I think that providers should treat everyone as if they were a survivor” </p><p>(Roberts et al, 1999)</p><p>Training staff to provide more sensitive care could improve the experience of cervical screening for all women, not only those who have experienced sexual violence. </p><p>39 References</p><p>Abrahamson V (1998) Do Occupational Therapists feel Equipped to Deal with the</p><p>Adult Legacy of Childhood Sexual Abuse? 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