Trauma informed approaches in Health Care Cervical Screening

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 age group – 1 st April 2017 to 31 st March 2018 2529 3034 3539 4044 4549 5054 5559 6064 2549 5064 SIMD 1 Most deprived 66% 71% 75% 76% 79% 77% 72% 75% 73% 77% 66% 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 • Q 1. Why might the NHS ask about sexual history prior to undertaking cervical screening and what is the best way to do it? • Q 2. What was there about the consultation that might have led the practitioner to consider sexual abuse in Kelly’s case? • Q 3. 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 • Q 1. 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? • Q 2. What were the negative behaviours by health professionals in Polly’s story and what were the more positive behaviours? • Q 3. 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/lear ning/one-out-of-four. aspx • Highland Policies – http: //intranet. nhsh. scot. nhs. uk/Staff/Gender. Bas ed. Violenceresources/Pages/Default. aspx

Any Questions?