In January of this year, the New York Times ran an article that generated a lot of buzz in the cervical cancer research community. The article concerned new findings revealing disparities in cervical cancer between Black women and white women as being significantly larger than previously thought. This revealed how all too commonly in health-care research, we miss critical pieces of the puzzle when looking at improving health care for women.
There are several issues that have been left out of the conversation about vulnerability for cervical cancer since the Times report, including sexuality, gender identity, citizenship status—and violence against women. One in four women experiences intimate partner violence during her lifetime. These experiences affect the range of women’s sexual and reproductive health-care decisions, including decisions about cervical cancer screening. If we care about preventing cervical cancer, we need to look critically at how we provide health care to women who have experienced assault or abuse.
We work on The(S)he Project, which is a five-year study looking at improving cervical health literacy among incarcerated women in jails (who typically are incarcerated for under a year), by following a cohort of about 200 women after they received a brief health intervention designed to improve their cervical health knowledge, reduce barriers to screening, and raise self-efficacy concerning navigating health-care providers and health systems. Through this study we’ve been looking in depth at the factors that affect incarcerated women’s access to knowledge of and opportunities for prevention of human papillomavirus (HPV) and cervical cancer. (HPV causes 99 percent of all cervical cancers.) Our past research has also shown a significant connection between interpersonal violence and cervical cancer risk.
Incarcerated women are one of the most vulnerable populations for cervical cancer, as they are four to five times more likely to have cervical cancer and 11 times more likely to have abnormal cervical exams. In our own studies, we have found that women who have abuse histories are more likely than women without abuse histories to have had abnormal Pap smears, a key indicator for cervical cancer risk.
Specifically, we found that women who experienced physical abuse before age 16 were six times as likely to have ever had an abnormal Pap smear as their counterparts. In addition, those who had previously experienced intimate partner violence were twice as likely to have had an abnormal Pap smear and five times as likely to have been treated for cervical cancer.
We believe this lifetime progression of abuse, from childhood to adulthood, likely contributes to instability in these women’s lives, preventing them from accessing potentially life-saving follow-up cervical cancer care. This violence and lack of security is only magnified by the trauma of incarceration.
When it comes to women with criminal justice histories, women who experience violence are often convicted either directly because of the circumstances of their abuse—whether they were trying to escape their abuser or forced into crime by an abuser—or indirectly, such as engaging in sex work or struggling with drug addiction in order to survive. A history of interpersonal violence is also a risk factor for women to be incarcerated in the first place, as three-quarters of women who are incarcerated have histories of severe physical abuse by an intimate partner. Furthermore, oftentimes women who are trying to defend themselves against their abusers end up incarcerated, further entwining the prison industrial complex and domestic violence with women’s health outcomes.
The connection between cervical cancer and domestic violence is a critical one to make. As researchers, health-care providers, and activists, we need to be vigilant about the ways in which domestic violence affects women and their health. Particularly in a time when cervical cancer screening programs could face cuts due to changes in health-care policy, we have to ensure that the most vulnerable women get cancer prevention care.
We can work to educate women about cancer screening and prevention and empower those women to take advantage of tests that can detect cancer-causing strains earlier. We can push ourselves to find better ways to communicate and engage in follow-up care with our patients. But we also have to continually interrogate policies and practices that leave women behind and find ways to link women with unique needs and barriers to prevention. After all, if a woman is too frightened of her abuser to leave her home, what use are those tests to her?