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Why Aren't More Women Getting Smear Tests?

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photographed by lily rose thomas
The finer details of Jade Goody's appearances on various reality television shows have been more or less forgotten but Goody, who died in 2009 at the age of 27, has had one lasting impact: The Jade Goody Effect. According to the Guardian, her highly-publicised and tragic battle with cervical cancer resulted in an increase of 400,000 more women than average getting their smear test between 2008 and 2009. Jade’s legacy was one of raising cancer awareness.

However, just as cultural references to "East Angular" no longer really register, the Jade Effect has also faded. According to the UK charity Jo’s Cervical Cancer Trust, one in four women aged 25-39 don’t attend their smear test. This is in spite of the fact that 1,000 British women die of cervical cancer per year – a statistic that only goes to show the importance of this week's Cervical Cancer Prevention Week.

Cervical cancer, in 99.9% of cases, is caused by HPV, an infection that most people – men and women – will contract at some point in their lives, via sexual contact. Due to the infection’s proliferation, and the fact most people who have it don’t go on to suffer any related ill-health, detection and prevention of its most-deadly effect – cervical cancer – is a matter of screening.

Screening involves a potential series of procedures: a smear test, a colposcopy (where a camera is used to check for abnormalities of the cervix), a LLETZ procedure (where a biopsy is taken) and a cone biopsy (where a large portion of the cervix is removed). Cancer Research UK tell Refinery29 that, of 3,405,038 women screened in 2013-2014, 199,322 were then referred for a colposcopy. Of those, 89% then had a biopsy to remove abnormal cells. The rate of cone biopsies is even smaller, according to Cancer Research.

GynaeHealthUK’s statistics, shared with Refinery29, show that 30% of women aged 25-39 find the overall experience of a smear test painful

However, the process has problems. The bad experiences of even the more minor procedures can speak volumes; young women told Refinery29 that medical professionals perhaps don’t note how rare the procedure is for the patient and that they've been met with “misleading” advice – post-smear heavy bleeding and cramps are given the cutesy euphemism of “spotting” when they can be just as agonising as a period and last weeks. Most have positive experiences, and leave the procedures with little complaint, but private health organisation GynaeHealthUK’s statistics, shared with Refinery29, also show that 30% of women aged between 25 and 39 find the overall experience of a smear test painful.

Public Health England (PHE) delivers most of the UK’s screenings, and Dr. Anne Mackie, Director of Screening there, tells us that: “For women who find cervical screening daunting, it can be helpful to book time with the nurse to discuss screening and any specific issues that may be of concern.” However, with GynaeHealthUK's stats reporting that 50% of this age group are finding it hard to get an appointment time, it’s hard to see how or when that extra meeting could happen.
This is where the great contradiction about the UK’s smear test system lies: While some women are daunted by screening, others proactively seek it but can’t get it. PHE has decided that, because womb changes produce false positives in up to one in three smear tests of women under 25, only women over 25 should be invited to attend a smear test once every three years. But just north of the border, Scottish rules differ, with all women over 20 invited to screening every three years.

"I was invited for screening aged 20 and it put my mind at rest," says Aimee, 24, from Edinburgh, who recently had a colposcopy after a smear came back showing abnormal cells. She now returns every six months for a colposcopy, but doesn’t understand why her friends can’t get a smear: "I feel bad for my friends in England who couldn’t just go and get a smear test even though there are cases of under 25s developing [cervical cancer]."

The disparity of rules between the UK’s four countries can be a matter of life or death. In October 2014, 23-year-old Sorcha Glenn from Northern Ireland died of terminal cervical cancer. According to the Belfast Telegraph, a year before being diagnosed, she had been refused a smear test by her GP, even though both of her grandmothers had died of the disease.

On the anniversary of her death, her MP Mark Durkan asked David Cameron in Parliament if smear tests could be made available to younger women on request, especially in cases of a family history of cervical cancer. But in a letter to Durkan seen by Refinery29, Cameron explains there will be no change to the system: "PHE does not confirm or even identify a clear link between cervical cancer and genetics… there is still no scientific evidence to support the re-introduction of screening for women under 25 years old.’

Screening can also, in some cases, "do more harm than good", says gynaecologist and obstetrician Mr. Jullien Brady, explaining: "The treatment for abnormal cells is removal of a piece of the cervix, which can, in rare cases, have effects on future fertility."

But for Becky*, 22, who suffered persistent UTIs and discomfort during sex, asking for a smear test was vital to her health. She wanted a smear test, but it took asking three doctors (on the advice of charity Marie Stopes UK) to get her smear test. After an administrative failure which meant she was erroneously informed of the need for a colposcopy and never informed of the appointment, she says she was "panicking as if something was wrong."

Becky eventually learned the colposcopy was unnecessary, but doctors did discover she has other gynaecological problems which she has managed to keep under some control by switching contraceptive pills three times. She’s relieved for now, but does worry about how doctors interpret complaints in future: "I wish the doctors would take me a little more seriously, and I wish they’d never cocked up with that letter."
Women of any age who bleed after sex, between periods, or experience pain or abnormal discharge are advised to speak to their GP, but a combination of factors – on top of fear of pain – put women off pursuing medical advice. Anxiety about talking about genitalia with a doctor makes Google a more accessible resource for young women, according to the Eve Appeal and Ovarian Cancer Action’s 2015 report. And formal sex education has proved so shoddy that 50% of 26-35 year-olds can’t even label their vagina on a diagram, according to the Telegraph. Gynae Health’s survey also found that only 40% of this age group could identify a cervix.

But, as Mr. Brady says, it’s important that "women engage with regular cervical screening to make sure that their cervical health is maintained, and that any potentially serious changes can be identified and treated early long before a cancer develops."

So how do we make that happen? Jo’s Cervical Cancer Trust explains: "There is no one-size-fits-all approach to increasing attendance which is why it is so important that politicians, policy makers and health professionals are investing in targeted approaches to tackle the barriers that exist for women of every age, ethnicity, location and circumstance."

To feel confident to talk about, and seek help for gynaecological problems as and when they arise, not just when smear tests come round again, young women must be given the right tools to do so; sensitive and attentive medical professionals, especially in the case of painful or traumatic smear tests and their follow-up procedures, increased awareness of the importance of health screening, a robust and compulsory sex education system, and we need more research into how the most dangerous strains of HPV can be eliminated or successfully vaccinated against.

@sophwilkinson
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