A smear test can trap a survivor in unstoppable and violent memories. Photo: Getty
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Why rape survivors often refuse cervical smears - even if it risks their lives

Cervical smear tests aren’t just stressful for rape survivors – they can trigger powerful flashbacks and violent memories. But avoiding a test can mean preserving your mental health at the risk of your physical well-being.

Like many women, Leanne hates having a smear test - to the extent that she would rather let pre-cancerous cells develop than go through with one.

Her reasons don’t involve pain or discomfort. She was raped as a teenager and the test is too reminiscent of her ordeal.

She is not alone. For some rape survivors a smear test is not just stressful; they fear it could trigger unstoppable and violent memories.

When Emily-Rose went for her smear test, the cold speculum wasn’t simply uncomfortable for her. It jolted her back to when she was raped six years ago. “Part of the attack involved metal kitchen objects,” she said.

Recent statistics show around 20 per cent of women do not reply to repeated invites for a smear test. Now, for the first time in the UK, possible connections between sexual violence and non-attendance of cervical screening are being discussed.

“As soon as I felt that cold metal inside of me I was back there. But it was a smear test and I had to have it. I didn’t know I had the right to insert the speculum myself, that might have helped control the flashbacks,”  Emily-Rose told me. Weeks later a letter informed her the test results were abnormal. A LLETZ procedure was required, which involved cutting out the area of the cervix where the abnormal cells had developed.

“It sounds a terrible thing to say, but if I had to go through it all again I would rather risk getting cancer,” said the 40-year-old. “The smear test, the procedure, it all triggered memories of the rape. My personality changed after the tests. I was jumpy, panicky, I couldn’t leave the house for a month. I stopped work, I’d spiralled into depression. I had cried quietly throughout the procedure, no one asked me why. I was another procedure to the doctors.”

Leanne is approaching her thirtieth birthday and is studying midwifery. She says the letters she receives “threaten” her that she will be registered as having refused smear testing if she doesn’t attend. She closes off from them, and when she does go to the doctor for asthma medication she always says that she is having her period.

“I’ve had more periods than anyone in the world,” she laughs. “After [the rape] I dropped out of everything. A smear test will mean flashbacks, and I’ll lose everything like before.

“If I let pre-cancerous cells develop there’s a low chance I might get cancer. If I go for a test, there’s a very high chance I will plummet in my head. So, do I want to be safe in my body or my mind?

“I don’t want cancer. That bastard took enough from me, I don’t want him killing me too. My mum’s sister had cervical cancer, but I keep telling myself she was in her fifties with two children.”

According to cervical cancer charity Jo’s Trust, it is the most common cancer in UK women under 35. Annually around 1,000 women die from it, but free NHS cervical screening is estimated to save 5,000 lives a year.

Two years ago, nurse researchers Louise Cadman and Lesley Ashdown-Barr became the first in the UK to examine the issue in women who had a history of sexual abuse.

Their findings show over 20 per cent of the women who reported a history of sexual abuse had not ever attended testing. Of those who had attended, a notable proportion were not doing so regularly – the number was significantly higher than in the general population.

They said the implicit lack of control involved in testing, the risk of it triggering painful memories, and “parallels” between the abuse and the test all contributed to avoiding smear testing.

For this article, nineteen women who have experienced sexual violence were interviewed. They repeatedly mentioned that “the language of control” was used in health care settings, cuttingly reminding them of their experiences.

Sarah, who is in her early thirties, likened her nurse’s “instructions” during cervical screening to the way her rapist had spoken to her.

She said: “[The nurse] said to me “Put your leg here” and pulled it forward. It was pretty similar to what he had done – “put your leg here” and then pulling me any which way he wanted. Then she said “If you do what I tell you to, it’ll be over quicker for you.” I couldn’t believe it, she was echoing everything he was saying. I blacked out, I couldn’t do it.”

Other women said being told to “relax” by nurses was unwittingly parroting what their rapists had said during the ordeal, making relaxation impossible.

“I would like to go somewhere where I don’t have to explain myself,” said Emily-Rose.

“I want a place where I can walk in and they know why I’m there, and I am in control. For me, a small thing like aromatherapy would make it easier. Smell would be an instant hit to the brain that would ground me away from my memories. I want to be asked things like if I want the door locked, or the window open. I want control of my environment.”

Others mentioned their choice of music playing in the background, being able to put pictures up in the room, changing the colour scheme with decorations, having massage before and after, and an initial session to build trust and discuss what phrases, positions, or touch may trigger memories.

One woman wanted “trial runs” – meaning four or five sessions building up to completion – so she could get flashbacks under control at each stage.

Currently the My Body Back project, which focuses on sexual health for survivors of sexual violence, is working with NHS sexual health centres in north-west London to pilot the UK’s first monthly smear testing clinic for women who have experienced sexual violence. It aims to be running within the next year.

“It’s an emotional experience, not a physical one,” said Leanne.

“When the NHS records me as refusing a smear test, I am being blamed for being raped again. I am not refusing a test that could save my life, something else is stopping me. No one has ever asked me what that is.

“They assume I’m worried about the pain. That is the least of my worries. I have to pick between my mental health and my physical health. I’ve chosen to keep my mental health, but I want both.”

Follow @mybodybackproj on Twitter, for sexual health support for survivors of sexual violence

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Erdogan’s purge was too big and too organised to be a mere reaction to the failed coup

There is a specific word for the melancholy of Istanbul. The city is suffering a mighty bout of something like hüzün at the moment. 

Even at the worst of times Istanbul is a beautiful city, and the Bosphorus is a remarkable stretch of sea. Turks get very irritated if you call it a river. They are right. The Bosphorus has a life and energy that a river could never equal. Spend five minutes watching the Bosphorus and you can understand why Orhan Pamuk, Turkey’s Nobel laureate for literature, became fixated by it as he grew up, tracking the movements of the ocean-going vessels, the warships and the freighters as they steamed between Asia and Europe.

I went to an Ottoman palace on the Asian side of the Bosphorus, waiting to interview the former prime minister Ahmet Davu­toglu. He was pushed out of office two months ago by President Recep Tayyip Erdogan when he appeared to be too wedded to the clauses in the Turkish constitution which say that the prime minister is the head of government and the president is a ceremonial head of state. Erdogan was happy with that when he was prime minister. But now he’s president, he wants to change the constitution. If Erdogan can win the vote in parliament he will, in effect, be rubber-stamping the reality he has created since he became president. In the days since the attempted coup, no one has had any doubt about who is the power in the land.

 

City of melancholy

The view from the Ottoman palace was magnificent. Beneath a luscious, pine-shaded garden an oil tanker plied its way towards the Black Sea. Small ferries dodged across the sea lanes. It was not, I hasten to add, Davutoglu’s private residence. It had just been borrowed, for the backdrop. But it reminded a Turkish friend of something she had heard once from the AKP, Erdogan’s ruling party: that they would not rest until they were living in the apartments with balconies and gardens overlooking the Bosphorus that had always been the preserve of the secular elite they wanted to replace.

Pamuk also writes about hüzün, the melancholy that afflicts the citizens of Istanbul. It comes, he says, from the city’s history and its decline, the foghorns on the Bosphorus, from tumbledown walls that have been ruins since the fall of the Byzantine empire, unemployed men in tea houses, covered women waiting for buses that never come, pelting rain and dark evenings: the city’s whole fabric and all the lives within it. “My starting point,” Pamuk wrote, “was the emotion that a child might feel while looking through a steamy window.”

Istanbul is suffering a mighty bout of something like hüzün at the moment. In Pamuk’s work the citizens of Istanbul take a perverse pride in hüzün. No one in Istanbul, or elsewhere in Turkey, can draw comfort from what is happening now. Erdogan’s opponents wonder what kind of future they can have in his Turkey. I think I sensed it, too, in the triumphalist crowds of Erdogan supporters that have been gathering day after day since the coup was defeated.

 

Down with the generals

Erdogan’s opponents are not downcast because the coup failed; a big reason why it did was that it had no public support. Turks know way too much about the authoritarian ways of military rule to want it back. The melancholy is because Erdogan is using the coup to entrench himself even more deeply in power. The purge looks too far-reaching, too organised and too big to have been a quick reaction to the attempt on his power. Instead it seems to be a plan that was waiting to be used.

Turkey is a deeply unhappy country. It is hard to imagine now, but when the Arab uprisings happened in 2011 it seemed to be a model for the Middle East. It had elections and an economy that worked and grew. When I asked Davutoglu around that time whether there would be a new Ottoman sphere of influence for the 21st century, he smiled modestly, denied any such ambition and went on to explain that the 2011 uprisings were the true succession to the Ottoman empire. A century of European, and then American, domination was ending. It had been a false start in Middle Eastern history. Now it was back on track. The people of the region were deciding their futures, and perhaps Turkey would have a role, almost like a big brother.

Turkey’s position – straddling east and west, facing Europe and Asia – is the key to its history and its future. It could be, should be, a rock of stability in a desperately un­stable part of the world. But it isn’t, and that is a problem for all of us.

 

Contagion of war

The coup did not come out of a clear sky. Turkey was in deep crisis before the attempt was made. Part of the problem has come from Erdogan’s divisive policies. He has led the AKP to successive election victories since it first won in 2002. But the policies of his governments have not been inclusive. As long as his supporters are happy, the president seems unconcerned about the resentment and opposition he is generating on the other side of politics.

Perhaps that was inevitable. His mission, as a political Islamist, was to change the country, to end the power of secular elites, including the army, which had been dominant since Mustafa Kemal Atatürk created modern Turkey after the collapse of the Ottoman empire. And there is also the influence of chaos and war in the Middle East. Turkey has borders with Iraq and Syria, and is deeply involved in their wars. The borders do not stop the contagion of violence. Hundreds of people have died in the past year in bomb attacks in Turkish cities, some carried out by the jihadists of so-called Islamic State, and some sent by Kurdish separatists working under the PKK.

It is a horrible mix. Erdogan might be able to deal with it better if he had used the attempted coup to try to unite Turkey. All the parliamentary parties condemned it. But instead, he has turned the power of the state against his opponents. More rough times lie ahead.

Jeremy Bowen is the BBC’s Middle East editor. He tweets @bowenbbc

This article first appeared in the 28 July 2016 issue of the New Statesman, Summer Double Issue