In their paper in this issue, Cadman et al.1 explore the barriers that women who have been sexually abused experience in accessing cervical screening. The background to their anxiety and distrust of the service stems from the overwhelming betrayal of trust that is childhood abuse. Adults who perpetrate these abuses have power and control over children which they cannot, or will not, use responsibly. Many carers talk to children about ‘stranger danger’ and what to do in dangerous situations, but an important fact to note is that “Most child sex offenders know their victims before they abuse them”.2 The offender may be a family member, teacher, sports coach, church member or leader, or a family friend: the list is endless. Consequently the emotional manipulation that accompanies the physical acts of sexual abuse can cause the child to feel self-blame, isolation, anxiety and to believe that they cannot tell anyone about the abuse.

The ‘grooming process’ is a method by which child abusers emotionally and psychologically prepare a child or young person for sexual abuse. The process involves desensitisation, silencing and transfer of responsibility. The desired result of the grooming process is for the child or young person to be coerced into silence and compliance. By transferring responsibility for the abuse to the victim, that child's self-esteem, self-concept and self-worth are all diminished. This distorted childhood perception can last long into adulthood and become so deeply embedded that it is very hard for the adult survivor to overcome. The sequelae experienced by some adult survivors of childhood abuse include mental health problems such as eating disorders, self-harming and addictions. Female survivors can find themselves in relationships where they inadvertently repeat the pattern of being abused in domestic violence situations from which they are unable to escape.

The National Association for People Abused in Childhood (NAPAC) currently responds to approximately 350 contacts per month from adult survivors who have suffered some form of abuse during their childhood. Of these contacts over two-thirds are from women. The reasons for contacting NAPAC are many and varied, but various prominent themes have emerged relating to the survivors’ self-worth, self-esteem and self-concept. These themes in turn impact on how women access health services, or care for and value themselves. Many of the female survivors we hear from talk about their fears and anxieties when accessing health services, particularly sexual health, gynaecology and breast well-being. Aside from the fears that many female survivors feel about accessing these intimate forms of health care, NAPAC is also aware of the lack of self-worth that many survivors feel and their perception that they are not deserving of health care services.

NAPAC receives contacts from female survivors of sexual abuse relating to concerns about cervical screening. Although each survivor's experiences are unique and different, we often hear very similar fears and anxieties about having smear tests. For some women, just receiving the reminder letter is enough to trigger flashbacks (when the experience of being raped as a child is re-lived in a very real and uncontrollable way), panic attacks and much fear. The smear test itself can evoke painful memories of the abuse; they may feel that they are not understood by the health practitioner and are not in control of what is happening to their body. For the woman this can feel just the same as the experience of being abused during childhood. Many of these female survivors talk about their fears that the test will trigger a flashback, and the anxiety evoked can cause physical tension or freezing during the test, thus causing pain or increased discomfort. Having a negative smear test experience can prevent women from attending future testing which therefore increases the risk of development of cervical cancer. Many survivors are aware of the increased risk of not being screened and we repeatedly hear that some survivors would rather deal with cervical cancer if it develops than face the experience of regular testing.

Common feelings among survivors of sexual abuse include shame, guilt, self-blame and feeling unclean, contaminated or dirty. These feelings can be compounded during the experience of a smear test. The physical position in which smear tests are taken is generally with the woman lying on her back with legs bent and knees parted. NAPAC hears from many women that this position is too similar to the physical positions they were forced into during the abusive acts against them.

Fortunately we have also heard from female survivors who have spoken positively about their experiences of attending cervical smear tests. Steps successfully taken to improve the experience of having a smear test taken include:

• The survivor having time and space to talk about their fears and anxieties of having the test.

• A friend or supporter being present during the test.

• The smear taker having an understanding and insight into the issues of childhood abuse and the legacy of issues that adult survivors can face.

• A discussion of words/responses which would trigger anxiety or flashbacks for a survivor and finding alternative ‘safe’ words to replace these. For example, many smear takers would tell the woman to try to relax during the test. The word ‘relax’ is often used by abusers and can be very frightening for survivors; an alternative is to agree a word in advance to use in discussions with the patient.

• A private and comfortable environment for undressing and for the smear test to be taken.

• A clear signal agreed beforehand for the woman to be able to halt the test if she needs to at any stage.

Despite the negative mental health sequelae with which many adult survivors of childhood abuse have to contend, there is much hope for healing and recovery. With good support and care survivors can come to a point where the memories and impacts of the abuse no longer dominate or destroy their lives.