A Qualitative Analysis of Barriers to Papanicolaou (Pap) Testing and Gynecological Care in Survivors of Intimate Partner Violence

Background and Purpose: Survivors of intimate partner violence (IPV) experience negative sexual health outcomes, including HIV/AIDS and STI risk, unplanned pregnancy, and cervical cancer. With proper care and resources, these outcomes are highly preventable and treatable. For example, HPV vaccine prevents cervical cancer, and Papanicolaou (Pap) testing can detect early signs of cancer when treatment options have a high success rate. Most STIs are treatable with proper diagnosis and medical care. Even for HIV/AIDS and genital herpes, which have no cure, anti-retroviral medications are effective at viral suppression. Despite these viable resources to optimize sexual health, survivors face numerous challenges in accessing gynecological care. This qualitative descriptive analysis explores and describes IPV survivors’ barriers in seeking and obtaining gynecological care.

: In this secondary analysis, data were drawn from a qualitative descriptive study of IPV survivors’ sexual health and healing. Data sources were verbatim, de-identified transcripts of 28 in-depth, in-person, semi-structured individual interviews with women, over 18, who reported any lifetime IPV. Three research team members, including the PI of the original study, developed a coding structure and corresponding codebook based on an inductive analysis. This analysis generated four categories of barriers to sexual healthcare: cognitive and affective barriers, partner-related barriers due to IPV, resource-related barriers, and healthcare system-related barriers. In a second round of analysis, team members identified subcategories within these categories and developed thematic statements to identify complexities and relationships within and across categories and subcategories.

Findings: First, IPV survivors described discomfort, shame, and fear and anxiety as affective barriers that discouraged them from seeking care. Rooted in social gendered sexual norms, participants described gynecological exams as “demoralizing” and STI diagnoses as “embarrassing.” Participants were afraid to discover test results and found their experience with providers anxiety-provoking in terms of IPV disclosure and prior sexual assault. Second, participants discussed resource barriers based on the cost of care and their uninsured health status. Misinformation about free and low-cost gynecological care created a compound barrier between cognitive barriers –that is, low levels of service knowledge—and lack of insurance. Third, partner control limited survivors’ abilities to seek healthcare. In the context of sexual abuse, partners controlled reproductive and sexual decision making: in a “DV situation you don’t really get the option...they don’t want kids, you get on the pill. They want children, you don’t.” , within the healthcare system, participants described sterile, uncomfortable environments, being dismissed and judged by healthcare providers, and ineffective provider communication that limited their ability to obtain care and impeded their ability to follow healthcare recommendations.

Conclusions/Implications: This research gives voice to IPV survivors’ perspectives on barriers to gynecological care. Addressing these barriers calls for interdisciplinary collaboration between social service, public health, and medicine. Social workers are uniquely positioned to foster these collaborations to meet the social work grand challenges of closing the health gap and promoting healthy relationships to end gender-based violence. Given the macro-level challenges described, future research can focus on healthcare systems and health policies as targets for intervention and reform.