Nuns don’t get cervical cancer.
It’s impossible to sum up in a sentence everything that has been wrong with Ireland’s attitude to women’s healthcare. But if you had to try, that apparently off-hand comment by a consultant to the grieving relatives of someone who died from cervical cancer – detailed in the Scally report into the Cervical Check controversy published last week – should do it.
If it struck you as harking back to a time when women were routinely shamed for their sexuality, you'd be absolutely right. "It is now well documented that the disease is rare in nuns and common in prostitutes," declared the British Medical Journal of cervical cancer in 1984.
Well documented, in this case, meant recorded by a doctor working in Italy in the 1840s, a surgeon called Rigoni-Stern, whose work was subsequently found to be "littered with errors of arithmetic". But never mind that. That "nuns and prostitutes" line caught on, and was trotted out by experts for years, as though there were only two possible types of women. It led, predictably, to cervical cancer being shrouded in unnecessary stigma and shame. Even today, the line is still used by the anti-HPV vaccination brigade on social media, along with the even more insidious "monogamous women don't get HPV".
As it turned out, there was a grain of science in Rigoni-Stern's observation. We now know most cases of cervical cancer are caused by the HPV virus, which is sexually transmitted. But that doesn't mean you have to be a sex worker to get HPV. You don't have to be engaging in regular sex at all. You might have had only one sexual encounter in your whole life, have used a condom, and you can still get cervical cancer. You can get it even if you've never had penetrative sex. You can have been in a monogamous relationship for years and years, and still test positive for HPV.
Precancerous cells
In my case, I was 11 years into a monogamous relationship when a smear I had, courtesy of the screening programme, identified precancerous cells on my cervix.
I was referred to a gynaecologist for treatment, and since I couldn’t tell her when my last period was, she popped me up on the table in her office for an ultrasound. And there she was, a tiny pulse of hope in the grey light of that room, the flicker that would become my daughter.
The precancerous cells were only “moderately abnormal”, or cin 2, so there was no need to panic. The treatment was postponed for a year.
By then, the cells I sometimes imagined clinging like a cobweb to the walls of my cervix had advanced to cin 3, or high grade, and I had to go for a cone biopsy. I don’t remember much about the treatment, except the gynaecologist kindly squeezing my knee.
The treatments successfully removed all the cells, but I didn’t get away completely unscarred: my cervix was left weakened, and my next child was born prematurely, something I’ve since learned is a known risk. Still, I was one of the lucky ones.
Many others are not. Suggesting to women in monogamous relationships that there’s no need to go for a smear, or scaring parents into not vaccinating their daughters, is the kind of talk that costs lives.
Here are the facts the anti-vaxxers might not be so quick to tell you:
There are 100 strains of HPV, 14 of which are linked to cervical cancer. It is so common that the American Center for Disease Control says everyone who is sexually active will become infected with one or other HPV strain at some point in their lives. If you’re in a monogamous relationship, it can lie dormant for years, only to emerge later. You can, unsuspectingly, pass it back and forth between you. Men can contract HPV, and can also die from related cancers.
Censorious approach
The HPV vaccine for both genders, the HPV test, and a well-run, properly resourced, trusted screening programme are the best ways to prevent cervical cancer. Suggesting to women that they become nuns is not.
Ireland has a history of a patriarchal, sexually censorious approach to women's healthcare. What has passed for public health policy for women has often been inspired by a hotchpotch of medicine, Catholic mores and moral judgment.
As the Scally report made clear last week, society might have moved on, but some things haven’t changed. Much of what was in the report we might have expected. Women’s health services are still secondary, as those working in the maternity services have been warning for years.
What we perhaps didn’t expect to see illustrated quite so vividly was how some of the most deeply entrenched, sexually censorious, misogynistic attitudes that once dominated Irish healthcare haven’t gone away. The women who spoke to Scally took the view that “the attitudes and lack of openness were accounted for by paternalism in the healthcare system”, that women’s health services are secondary; that women’s rights are not taken seriously. Grace and compassion were sorely lacking, Scally wrote. I’d happily sacrifice either if we could just have some respect.
Nuns don’t get cervical cancer, the consultant said. And everyone in the room knew exactly what he was saying.