Culture, Health & Sexuality

Unpacking cervical cancer stigma in healthcare: lessons learnt from Indonesian patients and health professionals

Indonesia has the highest cervical cancer incidence and mortality rates in Southeast Asia, with 36,000 new diagnoses and 21,000 deaths occurring in 2020. This situation stems from delayed introduction of free HPV vaccination, poor uptake of cervical screening, and widespread stigmatisation of cervical cancer. Ethnographic research conducted between 2019 and 2021 documented women's experiences of cervical cancer stigma in healthcare, stigmatising narratives and practices exhibited by health professionals, and non-stigmatising practices demonstrated by health professionals. Four dominant narratives were identified including stigma based on: perceived sexual immorality; marital status; low socio-economic status and/or education; and discourses of pollution associated with vaginal bleeding and female hygiene. Lessons learned provide culturally grounded insights for achieving stigma-free healthcare, such as avoiding: blaming women or their partners; linking cervical cancer with sexual impropriety; mentioning sex work or enquiring about women's or their partners' professions; negative references to female hygiene or vaginal bleeding; and reference to patients' class, education level, marital status or other personal attributes. The representation of HPV as a common infection occurring within marriage was shown to be an effective strategy for avoiding stigma, while institutional change was identified as necessary to remove barriers to reproductive health service access related to marital status.

Enacting power and constructing gender in cervical cancer screening encounters between transmasculine patients and health care providers

Transmasculine people are at risk of cervical cancer but have lower rates of cervical cancer screening than cisgender women. Disaffirmation of the patient's gender and unequal power dynamics between patient and provider during screening contribute to patient unwillingness to be screened. The mechanisms by which the balance of power may be shifted between patient and provider, and by which gender is constructed during the Pap test, are not well understood. A qualitative study using a modified grounded theory approach was undertaken to analyse patient interview and provider interview and focus group data pertaining to power and gender in the context of cervical cancer screening among transmasculine individuals. The study was conducted at an LGBTQ-focussed health centre in Boston, USA. Processes by which power is enacted included constraining or affirming patient choice, mitigating or exacerbating vulnerability, and self-advocacy. Gendering processes included naming patients and their bodies, invoking gender norms, de-gendering/re-gendering Pap tests, and othering or normalising trans bodies. The interplay between these processes promotes or constrains patient agency over body and health, impacting patient care, patient-provider interaction, and service utilisation. Understanding patient and provider roles in power and gender dynamics are critical for the provision of patient-centred care.

Navigating trans visibilities, trauma and trust in a new cervical screening clinic

Trans and gender diverse people are globally recognised as being under-served in clinical services, with significant implications for their health. During a national reorientation of the Australian cervical screening programme - from Papanicolaou smears to human papillomavirus screening - we conducted interviews with 12 key informants in cancer policy, sexual and reproductive health and trans health advocacy to understand how trans people's needs and experiences were being accounted for and addressed in health policy and practice. Themes captured the complexities of increasing visibility for trans people, including men and non-binary people with a cervix. These complexities reflect the extensive system and cultural change required in asking policymakers and practitioners to think differently about who is at risk of a disease typically associated with cisgender women. Informants drew on the language of trauma to explain the resistance many trans people feel when engaging with clinical services, particularly relating to sexual and reproductive health. In doing so, they argued for increasing resources and processes to elicit trans people's willingness to put their trust in such services. Thinking critically about the relationship between the politics of trans visibilities, trauma and trust can support effective and inclusive approaches to transgender health.