Illustration by Maryam Adam// On instagram @paintingonmars
Written by Hudda Khaireh
Smear tests used to illicit a very visceral reaction in me. When a NHS England or my local GP letter landed on my doormat, the hammock of muscles that made up my pelvic floor would contract; pull up and retreat inwards in defence, as if to say: “no, you will not enter!” But every day, eight people are diagnosed with cervical cancer in the UK. How did those people come to diagnosis? What levels of discomfort and illness did they live with before receiving this fateful news? What happened to them next? I think about this a lot; and it’s part of the reason that I finally decided to get a smear test done.
Since I was a baby in primary school, I’ve endured years of menstrual cramps that sent me dizzy, faint in pain, caused me to vomit and immobilised me for hours and days. This barrage of hormonal responses was my monthly ritual, my body’s cyclical Jeckyl to Hyde metamorphosis complete with acne, bloating and depression. And we firm it. Go to school, sit exams, turn up at work, even go out with our friends; you know, cause it’s only hormonal ‘women’s issues’. To complain is akin to being tender-headed, the only appropriate reply a comb to the head and reminder it could be so much worse.
Years of this meant that my pain threshold was wildly high. So when other health complications showed up for me in my late teens/early twenties, it took me a long time to figure out it wasn’t okay to feel this bad. Years later, I embarked on a health journey that I have committed to traversing for the rest of my life. Those cache of stress responses I listed earlier are no longer part of my repertoire, I don’t know that song. Taking personal, direct responsibility for how I feel in every aspect of my life are the lyrics to my ballad and smear tests are part of that refrain.
My first smear test was three years ago following a doctor’s appointment I made to speak about specific health complaints I had developed. My GP noted I’d never completed a cervical screening. I wondered if my doctor knew about the origins of gynaecology? The historical development of the speculum, forged following extensive experimentation on captive Africans, forced into enslavement in the New World. Did my GP know how British police and immigration services would employ doctors to subject people identified as women to ‘virginity tests’ at airports and consulates? Or the practice of involuntary prescribing birth control like Depo Provera to women of colour by the NHS? Was my GP aware of how people from cutting communities like mine can find that because of an ancient custom practiced on them, before they even understood what consent meant, they could be subject to police profiling, their vulva publicly described as ‘mutilated’?
I thought about Henrietta Lacks, the African American woman who died from cervical cancer, but not before medical researchers took samples from her without permission, sold them to laboratories to be used in the development of hundreds of different medicines and treatments across the world. Her cells, ‘immortal’, her life not. But it was a seven minute appointment and I had stuff to do, so I tentatively agreed to another appointment with the nurse, thinking I could always cancel if I didn’t want to take part.
I decided to get the smear test (or cervical examination) in the end because I began researching cervical cancer, specifically positive health outcomes linked to early diagnosis and treatment. I also read about the welfare gap for people of colour (or BME/BAME - basically people who weren’t white) in accessing medical services and it reflected back to my own history and experiences. I thought about myself, a black woman, and of Henrietta Lacks. I thought about how our concept of the universal and universal healthcare can recognise black people on a cellular level as not being different, but that “universality” only extends to the labour and the extraction from black people and not their treatment and care, therefore requiring the chorus ‘Black Lives Matter’. So, as an attempt to live as if my life mattered, to normalise taking preventative steps to avoid black people dying needlessly and cruelly from cervical cancer, I took the test.
The word ‘smear’ in smear test comes from the sample taken from the entrance of the cervix, which is ‘smeared’ onto a petri dish to examine for cell abnormalities and specifically human papillomavirus (HPV) which has been linked to cervical cancer. The actual exam itself doesn’t look for physical signs of cancer. Also, it doesn’t feel like a ‘smear test’, more a poke, a dull jab, at least that’s how it felt for me. Having had two smear tests now, my experience is that they get progressively easier.
I walked into my GP surgery in this COVID-19 world for my second smear test, equipped with facemask and gel hand-sanitiser. The nurse called my name in the waiting room or at least I thought she did, given the unfamiliar pronunciation and the face mask she too was wearing, it wasn’t entirely clear. But given there were only four other people in the waiting room and no one else responded to the nurse in blue scrubs, I leapt from my seat and followed her, not before applying hand sanitiser again from the station next to the door. We walked into the examination room together. The nurse invited me to take a seat and after complaining about the unseasonably hot weather proceeded to ask me about my cycle, specifically when the first day of my last period was. Oh, I thought, I have an app for that and went through my phone to provide an answer. Next, I was asked if I was taking any contraceptives, or had any IUDs/coils. This information was required to ensure the accuracy of the results as our hormones can impact how the test results can be interpreted.
The nurse explained how the cervical screening would take place and how she would talk me through what she was doing every step of the way. I was taken to a curtain and asked to expose my lower half and lie on the medical table where there was a spare square of paper. I was invited to drape it across me if it made me more comfortable.The curtains drawn and the nurse on the other side, I took off my shoes, then took off my underwear, placed them in my pocket and I sat on the long medical table with a paper towel laid across me. The sensation of the paper against my butt took me back to the last time I got waxed and it was a reassuring memory, affirmation again for my high tolerance for pain. I laid back, butt against the protective covering of the table, muff facing up towards the sky. My skirt was hitched up and gathered around my waist like a hula hoop. I giggled, embarrassed at how literally exposed I was.
Like when getting a wax, I was asked to bend my knees, bring my feet together, then open my legs wide so they made a diamond shape. Unlike a wax, the nurse then asked if I could close my hands into a fist and place them under my butt cheeks, which I did. Throughout the screening, the nurse continued to give me a running commentary of what she was doing. In the hybrid yogic supta baddha konasana-bridge pose I was in I couldn't see the nurse or what she was doing and I was fine with that. I took to pranayama breathing, taking long inhalations into my diaphragm, visualising my belly expanding counting to four, holding my breath then visualizing the breath travelling up and out my mouth. Then I gagged, tasting my funky breath behind the facemask. I switched to nasal breathing - same principle, I felt myself dropping into my body, imagining my muscles relaxed and open. The entire test literally took 4 minutes for me. I didn’t see the speculum but I felt a dull pressure inside me as it was inserted into my vagina. It could have been even less time but it took a few attempts to collect the sample with a brush, because, you see, the cervix is pretty rad.
The cervix is part of the uterus/womb, and is often described as the neck. Shaped like a doughnut, it produces mucus that depending on where you are in your cycle, can either prevent or promote pregnancy. The cervix acts as a barrier or door to the rest of the uterus from the vagina, which itself is a short muscular canal that connects the uterus with the outside world. During a smear test, the speculum is inserted into the vagina to create easier access to the cervix to collect the required sample. However this process isn’t always straight forward and can be painful for some people.
My first smear test was indeed very painful. I remember in that exam I was positioned with my spine laying flat back on the table and my pelvis not angled and lifted like my second screening. It took several attempts to get a sample and I left the doctor’s surgery feeling very bruised. The nurse explained that the cervix isn’t hiding as such, but for many of us our vagina and cervix aren’t aligned dead on. The cervix can point upwards or downwards and can also even sit further back in your pelvis. Our cervix will move around and change shape somewhat throughout your cycle and as we get older. For some of us, our cervix, and so our uterus in general, points backwards towards our spines and rectums rather than forward towards our vagina, making it difficult to locate.The process of the medical professional pushing and readjusting the speculum can be uncomfortable to say the least. One in five people who have a cervix have a tilted cervix or a ‘retroverted uterus’, and although generally it’s not a big deal, sometimes it can show up in other aspects of your life, like getting menstrual cramps in your lower back, finding it tricky to insert tampons or finding certain sexual positions the opposite of pleasurable.
Whether your cervix is tilted or not, there are still many ways a sample can be collected from you without pain and extreme discomfort. I come to this with the understanding that society not just normalises but requires the discomfort of certain bodies. Contesting pain, demanding that our bodies be treated with respect, to honour differences and to seek better health from that perspective is how to create healthcare that really is for us all. So when you go to your smear test, come as you are, hair, piercings, tattoos, thrush, all of it! Nurses have literally seen everything. The most important thing, the only thing, however is that they can collect a sample of your cervical mucus. And to take care of yourself.
Some pro tips:
Dress in whatever makes you feel comfortable, but know you will have to undress from the bottom down.
Try to book your smear test before the bleed phase of your menstrual cycle, or a week after as the blood cells can interfere with getting a clear reading on your sample.
Breathe and try your best to calm yourself, because when you’re tense, all your muscles including downstairs tense up, constrict and so make it harder to see your cervix, but when you are relaxed all your muscular channels are more open and it’s easier to locate your cervix.
If it’s uncomfortable or painful - you can stop the screening. You can ask the nurse to change things. They can use a different sized speculum, continue the examination with you in another position like on your side, legs lifted - whatever you body needs.
Take your time, this is service for you that shouldn’t require you to suffer needlessly. There are other ways to collect smear tests in a hospital if that serves you better. Listen to your body and know that it’s not OK to feel bad when you’re trying to figure out if everything is good with you.
Resources:
Jo’s Trust is a charity focused on cervical cancer and has a wealth of resources for you to go through, I would highly recommend looking them up. 9 things you didn’t know about your cervix
Paul Joannides Psy.D. in Psychology Today wrote a useful article about tilted and cervixes that are not directly aligned with the vagina and sex, with videos and diagrams: A Tipped Uterus and Intercourse Positions
Ryan K. Sallans, MA wrote a great piece about six specific narrative barriers inhibiting transgender men receiving adequate support in cervical cancer screenings Six Tips for Giving Good Health Care to Anyone With a Cervix
The Beautiful Cervix Project that seeks to change the way people understand their cervix by sharing photographs of cervixes at different life stages, conditions, after procedures etc as well as provide resources for self examination. https://www.beautifulcervix.com/cervix-photo-galleries/
Journalist Angela Sani wrote this piece in the Guardian on maternal health but it also relates to gynecology generally, about racism and health inequalities in the UK 'To be black or brown is to see your body suffer' | Angela Saini
Historian Deidre Cooper Owens has detailed text in ‘Medical Bondage Race, Gender and the History of American Gynecology’ explaining how the founder of modern gyanecology and inventor of the speculum Dr Marlon Sims experimented on enslaved people, as well as other ways slavery was instrumental in the development of gyanecology. Here is a review of the book by Rachel Zellers: Black Subjectivity and the Origins of American Gynecology
A brief historical overview of medicalised procedures such as “virginity tests” which were legal until 1968 but still found to be practiced at least until 1979. Research Notes: Race, Gender and the Body in British Immigration Control
Playwright Firdos Ali writes on the graphic discourse utlised by campaigners against FGM practices, reinscribing racist, misogynistic troupes and alienating people who come from communities where FGM is practised. FGM as spectacle: the dehumanisation and commodification of the black girl
The Immortal Life of Henrietta Lacks by Rebecca Skloot
Hudda Khaireh is an independent researcher with a background in Public International Law. Her practice focuses on the political position of Black people globally and has shared work at a number of forums including the Centre Editing Lives and Letter at UCL, Senate House, Printroom Rotterdam, Chisenhale Gallery and DIY Cultures. Hudda is also an associate of Numbi Arts and OOMK Zine.
