Martha made an appointment soon after moving to our area, seeking antibiotics for a malodorous vaginal discharge. It was a recurrent problem, she told me, and her previous doctor used to give her courses of metronidazole, which would clear it up just fine, albeit only temporarily.
In her late thirties, she wore baggy combats and had several piercings. There was a palpable tension about her. I reassured her that she could see a female GP if she’d prefer, or could have a chaperone present for any examination. That wouldn’t be necessary, she told me, because she couldn’t allow anyone – male or female – to examine her. We talked a bit more and she told me about the sexual abuse she’d experienced as a child. She had managed one sexual relationship many years ago, but it had lasted just six months before foundering on her extreme phobia of intimate contact.
I had every sympathy with her old GP. Faced with an inability to investigate her problem properly, he and Martha had fallen into a pragmatic conspiracy. Metronidazole brought short-term relief, so that was what she kept being given. I was uneasy, though. I explained that we needed somehow to check her cervix, which necessitates vaginal examination. After a lot of careful negotiation, she agreed to an urgent referral.
I briefed the loveliest female gynaecologist on our patch, who handled things with great sensitivity. Ultimately, though, Martha couldn’t permit examination, so an urgent MRI scan was arranged instead. The news was not good: there was a huge tumour at the neck of the womb, extending into the pelvis. If this was cervical cancer then it was far beyond the curable stage, but an operation could ameliorate horrendous symptoms from tumour progression. A lymphoma was also a possibility, and this would be more treatable.
Either way, Martha was facing a stark choice: to enter a programme of surgery, radiotherapy and subsequent follow-up checks, which would necessitate doctors examining her in ways she found intolerable; or to suffer an imminent and extremely unpleasant death.
Given months, if not years, a psychologist might have been able to help her overcome her phobia. But there was no time. Terrified, Martha fled to a town some distance away. But she remained in phone contact, and I did my best to support her as she tried to confront her living nightmare. She developed debilitating panic attacks. The last time we spoke, she mentioned how her breathing had become difficult, a classic physical symptom of morbid anxiety.
The next day she collapsed and died. The post-mortem showed a blood clot in a leg vein – something more common in cancer patients, especially when a large pelvic mass impedes blood flow. A piece of clot had broken off into her circulation and lodged in her lungs, with fatal results.
I will never know whether her breathing difficulty was really anxiety-related, or if it had been due to an earlier, smaller piece of clot. Her tumour was confirmed as advanced cervical cancer; she was never going to survive. That was the main crumb of comfort in the whole tragedy – that her inevitable death had been swift and her dignity had been preserved.
Cervical cancer is sexually transmitted and may well have been caused by a virus contracted from her abuser. It is readily preventable by smear tests but the psychological sequelae of the abuse were such that Martha could never contemplate being screened. Sexual abuse in childhood wrecks lives, and in Martha’s case it ended hers prematurely.
A friend of hers came to see me after the funeral. She told me that Martha had mentioned the way I and my gynaecologist colleague had related to her – one of the few times in her life she had felt fully respected. By the time we met Martha it was too late to save her, but the other crumb of comfort is that she found doctors who did their utmost to treat her with the dignity to which every person should be entitled.
For more information about cervical screening especially for women who have experienced sexual violence, see mybodybackproject.com
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