Cancer DIY: Gendered Politics, Colonialism, and the Circulation of Self-Sampling Screening Technologies in Canada
Innovative. Exciting. Easy. Painless. These are just some of the words used to describe the Delphi Screener — a sterile, plastic, syringe-like device that allows women to test themselves for cervical cancer. Requiring no training, speculum, or invasive gynecological exam, this novel technique was developed in 2015 by three Dutch gynecologists who wanted to design a cervical cancer screening device that empowered women by helping patients obtain their own vaginal samples in a comfortable and judgment-free way.
In recent years, self-sampling has emerged as a compelling technique for screening women for HPV and cervical cancer. With this method, physicians provide women with an at-home testing kit so that patients can take their own cell samples, as opposed to having a clinician manually scrape a small sample of cells from the cervix, as is done in a Pap test. Self-collection methods are quickly gaining traction in Canada, as many healthcare providers believe that the technique can be mobilized to combat the historically low rates of screening found in medically underserved populations, such as Indigenous women living in Northern Ontario.1
The popularity of DIY testing comes from its ability to challenge the 70-year-old status quo of cytology. According to a recent article in Current Oncology, self-sampling is a means of cancer prevention that is unequivocally empowering to women. Not only does it eliminate the social discomfort or emotional distress that comes from being subjected to a pelvic examination, but it also provides women with the knowledge and tools to take control of their own reproductive lives, thus improving screening rates and leading to a reduction in the incidence of and mortality from cervical cancer.
But are at-home sampling kits really a breakthrough in the field of cancer prevention? And do they represent a new era of feminist approaches to women’s sexual and reproductive health? By tracing the circulation of DIY cervical cancer screening methods in Canada, it becomes clear that self-sampling has long been part of the cancer control apparatus, and while these technologies have certainly created new opportunities for reproductive rights, they have not always been mobilized in a way that has been empowering to women.
A Brief History of Cervical Cancer Screening
Before self-sampling, women were tested using the scrape method of cervical cancer screening, otherwise known as the Pap test, developed by George Papanicolaou in 1943.2 Although the Pap test was well-received by physicians, many questions remained about its feasibility as a screening technology. Access and uptake were two of the most salient issues, as not all healthcare facilities offered the technique. Even where Pap screening services were available, many women were reluctant to undergo the test because of its invasive nature. Therefore, to make cervical cancer detection more accessible and attractive to women, researchers began to brainstorm a new screening method – one that did not require a gynecological examination.
One of the first techniques to approach this ideal was the “irrigation smear.” This technology, developed by Johns Hopkins University physician Hugh J. Davis in 1962, was a “do it yourself” method of screening designed to be used by the patient in the “comfort of her own home.”3 The irrigation smear consisted of a disposable plastic pipette that contained a cell preserving solution. Women were instructed to insert the pipette into the vagina, squeeze the bulb so that the solution could be released, squeeze it once more to recover the solution, and then finally send the pipette to the laboratory via mail for analysis.
Patients—A Preliminary Study,” Acta Cytologica 10, no.6 (1966): 418-420.)
Davis hoped that the autonomous nature of this test would empower women to take control of their reproductive health and would provide a cheap and safe means for screening in rural, isolated, or otherwise apathetic populations.4 In the years following Davis’s invention, many healthcare providers incorporated this new self-sampling method. However, it was not advertised and applied to all women in the same way. Although the 1960s and early 1970s marked a watershed moment in the history of women’s health and reproductive rights, characterized by the development of the birth control pill and the emergence of radical feminist health collectives along the west coasts of the United States and Canada, physicians had their own ideas about who should and should not have access to this new screening technology. In Canada particularly, these ideas were usually borne out of stereotypes about women’s bodies’ and behaviors and were often amplified along racist lines.
The Irrigation Smear: From the Consulting Room to the High Arctic
Davis’s invention caught the eye of the Canadian federal government in the early 1960s. Government officials in the Department of National Health and Welfare’s Indian Health Services believed that the technique could serve as a useful method for screening Inuit women, a population group who were “at the present time not being examined for cancer of the cervix by any other means.”5 Thus, in 1965, Indian Health Services solicited the help of the pathologist George Anderson and his technician Kurt Krakauer to launch a pilot study to see if the cytopipette could be used for Inuit women. That summer, these researchers secured passage aboard the government’s annual ship-based patrol to the Eastern Arctic, taking with them over 1,000 of Davis’ cytopipettes.6 Over the course of their three-month-long voyage, Davis and Krakauer acquired over 600 vaginal smear specimens from Inuit women, which were taken back to the Pathology Department of the Ottawa Civic Hospital for analysis at the end of the expedition.7
One key difference between Anderson and Krakauer’s survey of Inuit women and Davis’s original vision for the test was how the specimens were collected. Whereas Davis had designed the test so that women could screen themselves, the 647 Inuit women tested in Anderson and Krakauer’s 1965 study had their cytological samples obtained by a nurse on the ship.8 It is not clear why Anderson and Krakauer decided to deny Inuit women access to this newly developed means of self-screening. However, it is clear that since the stated objective of Anderson’s pilot study was to assess the validity of this DIY method of cervical cancer screening in the North, the decision to have a healthcare professional administer the pipette blatantly negated this goal.
What is perhaps even more distressing about this research study, though, is how the results were interpreted. Despite the fact that “no smears with atypical or malignant cells … [were] found,” Anderson and Krakauer concluded that irrigation smear screening in the Arctic should be continued, as “carcinoma of the cervix may be expected to become a significant cause of death as the [Inuit] population increases.”9 According to Anderson and Krakauer, this was because of “the early age at which sexual intercourse starts, and the generally poor genital hygiene [in Inuit populations]” — a view that American Indian Studies professor Dian Million has argued was part of a “‘normed’ racialized sexual imaginary” about Indigenous peoples, perpetuated by the Canadian state.10 Similar to a number of other exploitative government policies and practices carried out within Inuit communities over the course of the mid-twentieth century, Anderson and Krakauer’s use of the irrigation smear provided Indian Health Services with a new means of undermining Indigenous sovereignty by keeping tabs on the bodies of those least legible to state power.11
Anderson and Krakauer’s findings, and the idea that high rates of cervical cancer could be attributed to racially-rooted behaviors, had a big impact on how Canadian medical officials would carry out cervical cancer screening within Indigenous communities. Similar studies would also be carried out on Ojibwa, Odawa, and Potawatomi peoples on Manitoulin Island during the early 1960s, and later, on a group of 99 Metis women from Wapaskokimaw Reserve.
Like Anderson and Krakauer’s 1965 study, the way that these samples were collected were intimately linked with the colonial policies and practices of the Canadian nation-state, and likely stripped any female agency from this “DIY” method of testing.
The Disappearance and Resurgence of Self-Sampling Technologies
Irrigation smear methodology died down in the early 1970s for a variety of reasons. Not only was the technique’s efficacy increasingly called into question by experts, but the test’s credibility also floundered as a result of its association with Hugh J. Davis.12 Davis’s reputation fell into disrepute in the mid 1970s when the Dalkon Shield, his newly invented intrauterine device promising “almost perfect birth control protection with virtually no adverse side effects” was, in fact, associated with pelvic inflammatory disease, infertility, and death.13 It is perhaps because of this scandal that virtually no references to the irrigation smear can be found after 1975 when the Dalkon Shield was officially taken off the market.
Today self-sampling technologies are often framed as new inventions. Armed with flashy new-age names like the Viba-Brush, the iPap, and the Delphi Screener, these technologies market themselves as innovative approaches to cervical cancer screening. Although this makes it difficult to trace the genealogy of these devices, their goal to provide women with a simple, inexpensive and convenient private method of self-testing is almost identical to Hugh J Davis’s rationale for creating the irrigation smear. Also, like the self-sampling methods of yore, these new tests are primarily marketed to nonwhite and low-income populations, such as recent immigrants and Indigenous peoples, in an attempt to bolster screening rates in these populations.14 While the resurgence of self-sampling methods has the potential to empower women to participate in the screening process, the historical antecedents and misappropriations of this technique should also be considered, and acknowledged, before making this method the new best practice in the field of cervical cancer screening. While the technique does offer opportunities for empowering women, the uneven and unbalanced way in which this technology was used and misused in the past might also be partially responsible for why certain populations are reluctant to undergo screening in the first place.
Notes
- “Anishinaabek Cervical Cancer Screening Study,” Community Update Report (Thunder Bay, ACCSS, 2015), 1. Return to text.
- Dennis M. O’Connor, “A Brief History of Lower Genital Tract Screening,” Journal of Lower Genital Tract Disease 11, no. 3 (2007): 182–188; L. A. Reynolds and E. M. Tansey, eds. History of Cervical Cancer and the Role of the Human Papillomavirus, 1960-2000, Vol. 38 of the Witness Seminar series (London: Wellcome Trust, 2009). Return to text.
- Hugh J. Davis, “The Irrigation Smear: Accuracy in Detection of Cervical Cancer,” Acta Cytologica 6, no. 6 (1962): 462. Return to text.
- Hugh J. Davis, “The Irrigation Smear: A cytologic method for mass population screening by mail,” American Journal of Obstetrics and Gynecology 84, no. 7 (1962): 1017. Return to text.
- George H. Anderson, and Kurt Krakauer, “The Irrigation Smear in Office and Clinic Patients — A Preliminary Study,” Acta Cytologica 10, no. 6 (1966): 418–20. Return to text.
- This was the same patrol (also known as the Eastern Arctic Patrol) that participated in mass screening to identify cases of active tuberculosis, and the removal of Inuit patients to southern Canadian hospitals. For more information, see Pat Sandiford Grygier, A Long Way from Home: The Tuberculosis Epidemic Among the Inuit (Montreal: McGill-Queen’s University Press, 1997) and E Olofsson, TL Holton and IJ Partridge, “Negotiating Identities: Inuit tuberculosis evacuees in the 1940s-1950s,” Inuit Studies 32, no. 2 (2008): 127-49. Return to text.
- Anderson and Krakauer, “The Irrigation Smear: A New Cytodiagnostic Technique for the Detection of Cancer of the Uterine Cervix,” Canadian Association Medical Journal 96, no. 5 (1967): 268–72. Return to text.
- Anderson and Krakauer, “The Irrigation Smear: A New Cytodiagnostic Technique,” 272. Return to text.
- Anderson and Krakauer, “The Irrigation Smear: A New Cytodiagnostic Technique,” 270. Return to text.
- Dian Millon, Therapeutic Nations: Healing in an Age of Indigenous Human Rights (University of Arizona Press, 2013), 42. Return to text.
- For instance, by the mid-twentieth century Inuit were already being subjected to the “E-Number Identification System” (1945–1970), systematic tuberculosis evacuations (1946–1969), the disruption of traditional Inuit settlement patterns (1950–1960s), and the indiscriminate killing of Inuit sled dogs by the Royal Canadian Mounted Police (1950–1970). Return to text.
- For a critique of the irrigation smear’s efficacy, see Ralph M. Richart and Henry W. Vaillant, “The Irrigation Smear: False-Negative Rates in a Population with Cervical Neoplasia,” Journal of the American Medical Association 192, no. 3 (1965): 99–102. Return to text.
- Robert M. Thomas Jr., “Hugh J. Davis, 69, Gynecologist Who Invented Dalkon Shield,” New York Times (October 26, 1996): 1. Return to text.
- For instance, see I. Zehbe, P. Wakewich, A. D. King, K. Morrisseau and C. Tuck, “Self-administered versus provider-directed sampling in the Anishinaabek Cervical Cancer Screening Study (ACCSS): a qualitative investigation with Canadian First Nations women,” British Medical Journal Open 7, no. 8 (2017): 1–9. Return to text.
Jennifer Fraser is a PhD candidate studying the history of medicine at the University of Toronto's Institute for the History and Philosophy of Science and Technology. Her dissertation charts the history of Canadian cancer epidemiology, focusing specifically on how cancer control campaigns were advertised and applied to Inuit communities during the mid-late twentieth century.