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Abstract
Cervical cancer is the fourth-most frequent cancer suffered by women worldwide, but relatively few women grow sick with or die from invasive cervical cancer in wealthy industrialized countries, where mass screening-based prevention programs have been in place for decades and once epidemic rates of disease have dramatically declined. The consensus is that screening prevents cancer. But cervical cancer screening is also known for having created its own nebulous burdens and harms: invasive diagnostic and surgical procedures related to the “precancer” that screening aims to detect and remove, but also prevalent positive tests for human papillomaviruses (HPV), the sexually transmitted viruses that are both causally linked to cervical carcinogenesis and highly common and usually harmless. Conventionally based on “annual exams” where a speculum is used to hold open a woman’s vagina while a provider removes cells from the cervix uteri, cervical cancer screening choreographs rituals of women’s psychosexual socialization, demanding both active attendance and passivity. Rendered routine, un-enjoyable, and banal, it is a quintessentially feminized institution. But cervical cancer screening is also celebrated as an exemplary public health intervention of the twentieth century, and the molecular link of HPV to cervical cancer, further vindicating the “human oncovirus” hypothesis and enabling the development of a “cancer-preventing vaccine,” as one of that century’s scientific milestones. Cervical cancer screening’s public face of scientific and social value, thus, is based on an efficacy that proliferates crises of privatized kinds, perceptible within clinical walls and above all in the lifeworlds of women who, made to navigate “precancer” and a “cancer-causing STI,” become further entangled with its gendered figurations. This project examines the categories, techniques, and practices of screening-based cervical cancer prevention, asking how they constitute scientific achievement and medical efficacy, on the one hand, and considerable hardship for women, on the other—as clinicians work to mediate in the middle. Informed by an investigative reading of pre-molecular and present-day cervical cancer epidemiology and etiological theories, my analytic centers on the experiences of women diagnosed with advanced cervical dysplasia (CIN 3), the clinical entity defined as posing sufficient risk for invasive cancer that its surgical removal is recommended. I argue that the key categories of mass screening—HPV and dysplasia—become burdensome for women precisely because of how their definitions—as “sexually-transmitted” and as “risk,” respectively—have made them effective for molecular epidemiology and industrialized prevention. Compounding this, my ethnographic research indicates that advanced dysplasia diagnosis often follows periods of significant distress in women’s lives, suggesting that gendered distress may contribute to vulnerability to cervical lesions in the first place. Thus, while attending to how HPV and dysplasia are defined and enacted, this project further asks how the clinical information these categories produce might be mobilized, beyond the logics of risk and in alignment with the concerns of affected women, to disalienating ends. The dissertation is based on 18 months of ethnographic research across public health, clinical gynecology, and psychosomatic medicine in Germany, and in particular on over fifty interviews with women who had recently undergone treatment for advanced cervical dysplasia at two clinics in Berlin. Building on research on the physiopathology of structural violence (poverty, exploitation, environmental toxins, and publicly sanctioned misogyny and sexual violence), this dissertation considers early cervical carcinogenesis in a setting where overt structural violence is relatively minimized. Here, my empirical provocation is that the carcinogenesis diagnosed as advanced dysplasia often appears to coincide with more muted, apparently immaterial, and privatized experiences of gendered distress in intimate/sexual and family/kinship relations, but also at work, and also with respect to ongoing struggles experienced as more intra- than interpersonal in nature. But how, I ask, can these findings be discussed beyond the psychosomatics of “psychologization” and “psychophysiology,” and beyond the nineteenth-century division of the medical governance of dis-eased wombs into “somatization” and “surgery”? More broadly, this dissertation argues that recuperating a notion of embodied subjectivity as the processual locus of health/disease is a critical conceptual task to which sociocultural anthropology has much to contribute, and from which it has much to learn.