When modesty is an obstacle

Caryn Andrews had been in search of a dissertation topic when a member of her synagogue happened to pose a question: “Do you think religious Jews would be less likely to go for a mammogram?”

Intrigued, Andrews, a doctoral candidate at the University of Maryland School of Nursing, pondered the question with her rabbi, Susan Grossman, at Beth Shalom in Columbia, Md. “She suggested that I couldn’t look at religion; I had to look at modesty,” Andrews says.

It was a crucial distinction in a faith in which healing oneself and others is a requirement, but one that can often be difficult because of some forms of modesty practiced in the Jewish community.

A dissertation topic was born.

The concept of modesty and its role in Jewish culture led Andrews, an oncology nurse practitioner at Northwest Hospital Center in Randallstown, Md., to research whether modesty among Jewish women might discourage them from receiving breast cancer screenings.

Andrews hopes that her findings and further studies will have an effect on the administration of healthcare in any community where rules of modesty may pose obstacles to mammography, other forms of preventive healthcare and treatment.

Andrews began with a hypothesis: Invasive healthcare practices often clash with a culture dictated in part by tzeniut, the Hebrew notion of modesty in dress, conversation and personal habit. That clash could potentially be harmful to Jewish women’s health.

She knew, for example, that relatively few Israeli women participated in breast screening programs, most likely because the procedure is thought to violate Orthodox rules of modesty by requiring a woman to disrobe and have physical contact with a technician. In Israel’s Haredi community, the media even avoid using the term “breast cancer” for reasons of modesty.

Andrews also found studies of Muslim and Asian communities demonstrating “that modesty is an issue of healthcare utilization,” she says. She also found evidence of the same in the Amish population. “We know that women are not getting care,” she says.

Andrews further hypothesized “that cultures that have strict rules of modesty may also underutilize healthcare.”

But before she could prove her modesty theory, Andrews had to be able to define a concept with religious, cultural and psychological attributes that didn’t readily lend itself to quantitative measurement. “No one had defined modesty,” she says. “That’s where the research began.”

Andrews found participants through the Jewish community grapevine. Phone calls, e-mail and postcards mailed by the local Hadassah chapter led her to women from a wide spectrum of Judaism who expressed different degrees of modesty.

“A comfort level is essential for this very personal discussion,” Grossman says. “To have the same gender and same religion and be knowledgeable and have credentials in the community are not absolutely necessary, but they certainly facilitate entry and communication.”

With a research grant from the Women’s Health Research Group, Andrews designed and administered a questionnaire that asked Jewish women in Baltimore whether they agreed with statements about modesty. They were asked, for example, if they were comfortable wearing sleeveless clothes.

In interviews with 40 women, Andrews also gleaned the many dimensions of the role played by modesty in their lives, from the clothing they wore to the books they read.

The result, Andrews says, was the development of a “modesty scale that provides evidence that modesty can be measured.”

Now that a tool exists for defining modesty, “you can address it in healthcare,” says Andrews, who also received a doctoral scholarship from the Oncology Nursing Society to support her work. She received her doctorate in nursing last year.

Andrews’ measurement tool will lay the groundwork for further research on whether standards of modesty hinder healthcare and if so, what measures can be taken to provide healthcare while assuring that those standards won’t be violated.

“It may mean something as simple as putting up a curtain, or not leaving someone uncovered while waiting for a provider,” Andrews says. “It may mean letting somebody leave their clothing on.”

The barrier against mammography and other intimate procedures isn’t only modesty, but insensitive healthcare practices that offend cultural sensibilities, Andrews says. “If we adapt our healthcare to the culture of others, we’ll be more successful.”

Andrews has heard from other healthcare researchers interested in examining modesty’s role. For example, researchers working with the Muslim community in Dearborn, Mich., want to use the modesty scale, she says.

Andrews also hopes that her modesty scale may be modified to understand whether Orthodox Jewish men and Muslim men avoid colonoscopies and other screening tests for reasons of modesty.

Aside from the medical community’s growing awareness of cultural and religious rules of modesty, some healthcare facilities have found solutions. At one Maine hospital, an in-house seamstress creates hospital gowns that cover the entire body. The gowns are intended to encourage Muslim women from Somalia who have settled in southern Maine to follow through on medical appointments.

An increase in midwives who train specifically to serve the Orthodox community has also been attributed in part to women’s modesty requirements.

Within the outpatient treatment area where she works, Andrews has heightened sensitivity to modesty on behalf of patients, visitors and staff. Curtains are routinely shut and consultations are not held in hearing distance of others. “Paying attention: That’s all it is,” Andrews says.

For Andrews, the mother of two daughters, modesty is not simply an aspect of her faith. “I believe modesty is part of the quality of life,” she says. “It’s about self-respect and respect for others.”