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Tuesday, January 8, 2008

Religion, Race & Patient Privacy

How sociological factors affect our privacy and modesty requirements. An expanded look at the issues involved as religion is not the only variable involved.

44 comments:

Joel Sherman said...

This is obviously a sensitive issue which reflects widely in our society and involves constitutional rights. Here's an article which references the problem mostly in Europe. Here’s a Muslim view from this country.
I'd like to explore how our health system is coping with this. It also seems to me that it is possible to obtain more privacy on religious grounds than on grounds of modesty alone, especially for male patients.
Be interested in others thoughts on this and I will follow up on this topic.

Joel Sherman said...

Here's an article concerning Muslim medical practices. Search on 'modesty' for the most relevant sections. It is clear that practices can vary depending on country and sect and that same gender care is not considered mandatory. Yet it receives a much higher priority than most Western societies give it. Not surprisingly, modesty seems more of an issue to female patients than to men.
Those of you who desire same gender care would do well to look at diverse city hospitals which may cater to significant Muslim populations. I think your needs may be better met than at the usual American hospital.

Rosie said...

What an interesting article. With more and more Moslems in our country, it seems that their particular needs will represent a new challenge for the hospital staff. As a female, I like the added sensitivity to modesty. On my next hospital visit, I might just lie about my religion to get this consideration.

Anonymous said...

Nice article Joel,

Here's a twist that I'd like to add. We're expecting our third child in May and as I've said on Dr.Maurices board, my wife only gets female care. We've been fortunate enough to be near a place that has no problem accomodating our request for same gender care. When we first started advertising that we were expecting, the staff at her hospital started questioning why she didn't have the baby at her hospital. She told them that she was just more comfortable with a female. They made alot of snide comments toward her and tried to pressure her into having it there. There are three muslim doctors at our facility and when she approached me with this, I asked her where they went and took their wives for intimate care, she found out that two of the doctors wives went to female cargivers and the other doctor (a female) went to the same caregiver that my wife goes to? Very odd that these people would pressure my wife into an uncomfortable position and yet they demand same gender care for themselves or their wife based on religion. Jimmy

Joel Sherman said...

Thanks Rosie and Jimmy.
The point of this thread is twofold. First is to suggest that patients who want same gender care seek out Muslim physicians or those who care for them.
Secondly I just wanted to highlight the fact that religious convictions are treated far more respectfully than the same equally fervent convictions are on non religious grounds. I'm not sure that is wrong; it is certainly complicated though and involves constitutional questions. It extends to many other areas as well. For instance Mormons officially considered blacks as inferior and wouldn't let them become priests ( a much more significant part of their religion than in most as there are a large percentage of 'lay' priests in the religion). This official policy wasn't reversed until 1978, way after it was unacceptable everywhere else in our culture. And this was only reversed after the Mormon Church wanted to expand in heavily Negro areas of Africa and South America. It is still not clear (at least to me) how accepting they are of blacks in their religious hierarchy because they keep the data secret. If anyone knows differently, please correct me.

Anonymous said...

I can't really blame the Muslim father for not wanting a male anesthesiologist attending his wife if European doctors expose women the way this woman receiving epidural is exposed in this TRAINING video:

linkbr/>
(scroll down and click "epidural block")


CLW

Anonymous said...

Joel,

Sorry if I was off topic a bit. I was merely pointing out that these groups of people don’t have to deal with the pressure/comments that my wife was subjected to nor do they have to explain themselves to their peers because of their religion. I don’t understand why hospitals have put forth an effort to provide them with the care that they request and yet the common citizen can’t have these same accommodations. I’m sure it has something to do with income. These areas that you’ve pointed out all have a high population of Muslims so these facilities have just taken a step to change their practices so they can win their business and meet the patients needs. Don’t get me wrong, I think this is great for them. This is good marketing. I just feel every patient deserves the same consideration. That’s my two cents. Jimmy

Anonymous said...

Here's a piece I just wrote up that is at the periphery of the subject of "Religion and Patient Privacy." Mike of "howhusbandsfeel" might find it interesting.

Along the same lines as this piece, back in the early '70s when I was working on a Master's in Guidance and Counseling, I was exposed by a psychiatrist acquaintance to literature that advocated using patient transference to seduce patients into sexual relations with their therapists. This school of thought, which was apparently not as unpopular as most people wished it was, actually argued that the sexual encounters could be manipulated in a way to be therapeutic to patients. This acquaintance, who was one of my running partners, spoke at length of its utility. It was clear to me, however, that the utility was for him, not the patient. The school of thought seems to have been pretty ephemeral, falling out of vogue by the end of the 1970s following a rash of law suits by women who were seduced by their therapists. One of those cases was dramatized in a film. -- Ray

MEDICAL MASTURBATION

It is rare that one hears the term “hysterical” used with reference to the actions of a male. Indeed, I never have. In my experience, the term “hysteria” has been used to refer to the aggregate behavior of people who overreact to some crisis or perceived crisis in their social milieu such as the “mass hysteria” that followed H. G. Wells’ radio program “War of the Worlds” in which Wells posed as an announcer reporting on the invasion of Earth by Martians.
Otherwise, I have heard the term “hysteria” only with reference to the behaviors of women. To understand why that is, one might refer to an etymology dictionary where one will find that the term is Latin for “of the womb” or “suffering in the womb.” It was “originally defined as a neurotic condition peculiar to women and thought to be caused by a dysfunction of the uterus.”
There has been some scholarly writing on what, until the early 20th century, was the preferred and most common treatment for hysteria, the most recent among which was published by Rachel P. Maines entitled "The Technology of Orgasm: 'Hysteria,' the Vibrator, and Women’s Sexual Satisfaction." This recommended treatment logically followed from what was believed to be the cause of hysteria; viz., excessive sexual tension which was manifested in disturbing sexual fantasies and dreams, excessive vaginal lubrication, irritability, and pelvic discomfort. The cure – masturbation.
Unfortunately, Victorian women, being a highly religious lot, were socialized to believe not only that sexual fantasies constituted adultery, a mortal sin, but that the best way to purge themselves of these fantasies – masturbation – added to their waywardness. So, in droves, they visited physicians who sexually aroused them manually to the point of “paroxysm” or “release.” The use of these terms as euphemisms for “orgasm” in physicians’ professional literature was the way they desexualized the treatment thereby sanitizing and legitimizing it. Of course, medical masturbation did not really cure women’s hysteria, so they found themselves compelled to return for frequent treatments.
Apparently, most physicians did not look forward to manually treating hysteria. It was time consuming, taking upwards to an hour to complete. They breathed a sigh of relief when Joseph M. Granville, an English physician, patented his electromechanical vibrator at the end of the 19th century and marketed it to physicians as an alternative to manual masturbation for it significantly cut down the time before “release.” Maines suggests that physicians at the time conceptually distinguished between sex – which required penile-vaginal intercourse – and medical masturbation with a machine. “Since the external use of vibrators didn’t involve the vagina, it could not be considered to be sexual contact, and thus was a purely medical encounter.” Maines refers to this conceptualization as the “androcentric model of sexuality.”
As the Victorian era came to a close and the U.S. moved toward an encounter with its first sexual revolution of the 20th century – the 1920s, age of the flappers – advertisements for vibrators moved into the popular media, including the Sears and Roebuck catalogue, and the vibrator became a widely purchased product now used more frequently by women in the privacy of their own homes than by physicians.
By 1930, the vibrator as a household gadget lost is legitimacy as it entered the underworld of pornographic photography and films. By then, most physicians had already stopped using them, an unintended consequence of the sexual revolution of the ‘20s when people began to come to terms with the idea of women as sexual beings.

Joel Sherman said...

'Paroxysms' for Victorian women has to be the strangest historical medical therapy I've ever heard of, Ray. Can you give a link or reference for further details.

Anonymous said...

Some of what I wrote is from memory of what I read when I was going to graduate school in counseling psychology back in the '70s. I made reference to it in courses in Sociology of the Family that I taught many years ago. I also took some notes from Maines book. I read excerpts from it in a bookstore while I was waiting for my wife to finish her shopping. I fell asleep before I could finish the most interesting parts. -- Ray

Joel Sherman said...

Well here's another aspect of Muslim medical modesty, women physicians refusing to scrub their forearms preoperatively.
No matter how much you believe in personal modesty that goes too far in my opinion, potentially endangering the patient.

Anonymous said...

Here's an article on a gown designed for female muslim patients. Even I have to ask how in the world a doctor could examine a patient in this:

http://news.bbc.co.uk/2/hi/uk_news/england/lancashire/5315306.stm

Jimmy

Joel Sherman said...

Nice link Jimmy.
Fortunately for physicians women wearing burqas are a rarity in this country. I think I'd refuse to see a patient wearing one, although maybe that would cause even more trouble. But how can one have a personal relationship with a patient if you can't see her responses and pick up on what she's thinking? It’s more important than the possible limitations in the physical exam. It would be like trying to gauge the response of a robot to know if it understands what you're saying. Poor medicine IMO.

Anonymous said...

Here is a thought, why is someone...say a Muslim more deserving of consideration for thier modesty than say an atheiest who has strong feelings about the same? Is it really consideration for the patient that is behind the action or fear of backlash from politically correctness. Why should we value one persons desires and feelings over another simply because they are based on religion....and I am a Christian...but don't think that should give me any more or less rights than anyone else..do you? If you can accomidate for religion...you can accomidate period...but will you

Joel Sherman said...

Yes, that question is one of the main points of this thread. (The other is just to point out that religious reasons for privacy and modesty do indeed get more respect than other reasons.)
I personally have the sense that deeply held personal beliefs ought to count the same whether they're based on religious or secular grounds.
I'm not sure that political correctness is the cause of the difference, though that may be part of it. The other aspect is that our constitution guarantees freedom of religion, but doesn't mention protection for personal beliefs, at least as it is translated into concrete actions.
So religious beliefs are more protected. How far this protection goes is a complicated legal question that I could not answer offhand without substantial research. Certainly there are limits though. Religious beliefs can't justify putting others at risk in this country. I suspect it also depends on just how basic a tenet of the religion we are talking about. According to what I've read and posted Muslim medical modesty is not a law set in the Koran, but more of an interpreted custom. If so it has less weight, and indeed no hospital would guarantee to grant all requests for say same gender OR care automatically.

Anonymous said...

I think a lot of this has to do with the fact that Muslims are a minority in this country thus they are given more rights than the average citizen. This isn’t just Muslims; it’s every other minority out there. It also complicates things when our constitution guarantees freedom of religion. If cases go to our courts against hospitals concerning them not respecting the Muslim religion, who are we to determine what their religion really stands for? It really bothers me that our hospitals would put forth this effort to respect and protect them but we have to fight for that same level of respect. I also think some of it has to do with income. As more and more immigrate to this country, hospitals are trying to win their business so they change their practices to accommodate them. I guess all this boils down to the almighty dollar in a way, one to not have to get sued, and the other to make more money. I may be wrong but that’s just what it seems like. Jimmy

Joel Sherman said...

Here's an article, documenting that Harvard, certainly a stronghold of women's rights advocates, has initiated women's only time in their gym to accommodate Muslim women's modesty.
I have mixed feelings about this. It's not per se an unreasonable accommodation if it doesn't significantly decrease the ability of all students to use the gym. On the other hand, there are alternatives such as giving the women passes to women only gym facilities which I believe are abundant and legal in Massachusetts. The article said this is being done on a trial basis.

Joel Sherman said...

Here's a follow up on the article about Muslim women physicians refusing to scrub their forearms in the UK. Apparently some have also insisted on wearing veils when seeing patients.
A British council ruled basically against them, stating that they have to remove the veil if the patient is uncomfortable. I certainly would be uncomfortable in that situation. Much of our sense of communication comes through non verbal clues and facial expressions. Wouldn't want my physicians masked.
I'm not aware of these situations arising in the US. We have proportionately fewer Muslims and they are likely more integrated into our society. We certainly don't have a national organization that can mandate rules either.

Joel Sherman said...

Here's a brief interesting thread about what a pastoral visitor should do when visiting patients, and they 'see' more of their parishioners than they feel comfortable with.
In my experience, pastoral visitors usually leave the room when medical personnel come in, but I guess practice varies.

Joel Sherman said...

An article about a Muslim radiology technician who lost her job in the UK because she refused to bare her arms and scrub below the elbows. I guess there is a limit to political correctness in the UK.
I don't think we've had similar controversies in this country yet. I have no idea how they would be adjucated here. We apparently have a more moderate population of Muslims in the US.

Anonymous said...

Here's a nice article that gives a brief overview of modesty of different religious group:

http://www.communityoncology.net/journal/articles/0307443.pdf

Joel Sherman said...

Nice reference.
I note with interest however that the subject of male modesty isn't even considered as if it is non-existent. This is despite the fact that male Moslems aren't supposed to expose themselves either as I understand it.
The double standard in modesty seems to have religious origins as well as secular which I didn't really appreciate. The author of this article has totally ignored the fact that men also avoid medical care for reasons of modesty.

Joel Sherman said...

Here's another article (referenced by Bernstein) on Muslim UK problems with Western medicine. It includes Muslim medical students refusing to ask patients about alcohol and STDs and some refusing to examine opposite gender patients.
The British medical establishment opposes this, even though England is I believe more 'politically correct' than we are. Still and all, a physician in this country who missed a diagnosis because they refused to ask about it would have no protection from legal liability. As a physician you just can't put your head in the sand and pretend a problem doesn't exist because it offends you. A patient's health is the number one priority, not your own personal view of ethics or society.

Joel Sherman said...

My prior post makes me think of a parallel in this country (though it's not concerned with modesty): that is physicians refusing either to do abortions or prescribe abortifacients when asked for usually religious reasons or purely ethical reasons.
This is not a forum for a full discussion of the abortion controversy, but it is certainly pertinent if we're going to mention Muslim refusals to see opposite gender patients or care for certain conditions. We have precedents in this country.

Joel Sherman said...

Here's an article about Muslim women who arranged to take swimming lessons in private to protect their modesty. In order to arrange this, the Muslim community had to fork over $3000 to pay for curtains.
If at least some Muslims feel so strongly about it I'm surprised that I don't hear more about it in medical situations in my community. I've never heard the issue raised at the hospitals I frequent.

Anonymous said...

I recently read where several instituions including the University of Michigan, etc were using new gowns specifically designed to protect the modesty of muslim patients. I find this a little problematic in the fact that while everyone has known for years everyone hates the open back miniskirts that pass for gowns...there has been no effort to accomodate people for all these years even with the knowledge people do not like them....yet when the mulsim community protests we make accomodation. Now, don't get me wrong, it is not the accomodation for religous reasons that bothers me, it is the fact that accomodation COULD have been made as evidenced by the efforts for the Muslim community, but wasn't. Who gets to decide which is more important to a patient when deciding personal reasons or religion. Now we all understand, there are times such as surgery that the I.C.U. gowns (as in I see you..as a nurse friend refers to them)make sense, but there are many more cases where they are used but don't have to. I actually went for imaging where they provided me scrub type wear, and my father was provided with a long gown that overlapped....so...is it acceptable to provide accomodation for religous reasons that we would not for other reasons...who says one is more important than the other...is it right, is it legal?...and I am a devote Christian so I am not anti religion .......alan

Joel Sherman said...

Alan, it just emphasizes the basic messages of these blogs which is you need to request and/or complain to get a practice changed.
Hospitals don't do this because of greater respect for religion; they do it because of the higher level of complaints from Muslim patients. In areas of significant Muslim populations it boils down to money.
The basic principle is: Ask and you may receive.

Anonymous said...

Dr. Sherman I could not agree with you more. I think the key for individual accomodation is ask prior to committing to be there so you can go that way you can play the I will go .....and pay where they will accomodate.....the question becomse how does the average indviduals band together without the common base that religion provides to be a more powerful lobby through numbers....thats the tough part...alan

Joel Sherman said...

I've always thought that not only religion but race as well is an important variable here. Here's an abstract about adolescent male preferences for physical exams. The article states that African American adolescent males prefer women doctors for exams, even for genital exams. This was as opposed to Caucasians where the opposite was true. The primary variable they found was that the African American boys who preferred women were more likely to have been raised by a single mom. Not really a surprise but it certainly has broader implications for why we have the preferences we do.

MER said...

Interesting study, Joel. Somebody needs to really study this, comparing all the various studies, doing some new ones.

Studies like this show how complex this issue is. Dr. Bernstein keeps wanting to probe the psychosocial aspects of why patients feel the way they do about modesty. I think that's important -- but I think we'll find that the variables are great. I don't think they're really racial as much as they are socioeconomic. Much of what we consider culturally racial is really I think more socioeconomic. But this study seemd to indicate there may be some strictly racial preferences.

I do believe that if someone really studies this, though, they'll be able to categorize the variables into some subgroups that give us a better understanding of all the elements that go into the nature of human modesty and how much of it is constructed and how that happens, as well as how much of it may be hard wired.

Almost all cultures have taboos about some kind of privacy during elimination of waste. Although, even in Western culture, we see a huge difference public attitudes in that regard beginning in about the 1500's to 1600's. But there seems to be a basic sense of modesty in human nature -- even in societies like ours where it currently seems like modesty doesn't exist, when we watch the media. But does the media represent the average person?

In "Privacy: A Manifesto," the author, Wolfgang Sofsky writes:

"...everyday life is far less liberal than the media and advertising suggest. The effort to conceal sexual intercourse from others is just as widespread as it has every been. Even if more skin is shown, the line where shame begins is merely shifted. The visible body is largely de-sexualized, and in some cases even the genitals have lost their power to excite. Pious immigrants may consider Western culture to be shameless, but its inhabitants blush just as before, only not when they see naked bodies at the beach. The same person who regularly takes sun baths naked in public places turns off the lights at home when things get intimate." (p. 62)

This explains why a significant number of medical professionals live in two different worlds. The world of the hospital or exam room, which is supposidly gender neutral. And the world where they are patients and are faced with modesty issues. We too live in the public world, the world of the media -- Hollywood and advertising. And then there's our private world, the one we really don't talk about, the world the exists when we turn the lights off in our bedrooms.

I suppose my point is that I still believe that, despite the public face cultures often put on nakedness and modesty issues, whether it be prudish or libertine, there's still the private face that we rarely reveal to anyone but those closest to us. That underground attitude is difficult to get at -- but it's there nevertheless.

And I'm not convinced studies like this one and others like it are really delving deep enough into the foundations.

Anonymous said...

Dr. Sherman,
What exactly do you mean by "there are a large percentage of 'lay' priests in the religion" when refering to the Mormons?

I've been a Mormon all my life (don't worry, whatever you meant by it won't offend me) and I do feel some shame about how blacks were treated before 1978. In fact, if that change hadn't been made while I was still young I would have left the church for that very reason.

As a Mormon Missionary in Latin America I was very pleased to see how much diversity there is within the Mormon community. Down there, even more than the U.S., the color of a persons skin makes no difference. Though, when my father was a Missionary in the late 60's, also in Latin America, he was never allowed to teach black people. He didn't agree with it but was forced to follow the church rules. It's pretty disgraceful to think how it used to be.

Anyway, to get back on topic. I live in Northern Utah in a Mormon community but was raised outside of Utah. I've noticed here that there is more concern for modesty than in other places I've lived. I haven't spent any time in the hospital but some of my family members have and they say that gender preference isn't really a problem at the local hospital and clinics. I think it has a lot to do with Mormon family values and high morals.

I occasionally relate to my family some of the experiences I read on this and other boards and quite often they seem genuinely shocked. Things like female techs giving testicular sonograms and female nurses shaving men's private parts apparently are not very common here.

My father worked as an orderly here in the local hospital in the late 60's and said that in the year or so that he spent there he never once saw a naked female patient, only men. I'm sure it's changed a lot since then though, even here. But modesty still seems to be a higher priority here than in other places I've lived. There's definitely a much higher male nurse to female nurse ratio.

I imagine that it's still common to send a female nurse to do intimate care on men, but for those that request same-gender intimate care it's likely they'll accomodate. My mother has spent some time at the hospital and prefers female care. At her request they put a sign on her door that says "Female caregivers only". I've never heard if the same thing is done for male patients but I highly doubt it.

But my point is that I believe that religion has everything to do with the higher respect for modesty that exists here in Utah.

DG

Joel Sherman said...

DG, my knowledge of the Mormon faith is indeed limited. What I meant by lay priests are religious officials who have a fulltime secular life and business. In Catholicism, I believe they are called Eucharistic ministers and are not ordained. I'm sure that is not completely analogous to the Mormon faith, but I have read that many high ranking church officials are prominent business men. I don't know if they perform religious ceremonies.
Thanks for your comments on modesty and religion.

Anonymous said...

OK, I understand what you mean by lay priests. It's true.

I hope I didn't sound like I was offended by anything you said. I really wasn't. You were right. Thanks for this blog Dr Sherman.

DG

Anonymous said...

Here's an interesting story:

http://www.republicworldnews.com/news/health/modesty-in-surgery/

Jimmy

Joel Sherman said...

That's an amazing story for this country Jimmy. Keep a lookout for a follow up or more details. Was this in Detroit?
How many people would really prefer to die to preserve their modesty? Seems like there are some on these boards.
Reminds me somewhat of the notorious episode in Saudi Arabia in 2002 where the religious police prevented girls from being rescued from a fire at a girls school because they weren't properly dressed for the outside and many died.
Any other thoughts on this?

Anonymous said...

Just another example of what we've discussed. Seems this is becoming much larger than a few select hospitals.

http://query.nytimes.com/gst/fullpage.html?res=9C00E7DE1531F932A3575AC0A9629C8B63&sec=&spon=&pagewanted=all

Jimmy

Anonymous said...

What disgusts me about that last article is the fact that an astounding number of people of both genders won't seek medical help because of the humiliating and unethical way they know they'll be treated, yet very few people in the medical world ever gave it any thought until the female muslums began to complain. There are hundreds of thousands if not millions of Americans that have refused medical care for that very reason, and the medical world knows it but apparently hasn't cared until now.

Joel Sherman said...

This is somewhat off topic, but I found it of interest.
Here's an article about the French becoming more modest on public beaches rather than less.
Surprisingly it is a purely secular trend not associated with the increasing presence of Moslems in France.

Joel Sherman said...

There are not many reference guides on this subject so I thought I'd post this one.
This purports to be a comprehensive guide for religiously conscious healthcare providers covering all areas including modesty.
I have not seen a copy yet.

Anonymous said...

I was very dismayed when reading the "Acknowledgement of Procedural Consent" form from the LDS Hospital in Utah. Apparently we are forced to agree that photos and videos can be taken, we are forced to allow anyone to observe for educational reasons and non-medical professionals such as vendors will be allowed to watch. The Mormon hospital was my last hope in trying to find a place that understands ethics and morals.

Even more disturbing is a statement at the end saying "I understand the health care providers involved in my care, including those providing anesthesia services, may not be agents or employees of the hospital and that the hospital is not responsible for their actions or inaction." How can they do that? If they bring in other people the patients aren't even aware of how can they not be held responsible?

I had high hopes for the Mormons but even they can't be trusted to insure the safety, morality and ethics all human beings deserve. More proof that medical care is nothing but a business and patients are nothing but dollar signs.

Joel Sherman said...

I agree Anon that is a very disappointing statement. If I were a patient there I would make it clear that it is unacceptable. Do tell them you'll go elsewhere.
Legally they are responsible for anyone they allow in to watch procedures or operations. They cannot disavow responsibility.

Joel Sherman said...

Here's an extensive look from the Washington Post at the new airport screening devices and how different religions react to them.
I personally don't see how a safe compromise can be reached as long as we're subject to ongoing terrorist threats.

Joel Sherman MD said...

Here's an interesting and complex story from Dearborn MI where there is a large Muslim population. A male nurse working in a public clinic was given conflicting orders about dealing with Muslim women, then fired.
He is suing for damages.

Joel Sherman MD said...

Here's a follow up story on the above with fuller details.

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