Modesty in Health Care: A Cross-cultural PerspectivePosted by Marcia Carteret, M. Ed. in Special Topics
Studies have shown that obtaining accurate medical histories and diagnosing current symptoms can be adversely affected by a patients’ concerns about modesty. Though these concerns are not exclusive to cross-cultural encounters, the most challenging situations do often arise because of differences in modesty mores between providers and their patients. Though initially our tendency is to think of modesty in fairly simple terms (i.e. covering the intimate body parts), cultural values around modesty can be far more complex. Therefore, expanding our assumptions about modesty is important to ensure successful cross-cultural interactions. This includes understanding the impact of acculturation and assimilation. To avoid stereotyping individual patients and family members, we may start by considering normative behaviors for less acculturated individuals first, but then we always expand our view and test our assumptions. We allow for a great diversity among human beings’ values, beliefs, and behaviors.
“Modesty is not just about covering up or wearing specific clothing. By definition, modesty is about respect. A provider who takes cultural modesty into account is someone who shows respect and caring in the highest degree.” 1 Though we often associate modesty with the prescriptive doctrines of certain religions, modesty in many cultures often means showing propriety in speech, dress, or behavior and lack of pretentiousness. In many cultures, modesty demonstrates essential goodness in a person and is highly valued. Purity of thought and manners is as important as physical/sexual purity – and in fact the two are inextricably linked. In collectivist cultures where the family is the center of all loyalty, obligation and status, social approval is very important. Shame and honor are highly emphasized because a person’s bad action dishonors their entire family, tribe, village, and so on. In a highly individualistic culture, this is lesser concern because a person’s behavior reflects more on himself or herself.
In societies that place a high value on modesty, it is important for both sexes, but particularly emphasized for women. A woman’s sexual purity and chastity honors her entire family. American women may view this as more discriminatory than protective. It is important not to assume that women in high-modesty cultures are forced to accept the restrictions placed on them by men. In fact, for many women in these cultures modesty is an attribute to be admired and attained. Women often impose modesty on themselves and other women as a way of keeping boundaries of privacy and respect.
In the majority of health care visits, a routine handling of modesty and privacy concerns suffices. However, sensitive interactions do arise for cultural and religious reasons. There are no hard and fast rules for handling these situations, but being prepared to ask culturally sensitive questions is important in reducing anxiety and stress for patients and family members. Delicate situations require preparedness in the form of appropriate questions: After explaining what is usual in western medicine (drapes, closed doors and knocking before entering) asking “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?” Or, “In your culture, how would a doctor show respect for a female/male patient during the examination.”
Modesty in Traditional Arab Culture:
Strict cultural guidelines about modesty are very common in Arab cultures, especially among Muslims. The Islamic world view emphasizes the dependency of humans on God, and fear of God’s punishment tends to direct Arab Muslims to follow Islamic ethics. Modesty is stressed for both sexes, spiritually and physically. However, it is of greatest importance for Muslim women. Although there is considerable variation in the manner of dress and segregation of the sexes in different Arab countries, traditional custom dictates that women cover their hair, body, arms, and legs. This is a concern any time a woman might be seen by men who are not from her immediate family. Thus, special provisions should be made for female providers to examine Muslim women. Similarly, female nurses should be assigned, and a female nurse should always be present if a male doctor is treating a female Muslim patient. Some Muslim women may resist uncovering parts of the body not being examined. Opposite-sex medical interns, assistants and interpreters should be avoided. Sometimes a husband may ask to be present while his wife is being examined, and all efforts should be made to comply with his request. Muslim patients, both male and female, will appreciate privacy screens and consistency in closing examine room doors. They may be unsure about making direct requests for themselves about privacy measures, so being able to anticipate their needs will demonstrate real cultural awareness and sensitivity. Finally, many Muslims believe it is forbidden to touch a member of the opposite sex outside their family and will resist shaking hands. However, others will shake hands (unless they have just performed cleansing rituals that precede prayer). The important thing to remember is to mirror the behavior you witness. If you offer your hand and the other person does not respond, do not take this as a personal insult. American women, especially, may feel rejected when an Arab male refuses her hand, especially if she is a doctor. She should not attach her culture’s meaning to this behavior. In general, healthcare professionals should avoid touching opposite-sex Muslim patients except when giving direct care. Such hesitation isn’t as necessary with a patient who is of the same sex.
The above discussion of modesty in Arab culture provides the normative values and behaviors of people who have recently immigrated and are not yet acculturated in the U.S. Many of the Arab American families in our community will not express these same concerns about modesty. It is important to ask questions of each individual patient/family to determine where they are along the assimilation continuum and how strictly they adhere to traditional customs and practices. The extremely modest Arab may be the exception in a provider’s experience, but it is important to be prepared to handle the exceptional case when it appears.
Asian Cultures and Modesty:
In general, traditional Asian women place a high value on modesty and may be uncomfortable in health care interactions with male doctors. Even today, modesty is related to the relationship between genders specifically. Any overt display of affection in public between members of the opposite sex is unusual in parts of Asia, and even hand holding between men and women could be considered inappropriate unless they are married. This simple gesture of affection is more common between two women in China, for example, and does not in any way suggest a tendency towards homosexuality, which it might in American culture. In China over 90% of obstetrical or gynecological providers are women which averts the problem of women’s extreme modesty in health care interactions2. In many Asian cultures, sexuality usually gets discussed within the context of marriage and child bearing only. Thus, sex is still a taboo subject in many parts of Asia. Parents and healthcare professionals may be reluctant to provide sexual information to young people in their families.
Traditionally, modesty and chastity are highly valued qualities in young Asian women who are taught to avoid premarital sex because it would tarnish their family honor. As Chinese and other Asians are exposed to western cultural values around modesty and sexuality, these attitudes change. Many highly acculturated Asian women have no objection to being examined by a male physician, are comfortable discussing their bodies, their sexuality, and reproductive health. The astute health care provider is aware of the spectrum of values, beliefs and attitudes and asks culturally sensitive questions of each patient to avoid stereotyping.
Modesty in Latino Cultures:
As is the case in Arab and Asian cultures, acculturation is key to a person’s attitudes and behaviors around modesty and privacy in Latino cultures. More traditional women who have recently immigrated from Mexico and countries in central and South America, for example, may be very modest, whereas the typical second or third generation Americans from the same countries will likely be much more relaxed in health care interactions. Religiosity can also be an important contributor to ideas about modesty; many Latinos are strict Catholics and may feel that modesty is an important part of being faithful to the church. Finally, among many Latinos the concept of modesty is closely connected to respecto and privacy. Latino cultures are collectivist with a strong sense of in-group belonging, interdependency and responsibility. Illness is often considered a very private family matter, and sharing private matters in front of strangers may be regarded as wrong. In more traditional Latino cultures, a doctor might be someone a family has established relationship with over many years. A doctor is thus a trusted member of the community who can be trusted with personal health matters. In American culture, patients expect a formal and detached relationship with health care professionals. We don’t usually have close personal ties to our doctors and, for us, being open and less modest is easier with a professional we are unlikely to encounter outside the exam room.
Understanding the cultural aspects of modesty is especially important when dealing with less acculturated individuals, especially recent immigrants and refugees. Though cultural values around modesty are stressed for both sexes, purity, chastity, and lack of pretentiousness in women is greatly emphasized in many traditional cultures. Americans easily apply their own cultural values about independence and equality to people in other cultures, and may judge the restrictions placed on women in many societies as being discriminatory and even abusive. It is important to realize that women in many cultures impose modesty on themselves and others as a way of keeping privacy and respect. The key questions health care professionals can use to be culturally sensitive in handling issues around modesty are: “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?” Or, “In your culture, how would a doctor show respect for a female/male patient during the examination.”
1. Andrews, C. 2006 Modesty and healthcare for women: understanding cultural sensitivites. Community Oncology. Vol. 3 No. 7 443-445
2. Mo, B. 1992 Modesty, Sexuality, and Breast Health in Chinese-American Women. Cross-cultural Medicine – A Decade Later [Special Issue] West J. Med Sept; 157:260-264
Additional Resources for this Article
1. Galanti, G. 2003 The Hispanic Family and Male-Female Relationships: An Overview. Journal of Transcultural Nursing, Vol. 14 No. 3 180-185
2. Lawrence P., Rozmus, C. 2001. Culturally Sensitive Care of the Muslim Patient. Journal of Transcultural Nursing, Vol. 12 No. 3 228-233
3. Hammad, A., Kysia, R., Rabah, R, Hassoun, R., Connelly, 1999 M Guide to Arab Culture: Health Care Delivery to the Arab American Community. ACCESS Guide to Arab Cultur. 1-32