Pop question: A Muslim woman walks into a doctor’s office for a routine gynecological exam but refuses to be examined by a male physician. There are no female physicians available. What to do?
Aasim Padela, M.D., M.Sc., an emergency medicine physician and Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2008-2011), and a co-author pose this and other questions about the complex interplay of religion, health care behaviors and patient preferences in a paper published online in November in the Journal of Medical Ethics.
The paper explores various ways that religious values, cultural practices and gender interact to impede the delivery of quality care—and potentially undermine patient health.
Padela has studied health disparities among a number of groups in the past, but focuses this particular paper on Muslims because of their unique problems in the United States health system which, despite its increasing diversity, is still mainly led by white men who may not be familiar with Muslim practices.
“What I hope to do in this paper is to educate providers about Muslim women’s religious needs and give bioethicists a better understanding of the Islamic faith,” Padela says. The long-term goal is to “reintroduce the idea of humanistic practice, where providers try to accommodate people’s needs as best they can.”
Many providers already do that, he says. Jews, for example, are often offered kosher food, and Jehovah’s Witnesses are sometimes given the option of surgery without blood transfusions.
But providers could do a better job of meeting the unique needs of certain populations, including Muslim women, who are required by Islamic ethical regulations to dress modestly and avoid being alone with or touched by a non-related male. Meeting those needs will improve health outcomes and narrow health disparities, he says.
A more accommodating system, he adds, may prompt more Muslim women to get screened and treated for breast and cervical cancer, for example. These kinds of examinations, he notes, can pose threats to Muslim women’s religiosity.
Fear and distrust of an unaccommodating medical system, on the other hand, may lead Muslim women to forgo or delay screening or treatment or seek alternative—and potentially less effective—therapies, he says.
Little Data Available on Health Disparities Linked to Religion
Much is known about health disparities related to race and class, but there has been little research into disparities based on religious practice and affiliation. But studies show that minority populations as a whole receive inferior care in the United States, and Padela suspects this may also be true for Muslim women, who themselves may belong to different branches of Islam with varying practices. Cultural competence and patient-centered care can improve care and health outcomes, he says.
“I have found some Muslims who are very reticent to be admitted to a hospital,” says Padela, a Muslim. “They feel they have no control. People walk in or walk out of their rooms, or may be required to share a room, or even a bathroom, with someone else. As a result, they may delay seeking health care—or avoid it entirely.”
The problem, of course, is not unique to Muslim women. Islamic ethical mandates relating to seclusion and physical contact also apply to men, who also often express a desire to be treated by physicians of the same gender and religion. And other religious minorities have also experienced conflict between their values and beliefs and the practices of our health system. Some Jews, for example, have resisted porcine-based vaccines for influenza.
To ease patient concerns and improve health outcomes, Padela calls on providers to gain a better understanding of religious beliefs and practices so that they can make accommodations to Muslims—recognizing that diversity within Islamic communities may complicate their efforts.
When it comes to Islam, providers should learn to understand, and recognize when Islamic conceptions of modesty might come into conflict with care, he says. If possible, providers should make accommodations for patients who might be reluctant to change their dress, to expose parts of their bodies, to be physically examined, or to be alone with members of the opposite sex.
Providers could, for example, make an effort to provide Muslim women with doctors of the same gender. If that is not possible, providers could allow them to remain clothed or wear more concealing gowns. If the traditional open-back gown is necessary, providers could simply shut the door, close the curtains or knock before entering to give women more privacy.
Providers could also allow a chaperone to be present or in close proximity during patient interactions to prevent violations of Islamic prohibitions against seclusion. If that is not possible, they could keep doors slightly ajar during one-one-one meetings. And providers could approach physical contact—whether for an examination or simply to express empathy with a patient—with greater caution and sensitivity.
In answer to the pop question above, Padela recommends that a provider inform the patient that no female provider is available, ask if anything can be done to make her feel more comfortable and offer an examination performed by a female nurse practitioner under observation of a male physician.
Accommodations even as simple as this aren’t always possible in a system that is frequently overwhelmed, Padela says. At a minimum, providers should learn to communicate in a culturally sensitive manner. “The way we deliver the message means a lot,” he says. “It can make people feel human, understood and tolerated.”
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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