Tuesday, October 25, 2011

Modesty, A Woman's Perspective
by Nicole Lee

From their website.  Click on to read.
Nicole Lee is the creative director of Stirrups and Stories.   She has worked in the area of sexual and reproductive health for over five years: taking sexual histories, training others to do the same, working in HIV prevention, and providing quality control for clinic and agency management.

The word “modesty” is loaded with too much emotional and cultural connotative meaning to be a neutral concept.  Who is saying the word, and how, and to whom, and for what purpose?  Is “immodesty,” with all of its attendant frightful connotations, the shadow defining the edges of modesty?

In the context of health care provision, modesty is a double-edged ideal:  on one hand, respecting patient-initiated modesty enhances our ability to serve patients.  Some of the ways we do this include:  acknowledging and responding to the cues our patient gives us about her level of comfort; by asking for permission and consent before touching her; by echoing the language she uses; by avoiding unnecessary, invasive procedures; by acknowledging the legitimacy of her family structure.  We do this by listening – and hearing – what she is saying to us.  By explaining in language she understands why we are asking intrusive questions, and working with her to procure the necessary information.  By respecting a denial of consent and fully honoring the process of informed consent.  By seeking training on cultural competency specific to the populations we see.    

Such a type of respect requires our acknowledgement of the wholeness of the patient in front of us, including the soul and the heart that embraces that modesty.  No longer is she a composite of parts and organs and symptoms, a medical puzzle waiting for construction (or deconstruction):  her embodied self is not our disembodied medical task.  When we as health care workers are respecting a woman’s own sense of modesty, we are helping to make more visible the value system in which she functions.  Significantly, that value system is fundamental to the context in which our palliatives, prevention, and education must succeed, and is a potentially key part in identifying pathogens or risk.

On the other hand, if a health care worker or policymaker enforces modesty, the relationship between patient and provider is inhibited.  Such a dynamic can silence a patient, leaving health care workers without knowledge that may prove vital to providing care for a given woman. 

The enforcement of modesty is rarely overt, but instead typically a thoughtless perpetuation of a set of cultural norms that liken immodesty to being unladylike.  It provides a prescription of acceptable behaviors and appearances for women to assume, and defines the dimensions of space women are allowed to occupy.

Is it immodest and unladylike for a woman to disclose the number of sexual partners she has had?  To choose not to shave any particular body part?  To use abrupt or rough language to describe her experiences?  To talk openly and unashamedly about her partner(s), who may be of the same sex?  To speak of her abortion with sadness and no shame, or with no sadness at all? 

Is it unladylike for a woman to challenge our authority as medical care providers?

Women are faced with a variety of messages that often boil down to one – the feminine ideal is to be a lady, so avoid an immodest exposure of self.

Are our offices spaces where women can expose the necessary parts of themselves without fear of sanction?

If they are not safe because we (or our staff) judge our female patients for not abiding by the standards that we, possibly unconsciously, have for women, it is nearly impossible to conceal.  Our biases are conveyed in a plethora of ways both subtle and overt, including how we ask questions (and which questions we choose not to ask), our body language, our double standards for men and women.

Conversely, by ignoring a woman’s own unique modesty and sensibilities, we are imposing on her an authoritarian message of subservience and disrespect.  Without thinking, we risk telling her that “her body is ours” and that she has given up certain rights merely by seeking health care.  This encourages a retreat from visibility for many women and a reduced ability to successfully communicate with her health care provider.

What and how we communicate, and how we receive information given, can contribute to a woman’s reluctance to seek prevention or cure for any number of health concerns.
By respecting her values and that which she chooses to conceal or protect, we are inviting her to reveal more of herself to us.  In that exposure is the human for whom we are charged with caring, and in this new relationship is the true potential for health and healing.

By refraining from imposing our own values of modesty on our patients, we open up the possibility to clearly see our patient in her own context.  In that exercise of self-awareness and self-restraint, we lay the groundwork for a respectful and deeply therapeutic relationship with her.

The narrow channel between what we subscribe to and what we prescribe for others is a tricky space to navigate, but that is exactly what we must do. 


Joel Sherman MD said...

Thanks Nicole. This article reminds us that though men and women have many modesty issues in common, women still have issues that men do not. For instance, it is not a judgmental question for most men how many sexual partners they have had, but can be for women. Women and men still tend to be judged by different standards.
And of course the standard pelvic exam puts women in a much more vulnerable position than most men will ever find themselves in, at least not till much later in life when they are better equipped to handle it.
This blog will continue to welcome all perspectives on modesty.

Anonymous said...

Nicole Lee’s article discusses many interesting aspects regarding female medical modesty and is well worth reading. However, I would like to point out one statement that I believe is often at the root of conflicts between medical personnel and patients regarding modesty.

Ms. Lee asks “Is it unladylike for a woman to challenge our authority as medical care providers?”

A common definition of authority is “the right to control, command, or determine” and it is my contention that it is important for both patients and providers to realize that in that sense of the word those in the medical profession have absolutely no authority over their patients. As patients,unless unconscious or incompetent,we have the final say as to who will provide our care and exactly what types of care and examinations we will accept. We are the paying customers and our bodies belong to us and not the medical profession.

If providers believe they have “authority” over their patients, they are more likely to be resistant and authoritarian when patients refuse to be compliant regarding modesty or any other issues. After all, the provider’s “authority” is being undermined.

If patients believe that providers have “authority” over them, then they are much more likely to submit to exams or procedures that violate their modesty and then often suffer psychological consequences during and after such occurrences.

So I urge all of us to remember that simply because we have entered a medical office or a hospital we have not given up our autonomy. We are patients, not prisoners and the ultimate authority regarding what happens to us is ours.

Doug Capra said...

Very interesting and worthwhile article. Throughout most of the article, Nicole uses word "patient," which is gender neutral, although the focus of her article is about women. Much of what she says, especially in article beginning, could refer to both genders. But there are important differences, and she points this out in the article's second half. The basic issue of modesty transcends gender. But men and women need to learn and accept how this issue affects them commonly, and how it differs for them. We are all patients at time or another, males, females, doctors, nurses, lawyers, teachers, carpenters, rich, poor, famous, unknown. This issue involves all of us and we need to respect its various perspectives
Doug Capra

Violet to Blue said...

"Women are faced with a variety of messages that often boil down to one – the feminine ideal is to be a lady, so avoid an immodest exposure of self. Are our offices spaces where women can expose the necessary parts of themselves without fear of sanction?"

Interesting article. I'd suggest that women's reluctance in these situations is not solely down to modesty (which varies greatly from woman to woman due to personal and cultural factors), but also to exposing themselves to the possiblity of physical violation, or the triggering of the memory of an earlier violation. Certainly identifying and respecting whatever boundaries the patient has will assist greatly in helping the patient to relax, but a woman in stirrups is fairly helpless and knows it, whether she's carefully draped in a gown or stark naked.

I will add that male patients may have a history of being violated themselves (I can think of at least two men I know), and for whom the above will also be pertinent.

female pediatric urologist NYC said...

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Violet to Blue said...

I've just picked up on a recent UK study on women's experiences of cervical screening, and un-earthed the below article which was also included in the discussions around the study:


...regarding Canadian men's reluctance to cooperate with STI/STD testing due to socio-cultural factors. May be of relevant interest perhaps...?

Anonymous said...

It's hard to feel sorry for women when nearly all of the violations I've seen and heard of are healthcare women violating men. (The verb violar in Spanish means "to rape", how fitting)

Anonymous said...

I found this article while researching patient rights in situations like GYN exams and such. After a former student visited the school and was telling me about their nursing school experiences, they told me that they happened to witnessed female exams, even a pap, I got curious. I asked if the patient was ok with students watching such a personal matter. They couldn't answer, because no one asked the patient if it was alright to violate their privacy in such a way. Yes, I know medical students need to see things happen in person, and they need to learn this way. But these were nursing students, who were no older than 19 & 20. My first thought- if I were on that table, in such a vulnerable position, and young strangers came in to watch, no matter their reason for being there, my trust I had put in my GYN and the hospital/clinic/office would be completely gone. It's an invasion without permission. My second thought was, though it may be a far and away chance, what if one of those nursing students was one of my former students? I couldn't bear to think about how I would feel afterwards. Just thinking of the situation and outcome brings me to anger, betrayal, and tears.

Anonymous said...

i just want to share with you how worse we have it in india.
i had a pcos scare and had to go for a pelvic scan when i was just 15 years old. the radiologist was a lady, but she had her 12 year old pre adolescent son sitting next to the machine and just look over the patients. mine was fine but a pregnant woman got a trans vaginal scan done IN FRONT OF THAT BOY because the stupid radiologist said she will do just as she wishes, and if u r not okay with it, just get lost...
yeah, horrible, isn't it?

PV1966 said...

NHS is forced to apologise after a woman having a smear test specifically requested a female only to be met by a pre-op transgender medic 'with stubble and a beard'

* Patient asked to be seen by female nurse but was met by biologically male nurse
* When she pointed out the mistake, the nurse said 'I'm not male, I'm transsexual
* But the patient has now received an apology from the London-based NHS Trust



Patients should always be able to demand to choose the sex/gender of the provider they are most comfortable with to do an intimate exam or procedure on them, regardless of their own sex/gender.

And patients should not have to explain their reasoning. Their own 'comfort level' should be all that matters.

And that choice shouldn't just be allowed for female patients.

A male patient should not have to explain why he'd prefer having a woman doing an exam on him anymore than he should have to explain his reasoning for asking for a male provider.