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July 2006 ■ COMMUNITY ONCOLOGY 443
Volume 3/Number 7
Modesty may be a barrier to healthcare.
By taking modesty into account during examination and
treatment, healthcare providers can improve the care of
and sensitivity toward patients.
Perspectives of modesty among Asian, Hispanic,
Muslim, and Jewish female cultures are offered, so
that practitioners can better understand how modesty
influences healthcare.
Data for this article were based on personal interviews
with women from the three main branches of Judaism
(Reform, Conservative, and Orthodox), as well as
the unaffiliated. Additionally, literature from several
disciplines, including psychology and nursing, as well as
religious and lay sources were used to define modesty.
M
odesty has been suggested
as a variable that may in-
fluence healthcare utiliza-
tion.1–4 Regarding cancer
care, Chinese and Islamic
women have cited modes-
ty as the reason they do not obtain cervical cancer
screening or mammography.5,6
By understanding different norms of modes-
ty and the way women feel when modesty is pre-
served, providers will have a new insight into the
sensitivities and values of certain cultures, which
can enhance their ability to deliver quality care.
For example, among Jewish women, modes-
ty does not mandate female providers, whereas in
the Chinese culture this is much more important.
Some cultures value modesty as a way of protecting
women from the wider world. Providers can take
this into account when discussing private issues by,
for example, making sure the door is closed, rec-
ognizing signs of discomfort when talking about
sensitive subjects, and asking the individual if she
would like another person present. Some cultures
actually require a family member to be present even
during noninvasive physical exams.
This paper is an overview of perspectives of
modesty among Asian, Hispanic, Muslim, and
Jewish female cultures, with some suggestions for
enhancing the healthcare practitioner’s knowledge
of how modesty influences healthcare. The article
is based on original research, the first of a series of
small studies undertaken to define modesty and de-
scribe its attributes.7 Subsequent studies were then
conducted to develop and test a new instrument
Modesty and healthcare for women:
understanding cultural sensitivities
Caryn Scheinberg Andrews, PhD, CRNP
Alvin and Lois Lapidus Cancer Institute, Northwest Hospital Center, Randallstown, MD
Across diverse cultures and ethnicities, many women have named modesty as the reason they do not obtain
cervical cancer screening or mammography. This article is based on original research, exploring and defining
modesty among Jewish women in Baltimore, MD, and is part of a series of studies related to modesty and
healthcare utilization. Information from the literature on Muslim, Hispanic, and Asian forms of modesty are
included for comparison. Understanding phenomena such as modesty and the role it plays in women’s health
will significantly impact both intervention design and treatment practices. Culture and health, partnered in
care, could have an impact on utilization of healthcare services and the relaying of health messages.
to measure modesty, called “Your Views of Mod-
esty,” in the context of breast, cervical, and general
healthcare utilization by Jewish women.
Defining modesty
Modesty is not just about covering up or wear-
ing specific clothing. By definition, modesty is
about respect. A provider who takes cultural mod-
Psychosocial Oncology
Commun Oncol 2006;3:443–446 © 2006 Elsevier Inc. All rights reserved.
Manuscript received May 1, 2006; accepted June 27, 2006.
Correspondence to: Caryn Andrews, PhD, CRNP, Lifebridge
Health, Alvin and Lois Lapidus Cancer Institute, Northwest
Hospital Center, 5401 Old Court Road, Randallstown, MD
21133; telephone: 410-521-8393; fax: 410-521-7385; e-mail:
caryn.andrews@comcast.net.
444 COMMUNITY ONCOLOGY ■ July 2006 www.CommunityOncology.net
esty into account is someone who
shows respect and caring in the high-
est degree.
Modesty is a multidimensional
construct with various categories,
including:
■ culture,
■ appearance or dress,
■ behavior,
■ beliefs and values,
■ relationships between genders, and
■ relationships among patients and
healthcare providers.
Modesty also appears to have
four different dimensions, related
to:
■ religious practices,
■ self-esteem,
■ public behavior, and
■ the environment.7
To patients, modesty is not only
important from a cultural viewpoint;
it’s important throughout all aspects of
healthcare. In fact, many people regard
modesty as a contemporary answer to
invasion of privacy. Preserving one’s
modesty promotes a sense of control
and respect, beating back the indignity
that can come with being a cancer pa-
tient. Note the following excerpt from
a personal communication with Kath-
leen M. Dietz (2005):
“Two of the three places I have had
mammograms over the years have been
great for women. One of them, however,
had no privacy. I was required to change
clothes in a booth with a curtain that
couldn’t quite close, while other patients,
including men, sat facing the booths less
than 5 feet away. It was also necessary to
walk by this row of men while clutching
my purse and trying to keep the skimpy
paper top I was wearing from flopping
open.
In 2001 I went through breast cancer
treatments. I handled the surgery, chemo,
and radiation treatments just fine. But
I was very upset at my prep session for
the radiation. I spent 2 hours in a closed
room, while strange men drew things on
me. The worst was at one point when
there were three of them in the room at
once (no females at all), and I was ly-
ing completely naked from the waist up,
hands over my head in a position right
out of Playboy magazine, my disfigured
breast exposed to anyone who walked
in, while they calmly discussed me as if
I wasn’t there—or worse, as if I was a
breast with no person attached. I left the
place and cried for an hour. If they had
just put a light cover over me during the
times when I did not need to be exposed,
I would never have been so upset.
Modesty across cultures
Modesty is not unique to certain
cultures. “Keeping covered” is an in-
tegral aspect of modesty among His-
panic, Islamic, Chinese, and Jewish
women. Pudor, the Spanish word for
modesty, has been described in rela-
tion to issues of privacy and bodi-
ly exposure.8 In the Chinese culture,
modesty relates to the relationship be-
tween genders, specifically in health-
care.9 Modesty among Islamic wom-
en, called hejab, has aspects of both
the Hispanic and Chinese cultures,
whereby modesty is about keeping
covered and relationships between
genders.10
The following section is a brief
summary of Asian, Hispanic, Jew-
ish, and Muslim expressions of mod-
esty. These summaries were based on
an extensive review of the literature
about modesty.
Asian modesty (mapagpakumbaba)
In one review, a female Chinese-
American author described modes-
ty as a cultural value that prevents
women from obtaining breast ex-
ams and mammography.11 Chinese
women are not comfortable being
examined by a male provider, but
in China, most obstetrical or gy-
necological providers are women,
averting the problem. In the United
States, however, this gender diffi-
culty remains a problem for Chinese
women. This was demonstrated by
the Chinese-American community’s
response to a breast-health program.
Attendance by women in the com-
munity was poor; the lack of par-
ticipation in breast cancer screening
was attributed to the utilization of
male healthcare providers for breast
examinations.11
In a follow-up program, com-
munity participation increased
substantially when female nurs-
es were assigned to perform the
clinical breast examinations. In
contrast, preliminary research with
Jewish women indicated that having a
male or female provider did not mat-
ter with regard to modesty.7 Though
modesty may have “gender” impli-
cations, these may not be the same
across cultures.
In another study on breast self-
examination among Chinese wom-
en, research was aimed at identify-
ing factors influencing the decision
to seek a healthcare provider’s eval-
uation for self-discovered breast
symptoms. African-American, His-
panic, and non-Hispanic white wom-
en were compared with Chinese wom-
en. Though the sampling and design
of the focus groups were not optimal
for this type of research, results were
Is there something “wrong”
with cultures that maintain strong
levels of modesty?
Women in these cultures have
been called subservient and con-
trolled, dominated by men im-
posing rules upon them. My re-
search on Jewish women showed
that for most of them, modes-
ty is an attribute to be admired
and attained. However, some of
the women disagreed; essentially,
they were apologetic about their
modesty. But, overall, modesty in
the Jewish culture is imposed by
the women themselves as a way
to keep boundaries of privacy and
respect. For some, it also reflects
their vulnerability.
What’s wrong with
this picture?
PSYCHOSOCIAL ONCOLOGY Scheinberg Andrews
July 2006 ■ COMMUNITY ONCOLOGY 445
Volume 3/Number 7
similar to the study by Mo.11 One of
the themes reported was that having
a female provider for invasive ex-
ams is optimal; Chinese women
reported feeling uncomfortable if
their clothes were removed by a
male healthcare provider during
the examination.6,12
Hispanic modesty (pudor)
The word for modesty in Span-
ish is pudor. It is associated with con-
cepts of dignity and authority and is
a “quality of reserve, humility, and
modesty.”13 In a study conducted in
Spain, results of a qualitative study
showed a strong affinity among
Spanish people for privacy and mod-
esty. 14 The roots of modesty were
thought to be imposed by the Cath-
olic Church. For example, the dress
and behavior of nuns reflect the same
strict rules about keeping covered,
maintaining a posture of quiet, non-
flamboyant behavior, and separating
males and females. The opposite of
excitability, pudor considers self-
disclosure or the use of voice in-
tonation (either high or low) in
poor taste.
With pudor, telling a patient
about a poor diagnosis is con-
sidered to be in poor taste. As a
measure of respect, it’s prefera-
ble to have a physician withhold
bad news to preserve a patient’s
dignity. For an American practitio-
ner, it might be preferable, when tak-
ing care of some Hispanic patients,
to inform a family member first so
that they can break the news in pri-
vate and then return to the physician
with the patient.
Modesty is considered an impor-
tant aspect of a number of Hispanic
cultures, especially for older women.
As with Chinese and Muslim women,
“keeping covered” is an integral part
of the culture. In a study of Mexican-
American patients, keeping covered
included issues of privacy about any
medical procedures, such as breast ex-
amination or Pap tests.15
Jewish modesty (tznuit)
My research on modesty and
healthcare was based on the hypoth-
esis that the more a woman main-
tained high levels of modesty related
to religious practices, the lower her
utilization of healthcare. However,
the hypothesis was not supported by
my results.
Extreme modesty is found among
married Orthodox Jewish women who
cover their hair with a wig, scarf, or hat.
They cover their arms to at least be-
low the elbow; their necklines extend
past the collarbone; and they wear only
dresses or skirts, which cover the knee
and usually extend to the ankle.
Less-observant Orthodox women
may wear only dresses but leave their
heads uncovered. My research with
this group of women showed that the
degree of modesty was divided es-
sentially by the issue of head cover-
ing. Some groups, considered ultra-
Orthodox or haredi, wear stockings
or socks so that none of the body can
be viewed by an outsider; some dress
in the dark or under covers so as not
to expose the body at all.7,16 Mod-
esty implies a sense of humility and
downplaying one’s attributes,17 con-
sistent with the definition of modes-
ty used in research with children, in
which modesty is explored in relation
to self-enhancement,18 and is similar
to the Spanish concept of pudor.
Jewish modesty was described as
“beneath the surface,” that is, not just
about dress or clothing.19 Modesty,
accordingly, applies to both genders.
One explanation for modesty involves
the perception of women having a
“deeper understanding” of life and
possessing “powerful insights.” Keep-
ing covered is a way of differentiating
oneself or separating oneself from reg-
ularity or mediocrity and elevates the
individual to a higher level of respect.
Coopersmith stated that “danger ex-
ists if women are downgraded when
the societal focus is external such as
clothing or how one is physically at-
tractive. Although being “beautiful” is
still considered good, it is still possi-
ble to be attractive while covering the
physical body.19
Modesty was also described as a
way to maintain borders, implying
the border around someone to protect
their inner sense of who they are. It
is the “curtain that marks the transi-
tion—the border from what is not per-
sonal to what is personal, from what is
not private to what is private.”20
Muslim modesty (hejab)
Muslim modesty is described as
one of the five pillars of the Islamic
faith and includes restrictions on:
Asian (mapagpakumbaba)
■ Humbleness in behavior and dress
■ Female healthcare provider essential
■ Western medicine is invasive
■ Eastern medicine does not involve
taking off one’s clothes
Hispanic (pudor)
■ Dignity
■ Authority
■ Privacy
■ Modest appearance and behavior
■ Respect based on age and
relationship
Jewish (tznuit)
■ All females, married or unmarried,
cover torso (up to the neck), arms,
and legs in public
■ Married women cover their hair
■ No boasting or bragging
■ No flamboyance
■ Women and men sit separately
■ Women do not wear pants
Muslim (hejab)
■ Clothing must cover the entire body
(including the neck and head)
■ Clothing should not be form-fitting,
sheer, or eye-catching
■ Female clothing should not be similar
to male clothing
■ Must not suggest fame or status
■ Eye contact is not made between
members of opposite sexes
Aspects of modesty in
different cultures
Modesty and healthcare for women PSYCHOSOCIAL ONCOLOGY
446 COMMUNITY ONCOLOGY ■ July 2006 www.CommunityOncology.net
ABOUT THE AUTHOR
Affiliation: Dr. Scheinberg Andrews is a hema-
tology/medical oncology nurse practitioner at
Lifebridge Health and an infusion therapist at
Northwest Hospital Center, Randallstown, MD.
Conflicts of interest: None disclosed.
■ dress;
■ privacy;
■ the mention of anything related to
bodily functions;
■ direct eye contact with the oppo-
site gender; and
■ opposite gender medical care pro-
viders, except in cases of extreme
medical necessity.21
There have been several studies con-
ducted on Islamic culture and breast
healthcare. Muslims have specific laws
regarding modesty that are similar to
Jewish laws of modesty. “Keeping cov-
ered” is essential for traditional Mus-
lim women. Hair, body, arms, and legs
must be covered any time a woman
may come into contact with men who
are not family members. Touching be-
tween members of the opposite gender
is also forbidden.10
In a focus-group study on the veil
as a symbol of modesty, conducted in
an American-Muslim population,23
the results indicated that even though
Muslim law supported the ideal of
preventive healthcare, prevention was
not a “reality.” Because strict rules
about dress, manner, and be-
havior are considered so impor-
tant, “bodily exposure” preclud-
ed women from obtaining breast
health exams.22
Since preventive healthcare was
not considered essential in the Mus-
lim culture, subjects reported that
“there was no reason to expose one’s
body for the exam.”22 In addition,
women in the focus groups said
that they would rather obtain
healthcare from female health-
care providers.
Finally, this study touched upon an
important aspect not found in other
studies: Islamic women’s healthcare
diminished after their childbearing
years, since pregnancy care was
no longer important. Consequently,
older women, who are at much higher
risk of disease, access healthcare only
for illness.22 This is important because
exposure of the body, related to laws of
modesty and similar to other cultures,
is considered a barrier to healthcare
utilization, especially of Islamic wom-
en beyond their childbearing years.
Women who are at the highest risk
for breast cancer and most in need of
screening are those who are no longer
having children. Thus, they are not ob-
taining preventive healthcare.
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PSYCHOSOCIAL ONCOLOGY Scheinberg Andrews
