If this couple were members of the majority population, you might surmise that you were dealing with a domineering husband and decide that you need to get the woman alone in an examining room to get the answers to your questions without the husband’s interference. But you are not dealing with such a couple. In today’s multicultural health care environment, nurses cannot make assumptions about patients’ behaviors based on their own cultural backgrounds. In the opening scenario, the husband was not being domineering, according to his culture. He was merely demonstrating his care and concern as a loving husband. A culturally savvy nurse would need to be able to interpret the husband’s dominance of the nursing assessment interview and the wife’s acquiescence in the light of their cultural programming and not make assumptions based upon U.S. majority culture. When caring for women, it is particularly important to be sensitive to different culturally prescribed roles for men and women and for culturally prescribed roles in arriving at medical decisions.

Assessment of cultural influences that may have potential impact on the care a patient will receive is also an important regulatory issue. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard on assessment requires culture to be part of the initial assessment process. JCAHO considers culture as a possible barrier to the patient achieving his or her heath care goals. If the assessment reveals the patient’s culture to be a potential impediment, the assessment’s findings should be integrated into the nursing care plan.¹ Involving the patient and his or her family in as much of the care planning process as possible will mitigate many of the cultural pitfalls confronting the nursing staff.

Birth-to-Death Gender Roles

Culture determines and teaches attitudes about gender, femininity, sexuality and the practices surrounding them. This training starts in early childhood. Both boys and girls observe and experience how girls, as well as mothers and other female relatives, are received and treated. They also learn the values placed on having a baby girl versus a boy, for example, whether boys are considered more valuable than the girls. Children learn, too, whether it is culturally acceptable for brothers to abuse their sisters and later, their wives. Body image is another culturally transmitted value, which has a direct impact on health. Cultures instruct girls on whether they should be thin or fat, tall or short, or beautiful or just not seen. They learn early on whether big breasts or small breasts will gain admiration, whether an independent or dependent spirit is good, or whether strength or weakness is better. Right along with them, their brothers learn and support the images that girls develop about themselves.

Many gender attitudes are learned through role models. Infant girls soon sense the role and status of their mothers in the inner circles of contacts to which the babies are exposed. They observe whether other family members care for their mothers or whether their mothers assume the role of caretaker to the rest of the family. During childhood, girls follow what their mothers do when one of them is ill. Is it the mother’s role to offer tea, herbal concoctions, soup, or pills? Or do the mothers take their children to folk healers, herbalists, older members of the community, or physicians? Children soon find out if mothers are viewed as healers by witnessing community members’ visits for medicine, herbs, or advice when they are ill. On the other hand, mothers may not have a role in sickness or health at all, consulting someone else about illness, someone who may be a man, rather than a woman.

Girls develop their notions about sexuality from the culture in which they live. If any cultural rites of passage exist to becoming a woman, girls see them first as young observers in the community and later as participants in these rites. For example, the Navajos traditionally honor a girl’s rite of passage to womanhood by preparing special foods and excluding men from this celebration.² On the other hand, many other cultures view menstruation as an occurrence that makes women too impure to cook for their husbands and families or participate in religious rituals.³

Culture also determines attitudes toward virginity, the people with whom women should have intercourse, and whether women should enjoy sex or passively submit to it. It prescribes sexual conduct, for example, what sexual acts are allowed, whether or not husbands may have more than one wife or other sexual partners, and what rules and beliefs about cleanliness and the genitalia should be followed.

Culture is a primary factor in the development of any population’s notions about the maintenance of the health of mothers and their unborn children, birthing practices, and the care of mothers and children immediately after birth. Culture can also determine the level of prenatal and postnatal care sought by women, their dietary habits during pregnancy and nursing, their choice regarding breastfeeding, and the people they use to provide or promote their perinatal care.

Cultural differences may have an impact on the actual experience of menopause as well as beliefs surrounding it. A case in point is a study that demonstrated that Japanese women experience menopause differently from white women.⁴ The Japanese women in the study complained of stiff necks and aching shoulders during menopause more frequently than the hot flashes commonly reported by white women. However, investigators are examining differences in the Japanese diet, especially the use of soy protein, to determine their possible mitigating effect on hot flashes.⁵

As women progress through their life span, culture molds the ways in which they feel and behave toward aging and death. Cultural beliefs affect attitudes about whether families should care for dying women at home or whether they should be cared for in hospitals or nursing homes. Some members of Arab, African-American, and Chinese cultures prefer to die in hospitals to avoid the bad luck of dying in the home. Members of other groups, such as some Southeast Asian cultures, care for dying relatives in the home because not doing so may be viewed as shirking family duty. Culture also influences attitudes toward life support. People from cultures that ascribe to ancestor worship or believe that children are the reincarnation of dead ancestors may refuse consent to turn off the life support of an infant or adult for fear of later retaliation by the relative who will be reborn through that person. The notion of patient autonomy and advance directives may also be resisted for cultural reasons. One study found that the majority of ethnic elders from a sampling of different cultures did not wish to be informed about a negative prognosis or to discuss advance directives in the event of mental or physical incapacity.⁶ In general, it is unusual for members of most cultural groups to inform patients directly about impending death.

Examinations by Men

In today’s multicultural society, health providers who are men may be at a disadvantage when caring for women from many cultures. In some, a man cannot touch a woman if she is not his wife or daughter. In this tradition, for example, Muslim women may be reluctant to accept care from a physician or a nurse who is a man.⁷ In practice areas that have large Middle Eastern populations, female health care providers should perform physical exams, especially those including breast or pelvic exam. If a woman is not available to give care, the husband may insist upon being present or expect a female nurse to act as a go-between the male physician and the patient. On the other hand, because an Orthodox Jewish husband must avoid being touched by an adult woman, nurses need to refrain from such gestures as giving the husband an encouraging pat on the back while his wife is in labor. The man is forbidden to touch his wife during labor and, since emotional support during labor is relegated to female family members, he may prefer to remain outside of the delivery room. It is even advisable for a female physician to put the newborn down rather than hand it to the husband after birth.⁸

The Influence of Medical Traditions

Traditions in medical examinations as well as treatments vary greatly by culture. For example, in today’s traditional Chinese medicine, physicians make their diagnosis by taking a patient’s pulse and examining the tongue, eyes, and the color and resilience of the skin. However, in ancient times, Chinese physicians never touched the patient at all; instead, they attached a string between their wrists and the patient’s finger and instructed the patient to point to areas of discomfort. Although most present day Chinese medicine is a mixture of Western and Eastern tradition, this historical practice often influences the degree of invasiveness expected in examinations.⁹

Although great diversity exists amongst Latino cultures, all share a collective rather than an individualistic approach to decision-making. The family, not the individual, most often makes health care decisions.¹⁰ Caregivers who are unfamiliar with this custom often mistakenly equate a woman’s hesitation in making a health care decision without first discussing it with her husband with a fear of an over dominating spouse. In spite of professional attitudes about patient autonomy, if a patient seems to hesitate in making a decision or states outright that she can’t answer before consulting her spouse, it’s advisable to ask her if she’d prefer her husband or some other person to be present during the decision-making process. On the other hand, one of the woman’s primary roles is to not only nurture the family but also to maintain the health of her children and husband.¹¹ In the extended family life of female patients, the mother-in-law is often a powerful figure, and it is helpful to get her to buy-in to treatment plans that may impact either the dietary or daily life of the family.

Nurses in many countries do not receive the extensive education and training received by nurses in the U.S. Patients from countries in which nurses perform only clerical and custodial roles may be put off when a nurse, rather than a physician, takes her vital signs or performs minor tests. Patients from countries where only physicians are considered qualified to administer any sort of care or treatment may doubt the quality of their care if a nurse, nurse practitioner, or physician’s assistant performs any part of the history and physical exam. In fact, women from cultures where physicians are viewed as sole caregivers and authority figures might expect physicians to perform all facets of the examination, as well as make all health care decisions for them. Any attempt to have the woman participate in the decision-making process may be interpreted as evidence of a physician’s lack of knowledge and experience. When a nurse prepares a patient’s medical record by taking the patient’s blood pressure or weight, it may be better to preface these actions by mentioning that she is following the instructions of the provider.

Culture also has an impact on beliefs about fertility, contraception, and the importance of having children. In some countries, failure to produce a child in a culturally prescribed length of time can be grounds for divorce. Because women carry the children, some cultures blame wives alone for infertility and when they do give birth, hold them responsible for determining the sex of children. In China, children are culturally valued, but law penalizes having more than one. Fetal sex diagnosis and selection are frequent and male children are preferred because men (with their wives) are traditionally responsible for taking care of the parents in old age. Cultural preferences impact the ratio of girl to boy children worldwide, which the United Nations Children’s Fund (UNICEF) has labeled as “gender apartheid.”¹⁰ Practices may involve killing girl babies at birth, withholding immunizations from girls, and providing them with poorer nutrition than boys. This cultural preference for boys not only affects the physical health and wellness of girls, but also their mental health and feelings of self-worth.

When cultural beliefs are not harmful to the patient, caregivers should support them, no matter how strange or unreasonable they may seem from their cultural perspective. This practice is known as cultural accommodation. Negating beliefs will not change patients’ ways of thinking, but may make them wary of disclosing information about folk beliefs, practices, or remedies that might be vital to successful diagnosis or treatment. As a result, patients may lose trust in caregivers and the Western medical system. For example, what would you do if a relative of a Native American woman, who had just given birth, asked you for the umbilical chord or the placenta? If you were a culturally competent nurse working in a hospital or clinic that regularly served Native Americans, you would know that tradition requires that parts of the afterbirth be buried at the four corners of the family dwelling as a means of ensuring good health and good luck. Caregivers who honor this kind of request will be more successful in earning the trust and respect of patients, their families, and the entire cultural community.

When Culture Interferes with Care

Not all cultural and folk beliefs and practices are harmless to the patient. Caregivers need to earn the trust of their patients, so they can establish an open dialog that allows disclosure of other sources of care for evaluation. For example, people sometimes bring home remedies and medications into the U.S. from their native country at the time of immigration; relatives also may transport or send in medications. Some of these drugs are available over-the-counter in the home country, but only by prescription in the U.S. Patients may be inadvertently taking double doses of a drug by taking the prescription the caregiver has ordered as well as the same or a similar medication brought from home. On the other hand, patients may consult a traditional healer, medicine man, or herbalist who prescribes a natural herb that has the same properties as the prescribed one. They might even be taking natural or manufactured drugs that are contraindicated.

Whenever caring for culturally diverse patients, nurses should take the time to explore their cultural practices by asking such questions as: “What do you think made you ill? In your culture, how is this condition traditionally treated? Have you received advice from someone before visiting the physician or taken anything to help cure your condition?” If the woman tells the nurse that any drugs, herbs, or other “cures” have been (or are being) used, the nurse should gather as much information as possible and notify the woman’s provider. When any herbal products are contraindicated, the nurse should explain that the treatment being prescribed is so powerful that the other should be discontinued.

Female Genital Mutilation

An increasing number of the countries with a long tradition of performing circumcision rites, widely referred to as female genital mutilation (FGM), are beginning to reexamine and legislate against this practice. However, the custom of circumcising young girls may take several generations to change. The World Health Organization (WHO), which promotes the elimination of FGM, has estimated that between 100 and 140 million women have undergone genital mutilation and that two million more undergo some form of FGM every year.¹² The Centers for Disease Control and Prevention has estimated that 168,000 women (48,000 under the age of 18) have had FGM and are living in the U.S. today.¹³ Nurses working with women are likely to encounter women who have had FGM in their clinical practice. It is important not to assume that all these women want this condition reversed. In their culture, reversal of circumcision would make them unsuitable for marriage, libel for divorce, and virtually an outcast in their communities. For example, in one case, a 35-year-old Sudanese woman pregnant with her third child, who had been in the United States for three years, told her physician, that she would feel “abnormal and ugly with ‘a big gaping hole.’” Even after being told that she had a urinary tract infection that was a common result of infibulation, she still insisted that she wanted reclosure after delivery. She did change her mind, however, after, at the suggestions of her physician, she discussed the matter with other Sudenese women in her community who had “remained open” after child birth.¹⁴

FGM is typically performed when a girl is between 4 and 8 years old. It is practiced in about 28 African countries, Asia, the Middle East, and increasingly in Europe, Australia, Canada, and the United States.¹⁴ The WHO has identified four types of FGM. Type I, which is the only type that can accurately be referred to as female circumcision, is a clitoridectomy. The prepuce and all or parts of the clitoris are removed. This does not usually result in long-term complications. Type II involves an excision by which the clitoris and inner labia are removed. Women who have undergone this procedure may suffer from pain during intercourse and experience other long-term problems. Type III is infibulation or an extreme form of circumcision. The clitoris is removed; at least two-thirds of the labia majora are cut off, as well as the entire labia minora. Incisions are made in the majora to create raw surfaces, which are then stitched or held together (sometimes by tying the woman’s legs together), until a hood of skin grows to cover the urethra and vagina. A small hole, about the diameter of a matchstick, is made to allow menstrual blood and urine to escape. Type IV is pricking, piercing, or incising the clitoris and /or labia, cauterization by burning of the clitoris and surrounding tissue.¹³ Adverse effects include formation of cysts, abscesses, and scar tissue; sexual dysfunction; dysmenorrhea, chronic pelvic infections; damage to the urethra; incontinence; chronic pelvic and back pain; chronic urinary tract infections; and difficulties with childbirth.¹³

Women who have undergone FGM have been taught to believe that this rite of passage is normal. Reasons for having FGM include identification with cultural heritage and the initiation of girls into womanhood. Regardless of a nurse’s feelings, referring to this practice as “mutilation” or exclaiming something like, “What have they done to you?” would be culturally inappropriate. Instead, the nurse should ask how this process has affected the woman’s life, urination, and menstruation and try to refer her to a counselor from the same cultural background to discuss deinfibulation or other possible treatments, if needed.

Practices Around Menstruation

Attitudes about the cause and purpose of menstruation differ throughout cultures. For example, as mentioned earlier, the onset of menarche for Navaho girls symbolizes their passage into adulthood, whereas in both Iranian and Orthodox Jewish cultures, menstruation is a period of uncleanness. Iranian tradition also holds that menstrual blood can pollute the body unless discharged each month, a belief also held by many African-Americans. During menstruation, Moslems are forbidden to touch any holy object or to have intercourse. Because women are considered to be in a fragile condition during menstruation, they restrict showers and strenuous exercise. Women must also undergo a period of cleansing after each menstrual period, cleansing themselves thoroughly before participating in any religious rituals.²

Likewise, extremely Orthodox Jewish women separate themselves from all men during menses. According to Orthodox Jewish law, no man is allowed to touch or even sit where a menstruating woman has sat.² A state of impurity exists for at least 12 days — five days from the onset of the menstrual cycle and seven clean days following it, during which women are supposed to wear white underwear and sleep on white sheets to illustrate that they are clean. They then must attend a Mikvah or ritual bath before being allowed to engage in sexual intercourse with their husbands. In some extreme cases, a cloth wadding is even inserted in the vaginal canal for 20 minutes at sunset of the seventh day. If the cloth is clean, women may proceed to the ritual bath; if not, stringent rules determine which stains are insignificant and which require another seven-day cleansing period; some women are even expected to bring the wadding to a Rabbi.¹⁷

People steeped in African-American folk tradition view menstrual blood as a pollutant. They believe that menstruation is the body’s way of ridding itself of “bad blood.” Some African-Americans may consider medications that alter or reduce this flow to be harmful, fearing that this bad blood may back up and thicken, causing possible hemorrhage and death.¹⁸

Nurses must always keep in mind that adherence to any of the highlighted traditions is not constant throughout a culture. An individual woman’s degree of assimilation to mainstream culture, her family and religious ties, education, and a great number of other factors strongly influence her beliefs and practices. Because of the variety of cultural traditions that surround menstruation and the social and physical activities permitted during this period, nurses need to question each patient carefully, but indirectly, about her personal beliefs and practices before offering education or advice. Failure to do so may produce care based on cultural stereotypes, which can insult the patient or prove detrimental to care.

Culturally competent patient care includes questioning that encourages women to discuss their beliefs about the cause and the biological purposes for menstruation. Although they may seem strange and isolating, cultural and religious beliefs that label women unclean and thus unable to handle family food, touch holy objects, or engage in intercourse, are not physically harmful to patients. Since an explanation of “facts” probably will not change these beliefs, it is best for nurses to simply explain how customs in the U.S. and medical beliefs differ, while assuring the woman and her partner that providers will not interfere with these customs. A caregiver’s knowledge of patients’ traditions and cultural beliefs can be useful when investigating the reasons for their unwillingness to use particular drugs, such as oral contraceptives that tend to alter the flow of blood during menstruation. In the case of oral contraceptives, for example, nurses should explain in advance that although the pill may reduce blood flow, the change would not harm the patient.¹⁹

Offering Culturally Appropriate Care and Education

Regardless of a woman’s age or the number of children she has had, nurses should not assume that she has ever had a breast, vaginal, or rectal exam, a Pap test, or a mammogram. Culture can influence when patients seek professional medical advice or undergo cancer-screening practices, such as mammograms. In fact, a number of studies have investigated how, in some cases, culture plays a major role in delaying screenings for breast cancer. For example, one study found that psychosocial, cultural, and socioeconomic variables explained the difference between late-stage presentation of breast cancer between African-American and white women.²⁰ Another investigation found that Hispanic women had poorer outcomes with breast cancer, despite a lower incidence; although they may have been taught breast self-examination, women in this study presented later with breast tumors because of cultural influences.²¹

Preventive care procedures need full and careful descriptions, including what will be done, why and how they will be done, who will perform the exam, and what the patient will feel. If the examining caregiver is male, explain that although he will conduct the exam, a female nurse will be present. If the woman or her husband objects to a male examiner, it is best to try to make alternative arrangements with a female caregiver.

Caring for the Pregnant Woman

Not all women who are concerned about the health of their unborn children will seek prenatal care. Since childbirth is a natural phenomenon, many women view prenatal care as unnecessary unless evidence of an abnormality or other problem is available. Prenatal care is particularly discounted in cultures that have a strong sense of family and community. In these cultures, pregnant women customarily seek the advice from an elder woman in the community, an herbalist, or even one who reads fortunes or zodiac signs, rather than a health care professional. Healers in the community may advise herbal teas, potions, or special diets. Although often for different reasons, the advice may even be similar to guidance given by a Western practitioner. For example, pregnant Asian women are often advised not to use soy sauce in food, not because of its high sodium content, but because it is believed that soy sauce will darken the skin of the child, a characteristic not admired in that group. Nurses could use this Asian folk belief to strengthen advice about lowering sodium intake.

On the other hand, knowledge of folk beliefs and cultural practices can guide nurses to identify patients’ personal belief systems, individual assimilation to mainstream culture, or adherence to practices that could be harmful or prevent them from following medical advice. For example, in cultures that ascribe to the belief that pregnant women are “eating for two” and that encourage women to increase portions and eat fatty foods to gain weight, patient education about diet and pregnancy would be indicated. However, before appropriate teaching can take place, nurses should first ask a woman to explain her regular eating habits and diet, so that advice about diet could be modified to better fit her lifestyle. Each item on the diet would need to be reviewed to ascertain whether any of these foods are considered healthy or unhealthy during pregnancy.

Nurses need to heighten their awareness about the importance that role, culture, and tradition play in preventing and treating women’s unique health care problems. No matter what geographical area nurses work in, they will see more and more patients from other cultures. In fact, so called “minority” groups will outnumber what is now considered mainstream culture by the middle of this century with many new immigrants settling in the middle of the country, rather than the East or West Coast.^22,23 It is neither possible nor necessary for every nurse to learn everything about all these cultures. What is important is for all nurses to recognize that major cultural differences exist in not only the beliefs and practices of the women they care for, but also in their needs and expectations regarding care. Nurses should make an effort to learn more about the health beliefs of the particular cultural groups they are likely to serve. This knowledge and awareness will boost nurses’ competence even when they approach women who belong to cultures with which they are unfamiliar. The key to cultural competence in the care of women is an awareness and ability to identify differences in beliefs and practices about health maintenance and care and to evaluate their impact on patient satisfaction and adherence to care. Nurses need to view the practices of other cultures without judging them according to their own. When nurses have developed these sensitivities, they will be better equipped to encourage the women they care for to disclose any beliefs and practices that may have an impact on care and respond to them in an appropriate manner.