ABSTRACT

Objective:

Almost 50% of women with one or more children experience pelvic organ prolapse, and physical therapy for pelvic floor rehabilitation is one of the first-line treatments for women with pelvic organ prolapse seeking medical care. This study aimed to investigate whether ultra-orthodox women would proceed with pelvic floor rehabilitation taking into account Jewish religious laws—Halacha—or medical motivations.

Materials and Methods:

Between January and May 2015, 65 ultra-orthodox women aged 20–65 undergoing pelvic floor rehabilitation completed a questionnaire regarding their pelvic floor function, religion, and treatment motivations.

Results:

Most women considered both medical and Jewish religious law reasons for seeking treatment for pelvic organ prolapse (POP).

Sixty-five women completed the survey. More women sought treatment taking into consideration both medical and Jewish religious law reasons, as opposed to medical or Jewish religious law reasons alone. Upholding religious commandments was an important factor in seeking medical treatment.

The motivation to seek treatment for POP symptoms usually involves both medical and religious law reasons in ultra-orthodox Jewish women.

The study’s strength is that it is novel in examining the religious motivations for seeking therapy for symptoms associated with POP. However, no control group was included in this study, which is a limitation.

Conclusion:

The findings indicate that Jewish religious law motivations were an extremely important factor among ultra-orthodox women presenting for pelvic floor rehabilitation.

INTRODUCTION

Pelvic floor medicine deals with the treatment of tissue, muscle, and ligament deficiencies in the pelvic floor. These deficiencies sometimes result in urinary and fecal incontinence, sexual dysfunction, organ prolapse, and organ dysfunction.¹ Each symptom deeply affects a woman’s quality of life.² Religious, especially ultra-orthodox Jewish women suffer twofold: everyday functioning is impaired, and their ability to properly fulfil religious commandments is damaged.  In the ultra-orthodox Jewish community, the Jewish religious law—Halacha—has a great influence on every aspect of life. Thus, a medical problem will be handled when it is medically disturbing and especially when the problem leads to a conflict with Jewish religious law and the ability to fulfil religious commandments.

Urinary incontinence can arise from physical effort,³ leading to inability to restrain urine release, which impairs quality of life. Fecal incontinence is associated with impaired activity of the pelvic floor sphincters; however, its social consequences are far more extensive.^4,5 Between 9% and 39% of women aged over 60 report daily urinary leaks,⁶ whereas the prevalence of fecal incontinence is between 2% and 6%.⁷ It affects approximately 9% of women during the first 3 months postpartum.⁴ Moreover, when lack of gas control is considered, the frequency is even higher. Pelvic organ prolapse (POP) is a condition in which one or more pelvic organs have descended. It can occur with each of the pelvic organs, in part of an organ, or in several organs together.⁸ Prolapse occurs when the pelvic ligaments and muscles are damaged, weak, or under high or continuous pressure.⁹ Almost 50% of women with one or more children experience prolapse, and among them, 10%–20% are symptomatic.¹⁰

In this study, we focused on pelvic floor rehabilitation with regard to three conditions: incontinence, POP, and pain during vaginal intercourse. The aim of this study was to examine whether Jewish religious law repercussions are an additional cause for ultra-orthodox women to seek pelvic floor rehabilitation treatment, beyond the general medical motivation common to all women. We hypothesized that ultra-orthodox women attribute great importance to the Jewish religious law implications of a medical issue and seek pelvic floor physical therapy based on medical reasons and their ability to fulfil religious commandments.

MATERIALS AND METHODS

This study was conducted among ultra-orthodox religious women from the ultra-orthodox cities of Bnei Brak and Elad. The inclusion criteria were women aged 20 to 65 years who presented for pelvic floor rehabilitation and who agreed to fill out the questionnaire.

Ethics: This study was performed in line with the principles of the Declaration of Helsinki. The IRB at Galilee Medical Center (Helsinki Committee) approved this study (approval number: 0058-20-NHR, given on July 21^st, 2020). Participation in the study was voluntary. Patients who met the inclusion criteria received an explanation of the methods and procedures of the study, and if they were interested in participating, they signed an informed consent form. After signing the form, they filled out the questionnaire in a separate room next to the clinic. They were requested to complete the questionnaire anonymously after completing all treatment procedures, so that patient-therapist relationships to not affect their answers.

Tools: The questionnaire included 140 questions and was based on several Hebrew questionnaires as well as questions relevant to the topic of research. It was developed by the researchers and adapted to the unique topic of research and the target population. The questionnaire used a Likert scale where 1 expressed disagreement with the statement, opinion, or action, and 5 expressed strong agreement. For some of the questions, it was also possible to mark 6—irrelevant—because not all women experience the same symptoms.

After asking for the patients’ demographic information, the questionnaire was divided into eight groups of statements according to subject. In each group, the means of the answers on a scale of 1 to 5 or 1 to 6 were calculated.

Procedure

The data were collected in pelvic floor rehabilitation clinics in Bnei Brak and Elad by a single researcher (L.T.). The study continued until the desired number of subjects was reached. Questionnaires were in Hebrew and were filled out anonymously.

Statistical analysis

All statistical computations were performed using SPSS 21.0 for Windows (SPSS, Chicago, IL, USA). Descriptive statistics were used to characterize the sample, and the data are presented as means with standard deviation (SD) or as proportions. To examine the significance of the statements, we used different analyses. We compared the differences between the two age groups (20–50 and 50+ years) using a chi-square test. To check the ranking of sections dealing with the same domain, we used ANOVA for repeated measures. This process upgraded the sections, from the highest-average to the lowest-average section.

RESULTS

A total of 65 women, who identified as ultra-orthodox, completed the survey, and their demographic characteristics are presented in Table 1. The average age of the participants was 37.5 years (SD=1.57), ranging between 21–63 years, and most (95.4%) were married. The majority of the participants (78.5%) were native Israelis; of the remaining participants, four were from Turkey, Yemen, and Morocco (6.2%), four from France and Belarus (6.2%), one from Argentina (1.5%), and five were from the United States (7.7%). The majority (66.2%) of the participants had studied in a seminar, and 80% of the women declared that they were currently working. Only a few (6.2%) participants were pregnant at the time of the survey. Table 2 presents the three conditions of pelvic floor impairments that were studied. In the questionnaire, participants were asked to indicate the impairments from which they suffered and to answer the questions relevant to their condition. As shown in Figure 1, 100% of the women aged 50+ years reported urinary incontinence, compared to 67% of those aged between 20–50 years. This difference was statistically significant (p=0.02). In terms of prolapse, 38.5% of women aged 50+ years reported prolapse compared to 46.2% of women aged 20–50 years, which was not statistically significant. Women aged 20–50 years were significantly more likely to report sexual difficulties than those aged over 50 (36.5% vs 7.7%, respectively; p=0.04).

Figure 2 shows the mean period of time in years from symptom appearance to questionnaire completion. This period was the shortest for women with fecal incontinence (M=1.5 years, SD=1.00). The time period between symptom onset and questionnaire completion was longest among women with urinary incontinence. This finding may be related to the time taken for a patient to obtain a medical referral, which does not always coincide with the appearance of symptoms.

We then asked the following question with regard to each of the three main pelvic floor disorders: “In general, if you were asked to define the most crucial motivation when referring to physical therapy treatment, what is your answer?” Of the 42 women experiencing urinary incontinence, 50% reported both Halacha and medical motivations to seek treatment, whereas 45.2% reported solely medical motivation, and 4.8% reported solely Jewish religious law motivation (Figure 3). Of the 28 women experiencing POP, 42.9% reported combined motivations, 39.3% reported solely medical motivation, and 17.9% reported solely Jewish religious law motivation (Figure 4). Of the 19 women who reported pain during vaginal intercourse, 63.2% reported combined medical and Jewish religious law motivations, 21.1% reported solely medical motivation, and 15.8% reported solely Jewish religious law motivation (Figure 5).

All women, regardless of their specific pelvic floor disorders, were asked about Jewish religious law or medical motivations for treatment (Figure 6). Of the 65 women who reported whether they had Jewish religious law or medical motivations to pursue treatment for each of their particular symptoms, only 3.1% reported only Jewish religious law motivations for all disorders. While 23.1% reported only medical motivations for all disorders, 73% reported combined medical and Jewish religious law motivations for seeking treatment.

The Jewish religious law was shown to be an extremely important aspect of life for ultra-orthodox women with their responses to statements such as “Religion plays a central part in my life” (mean=4.84, SD=0.35) and “I feel obligated to fulfil religious commandments” (mean=4.94, SD=2.42).

When asked which situations would cause them to seek treatment immediately, difficulty getting pregnant because of a pelvic floor impairment was reported to be the most worrisome (mean=4.98, SD=0.14), followed by the feeling that their physical condition causes them to be ashamed in front of their husbands (mean=4.75, SD=0.74). The least worrisome situation was urinary incontinence (mean=4.00, SD=1.18), though it should be noted that the score, however, indicates a high degree of motivation to seek immediate treatment.

DISCUSSION

The most common motivations for women seeking treatment for pelvic floor disorders involved both medical and Jewish religious law motivations, which supports the research hypothesis. Of the 65 women who completed the questionnaires, only two indicated solely Jewish religious law motivations, whereas 15 noted solely medical motivations.

Between 7% and 37% of women in this study aged 20 to 39 years reported a certain level of incontinence, and nearly half of all women reported symptoms of POP. Many women are diagnosed by their gynaecologist as suffering from slight prolapse; however, it will not always be felt or accompanied by symptoms.¹¹ POP can cause symptoms such as loss of urine, difficulty in emptying the intestines, pain in the lower back or pelvis, pain or discomfort while having sexual intercourse, and decreasing self-image and quality of life.^10,12

Ultra-orthodox women have an obligation to pray, which cannot be done if she is viewed as unclean.¹³ Urinary or fecal incontinence will prevent a woman from praying, and bleeding due to POP prevents immersion in the ritual bath—the Mikveh.¹⁴ In the worst-case scenario, if an ultra-orthodox woman prays while she is seen as unclean, her prayer would be considered an abomination as if she had not prayed at all.^15-17 For an ultra-orthodox woman, this seriously impairs a religious way of life.

Pelvic floor disorders are also unpleasant and awkward from a personal and conjugal perspective. While this is common to all women, there are additional Jewish religious law implications for ultra-orthodox women.¹⁸ Pain or difficulty in sexual relations can occur as a result of over-contraction of the pelvic-floor sphincters or due do provoked vulvodynia—oversensitivity of the vestibule.¹⁹ Additionally, it can arise among couples during sexual intercourse when the woman experiences different forms of pain in the pelvic area. The pain impairs daily functioning and prevents the possibility of sexual contact.²⁰ This situation causes many couples to avoid intercourse, and as a result, it prevents an essential part of Jewish religious marital life, as well as procreation.^21,22

We discovered that among women experiencing urinary incontinence, the effect on their ability to fulfil religious commandments was significant and difficult. However, there was no significant difference in the proportion citing combined medical and Jewish religious law motivations for seeking treatment and those citing only Jewish religious law motivations. A higher proportion of women reported combined motivations for seeking treatment for prolapse; however, several women reported that they would immediately seek treatment if the prolapse led to difficulties or delays with immersion in the ritual bath. Among those who sought treatment due to difficulties during intercourse, combined Jewish religious law-medical motivations were the most common, and women indicated a strong correlation between the ability to fulfil commandments and bodily functioning. This symptom, in particular, influences both the woman’s personal life and her relationship with her partner. Thus, when there is Jewish religious law difficulty in addition to a medical dysfunction, the consequences are more severe and affect quality of life, and it motivates religious women to actively seek out treatment.

Bilu and Witztum²³ suggest that the starting point in the dialogue of the healthcare provider with ultra-orthodox women must consider understanding that religion is what provides the main set of emotions through which their illness is experienced. On this basis, therapeutic approaches can be creatively integrated into spiritual–religious elements.²³

The study is novel in examining the religious motivations behind seeking therapy for symptoms associated with POP. However, no control group was included in this study.

Multidisciplinary teams of medical professionals who treat women with pelvic floor disorders should be prepared to treat patients from diverse cultural/ethnic and religious backgrounds.²⁴

CONCLUSIONS

Caregivers engaging in these sensitive and intimate issues should recognize not only the language and terminology unique to diverse populations but also the factors that motivate them to seek treatment for these issues. This study demonstrated that the importance of Jewish religious law in the eyes of ultra-orthodox women is integrated into their daily lives and shapes their care-seeking behavior.