"I Would Consult a Doctor, But What the Rabbi Says Goes": Ultra-Orthodox Jews' Relationships with Rabbis and Doctors in Israel.

We examine relationships among ultra-Orthodox Israeli Jews, their doctors, and rabbis when medical decisions are made. Analyzing excerpts from sixteen focus groups with 128 ultra-Orthodox Jews, we determine how their belief system affects their decisions about whom to trust and follow when the doctor's instructions contradict the rabbi's advice. We argue that the strict behaviors described here with regard to relations among doctors, rabbis, and patients, function as social capital that raises the status of ultra-Orthodox Jews as members of an exclusive club that balances health decisions with the social demand to obey their religious leaders.

Support and Informational Needs of Ultra-Orthodox Jewish Women Coping with Advanced Cancer: A Pilot Observational Study.

In Israel, as in other countries, the emotional and physical needs of minority populations receiving palliative care, are largely unknown. The ultra-Orthodox Jewish sector is one such minority population. This study's goal was to identify perceived social support, desire to receive information about illness and prognosis, and willingness to disclose information to others. Various measures assessing perception of social support, psychological symptoms and information disclosure were completed. Fifty-one women consented to participate; approximately 50% of participants had disclosed the diagnosis to their rabbi or a friend, in addition to their spouse. Almost all of the participants would want to be told if their condition were worsening (86.3%), yet only 17.6% reported that their doctor had discussed future care options if their health situation were to worsen. Overall, participants felt that the level of support they received was high and reported low levels of mental distress. This is the first known study regarding perceptions and needs of ultra-Orthodox Jewish women with advanced-stage cancer. Both diagnosis disclosure and palliative care options should be addressed and discussed with these patients so they may make important end-of-life decisions.

Awareness, Incidence and Psychological Wellbeing of Childhood Sexual Abuse as Reported by Ultra-Orthodox Mothers.

The harm caused by child sexual abuse (CSA) is well-documented, calling for more awareness and efforts at prevention. However, CSA in closed religious societies is still tightly under wraps, and therefore underreported and understudied. We chose to use the mother's point of view, in order get an estimate of the prevalence, the reporting rates and their psychological wellbeing. The current study aims at addressing this in the Jewish ultra-Orthodox community, an insular religious one, which may thus serve as a test case for understanding other closed, religious communities. Three hundred forty-seven ultra-Orthodox Israeli women completed self-report questionnaires and reported on their, or their children's exposure to CSA sexual abuse, about their emotional coping, and about considerations regarding disclosing the abuse. About 24% the participants reported that they were victims of sexual abuse. Only 24.3% of cases were reported to the police or official welfare services, with cultural reasons offered by the women to explain it. Lower psychological wellbeing was found among mothers who themselves or their children were victims of child sexual abuse, compared to controls. Interestingly, mothers who reported having undergone psychological treatment suffered a higher degree of distress than those who had not. These findings contribute to the understanding of the dynamics of sexual abuse exposure and disclosure in the ultraorthodox community, and in close societies and highlight the changes required to improve safeguarding of children.

Ultra-Orthodox Women in the Job Market: What Helps Them to Become Healthy and Satisfied?

This study explored the mental health and job satisfaction of Ultra-Orthodox women who work in different cultural environments. Data were gathered from 304 Ultra-Orthodox women who belong to various streams in this society and who were recruited by the Midgam research panel. The participants filled out self-reported questionnaires that assessed their family quality of life, community sense of coherence, diversity climate, inclusive leadership, job satisfaction, and mental health. The participants ranged in age between 19 and 64 years (M = 30.86, SD = 8.71); 43.1% worked within the Ultra-Orthodox enclave, while 22.4% worked with both Ultra-Orthodox and secular individuals and 34.5% worked in mainly secular environments. We observed differences and similarities among the three groups of women. Community sense of coherence was weakest among those who worked outside the enclave, while diversity perception and inclusive leadership were highest among that group. In all three groups, family and community were the most important resources for mental health. Both traditional resources (i.e., family and community) and other resources (i.e., perception of diversity climate and inclusive leadership) were important for job satisfaction.

"I don't fit into any category": Adult perspectives on the dynamics of past sexual acts between siblings in Jewish Orthodox society.

BACKGROUND: 'Harmful sexual sibling behavior' is a term used in this study to refer to childhood sexual behaviors, including abuse (SSA), that are inconsistent with the category of age-appropriate curiosity. Although SSA may be the most prevalent and longest-lasting form of intrafamilial sexual abuse, it is the least reported, studied, and treated. OBJECTIVE: This study aims to deepen our understanding of the sexual characteristics and dynamics of such behavior, as perceived by those involved. PARTICIPANTS AND SETTING: Twenty adults from the Orthodox community in Israel, who experienced sexual interactions with one or more of their siblings, were recruited as participants. METHODS: This qualitative, constructivist, grounded-theory study was based on semi-structured interviews with 20 adults. RESULTS: Four types of sexual dynamics were revealed: an "abusive dynamic," "mutual relations," "sexual routine," and "incidental," with the latter stemming from a new understanding that deepens our knowledge of the subject. The participants discussed the broad, long-term consequences and life-long psychological implications of each dynamic and the coexistence of these dynamics. The results also reveal two cultural dimensions of the participants' perception of the sexual acts: "lack of sexual knowledge" and "the perception that all religious prohibitions are of equal severity." CONCLUSIONS: The findings highlight the importance of adapting interventions to the siblings' perceptions and avoiding treatment that exacerbates their complex situation. We employ the concepts of dynamics and dimension in describing the phenomenon rather than continuum. The study also highlights the importance of understanding relevant religious-cultural factors.

The Urologist's Guide to Religion and Male Factor Fertility Treatment.

OBJECTIVES: To create a reference guide for six of the major U.S. religions for use by reproductive health specialists to provide patient-centered care for a culturally diverse patient population. MATERIALS AND METHODS: We utilized primary source reviews of various religious texts and verified electronic databases to examine perspectives on use of, in vitro fertilization (IVF), intrauterine insemination (IUI), sterilization procedures such as vasectomy and tubal ligation, and surrogacy for six major U.S. religions: Catholicism, The Church of Jesus Christ of Latter-Day Saints (LDS), Hinduism, Judaism, Buddhism, and Islam. Each statement of religious belief was either taken directly from primary source documents or cross-referenced across several secondary sources to ensure accuracy. Perspectives were compiled into a reference document and table for clinical use. RESULTS: Most religions have focused statements concerning assisted reproduction and vasectomy. While there are caveats for most religions, IVF and IUI are largely opposed only by the Catholic church, surrogacy is not permissible in the LDS Church, Catholic Church, and Islam, and vasectomy is not permissible for the Catholic Church, LDS Church, Judaism, and Islam. Similarly, tubal ligation is also not permitted for these religions with the exception of Judaism of which while vasectomy is considered a violation of the Torah, sterilization of a woman is not explicitly discussed in the old testament. Instead, a rabbinic decree states permanent female sterilization as against the views of the faith. The religions with the most lenient rules concerning reproduction and permanent contraception explored include Buddhism and Hinduism each of which have no reservations pertaining to IVF, IUI, surrogacy, or permanent sterilization. CONCLUSION: Religion often plays a significant role in patients' attitudes towards use of ART, permanent sterilization, and surrogacy. Familiarity with the religious beliefs and perspectives is important for the reproductive health specialist in order to provide appropriate counseling for their patients. IMPACT STATEMENT: A summative reference guide can help provide patient-centered care for reproductive health and family planning.

A comparative study of mental health diagnoses, symptoms, treatment, and medication use among Orthodox Jews.

Historical clinical reports and media narratives suggest that Orthodox Jews are reticent to seek treatment for mental illness, present only with serious concerns, and hesitate to comply with treatment in general and psychopharmacology in particular. On the other hand, recent developments, and some limited research, suggest that Orthodox Jews may be likely to seek and comply with treatment. The current study compared the diagnostic, symptomatic, and treatment characteristics of 191 Orthodox Jews and 154 control patients all presenting to a large private mental health clinic with offices throughout greater New York. Results indicated that the groups were largely demographically similar, and that their diagnoses did not significantly differ. Orthodox Jews initially presented with lower levels of symptoms, terminated with similar symptom levels, attended a similar number of sessions, and were equally likely to use psychopharmacological interventions of similar types, compared to controls. This was equally true of ultra-Orthodox and modern Orthodox Jews. Clinicians providing mental health services to Orthodox Jews should be aware of these findings, which contrast with existing clinical and popular stereotypes. Further, excessive efforts to protect Orthodox Jewish patients against stigma may be unnecessary and counterproductive.

Child Sexual Abuse by Religious Authority Figures in Germany and Israel: The Experiences and Perceptions of Adult Survivors.

The current study is based on an in-depth thematic analysis of 20 interviews with German and Israeli adult survivors of child sexual abuse (CSA) by religious authority figures (RAF). This paper aims to explore survivors' experiences within the Jewish ultra-Orthodox and Christian communities, as well as to draw comparisons between the abusive structures and disclosure in these two contexts. The results point to the complexity of CSA by RAF, which is embedded in the survivors' perceptions of themselves as emotionally and cognitively captured by the perpetrators who are a symbol of a parent or God and faith. The participants expressed great concern regarding disclosing the abuse against the backdrop of familial, cultural, and community inhibitors, such as fear of social stigmatization, inability to recognize the abuse, and the taboo of sexuality discourse. The survivors' traumatic experiences were intensified in light of negative social responses to disclosure and encounters with insensitive officials. A comparison of the cultures revealed differences regarding the nature of community life and educational institutions, which may have shaped the disclosure and recognition of the abuse. The study highlights the importance of comparative follow-up studies related to this phenomenon in order to examine its universal and unique cultural contexts.

The Experience of Mothers from the Israeli Jewish Ultra-Orthodox Sector after Disclosure of Their Child's Sexual Abuse as Manifested in Drawings and Narratives.

Child sexual abuse is present in all strata of Israeli society. However, there is scant research on the emotional experiences of non-abusing mothers after disclosure. In particular, no studies have examined the experiences of these mothers from the Jewish Ultra-Orthodox community in Israel. The current study analyzed the drawings and short narratives of 21 Israeli Ultra-Orthodox mothers to explore the effects of the disclosure of their child's sexual abuse. A phenomenological approach was used to analyze the drawings and yielded four different phenomena: (1) squiggles that represented distress, (2) the mother-child relationship, (3) pseudo-sweet houses, and (4) split drawings. The drawings were either colorful, sweet or shallow, or alternatively were in black and white. As confirmed by the narratives, these drawings primarily expressed the negative emotions of shock, sadness, distress, guilt, and failure as mothers. While some mothers reported breaking down and that pain had permeated their daily lives others coped by dissociating the painful experience, putting up a façade of normalcy, or splitting their lives into two parts corresponding to before and after the disclosure.

How are psychotic symptoms and treatment factors affected by religion? A cross-sectional study about religious coping among ultra-Orthodox Jews.

Religious coping is prevalent among individuals diagnosed with psychotic disorders, however its clinical relevance has been insufficiently studied. Thirty ultra-Orthodox Jewish patients experiencing current psychotic symptoms and receiving treatment in the inpatient and day-care units were administered measures assessing severity of psychotic symptoms, psychological distress/well-being, beliefs about treatment credibility/expectancy, and aspects of religious belief and coping. Among men, negative religious coping was associated with lower treatment credibility. Among women, positive religious coping was associated with increased treatment expectancy and greater quality of life; and trust in God was associated with reduced psychiatric symptoms and greater treatment expectancy. Study findings indicate that religious factors may promote treatment motivation and engagement, crucial factors for subpopulations facing culturally-based barriers to treatment, as well as boost more favorable outcomes. Sensitivity to religious factors in treatment appears to play an important role in the management of psychotic disorders and should be engaged when culturally appropriate in order to maximize treatment potential.

The last Talmudic demon? The role of ritual in cultural transmission.

Recent work on the evolution of religion has approached religions as adaptive complexes of traits consisting of cognitive, neurological, affective, behavioural and developmental features that are organized into a self-regulating feedback system. Religious systems, it has been argued, derive from ancestral ritual systems and continue to be fuelled by ritual performances. One key prediction that emerges from this systemic approach is that the success of religious beliefs will be related to how well they are connected to rituals and integrated with other elements of the religious system. Here, I examine this prediction by exploring the rich world of Jewish demonology. As a case study, I briefly survey the historical trajectory of demonic beliefs across Jewish communities and focus on one demon, a ruach ra'ah, that has survived the vicissitudes of Jewish history and maintained its relevance in contemporary Jewish communities. I argue that it has done so because of its linkage with a morning handwashing ritual and its effective integration into the core elements of Jewish religious systems. This article is part of the theme issue 'Ritual renaissance: new insights into the most human of behaviours'.

The healthcare worker at risk during the COVID-19 pandemic: a Jewish ethical perspective.

The current COVID-19 pandemic has raised many questions and dilemmas for modern day ethicists and healthcare providers. Are physicians, nurses and other healthcare workers morally obligated to put themselves in harm's way and treat patients during a pandemic, occurring a great risk to themselves, their families and potentially to other patients? The issue was relevant during the 1918 influenza epidemic and more recently severe acute respiratory syndrome epidemic in 2003. Since the risk to the healthcare workers was great, there was tension between the ethical duty and responsibility to treat and the risk to one's own life. This tension was further noted during the 2014 Ebola outbreak in West Africa that left hundreds of healthcare workers dead. The AMA Code of Ethics states that physicians are to 'provide urgent medical care during disasters…even in the face of greater than usual risk to physicians' own safety, health or life.'1 Classic Jewish sources have dealt with this question as well. There is an obligation 'to not stand by idly when your friends life is in danger'; however, the question arises as to whether there are limits to this obligation? Is one required to risk one's own life to save another's? There is a consensus that one is not required but the question open to debate is whether it is praiseworthy to do so. However, regarding healthcare workers, there is agreement for ethical, professional and societal reasons that they are required to put themselves in harm's way to care for their patients.

Informal Milk Sharing for the Hospitalized at-Risk Infant in the Ultra-Orthodox-Haredi Jewish Community in the United States.

The process of human milk donation and sharing for the promotion of infant health is a phenomenon of interest as it directly affects children's health and well-being. Although its prevalence is currently unknown, informal sharing of human milk is occurring across the United States. The U.S. Food and Drug Administration recommends against informal sharing of human milk. However, the Ultra-Orthodox (Haredi) Orthodox Jewish population, who strictly observes Jewish laws and often consults with rabbis before making medical decisions, is known to donate and obtain milk through informal sharing. The objective of this study was to explore the lived experience of informal donation from the perspective of Ultra-Orthodox mothers from the Northeastern region of the United States who engaged in milk sharing to support hospitalized at-risk infants. Women were interviewed by an Orthodox Jewish member of the team, using a semistructured interview guide. Informal milk sharing was regarded as a positive empowering experience. Themes which illuminate the phenomena of milk sharing include faith, mistrust of the medical establishment, a strong reliance on social connectedness, and importance of sacred cultural traditions. Health care providers need to be aware of these specific needs to provide culturally sensitive care for safer milk sharing practices in cloistered and faith-based communities.

Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective.

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.

Religious observance and perceptions of end-of-life care.

This study examines the impact of the level of religious observance on the attitudes toward end-of-life (EOL) decisions and euthanasia of Jews in Israel-where euthanasia is illegal-as compared to Jews living in the USA, in the states where euthanasia is legal. A self-reporting questionnaire on religiosity and personal beliefs and attitudes regarding EOL care and euthanasia was distributed, using a convenience sample of 271 participants from Israel and the USA. Findings show that significant differences were found in attitudes between Jews of different levels of religious observance with respect to patient autonomy, right to die with dignity, and dying in familiar and supportive surroundings. The USA and Israeli Jews have similar knowledge regarding EOL care and expressed similar attitudes and perceptions toward the issues of authority of medical staff and religious figures and patient's autonomy. Findings indicate that the level of religious observance has more potency in shaping their attitudes and perceptions of EOL decisions than the state law. We conclude by discussing the implications of our findings with regard to multicultural health systems and providing practical recommendations.

Prioritizing Patterns and Life Satisfaction among Ultra-Orthodox Jews: The Moderating Role of the Sense of Community.

Recent research suggests that individuals differ in the extent to which they seek activities that promote hedonic or eudaimonic well-being. Prioritizing positivity describes a strategy of pursuing happiness by seeking pleasurable activities or circumstances that can lead to naturally occurring positive emotions, while prioritizing meaning describes a strategy of cultivating well-being by purposefully seeking activities that are conducive to experiencing meaning in life. While these notions have been examined among the general population, little is known about how these prioritizing patterns are linked with well-being in closed religious groups, who often promote the benefit of the collective group in lieu of the individual's personal choices and interests. Based on a sample of 407 Ultra-Orthodox Jewish individuals (mean age = 33.58, SD = 8.89), 55.5% of which were women, the results demonstrated that prioritizing meaning and sense of community were positively associated with life satisfaction. Moreover, a significant interaction of sense of community × prioritizing positivity was found, indicating a positive connection between prioritizing positivity and life satisfaction for individuals with a high sense of community, but a negative connection for those with a low sense of community. Our findings suggest that even in extremely close-knit community-oriented societies, a strong sense of belonging to a community enables individuals to prioritize more hedonic aspects of their lives in order to promote their life satisfaction.