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I read Robert Card's recent paper entitled ‘Is there no alternative? Conscientious objection by medical students’ with great interest.1 That Muslim students in America are able to conscientiously object (and this was entertained) to the cross-gender consultation is somewhat startling. I have just left the Middle East, where I worked as a medical educator for five-and-a-half years (2006–2011), and, to the best of my knowledge, even in the conservative, gender-segregated traditional Muslim culture of the United Arab Emirates, not once did a male or female student refuse to examine a patient of the opposite sex.
Several issues, many of which have been described by Padela and del Pozo,2 should be taken into consideration in relation to Muslim students’ conscientious objection to the cross-gender consultation on religious grounds. Although Islam prohibits touching or physical contact by the opposite gender, unless appropriate (eg, by a spouse), in some circumstances, the ‘prohibited becomes permissible’.3 Medicine is one such circumstance. Islam does not preclude a doctor from examining the opposite gender where a same-gender physician is not available, or in life-and-death situations.2–6 Islam recommends first a same-gender Muslim physician, followed by a same-gender non-Muslim and, failing their availability, a Muslim of opposite gender, and lastly an opposite gender non-Muslim doctor.3 ,5 In cross-gender consultations, however, Muslim women generally need to be accompanied by a same-gender third party.3–5
The ancient literature on medical care attests to the possibility of, and necessity for, cross-gender examinations. In the eighth century, Ibn Quaddama wrote that it was permissible for a male doctor to inspect whatever parts of the woman's body were warranted during the medical examination.4 Similarly, Ibn-Muflih stated that ‘A man doctor may inspect the awra of a women's body as far as the medical examination warrants if only a male doctor is available to treat her, even if he has to look at her private parts. The same would be true if a man is ill and there is but the woman doctor to treat him. She may inspect his body even his private parts’ (p. 3).4 Furthermore, this literature attests to the need for Muslims to seek the most qualified practitioner for their medical treatment. Some 600 years ago, Ibn Qayyim Al Jawziyya wrote in The Prophetic Medicine that Muslims should seek the best authority in each matter and field because such expertise will ensure that the task is done with excellence.7 Implicit in this hadith (narrative originating from the words or deeds of Prophet Muhammad) would be the need to consult an opposite gender physician if he or she was the most qualified.
The insistence of modern Muslim patients for the same-gender physician, or for Muslim medical students conscientiously objecting to the cross-gender consultation is interesting, considering the Islamic history of medicine during Prophet Muhammad's life. During that time, the medical corps comprised ‘lady healers’ or asiyaat, who were responsible for treating wounded soldiers, irrespective of the injuries. Cross-gender medical care was established during the battles of Badr and Uhud, and so according to the Prophet's tradition, the rule governing covering of areas of the body was waived in the interest of medical treatment.3 ,4
During interviews with final year male and female clerks about the cross-gender consultation in a society (United Arab Emirates) where women are generally not free to travel without a member of their mahram (non-marriageable male chaperone), some female students (more so than their male colleagues) had initially been apprehensive about touching a male body. Their mutawa (religious leader) reassured them that as medical students, they had to treat both male and female patients and were therefore allowed to touch males. From this study, it also emerged that although students accepted cross-gender touching in the clinical consultation, older Emirati women and men often refused male and female students, respectively. Patients were mostly women in obstetrics and gynaecology, and males in urology. As little has been published in this area, a group of local female students surveyed Emirati women's attitudes towards male and female medical students, as well as canvassed their physician preference. While their general preference was for a female student or physician, other factors, such as physician certification and patient education, impacted on what parts of the body the women would or would not allow a male student or physician to examine.8 ,9
As I indicated at the start of my response, it was startling for me that Muslim students in America could conscientiously object to the cross-gender consultation. It is difficult to reconcile how Muslim students living in a conservative, gender-segregated and traditional Middle Eastern society were able to accept that in Islam medical care should supersede religious teachings, and how Muslim students living in a western country are not able to adapt.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.