Dinnertime is nearing, and the kitchen in this tidy home is buzzing. Lamyaa Manty, a 29-year-old Iraqi refugee, wears a neon-pink T-shirt and stirs a big pot of eggplant, onion, potatoes and tomatoes on the stove, a staple of Iraqi cooking called tepsi.
Spinning around with a butterfly net in her hand and dancing to Arabic music is Fatima Abdullah, an exuberant 9-year-old.
At the center of the activity is Fatima’s aunt, Salima Abdullah Khalifa, a burgundy-haired matriarch from Baghdad, who pours Pepsi into small glasses on the table.
This is a found family. Manty was Khalifa’s neighbor in Baghdad. When Manty lost her entire family, Khalifa took care of her. The two spent five years together in Jordan, waiting for their refugee applications to be processed.
Khalifa's husband, brother and three sons were killed in Iraq, and restarting life in Buffalo, on the shores of Lake Erie, with such profound pain in her heart has been trying. Certain American customs bewilder her. When it comes to health care, Khalifa was startled to find that male doctors in the U.S. examine women and that she is supposed to get a checkup at the clinic even when she is not sick.
"We don't have primary [care] doctor in my country," said Walaa Kadhum, a fellow refugee and Khalifa's friend who helps translate. In Iraq, the women say, only the very sick or the very rich received medical treatment. But here in the United States, they have primary care doctors and get annual checkups.
Perhaps the most distressing of those checkups for many conservative Muslim women is a Pap smear, a screening test for cervical cancer. The test is rare in the developing world, according to global health experts, and for traditional Muslim women, like Manty, who are expected to be virgins until they marry, the invasive procedure is a profound threat.
"If she's not a virgin, she can't marry," explained Kadhum. "They say, 'This is a bad girl. We can't marry you. Until she [is] married, nobody [touches] her."
Manty said if she does not marry, she will never get tested for cervical cancer or have a vaginal exam. Khalifa, now 51, had her first exam at 45, when she resettled in Buffalo.
Physicians who treat refugee women say it's not uncommon to find undiagnosed cervical cancer, sexually transmitted diseases or chronic pelvic pain.
Dr. Magda Osman, an obstetrician and gynecologist at the Buffalo Medical Group who is originally from Egypt, said many of her refugee patients eventually agree to a Pap test once they understand the health benefits. But for women who still object, she tries to explain that Islam doesn't prevent them from taking care of their health.
"A lot of cultural issues may not be religious issues but they're so ingrained in people that they don't know the difference," said Osman.
The unmarried women she sees often fear a Pap test will break their hymen, which can be very problematic for a young woman if it calls her virginity into question. But it can be a strict culture — not the Quran — enforcing that idea, Osman said.
"A certain percentage of women will not bleed on the first time they're sexually active," she said. "But if you go to many cultures around the world, if there is no blood then that woman is ostracized. But that's not religion."
At the Jericho Road health clinic in Buffalo, the staff is well-versed in these cultural beliefs. Heidi Nowak, a family nurse practitioner, said she doesn't push patients to violate their beliefs, but she will advocate for their health.
The stereotype that traditional Muslim women who cover themselves are meek is a myth, Nowak said. Her female Muslim patients are assertive and many of them have questions about sex, she said.
"Some of the young Iraqi women will come to me. They're planning to get married in two months, and they want to be prepared, so they'll ask me questions about it," she said. "'What does sex feel like? How does it work?' Or I'll have them come to me after and say, 'It was terrible.'"
One of the biggest challenges serving strict Muslim refugee women, said Nowak, is their reticence — or outright refusal — to be seen by a male doctor.
Not far from the clinic, Kuresha Noor, a caseworker for Journey's End Refugee Services, a resettlement agency, visits the home of a Somali mother and her three children who resettled in Buffalo earlier this year.
The women, covered in traditional Somali robes and headscarves called garbasaars, sit on the couch in the threadbare apartment. The caseworker and her client are both pregnant and neither woman wants any male physicians to take care of them or attend their deliveries.
Americans seem to have a hard time understanding why many conservative Muslim women have a preference for female doctors, Noor said.
"They're not aware of it," she said of Americans. In her culture, she said, no man except her husband can look at her. If he did, she said, it would be as if "I'm not a good wife, like I'm not respecting his rights as a man. That's what I feel."
Doctors in Buffalo say the prohibition against male doctors has led to some harrowing moments in the delivery room — couples who refused to consent to male obstetricians, even during an emergency.
Fatuma Abdi Noor, the newly arrived pregnant mother from Somali, said her religion does allow a male doctor to help her in an emergency.
"It's not a sin. God knows you didn't do it on purpose," she said. "You won't feel shame or sinned, because God was always there and knows what's in your heart."
She was in a refugee camp in Kenya with little medical care during her past pregnancies. Now, in the U.S., she welcomes prenatal checkups, even if her culture and religion collide with some health care practices.
"It gives me peace," she said, "because I know the baby is healthy."
KHN's coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.