Debunking some myths about Jewish women and cervical cancer
by Sharon Lieberman
The enduring myth that male circumcision is the single most important explanation for the low rates of cervical cancer in Jewish women has been passed from generation to generation for over three-quarters of a century. However, studies have shown that for all women, their sexual behavior patterns play a far more active role in the etiology (cause and effect) of cervical cancer than the circumcision status of their male partners. For this reason alone, Jewish women must place the role of circumcision in a contemporary context that reflects current female sexual behavior.
The low incidence of cancer of the uterine cervix among Jewish women was first noted in British medical literature in 1901. From 1901 through 1960, nearly 15 major studies confirmed that original finding : Jewish women—Ashkenazic, Sephardic and Mizrachi—living under disparate economic and social conditions in the United States, Europe and Israel had significantly lower cervical cancer rates than white or black non-Jewish women. A 1950 study in New York City, for instance, observed that there were 4.6 cases of cervical cancer per 100,000 Jewish women compared to 20 cases for white non-Jewish women and 49.6 for black non-Jewish women.
The cervix is the lower end of the uterus which protrudes into the vagina. Cancers of the cervix are not believed to be directly related to diet or the body’s hormonal production, as are many cancers of other body sites. Actually, there is little disparity in cancer sites between Jewish men and women. Cancers related to sites of hormonal activity—the pancreas, the colon and even the breast—are more frequent in Jews, both women and men, than in other ethnic groups. Cancers of these sites are often attributed to a combination of genetic and dietary factors that affect hormonal activity. The uterine cervix, however is different; it does not secrete a hormone.
Cervical cancer is the second most common cancer in women, breast cancer being the most common. The high-risk age for cervical cancer in all women is from 35-55; however, the incidence of cervical cancer in Ashkenazi women appears to peak at age 70.
Cervical cancer does not progress as rapidly as breast cancer. If detected early, localized cervical cancer is 100% curable through cauterization or, more likely, a hysterectomy. The survival rates for advanced (spreading) cervical cancer are 60-85% 5 years after detection and treatment. Early detection is important. A Pap test once or twice a year is a wise policy for all women and especially for those who are sexually active or who have chronic vaginal or cervical infections.
Cervical cancer is believed to be linked to sexual and/or reproductive conditions favorable to a carcenogenic agent. In other words, a condition such as the repeated exposure through sexual intercourse to a possible carcinogenic agent—a virus or even sperm—could trigger abnormal cellular growth on the cervix.
Researchers, intrigued by studies of nuns and prostitutes, have pursued the theory that cervical cancer, like a venereal disease, may be sexually transmitted. An extreme but important study of over 3,000 Canadian nuns, conducted in 1950, observed a virtual absence of cervical cancer; a 1953 study of Danish prostitutes noted a frequent occurrence of the disease. Also, single women were found to have lower rates of cervical cancer than married women.
If cervical cancer is indeed related to sexual activity, scientists reasoned, then something in the sex life of married Jewish women might provide a clue to their low rates. The major difference in the sexual lives of Jewish and non-Jewish women was thought to be the circumcision status of their partners.
Circumcision is a religious requirement for Jewish males. Circumcision, or removal of the foreskin of the penis, prevents the accumulation of smegma on the penis. Smegma is the cheesy secretion of the lubricating glands beneath the foreskin. (However, an uncircumcised male who follows a regimen of penile hygiene —pulling back the foreskin and washing the penis—could himself prevent the accumulation of smegma.)
Smegma has been strongly implicated in lab studies as a possible agent of cervical cancer, particularly in viral theories of cancer. The vagina just may provide a hospitable environment for a virus that is transmitted in smegma. This virus, then, in combination with other factors, could trigger abnormal cellular changes in cervical cells.
But studies of circumcision as a cervical cancer preventative have shown gaps in scientific reliability. For instance, in 1958, two U.S. investigators studied 213 males who were admitted to a Midwestern hospital. Upon close examination, they found that 34% of the men provided incorrect information about their circumcision status. It was considered significant that if men were unsure about their circumcision status, then cervical cancer patients must be even less reliable informants.
Even more important, however, a National Cancer Institute study published in 1960 found that a considerable number of non-Jewish cervical cancer patients had sexual partners who were circumcised. Circumcision began to seem less of a key factor as it also became apparent from this study that New York Jewish women with cervical cancer had more uncircumcised partners than Israeli women with cervical cancer—but that New York and Israeli Jewish women shared equally low rates.
Both Jewish and Moslem men are ritually circumcised and both have very low rates of cancer of the penis, but there are no definitive studies to compare the cervical cancer rates of Jewish and Moslem women; surely such studies could prove invaluable and are without doubt called for. However, 1960 statistics gathered in Britain did show a high rate of cervical cancer in some Islamic countries. Since there may be an entire new generation of Soviet Jewish males who are not circumcised, some investigators have suggested cervical cancer studies for Soviet Jewish women.
At present, however, it seems clear that the alleged “protection” afforded Jewish women by circumcised Jewish men has been based on negative inferences: there was no substantial evidence that the uncircumcised penis promoted cervical cancer—but there is still no evidence that circumcision prevented it. Studies have been suggestive, not definitive.
The strongest correlations to conditions for cervical cancer are the sexual behavior patterns of women who have the disease: early sexual activity, multiple sex partners and early childbearing. The largest group of cervical cancer patients are women of low economic status. Cervical cancer studies have observed that women of low economic status tend to have sexual intercourse earlier in life with more partners than do middle class women.
Obviously, the low rates for Jewish women must transcend the sexual behavior patterns generally attached to class status. We can only speculate as to why our low rates appear to be a cross-class phenomenon. Were or are there unique rituals or traditions within Jewish life which affected sexual habits or behavior?
One 1948 study of Israeli Jewish women focused on the laws of niddah (menstruation), which codify marital relations between Jewish husband and wife. The niddah laws mandate sexual abstinence for the duration of the menses (at least 5 days) and for 7 days following. The approach in this study was that it sexual activity were strictly regulated according to the niddah laws, then their observance might account for the minimal cases of cervical cancer in Jewish women.
But the niddah factor lost scientific reliability when personal interviews revealed that the laws were rarely observed by Ashkenazic women, and observed more frequently among Sephardic and Mizrachi women—and yet both subgroups shared low rates for cervical cancer. Investigators found that Jews in Israel tended to follow unregulated patterns of sexual activity. Clearly, there was no basis for scientific control if Israeli Jews did not observe specific laws of abstinence within marriage. (No studies have yet been done, however, comparing cervical cancer rates among Jewish women who observed niddah strictly and those who don’t.)
Perhaps Jewish women of all classes have a tradition of conservative sexual behavior generally, which may or may not be the manifestation of a distinctly Jewish code of monogamy. Historians have described sexual monogamy among Jewish women and men not only as the custom but also the ideal, probably deriving from reasons of internal cohesion and harmony. Monogamy may have coincidentally served to protect Jewish women from exposure to disease processes that may be linked to non-monogamous sexual activity.
Jewish law requires a husband to provide his wife with sexual satisfaction [see article by Blu Greenberg in this issue]. Classical Jewish interpretation of the Mosaic commandment to “be fruitful and multiply” says that the male is responsible for fulfilling the commandment to procreate lest his woman “go seeking in the marketplace” (Genesis Rabbah 8:14).
Yet seeking in the marketplace is exactly what might change the cervical cancer rates for an entire generation of Jewish women who are only now entering the high-risk age group. The sexual freedoms of the past 15 years have altered the sexual behavior patterns of many women. Patterns of sexual behavior are now less class-defined. Young American women of all classes are now sexually active at earlier ages with more than one partner than most of the women studied from 1901 to 1960. Class status and even affluence should have less significance in emerging cervical cancer patterns where sexual behavior is a key factor in etiology.
It should be apparent by now that it is an uncertain business to make solid inferences from statistics. Most of the population studies discussed here were based on the records (not always face-to-face interviews) of women with cervical cancer. All the studies were retrospective, resulting in statistical observations of—not conclusions about—what had already happened, not what will happen. So while we know the rates for cervical cancer in our grandmothers’ or mothers’ generations, what about the current generation of women from ages 30 to 50?
Even individual sexual behavior may come to be less important on the list of cancer precursors in light of the widespread use of prescribed hormones. We are just beginning to witness the deleterious effects of long-term use of the Pill as well as estrogen replacement therapy for menopausal women. We have yet to see the full impact of oral contraceptives on women all over the world who are still of childbearing age.
An editorial in a recent issue of the American Cancer Society’s clinical journal points out that “the trend over the past years shows that cancer mortality would be declining but for the increase in estrogen use.” Other cancer researchers are more emphatic: prescribed hormones will precipitate an epidemic of breast, uterine —and cervical—cancers.
There is still much to be learned about the cause of cervical cancer. Continued studies of Jewish women are necessary to further basic understanding of cancer etiology. The most important variable, sexual behavior, deserves much more attention from the scientific community. If Jewish women share a racial or ethnic genetic immunity to cervical cancer, that should become clear in comparisons of American Jewish women—with our more “liberated” lifestyles—with Israeli Jewish women, whose sexual precocity is generally channeled into early marriage. If sexual monogamy has been a tradition for Jews, then surely Jewish men have also been monogamous, and this is an important contributing factor in studying sexual behavior patterns and their relationship to cervical cancer. All women— Jewish and non-Jewish—should call for cervical cancer studies that question men about their sexual behavior and do not make assumptions about “single” or “married” sex life.
Clearly, as Jewish women living in a secular environment, we must look beyond that comforting myth of the protection afforded us by male circumcision, and consider the responsibilities and risks that accompany lifestyles divergent from our Jewish traditions.
In demystifying the role of circumcision in cervical cancer, we have also established the sexual autonomy of the Jewish female. For if we believed that our circumcised men provided a cancer prophylaxis, we would rather arbitrarily enhance their desirability as sexual partners. But if we can acknowledge that, in fact, we control the risk of disease through our sexual behavior, we take on a responsibility for our sexual and reproductive lives, for our health, our bodies, our selves.
What Is a Jew?
The existence of the diaspora complicates genetic studies of Jews since Jews now living on five continents constitute a very wide range of genetic (inherited) characteristics. Most studies of Jews refer to three sub-groups: Ashkenazic (European), Sephardic (Mediterranean) and Mizrachi (Middle Eastern and Asian).
Jews do not share a common environment. Cancer studies of Jews usually compare those living in New York City (40% of the American Jewish population) and those in Israel. There are not only differences in environment and communal life between Israel and the U.S., but also differences between Jews who are foreign-born and native-born.
“Marital status” in population studies traditionally means whom one is legally married to, not who is one’s sexual partner. Marital status means very little if single (and married) women are sexually active and non-monogamous.
Occupation and income, two important variables in population studies, have too often been the attribute of the father or husband of the female being studied. This reveals the assumptions of the male-dominated sciences that a woman’s identity—her working condition, home environment, and lifestyle— is synonymous with that of a primary male.
An additional variable rarely mentioned in scientific literature when the relationship of economic status and disease is discussed, is access to medical care. Such access could mean early disease detection as well as basic health education about venereally transmitted diseases.
Is Herpes a Factor?
Research attention has shifted in recent years from the conditions favorable to cervical cancer to the actual carcinogenic agent. Genital Herpes virus, for example, is thought to be a precursor of the disease; this virus is believed to be transmitted by men.
Signs of Herpes virus infection have been found more often in cervical cancer patients than in women free of the disease; also, a virus that appears to be Herpes virus (type II) has been isolated from cervical cancer cells. A 1976 study by Dr. Irving I. Kessler at the Johns Hopkins University School of Public Health found an unusually high rate of cervical cancer in the wives of men who had previously been married to women who had developed cancer of the cervix. Dr. Kessler and others have hypothesized that the causative agent was genital Herpes virus passed through sexual intercourse.
Even more disconcerting are studies of sperm as a possible carcinogenic agent. A 1975 laboratory study by Drs. Aaron Bendich and Ellen Borenfreund of New York’s Sloan-Kettering Memorial Cancer Center discovered that sperm might, under certain favorable conditions, cause cervical cancer. Nothing conclusive, however, has been proved to directly connect either Herpes virus II or sperm to cervical cancer.
In fact, the male role in cervical cancer is just beginning to receive close attention. In studies published in 1976, several researchers have sketched out a profile of men they consider to be high-risk sources: those men with venereal disease, certain genital cancers, or multiple sex partners.
While all Jewish women have relatively low rates of cervical cancer, middle- and upper-class Ashkenazic Jewish women are considered a high risk for breast cancer.
There is mounting evidence that a diet high in saturated fats may adversely affect the metabolism of blood cholesterol. This may, in turn, overstimulate the body’s steroid hormones, giving impetus to tumor formation. A high-fat diet —usually associated with Western affluence—could possible trigger a genetic predisposition to breast cancer.
Early detection greatly reduces the mortality risk of breast cancer. In addition to self-examination for lumps, women with a family history of breast cancer (blood relatives who had the disease) and women with lumpy, cystic breasts, should have a mammography (breast X-ray) at least once, especially past age 35. Women over 50, with or without the history or symptoms, should also have a mammography at least once. Routine mammography (more than once or once a year) should be a decision between a woman and her doctor. Exposure to X-ray should not exceed 2 units per visit.
Sharon Lieberman is a member of Health-Right, a women’s health organizing collective, and Health Editor of Majority Report, a feminist newspaper in New York. She has a Master’s Degree in Community Health Education and is an activist and writer in the women’s health movement.