by Nachum Klafter, MD - Guest Blogger
Printed with authorization of the author. His complete bio appears at the end of this post.
An academic paper about sexual abuse among Orthodox Jews, "History of Past Sexual Abuse in Married Jewish Women," was published in the November, 2007 issue of the American Journal of Psychiatry (AJP) by Rachel Yehuda, PhD, et al. This paper has generated significant controversy in the Orthodox Jewish world. For the most part, the controversy is actually a reaction to an article in The New York Jewish Week (10/25/2007) by Debra Nussbaum Cohen, "No Religious Haven From Abuse," which characterizes the AJP study as follows: "New study finds Orthodox women are sexually victimized as much as other American women are." Orthodox Jewish mental health professionals have been debating the significance of the data from the AJP paper. The following is my critique of the study. My remarks will be organized in the following three sections:
- My demonstration that the AJP paper draws no conclusions about the rate of sexual abuse in the Orthodox community, and no conclusions about a comparison with the rate in the general population. The nature of this study would preclude any such findings, as I will clarify. In fact, this is clearly stated in the AJP paper. Therefore, the New York Jewish Week article by Debra Nussbaum Cohen is a gross misrepresentation of the study by Dr. Yehuda, et al.
- My critique of the paper, including my defense against some of its detractors.
- My recommendations for what the Orthodox community should and should not conclude from this study.
The AJP study can be summarized as follows: The investigators recruited observant, married women to answer an anonymous questionnaire "examining sexual life in marriage among observant women." Subjects were sought "across a large range of religious Jewish communities by advertising through synagogue bulletins, Jewish organizations, newspapers, Jewish oriented web-sites and list-serves, and a network of medical professionals… whose practices consisted of sizable numbers of Orthodox Jewish women." (p. 1700) Self-report of regular Mikvah use was the key inclusion criterion for this study. 26% of the total respondents (N=380) reported sexual abuse at least once, and 16% reported occurrence of abuse before age 13. Some very interesting patterns were observed. Ba'alei teshuva in their sample reported sexual abuse histories in this survey about twice as frequently as women raised in an Orthodox home, (36% vs. 19%).(p. 1701) Women who defined themselves as "ultra-Orthodox" reported abuse more frequently than those who defined themselves as "Modern Orthodox." Other interesting findings are reported, but I believe that these are the most significant with respect to the ensuing controversy.
The authors briefly comment on the rate of sexual abuse in the general population. In the Discussion (p. 1703), they state:
These estimates are consistent with data from several national surveys, in which 25%-27% of women, regardless of marital status or religious affiliation, reported sexual abuse A meta-analytic study by Gorey and Leslie concluded that approximately 22% of women report childhood sexual abuse, a figure slightly higher than was noted in the present study.The investigators made no attempt to measure the rate in the general population in this study. Therefore, a statistical comparison is impossible. Their mention of the prevalence of abuse in the general population is for the purpose of establishing a reference point for readers who are not familiar with the abuse literature. In fact, the authors repeatedly state that there are numerous indications that their sample is not representative of the larger population of married, Orthodox women, and they deny that they have drawn any conclusions about the rate of sexual abuse in the Orthodox community:
A major limitation of this study is that it was not feasible to obtain a representative sample of observant Jewish women, since no sampling frame was available…. We do not, therefore, claim that this study group is representative of all Jewish women. On the contrary, the high level of education, even among the ultra Orthodox, suggests a sampling bias…. For all of these reasons, the estimates of prevalence of sexual abuse reported here are not the actual prevalence of sexual abuse among Orthodox Jewish women. (p. 1704).Three papers are cited in the AJP paper to establish a 25%-27% rate in the general population. A careful examination of these references further clarifies why no conclusions can be drawn from the AJP data regarding the rate in the Orthodox community, or comparisons with general population. The 25%-27% rate is based on data from surveys which used random sampling methods from groups which are representative of the general population, and measured the response rate (i.e., what percentage of potential subjects agreed to be interviewed). By contrast, the AJP study made no efforts to measure the total number of women who saw the advertisement. Therefore, there is no way to estimate the response rate. For example, if 2,000 women saw this advertisement, her response rate would be 19%; if 10,000 women saw the advertisement, it would be only a 3.8% response rate. This is not a criticism of their study; it is simply a clarification of the kind of study this is. It is not an estimate of the rate of sexual abuse in the Orthodox community.
In addition, if these authors wished to draw conclusions about the rate of sexual abuse in the Orthodox community relative to the general population, they would need to consider the following: The rate of sexual abuse is about twice as high among subjects in their study who are ba'alei teshuva vs. subjects in their study who were raised Orthodox ("FFB women"). A plausible explanation for this curious finding (if the sample were representative, which it is not) is that there may be an actual lower rate of sexual abuse among FFB women vs. Jewish women raised among non-observant Jews.
In conclusion, it should be clear to anyone who reads this paper carefully that there is no data presented which justifies a conclusion about the rate of sexual abuse in the Orthodox community, or a statistical comparison with the rate in the general population. The investigators have made this abundantly clear. The fact that this is not clear to Debra Nussbaum Cohen, or the editorial staff of the New York Jewish Week may be evidence of a lack of sophistication with academic papers. I would never expect, for example, that a science writer at the NY Times would misunderstand this so significantly. The NY Jewish Week article makes assertions that are disavowed numerous times in the AJP paper!
Part 2: My critique of the paper, and response to Dr. Marvin Schick.
One might ask, "If these data are from a sample which is not representative of observant, married Jewish women, then what is the point of this study?" Admittedly, this paper is more significant for fellow researchers about sexual abuse than for the lay public. Sometimes, good research suggests more questions than it can answer. This study would suggest that the following questions need to be investigated. Why did FFB women in this sample report abuse about half as frequently as ba'alei teshuva? Would a questionnaire given to a randomly selected sample of women raised Orthodox show lower rates than an age matched unobservant or non-Jewish cohort sample? If Orthodox women were randomly sampled from some institutional settings, would they answer differently according to their identity as Haredi or Modern? Are Modern Orthodox girls better educated about avoiding sexual abuse? Or, are Haredi communities particularly impervious to representative sampling for scientific surveys?
I would fault the authors of this paper with only one thing: They fail to acknowledge the very plausible possibility that a lower rate of abuse in Orthodox communities would explain the difference they observed between FFB women and ba'alei teshuva. Instead, they offer the following speculation, "Thus, women who are sexually abused or threatened may be more likely to seek out a more structured and sexually restricted lifestyle." (p. 1704) In fairness to the authors, etiquette in scientific papers is that wide latitude is typically granted to authors to speculate about their findings in the Discussion. Actual statistics, conclusions based on actual statistics, and conclusions which are reported in a paper's Abstract are reviewed at a much higher level of scrutiny than the Discussion. Those familiar with reading the scientific literature realize this, and in my opinion it is not the fault of the authors that their paper was so greatly mischaracterized by the New York Jewish Week. Nevertheless, the addition of one sentence might have averted significant misunderstandings.
I would like to respond to Dr. Marvin Schick's lengthy remarks. He characterizes the AJP paper as "the reckless scholarship and statistics of Dr. Yehuda, et al which constitute a form of group libel and severe cruelty toward observant Jews." He makes numerous arguments against the validity of their data set. For example, he complains that the sample is too small to draw conclusions. In reality, smaller data sets increase the risk of Type II Errors (false negatives, i.e. failure to identify a legitimate finding), but not Type I Errors (false positives). Furthermore, if this were a representative sample (which it is not), then this sample size would be perfectly adequate for estimates. Schick states, "The greatest flaw in the research and presentation is that 137 or 36% of the respondents were not raised Orthodox, becoming observant later in life, a statistic that is incompatible with the distribution of ba'alei teshuva or return to Judaism women in the Orthodox population." To the contrary, the discrepancy between ba'alei teshuva and FFB women who were recruited via the same sampling methodology is one of the most interesting findings in this data set and worthy of future research. Despite dismissing the sample as unrepresentative, Schick concludes, "Contrary to popular wisdom which decrees confidently that the Orthodox tend not to report abuse, 44% of those raised Orthodox reported the incident. The comparable figure for those not raised Orthodox is 39%." He also states, "In sum, to the degree that this survey has any value, it appears to point to a lower, probably much lower, incidence of sexual abuse in the Orthodox community than in American society as a whole." It puzzles me that while he so eloquently estlablishes that the data are not representative, he is nevertheless willing to tentatively draw selective conclusions from it.
The most problematic aspect of Schick's remarks is that he appears to imply that it is he who has discovered that the data are not representative of the general population. (I do not assume he has done this deliberately.) For example, he cites the high graduate education rate (53%) amongst the ultra-Orthodox respondents, as well as the high proportion of subjects who have been treated with psychotherapy in the past (51%). Yet, he omits the fact that it is the authors of the AJP paper themselves who state that these particular findings indicate that their sample is not representative (p. 1704):
We do not, therefore, claim that this study is representative of all observant Jewish women. On the contrary, the high level of education, even among the ultra-Orthodox, suggests a sampling bias that may be associated with a willingness to participate in research. Furthermore, there was a high proportion of subjects receiving mental health treatment in this group, which also may reflect an openness to discussing sensitive topics with others.In summary, Schick unfairly portrays the AJP authors as though they have drawn conclusions about the rate of abuse in the Orthodox community and a comparison with the general population (which they have not), and inaccurately portrays himself (presumably inadvertently) as though he has discovered findings which indicate their data are not representative.
The authors of this study, Rachel Yehuda PhD, Michelle Friedman MD, Tali Rosenbaum PT, Ellen Labinsky PhD, and James Schmeidler PhD, have been subject to very unfair and inappropriate criticism from the Orthodox community. There is much to learn about sexual abuse in general population as well as in the Orthodox community. Their paper does suggest that religious identity and religious upbringing may exert effects on the prevalence of sexual abuse. That alone is a worthwhile contribution. Determining exactly what these effects are will require further research.
Part 3: My recommendations as to what Orthodox Jews can and cannot conclude from this paper.
Jewish Law imposes strong prohibitions against any premarital or extramarital sexual contact. The Jewish religious tradition emphasizes the cultivation of high personal and communal standards of modesty in all interpersonal relationships. It is, therefore, quite reasonable that Orthodox Jews should expect that there would be a significantly lower rate of sexual offenders brought up in an Orthodox environment. One might hope the same for violence, theft, tax-fraud, gossip, anger, and arrogance. The AJP paper does not present any evidence that there is a lower, comparable, or higher rate of sexual abuse in the Orthodox community as compared with the general population, and we must acknowledge that there is no scientific evidence to support an assumption that sexual abuse, or any other social evil, is less frequent in our communities. Being raised in a Torah environment is not a guarantee that someone will grow up to become an ethical, balanced, humble, and refined human being. How certain are we, for example, that arrogance and anger, despite admonitions against them by Chazal and in the mussar and Hassidic literature, are expressed less frequently or intensely among Orthodox Jews, as compared with unobservant Jews or the general population?
As far as the impact of Orthodox Jewish life on the rate of sexual abuse in a given community, I would suggest the following: It would be more relevant to investigate the percentage of sexual offenders in a given population, as opposed to prevalence of victims of sexual abuse. By way of analogy: Locks and burglar alarms probably reduce the incidence of theft, but not the prevalence of thieves. Prevention of sexual abuse is best achieved by implementing safety measures, and by enforcing the law. In other words, we wish to prevent potential sexual offenders from becoming actual sexual offenders, and to prevent one-time offenders from becoming serial offenders. Preventing the development of pedophilia is another matter.
I would also suggest that we must consider the following: Although this is highly controversial and although there is not yet a consensus in the scientific literature, there is an emerging body of evidence to suggest that pedophilia may be a manifestation of biological problems in the brain. I do not argue for leniency toward sexual offenders, regardless of the question of a biological disposition toward pedophilia. However, this consideration does suggest important theoretical questions about the degree to which a religious upbringing can be expected to prevent or reduce manifestations of biological abnormalities.
What should the Orthodox community conclude from this study? I would suggest only the following: We cannot rely upon lay Jewish media to accurately report on scientific developments, particularly those which are juicy and controversial. Sensationalizing scientific findings for the sake of noble causes (like protecting our children from sexual abuse) tends in the long run to undermine rather than bolster them. This study provides no conclusive information about the rate of sexual abuse in our communities, and should not factor into Jewish communal policy decisions.
In my opinion, there is currently a positive trend toward increased collaboration between lay leaders, rabbinic leaders, mental health professionals, and law enforcement agencies for how to prevent sexual abuse in our communities. The rights of the accused, the vulnerability of young children, and the charged nature of highly emotional reactions by most individuals in response to allegations of sexual abuse pose irresolvable dilemmas for those trying to formulate consistent policies. From my perspective as a psychiatrist and psychoanalyst, I believe that there is still not enough being done in Orthodox communities to prevent sexual abuse of children. The areas which I believe would be the most productive are preventive education for parents and children, and mandatory criminal background checks for all employees of day schools, seminaries, yeshivas, and summer camps. My perspective is informed by the following: (1) an understanding of the devastating consequences of childhood sexual abuse which comes from in-depth psychotherapy treatment of numerous patients who continue to struggle with the consequences of it during adulthood, (2) being privy to numerous incidents of sexual abuse in Orthodox communities across North America which have been horribly mishandled when mental health professionals and law enforcement were not involved, and (3) seeing numerous incidents of sexual abuse in Orthodox communities where involvement of the legal authorities and mental health professionals was enormously helpful to victims and their families, as well as to institutions and communities as far as preventing further incidents of abuse.
 It is clear to me that one must report allegations of child abuse (sexual or physical) when one is aware of it, (even if this means that the child might be places in a Gentile foster home). Rabbi Abraham Sofer Abraham, Nishmat Avraham Volume 4, pages 307-11, quotes responsa from Rabbis Auerbach, Elyashiv and Waldenberg in agreement on this point, that one must report cases of child abuse. No alternative view is quoted in this enclyopedic work. Rabbi Abraham writes:
A child or infant who is brought to a hospital with symptoms of being a battered child... it is prohibited, after an investigation, to return him to his home as they will continue to beat him until he might die. Because of the real danger, it is obligatory for the doctor to inform the courts, and with an order from the court, place the child with a foster parent or agency. There is no problem of informing since we are dealing with danger to life and the parents are the pursuers. This is permitted even if they will place the child, due to no choice, with a family or agency that is secular. It is incumbent upon the Jewish court to do everything in its power to insure that the child is placed with an observant family or agency. Particularly in the diaspora it is important that the Jewish court work to insure that the child not be placed with a Gentile family or agency. Rabbi Shlomo Zalman Auerbach agreed with all of the above.For more on this, see http://www.jlaw.com/Articles/mesiralaw2.html
Rabbi Yosef Shalom Elyashiv recounted to me that it is permitted for the doctor to inform the authorities even if it is possible that the child will be placed with a family or agency that is not Jewish...
Rabbi Waldenberg wrote "if there is a real risk that the parents will continue to hit the child... it is obligatory for the doctor to report the matter to the police..." Sexual abuse (of either boys or girls) is no different than physical abuse. [Rabbis Waldenberg, Elyashiv and Auerbach agree that reporting is mandatory also.] Rabbi Elyashiv writes "there is no difference between boys and girls since one is dealing with a seriously life wounding event (pegiah nafshit) and a danger to the public... this is much more serious than theft and one certainly must report this matter to the school administration and if nothing is done, even to the police even in the Diaspora."
 Avi Shafran (http://www.cross-currents.com/archives/2007/11/22/sin-and-subtext/) which correctly points out that the New York Jewish Week article is inaccurate. Marvin Schick (http://mschick.blogspot.com/2007/12/scholarly-abuse.html) has attempted to discredit the AJP paper. A brief critique is also offered by David H. Rosmarin et al (http://www.jpsych.com/abuse.html) which is similar in content to Schick's.
 A brief word about my qualifications to analyze this paper: As the Director of Psychotherapy Training in the Psychiatry Residency Training Program at the University of Cincinnati, one of my responsibilities is to help resident physicians learn how to read academic and scientific papers critically. The American Journal of Psychiatry is the most widely read academic journal by American general psychiatrists, and is widely read by clinicians as well as researchers. Its articles are not intended to require special expertise in statistics or neuroscience. Therefore, I submit that I am certainly qualified to critique this paper.
 In an exchange between Dr. Rachel Yehuda and myself on the list-serve for Nefesh International (an network of Orthodox Jewish mental health professionals), she has confirmed that I am correctly reading the intent of their paper. Dr. Yehuda states: "You [Klafter] are completely correct that our study does not permit conclusions regarding the exact rate of abuse in the Orthodox community. Given the nature of the sampling and -- more importantly -- the limited information we have about the sampling frame in general (i.e., demography of the Orthodox community) it is impossible for us to know the extent to which our sample is even representative of married, observant women. This is clearly stated in our paper. " (Nefesh International List-serve, January 1 2008, "Response to Dr. Klafter")
 The first source, Finkelhor, et al, reports data from a study conducted by a randomized phone survey. In other words, it is not comparable to the AJP data, which are from a self-selected group who chose to respond to a widely distributed advertisement. The second source, Vogeltanz, et al., reports data from a face to face interviews of women from two data sets with similar methodologies, one done in 1981 the other in 1991. The response rates were 92% and 91% respectively. As I discuss below, the response rates for the study by Dr. Yehuda et al. are unknown, but should be presumed to be much, much lower because it is a self-selected, non-randomized sample. The third source is a 1993 monograph by the National Research Council, "Understanding Child Abuse and Neglect." The full text of this valuable resource is available online: http://www.nap.edu/openbook.php?record_id=2117&page= Refer to pp. 78-105, "Scope of the Problem" where you will see that the studies cited do not resemble the study by Yehuda R, et al., because its samples are representative, randomized, and have known response rates.
 I would like to clarify, however, that I object to drawing any conclusions about the relative rate of sexual abuse among FFB women vs. ba'alei teshuva (i.e., that there is a lower prevalence of sexual abuse in the Orthodox community); as I have stated, this sample is not representative.
 I have been told by researchers that, in Israel, survey data from Haredi populations is widely suspected as being influenced by a strong cultural bias against participation in scientific research.
 Rabbi Avi Shafran (http://www.cross-currents.com/archives/2007/11/22/sin-and-subtext/) appropriately limits his criticism to the New York Jewish Week. He has correctly read the AJP paper, and understands that no conclusions were made about the rate of abuse in the Orthodox community.
 The response by David H. Rosmarin et al (http://www.jpsych.com/abuse.html) is also flawed. A couple of examples: This critique also incorrectly attributes conclusions to the AJP authors which they have not made regarding the prevalence of abuse in Haredi communities vs. Orthodox communities. Then, in order to refute this imaginary claim by Yehuda et al, Rosmarin et al offer the following convoluted suggestion: "If abused Ultra-Orthodox women were less likely to drop their affiliation with Orthodoxy than Modern-Orthodox women, perhaps because of a tighter communal structure among the Ultra-Orthodox and a resulting increase in emotional support for victims of abuse, then there is not necessarily any connection between the study's reported rates of abuse and the actual rates." I should not need to mention that since the samples are not representative (which Rosmarin et al argue), all such speculation is meaningless. Furthermore, in order to adduce evidence that the AJP sample (which contained a 53% rate of prior mental health treatments) is not representative Rosmarin et al state: "The general reluctance of Orthodox Jews to seek out psychological and/or psychiatric services is well-established." To justify this completely unsubstantiated claim, they quote Margolese (Am Jour Psychotherapy, 52:1, 37-53): "Prior to engaging in therapy, an Orthodox Jew may view psychotherapy with ambivalence at best and as heretical at worst." A review of the cross cultural literature on attitudes toward psychotherapy in any other ethnic and religious group will reveal similar things about stigma and resistance to treatment. Furthermore, Margolese's paper makes no effort to measure the rate of mental health treatment in the Orthodox community, rendering this entire argument and citation meaningless, not to mention that Dr. Yehuda et al have clearly acknowledged that this finding indicates their sample is not representative.
 For a sample of recent papers on this controversial and complex topic, see: Cantor JM, et al. Cerebral white matter deficiencies in pedophilic men. J Psychiatry Res. 2008 Feb,42(3):167-83; Schiltz K, et al. Brain pathology in pedophilic offenders: evidence of volume reduction in the right amygdala and related diencephalic structures. Arch Gen Psychiatry. 2007 Jun, 64(6):737-46; Joyal CC, et al. The neuropsychology and neurology of sexual deviance: a review and pilot study. Sex Abuse 2007 Jun 19(2):155-73; Cantor JM, et al. Grade failure and special education placement in sexual offenders' educational histories. Arch Sex Behav. 2006 35(6):743-51; Tost H, et al. Pedophilia: neuropsychological evidence encouraging a brain network perspective. Med Hypotheses 2004,63(3):528-31.
Dr. Nachum Klafter was born and raised in upstate New York, where he attended college and medical school. He also studied in Jerusalem at the Hebrew University and Yeshivat Darchei Noam. Dr. Klafter completed his residency training in psychiatry at the Thomas Jefferson University Hospital in Philadelphia, where he also served as Chief Resident. Dr. Klafter was recruited by the University of Cincinnati in 2000, where he continues to teach psychodynamic psychotherapy. He completed his training as a psychoanalyst at the Cincinnati Psychoanalytic Institute in 2011. Dr. Klafter maintains a private practice in psychiatry, psychoanalysis, and psychotherapy supervision. He serves on the teaching faculty of the Cincinnati Psychoanalytic Institute, which offers advanced training in psychotherapy and psychoanalysis for licensed mental health professionals. He writes a monthly essay for the list-serve of the Nefesh International organization, and and serves as a board member. He has delivered psychotherapy trainings for professional organizations regionally, nationally, and overseas. He has authored papers and book chapters on terrorism, the impact of sexual abuse, boundaries and boundary violations in psychotherapy, greed, fear of success, trust and mistrust in the clinical setting, and the various aspects of the interface between psychotherapy and Judaism. In his personal life, Dr. Klafter is an accomplished musician and photographer, and has given a regular shiur in his community in Choshen Mishpat for the last 10 years. He resides in Cincinnati with his wife and four daughters.