{"paper_id":"8e29d38f-fe57-4dac-8aac-296145bd20ab","body_text":"COMMENTARIES \nThe Necessity of Cultural Awareness in Healthcare Providers to \nReduce Diagnostic Delays in Reproductive Health for West Asian \nImmigrant Women \nDiyari Bekhtyar, MS (Biohazardous Threat Agents & Emerging Infectious Diseases), BS (Biology)1\n, Tomoko Y. Steen, Ph.D.1 \n1 School of Medicine, Georgetown University \nKeywords: PCOS, Endometriosis, Women's Health, Cultural Awareness, Marginalized Patients, Health Equity, Reproductive Health \nhttps://doi.org/10.52504/001c.162641 \nGeorgetown Medical Review \nVol. 10, Issue 1, 2026 \nWomen’s health is one of the most underfunded and under-researched areas of \nmedicine, with minority health being an even smaller subsection receiving little \nfunding and research. Polycystic ovarian syndrome (PCOS) affects more than \n10% of women globally; however, 70% of women with PCOS remain \nundiagnosed. Even more concerning is that for many girls and women across \nthe globe, access to women’s healthcare remains a privilege and is inaccessible to \nmany. This article explores how diagnostic delays occur for West Asian \nimmigrant women in the United States who have endometriosis and/or PCOS. \nIn studies about women’s health experiences across Western Asia, the reality is \neven worse for women living there. We discuss how fear of stigma often impacts \nwomen’s ability to seek healthcare in the United States. However, healthcare \nproviders can adopt a more empathetic lens to acknowledge patients’ fear of \nstigma and provide reassurance and support (instead of bias and projections of \ntheir own beliefs) by adopting a shift in mindset to include cultural awareness \nto address a wider and diverse patient population. By prioritizing cultural \nawareness, healthcare providers must acknowledge the societal reasons for \ndiagnostic delays for this patient population and work toward reducing that \nrisk. This ensures not only that immigrant health is taken seriously and \nadequately addressed but also that patients with reproductive conditions like \nPCOS and endometriosis feel safe enough to seek a diagnosis for conditions \nthat worsen when diagnosis is delayed. \nIntroduction  \nCultural awareness enhances healthcare outcomes and also promotes \ninclusive healthcare for West Asian women living in the United States. For \nthis commentary, we defined West Asian immigrants as women from Iraq, \nTurkey, Syria, Lebanon, Iran, Egypt, Yemen, and Pakistan. Also, the term \nhealthcare provider refers solely to physicians when referring to healthcare \nproviders outside of the United States; when referring to healthcare providers \nwithin the United States, the term can be used to refer to physicians, \nphysician’s assistants, or nurse practitioners. \nBekhtyar D, Steen TY. The Necessity of Cultural Awareness in Healthcare Providers to\nReduce Diagnostic Delays in Reproductive Health for West Asian Immigrant Women.\nGeorgetown Medical Review. 2026;10(1):35-43. doi:10.52504/001c.162641\n\nPolycystic Ovarian Syndrome and Endometriosis      \nWomen’s health is one of the most under-researched fields of medicine.1 \nTwo common reproductive conditions continue to impact and destroy the \nlives of women and girls globally: polycystic ovarian syndrome (PCOS) \nand endometriosis. PCOS is a condition that causes abnormal and painful \nperiods, elevated testosterone, accumulations of follicles on the ovaries, acne, \nexcess hair growth, and weight gain.2 Endometriosis is the invasion of the \nendometrial tissue, which typically only lines the inside of the uterus, into \nthe exterior of the endometrium.3 It is a painful condition that can cause \nabnormal pain, heavy menstruation, inflammation, and scarring of tissue.3 \nAccording to the World Health Organization (WHO), approximately 6% \nto 13% of women of reproductive age are affected by PCOS around the \nworld, yet up to 70% of them will go undiagnosed.2 Endometriosis is another \ncommonly undiagnosed reproductive condition, and it is estimated to impact \nover 190 million women and girls around the world according to the WHO.3 \nWhile we know there is no cure to eliminate either condition, the role of \nearly diagnosis and symptomatic relief for both PCOS2 and endometriosis3 \nare life-changing for patients who have these conditions. Of the $47.7-billion-\ndollar research budget the National Institutes of Health (NIH) received in \n2023,4 across the entirety of research conducted at different NIH research \ninstitutes, only $3.7 billion (8%) went to women’s health.5 Of the $3.7 \nbillion, approximately $700 million (19%) went to breast cancer research6; \nmeanwhile, $30 million or less (0.8%) went to PCOS and endometriosis \nresearch, each.6 This reveals a major gap in funding and lack of awareness \nof the need for increased prioritization of women’s reproductive conditions, \nespecially when both PCOS2 and endometriosis3 have no cure.6 Just because \nthe NIH received funding for women’s health does not mean it is shared \nequally: endometriosis is not at the top of the list, especially when compared \nwith the amount of funding breast cancer receives.5 \nOral birth control is used as way of symptom relief for many women \ndiagnosed with PCOS2 and/or endometriosis.3 However, limitations in \naccess to birth control options for West Asian women and girls is still an \nobstacle,7 especially owing to cultural and social stigmas8 that restrict or scare \naway unmarried patients from using birth control in Western Asia. Between \nreproductive conditions that are underfunded and a minority population \nthat is underserved, the opportunity for delays in care for endometriosis \nand PCOS is evident. This commentary aims to shed light on the reasons \nbehind these diagnostic delays and the impact cultural awareness can have on \nreducing the risk for delays in diagnosis and treatment, especially once West \nAsian women immigrate and seek care in the United States. \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 36\n\nThe Consequences of Diagnostic Delays in PCOS and         \nEndometriosis  \nAccording to the WHO, approximately 6% to 13% of women of reproductive \nage are affected by PCOS around the world, yet up to 70% of cases go \nundiagnosed.2 Endometriosis, another commonly undiagnosed reproductive \ncondition, is estimated to affect over 190 million women and girls around \nthe world, according to the WHO.3 Most importantly, the underlying threat \nthese two conditions share is that they are both the leading causes of \ninfertility in undiagnosed women. One study looked at how intervention \nwith glucagon-like peptide-1 receptor agonists (GLP-1RAs) in women with \nPCOS reduced inflammation, reduced insulin resistance, helped lower weight, \nbrought about more regular menstrual cycles, produced cardiovascular \nbenefits, relieved some symptoms of PCOS, and helped with ovulation, as \nobesity and insulin resistance were often two barriers affecting fertility.9 This \nis significant because, as reported in one study,10 PCOS has been found \nto have variations in how it presents physiologically depending on race/\nethnicity. The study looked at patients of different disparities and ethnicities \nin the United States and cited global studies that found different phenotypic \nexpression of classic PCOS symptoms in different ethnic and racial groups.10 \nThe difference was noted to be based on the expression level of the 5-alpha \nreductase enzyme, which is responsible for turning testosterone into \ndihydrotestosterone (DHT).10 Specifically, higher levels of 5-alpha reductase \nenzyme were associated with more DHT and, therefore, worse severity of \nhirsutism.11 This means that PCOS symptoms can look different for two \npatients with the same condition. For example, the study reported that \nhirsutism was more apparent in West Asian and Indian patients than in \nNorwegian and Finnish patients.10 The takeaway is that PCOS diagnosis and \ntreatment is not a one-size-fits-all approach; any physician suspecting PCOS \nshould not rule it out solely based on clinical comparison to another patient \nwho has PCOS. \nOne case report12 documented a patient’s 10-year journey to an \nendometriosis diagnosis, detailing the physical and psychological distress \nexperienced by the patient, who navigated everything from medical \ngaslighting to frustrating symptoms with no explanation. Currently, in the \nUnited States and within the general US population, it is reported to take \n7 to 10 years to get a diagnosis of endometriosis, after consulting with \nmultiple healthcare providers.13 We sought to address how much longer the \ndelay is for West Asian women in the diagnosis and treatment of symptoms, \nespecially immigrant women in the United States. Clinical consensus suggests \nthat timely diagnosis of PCOS and endometriosis is a critical factor in \nlowering the long-term risks2 of infertility.3 Therefore, any obstacles or health \ndisparities that result in diagnostic delays have the risk of impacting fertility \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 37\n\nand are worth being mitigated. Additionally, delays in diagnosis also mean \ndelays in medical intervention to address PCOS and endometriosis \nsymptoms. \nPCOS causes abnormal and painful periods, elevated testosterone, \naccumulations of follicles on ovaries, acne, excess hair growth, and weight \ngain.2 Endometriosis is a painful condition that causes heavy menstruation \nand abnormal pelvic pain (often meaning pain that disrupts daily life, which \ncan occur before, during, and/or after menstruation).3 Both conditions have \nsymptoms that can be alleviated by the use of birth control. In addition, \nleaving these conditions untreated has been correlated2 with a considerable \nmental burden from the difficulty of the symptoms, including excess weight \ngain, facial hair (hirsutism), and acne.3 The consequences of diagnostic delays \nare devastating, but this is an area in medicine that has drastic potential for \nimprovement. \nUnderstanding the Societal and Cultural History Behind        \nDiagnostic Delays   \nWest Asian women have historically needed to have resilience against gender-\nbased violence, gender disparities, the stigmas associated with mental \nhealthcare, and having a lack of autonomy, which affects whether a young \nwoman would be able to seek healthcare for their specific healthcare needs. \nFor example, one study14 looked at Syrian women and the consequences \nendured over the course of conflicts and long-term forced displacement, often \ninto Lebanon, opening up a world view to the mental health and sexual \nhealth conditions post-conflict that Syrian women may suffer from silently. \nThe outcomes of the study emphasized that these women endured violence, \ntrauma, posttraumatic stress disorder, and food insecurity.14 Conflict and \ndisplacement often goes hand-in-hand with extreme poverty and low access \nto healthcare, leaving these women highly vulnerable to poor sexual health \noutcomes, especially when seeking treatment for sexually transmitted \ninfections.14 One of the most important points from this study, which \naimed to evaluate the sexual health of 350 female patients, is that only 250 \nwomen actually participated, while the rest were either too busy with other \nresponsibilities or restricted by their husbands from being allowed into a \nstudy that would examine their sexual health, giving a glimpse into the lack of \nautonomy some of these women have.14 When women and girls are affected \nin conflict, their worries often shift and magnify into concerns over shelter, \nsafety, whether they have to leave their homes, and making sure they have \nenough food to eat, while actively avoiding violence and risk of death from \nwar. Hence, from the active threat against their lives and from fear of violence \n(via death or rape), these women and girls are forced to prioritize things \nlike physical safety and refuge over things like painful periods and hormonal \nacne, therefore deferring medical care. The current reality is that these women \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 38\n\nand girls are impacted by gender-based violence, sexual exploitation, abuse, \nand worse when war and displacement is destroying their lives and actively \ndisrupting them from seeking healthcare.15 \nEvery woman deserves access to healthcare, and that includes \nnondiscriminatory reproductive care, but according to the WHO, this \nfundamental human right is imperiled for West Asian women.16 Throughout \nWestern Asia, women’s bodily autonomy, especially unmarried women, is \noften threatened through restrictive families, societal thinking, \ndiscrimination, judgement, and shame regarding seeking reproductive \nhealthcare unless they are married.17 One report17 shared a midwife’s \nthoughts about working in Iran, stating, “It has been established in our \ncountry that infections and gynecological problems occur after marriage. \nThat is, unmarried women cannot have such issues.” The unfortunate reality \nis that the use of birth control in Western Asia is often correlated with \nthe sole thought that the woman is engaging in sexual activity, ignoring the \nreality that birth control can also be used to alleviate painful symptoms of \nPCOS and endometriosis.7 One study found that the attitudes and beliefs \nof physicians in Western Asia against unmarried women seeking access to \nsexual reproductive healthcare created barriers to quality of care because of \nphysicians’ resistance to inform patients about birth control and, as a result, \nthey acted on their beliefs instead of following the science and their medical \ntraining to treat patients ethically.7 These physicians had been found to \nridicule and judge both married and unmarried women for seeking sexual \nreproductive health counseling, especially when patients asked them \nquestions.7 They also gave poor counseling on contraception options, often \nmisinforming patients and aiming to avoid offering conversations on family \ncounseling.7 These physicians as well as other staff were especially rude and \njudgmental toward unmarried women who were seeking sexual reproductive \nhealthcare, as it was seen as opposing their beliefs for an unmarried woman \nto seek contraception and counseling from them.7 \nAnother study looked at Turkish college students and the social stigmas \nand shame surrounding birth control that are felt so strongly8 that to even \nsuggest birth control use for medical conditions seems impossible. The study \nresults focused on four main themes that display the perspectives surrounding \ncontraceptive use in that setting: individual views, sociocultural pressures, \nknowledge and awareness levels, and education and information needs.8 The \noutcomes highlighted how in the university setting, internal views and beliefs \nabout contraception being a “personal and practical” option contradict or \ncollide with societal, cultural, and/or familial pressures to hide or avoid \ncontraceptive use.8 The overarching opinion of the students was that they \nhad outgrown the sociocultural norms, attitudes, judgments, and stigma \nthat serve as barriers to accessing contraception, especially for unmarried \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 39\n\nparticipants.8 Nothing about this situation would make a woman feel safe in \nseeking reproductive healthcare and would more likely lead her to feel that \nher concerns are not worthy of seeking healthcare. \nThe social constructs and stigmas connected with the use of birth control in \nunmarried women in the Western Asia region is just one example leading to \ndiagnostic delays, and this creates another barrier to medical intervention for \nPCOS and endometriosis symptoms. \nThe Necessity of Cultural Awareness in Combatting Healthcare         \nProvider Bias   \nWith so much historical context, it is prudent to examine the healthcare \nsetting for immigrants in the United States and the healthcare provider’s role \nin immigrant healthcare outcomes. Healthcare provider bias, stemming from \nage, religion, race, marital status, and other factors, is heavily intertwined \nin this issue.18 The results from one research study19 found that when \nWest Asian women, especially Muslim West Asian women, were seeking \nhealthcare in the United States, they specifically avoided healthcare providers \nof their same religion or cultural background because they wanted to avoid \nnegative judgements, dismissiveness, neglect, and mistreatment. The study \nalso found that physicians who shared the same religion as West Asian \nwomen were withholding information, ignoring reproductive and sexual \nhealth conversations, and not providing contraception options, displaying a \nclear threat to the ethical basis of informed consent and autonomy.20 This \nshowed an obvious example of physicians’ prioritization of their own religious \nbeliefs and a protective cultural paternalism taking the lead over the health of \nthe patient, combined with the physician’s fear of judgement, as well as the \npatient’s fear of judgement. \nAdditionally, beneficence, which refers to protecting the best interest of the \npatient, was threatened during women’s healthcare visits when these patients \nwere not offered cancer screenings by their primary care providers, despite \nbeing of the same faith background.21 It is alarming that healthcare provider \nbias can carry such weight in the delivery of healthcare to women, yet this bias \nis not always acknowledged. Many of these women were treated unfairly by a \nhealthcare provider prior to immigrating to the United States, so they already \nhad mistrust,19 but how a healthcare provider handles and acknowledges \nawareness of those struggles is where a difference can be made in the quality \nof care she receives. \nCultural awareness is critical for healthcare providers in order to provide \nhealthcare that is inclusive of the patient and their background and to work \ntogether with the patient to choose their route of care. Cultural competency \ntraining for healthcare providers and their staff is a great way to introduce this \nin clinics, especially in locations that see higher rates of immigrant patients. \nHealthcare providers can also consult with social workers on how to navigate \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 40\n\nculturally sensitive healthcare and provide trauma-informed care. This effort \nhopefully enables a safe environment for patients to trust their healthcare \nprovider and receive the care they need, especially reproductive care for \nendometriosis and/or PCOS. A patient’s social determinants of health should \nnot cause healthcare providers to form a bias against them, so it remains \nessential for physicians to know how to provide equitable and inclusive care, \nfree from biases. \nConclusion  \nFuture suggestions for healthcare providers caring for immigrant West Asian \nwomen in the United States include expanding both the cultural perspective \nand their lens of empathy for these patients, in hopes of reducing diagnostic \ndelays. Endometriosis and PCOS are conditions that often disrupt a woman’s \nlife for 7 to 10 years before a diagnosis is properly made. For immigrant \nwomen this delay may be even longer, yet it does not have to be this way. \nWhen healthcare providers have cultural awareness, diagnostic and treatment \ndelays can be drastically shortened. To achieve this, cultural competency \ntraining can be implemented for healthcare providers and staff, especially in \nlocations that have higher rates of immigrant patients. In addition, healthcare \nproviders can consult with social workers on how to navigate culturally \nsensitive healthcare issues, such as contraception for West Asian women. \nPhysicians are some of the most trusted individuals with direct access to \nthese patients, often some of the most marginalized patient populations \nin the United States. Hence, it matters that healthcare providers are fully \ntrained to provide care that encompasses cultural awareness, empathy, and \nunderstanding. \nThere is great opportunity for improved healthcare outcomes when \nhealthcare providers are fully informed and aware of the hidden fears and \nconcerns that immigrant West Asian women in the United States may face. \nWhen a healthcare provider is culturally informed and aware of the social \ndeterminants of health and the numerous obstacles that these patients face, \nthen that is one step toward enhancing the quality and inclusivity of \nhealthcare that these marginalized patients receive in the United States. \nSubmitted: December 05, 2025 EDT. Accepted: May 14, 2026 EDT. Published: June 10, 2026 EDT. \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 41\n\nreferences \n1. Kumanyika SK, Morssink CB, Nestle M. 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December 1, 2023. Accessed February \n18, 2025. https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health \n17. Mohammadi F, Kohan S, Mostafavi F, Gholami A. The stigma of reproductive health services \nutilization by unmarried women. Iran Red Crescent Med J. 2016;18(3):e24231. doi:10.5812/\nircmj.24231 \n18. Solo J, Festin M. Provider bias in family planning services: a review of its meaning and \nmanifestations. Glob Health Sci Pract. 2019;7(3):371-385. doi:10.9745/GHSP.D.19.00130 \n19. Harper DM, Sen A, Tariq M, et al. Concordant physician patient characteristics lose \nimportance for Arab American women and their healthcare — cross sectional study. Lancet Reg \nHealth Am. 2022;10:100225. doi:10.1016/j.lana.2022.100225 \n20. Vahabi M, Lofters A. Muslim immigrant women’s views on cervical cancer screening and \nHPV self-sampling in Ontario, Canada. BMC Public Health. 2016;16(1):868. doi:10.1186/\ns12889-016-3564-1 \n21. Salman KF. Health beliefs and practices related to cancer screening among Arab Muslim \nwomen in an urban community. Health Care Women Int. 2012;33(1):45-74. doi:10.1080/\n07399332.2011.610536 \nThe Necessity of Cultural Awareness in Healthcare Providers to Reduce Diagnostic Delays in Reproductive Health for West…\nGeorgetown Medical Review 43","source_license":"CC0","license_restricted":false}