Abstract: Women post mastectomy may be uncomfortable being seen unclothed and thus delay mikveh immersion, with major impact on the physical relationship with their husbands. There are multiple halachic solutions that allow for immersion without the affected area being seen by the mikveh attendant. Physicians should encourage women to consult with their halachic advisor to find the solution that works for them. Physicians should not prevent women from using the mikveh unless there is a proven medical contraindication to do so.
Discussion: After a mastectomy, many women find it difficult to adjust to the new appearance of their bodies   . Post mastectomy premenopausal Jewish women who go to the mikveh are often particularly uncomfortable about being seen unclothed by the mikveh attendant. This causes some women to delay going to mikveh, denying themselves the physical closeness of their husbands during an already stressful time in their lives.
While the standard procedure at the mikveh is for the woman to stand unclothed before the mikveh lady for final inspection prior to immersion, it is important to understand that there are halachically acceptable alternatives. The halacha requires that an adult Jewish woman witness the immersion. Most mikvaot hire an official mikveh attendant who has been trained for her role. However, at many mikvaot it is possible, in special circumstances, to have another woman witness the immersion. Thus, if a woman would be more comfortable with a particular Jewish female friend or relative, special arrangements can often be made. Other breast cancer survivors are often willing to volunteer for this role. Such arrangements can be made through Sharsheret, a support organization for Jewish women with breast cancer.
The main role prescribed in halacha for the mikveh attendant is to ensure that all hair is under the water during immersion. In general, mikveh attendants perform an additional service in double-checking the back and other hard-to-reach places for possible barriers. However, the final responsibility for checking rests with the woman herself. Therefore, if the woman is careful and looks in a mirror to the best of her ability, rechecking by another woman is not strictly required. A woman who does not want her unclad body to be seen can also put on a robe and have the attendant check only her hands and feet. Or she can prepare herself, enter the mikveh so that only her head is above water, and have the mikveh lady enter the room just enough to see that all her hair is immersed. If even this is unacceptable to the woman, there may be additional arrangements that can be made with rabbinic consultation. A woman should never feel that surgical treatment for cancer will put mikveh immersion out of reach.
Some surgeons do not permit a bath, and by extension mikveh immersion, for a month after mastectomy because of the fear that the water pressure may adversely affect the scar. However, physicians should be aware that mikveh immersion can be valid if the body is under water for as little as five seconds. The water is just deep enough for the head and body to be completely submerged. Physicians should also take into account the stressful consequences of having no physical contact with one's spouse at such a time.
It is also not unusual for women undergoing cancer treatment to be concerned about physical intimacy. Discussion of this issue, privately between husband and wife or with the guidance of a health professional, can often help in the adjustment .
Implications for Patient Care: Counseling of post mastectomy patients regarding sexuality should include asking if she has hesitations about using the mikveh. If so, she should be encouraged to discuss this with her halachic advisor, as solutions that will make her comfortable can generally be found.
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 Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. J Adv Nurs 1999 May;29(5):1113-20.
 Witkin MH. Psychosexual counseling of the mastectomy patient. J Sex Marital Ther 1978 Spring;4(1):20-8.
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