Islamophobia: A Public Health Crisis

Biases and discrimination can affect health outcomes and care experiences

Getting the correct diagnosis isn’t always easy — especially when religious biases and stereotyping get in the way. 

Take for example one woman’s recent experience navigating the health care system. For months, her condition remained undiagnosed. Why? It may have been because the woman was wearing a hijab, said Dr. Umberin Najeeb, an internist at Sunnybrook Health Science Centre, Equity Lead in the Department of Medicine and Senior Advisor on Islamophobia at Temerty Faculty of Medicine at University of Toronto. That, combined with how she was presenting, led some physicians to mistakenly assume she was a victim of domestic violence. 

That’s no surprise to Tabassum Wyne, Executive Director of the Muslim Advisory Council of Canada. Ms. Wyne, who wears a hijab, once encountered a doctor in the ER who explained the health system as if she was a new Canadian (she was raised in Hamilton, ON.). When her Council surveyed Muslim experiences in health care, stories of discrimination poured in. 

Patients talked about feeling dismissed because of their religious identity. So did doctors. One Muslim physician said a patient told him they didn’t want him as their doctor because he must be from Saudi Arabia and a terrorist. 

There’s a term for anti-Muslim sentiments: Islamophobia. It can be defined as an irrational fear of, aversion to, hatred of or prejudice against Muslims. 

Islamophobia can play out in many ways. Muslims can feel it in the way they are “othered” or profiled in everything from workplaces to schools to public discourse. Islamophobia has health implications too. Studies have shown how anti-Muslim discrimination is associated with poorer mental and physical health outcomes. Even the health care system isn’t always seen as a safe place. Many Muslim patients report being hesitant about seeking care and having negative experiences when receiving it.

“Religious discrimination is something we need to talk about in medical education,” says Dr. Najeeb.

Ms. Wyne is blunt about the consequences: “Islamophobia is a public health crisis,” she says.

Discrimination takes a health toll

The crisis goes beyond health. A 2022 article from the Canadian Centre for Policy Alternatives called Islamophobia “a systemic disease in the Canadian body politic.”

In recent years, a series of opinion surveys revealed the extent of this illness (please see “High Levels of Anti-Muslim Feelings”).

We know from research of Muslim patients that repeated discrimination can create greater psychological distress, higher levels of fear and anxiety, lower self-esteem, and post-traumatic stress disorder. It can also increase the risk of other health issues. 

Like other settings in society, the health care system isn’t immune from biases. A literature review published in the American Journal of Public Health (based on studies performed in North America, Europe and Oceania) noted, “religious discrimination or perceived discrimination played a role in how Muslim populations accessed health care.” For instance, some studies found Muslim patients who wore religious attire reported more discrimination in health care settings.

Another study, in the Journal of Muslim Mental Health, drilled down further into how anti-Muslim discrimination crosses over from society to health care settings. People surveyed cited things like feeling excluded or ignored, and facing insensitive or offensive remarks. 

“While many factors contribute to disparities in health, including social, economic and educational level, there is indication that discriminatory behaviours, such as stereotyping and prejudice on the part of health care providers, may add to differences in the provision of care,” the study states.

“Religious discrimination is something we need to talk about in medical education”

If biases and discrimination are obvious barriers to optimal care, then education and understanding about patients as a group should be regarded as facilitators. Cultural competence in the care of Muslim patients can involve greater awareness about factors like diet, daily religious practices, privacy and dress, and religious values. This can help providers better grasp health care perceptions, decisions and needs.

However, even that sort of education comes with a caution. To better inform care, it’s always important for doctors to learn as much as they can about the person in front of them. For some patients, religion could be just one aspect that dictates beliefs and values, says Sarah Shah, an Assistant Professor of Sociology at the University of Toronto, Mississauga.

Religion is only a part of a patient’s identity. Ms. Shah says there’s also a danger in making generalizations about members of any faith. People may practise a religion to varying degrees or not at all. Canadian Muslims have a range of ethnic, racial, educational, socioeconomic and other backgrounds, like any other Canadians. “No two Canadian Muslims are alike,” says Ms. Shah. 

Treating people as individuals is always best. Yet, she says practitioners sometimes see the Muslim population as monolithic, which can lead to additional harmful outcomes. 

Ms. Shah co-authored a paper, called “Canadian Muslim Health Exceptionalism,” for the University of Toronto’s Institute of Islamic Studies. It underscores what’s often lacking in efforts to improve care. The paper looked at a range of studies done on the physical, mental, sexual and reproductive, and geriatric health status of Canadian Muslims.  

What Ms. Shah found is many of these studies operate from a framework of Muslim exceptionalism, which shapes their methodologies and analyses. Muslim exceptionalism refers to the way Muslims are seen “as the authors of their own poor socioeconomic outcomes,” Shah’s paper states, “rather than taking into account the structural inequities and discriminatory practices Canadian Muslims are confronted by.”

In the health care research she reviewed, a number of those studies assumed Muslim health would be poor, “and the assumption was justified by Muslim religio-cultural practices rather than Islamophobia or insensitive health care systems.”

Islamophobia is gendered  

At a June 2022 symposium on Islamophobia in Health Care held by McMaster University’s School of Medicine, Dr. Fatimah Jackson-Best (PhD) noted Islamophobia is deeply gendered. 

“Muslim women are often perceived as weak and vulnerable. When you characterize people as such, it becomes easier to target them,” says Dr. Jackson-Best, an Assistant Professor at McMaster’s Department of Health Research Methods, Evidence and Impact, and a public health researcher.

And individuals who have the intersectional experience of being Black, Muslim and female — such as Dr. Jackson-Best — are left to negotiate multiple oppressions: anti-Black racism, Islamophobia and sexism. 

In particular, the hijab has become a flashpoint. One study found 69 percent of Muslim women who wore one reported at least one incident of discrimination compared to 29 percent of women who didn’t wear the head covering.

The perception of the hijab was at the centre of a storm in the medical community in late 2021. That November, the Canadian Medical Association Journal had a cover photo showing two young girls in a classroom. One was wearing a hijab. In December, the CMAJ published a letter from a Quebec physician in response, who described the hijab as an “instrument of oppression” — that phrase was in the headline of the letter. 

The letter immediately sparked backlash. The Muslim Advisory Council of Canada, among others, identified the letter as Islamophobic and said it contributed to “dangerously harmful stereotypes about a demographic that has been targeted by some of the most violent forms of Islamophobia in this country.”

Quickly, the letter was formally retracted. The letter writer issued an apology and so did Dr. Kirsten Patrick, interim editor of the CMAJ.

Doctors feel discrimination too

Muslim physicians can feel discrimination from colleagues and patients alike. 

At the McMaster symposium, Dr. Aliya Khan, an Oakville endocrinologist who specializes in bone disorders, shared a disturbing story about her experience delivering a lecture at a medical conference. Later, as she was looking through the attendees’ feedback forms, one doctor had written, “Go back to Saudi Arabia!”

“I was stunned,” she says. “I have no connection to Saudi Arabia. He saw my headscarf and came to his conclusions. I think he was just revulsed that a Muslim woman was actually speaking.” 

Dr. Khan has also encountered patients who assumed she couldn’t speak English because she was wearing a hijab.

Other times, patients outright refuse care from a Muslim physician. Dr. Najeeb has received complaints from some patients who wanted to change the resident caring for them because the resident was wearing a hijab. 

Patients aren’t always explicit about the reasons, says Dr. Zainab Furqan, a psychiatrist and clinician-investigator at University Health Network in Toronto. A patient might just say they’d prefer another doctor. But the underlying feeling is clear: “I don’t want you and I don’t trust your care.” 

“You’re carrying that weight,” says Dr. Furqan.

Other times, hijab-wearing learners worry it may be perceived as a barrier if they choose to go into a surgical-related specialty. Dr. Najeeb reports several instances of learners being discouraged and prevented from wearing religious head coverings in sterile spaces, like operating rooms. 

But it is possible to allow individuals to fulfill religious obligations while upholding aseptic practices. In her role as a senior advisor on Islamophobia at the Temerty Faculty of Medicine, Dr. Najeeb helped develop a document to set out standards and expectations related to clothing worn by religiously observant individuals in hospital areas with sterile procedures, such as operating rooms. The document, approved by Toronto Academic Health Sciences Network (TAHSN) in June 2022, is now being implemented across its affiliated hospitals. Although initiated to help hijab-wearing Muslim women, the standards document also applies to observant Jewish and Sikh learners and health care workers. As Dr. Najeeb notes, when you use an equity lens to support one group, it helps others too.

Making assumptions

Dr. Furqan also sensed bias in her own medical education. One day, Dr. Furqan was chatting with a supervisor. The supervisor asked about her background and casually said that her journey to becoming a doctor must have been hard, what with the barriers in pursuing higher education.

What was behind that comment? While she can’t be certain about the thinking of the supervisor, Dr. Furqan (whose mother happens to be a physician as well) believes the supervisor was making assumptions about her ethnic background, Muslim religion and presumed obstacles. “This was a response to my identity,” says Dr. Furqan.

Muslim exceptionalism refers to the way Muslims are seen “as the authors of their own poor socioeconomic outcomes”

Dr. Najeeb and Dr. Furqan were co-senior authors on an article in the CMAJ in May 2022 that discussed gendered Islamophobia in medicine, particularly as it targets Muslim women. 

They cited a study showing Muslim medical trainees face the “paradox of being hypervisible and invisible” — standing out from their peers, yet having no voice in debates that are relevant to them. The article also noted how Muslim women physicians reported fewer teaching and learning opportunities, and feelings of alienation from their colleagues.  

Internalization

Dr. Javeed Sukhera knows about bias too. He has been called a terrorist by patients on multiple occasions, and has heard of colleagues in the OR who’ve been subjected to “jokes” about bombs and terrorism.

“These words convey that you don’t belong. There’s a cognitive blow. You can internalize that. It accumulates and can interfere with your work,” says Dr. Sukhera, who was a child and adolescent psychiatrist in London, ON., and is now Chief of the Department of Psychiatry at Hartford Hospital in Connecticut. 

He adds that anti-religious and racist feelings can become conflated. “There are messages in society of what good looks like and bad looks like, and of what Canadian looks like and what foreign looks like,” he says.

People on the receiving end of racism or religious prejudice can face a double burden. They have to deal with those experiences and with a system that often diminishes those experiences. That can happen in any setting, including health care institutions and medical schools.

In January 2022, Dr. Sukhera was the lead author of a study that appeared in Advances in Health Sciences Education on discrimination and harassment policies in 13 Canadian medical schools. Among the article’s observations:

• Those who report issues are positioned as having less agency, while having to legitimize the credibility of their lived experiences.
• Placing a disproportionate onus of responsibility on those facing discrimination to legitimize their experience “has the potential to erode self-esteem…and diminish reporting.”
• Perpetrators of discrimination have an “assumption of ignorance,” i.e., it’s presumed they can’t distinguish between what’s inappropriate vs. unacceptable. “They can therefore justify discriminatory acts by invoking good intentions.”

“The costs are compounded by the fact that nobody wants to talk about it and do anything about it, which in itself is a form of gaslighting,” says Dr. Sukhera.

Addressing Islamophobia

Addressing Islamophobia demands large-scale solutions. Injustices and inequities are systemic. Still, at an individual level, doctors can develop skills to combat Islamophobia, says Ms. Wyne.

• Don’t be a bystander — speak up when you see Islamophobia.
• Learn about microaggressions and commit to not perpetrating them.
• Learn about your own biases and where they may have come from (e.g., media stereotypes or uninformed opinions by those surrounding us).
• Ask what your Muslim patient, colleague or friend needs at the time of an Islamophobic incident.
• If you’re a leader in an organization, commit to annual Islamophobia training for your staff.

Doctors may not be able to solve societal ills alone, but their actions and attitudes can contribute to combatting the disease of Islamophobia.

High levels of anti-Muslim feelings in Canada

In recent years, a series of opinion surveys have revealed the extent of Islamophobia. One, from the Angus Reid Institute, asked Canadians whether they had favourable or unfavourable views of six religions: Christianity, Islam, Hinduism, Sikhism, Buddhism and Judaism. Islam came last with just 33 percent having favourable views.

Another survey from EKOS found Canadians are more likely to have negative stereotypes about Muslim Canadians than those belonging to other religions. For example, those surveyed consider Muslims to be less tolerant, less adaptable, less open-minded, more violent and more oppressive of women compared to others.

Such views aren’t only prevalent, they’re also not entirely hidden. An Ipsos survey reported 26 percent of Canadians say it has become more acceptable to be prejudiced against Muslims. The survey also showed Muslims are seen as the most likely targets of racism.

Yet another survey from Leger found that while 81 percent of respondents feel Canada is accepting of people with varying ethnic, cultural and faith backgrounds, one in three are concerned with the number of Muslim immigrants, and one in four don’t trust Muslims and say hijabs should be banned. 

It’s no wonder 26 percent of Muslims surveyed told Angus Reid they feel their beliefs are not welcome in Canadian society.

Anti-Muslim feelings and hate crimes spiked after the 9/11 attacks in 2001, and have been a continual presence since. According to Statistics Canada, the number of police-reported hate crimes targeting Muslims increased by 71 percent in 2021. On June 6, 2021 in London, ON., we saw how such discrimination can be fatal.

The Afzaal family was out for a walk on a lovely evening, a new routine during the pandemic. A truck slammed into them, killing Salman, 46, a physiotherapist; his wife Madiha, 44, who was completing her PhD at Western University; their daughter, Yumna, 15; and Salman’s 74-year-old mother, Talat. Another child, nine-year-old Fayez, was seriously hurt. Police deemed the collision to be deliberate and the attack to be an act of
anti-Muslim hate. A trial for the driver of the truck is set for September 2023.

Salman Afzaal graduated from the University of Toronto’s Department of Physical Medicine in 2013.

In the wake of the attack, Dr. Umberin Najeeb, an internist at Sunnybrook Health Sciences Centre, Equity Lead in the Department of Medicine and Senior Advisor on Islamophobia at Temerty Faculty of Medicine at University of Toronto, issued a statement on behalf of the Department of Medicine. It read in part, “we are witnessing an epidemic of hate, racism and religious discrimination in our communities.”

Dr. Najeeb also reminded colleagues that “in these challenging times, it is important to embody our role as social justice advocates to address Islamophobia and all forms of religious discrimination in our academic environments and health care settings.”