Keywords

The Social Fabric of Islam

Although Muslims constitute the majority of the population in 49 countries, rituals and cultural expectations vary greatly by region in these countries and often have little to do with Islamic principles. For example, gender differences sometimes seen in education have no root in Islam, as the Holy Prophet (Peace Be Upon Him) stated:

Quest of knowledge is the responsibility of each Muslim man and Woman even if you have to travel to China in that pursuit.

Dr. Alaa Murabit [7], a physician, has championed many causes related to women and is an emerging leader in global policy addressing issues related to women. Her work is notable for challenging the misogyny stemming from cultural beliefs in Muslim societies by researching the religious scriptures.

Unfortunately the West has stereotyped Muslim women as homogenous oppressed beings [8] who need to be rescued from patriarchy, overlooking the fact that the majority of the world’s cultures regardless of faith are patriarchal. However, Islam has made an effort to promote women’s rights within society by allowing women the right to work, handle their money, marry, divorce, and inherit.

Islamic history is rife with women taking many leadership roles: Bibi Khadija (Raziallahu Taala Anhu) was the Holy Prophet’s (Peace Be Upon Him) wife and owned and managed her own trading business [9]. Similarly, Bibi Nusaiba (RA) fought in the Battle of Uhud and is famous for having shielded the Prophet (PBUH). Bibi Aisha (RA) is famous for transmitting religious knowledge, narrating the highest number of Hadiths, and participating in political life. Muslims during that period regularly sought her opinion in matters pertaining to religion, politics, and social life.

The Central Position and Role of Women in Islam

The core tenets of Islam promote active involvement of Muslim women at home and in society. Their roles are central in many aspects of Muslim family life. Islam gave women a venerable role, and the word of God in the form of the Holy Quran strongly condemns injustice against women.

It is notable that Islam came at a time when the birth of a daughter was considered a reason for embarrassment and infant girls were buried alive in the Arab world. The Holy Quran strongly condemned and outlawed that practice. Furthermore, women at the time had no rights to inheritance, to education, or in marriage. They were traded off or passed along from one male member of the family to other males without their consent or any lawful proceedings.

Islam led to a paradigm shift by presenting a highly contemporary view of the role of women at the time when women in Europe and the rest of the western world had no rights to inheritance, voting, or major roles in the civil proceedings of society. Muslim women were empowered and their contributions in each role were religiously recognized. They were given rights which were unique to their roles.

The Holy Quran states that the pious acts of men and women determine who is closer to God and that gender alone is not a rite of passage. The following roles and entitlements are exclusively reserved for Muslim women and have been mentioned repeatedly in the Holy Quran and in the Hadith (sayings of the Holy Prophet, PBUH). Women’s rights are so critically important that in his last address to Muslims, the Holy Prophet (PBUH) urged Muslims to protect the rights of women.

Mother

Mothers hold a revered position in the Muslim household and society. Allah has strongly urged Muslims to be respectful of their mothers and to take good care of them in their old age. In fact, one of the biggest sins is disrespect toward the mother, with dire religious consequences. The matter of courtesy toward parents is emphasized so much so that the Holy Quran states the following:

And your Lord has decreed that you not worship except Him and treat your parents well. When one or both of them reach old age with you, say not to them even as much as ‘Hmm’ and do not repel them but speak to them a noble word. (Al-Isra 17:23) [10]

Muslims are urged to give thrice the respect and aid to their mothers given to their fathers in accordance with the teachings of the Holy Prophet (PBUH). When a man came to him for advice as towho should receive the benefit of his good behavior and kindness, the Holy Prophet (PBUH) told him “Be good to your mother” the first three times. When he repeated the same question the fourth time, he asked him to be good to his father.

Another famous Hadith states:

Heaven is under the feet of the mother.

This simple sentence not only sanctifies the prime position of a mother in a Muslim household but also dictates the obligatory duty of being humble, accommodating, kind, and respectful toward a mother. Islam encourages Muslims to regularly pay homage to mothers for their sacrifices for their children and to routinely ask God for blessing for their parents.

Respect, love, and kindness toward a mother should continue even after her demise, as the Holy Prophet (PBUH) encouraged Muslims to take care of their maternal aunts and friends in the same manner if the mother has passed away.

Interestingly, the revered position of a mother is not only for the biological mother but also for any women who have breastfed a Muslim. These women are called “Razaaee Mothers,” and the Holy Prophet (PBUH) himself practiced exemplary love, kindness, and respect toward his Razaaee Mother, Bibi Halima Saadia (RA).

Daughter

A famous Hadith narrates the following:

“Lucky is the woman whose first child is a daughter”. Muslim fathers are promised heaven if they raise three or more daughters, treat them well and marry them off. This was an avant-garde concept presented by Islam, as it encouraged its followers to treat their daughters on an equal footing with their sons.

The Holy Prophet (PBUH) set a commendable example with his love and kindness towards his daughters. He used to stand up at his daughter’s arrival and used to spread his shawl (wrap) on the floor for her to sit on.

One of his other Hadiths states:

Daughters are a blessing from God.

Such emphasis on the cardinal importance of the role of daughters empowered Muslim women in this role and solidified their importance in the Muslim family.

Wife

Contrary to the popular notion, Muslim women have a right to choose their partners. In fact the Holy Prophet (PBUH) disqualified a marriage contract because the woman was forced into the marriage by her father without her consent. A Muslim husband is required to give “Mehr,” a mandatory gift to his bride at the time of the marriage. The amount of Mehr is determined via collaboration between husband and wife. A husband is required to provide for her even if she is rich and has her own money. The woman has no obligation to give anything of her wealth to the husband. The husband must pay child expenses even after a divorce. If the wife is unwilling to breastfeed, the husband must pay another woman to nurse the baby. A husband also bears equal responsibility in raising children.

A Hadith narrates the following:

Best blessing for a man is a loyal and righteous woman

Another Hadith states:

A man has 3 fathers; his biological father, his wife’s father & his teacher

In the instance of a divorce, the wife retains all the gifts acquired in the marriage, and the man is to abide by the prenuptial contract (if any), as well as to provide her with at least 3 months of the same standard of living to which she was accustomed during marriage. Men are strongly forbidden from harassing women during or after divorce proceedings. Muslim women are allowed to remarry after the “iddat” (4 months and 10 days). This timing was mandated to ascertain the presence of pregnancy from a previous marriage.

Although polygamy is allowed for Muslim men, the rules regarding this are strict, and God has urged men to practice absolute equality between wives should they decide to marry more than one woman. This includes equality in the time spent with each wife as well as other rights. The scrupulous rules serve to discourage polygamy as a casual practice. It is also worth noting that marriage in many cultures has symbolic meanings and is considered a gesture of respect and peace between families. Additionally, owing to loss of lives during and after wars, this allowance provided a means for widows to pursue marital life with dignity. It is worth noticing that according to some surveys [11, 14], polygamy is practiced less by Muslims as compared with other faiths.

Sister

Muslim men are encouraged to be mindful of their sisters’ needs, to support them, and to treat them with kindness. Some scholars go as far as to say, “An unequivocal way to get rid of financial hardships is to take a small gift for your sister every time you go to her home” [12]. Muslim men are encouraged to support their sisters especially after the death of their father, and most Muslim societies reflect that collectivistic thinking.

Rights of Women in Islam

The passages above highlight Islam’s contributions toward Muslim women’s empowered existence. The following few paragraphs will narrate the unmistakable importance given to women and discuss rights often viewed as disparate by the western world. The role obligations involved reflect variations in rights for each gender. As mentioned above, Muslim men are expected to take care of their mothers, wives, daughters, and sisters – accounting for the seemingly different rights in certain roles.

Inheritance

Islam recognized inheritance as a basic right for both genders. Daughters are entitled to half the share as sons in inheritance due to the differences in role obligations. Women are not obligated to provide any financial support to their male relatives. The rights of inheritance led to accumulation of wealth and development of sizeable assets for some Muslim women. In the mid- sixteenth century Istanbul (Turkey), 36.8% of the “aawqaaf” (charitable donations) were from Muslim women. Similarly between the years of 1770 and 1840 in Aleppo, 51% of charitable contributions were from Muslim women. Moreover, eighteenth century Cairo received 25.4% of its charitable contributions from Muslim women [13].

Work

Historically, Muslim women have been involved in business and many other lines of work. The first woman of Islam Bibi Khadija (RA), the first Muslim woman, and first wife of the Holy Prophet (PBUH) was a business woman and financially independent. In fact, the Holy Prophet (PBUH) used to work for her prior to their marriage. During the time of the Holy Prophet (PBUH) and tenure of the second Caliph of Islam Hazrat Umar Farooq (RA), a woman was the superintendent of the bazaar which provided subsidized food and other items for the society at that time. Muslim women also served as doctors, nurses, and soldiers at various times during history. Notably, in the USA, women were only given the right to fight on the front lines in 2015.

In modern times, Dr. Alaa Murabit [7] sets an outstanding example as one of the 17 global sustainable development advocates appointed by the UN secretary general and the UN High Commissioner on Health, Employment and Economic Growth.

Ibtihaj Muhammad [14] is another notable Muslim woman in the modern era. She is the first female Muslim athlete to earn a medal at the Olympics wearing hijab. She has also served on US Department of State’s initiatives to empower women and girls through sports.

Hazrat Bibi Ayesha (RA) was a renowned Muslim scholar and active in political and social life of Muslim society at that time. In modern times, Fatima Jinnah, the sister of the founder of Pakistan, Muhammad Ali Jinnah, played a critical role in the Pakistani independence movement along with many other Muslim women of that time. Muslim women’s involvement in political life in Pakistan is also considered to be above that in the UK according to some estimates, although the gender differences in employment do not reflect comparable gains.

Muslim women across the globe have held key political positions and have served as heads of state, which to date has not happened in the USA. In fact, at one point in the 1990s, about 300 million Muslims had Muslim women as their state leaders. Dr. Almontasser [15] reports that in the last 40 years, nine Muslim women heads of state have served their nations, some of whom were elected more than once. Currently even some non-Muslim countries have Muslim women as heads of state, notably Singapore and Mauritius. In March 2017, out of the 15 female heads of state in the world, 2 were Muslim women [15, 16]. Notably, Ilhan Osman made history in 2016 by becoming the first Muslim Somali American woman legislator [17].

Education

Education holds a vital place in Muslim society as the first revelation of God was “Iqra,” which means “read.” The Holy Prophet (PBUH) had designated a separate day to teach women and encouraged women and men to seek useful knowledge. The gender differences in education seen in Muslim societies have no basis in the religious tenets as Bibi Ayesha (RA), wife of the Holy Prophet (PBUH), has narrated the largest number of Hadiths and holds a highly prestigious place among Muslim scholars.

Clinical Correlates and the Intergenerational Impact of Islamophobia on Muslim Women

Muslim women who can be easily identified due to their “hijab” or chaaddar (cloth covering the head) are at the receiving end of disproportionately high amount of Islamophobia experienced by Muslim women. This behavior may stem from many misconceptions and fears within western society toward the religion, along with pure gender and racial discrimination. Their choice of clothing is incorrectly perceived to be forced on them by men, and they are wrongly portrayed as submissive subjects of domestic violence in attacks carried out by Muslim men. Notably, Muslim women are also routinely a target of discrimination regardless of their dress preferences [18].

Unfortunately the fact that women across the globe, regardless of their religion or culture, are more likely to be subjected to abuse is conveniently overlooked. Hate crimes against Muslim women due to these prejudices result in isolating them by limiting social mobility and their opportunity to participate in social, occupational, or political life in the host culture, effectively impeding assimilation at all levels. Hate crimes are seldom reported due to fear and the risk of negative outcomes. The resulting psychological vulnerabilities are seldom addressed within the Muslim community or the larger western community. ENAR’s project [5] has tried to address this issue, by gathering information and exploring solutions especially by coupling anti-racism activity with feminist movements. This study has shown that Muslim women are excluded from jobs due to their dress choice, which can be seen as threatening or representing unwillingness to assimilate into the European community. Ethnic and religious discrimination starts prior to employment, as surveys have demonstrated that Muslim women are asked personal questions more frequently than their white counterparts and that Muslim women miss out on career advancement opportunities secondary to their religious adherence or sartorial preferences.

Intimidation by swearing and racial slurs is common on the streets. The media represents a very stereotypical image of Muslim women; those who are strong and independent are described as anomalous. The immense difficulties Muslim women face while living in a hostile environment place them at higher risk for developing PTSD, take a toll on their self-confidence, and hamper their ability to successfully assimilate into society. The hate crimes and constant negative rhetoric against Muslim women in the media not only adversely affect their quality of life and limit access to help but also affect their family functioning and child rearing capability. A depressed or anxious mother is usually disengaged and withdrawn. Maternal mental health issues directly affect children’s behaviors, academic performance, capacity to assimilate, and overall sense of well-being.

While all Muslim women are at risk, second-generation immigrant Muslims are likely to experience worse outcomes, harbor anger, and feel increasingly misinterpreted, marginalized, and victimized. This victimization is likely to create vulnerability for mental health problems as this group is younger and, unlike their mothers who spent the developmental years of their lives in accepting Muslim cultures, has not previously experienced an accepting society.

Islam’s View on Mental Health

Islam recognized the impact of mental health on social functioning more than 1500 years ago when mental illness was considered a curse globally. Long before McNaughten’s rule was established in the western world, Islam uniquely proposed that individuals struggling with mental health disorders leading to decreased or no awareness of their deeds or diminished capacity to know the wrongfulness of their acts were exempted from punishment as well as from the performance of religious rituals like daily prayers. The first known psychiatric hospital was built in Baghdad in 705 AD [19]. Many historical Muslim medical professionals including Razis (860–932 AD) and Avicenna (980–1037 AD) worked at debunking superstition in Islamic society. They encouraged therapy-based treatment for psychological problems [20]. Empathic listening and supportive therapy are very natural extensions of Muslim social rituals.

While the stigma toward mental health exists globally regardless of faith preference, the current wave of Islamophobia detrimentally affects health-seeking behavior by worsening anxiety which in turn reinforces cognitive distortions, stigma, and shame. Muslim women can fall prey to overgeneralization and personalization of the negative encounters. Mistrust toward western providers due to their limited understanding of the underpinnings of religion and culture is a veritable barrier to establishing an optimal therapeutic alliance.

Additionally some treatment modalities might be culturally insensitive – especially individuation-based approaches [21, 22].

Case Examples

  1. 1.

    A 12-year-old second-generation Muslim hijab-wearing girl was called a terrorist and ugly by peers in school. She was also told that no one will marry her. The incident led to body image anxiety and symptoms of bulimia.

  2. 2.

    A 32-year-old first-generation immigrant woman presented with depressed mood. She reported discrimination in the workplace. Instead of reportable verbal assaults, she experienced being ostracized from social events. She stated that only the Muslims who bashed Islamic rituals were accepted by coworkers.

Recommendations for Providers

Muslims are unable to receive optimal care secondary to the limited understanding of Islamic practices in clinical settings [10]. This disparity is likely to promote dissatisfaction with medical care in the Muslim women and decrease health-seeking behaviors. As mentioned above, the impact of the stress of Islamophobia on Muslim women and poor mental health delivery has far-reaching effects on the Muslim communities.

The following recommendations primarily focus on proposals to provide better care to Muslim women, but most of these hold true for all genders in the Muslim world.

  1. 1.

    Medication: Avoiding alcohol-based medication or medication containing other prohibited ingredients (pork, non-halal items) is more likely to promote compliance.

  2. 2.

    Food: Halal food is a requirement for Muslims; they are prohibited from consuming any products containing non-halal items, alcohol, or pork products. These products are allowed only as lifesaving measures. Providers should be mindful of this key concept when they weigh psychopharmacological and other medical management options. During inpatient stays, refusal to eat non-halal food should be explored to avoid labeling it as oppositional behavior or food refusal.

  3. 3.

    Clothing: Muslim women across the globe dress in a variety of different ways based on cultural nuances. The foundation of Islamic clothing is conservative, and many Muslim women typically dress conservatively and fully cover their bodies. Hospital clothing on inpatient units which does not align with faith-based dress preferences is likely to engender resentment and mistrust of the medical system. Moreover, most Muslim women feel uncomfortable with male providers, so physical therapists and 1:1 sitters for suicidal Muslim women should preferably be females.

  4. 4.

    Physical contact: Islam prohibits open physical contact between men and women except in a marital relationship and certain blood relations. Therefore, something as simple as a handshake can be a boundary violation. Similarly, providers should be mindful and inquire about the gender preference for administration of injectable preparations prior to prescribing such medication.

  5. 5.

    Faith-based healing practices and the role of religious healers: Muslims highly revere the saints, popularly called “Wali Allah” meaning “friends of God.” These are pious men and women whom Muslims, particularly Muslim women, routinely ask to pray for them. These saints often give them verses from the Holy Quran to recite and in some instances give them advice based on “Tib-e Nabwi” (PBUH) which is the medicinal practice of the Holy Prophet (PBUH) and is mainly food based. Honey and olive oil are staples in Islamic healing practices. Traditional Muslim societies used “Zavia,” Khanqaah, or local community gatherings for support and to search for the real meaning of life. The Holy Prophet (PBUH) also stated “smiling is charity,” which indeed has research-based positive effects. The recommendation of therapy is far more likely to be acceptable to Muslim women if it resonates with their social fabric and is presented in the context of their religious practice and promotes the therapeutic alliance.

  6. 6.

    Comprehensive case conceptualization: Due to the focus on the common good of the family and society, Muslim women often minimize or do not disclose their symptoms. The onus of responsibility lies on the providers to ask leading questions and explore:

    • Severity and frequency of Islamophobia

    • Resultant symptoms

    • Workplace discrimination

    • Social support systems or lack thereof

    • Discrimination secondary to adherence to Muslim tenets

    • Minimization of symptoms by family and friends

    • Effect on their offspring

    • Guilt

    • Safety risk

    It is critical to identify and monitor the role guilt and embarrassment secondary to perceived inability to carry out family obligations and the subsequent impact on their children.

  7. 7.

    Cognitive schema and its compatibility with therapy: Muslim women garner more respect and adoration as they age, and Muslim children defer to their mothers in many aspects of their lives regardless of their own age. Parents hold a revered position as mentioned earlier. Talking against parents and elders is considered inherently wrong and is incompatible with cognitive schema of most Muslims. This is of particular importance in the context of psychiatric or psychological evaluation of traits to avoid mislabeling these as dysfunctional.

  8. 8.

    Exploration of cognitive distortions like overgeneralization, over-responsibility, guilt, and labeling in the context of Islamophobia is pivotal. CBT is well suited to modify cognitive distortions in Muslims [23]. Therapy lends itself seamlessly to the Muslim society as the core social tenets of Islam promote empathic social conversations, Socratic questioning, and support. Rituals of death, illness, loss, and marriage all promote gathering together and kind words, reminding those who are suffering of the positive aspects of life.

  9. 9.

    Use of Islamic tenets to promote wellness: Five daily prayers provide structure and help patients with depression maintain their ADLs. Limiting use of handwashing to the religiously prescribed times may help in the treatment of OCD if framed in religious terms.

  10. 10.

    Identification of risk factors for experiencing Islamophobia and its long-term adverse outcomes:

    • Conservative sartorial choices

    • Adherence to religious norms

    • Young age

    • Second-generation immigrant

    • Limited social supports

    • Low socioeconomic status

    • Symptom minimization by family and community

    • Marginalization by other Muslims

  11. 11.

    Avoidance of assumptions: Not all Muslim women adhere to the faith so different Muslims will have different needs. Substance use, sexual history, and effects of non-religiosity should also be explored.

  12. 12.

    Psychoeducation: It is notable that many symptoms of mental disorders like hypersexuality in mania, religious delusions in schizophrenia, blasphemous thoughts in obsessive-compulsive disorder, and suicidal ideation in depression can be interpreted as lack of belief by other Muslims. This might lead to isolation from family and Muslim community and promote guilt in the patient. Psychoeducation can help mitigate guilt and blame.

  13. 13.

    Provider bias: It is imperative for healthcare professionals to make conscious efforts to recognize their own biases and limitations and to uphold the highest ethical standards.

  14. 14.

    Mindfulness- and meditation-based therapies and recommendations: The five daily prayers, Darood Sharif recitation (prayers for the Holy Prophet PBUH), and other tasbeehaat (prayers using rosary beads) are widely practiced by Muslim women and promote mindfulness and meditation. Therefore therapies incorporating mindfulness and meditation are very suitable.

Conclusions

Islamophobia is increasing at an alarming pace. When experienced by Muslim women, it has major ramifications for them and their children. The long-term sequelae, although not yet well studied, result in adverse mental health outcomes in Muslim women and their offspring and can pose a substantial burden on society. Despite flagrant spread of Islamophobia, the healthcare community, in particular the mental health disciplines, has not yet established guidelines to screen, evaluate, and deliver faith-centered care. Since religiosity is a known protective factor against mental health problems in Muslims, faith-centered management strategies are likely to encourage adherence to treatment and promote resilience against Islamophobia. There is a need for research to narrow the practice gap for identification and management of adverse outcomes of Islamophobia in Muslim women in order to prevent untoward mental health outcomes in Muslim women and their children.