Approach to Dermatological Care of Muslim Women

Although Muslims constitute 24% of the world population at an estimated 1.8 billion individuals, 1.1% of the United States population, and remain one of the largest religious groups in the world, barriers to care still persist in Muslim women obtaining dermatological healthcare. Cultural competency and understanding of Muslim cultural and spiritual values, diet, modesty, privacy, health practices, alternative treatments, and certain accommodations may alleviate some of the challenges in providing exceptional care for this patient population. Muslim women may prefer to have a female dermatologist examine their skin, have a family member present in the examination room, or limit the exam to only the areas they feel comfortable exposing. While all dermatologists are likely to treat a Muslim woman over the course of their career, the care of dermatological diseases in Muslim patients may provide challenges for many non-Muslim healthcare providers. The connection between culture and religion for Muslim patients offers a unique opportunity to cater dermatological services for a specific population’s healthcare delivery through heightened cultural awareness and sensitivity. This poster presents a thorough review of barriers and suggested areas of recommended cultural competency that are largely understudied for treating Muslim women in a dermatological setting.

In today’s multifaceted and diverse healthcare landscape, the importance of cultural sensitivity and awareness cannot be overstated. This becomes especially pronounced when considering the unique needs of Muslim women in dermatological settings. Muslim women represent a significant portion of the global and U.S. populations, and their specific religious and cultural practices frequently interface with healthcare systems that may not always be fully equipped to cater to their distinct needs. The consequential gaps in care and potential hesitancy to seek medical interventions are evident from the results of various studies. As teledermatology emerges as a significant pillar of medical consultations in the wake of the COVID-19 pandemic, there is a renewed urgency to address these gaps and ensure that care delivery, whether virtual or in-person, is tailored to respect and accommodate the cultural nuances of Muslim women. This paper delves deep into the challenges of providing culturally competent dermatological care to Muslim women and offers tangible recommendations for healthcare providers, underscoring the need for an amalgamation of cultural awareness, trust, and medical expertise to offer holistic care.

Background and epidemiology

The global Muslim population stands at approximately 1.8 billion, with 4.45 million residing in the United States. This American Muslim community, diverse in race and culture, largely shares healthcare principles rooted in their religious beliefs. These principles shape their expectations from medical professionals. For healthcare systems to offer improved experiences for American Muslims, there is a pressing need for enhanced cultural sensitivity, fostering trust, and an earnest attempt to accommodate the community’s unique values. Despite these needs, numerous barriers persist. A cross-sectional study revealed that 93.8% of Muslim female respondents felt their medical providers lacked understanding of their cultural and religious needs1. Additionally, 83.3% of healthcare providers reported facing challenges in interactions with Muslim female patients, with issues ranging from communication barriers due to language differences, to misunderstandings rooted in cultural and religious beliefs [1]. Moreover, a significant percentage of Muslim women delay seeking medical treatment due to a perceived lack of female practitioners. Their hesitancy is further compounded during religious practices such as Ramadan, where potential side effects of oral medications might deter them from adhering to treatments during the fasting period [2]. To bridge these gaps, recommendations include comprehensive provider education about Islamic religious and cultural beliefs, effective patient-provider communication training, and a broader emphasis on understanding the community’s unique health beliefs and practices.

Importance of cultural awareness and sensitivity

Cultural competency in medicine holds paramount significance. Ensuring a holistic approach when devising a patient’s care plan requires thorough consideration of all relevant factors, including any potential issues, symptoms, or findings during a physical examination. In particular, sensitivity to the cultural preferences of Muslim women plays a crucial role. A deficiency in cultural sensitivity and awareness can deter these women from actively seeking healthcare, notably in preventative screenings and body exams. Building a foundation of cultural awareness and sensitivity can bolster trust in the physician-patient dynamic, creating an environment where patients feel at ease sharing information and undergoing examinations, all of which contribute to optimal care. A cross-sectional prospective study underscored this point, highlighting that Muslim female patients were more inclined to undergo necessary physical exams and seek healthcare if the provider was female, showcasing their comfort preference. As the U.S. evolves into a more culturally diverse nation, it becomes imperative for healthcare professionals to be well-versed in various cultural and religious nuances. This ensures that groups, including Muslim women, do not compromise their health due to the lack of cultural accommodations or discomfort in medical settings.

Recommendations for dermatological care of Muslim women

There are multiple suggestions to guide dermatology healthcare professionals to provide culturally/religiously sensitive care and strengthen the physician-patient relationships for Muslim female patients. Taking into consideration that not all Muslim women wear the hijab (hair covering), yet most practice a certain level of physical modesty, the following recommendations apply to caring for all Muslim female patients in dermatological settings. Some changes in these settings can provide a more inclusive and welcoming environment to this patient population as well as more comfortable and fruitful interactions between patients and the healthcare team. It is crucial to understand the hijab and its practices and be able to address it respectfully. At the same time, it is important to acknowledge that every hijab-wearing or non-hijab-wearing Muslim patient may have different modesty preferences when receiving dermatological care, so avoiding assumptions and openly asking for a patient’s preferences is optimal [3]. When speaking with patients and referring to the hijab, the words “hijab,” veil, and headscarf are appropriate terms to use [3]. 

Prior to or during the visit, asking for a patient’s provider gender preference will allow them to comfortably share and feel supported. Hijab-wearing Muslim women cover their hair and skin in front of non-family males for modesty; therefore, they may prefer a female dermatologist [3]. Religiously, they may remove the headscarf or expose their skin in the presence of healthcare professionals for medical needs despite gender, but most prefer to preserve their modesty and feel more comfortable with strictly female providers [4]. This includes all members of the healthcare team who will be in the room during the history and physical exam, such as scribes and medical trainees. 

Just like all other patients seeking care, Muslim women already feel vulnerable when presenting with medical concerns, but this vulnerability is amplified when the concern involves their hair or a part of the skin that they usually cover. For a dermatologist, being able to respect their preferences, addressing the hijab appropriately, and maintaining patients’ privacy will strengthen the patient-physician relationship [3]. To respect their privacy, dermatologists can make sure that patients who will need to uncover the hair or parts of the skin are placed in exam rooms with low likelihood of accidental exposure when the door is opened5. Furthermore, a sign can be placed on the exam room door indicating a patient’s preference (such as no male staff allowed inside), or a curtain can be available in the room for covering the examination area [5]. Adding a note to a patient’s chart indicating her preferences can help inform future visits and other providers. In the case photographs need to be taken for monitoring disease progression and management, it is important to get the patient’s consent and explain to them in what capacity these will be used as well as who has access to their chart and photographs [3,5]. 

During the physical examination, following the appropriate draping etiquette that physicians were taught in medical school is ideal. The goal will be to maintain the patient’s level of modesty, respect their privacy, and limit their anxiety. When parts of the scalp and other covered body parts need to be uncovered during the physical exam, physicians should ask patients to adjust the covering for that body part while draping other non-pertinent body parts, and covering again once the physical exam is complete [3,5]. Asking patients to be the ones adjusting their hijab or clothing allows them to be in control and helps build trust. Informing patients of the steps of the physical exam and any other procedures as well as informing them before touch further ensures that they agree and are aware of their care. Also, recommending that patients wear loose clothing at their visit will ease uncovering body parts or the hijab during the exam [3]. Lastly, limiting the physical exam to uncovered skin parts and avoiding a thorough skin exam can put patients at a disadvantage, so it is a healthcare professional’s duty to make sure all patients are treated with equitable healthcare and cultural humility [3]. 

Once a year, Muslims partake in fasting during Ramadan, which is considered a holy month of connection with God in the Islamic faith. During this month, Muslims abstain from food and drink from dawn to sunset, resuming eating and drinking between fasting periods from sunset to the next day’s dawn. Understanding the basic principles of the Islamic fasting is important for healthcare professionals treating Muslim patients, especially in the cases of prescribing oral medication. Upon patients’ request and communication with their healthcare provider, they can work with their physician on adjusting their oral medications regimen to align with fasting rituals and eating hours of the day. Religiously, it is permitted for Muslims to use topical treatments while fasting, since those are not ingested by mouth and do not enter the GI tract, but some patients might still prefer to avoid emollients and creams while fasting. It is crucial to avoid making assumptions and respect patients’ preferences when prescribing topical and oral treatment during Ramadan. This will strengthen the patient-physician connection and patients’ satisfaction with their care as well as their compliance with treatment. In certain circumstances Muslims with chronic diseases requiring treatment during the fasting hours are religiously exempt from the obligatory fast. In such cases, physicians do not need to adjust any medication regimen. 

Dermatological conditions to consider in Muslim women

Within the realm of dermatology, there are certain dermatological conditions that physicians should be aware of when treating hijab-wearing Muslim women. Per some studies, hijab-wearing Muslim women are at risk of developing telogen effluvium, in association with vitamin D deficiency and seborrheic dermatitis, and traction alopecia [6]. Understanding the presentation of this condition and its prevalence within this population is crucial for recognizing and treating it before it becomes irreversible. The repetitive and severe stress on the scalp based on the style of hijab and hairstyle under the scarf can be the triggering factor for TA [3,6]. One of the signs of TA is the “fringe” of hair, which represents intact hair at the frontotemporal regions with hair loss posterior to that fringe of hair [3]. Treatment and prevention recommendations include advising patients on modifying their practices to loosen the tightness and pressure on the scalp [3]. Some approaches include choosing looser hairstyles, avoiding tight hair updos, choosing gentle fabric for the hijab, and avoiding hijab styles that are tight on the head. Depending on the level of TA, physicians may consider prescription treatments such as minoxidil or intralesional steroids. Chronic untreated TA can become irreversible, at which point hair transplantation is the only solution. 

Teledermatology and dermatological care

In light of the COVID-19 pandemic, tele dermatology and other forms of remote health consultations have surged in popularity, underscoring the need for adapting culturally sensitive care methods, especially for Muslim women [7]. When scheduling these virtual sessions, it is vital that Muslim women are proactively informed about available slots with female dermatologists, catering to their preference and comfort. Given that many Muslim women, particularly those wearing hijabs, traditionally cover their body and hair, it is advisable for them to don loosely fitted attire during the consultations [7]. This ensures ease in revealing affected areas momentarily during the examination before reverting to their covered state. Additionally, it is essential for these patients to be acquainted with, and grant consent to, any supplementary medical personnel participating in the call. Ensuring that physicians conduct tele dermatology sessions from private locales further amplifies the trust and comfort integral to these consultations.

Recommendations for future practice and ways to improve cultural sensitivity

To foster a more inclusive and compassionate dermatological care environment for Muslim women, it is imperative that healthcare providers elevate their cultural and religious awareness. As the dermatological community becomes increasingly cognizant of the potential discomfort Muslim women might feel—especially when it comes to exposing parts of their skin or hair for examination—they can craft a more tailored patient experience. This involves a deeper familiarity with cultural and religious practices that can influence dermatological conditions, such as the use of henna or limited sun exposure due to clothing choices. Emphasizing the importance of maintaining patient modesty, a tenet introduced in medical school, should be a continual focus throughout a healthcare professional's career, irrespective of the patient’s cultural or religious background. Furthermore, ensuring the privacy of Muslim women, both during in-person consultations and virtual visits, is paramount to fostering trust and reinforcing the sanctity of the patient-physician relationship.

In an increasingly interconnected and diverse world, the integration of cultural and religious sensitivities into healthcare practices remains paramount. While the global and U.S. Muslim populations continue to grow, significant challenges still exist, especially in the realm of dermatological care for Muslim women. These challenges, deeply rooted in both cultural and religious beliefs, can potentially deter Muslim women from accessing timely and appropriate care. However, with a committed shift towards cultural competency and tailored patient experiences, dermatological care can be transformed to be more inclusive and respectful of these nuances. As outlined in this study, from tele dermatology practices to the physical examination room, there are multiple touchpoints where modifications can lead to improved patient experiences and outcomes. The dermatological community must recognize the importance of these adaptations and continuously educate itself to ensure that Muslim women, like all patients, receive equitable, compassionate, and high-quality care. As we look towards the future, it becomes imperative for healthcare systems and professionals to not only understand these nuances but to actively embed them within their practices, ensuring that no patient feels marginalized or overlooked.