Muslim Women's Experiences with Stigma,Abuse,and Depression: Results of a Sample Study Conducted in the United States

Abstract

Purpose:

The aim of this study was to explore associations between internalized stigma, exposure to physical abuse, experiences with sexual abuse, and depression in Muslim women residing in the United States.

Materials and Methods:

We analyzed self-reported data collected online in late 2015. Women who self-identified as Muslim, were at least 18 years old, and were residents of the United States met the inclusion criteria (n = 373). Logistic regression models were used to estimate associations between socioeconomic status, nativity, and the abovementioned indicators.

Results:

Internalized stigma measured through heightened vigilance was associated with depression. Each increase in the abbreviated heightened vigilance scale (higher scores indicate lower vigilance) was associated with 7.6% lower odds of meeting the Center for Epidemiologic Studies Depression Scale 10 (CES-D 10) cutoff for depression (OR = 0.924, 95% CI = 0.888–0.962, p < 0.001). Among individual factors, education, household income, experience with physical abuse, and exposure to sexual abuse were associated with depression. Respondents who reported experiencing physical abuse had almost two times higher odds of meeting the cutoff for depression relative to respondents who had not experienced physical abuse (OR = 1.994, 95% CI = 1.180–3.372, p < 0.01). Likewise, respondents who reported exposure to sexual abuse had over two times higher odds of depression compared with respondents who had not been exposed to sexual abuse (OR = 2.288, 95% CI = 1.156–4.528, p < 0.05).

Conclusions:

These findings were from a group of well educated wealthy respondents; however, experience with negative exposures and rates of depression were high. Further research replicating these findings and evaluating evidence-based interventions designed to improve screening for mental illnesses and retention in care with this hard-to-reach population could produce valuable outcomes, particularly for clinicians and public health practitioners committed to improving population health.

Introduction

There is a dearth of research on American Muslims, and existing studies tend to be limited, focusing on small homogeneous samples.^1
–3 This knowledge gap is even more pronounced in the area of mental health research.^4
–6 While there are few empirical studies examining behaviors of American Muslim women, related research on minority stress, the healthy migrant effect, and stigma are abundant.^{7

–23} These studies are particularly relevant to the American Muslim experience. Specifically, stigma is the process by which a group, such as American Muslim women, is labeled as socially undesirable and devalued due to attributes and behaviors deemed as deeply discrediting⁷; these characteristics may be visible (e.g., ethnicity or type of clothing worn) or may be socially constructed such as opinions on what the practice of Islam entails. Stigma is a social phenomenon requiring at least two actors—us (non-Muslims) compared with them (Muslims); stigma is created and reinforced by social structure and interpersonal processes.⁸ Internalized stigma is often associated with self-deprecating feelings of shame, self-blame, embarrassment, low self-worth, and depression.^9

–12

Additionally, minority stress, as well as low socioeconomic status and experience with abuse, is known to have deleterious effects on mental health.^13

–17 Minority stress is experienced by stigmatized minorities; minority stress causes declines in physical and mental health outcomes.^18

–22 Minority stress theory is built upon the assumption that stigmatized minorities such as American Muslim women are exposed to distal and proximal stressors.^21
–23 Distal stressors, such as experiences with discrimination and exposure to violence, create proximal stressors (internalized stigma), yielding adverse health outcomes.^18,21,23 Researchers have found that racial minorities are more vigilant after experiencing discrimination and this heightened vigilance is associated with poor mental health.^21,23 Many American Muslim women are racial and/or ethnic minorities; thus, it is likely that they experience discrimination, then internalize stigma, and subsequently experience health consequences.

Although studies on mental health and minority stress in African Americans consistently identify associations between experienced discrimination, internalized stigma, and poor mental health, results of similar studies in American immigrants yield mixed results wherein experienced discrimination, internalized stigma, and poor mental health were not predictably associated.^24
–26 These results are often attributed to the healthy migrant effect, which asserts that foreign-born individuals are healthier and more resilient than their American-born counterparts; this is due to a selection bias, in that only the healthiest individuals from a given population emigrate to the United States (with the exception of refugees).^24
–26 Although the healthy migrant effect has been historically applied to physical health outcomes, recent studies have found this effect to be pertinent to research on mental health outcomes, specifically depression, anxiety, and panic attacks.^24
–26 Since many American Muslim women were born abroad, their nativity may be protective against the effects of experienced discrimination and internalized stigma.

Although limited, there are some empirical and demographic studies on American Muslim health; these studies provide valuable insights to the American Muslim experience. For example, the Pew Research Center found minimal differences in the educational profile of Muslims in the United States compared with Americans, in general; about 26% of Muslims compared with 28% of the population at large had an undergraduate degree.^27
–29 Similarly, about 14% of Muslims compared with 16% of all Americans reported high household incomes of $100,000 or more.^27
–29 Amer and Hovey's studies found that Arab Muslim Americans—both men and women, were at greater risk for depression and anxiety compared with other minority groups residing in the United States,^30

–34 and another study of 50 Muslim women suggested that associations exist between physical expression of Islam, specifically type of clothing worn (e.g., hijab), and depression.³³ Ting and Panchanadeswaran (2009) qualitatively explored intimate partner violence in immigrant communities and found identifying as Muslim influenced perceptions of violence acceptability.³⁵ Ammar et al. compared health outcomes related to intimate partner violence in Muslims (n = 34) compared with non-Muslims; they found that the primary perpetrator of violence against both Muslim and non-Muslim women was typically an intimate partner, but Muslim women reported higher rates of violence while pregnant, more frequent exposure to abuse, and endured violence at the hand of an intimate partner for longer durations compared with non-Muslim women.³⁶

In view of this knowledge gap, we undertook an exploratory study on the health of American Muslim women. For purposes of this study, American Muslim women self-identified as adherents of Islam; they hailed from countries spanning the globe; and had a wide range of cultural perspectives and varying world views.^37

–41 American Muslim women are a vulnerable population due to their religious minority status; their race, ethnicity, and/or ancestral origin; and their increased likelihood of experiencing discrimination and internalized stigma in the United States. Considering the existing evidence and gaps, the aim of this study was to explore associations between internalized stigma, exposure to violence, experience with sexual abuse, and depression in American Muslim women.

Materials and Methods

Study design and participants

The Muslim Women's Health project was funded by the University of Alabama at Birmingham School of Public Health's Back of the Envelope mechanism. This mechanism funds novel often underexplored topics. The goal of this study was to collect self-reported exploratory data on cardiovascular health, health lifestyle behaviors, reproductive health, mental health, experience with adverse life events, utilization of preventative health services, religious practice, and demographic information from American Muslim women. Respondents were recruited through online social networks, e-mail requests, and postings made to digital Muslim communities. Potential participants were directed to www.muslimwomenshealth.com to complete the survey or to learn more about this study. Information on the Muslim Women's Health project, the principal investigator, the funding institution, and ethical approval from the University of Alabama at Birmingham's Institutional Review Board No. X150413001 and contact information were available at this portal. Recruitment verbiage asked potential respondents to participate in this anonymous survey of American Muslim women's experiences and to share the survey with other American Muslim women in their social networks. Respondents were not compensated for their participation.

Online data collection occurred for 3 months between September 2015 and December 2015. Informed consent was attained by all respondents via an IRB-approved online consent form. Questions were presented in a standard order, and respondents were able to skip any question; no answers were required to progress through the survey. Questions were presented simply. The respondent was not provided definitions for terms such as physical abuse. Average time to complete the survey was under 15 minutes. Although online surveys have significant limitations, such as sampling bias, one major benefit is the ability to access difficult-to-reach populations, including those holding unpopular beliefs, small minority groups, and groups fearing persecution.⁴² Due to the employment of snowball sampling without unique personal identifiers, a response rate could not be calculated. The final sample size was n = 373.

Measures

Our primary outcome variable was depression, assessed by the 10-item Center for Epidemiologic Studies Depression Scale 10 (CES-D 10).⁴³ Compared with the full-length 20-item version, the short 10-item questionnaire showed good predictive accuracy.^44
–46 The CES-D 10 has been used with other Muslim samples living in the United States to measure depressive symptoms and has demonstrated strong reliability and validity in those studies.⁴³ The CES-D 10 items ask respondents how often during the past week they experienced the following: bothered by things that usually do not bother them, had trouble keeping their mind on tasks, felt depressed, felt everything was an effort, felt hopeful about the future, felt fearful, had restless sleep, felt happy, felt lonely, and could not get going. Responses were coded from 0 = rarely or none of the time to 3 = all of the time. Reverse coding was employed when applicable. Individual scores were summed into a continuous measure ranging from 0 to 30. A CES-D 10 cutoff score of 10 or higher indicated the presence of significant depressive symptoms.^44,45 For this study, respondents with a CES-D 10 score of 10 or higher were coded as 1 for having depressive symptoms, and those with a score below 10 were coded as 0 for not meeting the cutoff for depression. Cronbach's alpha for the CES-D 10 measured with the Muslim Women's Health survey was 0.79, showing comparable internal consistency to the original CES-D 10, which had a Cronbach's alpha of 0.80.⁴⁶

Our primary independent associates were internalized stigma, exposure to physical abuse, and exposure to sexual abuse. Internalized stigma was included rather than experiences of discrimination because prior studies have shown that the exposure to discrimination may or may not be internalized; when not internalized, these experiences do not affect health outcomes.^47,48 Internalized stigma was measured using the Heightened Vigilance Scale (Abbreviated) (AHVS), a scale developed for the Chicago Community Adult Study. The AHVS measured how respondents prepared for or anticipated discrimination. Four items were used to measure heightened vigilance by asking respondents how often they try to prepare for possible insults from other people before leaving home, feel they always have to be careful about their appearance (to get good service or avoid being harassed), carefully watch what they say or how they say it, and try to avoid certain social situations and places. Responses ranged from 1 = almost every day to 6 = never. Responses were summed into a continuous scale ranging from 4 to 24. Lower scores indicated higher heightened vigilance. The internal reliability of the AHVS measured with the Muslim Women's Health data (α = 0.83) was similar to the original version performed in the Chicago Community Adult Study (α = 0.72).^49,50

Respondents were asked two questions about physical abuse: if they had ever experienced physical abuse by a partner and if they had ever experienced physical abuse by a parent. Respondents who answered yes to either physical abuse by a partner or physical abuse by a parent were coded as 1, while all other responses were coded as 0. Similarly, respondents were asked if they had ever experienced sexual abuse by anyone; respondents who answered yes were coded as 1, while all other responses were coded as 0. Definitions of physical abuse and sexual abuse were not provided. Due to sensitivity around disclosing experience with physical and sexual abuse, particularly in such an understudied minority population, multiple questions on physical and sexual abuse were not asked.

We controlled for demographic characteristics, socioeconomic status, and religious sect. Demographics were assessed with three variables: age, ancestral origin, and nativity. Age was operationalized with a continuous variable. Ancestral origin was operationalized with a series of three indicators, including Middle Eastern or North African, South Asian, and other ancestral origin. Although these rates are reported in the univariate analysis, they are not included in the multivariate analysis. Nativity was assessed with a binary variable, coded as 1 if the respondent was born in the United States and 0 if the respondent was born outside the United States. Socioeconomic status was assessed with two variables: annual household income and education. Annual household income was grouped into four categories: under $24,999, $25,000–$74,999, $75,000–$99,999, and over $100,000. Education was coded into four categories: high school education, some college or vocational school, college graduate, and graduate or professional school. Respondents were asked what type of Islam they identified as, and response categories included: Sunni, Shia, and general Islam. General Islam was included for those who identified as Muslims, but did not align themselves with a sect. This would include Muslims who viewed themselves as secular, but still culturally identified as American Muslim women.

Statistical analysis

Univariate statistics were reported. Logistic regression models were used to estimate the relationship between depression, internalized stigma, exposure to sexual abuse, experience with physical abuse, and individual characteristics estimating the odds of meeting the cutoff for the CES-D 10. All models were estimated with Stata 13.0.

Results

Sample characteristics of American Muslim women (n = 373) are in Table 1. The age of respondents ranged from 18 to 69 years, with an average age of 30.6 years. Approximately 44% of the sample were born in the United Sates (43.7%), 41.6% went to graduate or professional school, and 40.8% reported annual household income of over $100,000. About 45% of the sample identified as Sunni Muslim (45.3%), 38.9% identified as Shia Muslim, and 15.5% identified as general Islam. Almost one-third of our sample reported having experienced physical abuse (31.1%) and almost one in six women reported having experienced sexual abuse (15.6%). The average score on the CES-D 10 scale was 10.8, with scores ranging from 3 to 26. Respondents reported numerous instances of heightened vigilance. Almost two-thirds of the sample reported carefully watching what they say and how they say it a few times a month or more frequently (63.4%). Approximately 48% of the sample (47.5%) reported avoiding certain social situations and places at least a few times a month, 37.8% reported being careful about their appearance, and 21.7% of the sample tried to prepare for possible insults from other people a few times a month or more frequently.

Table 1.

Characteristics of American Muslim Women

	Muslim women (N = 373)
Depression (CES-D 10), mean (SD)	10.76 (4.91)
11 or higher, N (%)	182 (45.50)
Below 11, N (%)	218 (54.50)
Demographic characteristics
Age, mean (SD)	30.61 (10.92)
Ancestral origin
Middle Eastern or North African, N (%)	100 (26.81)
South Asian, N (%)	174 (46.65)
Other, N (%)	99 (26.54)
Nativity
U.S.-born, N (%)	163 (43.70)
Foreign-born, N (%)	230 (57.50)
Education
High school, N (%)	39 (10.46)
Some college or vocational, N (%)	75 (20.11)
College graduate, N (%)	104 (27.88)
Graduate or professional school, N (%)	155 (41.55)
Socioeconomic characteristics
Household income
Under $24,999, N (%)	49 (13.14)
$25,000 to $74,999, N (%)	121 (32.44)
$75,000 to $99,999, N (%)	51 (13.67)
Over $100,000, N (%)	152 (40.75)
Religion
Islam
General Islam, N (%)	58 (15.55)
Shia, N (%)	145 (38.87)
Sunni, N (%)	169 (45.31)
Experienced abuse
Physical abuse, N (%)	116 (31.10)
Sexual abuse, N (%)	58 (15.55)
Heightened vigilance scale, mean (SD)	115.14 (5.97)
Prepare for possible insults (a few times a month, or more often), N (%)	81 (21.72)
Careful about appearance (a few times a month, or more often), N (%)	141 (37.80)
Careful about what is said (a few times a month, or more often), N (%)	237 (63.54)
Avoidance of certain social situations and places (a few times a month, or more often), N (%)	177 (47.45)

CES-D 10, Center for Epidemiologic Studies Depression Scale 10; SD, standard deviation.

Odds ratios from the multivariate regression analysis are presented in Table 2. Internalized stigma measured through heightened vigilance was significantly associated with depression, each increase in AHVS (higher scores indicate lower heightened vigilance) was associated with 7.6% lower odds of meeting the CES-D 10 cutoff for depression (OR = 0.924, 95% CI = 0.888–0.962, p < 0.001). Among individual factors, education, household income, experience with physical abuse, and exposure to sexual abuse were associated with depression. Relative to respondents with a high school education, respondents with a graduate or professional school education had ∼69% lower odds of meeting the cutoff for depression (OR = 0.314, 95% CI = 0.129–0.763, p < 0.05). Likewise, relative to respondents with an annual household income of less than $24,000, respondents with an annual household income over $100,000 were associated with 60% lower odds of meeting the cutoff for depression (OR = 0.404, 95% CI = 0.181–0.903, p < 0.05). Experience with abuse was significantly associated with depression. Respondents who reported experiencing physical abuse had almost two times higher odds of meeting the cutoff for depression relative to respondents who had not experienced physical abuse (OR = 1.994, 95% CI = 1.180–3.372, p < 0.01). Similarly, respondents who reported exposure to sexual abuse had over two times higher odds of depression compared with respondents who had not been exposed to sexual abuse (OR = 2.288, 95% CI = 1.156–4.528, p < 0.05).

Table 2.

Logistic Regression Results, Depression as Outcome

	OR (95% CI)
Heightened vigilance scale	0.924 (0.888–0.962)^a
Demographic characteristics
Age	0.986 (0.961–1.012)
Nativity
U.S.-born	1.064 (0.645–1.755)
Foreign-born	Referent
Socioeconomic status
Education
High school	Referent
Some college or vocational	0.553 (0.265–1.605)
College graduate	0.675 (0.277–1.649)
Graduate or professional school	0.314 (0.129–0.763)^b
Household income
Under $24,999	Referent
$25,000 to $74,999	0.454 (0.203–1.002)
$75,000 to $99,999	0.561 (0.0.221–1.424)
Over $100,000	0.404 (0.181–0.903)^b
Religion (Islam)
General Islam	Referent
Shia	0.947 (0.467–1.926)
Sunni	1.098 (0.564–2.139)
Experienced abuse
Physical abuse	1.994 (1.180–3.372)^c
Sexual abuse	2.288 (1.156–4.528)^b

p < 0.001.

p < 0.05.

p < 0.01.

Discussion

The purpose of this study was to examine associations between internalized stigma, experiences with physical abuse, exposure to sexual abuse, and depression in American Muslim women. We found statistically significant associations between depression and internalized stigma, depression and exposure to sexual abuse, and depression and experienced physical abuse. Respondents experienced physical abuse (30.3%) and sexual abuse (15.5%) at similar levels as American women in general (33.0% and 16.7%, respectively).^51,52 With such a high rate of foreign-born persons in this sample, we expected that negative consequences of internalized stigma would be mitigated by the healthy migrant effect.^53,54 We did not find this. Being foreign-born was not protective against depression. In fact, the average CES-D 10 score was 10.8, indicating high levels of depression in our sample. This is of note because certain Muslim populations have fled their homelands to resettle in the United States under duress, and a known gap in the health migrant effect is its inability to explain health outcomes of immigrants who have resettled due to necessity (e.g., asylum seekers). Our findings, therefore, highlight a potential exception to the extensibility of healthy migrant effect, American Muslim women.

Limitations

Limitations should be carefully considered when applying these findings. First, the survey was only available in English; non-English speakers were unable to participate. Although respondents were asked about ancestral country of origin, they were not asked to declare their race/ethnicity; specifically, those of African American descent were unable to identify as such. This is a notable limitation because heightened vigilance could have been compounded by racial discrimination. Additionally, selection bias existed. Respondents were more educated and wealthier than Americans in general, and we suspect, American Muslim women in particular. Although online surveys have their benefits (discussed earlier), they are less likely to reach the most disenfranchised. The study could have been improved had experiences of discrimination, in addition to internalized stigma, been captured. Additionally, clinical diagnoses of depression could have substantiated self-reported data.

Moreover, there are limitations with the way the sexual abuse and physical abuse measures were framed. Each was measured by one or two questions, and the cultural identity of some Muslim women may have influenced how they understood, internalized, and subsequently answered these questions.³⁵ For example, a respondent may have said yes to a question about being hit, but no to a question about experiencing physical abuse, due to stigma associated with the term abuse. Because the terms physical abuse and sexual abuse were not explained in detail, respondents were allowed flexibility in their conceptualization and subsequent response. Asking questions about specific acts of abuse may have yielded different outcomes. As a preliminary study, these results are not necessarily generalizable, but do offer a glimmer of insight into American Muslim women's experiences and health outcomes.

Future research

Since research on Muslim health is meager, there are ample opportunities for future research. Whereas this study explored associates of internalized stigma, research measuring enacted forms of discrimination may yield actionable results. Furthermore, studies that examine internalized stigma may benefit from capturing the source of discrimination (e.g., family, friends, coworkers, and strangers). There is also a need to reach Muslims residing in the United States who do not speak English fluently; therefore, the implementation of translated tools may provide useful findings. Although not the primary focus of this study, the rates of negative exposures and outcomes in these accomplished American Muslim women were startling, especially considering that experiences with physical abuse and sexual abuse are often underreported. Additional research corroborating our findings with larger samples would be beneficial.

Conclusion

Our findings have implications for clinical care, public health practice, and policy. Clinicians and public health practitioners who interface with Muslim patients may benefit from a better understanding of the experiences of these American Muslim women. Specifically, if these women have such high levels of internalized stigma, their experiences could impact the way they interact with the healthcare system. Studies have shown that stigma is associated with mental illness and this stigma creates psychosocial barriers to accessing healthcare.⁵⁵ Furthermore, Muslims residing in the United States are routinely discriminated against,^56
–58 thereby creating an environment of compounded stigma; depressed Muslim women are discriminated against both for being Muslim and for being depressed. Thus, American Muslim women may opt out of mental healthcare all together. In fact, our study found that American Muslim women routinely brace themselves for insults, avoid certain situations, and censor what they say. Clinicians and practitioners should be cognizant about these dynamics and work toward developing facilities and interventions that are sensitive to the Muslim identity. Prior research on stigma alleviation has found that implementing a patient-centered approach in healthcare settings, rather than simply delivering sensitivity or cultural training for staff, yielded improved health outcomes and patient engagement.⁵⁹

American Muslim women who manifest depressive symptoms may be internalizing the effect of experienced or perceived discrimination. Exploring the root or cause of internalized stigma may improve the delivery of healthcare, particularly mental health treatment. Policies exist, which protect minorities from discrimination in healthcare settings, and allow those who experience discrimination to seek reparation. However, these groups should be made aware of these policies, and these policies should be enforced. Furthermore, whereas American Muslim women may be able to respond to overt discrimination, covert discrimination, which may be subtle, seemingly passive, and embedded in the health system, is more difficult to address or even to prove.⁶⁰ Covert discrimination has been consistently linked to health disparities in racial and ethnic minorities.^24
–26,60 Advocates, both those in healthcare settings and those in the community, should promote the implementation of supportive policies and health services (e.g., availability of translators, access to nondenominational prayer settings). Healthcare settings should embrace population heterogeneity and eliminate stigmatizing policies (e.g., required removal of the hijab),⁶¹ which lead to pernicious mental health outcomes and encourage discrimination.⁶² Ideally, results of this study will spur discussion on curbing both covert and overt discrimination by healthcare providers, institutions, and existing social structures.^61,62 This study not only substantiates the harmful effects of internalized stigma but also brings to light its prevalence and its association with depression in American Muslim women.

Footnotes

Acknowledgments

The authors thank Ms. Jami Anderson for her administrative assistance and the University of Alabama at Birmingham's School of Public Health for funding the Muslim Women's Health project.

Author Disclosure Statement

No competing financial interests exist.

References

Abdullahi

, Copping

, Kessel

, Luck

, Bonell

. Cervical screening: Perceptions and barriers to uptake among Somali women in Camden. Public Health, 2009; 123:680–685.

Guerin

, Diiriye

, Corrigan

, Guerin

. Physical activity programs for refugee Somali women: Working out in a new country. Women Health, 2003; 38:83–99.

Al-Amoudi

, Cañas

, Hohl

, Distelhorst

, Thompson

. Breaking the silence: Breast cancer knowledge and beliefs among Somali Muslim women in Seattle, Washington. Health Care Women Int, 2015; 36:608–616.

Herner

UChicago researcher documents dramatic shortcomings tracking American Muslim health disparities. Science Life. 2015. Available at: https://sciencelife.uchospitals.edu/2015/04/06/uchicago-researcher-shows-dramatic-shortcomings-tracking-american-muslim-health-disparities/ Accessed August 10, 2016 .

Haque

Religion and mental health: The case of American Muslims. J Relig Health, 2004; 43:45–58.

Walpole

, McMillan

, House

, Cottrell

, Mir

. Interventions for treating depression in Muslim Patients: A systematic review. J Affect Disord, 2013; 145:11–20.

Erving Goffman

Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, 1963.

Link

, Phelan

. Stigma and its public health implications. Lancet, 2006; 367:528–529.

Kalichman

SC.

The harms of internalized AIDS stigma: A comment on Tsai et al. Ann Behav Med, 2013; 46:256–257.

10.

Person

, Bartholomew

, Gyapong

, Addiss

, van den Borne

. Health-related stigma among women with lymphatic filariasis from the Dominican Republic and Ghana. Soc Sci Med, 2009; 68:30–38.

11.

Kılınç

, Campbell

. “It shouldn't be something that's evil, it should be talked about”: A phenomenological approach to epilepsy and stigma. Seizure, 2009; 18:665–671.

12.

Mak

, Cheung

, Law

, Woo

, Li

, Chung

. Examining attribution model of self-stigma on social support and psychological well-being among people with HIV+/AIDS. Soc Sci Med, 2007; 64:1549–1559.

13.

Beck

, Alford

. Depression: Causes and treatment. Philadelphia, PA: University of Pennsylvania Press, 2009.

14.

Orth

, Robins

, Roberts

. Low self-esteem prospectively predicts depression in adolescence and young adulthood. J Pers Soc Psychol, 2008; 95:695.

15.

Endelstein

, Ryan

. Dressing religious bodies in public spaces: Gender, clothing and negotiations of stigma among Jews in Paris and Muslims in London. Integr Psychol Behav Sci, 2013; 47:249–264.

16.

Black

, Murphy

, Gardner

. Community pharmacist services for people with mental illnesses: Preferences, satisfaction, and stigma. Psychiatr Serv, 2015; 60:1123–1127.

17.

Earnshaw

, Bogart

, Dovidio

, Williams

. Stigma and racial/ethnic HIV disparities: Moving toward resilience. Am Psychol, 2013; 68:225–236.

18.

Meyer

IH.

Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull, 2003; 129:674–697.

19.

Clark

, Anderson

, Clark

, Williams

. Racism as a stressor for African Americans: A biopsychosocial model. Am Psychol, 1999; 54:805–816.

20.

Pascoe

, Richman

. Perceived discrimination and health: A meta-analytic review. Psychol Bull, 2009; 135:531–554.

21.

Dohrenwend

BP.

The role of adversity and stress in psychopathology: Some evidence and its implications for theory and research. J Health Soc Behav, 2000; 41:1–19.

22.

Meyer

, Northridge

, eds. The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual and transgender populations. New York: Springer, 2007.

23.

Williams

DR.

Race, socioeconomic status, and health: The added affects of racism and discrimination. Ann N Y Acad Sci, 1999; 896:173–188.

24.

Budhwani

, Hearld

, Chavez-Yenter

. Depression disparities in racial and ethnic minorities: The impact of nativity and discrimination. J Racial Ethn Health Disparities, 2015; 2:34–42.

25.

Budhwani

, Hearld

, Chavez-Yenter

. Generalized anxiety disorder in racial and ethnic minorities: A case of nativity and contextual factors. J Affect Disord, 2015; 175:275–280.

26.

Hearld

, Budhwani

, Chavez-Yenter

. Panic attacks in minority Americans: The effects of alcohol abuse, tobacco smoking, and discrimination. J Affect Disord, 2015; 174:106–112.

27.

Skerry

The Muslim-American muddle. National Affairs, 2011; 9.

28.

Lipka

Muslims and Islam: Key findings in the U.S. and around the world. 2015. Available at: www.pewresearch.org/fact-tank/2016/07/22/muslims-and-islam-key-findings-in-the-u-s-and-around-the-world Accessed August 11, 2016 .

29.

Center

PR.

Muslim Americans: Middle Class and Mostly Mainstream. Pew Research Center Religion & Public Life, 2007. Available at: www.pewresearch.org/2007/05/22/muslim-americans-middle-class-and-mostly-mainstream/ Accessed August 11, 2016 .

30.

Amer

, Hovey

. Socio-demographic differences in acculturation and mental health for a sample of 2nd generation/early immigrant Arab Americans. J Immigr Minor Health, 2007; 9:335–347.

31.

Amer

, Hovey

. Examination of the impact of acculturation, stress, and religiosity on mental health variables for second-generation Arab Americans. Ethn Dis, 2005; 15(1 Suppl 1):S1.

32.

Amer

, Hovey

. Anxiety and depression in a post-September 11 sample of Arabs in the USA. Soc Psychiatry Psychiatr Epidemiol, 2012; 47:409–418.

33.

Eaton

NR.

Hijab, Religiosity, and psychological wellbeing of Muslim women in the United States. J Muslim Ment Health, 2015; 9.

34.

Fonte

, Horton-Deutsch

. Treating postpartum depression in immigrant Muslim women. J Am Psychiatr Nurses Assoc, 2005; 11:39.

35.

Ting

, Panchanadeswaran

. Barriers to help-seeking among immigrant African women survivors of partner abuse: Listening to women's own voices. J Aggress Maltreat Trauma, 2009; 18.

36.

Ammar

, Couture-Carron

, Alvi

, San Antonio

. Experiences of Muslim and non-Muslim battered immigrant women with the police in the United States: A closer understanding of commonalities and differences. Violence Against Women, 2013; 19:1449–1471.

37.

Bell

The world's Muslims: Religion, politics and society. Pew Research Center on Religion and Public Life. 2013. Available at: www.pewforum.org/2013/04/30/the-worlds-muslims-religion-politics-society-overview/ Accessed August 11, 2016 .

38.

Hann

, Dunn

. (eds). Civil society: Challenging western models. London, United Kingdom: Routledge, 2004.

39.

Rosen

The culture of Islam: Changing aspects of contemporary muslim life. Chicago, IL: University of Chicago Press, 2002.

40.

Karim

WJ.

The status of Malay women in Malaysia: From culture to Islam and industrialization. Int J Sociol Fam, 1987; 17:41–55.

41.

Dawson

Religion and culture. Washington, DC: The Catholic University of America Press, 1948.

42.

Wright

KB.

Researching Internet-based populations: Advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. J Comput Mediat Commun, 2005; 10.

43.

Ghubash

, Daradkeh

, Al Naseri

, Al Bloushi

NBA

, Al Daheri

. The performance of the Center for Epidemiologic Study Depression Scale (CES-D) in an Arab female community. Int J Soc Psychiatry, 2000; 46:241–249.

44.

Radloff

LS.

The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas, 1977; 1:385–401.

45.

Andresen

, Malmgren

, Carter

, Patrick

. Screening for depression in well older adults: Evaluation of a short form of the CES-D. Am J Prev Med, 1994; 10:77–84.

46.

Kohout

, Berkman

, Evans

, Cornoni-Huntley

. Two shorter forms of the CES-D depression symptoms index. J Aging Health, 1993; 5:179–193.

47.

Fazelia

, Turan

, Budhwani

, Smith

, Raper

, Mugavero

, Turan

Moment-to-moment within-person associations between acts of discrimination and internalized stigma in people living with HIV: An experience sampling study. Stigma Health (in press).

48.

Turan

, Budhwani

, Browning

, et al. How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS and Behavior (In press) DOI: 10.1007/s10461-016-1451-5.

49.

Sternthal

, Slopen

, Williams

. Racial disparities in health. Du Bois Rev, 2011; 8:95–113.

50.

The Everyday Discrimination Scale. Available at: http://scholar.harvard.edu/davidrwilliams/book/export/html/32495 Accessed July 10, 2016 .

51.

Briere

, Elliott

. Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse Negl, 2003; 27:1205–1222.

52.

Basile

, Black

, Breiding

, et al. National intimate partner and sexual violence survey: 2010 summary report. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, 2011.

53.

Scribner

Paradox as paradigm-the health outcomes of Mexican Americans. Am J Public Health, 1996; 86:303–305.

54.

John

, De Castro

, Martin

, Duran

, Takeuchi

. Does an immigrant health paradox exist among Asian Americans? Associations of nativity and occupational class with self-rated health and mental disorders. Soc Sci Med, 2012; 75:2085–2098.

55.

Corrigan

How stigma interferes with mental health care. Am Psychol, 2004; 59:614.

56.

Akram

SM.

The aftermath of September 11, 2001; The targeting of Arabs and Muslims in America. Arab Stud Q, 2002; 24:61–118.

57.

Merskin

The construction of Arabs as enemies: Post-September 11 discourse of George W. Bush. Mass Commun Soc, 2004; 7:157–175.

58.

Salaita

SG.

Ethnic identity and imperative patriotism: Arab Americans before and after 9/11. Coll Lit, 2005; 32:146–168.

59.

Heijnders

, Van Der Meij

. The fight against stigma: An overview of stigma-reduction strategies and interventions. Psychol Health Med, 2006; 11:353–363.

60.

Chester

“Offensive Mechanisms.” In: Floyd

, ed. The black seventies. Boston, MA: Porter Sargent Publisher, 1970.

61.

Hatzenbuehler

, Keyes

, Hasin

. State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health, 2009; 99:2275–2281.

62.

Hatzenbuehler

, McLaughlin

, Keyes

, Hasin

. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. Am J Public Health, 2010; 100:452–459.