Looking Under the Hijab: Hair Loss and Cultural Competency

The United States is becoming increasingly diverse with a growing population of patients of color. With this ever-increasing change in patient population, significant health disparities still exist among underrepresented minorities in the United States. Many studies have shown that high-quality patient-physician interaction is characterized by a physician’s ability to provide culturally competent care, address social, cultural, and community influences on patients’ healthcare behaviors, and incorporate these factors into patient-centered care.¹ One of the most rapidly growing patient populations in the US is the Muslim population, with the 2020 census data estimating about 4.45 million Muslim individuals living in the US.² The rise of Muslim patients in the US will require dermatologists to become more culturally aware and understanding of how they think to treat their hijab-wearing patients, particularly when it comes to hair loss. 

Hair Loss in Women of Color

Hair loss is a common problem that affects all women regardless of ethnic background. The most common type of hair loss seen in women is androgenetic alopecia (AGA) or female pattern hair loss (FPHL).³ Other forms of hair loss that can be seen include alopecia areata (AA), telogen effluvium (TE), lichen planopilaris (LPP), central centrifugal cicatricial alopecia (CCCA), frontal fibrosing alopecia (FFA), and traction alopecia. Hair loss at any age can cause detrimental effects to a woman’s self-esteem and self-worth, contributing to a variety of psychosocial issues such as anxiety and depression. When honing in on women who wear hijabs, it is important to consider how the hijab can affect Muslim women’s hair and haircare practices. 

Muslim women often partake in the religious practice of wearing a hijab, a religious head covering, starting as early as 6 years old. When considering this, it is important to view how a woman’s hijab can influence their scalp and hair health. A woman’s hijab, though culturally important, can alter the scalp’s natural microbiome by reducing ventilation, increasing humidity, and causing less sun exposure. Studies have shown that the most common scalp species in hijab-wearing women were Propionibacterium acnes (P. acnes), Staphylococcus capitis (S capitis), and Malassezia restricta.⁴ Among these three bacterial species, P. acnes and S. capitis are the leading agents in predisposing hijab-wearing women to sensitive scalp and inflammatory skin diseases such as seborrheic dermatitis. As dermatologists, it is important to take into consideration the effects the hijab can have on patients’ hair, and how, as a physician, you are able to provide evidence-based care while being mindful of the cultural differences your patients may face. 

Cultural Awareness in Muslim Communities within the Clinic

Beginning to understand patients from a cultural standpoint is just the beginning of providing more culturally competent and sensitive care for patients of color. Many patients of color often experienced racism and hostility in either public, previous physician encounters, or both, resulting in hesitancy and fear of reaching out to new physicians. Islamophobia and hostility to those of Middle Eastern backgrounds can often hinder patients from getting the proper care that they need. As dermatologists, it is imperative to understand the importance of empathy and cultural humility, especially when treating patients of Muslim background. 

The hijab is both a religious and cultural garment that shapes a Muslim woman’s identity. Many Muslim women tend to prioritize modesty during clinical encounters, often opting for same-gender physicians and privacy during routine encounters. Patients who interacted with dermatologists who were knowledgeable about skin changes affecting patients with skin of color, provided modesty options for patients with hijabs, were understanding of dietary restrictions and the need for medication use adjustment during periods of fasting (Ramadan), and were aware of potential cost barriers to treatment often had better outcomes and more positive experiences.⁵ An understanding and respect for the cultural and religious needs of Muslim patients is essential for providing effective, patient-centered dermatologic care. Being able to provide the culturally sensitive care needed for Muslim patients, especially those who wear hijabs, requires a multifaceted approach addressing religious, cultural, and clinical needs. 

Future Steps for a Culturally Competent Clinic 

Negative patient experiences are often due to a provider’s lack of understanding of religious beliefs, modesty requirements, communication barriers, and lack of culturally appropriate resources. To begin building the trust and respect needed to provide adequate care to patients, physicians should begin incorporating cultural humility and religious awareness in staff education, partnering with community organizations and leaders for ongoing education and medical outreach, and facilitating open and safe spaces to improve patient trust and quality of care.⁶ Enhancement of cultural competency in the clinic setting provides patients with a safer space to address healthcare concerns and begin to remediate disparities in healthcare.