A few years ago, Altiraifi was hospitalized when her anorexia become so serious that her nails broke and her hair started to fall out. For the next two Ramadans, she followed her dietitian's instructions to abstain from the fast, but by 2015 Altiraifi was almost back to a healthy weight. Though she was eager to practice an important part of her faith again, she also wanted an excuse to eat less.
That summer, while her family diligently practiced Islam, Altiraifi strictly monitored her food intake. In the mornings, she would skip breakfast before proceeding to fast for 16 hours. After sundown, when her family would break their fast with a big meal called iftar, she would sip vegetable soup and pick at the plates piled high with falafel, fava beans, and moussaka that her parents and sisters feasted on.
She felt empowered by her self-control, but within a week, Altiraifi's dietician told her she would end up severely underweight if she continued to abstain from food. Reluctantly she began to eat a little during the day — small portions of steamed vegetables or cheese and crackers — but her family's fast continued to trigger her anorexic tendencies.
"The scariest thing for me is to be eating more than the people around me," says Altiraifi, who also suffers from depression and was recently told she might have borderline personality disorder. "I compare myself a lot to others, so I have to be the skinniest person in the room and have to be the person who eats the least in the room. When that's not true I'm very distraught."
Ramadan, which began Sunday, is a month in which Muslims devote themselves to religious study, self-discipline, and charity. The most important aspect of this religious observance is the fast, which can last for 15 hours each day between pre-sunrise and post-sunset meals. Many Muslims look forward to the communal meals that happen in homes or at mosques and the deep connection to Allah that comes with more frequent prayer. But the holy month can exacerbate eating disorders and mental-health illnesses that are often already stigmatized by their religious community.
Technically, the Koran specifies that Muslims who suffer from any kind of illness are absolved from the fast, so long as they make up the lost days once they are healthy or feed less fortunate Muslims throughout the month. But culturally, "illness" refers to physical ailments such as diabetes and cancer rather than depression or anorexia. Often Muslims with mental-health issues also come to believe their disorders aren't legitimate and feel too guilty or ashamed not to fast. "If this was cancer or diabetes I'd be like, 'Yeah, that's a real sickness,'" says Altiraifi. "But because it's anorexia I [always thought], Oh, it's just in my head. I should be able to overcome it in order to fast.' "
The religious observance exacerbates the dangerous habits of those who already starve themselves. During Ramadan, Muslims are expected to use discipline to ignore their hunger, the same mentality that fuels Altiraifi's anorexia. "The big victory for me was when I experienced that hunger and had the self-control to ignore it," she says. "That was empowering." Dr. Farha Abbasi, an assistant psychiatry professor at Michigan State University, says no Muslim with anorexia or bulimia should observe the fast.
Andleeb Gilani, a 33-year-old who until recently struggled with bulimia, says she would often throw up after the predawn meal and had a tendency to overindulge in fried foods such as samosas and pakoras when she broke fast at night. "Sometimes I noticed I was eating more than others," says Gilani, who a few years ago dropped from a size 6 to a 0 and also struggles with depression. "But I thought of it as a weight-loss month, too. I would tell myself, 'Remember, we're losing weight at the same time.'"
Ramadan can also exacerbate mental illnesses that aren't directly related to food. Abbasi says the two biggest risk factors involve sleep and medication. Many Muslims get less sleep during the holy month due to late-night prayers and predawn meals, which can lead to mood swings and exhaustion in people with bipolar disorder or depression. A study published in the journal World Psychiatry found that 45 percent of Muslims with bipolar disorder had suffered either manic or depressive episodes during Ramadan.
And because ingesting anything is prohibited during the fast, those who take medications often shift their schedules or forgo their prescriptions, which can have serious side effects. Certain medications, such as the mood stabilizer lithium, can reach toxic levels if the body is dehydrated.
Last year Tanvir Salahuddin, a 29-year-old who struggles with bipolar disorder and attention hyperactivity deficit disorder, plunged into a two-week depressive episode during Ramadan. He was taking the five medications that help regulate his mental health after sunset, which made him so exhausted during the day that he skipped his summer college classes and could barely get out of bed. He began to have suicidal thoughts, but when Salahuddin asked his imam whether it was okay to stop fasting given his symptoms, the religious leader from Egypt responded that it would be "kind of like a cop-out."
Maryum Khwaja, a Muslim psychotherapist, says imams who grew up in Muslim countries tend to be less understanding of mental-health struggles than their American-born colleagues. "There are taboos that if you were to pray more you wouldn't have these eating disorders or mental-health issues," she says. "If you covered your hair and dressed a certain way you wouldn't have body-image issues."
Kameelah Rashad, a Muslim minister at the University of Pennsylvania, says that at its core, Islam is a religion based on forgiveness rather than punishment. She advises Muslims who struggle with an illness of any kind to follow a doctor's orders regarding Ramadan. "If your intention is to fast and fully participate in this act of worship, God already knows that," she says. "[You] are encouraged to think about God's mercy." Yet the stigma that these illnesses are personal weaknesses, a stigma that extends far beyond the Muslim community, means many who shouldn't fast internalize dangerous mental-health taboos.
When Gilani's bulimia or depression has forced her to skip fasting over the past few years, she's felt "guilty" and worried that she "wasted an entire Ramadan." "I never shared my mental-health issues with anyone," she says. "Not even my best friend knew about it." In the past few years, when Altiraifi was asked by fellow Muslims about her fast, she'd lie and say, "Oh, it's going great," too embarrassed to admit she struggles with an eating disorder. "I feel like I'm cheating an important tenet of my faith," she says. "This is completely because of the stigma that exists around mental-health disorders."
Altiraifi plans to try to fast again this June under a dietitian's supervision. She has maintained a healthy weight for almost two months, and now eats from all food groups three times a day. She feels strong but still purges after eating trigger foods like doughnuts. She is eager to fast so she can "express solidarity with those less fortunate" than her "and refocus on social justice activism."
But she's also aware her decision poses a big risk. She knows how easily 16 hours without food could cause a slide back into old, life-threatening habits. If Altiraifi's dietitian tells her once again she cannot fast the entire month, she says she'll have trouble accepting it, but will try to remind herself that mental illness does not make her a religious failure. "There are so many ways you can connect to God during that month," she says. "You're not any less of a Muslim if you can't fast."