Within my first week of moving from Egypt to the U.S., I was forced to undergo a series of medical exams and receive a host of vaccinations. But it wasn’t the needles piercing into my left arm that made it an unpleasant welcome to a new country. It was the medical forms.

Before filling out my information at the student health center, I was asked to check an ethnicity box. I hovered my pencil over the given options: white, black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander.

I struggled to find where I fit in. And then, right there next to the ‘white’ category, it read in parenthesis, “A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.”

This was awkward. I was about to get a tuberculosis shot in order to stay in a place where I already felt like I didn’t belong.

Rather than having our own racial category, U.S. residents originating from the Middle East and North Africa (MENA) are made to check off “white” on their health forms. Even for someone like me, just arrived and whose jet-lag still hadn’t worn off, checking off that ethnic box was alienating. I couldn’t imagine what it would be like for those who had grown up here, and all the times they were made to check off a box that wasn’t theirs.

Beyond cloaking millions of people in invisibility, the lack of a MENA ethnic box has also proven problematic when trying to conduct research on the minority group’s mental health. Approximately 3.7 million Americans claim Arab ancestry, according to estimates by the U.S. Census Bureau. But there is no way to obtain nationwide data on Arab-Americans’ health because they are not identified as an ethnic group. This leads to major health disparities and an inability to provide for the group’s medical and psychological needs.

Germine Awad, a professor of psychology at the University of Texas, has been working with the U.S. Census Bureau to get a MENA category added for more than eight years now, and says that the bureau came really close to adding one for the year 2020.

“Frankly the reason why it’s not happening as of right now is the new administration,” she says.

When reached for comment, the U.S. Census Bureau responded in an email statement: “The Census Bureau remains committed to researching our population and the best way to measure its diversity, and we plan to consider additional research after the 2020 Census.”

But Awad clarifies that it’s not entirely on the bureau. In fact, census officials had reached out to her and other scholars from the MENA community in 2011 to get their feedback on the plan to add a MENA box. The bureau then recommended adding the census category to the incoming Trump administration.Their request was not approved.

“They’re not talking about it [nor] giving reasons why,” Awad says. “[The new administration] came in and put a stop on all of the suggestions that the bureau made about adding boxes. It’s all political, and isn’t really based in research.”

Meanwhile, no MENA box means crucial nation-wide data on the mental health of Arab-Americans’ continues to go unrecorded at a time when anti-Muslim rhetoric and its accompanying mental health stress is on the rise.

People of Middle Eastern descent are more prone to psychological distress, as revealed by a 2013 study that was the first to estimate the prevalence of psychological disorders among the MENA population in the U.S. The study compared the mental health disparities between people grouped as ‘non-Hispanic whites,’ revealing that ‘whites’ from the Middle East were twice as likely to report serious psychological distress when compared to whites of European descent. Additionally, Middle-Easterners suffering from psychological distress were less likely to have seen a mental health professional within the last 12 months, according to the study.

The mental health experts I spoke to for this piece, all of whom work with the MENA community, agree that Arab ethnicity in America is in itself a source of anxiety and depression under the current political climate.

Hate crime based on a person’s ethnicity increased by 18 percent from the year 2016, which marked the presidential elections, to 2017, according to the Department of Justice’s report.

The number of hate crimes had previously peaked in 2001 following the 9/11 attack, with incidents against Muslim-Americans rocketing from 28 to 481 in a single year. A 2011 survey by the Pew Research Center showed that 55% of Muslim Americans found that life in the U.S. became more difficult after 9/11, with 52% saying that anti-terrorism government policies single out Muslims.

A 2012 public post on Reddit asked, “Muslims of Reddit, how much did your life change after 9/11?” One user wrote “I have never been more scared or felt [more] alienated in my life,” after being harassed by the principal of his school. Another user received threatening notes in their locker when they were in the seventh grade, recalling, “I can honestly say, I’ve never felt so alone in my life.” And another told the story of his friend Osama who was bullied for his name, saying that although he tried to make a joke of it, “deep down…I know he’s hurting though.”

Among a sample of Arab-Americans surveyed post-9/11, 63% reported increased discrimination, and 50% reported symptoms of depression according to a 2012 study.

This most likely stems from a juxtaposition of hypervisibility and invisibility, as noted in Awad’s latest paper published in the American Psychologist in January 2019.

“There is nothing wrong with being identified as white if that is your experience, but if you’re going to identify people as white then you better treat them as white,” says Awad. “The thing that Arab-Americans have to deal with is that you have an ethnic minority experience but you’re not being recognized as an ethnic minority.”

While she is not quite sure if being ignored as an ethnic group has compounded the anxiety and stress of being a minority in the U.S., Awad does believe that experiences of prejudice against Arab-Americans go unvalidated.

Even those who work closely with the community find it difficult to identify and address the external factors affecting Arab-Americans’ mental health.

Mona Makki, the director of community health and research at the Arab Community Center for Economic and Social Services (ACCESS), has been trying to make the case that government facilities need to address the mental health needs of Arab-Americans. However, she has found it challenging because the available research is based on small sample sizes.

Makki says stigma, culture, tradition and lack of awareness create an added layer of difficulty when dealing with mental health within the Arab-American community.

On top of that, there aren’t enough mental health care providers in the U.S. equipped to treat these individuals because the needs of the community have not been recorded, explains Makki.

This lack of understanding can sometimes boil down to translation – both literally, and culturally. Sherief Eldeeb, a researcher in clinical psychology at Clark University and author of a 2017 paper that looked at mental health disparities among the Arab-American population, remembers a striking case study A therapist had brought in a translator for a session with a woman who had just immigrated to the U.S. from Iraq and was discussing issues related to her sexuality. Throughout the session, the translator would chime in with their own words in Arabic, shaming the woman or urging her not to discuss these issues with a male therapist.

“Even when people sought out help, the stigma was still inside the room,” says Eldeeb.

Unfortunately, many perceptions of mental health common to Middle Eastern societies have been carried over to communities in the U.S. Symptoms of mental health disorders continue to be disregarded and seeking professional help is viewed as a luxury.

Awad sees it with some of her patients. They start showing physical symptoms of mental health disorders. “Things like depression tend to show up more semantically…they complain of aches and pains,” she says. “Their mental health issues manifest physically.”

And for Awad, and other researchers who want to try and study the incidence of mental health disorders in the Arab-American community, they have to rely on sample sizes rather than population data. That makes it especially challenging for one very practical reason – funding.

It has been harder for Eldeeb and others in his field to receive funding for their research since they lack numbers and figures that show how widespread mental health issues are among the MENA population. In the past he hasn’t even studied real people, as he’s had to rely on literature review for his research. He notes that it is even difficult to estimate population figures of citizens of Middle Eastern descent since they are not a recognized ethnic group, and therefore the research will always have disparities.

“The major issue is that all the data that we have available tends to be regional in nature,” says Awad. “Researchers collecting data from the MENA population may have incident rates but we don’t have national level data available to speak to these issues.”

“We can’t really talk about disparities on a national or federal level because of the census box,” she adds.

This invisible box represents an unacknowledged minority – a group simultaneously denied an identity and ostracized for it.