Stereotypes and Signifiers
A name can reveal a lot about a person's heritage, and even more about the prejudices of the person hearing the name.
What’s in a name?
What’s in a name? In the acclaimed television series Breaking Bad, shady lawyer Saul Goodman breaks the ice in a first meeting with who will turn out to be meth kingpin Walter White over a presumed Irish heritage — this is when he still thinks he is speaking to a man with the surname Mayhew. Goodman reveals that his real surname is McGill, while ‘the Jew thing’ is for his clients. The most famous examples of changing one’s name to avoid, or to pander to, prejudices probably come from show business. The actor Charlie Sheen’s real name is Carlos Irwin Estévez and his father Martin Sheen’s real name is Ramón Estévez. The Egyptian actor Omar Sharif — عمر الشريف — (immortalized as Doctor Zhivago) was born as the very Christian-sounding Michel Yusef Dimitri Chalhoub — ميشيل يوسف ديمتري شلهوب. In this post, however, I will focus on names and name changes as they pertain to migration and medical education.
When we hear someone’s name, we become curious, make associations and assumptions, and indulge in stereotypes. We may wonder about the ethnic background of the person carrying the name if it sounds particularly distinctive; if the name was acquired by marriage when the person (woman) carrying it does not ‘look’ like someone who was born with that name; if the name has been changed or is being used to conceal another more ‘ethnic’ sounding name; the religion of the person; their gender, and much more.
‘O’Neill’ may evoke romantic visions of rolling hills narrated by rolling Rs, while ‘Osama’ conjures images of falling buildings. Names carry heavy symbolism: a good friend of mine who trained as a psychiatrist in a hospital in New York related to me the story of how, when the residents tried to assemble a committee on racial equality in the wake of the police murder of George Floyd in 2020, the name of Black1 Martinician anticolonial resistance fighter and psychiatrist Frantz Fanon was put forward as a possible namesake for the committee. They were quickly dissuaded from this and reminded ‘We’re a Jewish hospital’. The most popular name given to newborn boys in England is Muhammad, a source of great concern to those who fear the Great Replacement.
My first and last name are religiously ‘neutral’ names in my home country, meaning that they do not allow my interlocutor to know if I am Muslim or Christian — the only two options permitted.2 Any official documentation containing my full name betrays my Muslim origins however, to which I am administratively shackled by a series of Muhammads that have followed me into my British passport.3 As a child and teenager I enjoyed making people squirm when my name did not reveal my religion and they had to resort to a question to glean this vital bit of information while seeming somewhat polite: ‘Baher what?’ Ever since I became aware of the religious ambiguity of my first and last names, I have been interested in what a name signifies, both to the person who holds it and to those upon whose ears it falls. Every Christian in Egypt knows ‘the look’ when they are asked to state their name to a stranger, especially one with the power to make your life miserable — teacher, professor, or government clerk. I remember the grimaces in my own Muslim circles when a Girgis or Shenouda was mentioned.
I am also interested in why people change their names — the history of migration is replete with examples of this. The Australian sports commentator and broadcaster Les Murray was born László Ürge in Hungary and changed his name after migrating down under after the Hungarian revolution of 1956. The name of Lebanese-American poet Gibran Kahlil Gibran — جِبْرَان خَلِيل جِبْرَان — is spelled this way (rather than the typical English spelling Khalil) because a clerk at Josiah Quincy School of Boston spelled it Kahlil.
The history of psychiatry and psychology is doubly replete with such examples, especially Jewish psychoanalysts fleeing Nazism. S.H. Foulkes, British pioneer of group analysis, was born Siegmund Heinrich Fuchs in Germany. Henrich Stern, German Freudian psychoanalyst, Marxist, and secular Jew, changed his first name to Henri when he escaped to France. My favorite example from my research is from the First World War, however. Aron Mendel Michelson was a psychologist born in Latvia, then part of the Russian Empire. He studied psychology in Germany, and with the outbreak of the war and then the Bolshevik revolution made his way to Japan, and then Mexico. In Mexico, he changed his name to David Pablo Boder. His daughter Elena went to high school with a young Frida Kahlo. He finally settled in the United States and contributed to the Second World War effort by writing a manual on Morse code for soldiers. In 1946 he sailed to Germany with a tape recorder to collect oral histories of Jews who had survived the Nazi camps, some of which he published in his book I Did Not Interview the Dead.4
A name in clinical practice
In a different way, curiosity about my surname has followed me into my clinical work in Scotland, where it prompts indigenous (White) Scottish psychiatric patients to make Biblical associations with Abraham and assumptions about my origins in the Holy Land, often asking me if I am a Christian and if I would like to become one. The curiosity is a two-way street: I often learn about Scottish and Irish surnames for the first time from my patients. When walking through Glasgow Necropolis, seeing a surname on a headstone is sufficient to remind me of a particular patient, because that is the only person I know with that name. When the patient is ethnic minority British, the dynamic is different but just as interesting. A Mohamed may be known as ‘Mo’ to some people, but the honor of being allowed to call him Mohamed is bestowed upon me, usually after they have scrutinized my name badge and said the Islamic greeting of ‘Alsalam Alaikum’ to ‘test’ me.
Occasionally it can take sinister turns. On one occasion, I was speaking to a support worker who had referred a patient to a service I worked for. Upon hearing my name, this person said that it was best that I not see the patient ‘because of your name, I hope you don’t mind me saying’, ostensibly because the patient was racist. The fact that I had met the patient in question before and not experienced any racism, and that the referrer knew this, did not seem to make a difference. The irony that the patient had been born in Eastern Europe and had a surname that reflected this was lost on the referrer. Of course, I do not mind being warned that a patient may be racist, but this was the equivalent of saying to a female clinician ‘this patient has sexist views and you have big breasts, so it is better for someone else to see them’. That being said, this was not at all about the patient but about the assumptions the referrer made upon hearing a foreign accent and name on the telephone. A charitable and generous interpretation is that this was symptomatic of her enmeshment in the troubled young woman’s life and her desperation to get everything ‘right’ and predictable. An interpretation that ascribes agency to the referrer would simply conclude that they are of poor moral character. The former is psychiatric, the latter humanistic.
A name in medical education
I have been involved in teaching psychiatry to medical students and psychiatry residents, with a focus on teaching via simulated scenarios where an actor plays a psychiatric patient. Simulation education is interesting for many reasons, but here I want to touch on how it can reveal how well-meaning and highly educated people indulge in stereotypes in the name of objectivity and realism.
Because of logistics and funding, a single actor is recruited to play several psychiatric presentations throughout the day. It makes complete sense that in a country that is 92% White, the actor will likely be of this demographic. This rarely presents a problem, until the White actor is asked to roleplay a person with a foreign-sounding name that is obviously not White. For example, several studies point to higher rates of schizophrenia diagnoses in Black British people of Afro-Carribbean ancestry. In fact, the Black British Afro-Caribbean schizophrenic is something of a stereotype of British transcultural psychiatry.
It is felt by many who want to deliver high fidelity scenarios that this detail is important, to simulate being a member of the demographic that is diagnosed at higher rates. Leaving aside the discussion of whether this higher rate reflects accurate diagnosis or lower thresholds to diagnose, drug, and detain people from minority backgrounds — British Sri Lankan-born psychiatrist Suman Fernando dedicated his life to studying institutional racism in mental health care5 — it is not clear to me that this is a necessary element for medical student learning in a psychiatry simulation course. If it is, then it would help if the actor is Black and that the name chosen is actually reflective of Afro-Carribean and not West African ancestry, which would take a three second Google search if someone actually cared. It is also important to be conscious of not playing into stereotypes, in this case the well-documented association of psychosis with cannabis use overlaps with the cultural relevance of cannabis to the community in question. Without the necessary sensitivity, we are indulging in harmful stereotypes with little educational value.
Sometimes in a resource-poor setting medical students are recruited to play patients. Some time ago I was at a meeting where a very senior clinician and medical educator mentioned that a medical student playing a teenage girl seeking emergency contraception did not understand the term ‘vaginal sex’. The clinician went on to say of the student that ‘she was an international student who was from a member of an ethnic group that had clearly not had that conversation’. I will never know if the student did not know what vaginal sex was, but I am certain that it was a case of different pronunciation and accents — in technical education in non-English speaking countries, it is often pronounced vuh-juy-nal rather than the two syllable and quicker vaji-nal.
Let us imagine how some of the above conversations would go if things were reversed. We could give Irish names to actors simulating alcoholics,6 and Scottish surnames to actors simulating drug addicts.7 We could ensure we only get White female actors and give them names associated with working class communities to play girls seeking emergency contraception or termination of teenage pregnancy, all in the name of accuracy as this would be the demographic most likely to engage in permissive sexual behaviors needing emergency contraception.8 Of course, I am being deliberately crass and vulgar here to make a point. I know from experience that it does not go both ways, and that those in the majority —and those who associated themselves with them— have the privilege of disguising their prejudices as objectivity. That a crucial dimension of ‘objectivity’ is to ‘objectify’ is something they are unable or unwilling to see.
It is important to stress that not being White does not inoculate educators against such stereotypes and prejudices. The phenomenon of supremacy by association is well-known, whether it is African Christians in the United States voting for Donald Trump because of a presumed shared Christian background, or Honorary Aryans in Nazi Germany. I will end on this point by recalling an encounter with two admin personnel looking at my documents outside the American embassy in London in 2020. Two women were handling passports, a middle-aged White lady and a young Black lady. I will leave the reader to guess which one said, as she scrutinized my full name in my passport ‘Why do these people have so many names?’ I will also leave to the reader’s imagination what I would have said in response if I was not outside a heavily guarded building and surrounded by men with guns.
I have capitalized ‘Black’ per the current convention. I still feel uneasy about it, as it means I also need to capitalize ‘White’, which I cannot do without imagining the next word to be ‘Power.
Judaism is also recognized as an official religion in Egypt and recorded on national ID cards, but they are very few in number, for obvious reasons.
I have borrowed the imagery of administrative shackles from Eric Hobsbawm, who was similarly shackled to the Egyptian city of Alexandria, my hometown and his city of birth. He discusses this in his autobiography, Interesting Times: a Twentieth-century Life.
He conducted far more than the eight interviews compiled in this book, but he struggled to find a publisher because the times called for stories of redemption and overcoming adversity, not the degradation and ‘trauma’ of the Nazi camps. That would only become mainstream in the 1960s.
Fernando, S. (2010). Mental health, race and culture. Bloomsbury Publishing; Fernando, S. (2017). Institutional racism in psychiatry and clinical psychology London: Palgrave Macmillan.
More than half of Irish drinkers are classed as hazardous drinkers. The stereotype of the Irish drunk is of course well known, particularly as a result of attention to Irish immigrant populations in Britain and America.
Scotland has the highest rate of drug related deaths in Europe. It is three times as high as the next highest country, Ireland.
I would not dream of perpetuating sexist and classist stereotypes of this sort in the manner that racist stereotypes are perpetuated in the name of objectivity, but if I did want to, there is data to support it.
One study found that White British girls have the highest rate of first conception or maternity by Year 11 (48.8%), in contrast to 28.6% for South Asian girls and 29% for Black Africans, and 39.6% for Black Caribbean. It also found that South Asian girls are 85% less likely to conceive than White British girls, and Black African girls 36% less likely.
Another study reports that White British girls are over-represented among teenage mothers and account for the majority of school-age pregnancies. It also found that teenagers with the lowest aspirations were ‘more likely to have had sexual intercourse and to have been drunk more than once in the last month’ and that ‘one in five white girls reported going further sexually than intended because they were drunk’. Those school pupils who were eligible for free school meals were also more likely to conceive.