Can You Be Medically Exempt From Wearing a Face Mask?

PS: Those ADA "Face Mask Exemption Cards"? Totally fake.

After Amber Lynn Gilles was refused service at a San Diego Starbucks for not wearing a mask in June 2020, her complaint—via Facebook post—went viral. Gilles shared a picture of the young barista who wouldn't serve her, and wrote that she was medically exempt from wearing a mask. "Meet lenen from Starbucks who refused to serve me cause I'm not wearing a mask. Next time I will wait for cops and bring a medical exemption [sic]."

Gilles's attempt to shame Lenin the barista quickly backfired, as people commented saying that her frustration was "aimed at the wrong people" because Lenin was simply following company policy. Others questioned why she didn't go through the drive-through if she had a medical condition that meant she couldn't wear a mask. (Incidentally, in June 2020, a GoFundMe campaign entitled "Tips for Lenin Standing Up To A San Diego Karen" raised over $105,000 from almost 8000 people from around the world.)

But it's not just Gilles—various videos from across the country showed multiple men and women claiming to be medically exempt from wearing a mask during the COVID-19 pandemic. And according to The New York Times, certain "Face Mask Exemption Cards"—which were completely fake—were also circulating, claiming to give those in possession of them a pass not to wear a mask due to underlying health conditions. "Wearing a face mask posses a mental and/or physical risk to me. Under the Americans with Disability Act (ADA), I am not required to disclose my condition to you," read the card—which not only misspells "poses," but also incorrectly named the Americans with Disabilities Act and referenced the "Freedom to Breathe Agency," which does not exist.

All of these instances beg the same question: Do medical exemptions for face masks or coverings really exist? Here's what you need to know about when, where, and for whom wearing a face mask is necessary, and whether you can be exempt from wearing one.

Who Needs To Wear Face Masks?

The Centers for Disease Control and Prevention (CDC) recommends mask use based on both community and individual risk—low, medium, or high. If the COVID-19 community level of risk is "low", "wear a mask based on your personal preference, informed by your personal level of risk," per the CDC.

If the community level of risk for COVID-19 is "medium" and you are immunocompromised or at high risk for severe illness, the CDC recommends you talk to your doctor about wearing a mask or respirator while indoors in public. If you're getting together with someone who's at higher risk for severe illness, the CDC recommends getting tested prior to seeing them and wearing a mask while you're with them.

When the community risk level is "high", the CDC recommends everyone wear a mask indoors in public settings. And if you're at risk for severe illness or immunocompromised, they recommend a mask or respirator that offers greater protection.

The World Health Organization (WHO) breaks down who should wear surgical or medical face masks and who should wear cloth face coverings. According to the WHO:

Surgical or medical face masks are for:

  • Health care workers
  • People with COVID-19 symptoms
  • People taking care of someone with suspected or confirmed COVID-19
  • People who are 60 years old or older (when social distancing isn't possible in areas with widespread COVID-19)
  • People who have underlying health conditions (when social distancing isn't possible in areas with widespread COVID-19)

Cloth face coverings or fabric masks are for everyone when:

  • COVID-19 is widespread
  • Physical distancing of at least 6 feet isn't possible (including on public transportation, workplaces, stores, and other crowded environments)

Can You Be Medically Exempt From Wearing a Face Mask?

According to the CDC, children younger than two should not wear masks or face shields. Putting a face shield or mask on your baby could increase the risk of sudden infant death syndrome—or could strangle or suffocate your child.

The CDC also mentions people of any age with disabilities as possibly being exempt from wearing a mask. "Challenges may be caused by being sensitive to materials on the face, difficulty understanding the importance of mask wearing for protection, or having difficulty controlling behavior to keep the mask in place," per the CDC.

In a July 2020 Journal of the American Medical Association (JAMA) article, the authors of the article, "Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians," stated that there were very few guidelines for determining who should get a medical exemption, but that in addition to those already named by the CDC, the list should also include "some individuals, particularly children, with sensory processing disorders" and people with "facial deformities that are incompatible with masking."

Beyond that, every state and workplace had its own guidelines regarding the wearing of face coverings. In California, the state's Department of Public Health gave mask exemptions to "persons with a medical condition, mental health condition, or disability that prevents wearing a face covering." This included "persons with a medical condition for whom wearing a face covering could obstruct breathing or who are unconscious, incapacitated, or otherwise unable to remove a face covering without assistance." In New York City, you didn't have to wear a face covering if you had "a health issue that makes you unable to tolerate [one]."

But here's where it got tricky: None of the health agencies specified any health conditions that would constitute a mask exemption—and some health professionals didn't believe these stated, unspecific exemptions for surgical masks or cloth face coverings were necessary. "There are no known medical conditions aside from a severe skin condition [like a very severe burn that needs medical attention] on your face that would prevent a person from wearing this type of mask," David Kaufman, MD, pulmonologist and director of the medical ICU at Tisch Hospital, told Health. "If you can wear a scarf to keep your face warm in the winter, you can wear a mask to prevent the spread of disease."

According to Dr. Kaufman, there's an important distinction between the types of masks average citizens can and should wear (like surgical masks and cloth face coverings), versus the ones health care professionals and those at higher risk of severe disease should wear in certain settings (like N95 respirator masks). The tight-fitting N95 masks, Dr. Kaufman said, filter the air you breathe and protect you from inhaling small particles like dust or germs that cause disease. Those respirator masks do add some resistance to breathing in, and some people with severe lung disease may find breathing more difficult while wearing one, said Dr. Kaufman.

Looser fitting masks, like surgical masks or fabric face masks, however, block some of the air you breathe out. "If you are infected with a contagious disease like COVID-19, a surgical mask limits how much you might spread the disease," said Dr. Kaufman.

Essentially, this means even people with respiratory illnesses—asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases—can probably safely wear either surgical or fabric masks in public. "Finding a mask that fits well or a face covering with a fabric that is soft will help you stay comfortable while you help keep your family, friends, neighbors, and community safe from COVID-19 and other contagious diseases," said Dr. Kaufman.

Jim Keany, MD, emergency physician, patient safety physician champion, and former chief of staff at Mission Hospital in Orange County, California agreed that there are no medical conditions that would preclude someone from wearing a simple surgical or cloth face mask, because both masks have "no effect on respiratory mechanics."

According to Dr. Keany, however, if you are having trouble breathing while wearing a cloth or surgical mask, you may not be wearing it correctly. "If you feel like you're sucking air through the mask, you are wearing the mask too tight," said Dr. Keany. "Simply look for a mask that has some stiffness to it, so that you don't suck it into your mouth [while breathing]."

And if you can't find a face mask that feels comfortable, Dr. Keany suggested using a face shield that drops down below the level of the chin as an alternative—although he warned that this mode of protection isn't as "tried and true" as face masks. "Theoretically, the shield would also stop the droplets from being dispersed and from landing on the person's face. The mask is essentially functioning as a shield, not as a filter," said Dr. Keany. "So the two may be almost equivalent. But I am unaware of any head-to-head comparisons confirming this." (Note: after this article was originally written, a February 2021 study published in the International Journal of Environmental Research and Public Health did compare face shields to masks and found the face shields to be very comparable to masks in protecting people from airborne droplets.)

The bottom line: Neither Dr. Kaufman nor Dr. Keany had received any specific, official guidelines on who would be exempt from wearing a face mask. It's more important to worry about how to properly wear a face mask, rather than who may or may not have to. "I believe that most people need education on proper use rather than an exemption from such a simple and effective device to keep them and others safe," Dr. Keany said.

In Dr. Keany's opinion, if your respiratory status is truly that tenuous that you're not able to breathe through a cloth face covering, you should stay home and not expose yourself to any risk. "If you are truly that fragile, a COVID-19 infection could be a death sentence," said Dr. Keany.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.

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