“Doctor, I can’t wear a face mask, can you write me a medical excuse?”

My first reaction was a resounding No. COVID-19 cases are surging in many parts of the country; we’ve only just emerged from our own deadly surge in Boston. It’s essential that we employ every measure we can to prevent spreading this deadly virus—and that includes universal masking.

But then this patient described how she had suffered a terrible physical assault years before: “The attacker put his arm over my throat, and I couldn’t breathe. [Now] every time I put a scarf over my nose and mouth I’m triggered,” she told me. “It’s traumatizing and unbearable.” She hadn’t thought of the trauma in more than 15 years, but “all of it was brought back. Running into a grocery store thinking, I can’t breathe.” On top of the panic, she felt shame in not being able to tell anyone the reason she wasn’t masking, and she faced public ridicule in person and even name-calling on social media (the one that stings most: “selfish bitch”). “It was too much for me,” she said.

I told her I’d have to think about the exemption. Here was a patient with classic post-traumatic stress disorder (PTSD), in this case, triggered by the attack. But there are many potential causes of PTSD. First described as war-related combat stress, it is now recognized that civilians exposed to violence, natural or human-caused disasters, sexual assault, intimate partner violence, child abuse, or other threats to one’s life can develop post-traumatic stress.

Symptoms include nightmares, recurring thoughts about the events, and flashbacks. The memories can lead to numbing and avoidance or suppression of memories of the trauma, or lifelong mistrust, or to persistent hyperarousal – that is, an exaggerated response to a stimulus – such as heart pounding, feeling afraid after something like an ordinary door slamming. A trigger can be a person, place, situation, or memory that sets off a flood of emotions and reactions, such as heart racing, sweating, a feeling of panic, or even a sense of doom. And it’s certainly possible that a mask could be the trigger.

As a physician working with human trafficking survivors, I have become accustomed to those with a history of surviving violence. But the patient in question is in my general primary care practice. This should highlight to care providers that there may be many more patients out there who have been exposed to trauma in their past, and we need to take this into account. One way to be inclusive is to incorporate the substance abuse and mental health services administration principles of trauma-informed care into practice.

The first principle is to be impartial and provide a safe environment in which patients feels open to sharing their feelings. In order to uncover a trauma history, we need to gently, but directly, ask. For example: Have you had an experience that has overwhelmed your ability to cope? (This is the definition of trauma in its broadest sense). This can be a major illness, surviving a hurricane, losing your home, a major motor vehicle accident. Direct questions are more likely to get an answer. The goal of trauma-informed care is to approach patients with a basic understanding of how trauma affects the life of an individual seeking service, acknowledge the impact of trauma on survivors, build rapport, trust and a sense of safety, and ensure that survivors are not revictimized in the process of seeking help.

In reality, there are very few medical conditions that preclude someone from wearing a mask (e.g., respiratory failure, facial injuries). And I do not mean to open the door to false excuses; trauma-informed care should not do that. Still, we should be aware of the invisible wounds of trauma and how that complicates our COVID response.

If someone reports mask-wearing anxiety, it is important to dig deeper. Ask specifically: Has anyone tried to choke you? In the field of human trafficking, I see patients who have been physically beaten and strangled to the point of unconsciousness. Strangulation is a particularly lethal form of assault, and often familiar those subject to intimate partner violence. Even non-fatal strangulation, especially if repeated, can have detrimental effects on memory and neurologic function (attention, reasoning, decision making), as well as the psychological toll of daily fear.

Along with its danger, strangulation can be difficult to detect, so it may never have been documented in a patient’s medical record.

After a day of consideration, I wrote my patient the exemption so she could board a flight the next day. I recommended she wear a sheer, thin scarf while boarding and deplaning and at moments when she was closest to others. I have since also recommended she wear a face shield in public—this is also good protection and may be more tolerable than a cloth mask. As her care provider, I need to balance protecting her from retraumatization with protecting her (and her seatmates) from COVID spread.

These are the invisible wounds we do not see – and do not know about if we do not ask.

Andrea Reilly is an internal medicine-pediatrics physician.

Image credit: Shutterstock.com