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(NEW YORK) — With COVID-19 vaccine mandates proliferating across the country in the public and private sectors as well as some school districts, the pushback from those unwilling or hesitant to get their shots is heating up.

The vaccination effort has raised new questions about exemptions because mandates for adults are generally rare outside of settings like healthcare facilities and the military, and the inoculations are relatively new.

While there is no overall data yet on exemptions for COVID-19 vaccines, a number of companies and state governments have seen interest in religious exemptions — a protection stemming from the Civil Rights Act of 1964.

This leaves employers in the difficult and legally precarious position of determining whether the requests are valid. As such, some states have tried to do away with non-medical exemptions overall for their employees.

In school settings, where vaccines have long been recognized as crucial to preventing communicable diseases, state-level mandates are common and have been tested in the courts.

“One of the most important public health practices we have to alleviate outbreaks and things like measles and whooping cough are vaccines required for school or for daycare entry,” Dr. Joshua Williams, an assistant professor of pediatrics at the University of Colorado School of Medicine, told ABC News.

In addition to California announcing that it is adopting a state-wide mandate, individual education boards in cities like Los Angeles have started adding the Pfizer vaccine, which was granted full FDA approval in September and is currently the only vaccine approved for children older than 12, to their list of immunization requirements.

Experts say other school districts are likely to follow suit and have strong legal ground to enforce the requirement set forth in the 1944 Supreme Court case Prince v. Massachusetts.

Here’s what to know about the debate over non-medical exemptions:

On the rise in schools

Data from the Centers for Disease Control and Prevention (CDC) shows that while requests for medical exemptions in schools remain low and fairly constant (around 0.3%), non-medical exemptions (including religious and personal belief exemptions) have risen from 1.4% in the 2011-’12 school year to 2.2% in the 2019-’20 school year (a 57% increase).

In Idaho, for instance, in the 2019-’20 school year, 7.2% of kindergarteners had non-medical exemptions, according to the CDC data. That contrasts with around 1% for states like Massachusetts, Louisiana and Alabama.

Ellen Wright Clayton, a professor of pediatrics, law and health policy at the Vanderbilt University Law School, believes that schools should take a stand against religious exemptions in the interest of protecting public health.

“The fact of the matter is, parents are not entitled, for any reason, to expose other people’s children or other people to [COVID-19] for religious reasons,” Clayton said.

Schools from all 50 states have historically required immunization starting in kindergarten level to curb the spread of contagious diseases such as measles.

Forty-four states and the District of Columbia currently offer religious exemptions to vaccines, of which 15 offer broader personal belief exemptions for personal, moral or spiritual ideologies. The remaining six states — California, Connecticut, Maine, Mississippi, New York and West Virginia — only offer medical exemptions.

More religious exemptions despite decreasing religiousness

Williams, from the University of Colorado, noted that despite a decrease in religiosity among Americans, there has been an increase in religious exemption requests for vaccination, implying that these exemptions are “no longer serving their original purpose.”

It has increased even as some religious leaders, including Pope Francis and Rabbi Chaim Kanievsky, a leading authority in Israel’s ultra-Orthodox Jewish community, have made clear that vaccines are necessary for the common good and take precedence over religious beliefs.

In his research, Williams also investigated the influence of the availability of personal belief exemptions in states on the rate of religious exemptions for childhood vaccinations. In 2016, Vermont eliminated its personal belief exemption policy which was followed by an increase in religious exemption applications from 0.5% to 3.7%.

This suggests that “perhaps people were increasingly using that religious exemption category, even though they might not necessarily have a religious objection to vaccines,” Williams said.

“One thing that people have done previously has shown that the harder it is to obtain an exemption, the lower the rate of exemptions becomes,” he added.

Unlike personal belief exemptions, which are relatively broad, religious exemptions have to be integrated into a holistic belief system, said Dorit Reiss, a professor of law at UC Hastings College of the Law.

“You can’t just grab onto a biblical verse when it’s convenient,” Reiss, who has written about the legality of vaccine mandates in law journals, said.

How the exemptions work

Individuals’ rights to claim a religious exemption from immunization is protected under Title VII of the Civil Rights Act of 1964. However, as seen in some states, this right can be overruled in the interest of public health.

In the wake of the 2019 measles outbreak in the states of New York and Washington, where most cases were reported among the unvaccinated, the states eliminated religious exemptions.

In the face of a religious exemption application, employers or schools have the right to probe the exemption and question the applicant. In other words, it is on them to assess the sincerity of the belief, not the accuracy or validity.

Employers can require their employees to explain the basis of their belief in detail and don’t need to accept a cursory attestation to grant the exemption, Reiss said.

“You can’t try and assess if the belief is rational,” Reiss clarified. “You can ask them a tough question to gauge sincerity.”

However, employers cannot discriminate in favor of organized religions and hence aren’t allowed to request letters from clergy or priests as proof. Employees’ rights to challenge accommodations provided by their employer are also protected by the Equal Employment Opportunity Commission with whom they can file an official complaint.

Employers can maintain high proportions of vaccinated individuals and still make accommodations for those with sincere religious beliefs as demonstrated by the Conway Regional Health System.

But allowing religious exemptions on the basis of how convincing the justification is, Reiss explained, is problematic because it opens the door for people who’ve attended anti-vaccine workshops or “people who are just better liars” to game the system.

Building trust for vaccinations

According to Williams, vaccine hesitancy and the misuse of religious exemptions can be attributed to not only a gap in knowledge caused due to vaccine misinformation and disinformation, but also due to a lack of trust between individuals and public health experts.

“It comes down to something scaring them of the vaccine and they’re using the religious exemption as a cover,” Reiss said.

A common concern among vaccine opponents is the use of fetal cell lines in vaccine research and development, although not an actual ingredient in the vaccine.

When asked about alternatives to curb the spread of misinformation regarding vaccine side effects and composition and the misuse of religious exemptions, Williams suggested a collaboration with religious and faith leaders whom individuals have already built trust with.

“All major faith traditions support vaccinations. And they all support COVID vaccines as well,” Williams said. Reverends and bishops across the country have started collaborating with governments to build trust in the COVID-19 vaccine. It then often comes down to individual interpretations of scripture that lead to religion-based anti-vaccine beliefs.

According to Williams, facilitating an ongoing conversation between faith leaders, public health experts and community members would provide for a safe space for individuals to voice their concerns and get answers in a comfortable environment.

With its relatively recent onset, experts agree that it might be too early to talk about the rate of religious exemptions on the COVID-19 vaccine mandate rollout.

It’s important to highlight how problematic it is to misuse religious exemptions is, Reiss pointed out. “Because in a real sense, it’s abusing religion. It’s making a mockery of real belief and encouraging people to lie about religion, which no religion I think supports.”

Copyright © 2021, ABC Audio. All rights reserved.

(NEW YORK) — Shayla, a 22-year-old from Georgia, has had days during the coronavirus pandemic when she said it has been a struggle to get out of bed.

The part-time college student said she was out of work for a time due to restaurants being closed during the lockdown, and in addition to the financial stress, struggled with not being able to see friends and socialize.

As a person with an underlying health issue, she said she also struggled with fears about getting COVID-19 since she is at risk for complications from the virus.

“It has been very hard on my mental health,” said Shayla, who asked that her last name not be used. “I had a lot of things to think about already and then COVID just added to it, so it was a lot of pressure.”

Shayla turned to therapy to cope, the first time in her life she has sought professional help for her mental health.

“It was like I was just in this box and I didn’t know how to get out of it,” she said. “Mentally and physically, I was just exhausting myself.”

Shayla is not alone in her mental health struggles during the pandemic, research shows.

In the United States, rates of anxiety and depression remain higher than they were pre-pandemic, according to data released this week by the Centers for Disease Control and Prevention.

Mental health experts have described the pandemic as a kind of “perfect storm” in negatively impacting mental health.

In addition to the fear, grief and anxiety around the virus itself, for many people the pandemic has brought on financial instability, job loss, isolation, additional caregiving responsibilities, uncertainty around school and work and related political disagreements.

Now as the global community marks World Mental Health Day on Oct. 10, the pandemic has continued far beyond what people initially thought possible, for nearly two years.

“I’ve heard the pandemic described as a disaster of uncertainty because it seems like the finish line keeps moving,” said Dr. Erica Martin Richards, chair and medical director of the department of psychiatry and behavioral health at Sibley Memorial Hospital in Washington, D.C. “And that makes it harder to come up with a plan [to cope].”

The pandemic has also proven to disproportionately impact women’s mental health.

One study, published by the Kaiser Family Foundation in April, found that 55% of women across all age groups said their mental health had declined during the pandemic, compared to 38% of men. Another, published last month in Lancet Regional Health-Americas, also found women were more likely than men to report higher psychological distress during the pandemic, especially anxiety.

Richards, also an assistant professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, said women’s mental health has suffered disproportionately during the pandemic for a number of reasons.

First, even in non-pandemic times women are already two to three times more likely than men to experience a major depressive episode in their lifetime, according to Richards.

Then during the pandemic, women took on additional caregiving responsibilities and were hit disproportionately hard by job loss, data shows.

Women, and especially women of color, also faced more barriers to accessing support during the pandemic, according to Richards.

“The pandemic uncovered a lot of things that people are typically able to cope with because they’ve had years to develop those coping strategies,” she said. “When you don’t have that anymore, a lot of people felt more isolated and felt like there was a lack of overall support.”

For some women, their mental health struggles may have played out during the pandemic in an increasing dependence on alcohol, or increased control over their food, according to Dr. Jessi Gold, an assistant professor in the department of psychiatry at Washington University School of Medicine.

Data shows that incidences of eating disorders and alcohol-related liver disease rose during the pandemic, particularly among young women.

“Those are easy coping mechanisms that people know work,” said Gold. “There are ways that people can deal. And there’s a lot of people who function to a point, until they can’t.”

Both Gold and Richards said they have seen an increasing need for professional mental health as the pandemic has continued on, at some points with seemingly no end in sight.

“Anxiety was the thing that emerged first for a lot of people because anxiety does not like uncertainty and that’s what we’ve been dealing with during the pandemic,” said Gold. “And the longer the anxiety goes on, the more people start to feel on the depressive side of things.”

Warning signs that it is time to seek professional help for mental health include everything from depressive and hopeless thoughts to undesired weight loss or weight gain, suicidal thoughts, excessive feelings of worry, irritability and changes to sleep patterns. They key is to notice if any of those things begin to affect your ability to function in your daily life, according to Richards.

“When stress is becoming overwhelming, ask for help from a professional,” she said. “That professional can come in a number of ways — religious leaders or groups, OB-GYNs, primary care doctors. Those people should be able to, if not help, point you in the right direction.”

There are also ways people can protect and strengthen their mental health on their own, tools that become even more critically important as the pandemic continues, according to Gold.

“There will be things that will continue to be frustrating about this experience,” she said. “Things will be up and down and we have to have some acceptance about that. Just think, ‘I’m just trying to do the best I can,’ and that’s where you have to land.”

Here are five mental health-boosting tips from Gold and Richards:

1. Get plenty of sleep: “It’s easier said than done but it makes a big difference,” said Gold. “Sleep is all about routine, which is why as a kid it worked that your parents gave you a bath, put you in your pajamas and read books. It works the same as an adult, we just don’t take time to do things like that.”

2. Take time for yourself, especially when you think there’s no time: “When you spend the majority of your life focused on other people, try to factor in time for yourself in some capacity,” said Gold. “Ask yourself how you’re doing and name the feelings and validate them and let them be something that you take the time to stop and acknowledge instead of powering through.”

“Doing self-assessments like that can make you stop and say, ‘I’m here, too. What am I feeling?'” added Gold. “Ask yourself, ‘Have I been sleeping? Have I been eating? What have I enjoyed about the day? What’s been hard?’ and listen to your body in moments like that, too.”

3: Keep the positives of the pandemic: “I think we have to embrace some of the changes that have come out of the pandemic,” said Richards. “For some people, it was I can stay home, I can bake more, I can take a walk with my loved ones twice a week, I can go check on my neighbor.”

“A lot of people have really made commitments to those sorts of things, and it’s important to continue that, but it is also important to understand what our social needs are as a community as well, and the importance of getting together, safely,” she said. “Everyone has to find their own balance, not only with what keeps them safe, but what really they find helps with their mental health as well.”

4. Say no when you need to: “It is sometimes important to really just say no and set limits,” said Richards. “Even though that might seem difficult, you’re actually able to help people more down the road if you’re able to really take time for your own mental health first.”

5. Do self-care you enjoy, not what you think you should do: “Look at self-care or coping skills as hobbies and things that you actually enjoy,” said Gold. “So do you like meditating or are you doing that because someone told you that’s the way to feel better? Do you like exercise, or do you want to watch a TV show instead? Figuring out what you like and what makes you feel better is more important than doing things you’re told you’re supposed to do.”

If you are in crisis or know someone in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741. You can reach Trans Lifeline at 877-565-8860 (U.S.) or 877-330-6366 (Canada) and The Trevor Project at 866-488-7386.

Copyright © 2021, ABC Audio. All rights reserved.

(NEW YORK) — Dr. Jennifer Ashton’s anxiety attacks started to happen after she had a severe allergic reaction to a food.

“I had a couple of episodes where I thought mistakenly that I had eaten that same food that I was allergic to,” said Ashton, ABC News’ chief medical correspondent and a board-certified OBGYN. “And even though I was not having any true physical symptoms of an anaphylactic reaction, once my mind went there, it was almost like a marble rolling off the edge of a table.”

“I started to feel dizzy. I started to feel chest tightness. My heart was racing. I was short of breath, but objectively, I was not having an allergic reaction,” she said. “And even though I recognized that I was having an anxiety attack, I was unable to stop it.”

Ashton spoke out about her own experience with anxiety during Mental Health Awareness Month to put a spotlight on a condition that is common but not always easily understood.

Anxiety is the feeling evoked when someone experiences fear of something bad happening, and it can lead to avoidance, attacks, excessive worrying or other symptoms. Everyone has anxiety sometimes, but when anxiety becomes overwhelming to the point it consistently interferes with daily life, or in the case of Ashton, prompts anxiety attacks that interfere with daily life, it can be an anxiety disorder, according to the U.S. Office on Women’s Health (OWH).

Anxiety disorders are so common they affect about 40 million American adults every year, according to OWH.

And women are more than twice as likely as men to get an anxiety disorder in their lifetime, a discrepancy not yet completely understood from a medical perspective. Some experts say it may be due, in part, to women’s changing hormones and different responses to stress, and women may report symptoms of anxiety more frequently than men.

The prevalence of anxiety underscores that it is a serious mental health concern and not something to be dismissed by doctors or patients, according to Ashton.

“What I learned from my own experience with anxiety attacks is that I think a stigma occurs in a lot of society with people thinking that it’s not real, or it’s not serious or it’s insignificant because we all know that there’s no actual situation occurring,” she said. “But none of that matters. The physical manifestations, the symptoms that I felt when I experienced these anxiety attacks, were absolutely real.”

Ashton noted the coronavirus pandemic, an anxiety-inducing global event that has now lasted more than one year, should have highlighted for people the importance of taking anxiety seriously and treating it just as one would any other medical condition.

“There was not a week that went by that I didn’t hear from patients that they were experiencing anxiety,” she said. “I think what needs to happen is a very objective assessment, not only of ourselves as individuals, but collectively, and what’s going on in the world, so then you can say, ‘This is not surprising, really … it’s common. It’s understandable.'”

What to know about anxiety disorders

Like most mental health conditions, anxiety falls on a spectrum, with differing degrees of severity.

Generalized anxiety disorder is described as worrying, “excessively about ordinary, day-to-day issues, such as health, money, work, and family,” according to OWH. Women with GAD may be anxious about just getting through the day, may have difficulty doing everyday tasks and may have stress-related physical symptoms, like difficulty sleeping and stomachaches, according to OWH.

Panic disorder, also twice as common in women as in men, may see people having panic attacks, described by OWH as “sudden attacks of terror when there is no actual danger.” People having panic attacks may feel like they’re having a heart attack, dying, or losing their minds.

A third type of anxiety disorder, social anxiety disorder, is diagnosed when people “become very anxious and self-conscious in everyday social situations,” including embarrassing easily, according to OWH. People with social anxiety disorder can often have panic attack symptoms around social situations.

The fourth type of disorder, specific phobia, is an intense fear of something, like heights, water, animals or specific situations, that poses “little or no actual danger,” according to OWH.

In addition to fearful thoughts, all four types of disorders also have physical symptoms that can include shortness of breath, chest tightness, nausea, sweating, numbness around the mouth and hands and hyperventilation, according to Ashton.

“There’s a spectrum of severity, so it can be mild, it can be severe. It can be intermittent or it can be constant,” she said. “Most people will admit to having anxious thoughts or feeling anxious at some point during their lives; however, people who really suffer from a true anxiety disorder find that those thoughts feelings or symptoms are occurring more frequently with greater severity.”

Ashton also pointed out that the causes of anxiety can range from the known to unknown.

“Sometimes there is an actual trigger and a clear-cut, rational explanation for where it started. For example, in my case, I had an anaphylactic reaction and experiencing that medical emergency triggered anxiety attacks in similar situations or what I thought were similar situations,” she said. “But other times, people develop an anxiety disorder and they have no known actual trigger. That doesn’t make it any less real. That doesn’t make it any less severe.”

Even with the number of people affected by anxiety during the pandemic, and with celebrities like Camilla Cabello and Prince Harry recently speaking out about their experiences, the topic of anxiety, like most mental health disorders, is still a taboo topic.

“Having an anxiety disorder is still something that’s whispered about, still something that has a societal bias or stigma,” said Ashton. “In a lot of ways, any psychological, emotional or psychiatric disorder still tends to be looked at as a sign of weakness.”

“It is definitely past time that we change that,” she said. “As a medical doctor, I literally do not look at anything that occurs from the neck up as any different than something that occurs from the neck down, so anxiety should be looked at no differently than asthma. As such, it should be managed with a full arsenal of approaches meaning support groups, talk therapy, behavioral therapy, modifying one’s environment or behavior and, if necessary, prescription medication.”

When it comes to medication, a prescription medication to treat and prevent future episodes of anxiety on a long-term basis is different than a medication like Xanax or Valium that is intended for infrequent treatment of acute anxiety, noted Ashton.

“I see this all the time in women where they think, ‘Well, it’s happening more and more frequently, so I’ll just take the medication more and more frequently,'” she said. “[Drugs like Xanax and Valium] are not meant nor are they really safe for long-term, chronic use on a daily basis. That’s why you really should be managed by a psychiatrist by a credentialed mental health professional.”

Treatment for anxiety disorders often includes a combination of counseling and medication — and both together is often most effective. When it comes to counseling, cognitive behavioral therapy (CBT) is often used to help people change thinking patterns around their fears, according to OWH.

The differing degrees of anxiety may make it difficult for people to determine whether they should seek treatment, but what matters is how it is affecting a person individually, according to Ashton.

“There is a big difference between someone who has one anxiety attack or a panic attack per year and someone who has one per day,” she explained. “There’s a big difference between someone who can manage their anxiety and still function at home and in the workplace, and someone who has to leave meetings at work or who has to go home from celebrations or social gatherings. So whether or not you have anxiety that is interfering in your life is very subjective, but in general, it’s whether or not it’s interfering to a degree that is not acceptable to you.”

Other factors like physical activity, nutrition and mindfulness can also play a role in coping with anxiety, although less is known about the role they play in treating anxiety disorders, according to the National Center for Complementary and Integrative Health, an entity of the National Institutes of Health (NIH).

Ashton said women can look to their gynecologist or family physician as their first point of contact in discussing the possible need for anxiety treatment.

“Bring this up with your gynecologist. He or she is very familiar with dealing with anxiety disorders in patients — we see it as women’s health experts on a daily basis,” she said. “This is something that you should bring up at your next well-woman checkup with your gynecologist, with your nurse practitioner, with your family practitioner, and talk about it just like you would talk about a change in your period or if you were having daily headaches.”

Speaking of what it should be like for a person to speak about their anxiety out loud, Ashton added, “We’re just admitting something as plainly as we’re saying it’s cloudy outside.”

Copyright © 2021, ABC Audio. All rights reserved.