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more significant, we are not very good at predicting who is likely to be dangerous in the future.

“Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

“Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the s

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group

But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.

While most police commanders have denied putting a quota in place, city officials have not shied from explaining that they keep close track of how productive their officers are, as would any other employer of a large work force.

A 2010 state law forbids the department from retaliating against officers for not making a certain minimum number of street stops. But Mr. Beirne testified that performance goals did not violate that law. “My feeling was that the supervisors or the department could set performance goals for employees,” Mr. Beirne said. “Whether they be numerical or not was not an issue.”

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“The outcome of this clash of national ambitions will be one of the great, perhaps perilous stories of the next several decades,” said David M. Lampton, a professor at the Johns Hopkins School of Advanced International Studies.

the pomp will also be a chance for Mr. Xi to showcase his “China Dream” — a vision of his nation joining or perhaps supplanting the United States as a superpower leading the world.

Mr. Xi is expected to propose some version of what he has called a “new type of great power relations,” the idea that China and the United States should share global leadership as equals and break a historical pattern of conflict between rising and established powers.

Mr. Xi has positioned China as a stable alternative to the United States, willing to take on the obligations of global leadership and invest in big infrastructure projects across Asia and Europe much as the United States did after World War II.

Mr. Xi is now the unquestioned paramount leader of China, Professor Yan added, while Mr. Trump only “represents himself.”

“The word ‘partnership’ has a long and sad history in the vocabulary of U.S.-China relations,” Professor Lampton said. “American politicians since have avoided the word partnership.”

The statute does not apply to a state’s procedural rules on issues like scheduling the execution date, the government told the justices. In a two-sentence order, the court lifted the D.C. Circuit’s stay. Justices Stephen Breyer, Sonia Sotomayor and Elena Kagan indicated that they would have left the stay in place.

A third case involved whether Montgomery was ineligible for the death penalty due to mental illness. Montgomery’s attorneys argued that she had bipolar disorder, suffered intense hallucinations and continued to experience psychological effects of severe childhood sexual abuse.

Finally, Montgomery argued in a fourth case that the Justice Department violated a federal regulation when it scheduled her execution.

“If the date designated for execution passes by reason of a stay of execution, then a new date shall be designated promptly by the Director of the Federal Bureau of Prisons when the stay is lifted.”

Montgomery was the first woman to be executed by the federal government since 1953. No other women are currently on federal death row.

Montgomery also became the 11th person to be put to death by the federal government since last July, when the Trump administration ended a 17-year moratorium on federal executions.

Police will soon release 911 tapes, body camera footage

Community members gather in West Philly

A racially diverse crowd came together Tuesday evening at Malcolm X Park, not far from the West Philadelphia neighborhood where Wallace was killed.

"far too many comfortable white people here tonight."

"Stop this looting and stop and stop burning our city down," the elder Wallace told CNN.

"It's not going to solve anything," he said. "I don't want to leave a bad scar on my son and my family with this looting and chaos stuff." Wallace's killing was captured on cellphone video and posted to social media, where it went viral.

Family reportedly called for an ambulance, not police

Wallace's wife told the officers when they arrived that her husband had bipolar disorder and urged the officers to stand down.

They ordered Wallace to drop the weapon, saying that he "advanced towards officers."

Both officers fired their guns at Wallace. He was taken to the hospital, where he was pronounced dead.

Many people may rightly say: “I had nothing to do with how this all started. I have nothing to do with the sins of the past. My ancestors never attacked Indigenous people, never owned slaves.” And yes

Live with it long enough, and the unthinkable becomes normal. Exposed over the generations, we learn to believe that the incomprehensible is the way that life is supposed to be.

Like other old houses, America has an unseen skeleton: its caste system, which is as central to its operation as are the studs and joists that we cannot see in the physical buildings we call home.

Caste is the infrastructure of our divisions. It is the architecture of human hierarchy, the subconscious code of instructions for maintaining, in our case, a 400-year-old social order.

Throughout human history, three caste systems have stood out. The lingering, millenniums-long caste system of India. The tragically accelerated, chilling and officially vanquished caste system of Nazi Germany. And the shape-shifting, unspoken, race-based caste pyramid in the United States. Each version relied on stigmatizing those deemed inferior to justify the dehumanization necessary to keep the lowest-ranked people at the bottom and to rationalize the protocols of enforcement.

Race does the heavy lifting for a caste system that demands a means of human division. If we have been trained to see humans in the language of race, then caste is the underlying grammar that we encode as children

We may mention “race,” referring to people as Black or white or Latino or Asian or Indigenous, when what lies beneath each label is centuries of history and assigning of assumptions and values to physical features in a structure of human hierarchy.

What people look like, or rather, the race they have been assigned or are perceived to belong to, is the visible cue to their caste. It is the historic flashcard to the public of how they are to be treated, where they are expected to live

in recent decades, we have learned from the human genome that all human beings are 99.9 percent the same. “Race is a social concept, not a scientific one,” said J. Craig Venter, the genomics expert who ran Celera Genomics when the initial sequencing was completed in 2000. “We all evolved in the last 100,000 years from the small number of tribes that migrated out of Africa and colonized the world.

Which means that an entire racial caste system, the catalyst of hatreds and civil war, was built on what the anthropologist Ashley Montagu called “an arbitrary and superficial selection of traits,” derived from a tiny fraction of the tens of thousands of genes that make up a human being

“The idea of race,” Montagu wrote, “was, in fact, the deliberate creation of an exploiting class seeking to maintain and defend its privileges against what was profitably regarded as an inferior social caste.”

Caste is the bones, race the skin. Race is what we can see, the physical traits that have been given arbitrary meaning and become shorthand for who a person is. Caste is the powerful infrastructure that holds each group in its place.

Caste is rigid and deep; race is fluid and superficial, subject to periodic redefinition to meet the needs of the dominant caste in what is now the United States

While the requirements to qualify as white have changed over the centuries, the fact of a dominant caste has remained constant from its inception — whoever fit the definition of white, at whatever point in history, was granted the legal rights and privileges of the dominant caste.

Thus we are all born into a silent war game, centuries old, enlisted in teams not of our own choosing. The side to which we are assigned in the American system of categorizing people is proclaimed by the team uniform that each caste wears, signaling our presumed worth and potential.

he said to himself, “Yes, I am an untouchable, and every Negro in the United States of America is an untouchable.” In that moment, he realized that the Land of the Free had imposed a caste system not unlike the caste system of India and that he had lived under that system all his life.

One afternoon, King and his wife journeyed to the southern tip of the country, to the city then known as Trivandrum in the state of Kerala, and visited with high school students whose families had been untouchables. The principal made the introduction.“Young people,” he said, “I would like to present to you a fellow untouchable from the United States of America.”

Social scientists often define racism as the combination of racial bias and systemic power, seeing racism, like sexism, as primarily the action of people or systems with personal or group power over another person or group with less power

over time, racism has often been reduced to a feeling, a character flaw, conflated with prejudice, connected to whether one is a good person or not. It has come to mean overt and declared hatred of a person or group because of the race ascribed to them, a perspective few would ever own up to

Who is racist in a society where someone can refuse to rent to people of color, arrest brown immigrants en masse or display a Confederate flag but not be “certified” as a racist unless he or she confesses to it or is caught using derogatory signage or slurs?

With no universally agreed-upon definition, we might see racism as a continuum rather than an absolute. We might release ourselves of the purity test of whether someone is or is not racist and exchange that mind-set for one that sees people as existing on a scale based on the toxins they have absorbed from the polluted and inescapable air of social instruction we receive from childhood.

Caste is the granting or withholding of respect, status, honor, attention, privileges, resources, benefit of the doubt and human kindness to someone on the basis of their perceived rank or standing in the hierarchy.

Caste is insidious and therefore powerful because it is not hatred; it is not necessarily personal. It is the worn grooves of comforting routines and unthinking expectations, patterns of a social order that have been in place for so long that it looks like the natural order of things.

Any action or institution that mocks, harms, assumes or attaches inferiority or stereotype on the basis of the social construct of race can be considered racism

Because caste and race are interwoven in America, it can be hard to separate the two

Any action or structure that seeks to limit, hold back or put someone in a defined ranking, seeks to keep someone in their place by elevating or denigrating that person on the basis of their perceived category, can be seen as casteism.

Casteism is the investment in keeping the hierarchy as it is in order to maintain your own ranking, advantage or privilege or to elevate yourself above others or keep others beneath you

What race and its precursor, racism, do extraordinarily well is to confuse and distract from the underlying structural and more powerful Sith lord of caste. Like the cast on a broken arm, like the cast in a play, a caste system holds everyone in a fixed place.

For this reason, many people — including those we might see as good and kind people — could be casteist, meaning invested in keeping the hierarchy as it is or content to do nothing to change it, but not racist in the classical sense

Actual racists, actual haters, would by definition be casteist, as their hatred demands that those they perceive as beneath them know and keep their place in the hierarchy.

Caste, along with its faithful servant race, is an X-factor in most any American equation, and any answer one might ever come up with to address our current challenges is flawed without it.

Race and caste are not the cause of and do not account for every poor outcome or unpleasant encounter. But caste becomes a factor, to whatever infinitesimal degree, in interactions and decisions across gender, ethnicity, race, immigrant status, sexual orientation, age or religion that have consequences in our everyday lives

The younger country, the United States, would become the most powerful democracy on Earth. The older country, India, would become the largest.

as if operating from the same instruction manual translated to fit their distinctive cultures, both countries adopted similar methods of maintaining rigid lines of demarcation and protocols.

The American system was founded as a primarily two-tiered hierarchy with its contours defined by the uppermost group, those identified as white, and by the subordinated group, those identified as Black, with immigrants from outside Europe forming blurred middle castes that sought to adjust themselves within a bipolar structure, and Native Americans largely exiled outside it.

The Indian caste system, by contrast, is an elaborate fretwork of thousands of subcastes, or jatis, correlated to region and village, which fall under the four main varnas — the Brahmin, the Kshatriya, the Vaishya, the Shudra and the excluded fifth, the Dalits. It is further complicated by non-Hindus — including Muslims, Buddhists, Sikhs and Christians — who are outside the original caste system but have incorporated themselves into the workings of the country, at times in the face of resistance and attack, and may or may not have informal rankings among themselves and in relation to the varnas.

African-Americans, throughout most of their time in this land, were relegated to the dirtiest, most demeaning and least desirable jobs by definition. After enslavement and well into the 20th century, they were primarily restricted to the role of sharecroppers and servants — domestics, lawn boys, chauffeurs and janitors. The most that those who managed to get an education could hope for was to teach, minister to, attend to the health needs of or bury other subordinate-caste people.

the caste lines in America may have at one time appeared even starker than those in India. In 1890, “85 percent of Black men and 96 percent of Black women were employed in just two occupational categories,” wrote the sociologist Stephen Steinberg, “agriculture and domestic or personal service.”

So, too, with groups trained to believe in their inherent sovereignty. “The essence of this overestimation of one’s own position and the hate for all who differ from it is narcissism,” wrote Erich Fromm, a leading psychoanalyst and social theorist of the 20th century. “He is nothing,” Fromm wrote, “but if he can identify with his nation, or can transfer his personal narcissism to the nation, then he is everything.”

“Narcissus could not conceive that he was in love with his own reflection,” wrote the Harvard clinical psychologist Elsa Ronningstam in her 2005 book, “Identifying and Understanding the Narcissistic Personality.” “He was caught in an illusion.”

The political theorist Takamichi Sakurai, in his 2018 examination of Western and Eastern perspectives on the topic, and channeling Fromm, wrote bluntly: “Group narcissism leads people to fascism.” He went on, “An extreme form of group narcissism means malignant narcissism, which gives to rise to a fanatical fascist politics, an extreme racialism and so on.”

“The survival of a group,” Fromm wrote, “depends to some extent on the fact that its members consider its importance as great as or greater than that of their own lives.”Thus, when under threat, they are willing to sacrifice themselves and their ideals for the survival of the group from which they draw their self-esteem.

Johnson said that Wallace was suffering and in a doctor's care, and that he was receiving treatment for his mental health issues.

"It's emotionally taxing to think about how you can call for assistance and wind up with the people who you called killing you," he said.

The message is not that we should expect to bow to every misdeed or atrocity. It is that the “good guys” — granted the impossibility that we can ever reach global consensus about who these are — cannot and should not intervene militarily whenever they see bad stuff happen.

I am just completing a book on the Cuban Missile Crisis. One of its most important lessons is that while Kennedy played a masterly diplomatic hand, it is most unlikely that America’s will could have prevailed — the Soviet nuclear weapons withdrawn from Cuba — without the underpinning threat of American force.

Soviet leader Nikita Khrushchev and even his most hawkish generals knew that America possessed an overwhelming superiority, both of conventional weapons in the Caribbean region and nuclear missiles capable of destroying the Soviet Union. US superiority of the latter was on the order of 17 to 1. And thanks to the intelligence officer Colonel Oleg Penkovsky, who slipped his nation’s secrets to the West, the Americans knew that the Soviets recognized their own weakness.

Moreover, the will and solidarity of the US and its allies to confront the Soviets remained strong in the Cold War. American presidents often found themselves having to restrain the eagerness not only of the military brass, but also of some ordinary citizens, to go head to head with “the Russkies.”

The bipolar Cold War planet has been replaced by a multipolar one, in which a tenuous American superiority persists, but is no longer unchallengeable.

If you think this represents appeasement, watch the new Netflix movie “Munich: The Edge of War,” which stars Jeremy Irons as Neville Chamberlain.

A well-briefed military friend of mine believes that the Chinese are not yet quite ready for a showdown over Taiwan, but he thinks they will seek one within a few years, confident of a local victory.

Biden deserves more sympathy than he is currently receiving for his vacillation on Ukraine. The old, moth-eaten allegation of appeasement is being levelled by his foes both at home and abroad. Yet the US cannot be expected to face down Putin alone, far less to go to war with him.

Today we live in an entirely different strategic environment

Thus, the likelihood is that if Putin attacks Ukraine, he can secure the territory he wants without suffering serious military consequences, beyond whatever losses the courageous Ukrainians can inflict on Russian forces.

The real challenge for the West is to summon the will to punish Putin and his friends in the language they understand best — that of money. Economic sanctions against Russia as a country are right, but not remotely sufficient. The only meaningful weapon is an assault upon the fortunes and lifestyles of the Kremlin’s gangster clique, held and invested around the world.

As for the US, the only party to the confrontation that matters, it seems absolutely right to do everything possible to deter Putin, and to punish him if he goes ahead with his cold-blooded plan to kill thousands of people, to score a victory that shores up his unpopular domestic polity. But one should not resort to threats, nor offer promises to the Ukrainians, that there is no intention of fulfilling.

Most of America’s European “allies” — the quotation marks are emphatic — are too fearful that the Kremlin will cut off their gas supplies to provide Washington with meaningful backing. Europe’s attitude to serious foreign policy and security issues is frankly decadent.

by cutting his 1938 deal with Hitler, he bought vital time for Britain to re-arm before the war that he recognized was coming.

Harris makes a good additional point, that Hitler thought himself cheated out of a military assault on Czechoslovakia that he wanted, and expected to get. In other words, appeasement was clever.

As a historian, I do not go all the way with Harris about this. He seems right that Britain could not realistically have fought in 1938.

I still think that Chamberlain was a weak, foolish old man who shrank from unwelcome realities.

His worst contribution to history is that Munich gave appeasement — which some of us would call a recognition of realities — a bad name. My hero among historical and strategic gurus, the Oxford professor Michael Howard, often said, “If you are dealing with foreign leaders less monstrous than was Hitler, appeasement can be a very sensible policy.”

We must reluctantly acknowledge that both Russia’s Putin and China’s President Xi Jinping can commit acts of aggression in their own backyards that we are unable to prevent, and which are not worth a general war.

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

few analysts expect major legislative or regulatory changes to the program.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

Nearly three quarters of the child and adolescent population in Pakistan experienced learning difficulties after widespread floods devastated the country in 2010.

For many young people, worry over threats of future climate change results in panic attacks, insomnia, obsessive thinking, and other symptoms

And those feelings are often amplified by a pervasive sense that older people aren’t doing enough to fix the climate problem. “There’s a feeling of intergenerational injustice,” says Lise Van Susteren, a general and forensic psychiatrist based in Washington, DC, who specializes in the mental health effects of climate change. “Many young people feel invalidated, betrayed, and abandoned.”

Research on effective interventions is virtually nonexistent, and parents and other people who want to help have little to go on. Professional organizations are only now beginning to provide needed resources.

News reports and researchers often refer to these feelings collectively as climate anxiety, or eco-anxiety, but Pinsky admits to having misgivings about the terms.

“Many people interpret anxiety as a pathological response that needs to be treated and solved,” she says. “But it’s also a constructive emotion that gives us time to react in the face of danger. And anxiety in the face of climate change is a healthy response to a real threat.”

others become progressively hyperaroused and panicky, Pinsky says, or else fall into a sort of emotional paralysis

Some people manage their climate-triggered emotions without spiraling into distress

These reactions can be especially debilitating for people who already struggle with underlying mental health disorders.

anxieties over climate change can interlace with broader feelings of instability over the pace of technological and cultural change,

“Technology is accelerating faster than culture can keep up, and humans in general are unmoored and struggling to adapt,” she says. “For some people, climate change is psychologically the last straw. You realize you can no longer count on the stability of your planet, your atmosphere — your very world.”

Van Susteren describes that anxiety as a type of pre-traumatic stress disorder, with few existing precedents in the United States apart from fears of nuclear annihilation and the decades-ago experience of living through classroom drills on how to survive an atom bomb attack.

Talk therapy for anxiety typically aims to help people identify and replace irrational thoughts, called cognitive distortions, with alternative thinking that isn’t so stressful. But since climate anxiety is based on rational fears, this particular approach risks alienating anyone who might feel their worries are being dismissed.

Younger people were increasingly arriving at Bryant’s office frightened, depressed, and confused about how to manage climate-triggered emotions. Some were even wondering if they should bring children into such a world.

“We’re not saying that anxiety is good or bad,” he says. “We just want to bring those feelings out into the open. It’s more about validating that climate concerns are reasonable given what we’re reading in the news every day.” Ann-Christine Duhaime

Emerging evidence suggests that young people do best by cultivating a sense of agency and hope despite their climate concerns.

getting to that point involves talking through feelings like despair, grief, or rage first. Without doing that, he says, many people get stuck in maladaptive coping strategies that can lead to burnout, frustration, or hopelessness. Bryant describes jumping into an urgent, problem-focused coping strategy as “going into action mode so you don’t have to feel any grief.”

Problem-focused coping has a societal benefit in that it leads to “pro-environmental behavior,” meaning that young people who engage in it typically spend a lot of time learning about climate change and focusing on what they can do personally to help solve the problem

But climate change is far beyond any one person’s control, and problem-focused coping can leave people frustrated by the limits of their own capacity and make them unable to rid themselves of resulting worry and negative emotions

she and her colleagues describe emotion-focused coping, whereby young people ignore or deny climate change as a means of avoiding feeling anxious about it. In an email, Ojala notes that people who gravitate toward emotional distancing typically come from families that communicate about social problems in “pessimistic doom-and-gloom ways.”

Ojala

Ojala and other experts favor a third coping strategy that balances negative feelings about climate change with faith in the power of social forces working to overcome it. Called meaning-focused coping, this approach takes strength from individual actions and climate beliefs, while “trusting th

her societal actors are also doing their part,”

since meaning-focused coping allows negative and positive climate emotions to coexist, young people who adopt it have an easier time maintaining hope for the future.

The overall goal, she says, is for young people to achieve more resilience in the face of climate change, so they can function in spite of their environmental concerns

When people find meaning in what they do, she says, they have a greater sense of their own agency and self-efficacy. “You’re more empowered to take action, and that can be a powerful way to deal with strong negative emotions,”

Duhaime cautions that anyone taking action against climate change should know they shouldn’t expect a quick payback

The brain’s reward system, which forms a core of human decision-making, evolved over eons of history to strengthen neural associations between actions and outcomes that promote short-term survival. And that system, she says, responds to the immediate consequences of what we do. One problem with climate change, Duhaime says, is that because it’s so vast and complex, people can’t assume that any single act will lead to a discernible effect on its trajectory

young people may benefit from seeking the rewards that come from being part of a group or a movement working to advance an agenda that furthers actions that protect the planet’s climate. “Social rewards are really powerful in the climate change battle, especially for young people,

Recognizing the mismatch between how the brain processes reward and the novel challenges of the climate crisis may help people persist when it feels frustrating and ineffective compared to causes with more immediately visible effects. Even if you don’t see climate improvements or policy changes right away, she says, “that won’t diminish the importance of engaging in these efforts.”

Malits adds that she wasn’t overly burdened by her emotions. “I’m an optimist by nature and feel that society does have the capacity to make needed changes,” she says. “And what also helps me avoid climate anxiety on a daily basis is the community that I’ve been lucky enough to connect with here at Harvard. It helps to surround yourself with people who are similarly worried about these issues and are also engaging with you on solutions, in whatever capacity is meaningful to you.”

“Climate anxiety is an important catalyst for the work I do,” Malits says. “I think you need avenues to channel it and talk about it with loved ones and peers, and have communities through which you can process those feelings and come up with remedies.” Collaborative activism dampens the anxiety, Malits says, and gives young people a sense of renewed hope for the future. “That’s why it’s important to roll up your sleeves and think about how you’d like to tackle the problem,”

Malits says she worries most about how climate change is affecting marginalized communities, singling out those who live in urban heat islands, where inadequate green space intensifies extreme heat.

nearly 30 percent of Honduras’s population works for the agricultural sector, where rising temperatures and drought are contributing to a mass exodus, as documented that year by PBS NewsHour.

Researchers are finding that young people with the most extreme fears over climate change live predominantly in the developing world. The Philippines and India, for instance, are near the top of a list of recently surveyed countries where young people report climate-driven feelings that “humanity is doomed” and “the future is frightening.”

Nearly a year after Hurricane Andrew struck South Florida in 1992, 18 percent of children living in the area were still struggling with PTSD-like symptoms, and nearly 30 percent of those who lived through Hurricane Katrina in 2005 wound up with complicated grief, in which strong feelings of loss linger for a long time.

Even when people are not uprooted by disaster, a variety of climate-related mechanisms can affect their mental health or the safety of their mental health treatment. High heat and humidity worsen irritability and cognition, he points out, and they can also exacerbate side effects from some common psychiatric medications

Levels of lithium — a mood stabilizer used for treating bipolar disorder and major depression — can rise to potentially toxic concentrations in a person who is perspiring heavily; they can become dehydrated and  may develop impaired kidney funtion, potentially causing tremor, slurred speech, confusion and other dangerous effects

“I believe the fundamental and best treatment for youth climate distress is a rapid and just transition from fossil fuels,” Pinsky says. “I genuinely consider all that work to be in the area of mitigating climate anxiety.”    

Besides teenage girls, another new group was referred to us: young people from the inpatient psychiatric unit, or the emergency department, of St. Louis Children’s Hospital. The mental health of these kids was deeply concerning—there were diagnoses like schizophrenia, PTSD, bipolar disorder, and more. Often they were already on a fistful of pharmaceuticals.

Being put on powerful doses of testosterone or estrogen—enough to try to trick your body into mimicking the opposite sex—-affects the rest of the body. I doubt that any parent who's ever consented to give their kid testosterone (a lifelong treatment) knows that they’re also possibly signing their kid up for blood pressure medication, cholesterol medication, and perhaps sleep apnea and diabetes. 

There are rare conditions in which babies are born with atypical genitalia—cases that call for sophisticated care and compassion. But clinics like the one where I worked are creating a whole cohort of kids with atypical genitals—and most of these teens haven’t even had sex yet. They had no idea who they were going to be as adults. Yet all it took for them to permanently transform themselves was one or two short conversations with a therapist.

Other girls were disturbed by the effects of testosterone on their clitoris, which enlarges and grows into what looks like a microphallus, or a tiny penis. I counseled one patient whose enlarged clitoris now extended below her vulva, and it chafed and rubbed painfully in her jeans. I advised her to get the kind of compression undergarments worn by biological men who dress to pass as female. At the end of the call I thought to myself, “Wow, we hurt this kid.”

How little patients understood what they were getting into was illustrated by a call we received at the center in 2020 from a 17-year-old biological female patient who was on testosterone. She said she was bleeding from the vagina. In less than an hour she had soaked through an extra heavy pad, her jeans, and a towel she had wrapped around her waist. The nurse at the center told her to go to the emergency room right away.

We found out later this girl had had intercourse, and because testosterone thins the vaginal tissues, her vaginal canal had ripped open. She had to be sedated and given surgery to repair the damage. She wasn’t the only vaginal laceration case we heard about.

Bicalutamide is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of men who take it, including the appearance of breasts. The center prescribed this cancer drug as a puberty blocker and feminizing agent for boys. As with most cancer drugs, bicalutamide has a long list of side effects, and this patient experienced one of them: liver toxicity. He was sent to another unit of the hospital for evaluation and immediately taken off the drug. Afterward, his mother sent an electronic message to the Transgender Center saying that we were lucky her family was not the type to sue.

Here’s an example. On Friday, May 1, 2020, a colleague emailed me about a 15-year-old male patient: “Oh dear. I am concerned that [the patient] does not understand what Bicalutamide does.” I responded: “I don’t think that we start anything honestly right now.”

There are no reliable studies showing this. Indeed, the experiences of many of the center’s patients prove how false these assertions are. 

Many encounters with patients emphasized to me how little these young people understood the profound impacts changing gender would have on their bodies and minds. But the center downplayed the negative consequences, and emphasized the need for transition. As the center’s website said, “Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.” 

When a female takes testosterone, the profound and permanent effects of the hormone can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Our patients were told about some side effects, including sterility. But after working at the center, I came to believe that teenagers are simply not capable of fully grasping what it means to make the decision to become infertile while still a minor.

To begin transitioning, the girls needed a letter of support from a therapist—usually one we recommended—who they had to see only once or twice for the green light. To make it more efficient for the therapists, we offered them a template for how to write a letter in support of transition. The next stop was a single visit to the endocrinologist for a testosterone prescription. 

The doctors privately recognized these false self-diagnoses as a manifestation of social contagion. They even acknowledged that suicide has an element of social contagion. But when I said the clusters of girls streaming into our service looked as if their gender issues might be a manifestation of social contagion, the doctors said gender identity reflected something innate.

Frequently, our patients declared they had disorders that no one believed they had. We had patients who said they had Tourette syndrome (but they didn’t); that they had tic disorders (but they didn’t); that they had multiple personalities (but they didn’t).

The girls who came to us had many comorbidities: depression, anxiety, ADHD, eating disorders, obesity. Many were diagnosed with autism, or had autism-like symptoms. A report last year on a British pediatric transgender center found that about one-third of the patients referred there were on the autism spectrum.

This concerned me, but didn’t feel I was in the position to sound some kind of alarm back then. There was a team of about eight of us, and only one other person brought up the kinds of questions I had. Anyone who raised doubts ran the risk of being called a transphobe. 

I certainly saw this at the center. One of my jobs was to do intake for new patients and their families. When I started there were probably 10 such calls a month. When I left there were 50, and about 70 percent of the new patients were girls. Sometimes clusters of girls arrived from the same high school. 

Until 2015 or so, a very small number of these boys comprised the population of pediatric gender dysphoria cases. Then, across the Western world, there began to be a dramatic increase in a new population: Teenage girls, many with no previous history of gender distress, suddenly declared they were transgender and demanded immediate treatment with testosterone. 

Soon after my arrival at the Transgender Center, I was struck by the lack of formal protocols for treatment. The center’s physician co-directors were essentially the sole authority.

At first, the patient population was tipped toward what used to be the “traditional” instance of a child with gender dysphoria: a boy, often quite young, who wanted to present as—who wanted to be—a girl. 

During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility. 

I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to “do no harm.” Instead, we are permanently harming the vulnerable patients in our care.

Today I am speaking out. I am doing so knowing how toxic the public conversation is around this highly contentious issue—and the ways that my testimony might be misused. I am doing so knowing that I am putting myself at serious personal and professional risk.

Almost everyone in my life advised me to keep my head down. But I cannot in good conscience do so. Because what is happening to scores of children is far more important than my comfort. And what is happening to them is morally and medically appalling.

For almost four years, I worked at The Washington University School of Medicine Division of Infectious Diseases with teens and young adults who were HIV positive. Many of them were trans or otherwise gender nonconforming, and I could relate: Through childhood and adolescence, I did a lot of gender questioning myself. I’m now married to a transman, and together we are raising my two biological children from a previous marriage and three foster children we hope to adopt. 

The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on. This premise was shared by the center’s doctors and therapists. Given their expertise, I assumed that abundant evidence backed this consensus. 

All that led me to a job in 2018 as a case manager at The Washington University Transgender Center at St. Louis Children's Hospital, which had been established a year earlier. 

The systems and social media making teenagers sad, angry and afraid today were shaped in part by adults who grew up sad, angry and afraid themselves.

Nearly 1 in 3 high school girls reported in 2021 that they had seriously considered suicide

Teen girls reported the highest ever levels of sexual violence, sadness and hopelessnes

Rates of bullying were increasing in the state even in 2018, and researchers at Drake University found some forms of it significantly correlated with feeling sad or hopeless and attempting suicide.

One in 5 — nearly 53 million people — had a mental illness in 2020, ranging from anxiety to depression to bipolar disorder.

Yes, social media delivers concentrated, addictive stress to developing minds that were held captive by the pandemic. No, logging off TikTok and returning to school will not fix the problem — because each teen’s life ricochets off family, friends and neighbors with struggles of their own in a polity with troubles of its own.

“Increasing the sense among all students that they are cared for, supported, and belong at school” is one, as is growing access to mental health and substance use prevention services for kids and their families and health education classes to teach teens to manage their boundaries and emotions and to ask for help. These positive practices build resilience.

can we acknowledge the weight this puts on underpaid teachers and part-time counselors and nurses? People who, if they haven’t already burned out, are practicing active-shooter drills, catching students up on 18 months of lost learning and ensuring kids have enough food to concentrate in class.

A school’s four walls cannot hold back the trauma of society as well as, perhaps, the personal nightmare waiting for kids at home.

Which brings us to the adults

Solutions start with compassionate, radical honesty: American kids are unwell because American society is unwell.

Nearly 28 million adults had an alcohol use disorder.

As many as 3 in 100 people will have a psychotic episode in their lives

we, too, need a sense that we are cared for, supported and belong.

As kids, 61 percent of adults in the United States experienced abuse or neglect, grew up with poverty, hunger, violence or substance abuse, experienced gender-based discrimination and racism or lost a parent to divorce or death.

If not you, then someone you know is doing their best to stitch up those invisible wounds.

Here’s more hope: Brains wired by toxic stress, such as the sexual violence that 1 in 10 teen girls are facing today, have the ability to essentially heal when exposed to positive experiences.

Good nutrition, adequate sleep, mindfulness practices all help. Adults as well as children have neuroplasticity, and family resilience and connection are positive influences.