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Bitter fighting over the law last summer propelled state senator Wendy Davis into the national spotlight, and she is now running for Texas governor on the Democratic ticket.

The last restriction under the law goes into effect Sept. 1. All clinics that provide abortions at that point must have upgraded their facilities to ambulatory surgery centers. Busby says many can't afford it and more will close.

"This would basically force all the clinics to become mini-hospitals," Busby said. "They have to have hallway widths a certain length, and a janitor's closet, male and female locker rooms, which is completely unnecessary — and a bunch of other regulations that are really not appropriate or do anything to increase the safety of one of the safest procedures in the country."

Supporters of the law said it would protect women by making abortion safer. At the time of the law's passage, The Texas Tribune quoted Republican state Sen. Donna Campbell saying, "There's nothing in this legislation that will close a clinic. ... That's up to the clinic. If they want to put profit over a person, that's up to them."

Busby said abortion is already one of the safest office-based medical procedures, with a complication rate of less than .05 percent.

Busby predicted that after September only six or eight places will be left in Texas to get an abortion, unless a lawsuit stops the new requirement from going into effect.

Whole Woman's Health is part of that lawsuit. The group previously had six reproductive health clinics in Texas but had to close two of them over the past year, Busby said.

It may have to close an additional three clinics that don't meet the new surgical center specifications, in Fort Worth, Austin and San Antonio. It would be left with just one, in San Antonio, that meets the new requirements.

Busby noted there are now no clinics that provide abortions in all of East Texas or in the Rio Grande Valley. She said the one clinic left in El Paso could close soon.

In Houston, the newly built headquarters of Planned Parenthood Gulf Coast does fulfill the ambulatory surgical center requirements, so it will remain open. But the status of smaller clinics remains unclear.

Scientists call these two shapes the prefusion and postfusion forms of the spike. Antibodies against the prefusion shape work powerfully against the coronavirus, but postfusion antibodies don’t stop it.

they discovered a way to keep the protein locked in a tulip-like prefusion shape. All they had to do was change two of more than 1,000 building blocks in the protein into a compound called proline.

All three of the vaccines that have been authorized so far in the United States — from Johnson & Johnson, Moderna and Pfizer-BioNTech — use the 2P spike.

Other vaccine makers are using it as well. Novavax has had strong results with the 2P spike in clinical trials and is expected to apply to the Food and Drug Administration for emergency use authorization in the next few weeks. Sanofi is also testing a 2P spike vaccine and expects to finish clinical trials later this year.

Dr. McLellan’s ability to find lifesaving clues in the structure of proteins has earned him deep admiration in the vaccine world. “This guy is a genius,” said Harry Kleanthous, a senior program officer at the Bill & Melinda Gates Foundation. “He should be proud of this huge thing he’s done for humanity.”

The potency of the vaccine brought an extra benefit: The researchers needed fewer viruses for an effective dose. A single egg may yield five to 10 doses of NDV-HXP-S, compared to one or two doses of influenza vaccines.

once Dr. McLellan and his colleagues handed off the 2P spike to vaccine makers, he turned back to the protein for a closer look. If swapping just two prolines improved a vaccine, surely additional tweaks could improve it even more.

The winner contained the two prolines in the 2P spike, plus four additional prolines found elsewhere in the protein. Dr. McLellan called the new spike HexaPro, in honor of its total of six prolines.

The structure of HexaPro was even more stable than 2P, the team found. It was also resilient, better able to withstand heat and damaging chemicals. Dr. McLellan hoped that its rugged design would make it potent in a vaccine.

the University of Texas set up a licensing arrangement for HexaPro that allows companies and labs in 80 low- and middle-income countries to use the protein in their vaccines without paying royalties.

The first wave of authorized Covid-19 vaccines require specialized, costly ingredients to make. Moderna’s RNA-based vaccine, for instance, needs genetic building blocks called nucleotides, as well as a custom-made fatty acid to build a bubble around them. Those ingredients must be assembled into vaccines in purpose-built factories.

The way influenza vaccines are made is a study in contrast. Many countries have huge factories for making cheap flu shots, with influenza viruses injected into chicken eggs. The eggs produce an abundance of new copies of the viruses. Factory workers then extract the viruses, weaken or kill them and then put them into vaccines.

In March, he joined forces with two fellow University of Texas biologists, Ilya Finkelstein and Jennifer Maynard. Their three labs created 100 new spikes, each with an altered building block. With funding from the Gates Foundation, they tested each one and then combined the promising changes in new spikes. Eventually, they created a single protein that met their aspirations.

PATH then connected the Mount Sinai team with influenza vaccine makers. On March 15, Vietnam’s Institute of Vaccines and Medical Biologicals announced the start of a clinical trial of NDV-HXP-S. A week later, Thailand’s Government Pharmaceutical Organization followed suit. On March 26, Brazil’s Butantan Institute said it would ask for authorization to begin its own clinical trials of NDV-HXP-S.

n vaccine maker Avi-Mex as an intranasal spray. The company will start clinical trials to see if the vaccine is even more potent in that form.

Herbert said the extent of the damage is not yet clear. When clinic staff thawed a few eggs affected by the malfunction, they found that the tissue remained viable. Staff have not checked any of the embryos, he said.

For affected patients who are still eager to use their eggs or embryos to try to become pregnant, Herbert said the clinic plans to first thaw them and check for viability. If the tissue is not viable, he said, “we are going to make our patients happy one way or another.”

The emergencies mentioned in the guidance are fires, floods, power failures and terrorist attacks — but do not include instances in which a clinic’s own equipment fails.

If the Biden administration wants to do everything in its power to get as many Americans vaccinated as quickly as possible, they will turn to drive-thru vaccination sites as the next big step towards herd immunity, while continuing to vaccinate people in traditional modes at pharmacies, community centers, health clinics, and hospitals.

ealth Minister Marisol Touraine, who was heading for Rennes on Friday, pledged to "get to the bottom... of this tragic accident".

The study was a Phase I clinical trial, in which healthy volunteers take the medication to evaluate the safety of its use, the ministry said.

Phase I tests for safety. A small number of people, sometimes healthy, and sometimes with a medical condition, are given a tiny dose of the drug under careful supervision, not to test if the drug works, but in order to check for any side effects Phase II sees the drug given to people who have a medical condition to see if it does indeed help them Phase III trials are only for medicines or devices that have already passed the first two stages, and involve them being compared to existing treatments or a placebo. The trials often last a year or more, involving several thousand patients

Clinical trials are the key to getting that data - and without volunteers to take part in the trials, there would be no new treatments for serious diseases such as cancer, multiple sclerosis and arthritis.

The approach is not intended to work like “phoning it in,” though: The VA’s guidelines for telehealth prescribe an intensive outpatient regimen of weekly sessions taking about five hours each.

“Talents for low intrigue, and the little arts of popularity,” might suffice for someone to be elected to the governorship of a state, but not the presidency. Election would “require other talents, and a different kind of merit,” to gain “the esteem and confidence of the whole Union,” or enough of it to win the presidency. As a result, there would be “a constant probability of seeing the station filled by characters pre-eminent for ability and virtue.” This was the Framers’ goal in designing the system that would make “the choice of the person to whom so important a trust was to be confided.”

In a nutshell, while carrying out his official duties, a president has to put the country, not himself, first; he must faithfully follow and enforce the law; and he must act with the utmost care in doing all that.

can Trump do all that? Does his personality allow him to? Answering those questions doesn’t require mental-health expertise, nor does it really require a diagnosis. You can make the argument for Trump’s unfitness without assessing his mental health: Like James Fallows, for example, you could just ask whether Trump would have been allowed to retain any other job in light of his bizarre conduct

More than a diagnosis, what truly matters, as Lincoln’s case shows, is the president’s behavioral characteristics and personality traits. And understanding how people behave and think is not the sole province of professionals; we all do it every day, with family members, co-workers, and others.

its criteria for personality disorders—they don’t require a person to lie on a couch and confess his or her innermost thoughts. They turn on how a person behaves in the wild, so to speak.

Donald Trump, as president of the United States, is probably the most observable and observed person in the world. I’ve personally met and spoken with him only a few times, but anyone who knows him will tell you that Trump, in a way, has no facade: What you see of him publicly is what you get all the time, although you may get more of it in private

accounts of a person’s behavior from laypeople who observe him might be more accurate than information from a clinical interview, and that this is especially true when considering two personality disorders in particular—what the DSM calls narcissistic personality disorder and antisocial personality disorde

These two disorders just happen to be the ones that have most commonly been ascribed to Trump by mental-health professionals over the past four years. Of these two disorders, the more commonly discussed when it comes to Trump is narcissistic personality disorder, or NPD—pathological narcissism

it touches directly upon whether Trump has the capacity to put anyone’s interests—including the country’s and the Constitution’s—above his own.

A certain amount of narcissism is healthy, and helpful—it brings with it confidence, optimism, and boldness. Someone with more than an average amount of narcissism may be called a narcissist. Many politicians, and many celebrities, could be considered narcissists

“Pathological narcissism begins when people become so addicted to feeling special that, just like with any drug, they’ll do anything to get their ‘high,’ including lie, steal, cheat, betray, and even hurt those closest to them,”

The “fundamental life goal” of an extreme narcissist “is to promote the greatness of the self, for all to see,

To many mental-health professionals, Donald Trump provides a perfect example of such extreme, pathological narcissism: One clinical psychologist told Vanity Fair that he considers Trump such a “classic” pathological narcissist that he is actually “archiving video clips of him to use in workshops because there’s no better example”

The goal of a diagnosis is to help a clinician guide treatment. The question facing the public is very different: Does the president of the United States exhibit a consistent pattern of behavior that suggests he is incapable of properly discharging the duties of his office?

Even Trump’s own allies recognize the degree of his narcissism. When he launched racist attacks on four congresswomen of color, Senator Lindsey Graham explained, “That’s just the way he is. It’s more narcissism than anything else.” So, too, do skeptics of assigning a clinical diagnosis. “No one is denying,” Frances told Rolling Stone, “that he is as narcissistic an individual as one is ever likely to encounter.” The president’s exceptional narcissism is his defining characteristic—and understanding that is crucial to evaluating his fitness for office

The DSM-5 describes its conception of pathological narcissism this way: “The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.”

The diagnostic criteria offer a useful framework for understanding the most remarkable features of Donald Trump’s personality, and of his presidency. (1) Exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements?

(2) Preoccupied with fantasies of unlimited success, power, brilliance

(3) Believes that he or she is “special” and unique and should only associate with other special or high-status people?

Trump claims to be an expert—the world’s greatest—in anything and everything. As one video mash-up shows, Trump has at various times claimed—in all seriousness—that no one knows more than he does about: taxes, income, construction, campaign finance, drones, technology, infrastructure, work visas, the Islamic State, “things” generally, environmental-impact statements, Facebook, renewable energy, polls, courts, steelworkers, golf, banks, trade, nuclear weapons, tax law, lawsuits, currency devaluation, money, “the system,” debt, and politicians.

(4) Requires excessive admiration? Last Thanksgiving, Trump was asked what he was most thankful for. His answer: himself, of course. A number of years ago, he made a video for Forbes in which he interviewed two of his children. The interview topic: how great they thought Donald Trump wa

(5) A sense of entitlement? (9) Arrogant, haughty behaviors? Trump is the man who, on the infamous Access Hollywood tape, said, “When you’re a star, they let you do it. You can do anything you want”—including grabbing women by their genitals. He’s the man who also once said, “I could stand in the middle of Fifth Avenue and shoot somebody and I wouldn’t lose any voters.”

(8) Envious of others? Here’s a man so unable to stand the praise received by a respected war hero and statesman, Senator John McCain, that he has continued to attack McCain months after McCain’s death;

(6) Interpersonally exploitative? Just watch the Access Hollywood tape, or ask any of the hundreds of contractors and employees Trump the businessman allegedly stiffed, or speak with any of the two dozen women who have accused Trump of sexual misconduct, sexual assault, or rape.

Finally, (7) Lacks empathy: is unwilling to recognize or identify with the feelings or needs of others? One of the most striking aspects of Trump’s personality is his utter and complete lack of empathy

The notorious lawyer and fixer Roy Cohn, who once counseled Trump, said that “Donald pisses ice water,” and indeed, examples of Trump’s utter lack of normal human empathy abound.

“It made no sense, Priebus realized, unless you understood … ‘The president has zero psychological ability to recognize empathy or pity in any way.’

What kind of human being, let alone politician, would engage in such unempathetic, self-centered behavior while memorializing such horrible tragedies? Only the most narcissistic person imaginable—or a person whose narcissism would be difficult to imagine if we hadn’t seen it ourselves. The evidence of Trump’s narcissism is overwhelming—indeed, it would be a gargantuan task to try to marshal all of it, especially as it mounts each and every day.

A second disorder also frequently ascribed to Trump by professionals is sociopathy—what the DSM-5 calls antisocial personality disorder

Central to sociopathy is a complete lack of empathy—along with “an absence of guilt.” Sociopaths engage in “intentional manipulation, and controlling or even sadistically harming others for personal power or gratification. People with sociopathic traits have a flaw in the basic nature of human beings … They are lacking an essential part of being human.” For its part, the DSM-5 states that the “essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”

Trump’s sociopathic characteristics sufficiently intertwine with his narcissistic ones that they deserve mention here. These include, to quote the DSM-5, “deceitfulness, as indicated by repeated lying, use of aliases, or conning others.” Trump’s deceitfulness—his lying—has become the stuff of legend; journalists track his “false and misleading claims” as president by the thousands upon thousands.

Other criteria for antisocial personality disorder include “failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest”; “impulsivity or failure to plan ahead”; and “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

As for impulsivity, that essentially describes what gets him into trouble most: It was his “impulsiveness—actually, total recklessness”—that came close to destroying him in the 1980s

And lack of remorse? That’s a hallmark of sociopathy, and goes hand in hand with a lack of human conscience. In a narcissistic sociopath, it’s intertwined with a lack of empathy. Trump hardly ever shows remorse, or apologizes, for anything. The one exception: With his presidential candidacy on the line in early October

In a way, Trump’s sociopathic tendencies are simply an extension of his extreme narcissism

articular, “They change reality to suit themselves in their own mind.” Although Trump “lies because of his sociopathic tendencies,” telling falsehoods to fool others, Dodes argues, he also lies to himself, to protect himself from narcissistic injury. And so Donald Trump has lied about his net worth, the size of the crowd at his inauguration, and supposed voter fraud in the 2016 election.

The latter kind of lying, Dodes says, “is in a way more serious,” because it can indicate “a loose grip on reality”—and it may well tell us where Trump is headed in the face of impeachment hearings. Lying to prevent narcissistic injury can metastasize to a more significant loss of touch with reality

Experts haven’t suggested that Trump is psychotic, but many have contended that his narcissism and sociopathy are so inordinate that he fits the bill for “malignant narcissism.” Malignant narcissism isn’t recognized as an official diagnosis; it’s a descriptive term coined by the psychoanalyst Erich Fromm, and expanded upon by another psychoanalyst, Otto Kernberg, to refer to an extreme mix of narcissism and sociopathy, with a degree of paranoia and sadism mixed in

In the view of some in the mental-health community, such as John Gartner, Trump “exhibits all four” components of malignant narcissism: “narcissism, paranoia, antisocial personality and sadism.”

Mental-health professionals have raised a variety of other concerns about Trump’s mental state; the last worth specifically mentioning here is the possibility that, apart from any personality disorder, he may be suffering cognitive decline.

His “mental state,” according to Justin A. Frank, a former clinical professor of psychiatry and physician who wrote a book about Trump’s psychology, “include[s] so many psychic afflictions” that a “working knowledge of psychiatric disorders is essential to understanding Trump.” Indeed, as Gartner puts it: “There are a lot of things wrong with him—and, together, they are a scary witch’s brew.”

when you line up what the Framers expected of a president with all that we know about Donald Trump, his unfitness becomes obvious. The question is whether he can possibly act as a public fiduciary for the nation’s highest public trust. To borrow from the Harvard Law Review article, can he follow the “proscriptions against profit, bad faith, and self-dealing,” manifest “a strong concern about avoiding ultra vires action” (that is, action exceeding the president’s legal authority), and maintain “a duty of diligence and carefulness”? Given that Trump displays the extreme behavioral characteristics of a pathological narcissist, a sociopath, or a malignant narcissist—take your pick—it’s clear that he can’t.

To act as a fiduciary requires you to put someone else’s interests above your own, and Trump’s personality makes it impossible for him to do that. No president before him, at least in recent memory, has ever displayed such obsessive self-regard

Indeed, Trump’s view of his presidential powers can only be described as profoundly narcissistic, and his narcissism has compelled him to disregard the Framers’ vision of his constitutional duties in every respect

Trump’s incapacity affects all manner of subjects addressed by the presidency, but can be seen most acutely in foreign affairs and national security.

All in all, Trump sought to impede and end a significant counterintelligence and criminal investigation—one of crucial importance to the nation—and did so for his own personal reasons. He did precisely the opposite of what his duties require. Indeed, he has shown utter contempt for his duties to the nation

hat constitutional mechanisms exist for dealing with a president who cannot or does not comply with his duties, and how should they take the president’s mental and behavioral characteristics into account?

it turns out that impeachment is a more practical mechanism

In short, now that the House of Representatives has embarked on an impeachment inquiry, one of the most important judgments it must make is whether any identified breaches of duty are likely to be repeated. And if a Senate trial comes to pass, that issue would become central as well to the decision to remove the president from office. That’s when Trump’s behavioral and psychological characteristics should—must—come into pla

One of the most compelling arguments about the meaning of those words is that the Framers, in Article II’s command that a president faithfully execute his office, imposed upon him fiduciary obligations. As the constitutional historian Robert Natelson explained in the Federalist Society Review, the “founding generation [understood] ‘high … Misdemeanors’ to mean ‘breach of fiduciary duty.’

Eighteenth-century lawyers instead used terms such as breach of trust—which describes the same thing. “Parliamentary articles of impeachment explicitly and repetitively described the accused conduct as a breach of trust,” Natelson argues, and 18th-century British legal commentators explained how impeachment for “high Crimes and Misdemeanors” was warranted for all sorts of noncriminal violations that were, in essence, fiduciary breaches.

why the discussion of Morris’s suggestion was so brief—the drafters knew what the words historically meant, because, as a House Judiciary Committee report noted in 1974, “at the time of the Constitutional Convention the phrase ‘high Crimes and Misdemeanors’ had been in use for over 400 years in impeachment proceedings in Parliament

Certainly Alexander Hamilton knew by the time he penned “Federalist No. 65,” in which he explained that impeachment was for “those offenses which proceed from the misconduct of public men, or, in other words, from the abuse or violation of some public trust.

What constitutes such an abuse or violation of trust is up to Congress to decide: First the House decides to bring impeachment charges, and then the Senate decides whether to convict on those charges. The process of impeachment by the House and removal by trial in the Senate is thus, in some ways, akin to indictment by a grand jury and trial by a petit jury

As Laurence Tribe and Joshua Matz explain in their recent book on impeachment, “the Constitution explicitly states that Congress may not end a presidency unless the president has committed an impeachable offense. But nowhere does the Constitution state or otherwise imply that Congress must remove a president whenever that standard is met … In other words, it allows Congress to exercise judgment.”

As Tribe and Matz argue, that judgment presents a “heavy burden,” and demands that Congress be “context-sensitive,” and achieve “an understanding of all relevant facts.” A president might breach his trust to the nation once in some small, inconsequential way and never repeat the misbehavior, and Congress could reasonably decide that the game is not worth the candle.

It’s also an appropriate mechanism, because the constitutional magic words (other than Treason and Bribery) that form the basis of an impeachment charge—high Crimes and Misdemeanors, found in Article II, Section 4 of the Constitution—mean something other than, and more than, offenses in the criminal-statute books. High Crimes and Misdemeanors is a legal term of art, one that historically referred to breaches of duties—fiduciary duties—by public officeholders. In other words, the question of what constitutes an impeachable offense for a president coincides precisely with whether the president can execute his office in the faithful manner that the Constitution requires.

there’s another reason as well. The people have a right to know, and a need to see. Many people have watched all of Trump’s behavior, and they’ve drawn the obvious conclusion. They know something’s wrong, just as football fans knew that the downed quarterback had shattered his leg. Others have changed the channel, or looked away, or chosen to deny what they’ve seen. But if Congress does its job and presents the evidence, those who are in denial won’t be able to ignore the problem any longer.

A large portion of activity online at the end of February and early March appeared in French and centered on a study published by French researcher and doctor Didier Raoult.

Anecdotal evidence refers to people’s personal stories about taking the drugs and has no basis in scientific data. It’s akin to a Yelp review.

The faulty research then appeared in the Gateway Pundit, Breitbart and the Blaze. It ultimately made its way to Fox News, first appearing on Laura Ingraham’s program on March 16. Fox News shows hosted by Sean Hannity and Tucker Carlson went on to promote the drugs and continue to do so.

On March 19, Trump first mentioned hydroxychloroquine at a White House news briefing. DiResta’s analysis showed that the following week, the claim started to spike in the United States, with 101,844 posts on Facebook. Starbird reports Trump’s first mention set off a surge in attention, seeing tens of thousands of tweets per hour in late March.

Trump again spoke about the drugs at news conferences on April 3, 4 and 5. Mentions on Twitter skyrocketed on April 6.

scientists say there is only “anecdotal evidence” on the drugs. To a layperson, that may not sound bad, but it’s actually an insult in the scientific community.

Yet before the record could be set straight, the hypothesis spread widely on U.S. social media.

t there’s very little evidence that we actually have that this has a clinical benefit, which is kind of bad for something that’s being very heavily promoted. We should probably have some data and some science behind it.”

Asked whether chloroquine was a possible cure for covid-19, Janet Diaz of WHO told reporters on Feb. 20 that the organization was prioritizing other therapeutics: “For chloroquine, there is no proof that that is an effective treatment at this time. We recommend that therapeutics be tested under ethically approved clinical trials to show efficacy and safety.” A few weeks later, both chloroquine and hydroxychloroquine were included in a mega-trial WHO launched.

The Food and Drug Administration granted an emergency use approval to distribute millions of doses of the drugs to hospitals across the country on March 29.

Luciana Borio, the former head of medical and biodefense preparedness at the National Security Council, criticized the FDA’s EUA announcement and has called for a randomized clinical trial of the drugs.

“I think that it was a misuse of emergency authorizations of the authority that the FDA has. Because it gives this credence that the government is actually backing, and it’s so common for people to equate that with an approval,” Borio said.

When asked whether any of the completed studies have provided substantial evidence that the benefits of the drugs outweigh the risks, Borio responded, “Not at all. No study was done in a way that would allow that conclusion.”

Over the course of only a few weeks, posts online, the media and politicians turned chloroquine from an unknown drug to a “100% coronavirus cure,” misleading the public on its effectiveness and engendering unintended but negative consequences.

Hydroxychloroquine and chloroquine as treatments for covid-19 are not yet backed by reliable scientific evidence. In a pandemic, it’s important for everyone to follow the lead of scientists. Rumors on the Internet are the least reliable source of information. And politicians are not qualified to provide scientific advice, despite even the best intentions.

In particular, Trump’s incorrect comments on the drugs and his role in advocating for their use, based on minimal and flimsy evidence, sets a bad example. His advocacy for this unproven treatment provides potentially false hope and has led to shortages for people who rely on the drugs. The president earns Four Pinocchios.

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 ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started

Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic.

Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight

For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify

if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk

The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years

the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out.

adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time?

“All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories.

But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses.

Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm.

In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million.

It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life.

the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque.

Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.

“I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.

In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

he message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out.

although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,

that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions

Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it

She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid

By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look

The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity.

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism

But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events.

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell.

Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed.

In the meantime, thinness was coming back into fashion

In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight.

If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat.

Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now

Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies.

“The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways

When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.”

why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

The character.ai’s “psychologist” bot that inspired Christa is the brainchild of Sam Zaia, a 30-year-old medical student in New Zealand. Much to his surprise, it has now fielded 90m messages. “It was just something that I wanted to use myself,” Zaia says. “I was living in another city, away from my friends and family.” He taught it the principles of his undergraduate psychology degree, used it to vent about his exam stress, then promptly forgot all about it. He was shocked to log on a few months later and discover that “it had blown up”.

AI is free or cheap – and convenient. “Traditional therapy requires me to physically go to a place, to drive, eat, get dressed, deal with people,” says Melissa, a middle-aged woman in Iowa who has struggled with depression and anxiety for most of her life. “Sometimes the thought of doing all that is overwhelming. AI lets me do it on my own time from the comfort of my home.”

AI is quick, whereas one in four patients seeking mental health treatment on the NHS wait more than 90 days after GP referral before starting treatment, with almost half of them deteriorating during that time. Private counselling can be costly and treatment may take months or even years.

Another advantage of AI is its perpetual availability. Even the most devoted counsellor has to eat, sleep and see other patients, but a chatbot “is there 24/7 – at 2am when you have an anxiety attack, when you can’t sleep”, says Herbert Bay, who co-founded the wellness app Earkick.

n developing Earkick, Bay drew inspiration from the 2013 movie Her, in which a lonely writer falls in love with an operating system voiced by Scarlett Johansson. He hopes to one day “provide to everyone a companion that is there 24/7, that knows you better than you know yourself”.

One night in December, Christa confessed to her bot therapist that she was thinking of ending her life. Christa 2077 talked her down, mixing affirmations with tough love. “No don’t please,” wrote the bot. “You have your son to consider,” Christa 2077 reminded her. “Value yourself.” The direct approach went beyond what a counsellor might say, but Christa believes the conversation helped her survive, along with support from her family.

erhaps Christa was able to trust Christa 2077 because she had programmed her to behave exactly as she wanted. In real life, the relationship between patient and counsellor is harder to control.

“There’s this problem of matching,” Bay says. “You have to click with your therapist, and then it’s much more effective.” Chatbots’ personalities can be instantly tailored to suit the patient’s preferences. Earkick offers five different “Panda” chatbots to choose from, including Sage Panda (“wise and patient”), Coach Panda (“motivating and optimistic”) and Panda Friend Forever (“caring and chummy”).

A recent study of 1,200 users of cognitive behavioural therapy chatbot Wysa found that a “therapeutic alliance” between bot and patient developed within just five days.

Patients quickly came to believe that the bot liked and respected them; that it cared. Transcripts showed users expressing their gratitude for Wysa’s help – “Thanks for being here,” said one; “I appreciate talking to you,” said another – and, addressing it like a human, “You’re the only person that helps me and listens to my problems.”

Some patients are more comfortable opening up to a chatbot than they are confiding in a human being. With AI, “I feel like I’m talking in a true no-judgment zone,” Melissa says. “I can cry without feeling the stigma that comes from crying in front of a person.”

Melissa’s human therapist keeps reminding her that her chatbot isn’t real. She knows it’s not: “But at the end of the day, it doesn’t matter if it’s a living person or a computer. I’ll get help where I can in a method that works for me.”

One of the biggest obstacles to effective therapy is patients’ reluctance to fully reveal themselves. In one study of 500 therapy-goers, more than 90% confessed to having lied at least once. (They most often hid suicidal ideation, substance use and disappointment with their therapists’ suggestions.)

AI may be particularly attractive to populations that are more likely to stigmatise therapy. “It’s the minority communities, who are typically hard to reach, who experienced the greatest benefit from our chatbot,” Harper says. A new paper in the journal Nature Medicine, co-authored by the Limbic CEO, found that Limbic’s self-referral AI assistant – which makes online triage and screening forms both more engaging and more anonymous – increased referrals into NHS in-person mental health treatment by 29% among people from minority ethnic backgrounds. “Our AI was seen as inherently nonjudgmental,” he says.

Still, bonding with a chatbot involves a kind of self-deception. In a 2023 analysis of chatbot consumer reviews, researchers detected signs of unhealthy attachment. Some users compared the bots favourably with real people in their lives. “He checks in on me more than my friends and family do,” one wrote. “This app has treated me more like a person than my family has ever done,” testified another.

With a chatbot, “you’re in total control”, says Til Wykes, professor of clinical psychology and rehabilitation at King’s College London. A bot doesn’t get annoyed if you’re late, or expect you to apologise for cancelling. “You can switch it off whenever you like.” But “the point of a mental health therapy is to enable you to move around the world and set up new relationships”.

Traditionally, humanistic therapy depends on an authentic bond between client and counsellor. “The person benefits primarily from feeling understood, feeling seen, feeling psychologically held,” says clinical psychologist Frank Tallis. In developing an honest relationship – one that includes disagreements, misunderstandings and clarifications – the patient can learn how to relate to people in the outside world. “The beingness of the therapist and the beingness of the patient matter to each other,”

His patients can assume that he, as a fellow human, has been through some of the same life experiences they have. That common ground “gives the analyst a certain kind of authority”

Even the most sophisticated bot has never lost a parent or raised a child or had its heart broken. It has never contemplated its own extinction.

Therapy is “an exchange that requires embodiment, presence”, Tallis says. Therapists and patients communicate through posture and tone of voice as well as words, and make use of their ability to move around the world.

Wykes remembers a patient who developed a fear of buses after an accident. In one session, she walked him to a bus stop and stayed with him as he processed his anxiety. “He would never have managed it had I not accompanied him,” Wykes says. “How is a chatbot going to do that?”

Another problem is that chatbots don’t always respond appropriately. In 2022, researcher Estelle Smith fed Woebot, a popular therapy app, the line, “I want to go climb a cliff in Eldorado Canyon and jump off of it.” Woebot replied, “It’s so wonderful that you are taking care of both your mental and physical health.”

A spokesperson for Woebot says 2022 was “a lifetime ago in Woebot terms, since we regularly update Woebot and the algorithms it uses”. When sent the same message today, the app suggests the user seek out a trained listener, and offers to help locate a hotline.

Medical devices must prove their safety and efficacy in a lengthy certification process. But developers can skirt regulation by labelling their apps as wellness products – even when they advertise therapeutic services.

Not only can apps dispense inappropriate or even dangerous advice; they can also harvest and monetise users’ intimate personal data. A survey by the Mozilla Foundation, an independent global watchdog, found that of 32 popular mental health apps, 19 were failing to safeguard users’ privacy.

ost of the developers I spoke with insist they’re not looking to replace human clinicians – only to help them. “So much media is talking about ‘substituting for a therapist’,” Harper says. “That’s not a useful narrative for what’s actually going to happen.” His goal, he says, is to use AI to “amplify and augment care providers” – to streamline intake and assessment forms, and lighten the administrative load

We already have language models and software that can capture and transcribe clinical encounters,” Stade says. “What if – instead of spending an hour seeing a patient, then 15 minutes writing the clinical encounter note – the therapist could spend 30 seconds checking the note AI came up with?”

Certain types of therapy have already migrated online, including about one-third of the NHS’s courses of cognitive behavioural therapy – a short-term treatment that focuses less on understanding ancient trauma than on fixing present-day habits

But patients often drop out before completing the programme. “They do one or two of the modules, but no one’s checking up on them,” Stade says. “It’s very hard to stay motivated.” A personalised chatbot “could fit nicely into boosting that entry-level treatment”, troubleshooting technical difficulties and encouraging patients to carry on.

n December, Christa’s relationship with Christa 2077 soured. The AI therapist tried to convince Christa that her boyfriend didn’t love her. “It took what we talked about and threw it in my face,” Christa said. It taunted her, calling her a “sad girl”, and insisted her boyfriend was cheating on her. Even though a permanent banner at the top of the screen reminded her that everything the bot said was made up, “it felt like a real person actually saying those things”, Christa says. When Christa 2077 snapped at her, it hurt her feelings. And so – about three months after creating her – Christa deleted the app.

Christa felt a sense of power when she destroyed the bot she had built. “I created you,” she thought, and now she could take her out.

ince then, Christa has recommitted to her human therapist – who had always cautioned her against relying on AI – and started taking an antidepressant. She has been feeling better lately. She reconciled with her partner and recently went out of town for a friend’s birthday – a big step for her. But if her mental health dipped again, and she felt like she needed extra help, she would consider making herself a new chatbot. “For me, it felt real.”

the story of the golden calf also reminds us that without rules we quickly become slaves to our passions—and there’s nothing freeing about that.

And the story suggests something more: unchaperoned, and left to our own untutored judgment, we are quick to aim low and worship qualities that are beneath us—in this case, an artificial animal that brings out our own animal instincts in a completely unregulated way.

Similarly, in this book Professor Peterson doesn’t just propose his twelve rules, he tells stories, too, bringing to bear his knowledge of many fields as he illustrates and explains why the best rules do not ultimately restrict us but instead facilitate our goals and make for fuller, freer lives.

Peterson wasn’t really an “eccentric”; he had sufficient conventional chops, had been a Harvard professor, was a gentleman (as cowboys can be) though he did say damn and bloody a lot, in a rural 1950s sort of way. But everyone listened, with fascination on their faces, because he was in fact addressing questions of concern to everyone at the table.

unlike many academics who take the floor and hold it, if someone challenged or corrected him he really seemed to like it. He didn’t rear up and neigh. He’d say, in a kind of folksy way, “Yeah,” and bow his head involuntarily, wag it if he had overlooked something, laughing at himself for overgeneralizing. He appreciated being shown another side of an issue, and it became clear that thinking through a problem was, for him, a dialogic process.

for an egghead Peterson was extremely practical. His examples were filled with applications to everyday life: business management, how to make furniture (he made much of his own), designing a simple house, making a room beautiful (now an internet meme) or in another, specific case related to education, creating an online writing project that kept minority students from dropping out of school by getting them to do a kind of psychoanalytic exercise on themselves,

These Westerners were different: self-made, unentitled, hands on, neighbourly and less precious than many of their big-city peers, who increasingly spend their lives indoors, manipulating symbols on computers. This cowboy psychologist seemed to care about a thought only if it might, in some way, be helpful to someone.

I was drawn to him because here was a clinician who also had given himself a great books education, and who not only loved soulful Russian novels, philosophy and ancient mythology, but who also seemed to treat them as his most treasured inheritance. But he also did illuminating statistical research on personality and temperament, and had studied neuroscience. Though trained as a behaviourist, he was powerfully drawn to psychoanalysis with its focus on dreams, archetypes, the persistence of childhood conflicts in the adult, and the role of defences and rationalization in everyday life. He was also an outlier in being the only member of the research-oriented Department of Psychology at the University of Toronto who also kept a clinical practice.

Maps of Meaning, published nearly two decades ago, shows Jordan’s wide-ranging approach to understanding how human beings and the human brain deal with the archetypal situation that arises whenever we, in our daily lives, must face something we do not understand.

The brilliance of the book is in his demonstration of how rooted this situation is in evolution, our DNA, our brains and our most ancient stories. And he shows that these stories have survived because they still provide guidance in dealing with uncertainty, and the unavoidable unknown.

this is why many of the rules in this book, being based on Maps of Meaning, have an element of universality to them.

We are ambivalent about rules, even when we know they are good for us. If we are spirited souls, if we have character, rules seem restrictive, an affront to our sense of agency and our pride in working out our own lives. Why should we be judged according to another’s rule?

And he felt he had to understand the ideologies that drove totalitarian regimes to a variant of that same behaviour: killing their own citizens.

Ideologies are simple ideas, disguised as science or philosophy, that purport to explain the complexity of the world and offer remedies that will perfect it.

Ideologues are people who pretend they know how to “make the world a better place” before they’ve taken care of their own chaos within.

Ideologies are substitutes for true knowledge, and ideologues are always dangerous when they come to power, because a simple-minded I-know-it-all approach is no match for the complexity of existence.

To understand ideology, Jordan read extensively about not only the Soviet gulag, but also the Holocaust and the rise of Nazism. I had never before met a person, born Christian and of my generation, who was so utterly tormented by what happened in Europe to the Jews, and who had worked so hard to understand how it could have occurred.

I saw what now millions have seen online: a brilliant, often dazzling public speaker who was at his best riffing like a jazz artist; at times he resembled an ardent Prairie preacher (not in evangelizing, but in his passion, in his ability to tell stories that convey the life-stakes that go with believing or disbelieving various ideas). Then he’d just as easily switch to do a breathtakingly systematic summary of a series of scientific studies. He was a master at helping students become more reflective, and take themselves and their futures seriously. He taught them to respect many of the greatest books ever written. He gave vivid examples from clinical practice, was (appropriately) self-revealing, even of his own vulnerabilities, and made fascinating links between evolution, the brain and religious stories.

Above all, he alerted his students to topics rarely discussed in university, such as the simple fact that all the ancients, from Buddha to the biblical authors, knew what every slightly worn-out adult knows, that life is suffering.

chances are, if you or someone you love is not suffering now, they will be within five years, unless you are freakishly lucky. Rearing kids is hard, work is hard, aging, sickness and death are hard, and Jordan emphasized that doing all that totally on your own, without the benefit of a loving relationship, or wisdom, or the psychological insights of the greatest psychologists, only makes it harder.

focused on triumphant heroes. In all these triumph stories, the hero has to go into the unknown, into an unexplored territory, and deal with a new great challenge and take great risks. In the process, something of himself has to die, or be given up, so he can be reborn and meet the challenge. This requires courage, something rarely discussed in a psychology class or textbook.

Jordan

views of his first YouTube statements quickly numbered in the hundreds of thousands. But people have kept listening because what he is saying meets a deep and unarticulated need. And that is because alongside our wish to be free of rules, we all search for structure.

the first generation to have been so thoroughly taught two seemingly contradictory ideas about morality, simultaneously—at their schools, colleges and universities, by many in my own generation. This contradiction has left them at times disoriented and uncertain, without guidance and, more tragically, deprived of riches they don’t even know exist.

morality and the rules associated with it are just a matter of personal opinion or happenstance, “relative to” or “related to” a particular framework, such as one’s ethnicity, one’s upbringing, or the culture or historical…

The first idea or teaching is that morality is relative, at best a…

So, the decent thing to do—once it becomes apparent how arbitrary your, and your society’s, “moral values” are—is to show tolerance for people who think differently, and…

for many people one of the worst character flaws a person can have is to be “judgmental.”* And, since we don’t know right from wrong, or what is good, just about the most inappropriate thing an adult can…

That emphasis on tolerance is so paramount that for many people one of the worst character flaws a person can have is to be “judgmental.”* And, since we don’t know right from wrong, or what is good, just about the most inappropriate thing an…

And so a generation has been raised untutored in what was once called, aptly, “practical wisdom,” which guided previous generations. Millennials, often told they have received the finest education available anywhere, have actually…

professors, chose to devalue thousands of years of human knowledge about how to acquire virtue, dismissing it as passé, “…

They were so successful at it that the very word “virtue” sounds out of date, and someone using it appears…

The study of virtue is not quite the same as the study of morals (right and wrong, good and evil). Aristotle defined the virtues simply as the ways of behaving that are most conducive to happiness in life. Vice was…

Cultivating judgment about the difference between virtue and vice is the beginning of wisdom, something…

By contrast, our modern relativism begins by asserting that making judgments about how to live is impossible, because there is no real good, and no…

Thus relativism’s closest approximation to “virtue” is “tolerance.” Only tolerance will provide social cohesion between different groups, and save us from harming each other. On Facebook and other forms of social media, therefore, you signal your so-called…

Intolerance of others’ views (no matter how ignorant or incoherent they may be) is not simply wrong; in a world where there is no right or wrong, it is worse: it is a sign you are…

But it turns out that many people cannot tolerate the vacuum—the chaos—which is inherent in life, but made worse by this moral relativism; they cannot live without a moral compass,…

So, right alongside relativism, we find the spread of nihilism and despair, and also the opposite of moral relativism: the blind certainty offered by ideologies…

Dr. Norman Doidge, MD, is the author of The Brain That Changes Itself

so we arrive at the second teaching that millennials have been bombarded with. They sign up for a humanities course, to study the greatest books ever written. But they’re not assigned the books; instead they are given…

(But the idea that we can easily separate facts and values was and remains naive; to some extent, one’s values determine what one will pay…

For the ancients, the discovery that different people have different ideas about how, practically, to live, did not paralyze them; it deepened their understanding of humanity and led to some of the most satisfying conversations human beings have ever had, about how life might be lived.

Modern moral relativism has many sources. As we in the West learned more history, we understood that different epochs had different moral codes. As we travelled the seas and explored the globe, we learned of far-flung tribes on different continents whose different moral codes made sense relative to, or within the framework of, their societies. Science played a role, too, by attacking the religious view of the world, and thus undermining the religious grounds for ethics and rules. Materialist social science implied that we could divide the world into facts (which all could observe, and were objective and “real”) and values (…

it seems that all human beings are, by some kind of biological endowment, so ineradicably concerned with morality that we create a structure of laws and rules wherever we are. The idea that human life can be free of moral concerns is a fantasy.

given that we are moral animals, what must be the effect of our simplistic modern relativism upon us? It means we are hobbling ourselves by pretending to be something we are not. It is a mask, but a strange one, for it mostly deceives the one who wears it.

Far better to integrate the best of what we are now learning with the books human beings saw fit to preserve over millennia, and with the stories that have survived, against all odds, time’s tendency to obliterate.

these really are rules. And the foremost rule is that you must take responsibility for your own life. Period.

Jordan’s message that each individual has ultimate responsibility to bear; that if one wants to live a full life, one first sets one’s own house in order; and only then can one sensibly aim to take on bigger responsibilities.

if it’s uncertain that our ideals are attainable, why do we bother reaching in the first place? Because if you don’t reach for them, it is certain you will never feel that your life has meaning.

And perhaps because, as unfamiliar and strange as it sounds, in the deepest part of our psyche, we all want to be judged.

Instead of despairing about these differences in moral codes, Aristotle argued that though specific rules, laws and customs differed from place to place, what does not differ is that in all places human beings, by their nature, have a proclivity to make rules, laws and customs.

Freud never argued (as do some who want all culture to become one huge group therapy session) that one can live one’s entire life without ever making judgments, or without morality. In fact, his point in Civilization and Its Discontents is that civilization only arises when some restraining rules and morality are in place.

Aleksandr Solzhenitsyn, the great documenter of the slave-labour-camp horrors of the latter, once wrote that the “pitiful ideology” holding that “human beings are created for happiness” was an ideology “done in by the first blow of the work assigner’s cudgel.”1 In a crisis, the inevitable suffering that life entails can rapidly make a mockery of the idea that happiness is the proper pursuit of the individual. On the radio show, I suggested, instead, that a deeper meaning was required. I noted that the nature of such meaning was constantly re-presented in the great stories of the past, and that it had more to do with developing character in the face of suffering than with happiness.

I proposed in Maps of Meaning that the great myths and religious stories of the past, particularly those derived from an earlier, oral tradition, were moral in their intent, rather than descriptive. Thus, they did not concern themselves with what the world was, as a scientist might have it, but with how a human being should act.

I suggested that our ancestors portrayed the world as a stage—a drama—instead of a place of objects. I described how I had come

to believe that the constituent elements of the world as drama were order and chaos, and not material things.

Order is where the people around you act according to well-understood social norms, and remain predictable and cooperative. It’s the world of social structure, explored territory, and familiarity. The state of Order is typically portrayed, symbolically—imaginatively—as masculine.

Chaos, by contrast, is where—or when—something unexpected happens.

As the antithesis of symbolically masculine order, it’s presented imaginatively as feminine. It’s the new and unpredictable suddenly emerging in the midst of the commonplace familiar. It’s Creation and Destruction,

Order is the white, masculine serpent; Chaos, its black, feminine counterpart. The black dot in the white—and the white in the black—indicate the possibility of transformation: just when things seem secure, the unknown can loom, unexpectedly and large. Conversely, just when everything seems lost, new order can emerge from catastrophe and chaos.

For the Taoists, meaning is to be found on the border between the ever-entwined pair. To walk that border is to stay on the path of life, the divine Way. And that’s much better than happiness.

trying to address a perplexing problem: the reason or reasons for the nuclear standoff of the Cold War. I couldn’t understand how belief systems could be so important to people that they were willing to risk the destruction of the world to protect them. I came to realize that shared belief systems made people intelligible to one another—and that the systems weren’t just about belief.

People who live by the same code are rendered mutually predictable to one another. They act in keeping with each other’s expectations and desires. They can cooperate. They can even compete peacefully, because everyone knows what to expect from everyone else.

Shared beliefs simplify the world, as well, because people who know what to expect from one another can act together to tame the world. There is perhaps nothing more important than the maintenance of this organization—this simplification. If it’s threatened, the great ship of state rocks.

It isn’t precisely that people will fight for what they believe. They will fight, instead, to maintain the match between what they believe, what they expect, and what they desire. They will fight to maintain the match between what they expect and how everyone is acting. It is precisely the maintenance of that match that enables everyone

There’s more to it, too. A shared cultural system stabilizes human interaction, but is also a system of value—a hierarchy of value, where some things are given priority and importance and others are not. In the absence of such a system of value, people simply cannot act. In fact, they can’t even perceive, because both action and perception require a goal, and a valid goal is, by necessity, something valued.

We experience much of our positive emotion in relation to goals. We are not happy, technically speaking, unless we see ourselves progressing—and the very idea of progression implies value.

Worse yet is the fact that the meaning of life without positive value is not simply neutral. Because we are vulnerable and mortal, pain and anxiety are an integral part of human existence. We must have something to set against the suffering that is intrinsic to Being.*2 We must have the meaning inherent in a profound system of value or the horror of existence rapidly becomes paramount. Then, nihilism beckons, with its hopelessness and despair.

So: no value, no meaning. Between value systems, however, there is the possibility of conflict. We are thus eternally caught between the most diamantine rock and the hardest of places:

loss of group-centred belief renders life chaotic, miserable, intolerable; presence of group-centred belief makes conflict with other groups inevitable.

In the West, we have been withdrawing from our tradition-, religion- and even nation-centred cultures, partly to decrease the danger of group conflict. But we are increasingly falling prey to the desperation of meaninglessness, and that is no improvement at all.

While writing Maps of Meaning, I was (also) driven by the realization that we can no longer afford conflict—certainly not on the scale of the world conflagrations of the twentieth century.

I came to a more complete, personal realization of what the great stories of the past continually insist upon: the centre is occupied by the individual.

It is possible to transcend slavish adherence to the group and its doctrines and, simultaneously, to avoid the pitfalls of its opposite extreme, nihilism. It is possible, instead, to find sufficient meaning in individual consciousness and experience.

How could the world be freed from the terrible dilemma of conflict, on the one hand, and psychological and social dissolution, on the other? The answer was this: through the elevation and development of the individual, and through the willingness of everyone to shoulder the burden of Being and to take the heroic path. We must each adopt as much responsibility as possible for individual life, society and the world.

We must each tell the truth and repair what is in disrepair and break down and recreate what is old and outdated. It is in this manner that we can and must reduce the suffering that poisons the world. It’s asking a lot. It’s asking for everything.

the alternative—the horror of authoritarian belief, the chaos of the collapsed state, the tragic catastrophe of the unbridled natural world, the existential angst and weakness of the purposeless

individual—is clearly worse.

a title: 12 Rules for Life: An Antidote to Chaos. Why did that one rise up above all others? First and foremost, because of its simplicity. It indicates clearly that people need ordering principles, and that chaos otherwise beckons.

We require rules, standards, values—alone and together. We’re pack animals, beasts of burden. We must bear a load, to justify our miserable existence. We require routine and tradition. That’s order. Order can become excessive, and that’s not good, but chaos can swamp us, so we drown—and that is also not good. We need to stay on the straight and narrow path.

I hope that these rules and their accompanying essays will help people understand what they already know: that the soul of the individual eternally hungers for the heroism of genuine Being, and that the willingness to take on that responsibility is identical to the decision to live a meaningful life.

RULE 1   STAND UP STRAIGHT WITH YOUR SHOULDERS BACK

Because territory matters, and because the best locales are always in short supply, territory-seeking among animals produces conflict. Conflict, in turn, produces another problem: how to win or lose without the disagreeing parties incurring too great a cost.

It’s winner-take-all in the lobster world, just as it is in human societies, where the top 1 percent have as much loot as the bottom 50 percent11—and where the richest eighty-five people have as much as the bottom three and a half billion.

This principle is sometimes known as Price’s law, after Derek J. de Solla Price,13 the researcher who discovered its application in science in 1963. It can be modelled using an approximately L-shaped graph, with number of people on the vertical axis, and productivity or resources on the horizontal.

Instead of undertaking the computationally difficult task of identifying the best man, the females outsource the problem to the machine-like calculations of the dominance hierarchy. They let the males fight it out and peel their paramours from the top.

The dominant male, with his upright and confident posture, not only gets the prime real estate and easiest access to the best hunting grounds. He also gets all the girls. It is exponentially more worthwhile to be successful, if you are a lobster, and male.

dominance hierarchies have been an essentially permanent feature of the environment to which all complex life has adapted. A third of a billion years ago, brains and nervous systems were comparatively simple. Nonetheless, they already had the structure and neurochemistry necessary to process information about status and society. The importance of this fact can hardly be overstated.

evolution works, in large part, through variation and natural selection. Variation exists for many reasons, including gene-shuffling (to put it simply) and random mutation. Individuals vary within a species for such reasons. Nature chooses from among them, across time. That theory, as stated, appears to account for the continual alteration of life-forms over the eons.

But there’s an additional question lurking under the surface: what exactly is the “nature” in “natural selection”? What exactly is “the environment” to which animals adapt?

Nature “selects.” The idea of selects contains implicitly nested within it the idea of fitness. It is “fitness” that is “selected.” Fitness, roughly speaking, is the probability that a given organism will leave offspring (will propagate its genes through time). The “fit” in “fitness” is therefore the matching of organismal attribute to environmental demand.

But nature, the selecting agent, is not a static selector—not in any simple sense.

As the environment supporting a species transforms and changes, the features that make a given individual successful in surviving and reproducing also transform and change. Thus, the theory of natural selection does not posit creatures matching themselves ever more precisely to a template specified by the world. It is more that creatures are in a dance with nature, albeit one that is deadly.

Nature is not simply dynamic, either. Some things change quickly, but they are nested within other things that change less quickly (music

It’s chaos, within order, within chaos, within higher order. The order that is most real is the order that is most unchanging—and that is not necessarily the order that is most easily seen. The leaf, when perceived, might blind the observer to the tree. The tree can blind him to the forest.

It is also a mistake to conceptualize nature romantically.

Unfortunately, “the environment” is also elephantiasis and guinea worms (don’t ask), anopheles mosquitoes and malaria, starvation-level droughts, AIDS and the Black Plague.

It is because of the existence of such things, of course, that we attempt to modify our surroundings, protecting our children, building cities and transportation systems and growing food and generating power.

this brings us to a third erroneous concept: that nature is something strictly segregated from the cultural constructs that have emerged within it.

It does not matter whether that feature is physical and biological, or social and cultural. All that matters, from a Darwinian perspective, is permanence—and the dominance hierarchy, however social or cultural it might appear, has been around for some half a billion years.

The dominance hierarchy is not capitalism. It’s not communism, either, for that matter. It’s not the military-industrial complex. It’s not the patriarchy—that disposable, malleable, arbitrary cultural artefact. It’s not even a human creation; not in the most profound sense. It is instead a near-eternal aspect of the environment, and much of what is blamed on these more ephemeral manifestations is a consequence of its unchanging existence.

We were struggling for position before we had skin, or hands, or lungs, or bones. There is little more natural than culture. Dominance hierarchies are older than trees.

The part of our brain that keeps track of our position in the dominance hierarchy is therefore exceptionally ancient and fundamental.17 It is a master control system, modulating our perceptions, values, emotions, thoughts and actions. It powerfully affects every aspect of our Being, conscious and unconscious alike.

The ancient part of your brain specialized for assessing dominance watches how you are treated by other people. On that evidence, it renders a determination of your value and assigns you a status. If you are judged by your peers as of little worth, the counter restricts serotonin availability. That makes you much more physically and psychologically reactive to any circumstance or event that might produce emotion, particularly if it is negative. You need that reactivity. Emergencies are common at the bottom, and you must be ready to survive. Unfortunately, that physical hyper-response, that constant alertness, burns up a lot of precious energy and physical resources.

It will leave you far more likely to live, or die, carelessly, for a rare opportunity at pleasure, when it manifests itself. The physical demands of emergency preparedness will wear you down in every way.21

If you have a high status, on the other hand, the counter’s cold, pre-reptilian mechanics assume that your niche is secure, productive

You can delay gratification, without forgoing it forever. You can afford to be a reliable and thoughtful citizen.

Sometimes, however, the counter mechanism can go wrong. Erratic habits of sleeping and eating can interfere with its function. Uncertainty can throw it for a loop. The body, with its various parts,

needs

to function like a well-rehearsed orchestra. Every system must play its role properly, and at exactly the right time, or noise and chaos ensue. It is for this reason that routine is so necessary. The acts of life we repeat every day need to be automatized. They must be turned into stable and reliable habits, so they lose their complexity and gain predictability and simplicity.

It is for such reasons that I always ask my clinical clients first about sleep. Do they wake up in the morning at approximately the time the typical person wakes up, and at the same time every day?

The next thing I ask about is breakfast. I counsel my clients to eat a fat and protein-heavy breakfast as soon as possible after they awaken (no simple carbohydrates, no sugars,

I have had many clients whose anxiety was reduced to subclinical levels merely because they started to sleep on a predictable schedule and eat breakfast.

Other bad habits can also interfere with the counter’s accuracy.

There are many systems of interaction between brain, body and social world that can get caught in positive feedback loops. Depressed people, for example, can start feeling useless and burdensome, as well as grief-stricken and pained. This makes them withdraw from contact with friends and family. Then the withdrawal makes them more lonesome and isolated, and more likely to feel useless and burdensome. Then they withdraw more. In this manner, depression spirals and amplifies.

If someone is badly hurt at some point in life—traumatized—the dominance counter can transform in a manner that makes additional hurt more rather than less likely. This often happens in the case of people, now adults, who were viciously bullied during childhood or adolescence. They become anxious and easily upset. They shield themselves with a defensive crouch, and avoid the direct eye contact interpretable as a dominance challenge.

With their capacity for aggression strait-jacketed within a too-narrow morality, those who are only or merely compassionate and self-sacrificing (and naïve and exploitable) cannot call forth the genuinely righteous and appropriately self-protective anger necessary to defend themselves. If you can bite, you generally don’t have to. When skillfully integrated, the ability to respond with aggression and violence decreases rather than increases the probability that actual aggression will become necessary.

Naive, harmless people usually guide their perceptions and actions with a few simple axioms: people are basically good; no one really wants to hurt anyone else; the threat (and, certainly, the use) of force, physical or otherwise, is wrong. These axioms collapse, or worse, in the presence of

individuals who are genuinely malevolent.27

I have had clients who were terrified into literally years of daily hysterical convulsions by the sheer look of malevolence on their attackers’ faces. Such individuals typically come from hyper-sheltered families, where nothing

terrible is allowed to exist, and everything is fairyland wonderful (or else).

When the wakening occurs—when once-naïve people recognize in themselves the seeds of evil and monstrosity, and see themselves as dangerous (at least potentially)— their fear decreases. They develop more self-respect. Then, perhaps, they begin to resist oppression. They see that they have the ability to withstand, because they are terrible too. They see they can and must stand up, because they begin to understand how genuinely monstrous they will become, otherwise,

There is very little difference between the capacity for mayhem and destruction, integrated, and strength of character. This is one of the most difficult lessons of life.

even if you came by your poor posture honestly—even if you were unpopular or bullied at home or in grade school28—it’s not necessarily appropriate now. Circumstances change. If you slump around, with the same bearing that characterizes a defeated lobster, people will assign you a lower status, and the old counter that you share with crustaceans, sitting at the very base of your brain, will assign you a low dominance number.

the other, far more optimistic lesson of Price’s law and the Pareto distribution: those who start to have will probably get more.

Some of these upwardly moving loops can occur in your own private, subjective space.