Colby was in his 20s — far too young, according to some, to struggle with this particular thing — when he noticed an issue: When he wanted to get intimate, he couldn’t stay hard. 

The now-33-year-old, who, like everyone else in this story, asked Vox not to publish their last name so he could speak more openly about his sex life, was unsure if his issues were truly physical or if they stemmed from something else. He saw a doctor who did some blood work — his testosterone levels, while still normal, were slightly low. A specialist put him on testosterone, but Colby was concerned about negative long-term side effects, and eventually wanted to try something else: Viagra.

His doctor wasn’t so sure. You’re only 28. We don’t think you need it, Colby remembered his doctor telling him. But if you want to try it and see how it works for you, let us know. They wrote him a script. 

When considering the stereotypical Viagra patient, the mind conjures up an image of a man decidedly older than his 20s, after all. But that picture is changing. 

Studies vary when it comes to how many adult men under 40 seek out medications for erectile dysfunction, but some estimates are as high as 39 percent. In a major medical journal, one pediatric urology practice reported a 31-fold increase in adolescent males who experienced erectile dysfunction between 2014 and 2024. According to the urologists and the very sincere, very open men I spoke to, younger guys are taking dick pills for a multitude of reasons: genuine erectile dysfunction, sure, but also to optimize their day-to-day as well as their sex lives. The fact that these drugs are cheaper and more accessible — and less embarrassing to get — only makes them more appealing. 

I, like so many women in America, have been horrified and dismayed as details surrounding some young men’s behaviors and attitudes toward women and sex became public. When reporting this story, however, I found nearly the opposite to be true: The guys I spoke with were earnest and vulnerable when it came to their struggles and their willingness to enhance their pleasure. 

Urologist Amy Pearlman said there is an increased awareness that is leading more guys to seek treatment — whether or not they really need it. “A lot of the guys who come in are not coming from a place of deficiency,” she told Vox. “There is abundance.”

Colby and Viagra weren’t a perfect match, he told me. The side effects — vivid dreams, terrible headaches — turned him off. But Cialis? Why not give it a try? He’s been on it ever since.

“Do I think Cialis would be something that I’ll probably keep on hand?” Colby said. “Yeah.” 

The sex lives of young people — young men, in particular — are full of contradictions. Gen Z craves sex, but is too afraid of rejection to date. Porn is easily accessible and highly consumed, but isn’t an accurate representation of real sexual encounters. The female orgasm gap persists. Young men say they distrust health information shared by influencers, yet admit to trying wellness trends or self-diagnosing based on what they’ve seen online. Young women are moving further left, but 21 percent of Gen Z men think “a real woman should never initiate sex” (compared with just 7 percent of baby boomer men). More people are speaking openly about the poor state of men’s collective mental health, but the restrictive masculinity norms at the root of it are stubbornly persistent. 

The increased acceptance of drugs once reserved for older men, drugs once mired in so much stigma, speaks to a culture that is awkwardly navigating these shifting expectations. Are men getting more comfortable addressing their problems directly — and finding a genuinely healthier relationship with sex? Or just finding new ways to meet the old pressure to perform?

ED pills are cheap and accessible

There has never been a better time to get into dick pills. Over the last decade, more generics have hit the market and have brought the cost way down. Sildenafil, the generic version of Viagra, was first made available in the US in 2017, and tadalafil — generic Cialis — hit the market a year later. 

Around the same time, direct-to-consumer telehealth platforms like Hims, Ro (formerly Roman), and BlueChew launched, offering these drugs at an even lower cost — and all without a trip to the doctor. The typical Hims patient, per New York magazine in 2021, is a man in his 20s or 30s, keen to score generic Viagra. These websites are intentionally discreet and eliminate deeper diagnostic conversations with medical providers — for better or for worse. Customers need only answer a few simple questions before they’re offered a prescription, even if they don’t meet the diagnostic criteria for ED. 

These companies offer a seductive vision: One Hims TV spot is sleekly filmed — soft lighting, young, attractive actors cuddling in the grass — and doesn’t mention the words “erectile dysfunction” once. “Searching for the simplest way to treat ED?” a nonjudgmental voiceover asks. The whole production seems to beckon young men into a warm embrace. Erectile dysfunction is passé. You are youthful, and it’s okay if you struggle to stay hard. Good-looking people, like you, discreetly shop for health treatments online. These medications aren’t just about sex; they’re for your health. They are for you.

And that means that more men are asking their doctors for them, too. 

Pearlman, the Florida urologist, told me that she treats many men under 40 — and even some teenagers — who just want “to make it a little easier to get erections when they want them.” 

“The reality is there’s nothing wrong with optimizing,” she said. “I don’t need a patient to plead their case that they’re suffering…to warrant a medication that I would consider to be one of the safest medications ever available to people. And what a blessing it is that it’s so accessible and cost-effective and has so many reasons that it could help people.”

Young men may also be pill-curious simply because the meds are hard to avoid. Unregulated sexual performance “supplements” that promise increased stamina but may just actually be massive doses of bootleg Viagra or Cialis laced with printer ink or drywall have lurked in plexiglass cases in the gas station, but many men — reasonably — were perhaps too scared or embarrassed to buy them. Now, though, higher-quality options are everywhere. Direct-to-consumer platforms like Hims have funneled millions of dollars into advertising — on subways, television, and podcasts — on the one hand, helping to destigmatize and normalize men’s sexual health, and on the other, perhaps nudging suggestible young people into thinking they have a problem. 

The growing interest in dick pills speaks to Hims’ megaphone in particular. “I do think that the power and talent, just in terms of marketing and communications, and the budget of a company like Hims for getting the word out and educating the public about a medical condition dramatically dwarfs the marketing talent, the budgets, and communication abilities of conventional private practices, health systems,” Peter Stahl, senior vice president of men’s sexual health and urology at Hims & Hers, told Vox. 

Once ED becomes fodder for commercial breaks on your favorite TV shows and podcasts, you might not consider the medication out of the realm of possibility for you.

Some doctors see these telehealth sites as a net benefit given that they bring more men into the healthcare system. As children, both boys and girls commonly visit a pediatrician, but once they become adults, women are more likely to regularly visit their primary care physician or their OB-GYN. 

Telehealth offers a third option besides googling symptoms or going to a doctor’s office. Online healthcare is “now the gateway to men’s health where people — at a superficial level — get to learn about how these medications help them, but they don’t know why,” said Justin Dubin, a urologist and director of men’s sexual health at Baptist Health South Florida. Dubin sees this as a net positive, he told Vox. If men are asking questions about their boners — Why are these pills so effective? What’s going on with my body? — and it gets more guys to the doctor, that’s a good thing. 

The side effect effect

Since being diagnosed with depression and PTSD a few years ago, 31-year-old Alexander (a pseudonym) cycled through a series of antidepressants until he finally found one that helped him. Mentally, he was feeling better, but his sex drive took a nosedive, a common side effect of some SSRIs. His doctor prescribed Viagra.

About one in six American adults take antidepressants, which are among the most prescribed medications in the country. Depending on the drug, anywhere from 20 percent to 70 percent of people taking an antidepressant reported sexual dysfunction. Other medications particularly popular among young men, like those treating hair loss, have also been linked to lower libido and an inability to get hard. 

Ironically, the same direct-to-consumer platforms selling erectile dysfunction medications also prescribe antidepressants and hair loss treatments — the very drugs that cause ED. “I think it is notable that the same companies are marketing those two drugs together,” Kristen Mark, a professor and the director of the Eli Coleman Institute for Sexual and Gender Health at the University of Minnesota Medical School, told Vox.

Another man, 35-year-old Tristan, was prescribed an ADHD medication in his late 20s, which he said made it hard for him to get an erection. Since then, he’s taken Cialis daily, and it’s not only benefited his sex life, but his overall mood, too. “I have a much better pump at the gym,” he told me. “I would be really bummed if there was some medical reason later on in life that I had to stop taking it,” he said. He plans on taking it for the rest of his life.

The anxious generation

For many young men, the issue may not be physical at all, but mental. Unlike older patients — who are generally more likely to have ED — whose impotence stems from high blood pressure, obesity, diabetes, and high cholesterol, younger men’s issues in the bedroom tend to stem from anxiety and depression. 

The sense that there’s pressure to perform is giving more men anxiety. “We see that far and above any other reason, ED is diagnosed in younger populations because of performance anxiety,” Mark said. They may not have any underlying health conditions preventing them from getting an erection, but young guys can get in their heads with new partners, especially if there are any lingering negative feelings from a bad breakup, past trauma, or heightened stress and anxiety. 

Charles Welliver, director of men’s health and an associate professor of urology at Albany Medical Center, finds his younger patients’ mental block typically stems from a specific event, like the end of a relationship. He’ll prescribe them Viagra to help them regain confidence, he said, a little nudge to get back out there. While he notes there’s little evidence these medications can cause physical dependence, men may become mentally reliant on them. “Psychological dependence is a different situation where guys think they need it to perform,” Welliver told Vox.

Inexperienced and perhaps operating under the unrealistic expectation that they must perform like the guys they’ve seen in porn, some of young men’s formative sexual experiences may be thwarted by fear or latent misogyny.

“It’s an age-old story you can see in movies or TV of the guy that’s a young teenager and trying so hard to perform for the pretty girl, and then it just doesn’t happen,” Colby said. As teens and 20-somethings forge their sexual identities, their views are shaped by the content they consume online and the experiences of their peers. If their favorite podcaster is touting a supplement likening an erection to a flagpost, they might suspect they’re lacking in some way, should they get nervous during a first sexual encounter, despite it being incredibly normal and common. Using medication as a mask of masculinity in lieu of addressing deeper insecurities may prevent young men from developing intimacy.

“This performance anxiety piece is certainly not going to be solved by just continuing to take Cialis or Viagra,” Mark said. “They need better coping mechanisms for addressing that anxiety in the moment, and they’re not getting any of that by just taking a drug.”

Some of those self-soothing strategies, according to Mark, include remaining present, feeling connected to your partner, and taking a break if you’re too in your head. It’s important to understand where the performance anxiety is coming from. “Think about what is it about this setting that I am here for? Why am I doing this?” Mark said. “Focus in on how that feels for you, rather than just pressing on.” 

These conversations and practices are decidedly less likely in the context of casual sex. The familiarity and comfortability to discuss your sex life is among the many virtues of long-term relationships. Few men would consider pausing a hookup to interrogate their emotional hang-ups. Popping a pill is easier than talking to your situationship about your nerves. It’s hard to stay in the moment and relax when you’re thinking about how the stranger in your bedroom is judging you or will reject you outright if you can’t perform. 

These anxieties may simply be a product of youth, something to outgrow with time and wisdom and experience. Vulnerable conversations about sex can be less taboo among friends and within couples as you age; there comes a realization that porn isn’t real, that sex doesn’t necessarily mean penetration, and that the other person’s (or people’s) pleasure is probably more important than your own. 

Ultimately, ED pills will only go so far if the problem is in your head. Colby, the 33-year-old who was prescribed Viagra and Cialis, said he once had a hookup tell him to drive her home because he couldn’t get hard. “You can take all the medication that you want, but if you’re mentally not in a relaxed state, medication’s not going to do shit for you,” he said. 

The quest for optimization

Sometimes the desire for dick pills doesn’t stem from lack or insecurity or a side effect, but simply to get, and give, more of a good thing. 

In the biohacking corners of the internet, Cialis is touted as an effective pre-workout supplement, giving men like Tristan, the 35-year-old who takes it to offset his ADHD medication’s side effects, a temporary boost in muscle swelling after a lift. “It is improving blood flow throughout your body, and that’s why you’re seeing the benefits,” Dubin, the Baptist Health doctor, said. “That’s why many men say that they do get a better pump at the gym, they feel a little bit better.” (The good news for frequent and off-label users of ED medications is that doctors said they are safe for prolonged use in men without cardiovascular disease and are difficult to misuse.)

In the endless pursuit of masculine self-optimization, testosterone replacement therapy has become a trendy touchpoint, something of a catchall for overall enhancement. Research has shown TRT does have some benefits: the treatment has been shown in research to improve vascular function, mood, muscle strength, bone density, and sexual function in healthy men. According to doctors, some patients come in either associating their ED with low testosterone or are concerned their levels are low. But low testosterone isn’t always a contributor to ED, Raevti Bole, director of the Center for Male Fertility at the Cleveland Clinic, told Vox — which means taking T might not do anything for erections. With that in mind, doctors are much more likely to prescribe an ED drug to younger men than to put them on testosterone. 

Maybe you don’t care about T, your mental health is fine, and you just want to get the most out of sex. Every now and then, when the mood strikes him, 39-year-old Jake attends a sex party. “Straight guys have fantasy football leagues,” he told Vox. “Gay guys fulfill their fantasies at regular scheduled orgies.” If he paid to get in, which he often does, he wants to maximize his time, money, and enjoyment. So he asked his doctor for a little assistance — not that he needed it. He just wanted an enhancement. Jake was prescribed three months’ worth of Cialis. “You can always walk,” he said, “but it’s more fun to fly.” 

Jake only needed a handful of pills for his recreational use, and now, suddenly, he was flush with Cialis. He certainly wasn’t going to use them all, so, rather than let them go to waste, he decided to spread the wealth. “I’ve been handing them out to straight men supportively to be like, we can talk about your life. It’s so fine if you need this,” Jake said. He’s given pills to baristas, coworkers, and patrons at the bar where he works. (A note: sharing prescription medication, including Viagra and Cialis, is illegal and can be dangerous, especially if the recipient has underlying health issues or takes other drugs that interfere.) If he can, in some small way, spark a conversation about intimacy, about common biological experiences, that’s a win. If he could facilitate a fun, sexy time, even better.

If some men don’t feel quite ready to have earnest conversations about their sex lives, maybe they need a wink and a nudge from someone like Jake. 

But perhaps more than anything, maybe young men could use a reminder that they don’t need the stamina of a porn star or to be expected to perform at a moment’s notice. A reminder they can be vulnerable and masculine, anxious and deserving of intimacy. With age and a willingness to be open with their partners, they may come to discover they don’t actually have erectile dysfunction; they just get nervous with a new partner, or they don’t actually feel like having sex after a stressful day at work. You know, normal parts of the human experience that don’t necessarily need to be pathologized or cured. In fact, it could be empowering.

It’s a balance Jake is still navigating himself. As he approaches his 40s, casual sex is losing its luster. Hookups aren’t like they were in his 20s when he could perform regardless of whether he found the person attractive. “Now, my emotions are getting in the way, which I think isn’t wrong,” Jake said. Sure, Cialis helps move things along, but to what end? 

“Maybe I should be asking myself, ‘Jake, are you doing this more for him than for you?’” he said. “Are you fulfilling other people’s desires more than you’re fulfilling your own?”

When the Mariana crow calls, it’s taken as a warning. 

To the Indigenous CHamoru people of the Mariana Islands, the bird is known as the Åga, an ancestral messenger who alerts the community of impending illness or weather disaster. In the dense canopy of Rota’s limestone forest, where the Mariana crow lives, it is a gardener — a key seed disperser from which the lush canopy grows. 

According to the US Fish and Wildlife Service, the species is endemic to Guam and the nearby island of Rota, a US territory, which means they live nowhere else on Earth. They once numbered in the thousands. But over the past 60 years, they have vanished from Guam and dwindled on Rota. Roughly 300 survive today.

Now teetering on the brink of extinction, every remaining Mariana crow represents a fragile ecosystem and a deep cultural lineage the islands cannot afford to lose. Researchers from the University of Washington and ecologists from the San Diego Zoo Wildlife Alliance are working tirelessly to make sure that doesn’t happen. 

The effort to prevent the bird’s precipitous decline in the wild has been underway for more than two decades. Beginning in 2005 with field monitoring and observation, researchers realized they would have to step in and raise the birds in human-assisted aviaries to save the species. By 2016, teams collected their first clutch of wild eggs and successfully released the first cohort back into the forest the following year. In the years since, the active recovery program has bred dozens of birds in captivity and has given the wild population a boost that researchers hope the birds can eventually sustain on their own — all made possible through millions of dollars in federal grants and academic funding, decades of field research, and tight coordination among local and federal partners. 

But in July, the entire effort was endangered by one of the most drastic events to hit the region in years. For days, Category 5 Super Typhoon Bavi pummeled the island. As it barreled down, conservationists realized they needed to act fast and save the species, so they assembled makeshift indoor aviaries inside the scientists’ quarters on the research base. The small crew boarded up windows and stocked up on food. Only weeks into their new lives in the forest, the crows were back inside. Their caretakers would ride out the storm beside them. 

The decision saved the flock. 

The team successfully brought 13 birds to safety before the storm hit. Of the nine that weren’t captured, two died, and one was emaciated and had a minor wing injury from the storm. The rest of the wild population took a hit, too, though researchers are still accounting for the total loss. The toll on the ongoing conservation work was profound. Bavi obliterated the facility’s outdoor aviaries, leaving an exhausted crew to care for the agitated Mariana crow in a compound that still remains without power just as another storm, Category 4 Typhoon Champi, passed through the islands in mid-October. 

Ecologist Sarah Faegre, the primary investigator for the University of Washington’s Rota Avian Behavioral Ecology Program, was there to assess the damage. The enormous aviary, which her own father, an architect, built more than a decade ago, had survived its fair share of typhoons. But last month, it lay collapsed. “It was heartbreaking,” she told me. “It nearly made me cry.” The massive, industrial-grade plastic pipe frame that held the aviary together, Faegre said, “looked like a pile of broken bones.”

Around the world, countless endangered animals are a single disaster from absolute collapse. 

Decades of habitat loss, shifting climate and degrading ecosystems have pushed much of the planet’s biodiversity to precariously low populations. But advances in science and conservation have yielded remarkable recoveries: The Endangered Species Act alone has clawed back nearly 300 species — the bald eagle, humpback whale, and grizzly bear among them — from the precipice. 

Still, the survival of many more animals today faces a dangerous bottleneck — sometimes it’s just a single aviary, a small team of researchers, and a modest pot of funding that stands in the way of extinction. 

At the same time, shifting political tides threaten to undermine those efforts even further. In the US, the Trump administration has slashed the very funding that could help an effort like breeding the Mariana crows recover from a major storm.

“If we’re no longer able to access funding and take action to do restoration work, it’s less likely that the species will ever recover and be able to be removed from the [endangered species] list,” said Sara Gottlieb, with the Nature Conservancy. 

With such existential challenges, it’s worth questioning why Faegre and others are so dedicated to saving the Mariana crow population. But in late October, even in the midst of Bavi’s aftermath, the research team discovered something hopeful. 

A precarious moment

The Mariana Islands, a 15-island archipelago that includes the US territories of Guam and the Northern Mariana Islands, are regularly hit with tropical storms. But for generations, the Mariana crow was able to persist in the remote, northern island of Rota — a model of a small, resilient ecosystem in part because its geography has protected it from the most severe disasters.

“Rota and the Mariana crow have seen many typhoons throughout history and have proven resilience,” said Phillip Hannon, research coordinator for the San Diego Zoo Wildlife Alliance’s Mariana crow rear-and-release program. “The jungle, too, regenerates very quickly in the heat and humidity of a tropical island.” 

But as climate change has fueled more frequent and severe storms, even the historically buffered areas are more exposed than ever. And this year, abnormally warm ocean temperatures in the Pacific have caused an unusual clustering of typhoon activity this year. 

For the Mariana crow, the situation was already grave. The population was completely wiped out from Guam by the late 1990s and early 2000s after a new predator, the brown tree snake — introduced into Guam via World War II military cargo ships — devastated native nests. With Guam’s population gone, the species’ survival now hinges entirely on Rota, a 33-square-mile island north of Guam where severe typhoons repeatedly thrash the native forest canopy the species uses for nesting. 

But intensifying super typhoons are striking an ecosystem already fractured by habitat loss and invasive species from rampant militarization. With every storm hitting an already diminished population, the work of conservationists is a crucial step to buy more time so that wildlife can eventually rebound on its own.

The joint Mariana crow recovery project by the San Diego Zoo Wildlife Alliance (SDZWA), the University of Washington, and local partners across Guam and the Northern Mariana Islands has boosted the population from its lowest — just roughly 130 individuals — to  300 birds, 79 of which were reared and reintroduced by SDZWA.

But this conservation breeding approach is “a method of last resort” only used when a species is on the absolute brink of extinction, like the California condor or the Hawaiian crow known as ‘Alalā, said Ronald Swaisgood, director of recovery ecology at the San Diego Zoo.

“All of these species absolutely depend on the critical habitat; otherwise, they’ll all be in breeding centers, and none will be in the wild,” Swaisgood said. “But sometimes that’s where we unfortunately finish because increasingly more species require this kind of infrastructure, which is very costly, but it’s our only remaining tool to prevent extinction of some of these species.”

Although it might sound like a long shot, many of these last-resort strategies have had real success. In East Tennessee, ecologists successfully recovered the Smoky Madtom. In the 1980s, decades after the tiny, nocturnal Smoky Madtom catfish was accidentally wiped out of its native creek, a researcher named Gerry Dinkins rediscovered a fragile surviving population. With the help of federal funding, scientists gathered a handful of wild eggs during the summer spawning season, brought them back to the lab to incubate, then nurtured the fragile fry in specialized aquariums, away from predators and other threats. Once the young madtoms were strong enough to fend for themselves, they carried them back to their native home in Abrams Creek, slipping them into the water at night to match their nocturnal habits and keep hungry birds and larger fish at bay.

These surviving populations provide more time to address the core causes of long-term decline. A 2020 US Fish and Wildlife Service review warned that climate change poses a growing long-term threat to the Smoky Madtom, as rising temperatures and extreme droughts dry up critical stream habitats. Severe low-water events, like the 2016 drought that left up to half of Citico Creek bone-dry, could endanger the catfish by disrupting nesting, reducing reproduction, and increasing mortality. 

“Anything that significantly changes the habitat condition in the area, including catastrophic storms causing large areas of tree blow-downs and landslides or wildfire leading to sudden inputs of sediments or toxins into the streams where these fish live could result in major impacts to the species,” Gottlieb said. 

All it takes is one wild nest

After Champi passed in mid-October, Faegre was walking through Rota’s forests when she spotted an encouraging sign that a Mariana crow — that had been reintroduced into the forest years ago — had left behind: a single, modest nest. 

It was one of the first that researchers found in October since Bavi made landfall. The island’s canopy remains noticeably more patchy and open than the Mariana crow’s preferred dense nesting habitat, but Faegre watched a released trio — made up of two males and an unrelated female — actively collecting roots and plant fibers, putting the finishing touches on a nest that’s now nearly complete. 

Because the crows typically begin nesting in August, researchers were unsure if they would attempt to breed at all this season. Yet despite the compromised environment and a delayed start, Faegre said if all goes well, the throuple — as the team has taken to calling them — could lay eggs in a week or two.

Nearly two weeks after Bavi battered the island, the Mariana crows that researchers scrambled to save during the worst days of the storm were rereleased into the wild. Fallen trees and downed power poles blocked the roads, delaying the birds’ return. In the meantime, the team built emergency outdoor aviaries to get the birds back outside. But with island power knocked out for months, survival became a logistical battle, Faegre said. The facility relied on a generator to preserve the crows’ food, running it just a few hours a day to stretch scarce fuel. When the freezer food eventually spoiled, the team turned to shelf-stable rations and later called on partners in Guam to ship in the fresh food the crows desperately needed. 

“Bavi was an incredibly powerful storm, much worse than any in the living memory of the people of Rota,” Faegre said. “To this day, more than three months later, the Mariana crow facility and many homes on Rota remain without power,” adding that some of the crew members with power are storing the Mariana crow’s food at their homes.

Just before Bavi struck, the team was already caring for eight injured Mariana crow. Two were previously released birds recovering from injuries sustained during Super Typhoon Sinlaku, a Category 5 storm that hit just months earlier. According to Faegre, injured crows are typically transferred for rehabilitation and eventual rerelease. But due to the severity of the injuries, six of the birds could not return to their native habitat and were relocated to the St. Louis Zoo early this month.

Schoolchildren who took frequent field trips to the Rota facility named two of the relocated birds, according to Faegre. One named Suette means “lucky” in CHamoru, while another named Lina’la means “life.”

“The sentiment is that these birds were lucky and got a second chance at life,” Faegre said. “Suette, for example, tackled a crab that was a bit too big for him when he was a young bird in the wild. He lost a wing to the crab but has done very well in human care since then.”

As climate change accelerates, Swaisgood said relying on second chances won’t be enough. To ensure the Mariana crow survives the next storm and thrives beyond it, the team has been exploring new ways to diversify and expand the Mariana crow’s habitats across safer, more varied ecosystems like the neighboring Northern islands. 

But to do so, they need funding. The program has already proven successful, with recent analyses indicating a modest recovery in the Mariana crow population and that the decline has stopped. Yet Swaisgood said appropriated federal funds are failing to reach them. “Several of our projects, the ones that depend on federal funding, are running out,” he said. 

The question is whether nature can do so fast enough to survive more upheaval. While forests and habitats may eventually rebound, time is running out faster than evolution or natural recovery can match. Still, targeted conservation acts as an indispensable bridge to keep species hanging on while working towards larger systemic solutions.

“Everywhere in the world, including the environment, is always going to be impacted,” Gottlieb said. “But what we do see over and over is that these areas can recover. Sometimes even on their own.” 

When HIV was first discovered in the early 1980s, it was virtually a death sentence. Now, we have treatments that can keep it at bay and prevent it from progressing to AIDS — but for some people, the disease never progresses, even without treatment. These so-called elite controllers make up perhaps less than 0.5 percent of all HIV patients, and their survival could hold the secret to a lasting “functional” cure to the disease. In this month’s Highlight cover story, Diana Kwon investigates what makes “elite controllers” different, how their HIV resistance functions, and whether it’s replicable for others. Also in this issue: young men and Viagra. Sports gambling’s table tennis mania. How robots are revolutionizing mastectomy surgery. And climate-proofing conservation.

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Trump wants an immigration deal. He could start with caregivers.

By Rachel Cohen Booth

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Are you abandoning the fight if you move from a red state to a blue one?

By Sigal Samuel

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Robots could transform breast surgery forever

By Anusha Subramanian

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HIV was supposed to kill them. Now they could help scientists find a cure.

By Diana Kwon

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Scientists were racing to save this rare bird from extinction. Then came the super typhoon.

By Rachel Ramirez

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Why are so many young guys taking Viagra?

By Allie Volpe

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Why online gamblers are obsessed with table tennis

By Jack Meserve

Coming November 13

Paul Boakye was 22 when he was diagnosed with HIV. It was winter 1986, five years after the world first became aware of the deadly disease that would become known as acquired immune deficiency syndrome (AIDS). After receiving the news, Boakye was certain he was going to die young. “I distinctly remember a doctor telling me that I probably wouldn’t live to see 30,” he said. 

Years passed, and Boakye watched as both his former partner and many of his friends died of complications from HIV, which infiltrates immune cells and weakens the body’s defenses. During the early days of the HIV pandemic, a diagnosis was essentially a death sentence. Without getting treatment, HIV infections can eventually develop into AIDS — the stage in which a person’s immune system has deteriorated to the point that they become vulnerable to typically harmless infections and rare cancers. Once AIDS manifests, life expectancy drops to just a few years. 

But Boakye was an exception. 

Now four decades after his diagnosis, at age 63, he remains symptom-free. He is one of the rare people with HIV whose immune systems can fight off the virus without treatment. These individuals, known as “elite controllers,” make up less than 0.5 percent of those who get infected with HIV.

For many scientists, this group of people provides a roadmap for a so-called functional cure, a state akin to cancer remission, where the infection is under control, but not completely eliminated. 

A cure for HIV is still much needed. In 2025, approximately 1.2 million people around the globe became newly infected and around 570,000 died from HIV-related causes. Today’s clinicians now have an arsenal of effective medications to both prevent and treat HIV infections. “There are a lot of tools to fight HIV, but it’s also evident that this is not enough,” said Asier Saez-Cirion, leader of the Viral Reservoirs and Immune Control Unit at the Pasteur Institute in Paris. 

To keep HIV as a survivable disease, people with the virus must take treatments for life, which brings up widespread issues of cost and access. When those become a barrier, it ends up costing lives. But researchers have been working on deciphering the lasting secrets of elite controllers like Boakye, in hopes of one day developing a functional cure for millions more people living with HIV. This work has led to many new strategies for fighting the virus — and several new treatments are now being evaluated in clinical trials. 

The elite controllers of HIV 

Joel Blankson, an associate professor of medicine specializing in infectious diseases at the Johns Hopkins University School of Medicine, remembers when he encountered an HIV elite controller for the first time. It was 1998, and a woman had come to the clinic after testing positive for HIV. That test result showed that her immune system had encountered the virus and produced antibodies to fight it. 

But further tests revealed something baffling. Normally, as an HIV infection progresses, the virus infiltrates key immune cells, known as CD4 T cells, hijacking their internal machinery to make more copies of itself, and killing the host cells in the process. This patient, however, had no detectable levels of virus in her blood and appeared to have a healthy number of CD4 T cells. “That was fascinating,” Blankson said, since clinicians at the time did not think that could be possible. 

Starting in the 1990s, researchers in the US and elsewhere in the world started documenting such cases. A few years earlier, Bruce Walker, a physician-scientist and director of the Ragon Institute of Mass General Brigham, MIT, and Harvard, had been similarly astounded by a patient who had been HIV positive for 16 years with no signs of disease. “I thought initially he couldn’t possibly be infected because everybody we saw had progressive illness,” Walker said. 

For any virus, whether it’s HIV or influenza or Covid-19, people have a range of responses — some people become severely ill while others may have no symptoms at all. But HIV is exceptionally good at evading the immune system’s defenses, so the research community was glad to see that there were some people who seemed to be able to naturally fight off HIV. “It was particularly exciting to see that they were able to maintain this control in the long term,” Saez-Cirion said. 

So the natural question was: What made these people different from those who became severely ill from HIV? 

Some researchers hypothesized that these elite controllers had been infected by a defective version of HIV. Early evidence appeared to support this claim: In 1992, researchers described a small group of long-term, symptom-free HIV-positive individuals who had all been inadvertently infected through blood transfusions from an asymptomatic individual. The transfusions had occurred in 1985, before blood was routinely screened for HIV. Both the donor and the recipients harbored a strain of the virus with genetic mutations that hindered its ability to replicate. 

But this incident turned out to be the exception. Later studies found that most people who survived for many years without disease progression did not carry weakened versions of HIV. For example, when Blankson and his colleagues isolated HIV from elite controllers’ cells, they found that the virus was able to multiply effectively in a lab dish just as well as the virus from people who became ill from HIV. And when they used the virus from these elite controllers to infect mice engineered to have human-like immune systems, the pathogen was still able to spread through the animals with ease. All of this suggested there was something unique not about the infecting strain of the virus but instead about these individuals’ immune systems. 

As the tests for detecting the virus in blood samples improved, researchers found that there were even different levels of how much some people could control the virus. There were, for example, “viremic controllers,” who are often defined as those with less than 2,000 copies of HIV within a milliliter of blood, and “elite controllers” who have less than 50. For comparison, a typical HIV-positive person can have anywhere from tens of thousands to more than 1 million HIV particles in a milliliter of blood, depending on the stage of their infection.

More recently, another group of intriguing patients has emerged: post-treatment controllers, who, after taking antiretroviral treatment for many years, become capable of controlling HIV without medication.^.This group is giving even more hope that controllers may hold a clue to finally creating a lasting cure for the disease. 

Unraveling the mechanisms of elite control 

Once people who seemed to be beating back HIV on their own began to emerge, researchers went searching for more of them. Eventually, several research teams were able to assemble large cohorts of these patients: Walker and his colleagues, for instance, found around 1,000 elite controllers to begin to study them en masse to search for trends.  

Some of the earliest studies looked into elite controllers’ genetics. Using a technique known as genome-wide association, which involves screening the genetic material of many people for links to disease, scientists discovered that a large proportion of elite controllers possessed variants of genes that code for structures responsible for presenting antigens — the fragments of viruses and other substances that immune cells use to detect pathogens. 

Researchers have drawn inspiration from these studies to develop new strategies for fighting HIV.

This led scientists to zero in on cytotoxic T cells, immune cells that zero in on these fragments to identify foreign and infected cells to attack. In elite controllers, these cellular soldiers appeared to be exceptionally good at seeking out and eliminating HIV. How these individuals’ immune responses accomplish this has been a matter of intense investigation: Some researchers, such as Mark Connors, an HIV researcher at the US National Institute of Allergy and Infectious Diseases, and his team have found that elite controllers’ cytotoxic T cells increase the production of a specific molecule that pokes holes in infected immune cells to kill them — something that the same type of cells in other HIV-positive people are unable to do. Other groups, such as Walker’s team, have found that cytotoxic T cells are able to launch highly specific attacks on vulnerable regions within the virus’s structure. 

Over the years, scientists have found that there is likely no one-size-fits-all explanation for why elite controllers’ immune systems are such formidable opponents for HIV. Studies have also found that these individuals also appear to possess exceptionally robust natural killer cells, which are immune foot soldiers that are some of the first to find and kill invading pathogens. 

Other investigations have looked beyond specific cells to the aftermath of an elite controllers’ immune response. Xu Yu, an HIV researcher at the Ragon Institute, along with Walker and their colleagues, have found that immune systems of some elite controllers keep HIV locked away in so-called gene deserts, where it is unable to make more copies of itself — an essential task for the virus’ success. 

Yu says that this is likely the result of unusually strong immune surveillance. Elite controllers’ immune systems were likely able to kill off the cells in which the virus had integrated itself into parts of the genome to multiply. This left only those cells with ineffective viruses behind. How the immune system actually does this remains a mystery, but according to Yu, it’s likely that multiple parts of controllers’ immune systems work together to launch particularly powerful responses. 

In addition to uncovering how, exactly, the immune system accomplishes this feat, Yu is also hoping to replicate this process in people who aren’t elite controllers. The good news is, evidence so far suggests that this may indeed be possible: In a 2023 study with eight people who had been on long-term anti-retroviral therapy, Yu’s team found that it was also possible for non-elite controllers to lock HIV away in these gene deserts — but only after more than two decades of treatment. 

The next step is to determine how to make people reach this state faster, so that they can one day stop needing treatment altogether, Yu says.

Researchers have drawn inspiration from these studies to develop new strategies for fighting HIV. Several are currently being tested in people with the virus. Walker’s team, for example, has developed a trial vaccine designed to train a person’s T cells to attack the most vulnerable parts the viruses’ structure — both as a way of preventing and of treating infection, in an early-stage trial. Saez-Cirion and his team have several ongoing trials, including one effort that involves administering immunotherapy in combination with antiretrovirals in people with newly diagnosed infection to try to coax their immune systems into developing the potent immune response found in elite controllers. 

The elite road to a cure? 

Experts are generally reluctant to say that elite controllers — even those who have lived symptom-free for decades — are “cured” of HIV. The main reason is that HIV is notorious for hiding in so-called reservoirs, cells in which HIV lingers without replicating. 

The virus in these reservoirs escapes detection from a person’s immune system and from current HIV medicines. From here, it can then become active after remaining quiet for years. Because HIV infects immune cells, which travel all around the body, the virus can hide in deep tissues, such as the brain, that are extremely difficult to probe in living people. 

And there are documented cases of the virus eventually breaking through an elite or viremic controller’s immune defenses, kick-starting disease progression — even if they have lived symptom-free for years or decades. It’s still unclear what factors determine when that point will come. So, many controllers are also on antiretroviral therapy.

There are, however, two elite controllers who are widely considered to be cured. One is the “Esperanza patient,” named after the Argentinian city where she lived, for whom researchers analyzed more than a billion cells and found no intact HIV. And the other, Loreen Willenburg, a Californian woman, kept the virus at bay for more than three decades without treatment — even while receiving immune-suppressing treatment for lung and brain cancer. Before she died in April, Willenburg donated her body to science; Yu and her colleagues have been carefully analyzing autopsy samples to determine whether there are intact viruses hidden somewhere within her body. 

But these are the incredibly rare known examples among the 92 million people who have acquired HIV since the virus was first described. So even the elite controllers must stay vigilant for the virus’s reemergence. Boakye regularly gets his blood screened to make sure that HIV has not begun to spread. Today, he lives in the UK working as a playwright, and he remains active and healthy — and HIV remains undetectable in routine tests, even after four decades without treatment.

For years, he has tried to enroll in a study in hopes of helping scientists understand how his immune system has managed to fight HIV all these years, and last year, he became involved in three research projects. One of these is at the Ragon Institute, where Yu’s team analyzed more than 1 million cells in Boakye’s blood and found only a tiny number of HIV fragments — and only one that appears to be intact. Whether this fragment is capable of replicating remains unknown.

“They believe that my immune system is ignoring all the defective fragments and just controlling the one fragment that could replicate,” Boakye said. How his immune system does this is still a mystery, but Boakye hopes that by studying him and other elite controllers, scientists will be able to reverse engineer new treatments. 

While a cure for HIV remains elusive, this research is bringing us closer than ever to that goal. There are multiple trials trying to mimic the responses found in elite controllers around the world, and the results of these efforts will emerge over the next five years or so, which is quite an exciting prospect, Saez-Cirion said. “We need additional tools that will allow people to live with HIV but without antiretrovirals. And if we can cure it — even better,” Saez-Cirion said.

“Wait, I can feel that?” Ami Brasure remembers thinking.

For most of us, the experience that dazzled her couldn’t be more ordinary: You’re standing around, maybe in your kitchen or living room, drinking something a little too carelessly, and before you know it, the liquid is dribbling down your chin and trickling down your chest — and you can feel it. It’s a familiar sensation (in this case, perhaps an embarrassing one). But for Brasure, a 50-year-old retail sales manager from the Washington, DC, area, it was life-affirming. 

At the time, she was recovering from a double mastectomy in the wake of a stage one breast cancer diagnosis. She vividly remembers the chill from her spilled drink as it snaked its way inside the compression garment she was wearing as part of her recovery process. The sudden dampness came as a shock — not because it was unpleasant, but because she never expected to feel anything in that area at all, certainly not so soon after surgery. 

As Brasure knew, many people who get mastectomies are left with little to no feeling in their chests. That loss of sensation can affect a patient’s psychological well-being, sometimes actively alienating them from their bodies as they adjust to life after treatment. 

“Every patient will have their own surgical goals. And mine was to look and feel as close as I did to how I looked and felt before I went into that operating room,” Brasure told me.

So when Dr. Lucy De La Cruz, chief of breast surgery at MedStar Georgetown University Hospital, offered Brasure the chance to be the hospital’s first patient to undergo a surgery that deployed a new robotic nipple-sparing mastectomy technique, she was enthusiastic. Especially because it was a procedure that some surgeons and studies have suggested leads to better preservation of feeling. 

Using a robot to aid a mastectomy is not entirely novel — surgeons around the world have been experimenting with this technique for the past decade. 

But what is new is that De La Cruz’s novel surgical plan combined several procedures into one operation. Using the da Vinci single-port robotic surgical system, she removed the breast tissue while preserving the nipples and skin. In the same operation, her team checked the lymph nodes, reconstructed the breasts with implants, and reconnected the nerve to the nipples to help restore sensation. In most robotic nipple-sparing mastectomies, the surgical incision is made along the armpit or the side of the chest. But here, De La Cruz and her team did everything through a single, 4-centimeter incision on each breast, naturally hidden under its fold. The hidden surgical scar and shorter recovery period, along with the possibility of having sensation back in her breasts post-surgery, were alluring for Brasure.

Normally, surgeons performed nipple-sparing mastectomies through more conventional “open” techniques, typically through a long incision at the bottom of the breast. It is a technically challenging operation. Breast tissue extends all the way up to the collarbone, and surgeons have to reach it through a tight space with limited visibility, relying on their hands and eyes to look and feel their way around the breast. An assistant often uses large metal retractors to lift the skin around the incision to keep the area exposed and visible. 

The procedure also carries a known risk of injury to the skin and nipple, sometimes severe enough that patients can lose the nipple and surrounding skin. These challenges led some surgeons to explore whether a robot-assisted surgery could help mitigate certain risks of open nipple-sparing mastectomies. But it was only in December 2025 that the Food and Drug Administration specifically cleared the use of the da Vinci single-port machine to perform mastectomies in the United States. 

And at least for Brasure, it seems to have made all the difference, helping her feel better connected to her body after a procedure that might, under other circumstances, have left her with a radically altered sense of it.

In theory, robotic nipple-sparing mastectomies sound like an amazing example of where surgical technology can take us. The American Cancer Society estimates that, in 2026, about 321,910 new cases of invasive breast cancer will be diagnosed in women. Many women opt for mastectomies not just as an active cancer treatment but also preventatively to reduce their risk, especially when they have a BRCA mutation — which indicates a very high likelihood of developing breast cancer — or a family history of the disease. A surgery with the potential to preserve more sensation, leave fewer surgical scars, and allow patients to recover more quickly promises to be a boon to women’s health. 

Instead, robotic nipple-sparing mastectomies have proved extraordinarily divisive among oncological surgeons. Some, including De La Cruz, have embraced them. Others worry that the technology has gotten ahead of the evidence, especially on one of the most important measures in cancer treatment: making sure that the cancer doesn’t come back.

The case for robotic mastectomies

Maleeha Aziz, a 33-year-old deputy director at an abortion fund in the Dallas-Fort Worth area, grew up around breast cancer. 

Aziz was 3 years old when her mother was first diagnosed. As a child, even though she couldn’t completely understand what was happening, she remembers her mother slowly losing her luscious, thick hair and how she could no longer pick Aziz up after the double mastectomy surgery. 

It was clear that there was a family history, and Aziz felt like the cancer wasn’t skipping a single person. Her nani, or maternal grandmother, and her aunt had been diagnosed with ovarian and breast cancer, respectively. But the last straw was when her 32-year-old cousin — as close to her as a sister — received a stage three breast cancer diagnosis while she was pregnant. 

Having seen the ravages of the disease firsthand and knowing from genetic testing in her early 20s that she was a BRCA carrier, Aziz ultimately decided that it would be better to get a preventative double mastectomy and reduce her cancer risk rather than live with pervasive anxiety from screening to screening. 

“Preventative care is not radical. What is radical is to get cancer,” she told her family when they worried that it was an unnecessary medical intervention. A preventative mastectomy can lower the risk of breast cancer by close to 90 percent. 

Aziz, like Brasure, was keen on sensation preservation. She remembered hating the numbness on her abdomen after her C-section delivery when she had her daughter, and couldn’t imagine the same around her breasts. 

So in 2023, at the age of 29, Aziz opted for a preventative robotic nipple-sparing mastectomy at the University of Texas Southwestern Medical Center as part of surgical oncologist Dr. Deborah Farr’s study on the feasibility of using the da Vinci single-port machine to perform the procedure. Farr was one of the few who were approved by the FDA to research and perform the robotic nipple-sparing mastectomy before it was officially cleared in 2025. More than three years later, Aziz has no regrets about her decision, especially since she has “pretty decent sensation” in her breasts, unlike her cousin who underwent a traditional mastectomy.

Aziz isn’t alone in her desire to preserve sensation in her breasts. 

Breast cancer, like all cancers, can prove to be a psychological malady as surely as it is a physical one. Body image is about much more than just appearance, said Danielle Saff, an oncological social worker at CancerCare, a nonprofit providing support and counselling for people diagnosed with cancer. Body image is also about familiarity with one’s body, connections and sensations. 

Saff told me that she often encounters patients who feel guilty for caring about things like how their breasts will look or how their body will change, fearing that such considerations are trivial when their lives are on the line. But patients must be allowed to ask these questions, Saff said, because they are important to their life after treatment. 

“When treatment ends, [that] doesn’t mean that one’s life goes back to quote unquote normal,” Saff said. “There’s so much adjustment that happens and so much grief throughout the process.”

Losing sensation in the breasts or nipples can also affect how some patients experience intimacy, Saff said, because the surgery can affect how they feel about their changed bodies. 

But for De La Cruz, however, sensation preservation goes beyond helping patients still enjoy intimacy after mastectomies — it is also about safety. What if boiling water splashes on you while you’re cooking or you accidentally hit yourself with a curling iron while doing your hair in the bathroom, she noted by way of example. Being able to feel external stimuli like pain, heat, cold, or pressure on your body is key to protecting it. 

How robotic surgery works

In a robotic mastectomy, the surgeon sits at a console a few feet away from the patient and controls every movement of the machine’s instruments with their hands. The da Vinci single-port robot, the version cleared for nipple-sparing mastectomies, has one arm that enters the body through a single small incision usually along the side of the chest or, in some cases, in the fold beneath the breast. The arm has three multi-jointed instruments at one end, which the surgeon can use to bend, grasp, and dissect breast tissue, nerves, and blood vessels much like they would with their wrists and fingers in a traditional non-robotic (“open”) surgery. Usually, a plastic surgeon is also in the operating room ready to begin reconstruction once the cancer is removed.

Because these robots also have an endoscope — a medical device with an attached light used to look inside body cavities — the interior of the breast is visible to the surgeon in great three-dimensional detail and size on a display screen outside the body. This makes it much easier for surgeons to navigate complicated tissue and nerve structures once they have been properly trained on the robot.

Aziz’s surgeon, Farr, a surgical oncologist who specialises in breast cancer at the University of Texas Southwestern Medical Center, believes that the robotic nipple-sparing mastectomy is essentially the same as the open one, but with much better control and visibility. 

At UT Southwestern, she often taught doctors how to perform procedures like the open nipple-sparing mastectomy.

“It is a procedure that is technically challenging for breast surgeons, and it’s really difficult for us to teach because really the only person who can see anything is the operating surgeon,” she said, adding that it’s difficult to communicate the steps and what the trainee should be doing if they can’t see inside the body.

In a traditional mastectomy, the surgical cut is held physically open with instruments called retractors, which can cause considerable physical trauma and pressure in the area around it. By contrast, in robotic surgery, carbon dioxide gas is used to open up the space in a much gentler manner. Farr believes that reduced trauma to the skin and better visualization of structures (and hence increased ability to avoid critical nerves) in robot-assisted surgery could be the reason that some patients report more sensation after nipple-sparing mastectomies performed with the da Vinci single-port machine. 

Notably, in her own patients, she did not see a difference in pain or other recovery metrics for those who opted for robotic surgery compared to those who opted for an open surgery instead. That makes sense to her because, as far as she’s concerned, she is doing the same surgery, open or robotically, just using a different tool. 

Nevertheless, the enhanced three-dimensional visualization, better likelihood of preserving breast sensation, and the ability to more easily teach the operation to trainees make it worthwhile for her to continue practicing and studying robotic nipple-sparing mastectomies.  

Why is the procedure so divisive?

Despite all of that — the potential for patients and the advantages for surgeons alike — robotic nipple-sparing mastectomies remain controversial. 

Surgeons we spoke to who remain cautious about adopting robotic nipple-sparing mastectomies are worried about one thing in particular: No study has yet shown clinical evidence that, in the long term, the patients who have undergone robotic nipple-sparing mastectomies have the same cancer survival outcomes as compared to open nipple-sparing mastectomy patients. 

Their fear appears to have a valid basis. 

In the United States, robot-assisted or laparoscopic surgery began to be broadly adopted around 2006 as a minimally invasive method to perform radical hysterectomies, a surgery in which the uterus, cervix, both ovaries and fallopian tubes, and nearby tissues are removed, usually as a treatment for early-stage cancers. There was limited research at the time to show that doing it this way produced long-term survival outcomes for patients that were equivalent to open radical hysterectomies — the existing, accepted standard of care.  

Then, a randomized controlled trial published in 2018 found that patients who underwent the minimally invasive version of the radical hysterectomy had lower rates of disease-free survival as well as overall survival. In other words, the more traditional, non-robotic approach was better for patient health in the long term. The researchers note that the study was not designed to establish what is causing this result and that it is still unclear.    

While robot-assisted hysterectomies may or may not be the most appropriate analog for nipple-sparing mastectomies, it remains true that it is a robotic procedure that received widespread attention, was adopted quickly, and ultimately seems to have had worse outcomes.    

In fact, the FDA referenced that radical hysterectomy study when it published two warnings in 2019 and 2021, cautioning against the practice of robotic breast surgery without a proper randomized controlled trial with long-term evidence on cancer metrics. The FDA asked that anyone experimenting with robotic nipple-sparing mastectomy should do so only within the boundaries of a clinical trial that it approved. 

Soon after, Intuitive — the company that manufactures the single-port da Vinci machine — sponsored a randomized controlled trial that was set to wrap up in 2031 and even published data from the initial 74 participants this year. It concluded that using the da Vinci single-port machine was feasible for robotic nipple-sparing mastectomies and that its safety was comparable to the open procedure in terms of early outcomes after the surgery and the ability to neatly remove tumors. It is worth noting that the robot-assisted surgery takes longer than the open one — so the patient spends more time under anesthesia — but the researchers largely attributed that to the unfamiliarity of surgeons with robotic surgery. They believed that operating time would reduce with better training and exposure to the machine. 

The researchers themselves acknowledge that published results from this study were focused on safety and early post-surgical outcomes, and they say that long-term oncological outcomes will likely be published later. The study was also statistically underpowered due to the small number of participants — enrollment of patients was stopped after FDA clearance was granted in December 2025. 

In a written statement to Vox, an Intuitive spokesperson said, “Da Vinci SP’s clearance for NSM was supported by a robust evidence package for this indication, including a U.S. randomized controlled trial comparing da Vinci SP with open surgery and global evidence from some of the regions where da Vinci SP was already approved for NSM — Europe, Japan, Korea and Taiwan.” They added that the FDA cleared the device after stringent review of the evidence. 

The company also said that patient safety is their top priority and noted that they will continue generating evidence for both short- and long-term outcomes in patients undergoing robotic nipple-sparing mastectomy using the da Vinci single-port machine globally.

The FDA cleared the da Vinci single-port for use in nipple-sparing mastectomies under what’s known as the 510(k) process, which is used for “low to moderate risk” devices if they are “substantially equivalent” to another device that has already been cleared by FDA before. In a written statement to Vox, the FDA said that the clearance reflects their evaluation of the evidence submitted by Intuitive and available scientific evidence under the “applicable regulatory framework.”

“Importantly, the clearance is based on the device’s use as a surgical tool, meaning the sponsor demonstrated that the device can be used safely as a tool in performing nipple-sparing mastectomy procedures,” said the FDA. “This differs from evaluating the device as a potential treatment for cancer, which would require evidence supporting its effectiveness in treating the disease.”

In other words, the FDA found that the device was safe for surgery, but it withheld judgment on whether performing robotic nipple-sparing mastectomies with the da Vinci single-port surgical system would lead to optimal cancer outcomes. In their statement, the FDA also said that they would continue keeping an eye on it (along with other devices they have cleared) and may take additional regulatory action if patient safety is affected. 

Despite the initial data and what Farr describes as “favorable” evidence from studies outside the United States, some critics strongly believe that no conclusive long-term evidence is available to show that robotic mastectomies are at least as effective as open mastectomies in treating cancer. 

Dr. Laurie Kirstein, surgical oncologist at Memorial Sloan Kettering Cancer Center, said that most of the studies done to date establish that robotic nipple-sparing mastectomies are technically safe, which is the first level of evidence needed to evaluate whether they can be more widely performed. For example, such studies consider metrics like whether patients experience bleeding complications or abnormal levels of skin or tissue death called necrosis. 

But, she also notes, the evidence still doesn’t move beyond that to establish strong cancer outcomes, either because the clinical studies are not designed to test for those outcomes or because there isn’t data on long-term outcomes from a randomized controlled trial in a well-defined patient population. 

“After a mastectomy, you’re only going to be getting a physical exam twice a year, right? So there’s no imaging screening,” Kirstein said. “So the mastectomy has to be good enough oncologically to reduce the amount of breast tissue left behind, and that has to be done and proven without a shadow of a doubt, and unfortunately right now those studies don’t exist.” 

What Kirstein is getting at is that the mastectomy surgery, which removes most or all breast tissue, is meant to be the ultimate safeguard. Once the patient undergoes that procedure, regular breast cancer screenings like mammograms generally stop, unless the doctor or patient feels something is abnormal, and the patient is instead monitored through physical exams. If any breast tissue is accidentally left behind, it could be harder to catch a cancer recurrence early. 

In contrast, people who opt for a lumpectomy — a surgery to remove breast tumors while preserving the remainder of the breast tissue — keep getting regular breast image screenings. That’s why surgeons are asking for irrefutable proof that the robotic approach removes the breast tissue just as thoroughly as open surgery does. In the absence of that certainty, some worry that the possibly more selective excisions in robot-assisted surgery may leave an opportunity for cancer to spring up, possibly unmonitored.  

A medical catch-22

Bringing exciting new medical technologies to the market in a responsible manner almost inevitably invites a paradox of sorts. Irrefutably showing that a new surgery is at least equivalent to existing methods and safe, requires performing it on real patients to gather data. And yet without data, there is considerable risk in subjecting patients to it.  

Clinical trials are meant to resolve that tension by testing a new technique under close oversight before it becomes routine. In this case, though, the FDA cleared the robot before Intuitive’s trial was complete, and the trial stopped enrolling patients soon after.

“I truly believe it is a better surgery when done properly,” Farr said. “It was a blessing and a curse that it was approved when it was.” 

For years, only her own study team could use the robot for these surgeries. Now she can teach it to her residents, fellows, and surgeons around the country. But once a device is cleared, “there’s really no further regulation in terms of who can do it and who can’t,” she said. That decision now rests largely with hospitals and with patients. 

Dr. Rosa Hwang, a surgical oncologist at the University of Texas MD Anderson who worked on Intuitive’s US trials, said surgeons will need dedicated training to learn how to perform robotic nipple-sparing mastectomies safely. She chooses her own robotic nipple-sparing mastectomy patients carefully. 

“I err on the side of being conservative for the robotic nipple-sparing mastectomy,” she said. Someone who might be a reasonable candidate for an open nipple-sparing mastectomy, for example, isn’t automatically one for the robotic version.

Farr said that she can understand why critics are skeptical about the existing data on robotic nipple-sparing mastectomies and while she believes the surgery needs more study, she doesn’t think that’s a reason to abandon it. She believes that criticism is healthy for the field, ultimately helping surgeons learn more and better test for the best outcomes.  

“I have a lot of respect for the people who have criticized me,” Farr said. “The response to critics,” she said, “should be not with defense but with data.”

If there is one thing that surgeons on both sides of the robotic mastectomy debate agree on, it’s that patients are asking for this. For women like Brasure and Aziz, beating breast cancer or avoiding it altogether was never the only goal. They also wanted to come out the other side living normal, safe lives in bodies that still felt like their own. The robot may or may not turn out to be the best way to get there — only long-term data will tell. But what’s already clear is that for many women, sensation is no longer an afterthought.

“Nothing feels the same,” Aziz said, “but I have feeling pretty much everywhere, and I feel good.”

Unlike projecting how many jobs AI may eliminate over the next 10 years, or what a country’s birth rate might look like, there’s far less debate among policymakers about how large America’s older population will be in a decade’s time, and how many of them are likely to need direct care for disabilities.

By 2036, as the baby boomers continue to retire, the US population 65 and older is expected to grow from 65.6 million to 77.5 million people, according to the Congressional Budget Office. The number of people 85 and older is also expected to nearly double in that time, from 6.8 million to 11.1 million.

The question of whether the United States will have enough direct care workers — an umbrella term that refers to home health aides, personal care aides, and nursing assistants — looms large. These are workers, primarily women, who help older adults and people with disabilities bathe, dress, eat, take their medication, and generally get through a day, either in a nursing home or in someone’s own home. It’s a massive, often ignored workforce (the American Community Survey estimates there were 3.62 million of them in 2024) and it’s paid for largely by Medicaid, the joint federal-state health insurance program that most people associate with coverage for impoverished Americans but which is actually the dominant payer for long-term care in this country. 

Depending on which researcher you ask, the US will need somewhere between 625,000 and 1.3 million additional direct care workers over the next decade to keep pace with the growing number of older and disabled Americans — and that’s just to maintain today’s level of care as the population ages, not to fix the shortage that already exists. If you’ve talked to anyone currently trying to coordinate long-term care, you probably already know the country is understaffed as it is.

To close the gap, policy experts say the United States should bring more immigrants into a sector that’s already about one-third immigrant, while also protecting the roughly 12 percent of current direct care workers who are noncitizens, some of them undocumented. PHI, a national nonprofit that researches and advocates for the direct care workforce, projects 9.6 million direct care job openings between 2025 and 2035, the bulk of which will come from existing workers changing fields, retiring, or otherwise leaving the workforce.

“We can’t do it with the current US-born workforce,” Amy Robins, the senior director of policy at PHI, told me. “We need to have mechanisms where people can come into this country and do this work.”

Immigration reform has felt politically impossible in Washington for years, but after the brutal defeat Republicans suffered in the midterms, there’s a suddenly a much stronger case that this corner of the fight is different. Days after the election, President Donald Trump gave an interview saying his deportation policy was “too tough” and he’d be open to some sort of immigration reform deal to protect workers. In September 2025, Sens. Kevin Cramer (R-ND) and Dick Durbin (D-IL) reintroduced a bill to recover green cards that went unused in earlier years and redirect them to nurses and doctors. Coordinating care for older adults is a problem that reaches families in every corner of the country, and even comfortable households wonder whether they can secure a dignified life for an aging parent, or, eventually, for themselves.

With family caregivers growing in number and nursing homes turning residents away because they can’t find staff, caregiving may be the one corner of immigration policy Congress is actually willing to fix.

A growing menu of options

Over the last year or so, three different proposals have emerged that suggest that caregiving is the immigration battle Washington is finally ready to fight. 

In July 2025, Reps. María Elvira Salazar (R-FL) and Veronica Escobar (D-TX) introduced the Dignity Act, which pairs tougher border enforcement with legal status for undocumented immigrants who’ve been in the country since before 2021. It also offers permanent residency for Dreamers and a handful of green card reforms. Salazar herself has pitched the bill partly as a remedy for the same aging-population squeeze driving the caregiver shortage, and eldercare groups such as LeadingAge and the American Seniors Housing Association have thrown their support behind it. 

The legislation rests on an idea at the center of the caregiving political fight, which is that immigration enforcement alone won’t get the US the labor it needs.

Since then, the Dignity Act has gathered around 40 cosponsors, split nearly down the middle between the parties, and this spring it won the endorsement of the Problem Solvers Caucus, a group of roughly 60 members whose mandate is passing legislation both sides can live with. Following Trump’s recent comments that he’d be open to an immigration deal, Salazar praised him on X, urging him to throw his weight behind the Dignity Act. “You can surpass Reagan’s legacy by delivering a historic immigration reform,” she posted. “This is your moment.”

There are other ideas on the table, too. Over the summer, Rep. Gabe Vasquez (D-NM) introduced the Careworker Visa Act, a bill that would create a new temporary visa allowing up to 100,000 immigrants a year to work in childcare, eldercare, and home-based disability care. It would also let some immigrants already living in the US obtain work authorization through the program and give participating workers a pathway to permanent residency.

“We all know that immigrants are already taking on these jobs in large numbers,” Vasquez told me. “One of the conversations we’re having amongst the Democratic coalition is how to craft meaningful immigration-related legislation that can be bipartisan on a couple specific issues. And certainly this bill rises to the very top of that conversation.”

And the most recent entry came in September, from Tara Watson, an economist at the Brookings Institution. In a new caregiving visa proposal, she offers the idea of a visa open to immigrants with at least two years of direct care experience who want to come to the US to work as home health aides, personal care aides, or nursing assistants. It would start at 30,000 visas a year before rising to 65,000 after three years, and employers would have to pay above-market wages and provide health insurance.

Learning from what didn’t work

Neither of the two dedicated caregiving visa proposals is starting from scratch. In 1999, Congress created a visa for nurses to work in understaffed hospitals, but the process had such strict eligibility rules that fewer than 15 hospitals nationwide ever qualified to use it. And it was burdensome for qualifying workers, too: If a nurse ever wanted to switch their hospital, they had to start their visa certification process all over again. Over the course of a decade, barely a thousand visas were ever issued, and lawmakers let the program expire in 2009. 

Other countries have gone the opposite direction. The UK made care workers eligible for its Health and Care Worker visa in 2022, and the numbers took off almost immediately, with 106,000 visas granted in 2023 alone. But exploitation was rampant. Some contracts required workers to repay thousands of pounds to their employer if they left before their visa term was up — one worker’s contract demanded more than 11,000 British pounds — which made leaving a bad job financially impossible for people who’d often already gone into debt just to get the job in the first place. More than 43,000 workers were affected when their employers’ sponsor licenses were revoked amid widespread reports of exploitation. The UK ended overseas recruitment for care workers in 2025, though the broader Health and Care Worker visa remains in place.

Both experiments reflected the fact that workers often had no way out, no matter how poorly an employer behaved. Watson and Vasquez say they kept that front of mind when crafting their proposals, both of which allow workers to switch jobs rather than staying locked to whoever sponsored them. 

“You really do see this tension — the more you try to make sure the workers are protected, the more onerous it becomes for the employers,” Watson told me. “You’re choosing between scale and some of those restrictions. I’m trying to hit somewhat of a middle ground.”

Vasquez pointed to the H-2A visa program for farmworkers, which he said has also had real, ongoing problems with employers abusing the system. 

“Anytime that we are creating new programs for immigrant workers in which their job status depends on them achieving legal status, we should always be aware that there may be bad folks that are seeking to abuse that system,” he told me. “That’s going to require some thoughtful support for the Department of Labor for enforcement of laws just like this.”

States can’t fix this alone

These federal ideas build on top of a patchwork of state-level attempts to raise direct care wages in order to incentivize more people living here to enter and stay in the field. Yet for all the state mandates, bonuses, and training programs, care programs are usually among the first casualties when money gets tight. And even in states that have pulled off real wage increases, inflation has frequently swallowed those gains before they could do much to close the gap.

LeadingAge, which represents nonprofit nursing homes, assisted living communities, and home care agencies, says no single state’s budget can fix this. Linda Couch, the organization’s senior vice president of policy, says states are now facing significant cuts to their Medicaid funding under last year’s federal budget law, which will squeeze what providers can pay their staff.

“Federal policymakers hold a lot of the cards for systemic change to meet the needs of older adults,” Couch told me. “Without action to secure immigration reform and reverse Medicaid cuts, we’re putting access to aging services at risk for older adults across the country.”

LeadingAge’s members are already feeling this. Couch said one of its Massachusetts members, Hebrew SeniorLife, had to let go of nearly 40 Haitian workers this year after their Temporary Protected Status ended, some of whom had worked there for more than a decade. A Florida provider lost 10 workers from Cuba and Haiti after a humanitarian parole program shut down.

Congressional Republicans to date have primarily rallied around tax credits and retirement protections for the nation’s 63 million family caregivers. Robins of PHI, though, doesn’t see the two approaches as inherently at odds. 

“There are way more family caregivers in this country than there are direct care workers, and that will always be true,” she told me. It’s a “yes, and” when it comes to supporting family caregivers, she said, and direct care workers are a “fundamental way that we support family caregivers who are taking on tremendous care responsibilities in our country right now.” A paid home health aide coming a few days a week, in other words, can be what lets a daughter or spouse keep working, or just get a full night’s sleep, while still caring for a parent at home.

The population who will need this care by 2036 is already here. It may not be much, but caregiving, as Watson said, is “low-hanging fruit, if there is any low-hanging fruit.” In an immigration debate this stuck, that counts for something.

Your Mileage May Vary is an advice column offering you a unique framework for thinking through your moral dilemmas. It’s based on value pluralism — the idea that each of us has multiple values that are equally valid but that often conflict with each other. To submit a question, fill out this anonymous form. Here’s this week’s question from a reader, condensed and edited for clarity:

I’m considering moving my family from a red state to a blue state. I’ve lived in a red state my whole life, and as a lesbian with a wonderful trans wife, it is hard. Moving to a blue state could give my wife and I better nondiscrimination protections, better worker protections, and better access to health care.

However, I feel like moving would be abandoning the good fight in my home state. I am well aware of how the red state exodus and the red state brain drain are already affecting our community. It’s hard to weigh what may be best for my wife against what’s best for our fellow red state residents.

Dear Should I Stay or Should I Go,

I feel your question deep in my bones. Not long ago, I made the decision to move with my partner from the US to Canada, where I’m originally from. We’re also a queer couple. And we grappled with many of the same questions you’re wrestling with now.

Is it selfish to leave? If you leave, would you be putting your own family’s well-being above the well-being of your wider community? Does that mean you’re reneging on your values? 

A few key philosophical ideas really helped me navigate these questions, so I’ll walk you through them. Whether you agree or disagree, they should clarify the terms in a way that makes it easier for you to decide one way or another.

Let’s start with your concern about how to weigh what’s best for your wife against what’s best for your wider community.

One strain of thought in modern philosophy — promoted by utilitarians like Peter Singer — says that we should aim to maximize the overall good, and that means doing good impartially rather than prioritizing certain people just because they happen to be our nearest and dearest. This perspective has become so influential in the past century that it’s probably shaping your thinking here, even if you’re not explicitly aware of it.

But I want you to know that other philosophers have pushed back. Bernard Williams, a staunch critic of utilitarianism, argued that it can actually be totally normal and morally appropriate to show partiality toward our loved ones.

In a famous passage, Williams said that if a man sees two people drowning, and one is his wife and the other is a stranger, and he pauses to consider whether rescuing his wife would maximize the overall good more than rescuing the stranger, he has had “one thought too many.”

Williams argued that moral agency does not sit in a contextless vacuum — it is always some specific person’s agency, and as specific people we have specific commitments. When you got together with your wife, you made a commitment to ensuring her well-being, over and above your general wish for all people everywhere to be well. Utilitarianism says you have to consider everyone’s well-being equally, with no special treatment for your own family members — but to Williams, that’s just an absurd demand. It alienates you from a core part of yourself, destroying your integrity as a moral agent.

According to this view, putting your wife’s safety first isn’t some moral lapse that should embarrass you. Honoring special obligations to our nearest and dearest is actually part of what makes a life ethical.

Besides, even though living an ethical life does sometimes involve being willing to sacrifice some of our own well-being, it’s important to recognize that everybody exists at a different vulnerability level. We shouldn’t expect someone who’s trans to take on risk to the same degree as someone who is not particularly marginalized or endangered. 

Given the assault on trans rights in recent years, I’d be really skeptical of anyone who tries to argue that you and your wife have a moral obligation to stay put and “fight the good fight” if she’d be happier and safer elsewhere. Mind you, I also want to caution you to consider all the factors that go into making a happy life before you come to any decision about moving. If your wife has a robust and loving community of friends in your current red state, but knows nobody in the blue state you’re thinking of moving to, she may end up unhappier there on balance. (Plus, as the recent midterms showed, red states don’t necessarily stay red, and even blue states can pass anti-trans rights ballot measures.)

I also think a bigger reframe is in order here. You say, “I feel like moving would be abandoning the good fight in my home state.” But would it really? I’d argue that the key consideration is: Where can you keep fighting the longest? The hardest? The most effectively?

The work of contemporary philosopher Lisa Tessman is instructive here. In her book Burdened Virtues, she argues that situations of oppression can demand certain traits of people — like sustained anger at injustice, fierce loyalty to one’s group, constant vigilance and sensitivity to others’ suffering — that can damage the people who embody them even though they are real virtues. These traits can undermine the well-being of the bearers over time, keeping them from flourishing. What’s more, they can potentially even warp their bearers’ moral character — for example, when anger grows into an all-consuming state. 

You said that you’ve lived in a red state your whole life and found it hard. So I think it’s worth asking yourself: Are the traits you’ve had to develop under those circumstances — however virtuous they may be — actually eroding your ability to keep showing up, both for yourself and for your wider community, in the way you’d like? If you feel that, say, constant vigilance is starting to take its toll, moving might give you a mental reset that allows you to be more — not less — active in enacting your values.

Plus, a quick look at the historical record can defuse the idea that leaving a place means “abandoning the good fight.” Consider what happened in the Great Migration, the exodus of Black Americans from the Jim Crow South. Did those migrants “abandon the good fight”? Absolutely not. Once in the North and West, they built up political power and institutions that ended up feeding into and supporting the civil rights movement. 

The point is not that the two situations are exact parallels — they aren’t. The point is that when people leave a place, they can choose to use the affordances of their new home in a way that helps their old home. So, although worries about a red state exodus and red state brain drain are totally understandable, I don’t think they decide the question of whether a move would be net-negative or net-positive for your wider community. 

What will decide that is what you choose to do with your newfound resources — including, plausibly, an increased sense of safety, security, and mental health — if you do relocate. 

Life gets busy really fast, especially after a big move. (I should know — months after moving, I still haven’t gotten around to putting up any art on my walls!) So, if you leave your home state, my strong recommendation to you is this: Make a plan, in advance, for how you will keep fighting the good fight once you reach your new destination. Will you organize remotely? Can you connect right now with the relevant leaders at red state groups you want to support? Which organizations will you donate to, how much will you give, and when?

To boost accountability and prevent mission drift, be as concrete and specific as possible, discuss your plans aloud with your wife, and write them down.

And once you’ve done all this? My dear, let go of your guilt and live.

Bonus: What I’m reading

• I loved this Aeon essay about “love with nowhere to go.” It notes that, although we have established social scripts for grief that arises in the wake of a death, we don’t have practices for recognizing and working through grief that’s not death-related. That’s a problem because “when we are unable to honor other profound losses, we become strangers to ourselves.”

• Noema published an absolutely wonderful piece by Atoosa Kasirzadeh on how AI is changing math — and how it should! In fact, the AI revolution can have the great effect of reorienting the field to things that really matter according to humans. In my opinion, this is a model for how many other fields should adapt, so it’s really worth reading even if you’re not “a math person.” 

• Most Westerners don’t have a good window into how people in China think about AI. So I was excited to see Persona publishing Jen Zhu on why the West’s habit of thinking about AI as an arms race misses the mark from a Chinese perspective. “When you watch a competitor sprint, you assume the finish line is the same as yours,” she writes. “But China is not running America’s race. It is continuing a 3,000-year-old project of ordering society as a single organism, harmonized rather than unleashed.” 

Editor’s note, October 4, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last year.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

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My partner and I did IVF recently and luckily we ended up with several embryos. One of those will be implanted in me so I hopefully get pregnant. But which one?

My fertility clinic is encouraging me to do PGT-A testing, which would screen for things like Down syndrome and would also let me see the sex of each embryo so I could potentially choose whichever I want. (And to be honest, I really want a girl!) I’m also hearing about these new companies that can test embryos for all kinds of things — like how smart the kid might be, how tall they’ll get, and whether they’ll have a lower chance of getting breast cancer, diabetes, mental illness, stuff like that.

I don’t know how to feel about any of this. On the one hand, it feels weirdly eugenics-y to do so much tinkering with embryos, and I can’t help feeling a little pressured into overmedicalizing everything with these expensive tests. But then again, if I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power? What does a parent owe their child?

Dear Expecting,

This is such an exciting — and also confusing — time. You’re about to have your first kid, and that comes with all sorts of fears and insecurities and hopes and dreams. You want to do the right thing — no, the best thing! — for your child. It’s a beautiful impulse. Unfortunately, it makes it easy for companies to prey on you.

So let me walk you through what these companies can and can’t really provide. After we talk about the science, we can talk about the ethics. 

The simpler test you mentioned, PGT-A, has been around since the 1990s. It can indeed screen for conditions like Down syndrome and let you see the sex of each embryo. Mind you, that doesn’t predict what gender your child will ultimately end up identifying with — more on that soon.

The newer testing you mentioned is called polygenic testing. The conditions it screens for are complex ones, influenced by thousands of genes. We’re talking about everything from breast cancer to depression. Some companies even offer screenings not for disease prevention, but for genetic enhancement — so you can select for a taller kid or a kid with higher IQ.

Polygenic testing companies claim to predict each embryo’s risk for each condition, and the potential reduction of risk you’ll get if you choose one embryo over another. As the statistical geneticist Sasha Gusev explains, it’s very, very easy to be misled by this claim. If the company claims to lower absolute risk of Type 2 diabetes by 12 percent, you might think this means, “The chance of my kid ever developing diabetes just went down by 12 percent — great!” But really what it means is that, all else equal, a kid who would’ve developed diabetes is likely now at the high end of pre-diabetes instead, or just develops diabetes a few years later. The same holds true for other conditions, like breast cancer. Sure, if your kid is going to develop diabetes or breast cancer, you’d rather they develop it later — but it’s not the bill of perfect health customers might imagine.  

“Typical risk reduction estimates tend to exploit statistical assumptions to overstate their benefits and lead to confusion,” Gusev writes.

It’s also important to note that there’s a difference between a physical disease like cancer, which is straightforwardly and universally negative, and a complex mental health condition like depression. For one thing, polygenic scores don’t perform as well in psychiatry, as the psychologist Eric Turkheimer notes. Plus, most mental health conditions come in mild to moderate to severe forms, and it’s not clear that we should want to get rid of mild or moderate manifestations. 

“Sure, it would be nice if no one ever got depressed, but what would that actually mean?” Turkheimer writes. “People are going to be sad, and the most modern models of psychiatric disorders view most of them as extremes on continuous dimensions of normal behavior. I don’t think we want some kind of genetic version of Soma.”

To give a personal example: I have generalized anxiety with some obsessive tendencies. Is that a major pain in the butt sometimes? You bet. But if I could wave a magic wand and get rid of it, would I? No. In my experience, this trait is linked to another trait I deeply value: my creativity. The same thing that propels me down rabbit holes of worry also propels me down rabbit holes of getting super curious about some topic, researching it into the wee hours of the morning, and then writing a novel or children’s book about it.

That brings me to one other scientific issue: pleiotropy. It’s a fancy term for a simple truth, which is that genes can have an effect on more than one trait. When it comes to behavioral polygenic testing, we actually know very little about which genes cause what — a gene that’s correlated with depression or anxiety may also be correlated with a bunch of other things. So, if everyone were to start selecting embryos to try to protect their kids from depression or anxiety, what would happen? We don’t know! 

Pleiotropy is a scientific issue, but it’s also a moral issue, because in trying to protect your kid from a negative outcome, you could also be accidentally barring them from a positive one.

And that’s just the tip of the moral iceberg.

Another issue is the potential psychological harm that can result from commodifying our kids — treating them like consumer objects with selectable parts. Let’s say you use polygenic testing to try to select for high IQ. Even if the company’s predictor is right 80 percent of the time, that means it’s wrong 20 percent of the time. What happens if it’s wrong about your kid, and they end up with a low IQ instead of a high one? How will your kid feel? Unless you hide the truth from them, they’ll know that they are not what you wanted, that they failed to live up to the vision you went out of your way to chase.

The same goes for sex selection via good old PGT-A. I know you really want a girl. But what would happen if you select for a girl, and then your child grows up and turns out to be trans? They may feel an extra sense that they’re letting you down by not conforming to the gender expectations you had for them.

Then there are the ethical questions around unequal access. Polygenic testing isn’t cheap. (One company, Orchid, charges $2,500 per screened embryo. Test 10 embryos and that’ll cost you $25,000.) So, at least in the short term, that raises the specter of entrenching a caste system, where the gap between rich and poor expands dramatically as the rich get smarter and stronger.

Technologies tend to get cheaper over time, so maybe everyone will ultimately be able to afford polygenic testing. But that raises another problem: implicit coercion. If more and more of us make ourselves smarter and stronger, we may create a society in which everyone feels pressure to alter their child’s biology — even if they don’t want to. To refuse embryo selection would mean to put a child at a huge professional disadvantage, or to face moral condemnation for making “suboptimal” kids when optimization is possible. Society may no longer offer health insurance benefits or accommodations for kids with disabilities (or even non-enhanced IQ), reasoning that “it was the parents’ choice.” 

Some philosophers, like Julian Savalescu, already argue that parents have a “moral obligation to create children with the best chance of the best life.” Polygenic testing companies love that argument; Orchid founder Noor Siddiqui tells parents that “the responsible decision” is to “protect their children” from disease, using language like, “What if you could have stopped it…but chose not to?” And we generally live in a culture that’s obsessed with optimization. 

So it’s no wonder that you find yourself asking, “If I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power?” 

It’s a view that will be very appealing to utilitarians, who believe the right action is the action that maximizes well-being or happiness. But maximizing principles can be dangerous. If we’re laser-focused on maximizing one value, however noble it may be, that can lead us to overlook a host of other important values. Think about diversity, for example; polygenic testing could lead to a less diverse world. 

And it’s not even clear how to maximize well-being given that each embryo will have some downsides: How would you choose between one embryo with a slightly elevated risk for schizophrenia, another with a moderately elevated risk for cancer, and a third with a high risk for Alzheimer’s? You’d have to decide how to rank the importance of each condition, which would require a dizzying bit of moral math: How much weight do you put on the longevity associated with each condition, how much on patient-reported quality of life for each condition, and how much on your own ability to cope with each — and society’s ability (which will change over the years)? Plus, even if the screening does end up optimizing life for your individual child, it could have negative effects on the population level, for the reasons we covered above.

As the Nobel laureate Herbert Simon pointed out, many problems contain way more variables and way too much uncertainty for maximizing along a single axis to be feasible or even desirable. So it often makes sense to just go with an option that’s “good enough.” He coined the term “satisficing” — a portmanteau of “satisfying” and “sufficing” — to describe opting for this good enough choice.

What would satisficing look like in the context of embryos? If there’s a very serious condition that runs in your family — like Tay-Sachs or the BRCA mutation that markedly increases cancer risk — then I do think there’s a strong case for screening for that. These conditions are debilitating and can lead to early death. Nobody wants them. Genetic testing that lets us prevent them is an awesome gift. 

Then there are conditions that can include suffering, like autism, but can also be very compatible with a happy life. Mental health conditions in particular are heavily socially constructed — a lot of the associated suffering comes about because society constructs a certain biological reality as a problem and doesn’t support the people who have it. In these cases, if you want to give your child a “good enough” or even “optimized” life, remember that you don’t have to achieve that by biological means; working to change the social environment can be just as important, and it doesn’t carry the societal risks associated with polygenic testing. 

Ultimately, when considering what counts as a “good enough” life, each parent will draw the line in a slightly different place. And there’s a part of that that can’t be boiled down to objective facts about disease, because this is also about how well-resourced the parent feels — emotionally, socially, and financially — to deal with a certain condition. What feels manageable to one parent may feel crushingly hard to another. 

So, I can’t tell you exactly which screenings to do and which to forgo. What I do want to tell you is to resist being bullied or shamed by others, especially those with a profit incentive to push you in a certain direction.

As the epidemiologist Abby Lippman has noted, genetic testing is supposed to offer parents more choice, but it too often has the opposite effect. When someone like Orchid’s Siddiqui says about a disease, “What if you could have stopped it…but chose not to?” — well, that language preys on parents’ worst fears and insecurities. It holds parents hostage while pretending to be giving them more autonomy. 

You are nobody’s hostage. You are a moral agent free to look at the many different relevant factors, weigh them all in the balance, and then make the choice that works well enough for your family.   

Bonus: What I’m reading

• Silicon Valley is obsessed with IQ, so it’s no surprise that tech execs there are using polygenic testing in hopes of creating supersmart babies. This article shows the kind of mental pretzels customers get into when trying to figure out whether to select the embryo with the highest predicted IQ or that with the lowest risk of disorders. One couple asks: “How much additional risk of ADHD cancels out against 10 extra IQ points?”

• Rereading “The Last Children of Down Syndrome,” Sarah Zhang’s 2020 Atlantic feature on prenatal testing, it struck me that when people think “prenatal testing,” Down syndrome is often the first condition that comes to mind, even though it’s not the most severe or straightforwardly negative (it’s compatible with a happy life). It’s just that Down syndrome was easy to test for, so we started testing for it early. I wonder if that built up the condition as a bogeyman in the expectant parent’s imagination — if the fact that we could screen for it shaped the public’s perception of Down syndrome as something that should be screened for and potentially screened out.

• One trait that many people assume we should select for is a great memory. But I highly recommend the short story “Funes the Memorious” by Jorge Luis Borges. It’s a reminder that having too good a memory is not always a benefit.  

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In the moody alcoves of a lobby bar in Chicago in 2021 over French 75s, Dr. Louise King, a gynecologic surgeon, and Katie L. Watson, a bioethics professor, found themselves in conversation about a topic that had long frustrated them both: Female surgeons are consistently underpaid compared to male surgeons, even after accounting for specialty, rank, age, and other factors. 

What troubled them even more was how the pay gap compounded in King’s own field. Surgeons who perform procedures that are specifically for women, like gynecological surgeries, are paid less for their services than surgeons who perform comparable surgeries for the male anatomy. Gynecologic surgeons are also predominantly women. Over the course of the conversation, Watson termed this situation “double discrimination,” a phrase that captures the overlapping dilemma of lower pay for surgeries in a specialty that is overwhelmingly female and also serves a primarily female patient population.

That term, which has since entered the medical literature, stuck because the problem it describes has been well documented for decades. In 1997, a group of gynecologic surgeons published a paper in the journal Gynecologic Oncology with a title that gets straight to it — “Is Adam worth more than Eve?” Dr. Barbara A. Goff, now chair of Obstetrics and Gynecology at University of Washington Medicine, and colleagues found that doctors are paid around 44 percent more for performing male-specific procedures than analogous female-specific ones. 

In the three decades since, the problem hasn’t been fixed. To the contrary, it has been effectively institutionalized, built into the systems and codes that determine how surgeons bill for procedures of all kinds. Today, gynecologic or female-specific procedures are in large part still reimbursed at lower rates than male-specific procedures even when they take similar time and skill.

Those disparities have consequences that extend beyond the compensation of individual doctors. When gynecological procedures don’t bring in as much money to hospitals, those same hospitals are disincentivised to offer women’s health services. That can lead to worse care for women and, crucially, fewer training opportunities for the surgeons who do that work. 

But this historically persistent inequality is not a foregone conclusion.

How healthcare services are billed changes all the time as procedures get reevaluated, new ones get added, and medical societies and experts push for revisions. In fact, one of the biggest changes in how maternity care is billed and reimbursed is set to take effect early next year, splitting up services for prenatal care, delivery, postpartum care, and more. While this is a long-overdue fix for obstetrics, gynecologic surgery — which covers most of a woman’s life outside of childbearing years — continues to be left out of the conversation. 

And although real change will require concerted efforts, King and Watson — and other advocates who have spent years documenting this disparity — have a fairly clear sense of how to start fixing it.  

How surgical procedures are valued

The work of deciding how much a medical procedure is worth starts well above the head of any given doctor, medical practice, or hospital. In the United States, the Centers for Medicare and Medicaid Services, a federal agency that administers healthcare and health insurance policies, sets rates for different procedures based on a metric called relative value units (RVUs). An RVU is supposed to take into account how long a procedure takes, the skill it requires, and the intensity of work it demands. Both Medicare and private insurers consider these figures when they’re settling on reimbursement levels. If a procedure has a higher RVU, it is valued more highly, and makes more money.

In a recent study, cheekily titled “Price and Prejudice,” researchers from the Mount Sinai Health System found that out of 55 pairs of sex-specific procedures that they evaluated in 2023, 75 percent had lower RVUs for procedures on female patients. On average, RVUs for male-specific procedures were 30 percent higher, and when those procedures were performed in a hospital or surgical center, surgeons were paid around 26 percent more.

For example, doctors will often perform biopsies — taking a small sample of tissues, cells, or fluids — on both male and female genitalia to diagnose problems. In 2023, researchers found that Medicare’s standard national rate for reimbursing surgeons was $121.32 for a penile biopsy but only $65.74 for a vaginal biopsy. 

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King, the director of reproductive bioethics at Harvard Medical School Center for Bioethics and a contributor on the study, believes that when the RVU system was created back in the 1990s, gynecological services were largely ignored, leaving the specialty undervalued from the start. While Medicare and Medicaid Services have undertaken some efforts to make RVUs more equitable across specialties over the years, that undervaluation has persisted. 

That problem may come down to how those values are determined in the first place — and who determines them. RVUs are set by a committee of doctors convened by the American Medical Association (AMA), with most of the seats allocated to members of major medical societies. The committee surveys different doctors on the time and skill required for procedures in their specialties. Based on these responses, the committee recommends values for each service to the federal government, which has historically accepted nearly 90 percent of them.

While the data quality of the underlying surveys has improved over the years, it is still not very high, said Dr. Miriam Laugesen, a tenured associate professor of health policy and management at Columbia University Mailman School of Public Health. Because the committee’s process isn’t transparent, it is often unclear what evidence its valuations rest on. This leads to distortions of all kinds, she said.

“It’s not a government process; It’s not a federal advisory committee,” Laugesen said. “It’s just a committee that was put together by the [AMA]. It’s pretty unusual in terms of how policy is made.”

In particular, King said that the surveys have a very low response rate from some specialties and are only sent to a small subset of doctors. She has never received a committee survey in the 17 years that she has practiced. 

The American College of Obstetricians and Gynecologists (ACOG) has a core seat on the committee that determines RVUs. But most ACOG members are general OB-GYNs, who split their time between obstetrics and gynecology and typically operate relatively rarely. The surgeons who perform the bulk of gynecologic operations are subspecialists – gynecologic oncologists, urogynecologists, and minimally invasive gynecologic surgeons — who complete an additional fellowship after residency. They mainly belong to their own societies and don’t have a seat at the table when RVUs are being determined. 

“From a purely cynical or economic standpoint, [ACOG] has no reason to advance billing for gynecology. It doesn’t represent a large portion of the practices of their members,” said King, adding that ACOG has been heroic in its efforts to obtain reimbursement equity for its own members. (One unintended possible result of that advocacy is that pushing for a smaller pay gap for services related to pregnancy has in turn sent the message that women’s bodies are literally worth less, and are less deserving of care when they’re not engaged in the god-given duty of reproduction.)

The result is that doctors in specialties like OB-GYN who operate infrequently are answering the surveys about complicated surgical procedures that gynecologic surgeons perform more frequently. King said that her surgical schedule aligned more closely with those of general surgeons. For example, she operates two to three times a week whereas, according to her, an average OB-GYN will likely operate once a month. 

“So they’re not the right people to be answering these surveys. They [the survey committee and ACOG] don’t target the surveys to people who operate a lot,” she said. 

Part of the problem with using surveys to determine a key foundation of medical reimbursements is that the data is self-reported by doctors. This is especially relevant when more objective avenues may be available. One of those avenues is the American College of Surgeons’ National Surgical Quality Improvement Program, which is an initiative that collects and manages key surgical data to track quality and improvement in surgical fields, including the actual time spent performing surgical procedures, making it a more definitive measure than self-reported surveys.

Dr. Shitanshu Uppal, a gynecologic oncologist and division chief for gynecology oncology services at the University of Michigan, and his colleagues analyzed 901,917 surgeries using both the National Surgical Quality Improvement Program as well as the self-reported surveys used to determine RVUs. They found that median RVUs per hour vary widely between specialties. Gynecology had the third-lowest median RVUs per hour of all the specialties studied. In effect, that means that gynecological surgeons are paid less for every hour that they work. 

The researchers also found that compared to the operating times logged for real surgeries in the Surgical Quality Improvement Program, surgeons in certain specialties tended to report longer procedure times in the self-reported surveys sent out by the RVUs committee. Specialties that reported longer operating times were more likely to be awarded higher RVUs, leading to greater hourly rates of reimbursement.

According to Uppal’s analysis, urologists — a profession most often associated with procedures on men because their work routinely concerns the prostate and the testicles — reported times that exceeded the baseline data by a median of 20 minutes. By contrast, estimates from gynecologists only exceeded the actual time by a median of five minutes, meaning that urologists tended to overestimate their time spent in surgery by four times as many minutes. Generally, urologists earn much more than general OB-GYNs, who in turn earn more than other subspecialties like gynecologic surgery. Despite having access to reliable electronic records of operating time, Uppal and his colleagues note, the AMA committee still continues to use self-reported operating times, which influences their RVU recommendations, ultimately cementing disparities in female-specific procedures. 

“The system that they have now developed over time,” King said, “now creates discrimination because of its complexity.” She added that this is how systemic discrimination is perpetuated, even if systems or rules appear seemingly neutral.

How low reimbursement rates make women’s lives worse

The US healthcare system has never been especially good at putting its money where its mouth is when it comes to women’s health. Experts have been sounding the alarm on sex-based disparities in medical billing for a long time — long enough that governing authorities like the committee responsible for RVUs and ACOG have had time to respond to the concerns. 

Over the years, the gap between male-specific procedure reimbursements and female-specific reimbursements has decreased slightly. But researchers of the Price and Prejudice study showed that between 2003 and 2023, there were no statistically significant improvements to the pay disparities. Comparing a smaller set of procedures across 1997, 2015, and 2023, they found that the gap had narrowed only minimally.

One common justification that ACOG provides for the pay gap is that obstetrics and gynecologic services see a higher-than-average share of patients on Medicaid, which pays doctors less than other insurers. King agreed this is a real factor, but it doesn’t explain why Medicare itself values procedures on women lower in the first place. And as her account of double discrimination makes clear, undervaluing gynecology ultimately affects women everywhere for the worse.

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy.”

Dr. Louise King

Lower reimbursements in gynecologic surgery disproportionately affect female surgeons because they represent a majority of this specialty. It’s not just the surgeons’ salaries that are affected. Hospitals and facilities work on a revenue-based model — if gynecologic surgeries are not bringing in enough money, institutions tend to allocate fewer resources to those procedures. That, in turn, can limit access to operating rooms, surgical staff, and operating times. 

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy,” King said. As a minimally invasive gynecologic surgeon, she surgically treats women with endometriosis, fibroids, cysts, or other such conditions.

It also affects the training that gynecologic surgeons receive. When there aren’t enough resources to operate regularly, opportunities to train residents are rarer than they should be. The result is that low reimbursement rates have contributed to a workforce of low-volume gynecologic surgeons who are sometimes not as well-trained as other surgeons who operate frequently.

The relationship between volume of surgeries performed and patient outcomes is well-documented in other fields. Research shows that surgeons who operate infrequently have worse outcomes, including more complications before, after, and during surgeries, compared to surgeons who operate regularly. 

Low-volume gynecologic surgeons — who perform a particular procedure less than 12 times a year — have significantly higher rates of causing bowel and urinary tract injuries in their patients. Especially in benign gynecological surgery (procedures not related to cancer), having surgeons who operate frequently also increases the number of minimally invasive procedures performed, which is related to better patient outcomes. 

Payment reform is an uphill battle, but not a lost cause

It takes multiple years and pressure from different entities to update or add new RVUs for procedures — but crucially, it is not impossible. The first few steps to creating a sustainable system might look like submitting gynecology-related procedure codes for reevaluation to the AMA committee or prompting a congressional report on the matter. 

For example, for years there has only been one billing code for endometriosis, regardless of the complexity of surgery or technique used. This disincentivizes surgeons from taking on complicated surgical cases of endometriosis because of the low reimbursement rate. Reevaluating that rate or diversifying the various surgical approaches that different cases require would help affected women get the care they deserve.

Medicare’s payment system also has what’s called a budget neutrality rule, which dictates that significantly increased payments for any given procedure must be offset by cuts elsewhere. The AMA itself believes that reforming this rule would make it easier to work toward reimbursement equity for female-specific procedures.  

Experts have suggested creating gynecology-specific conversion factors to bring parity to a system that naturally undervalues these procedures, while others think that eliminating sex-specific billing codes whenever possible is the right move. For example, the code for genitalia biopsies is different for men and women. This means that those procedures can be reimbursed differently even though they are essentially similar. Adopting one sex-neutral code for any genitalia biopsies would avoid this. While the reform required for this would be substantial, researchers believe that it would narrow the billing gap significantly.     

Authorities often justify lower RVUs for female-specific procedures by pointing to training: Gynecologists spend fewer years learning to operate than urologists and other higher-paid surgical specialists, according to King.

Historically, surgeons who operated on the female pelvis trained in ways that were more closely aligned with general surgeons than OB-GYNs. When obstetrics and gynecology merged into one specialty in the 1900s, the training for gynecologic surgery was truncated. 

“General OB-GYNs will train for four years and of that four years about 18 months is devoted to surgical training in gynecology,” said King, contrasting the new training period to those of general surgeons, which is in years. 

She believes that training periods should be increased for gynecologic surgeons. That change would secure better reimbursement for the speciality, while also producing better trained surgeons who would be more attuned to advances in minimally invasive surgery that will ultimately improve the outcomes for their female patients. In some cases, the experience gained during a two-year fellowship in gynecologic surgery was equivalent to 19 years in practice.  

In their initial work on double discrimination, Watson and King argued that failing to implement solutions for parity is tantamount to saying that female patients deserve less well-trained surgeons than male patients.  

As with most women’s health issues, it is unclear if this systemic disparity in medical reimbursement is the result of conscious misogyny or a by-product of ignorance. But that question of origins matters little when its consequences have been enshrined in medical policy, with lasting consequences for the practice of medicine more generally. We have allowed this wage gap to persist, even as many have sounded the alarm for decades. It is long past time to heed their warnings.

October 7, 2026, 5:50 pm ET: This story was originally published on October 2 and has been updated to include the sourcing on the RVU gap resulting from training for gynecologic surgery.  

After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was one upside: He knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.

But then when he got there, they asked about his medical history and he mentioned prior kidney problems. When he received a bill a few weeks later, he had been charged twice for the same appointment: Once as that free preventive visit, once as an “office sick visit” because of the kidney conversation. He was flummoxed — and very annoyed, as he shared on social media. “No copayment means no copayment, exactly as stated in the insurance guidelines,” Kuo told me over email. “What is written and agreed upon should be honored.”

He is far from alone. On Reddit, I easily found more than a dozen examples in just the past year of people getting a surprise bill for what they thought was going to be a free visit. 

One woman posted a nearly $1,000 bill she’d received for what she thought was going to be a preventive gynecology visit. Another woman said that she ended up facing roughly $3,000 bills because she was given an ultrasound (which she said she didn’t request) at a preventive visit, and then her blood draw was sent to an out-of-network lab. Another person lamented that they had been billed $170 for an office visit because they had briefly mentioned back stiffness.

It’s not supposed to be like this. Americans don’t get much when it comes to our healthcare, but most of us are supposed to be entitled to at least one thing: Once every year, no matter your health insurance, you can go to the doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health screenings. The Affordable Care Act made that the law in 2010.

But more than 15 years later, people all over the country are walking into their doctor’s office, thinking they’re entitled to that one free visit every year, and walking out being billed for a sick visit, blood labs, and more. Researchers estimate that Americans spend tens of millions, maybe hundreds of millions of dollars every year on services that are supposed to be free under the ACA.

Dr. Yalda Jabbarpour, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, told me she still deals all the time with people’s confusion about what a preventive visit really means.

“Every single time I’m in the clinic, this issue comes up with a patient. And it’s sad that it comes up,” Jabbarpour told me. “In my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve.”

How could a seemingly simple promise of one free annual doctor’s visit result in a situation so convoluted that patients and doctors are still struggling with it nearly two decades later? And how might we fix it?

Patients are getting surprise bills from their doctors — and they’re pissed off

The goal of the ACA was to expand coverage and make sure health insurance would be comprehensive to actually help people stay healthy. As part of that project, the authors of the law added a mandate for insurers to cover those services, including an annual wellness exam. The problem is, they did not define what the parameters of that preventive visit actually were, said Alex Hoagland, a healthcare economist at the University of Toronto. 

“It didn’t establish a clear definition of…all the diagnosis codes and procedure codes and how frequently you get that combination within a year,” he said. “They don’t define what actually is preventive care and what’s not.”

That has left each insurer to define a preventive visit on their own — and that’s where the perverse incentives that leave patients in a lurch begin. Preventive visits are supposed to be reserved strictly for screenings and talking about other preventive measures you can take to protect your long-term health, but you may get billed for an “office visit” or a “sick visit” if you talk about any specific symptom you’re experiencing, the same as if you had come in because you had the flu. 

Health insurers have an incentive to keep the definition of preventive care as narrow as possible, so they have to pay fewer claims without any contribution from the patient. At the same time, doctors want to be paid for the actual services that they are providing. If somebody does bring up a bigger health problem during a preventive visit, then the doctor reasonably wants to be paid accordingly. 

“I know, particularly in the healthcare space, it’s really popular to blame one party or another, and here I don’t think it’s a matter of corporate greed or physician incompetence or whatever,” Hoagland said. “It’s just a natural mismatch of incentives.”

So the reality is that “one free doctor’s visit” sounds straightforward, but, in practice, it’s much more complicated. You as the patient might think of it as one visit, but in our fee-for-service healthcare system, where providers bill based on each specific thing they do, it’s not. The conversation about your vaccination may be free — but asking about your back pain is not. If you get blood tests ordered, that’s another line item. The list goes on. “It’s not like you walk into a doctor’s office and it’s just one thing that happens, right?” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s multiple different things that are happening when you go into a doctor’s office.”

Part of the problem may be that it’s one free visit. We Americans are consumers at heart: Tell us we’re going to get something for free and we want to take advantage of it. But having just one free visit may also lead to people bringing a laundry list of questions to that preventive visit, because they think of it as their only chance to ask everything of their doctor. 

That makes it easy for the discussion to tip over into a sick visit — and not only does that lead to a surprise bill, it can also crowd out the conversation about prevention that the visit is supposed to be focused on.

“What ends up happening a lot…is that a patient comes in for their annual visit, and in their mind, that is their time to bring up every single thing that’s been happening during the year, because they see it as the free visit to bring up everything that’s happened during the year. For some patients, that takes up the entire visit,” Jabbarpour told me. “They leave, and it’s like, ‘Oh my god, we forgot to do all the screening things: the vaccinations, the cancer screenings, and the cardiovascular risk screening.’ And then something happens down the line because you never address those screenings.”

A 2021 study by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance had in 2018 alone paid between $75 million and $219 million in medical bills that should have been free. They were more likely to be charged for things like contraception or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for those services.

Hoagland told me he had been billed for preventive visits because he has type 1 diabetes and the system automatically categorized his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic conditions were more likely to be charged for preventive care. Corlette said that she too had recently been charged for what was supposed to be a preventive visit after she mentioned an issue as an aside. And these are folks who study health care for a living.

“It was literally maybe a 10-second conversation where I would ask the doctor a question about something,” she said. “And that triggered it.”

Colonoscopies are another dramatic example of how this issue plays out in real life; Corlette told me the procedure was one of the first services where this fuzzy line between prevention and treatment under the ACA became obvious. People go under for what is supposed to be a preventive colonoscopy. But then their doctor finds a polyp and decides to remove it — good clinical practice, but as a result, their patient could end up being charged thousands of dollars because the colonoscopy was no longer preventive once that polyp was snipped.

“All of a sudden, that would trigger what the patient thought was a preventive service into a cost-sharing obligation,” Corlette said. “Colonoscopies can be thousands of dollars. That was when we were first like, ‘Oh, yeah, this is a more complicated area than I think the lawmakers that drafted this provision originally envisioned.’”

How the US could fix our preventive visit headaches

The ACA’s preventive visit promise was clearly well-intentioned and it’s worth remembering that, if you look in the aggregate, more Americans are getting more free preventive care than they did before the law was passed. The problem, as much as anything, is expectations: People think they’re entitled to a free visit and are understandably frustrated when they get billed for it.

“The difference is before the Affordable Care Act, maybe they anticipated some kind of cost-sharing,” Hoagland said. “But after, they expect it to be free.”

It doesn’t have to be this way. Corlette’s team at Georgetown University recently released a proposal that Americans be entitled to three primary care and two urgent care visits every year with no cost-sharing. This approach has two virtues, she told me: It will help people feel like they are actually getting value from their insurance — the very complaint that Steve Kuo raised — and, because we know primary care helps prevent problems down the road, it should also improve people’s health in the long term. Take the pressure off that one free visit and let people see the doctor a few times a year without worrying about being charged.

“In employer-based insurance, a lot of people feel like, ‘What the hell am I getting for my premium each month?’” Corlette said. “We wanted people to feel like they’re getting good value, and we wanted to get to better population health.”

Hoagland also endorsed the idea of at least one free physician’s visit every year, no matter what’s discussed. In the long term, Jabbarpour said she’d like to see copays eliminated entirely for primary care. 

But any payment reforms are not going to happen immediately. What can we do right now?

For one, doctor offices could make an effort to be as transparent as possible. Jabbarpour’s MedStar system has started calling people a couple of days before their appointment with a brief script that tells the patient that they could be charged if the conversation with their doctor touches on additional medical problems. If your doctor’s office doesn’t proactively bring it up, ask when you schedule your appointment or when they call you to confirm it. Worst-case scenario, ask your provider what they consider preventive care when your visit begins. You might also want to educate yourself on what services are generally considered preventive and should be available for free: Your insurer may make that information available on their website, or KFF has a database you can peruse.

It’s not a perfect solution. “What ends up happening is patients come in, and they say, ‘I know I’m not supposed to talk to you about anything else, so I’m not going to tell you about anything else.’ And you don’t want that to happen,” Jabbarpour said. You should ask your doctor directly: What do you consider to be preventive care? Establish boundaries at the start. That way, you can at least be aware if you are going to get charged because the conversation crossed the line to discussing an active health problem.

And if you want to see the underlying laws change, start organizing. Contact your state and federal reps and ask them what they are doing to ensure this stops happening. Things could be different: Jabbarpour said she hopes to one day work in a health system where the cost of a single primary care visit isn’t so high-stakes, where doctors and their patients can manage their health according to their particular needs, rather than worry about how to bill for one specific conversation that covers the whole range of somebody’s health — like primary care is supposed to do.

“I think some patients can be managed by seeing us once every year, once every two years, and some patients need to see us monthly,” Jabbarpour told me. “To put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.”

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

My favorite restaurant, here in Madison, Wisconsin, closed this week. 

It was not my favorite because it had the greatest food I’d ever had, nor the most memorable ambiance. But I loved the Mad Rabbit Cafe because it had become my anchor in the neighborhood — it felt like home to me and a core group of friends as surely as the century-old houses lining the surrounding city blocks. Most importantly, it was entirely vegan — a rarity in this city, which, despite its ultra-progressive politics, embraces Wisconsin’s identity as “America’s Dairyland.” It was a refuge where my most closely held values found expression.

That closure is part of a national trend. US plant-based restaurants appear to be going through a contraction, amid the tumultuous aftermath of the Covid-19 pandemic and, perhaps, an anti-plant-based cultural vibe shift.

VegNews magazine reported that data from HappyCow, an app that lists vegan and vegetarian restaurants, finds the number of vegan restaurants in three of the country’s top destinations for vegan dining — New York City, Los Angeles, and Portland, Oregon — decreased by between 21 and 25 percent from 2022 to late 2024. Those cities alone make up a significant share of America’s vegan restaurants. Then, in 2025 and 2026, some of the country’s most renowned, long-running plant-based restaurants also announced that they’d shut down: Modern Love and Candle in New York City, the Vegan Joint in LA, Millennium in Oakland, a more than three-decade-old institution (though it later reopened as a leaner operation), among many others. 

According to a Vegan Society report, in October 2025, HappyCow (which is like Yelp but for plant-based dining) listed 1,717 all-vegan restaurants in the US. As of this writing, HappyCow lists 1,509.

Madison has never had anything like the vegan riches of New York or San Francisco, but even we are having our own vegan recession. When Mad Rabbit opened in early 2024, the city had four fully vegan restaurants; now, depending on how you count, one or two remain (and even the one that’s unambiguously vegan is a food-court-style stall). I visited Mad Rabbit at its last Sunday brunch, where it served what many people have described as the best tofu scramble they’ve ever had, and a crowd-pleasing rotation of crepe specials (this month, it was mango lassi). It’s a culinary niche that, once gone, is hard to replace in a mid-tier city like this one. 

Mad Rabbit’s owner, Nate Anger, told me the business hadn’t been in particularly bad financial shape; it was profitable for each of the three years in which it operated, but not profitable enough to justify the punishing time commitment required to run it. Managing it had taken over his life, as it’s wont to do for many people in the food service industry. “I live here. I spend far more time here than anywhere else,” he told me in a recent interview at the restaurant. “I’ve missed my kids’ baseball game and tournaments and school band recitals.” I looked around at the oddball, DIY space he’d conjured — walls covered in houndstooth print, an Alice in Wonderland-like vortex, and art of rabbits in mischievous-looking moods, one brandishing a pair of large knives (the sort of room you wouldn’t want to encounter while stoned). 

The animal rights movement has two very different emotional registers: the grief and terror of looking squarely at factory farming, and the joy of discovering how much creativity, abundance, and pleasure can exist outside it. All-vegan restaurants represent perhaps the fullest embodiment of that second feeling — like “a little heaven,” as Krupa Panchal, co-owner of Bombay Food Junkies, a vegan Indian spot in suburban St. Louis, put it to me. 

Even as vegan businesses struggle to survive, plant-based options at non-vegan restaurants have become far more mainstream than they were a decade or two ago. Set against the stagnating (if not declining) share of Americans who identify as vegan or vegetarian, that raises difficult and even paradoxical questions for the animal movement.

For that reason, the mass die-off of plant-based restaurants has been much dissected and lamented in the vegan community. As I faced losing my own — a possibility I’d always feared and tried to forestall by supporting it as much as possible — the problem became much more visceral for me. I found myself thinking about why it mattered to me so much: What is lost when these places disappear, and what does that tell us about whether the plant-based movement can grow and endure?

What vegan restaurants are for

The vegan restaurant predates the word “vegan” itself — and so, apparently, do questions about whether they can be financially viable. More than a century ago, French anarchist Georges Butaud co-founded the Foyer Végétalien in Paris, writing in a 1923 letter that he was unsure whether it would attract a sufficient “clientèle végétalienne” to sustain itself. Why start such a business at all, when the audience for plant-based food is so vanishingly small? “I already have some positive results. A few people have become vegan since we opened,” Butaud wrote. The restaurant “is a school where we reciprocally teach one another…I have believed in the usefulness of creating it, and I will be happy if, over the months to come, the number of vegans increases.” 

Many vegan restaurant proprietors today still share that ambition — to be good enough to help the movement grow. 

Long before it became routine to find plant-based options on normie restaurant menus (iceberg lettuce leaves don’t count), plant-based restaurants compensated for vegans’ exclusion from mainstream cuisine. But they have also aimed to provide proof of concept of the diverse, surprising possibilities of plant-based food for a larger audience, showing that plant-based food need not be confined to marginalia. 

Today, of course, restaurants are far more central to our daily lives than they were in Butaud’s time. Americans consume about a third of their calories and the majority of their food budgets outside the home, and food-serving businesses are perhaps our most important third spaces. Meanwhile, the problems associated with animal agriculture and overconsumption of animal products grow unabated in America and around the world. The US alone slaughters 10 billion land animals for meat every year, the overwhelming share of them raised in appalling conditions, and those farmed for milk and eggs endure no better. Reciting these grim facts tends not to be a very fruitful path toward making friends or convincing people that veganism can be a positive and enjoyable lifestyle. Plant-based restaurants, on the other hand, make veganism feel less like a prohibition than an invitation; hospitality rather than horror. 

Anyone who has ever gone vegan knows what it’s like to incessantly be asked the well-meaning but bewildering question: “What do you eat?” (And, I get it! It’s confusing for those of us who grew up viewing food free of animal products as side salad or overcooked green beans.) Plant-based businesses have long been laboratories for answering it, developing techniques that draw richness and variety from ingredients not often treated as the main event in Western cuisines.

The more than 50-year-old Moosewood Restaurant (although mostly vegetarian, not fully vegan) was an early conduit between restaurant experimentation and home cooking, its recipes spreading far beyond Ithaca, New York, through its enormously popular cookbooks. Soul Vegetarian in Atlanta, opened in 1979, developed a plant-based soul food repertoire that helped cut a path for dozens of other vegan soul restaurants across the US; the Chicago Diner, in the city long identified with stockyards and slaughterhouses, helped popularize plant-based versions of American diner and deli staples. And chef Miyoko Schinner, at her erstwhile San Francisco restaurant Now & Zen, experimented with plant-based cheeses long before launching Miyoko’s Creamery, one of the most acclaimed and influential vegan dairy companies of the past decade. 

The 21st century in particular has seen a flowering of vegan restaurants serving every palate and national cuisine, in every possible aesthetic — punk, hippie, psychedelic, fussy and upscale. They still expand my mind today, showing that a lifetime wouldn’t be enough to discover all the ways we can eat without the exploitation of animals.

The longtime Grasshopper restaurant in Boston, whose pan-Asian fare draws partly from Vietnamese Buddhist temple cuisine, makes mock meats that are worlds away from the rubbery substitutes that many Americans associate with the category (it closed its beloved, homey restaurant space in 2024, later reopening a stall inside a food court). Mad Rabbit changed even this longtime vegan’s idea of what tofu could be. Chicago-based Penelope’s Vegan Taqueria makes, as far as I’m concerned, the most exceptional Mexican food — vegan or not — this side of the Rio Grande. V-Grits, a Southern comfort spot in Louisville, Kentucky (RIP, 2024), provided evidence that some of America’s most exciting plant-based food could be found far from the big coastal cities best known for it. 

So why are so many of these places shuttering now? 

The vegan restaurant death spiral? 

Theories abound about the great dying of vegan restaurants.

Some of the casualties, it must be said, just weren’t very good in the first place. The raw vegan boom of the 2000s and 2010s, for example, produced numerous establishments built around that especially unforgiving constraint — no cooking. The result was often less-than-thrilling food (which isn’t to say it’s never good!), all in service of a restriction with scant evidence of health benefits to support it. Lots of these restaurants have closed in the 2020s, reflecting diminishing demand for that particular variant of vegan food. 

But the 2010s weren’t merely a golden age for zucchini noodles and date-walnut brownies — vegan restaurants of all stripes were multiplying, as was interest in the new generation of plant-based meats (Beyond and Impossible). It really did appear, for a minute there, that the future might be plant-based, vindicating decades of animal advocates’ work to push veganism into the mainstream. 

“I felt like veganism had really hit a big stride” in that period, Anger, the Mad Rabbit founder, said. Everyone was streaming documentaries advocating for plant-based diets — Forks Over Knives, Cowspiracy, What the Health, among others. Some polls suggested the share of Americans who called themselves vegan was growing. Anger said his market research led him to believe that the overall trend line for veganism would continue going up, even a little. Instead, “it just rolled right back over.” His restaurant had a core customer base of committed vegans, but its heavy reliance on regulars also showed how limited its reach was; stagnating interest in veganism may have been putting a ceiling on its growth. Keith Uruski, owner of Nooch, a vegan restaurant in Windsor, Ontario, open since 2018, told me that the business had thrived in its first few years, but has since slowed considerably, and he hasn’t paid himself in three years.  

In the years leading up to the pandemic, the assumption that the audience for vegan food would keep growing shaped much bigger bets than Mad Rabbit. Vegan chain restaurants including Veggie Grill, Native Foods, and Planta had pursued aggressive growth plans in the 2010s and early 2020s but eventually retrenched, closing locations and abandoning the scale they’d once envisioned. (Again, some of this may be merit-based rather than evidence of a broad rejection of veganism — YMMV, but I found Veggie Grill, at least last time I had it pre-Covid, to be mid.) “Most dedicated vegan chains are now in kind of a managed decline,” Lizzy Bartlett, senior director of menu research and insights at Technomic, a food service industry research firm, told me.  

The cultural winds have certainly shifted. The Make America Healthy Again (MAHA) movement has probably contributed to a thermostatic swing away from “unnatural”-seeming diets and simulacra of traditional foods, like plant-based meat and milk. I also think society has deep carnist antibodies that activate whenever meat-eating faces heightened moral scrutiny. In the last few years, that’s taken the form of a protein obsession that has hijacked the minds of otherwise rational people, convincing them tofu and beans lack sufficient protein to build muscle.

But perhaps my favorite explanation was articulated by Financial Times journalist Henry Mance last year: “The decline in idealism,” reflected in the reelection of Donald Trump — the triumph of our collective id.  

There’s a risk of reading too much into all this, however. Many restaurants, vegan or not, suffered during Covid and from prolonged inflation in food and energy prices. This year, consumers are spending less at restaurants because of elevated fuel prices due to the war in Iran. Panchal, of Bombay Food Junkies, said that her sales have been down in 2025 and 2026 compared to the years prior, but she doesn’t believe vegan restaurants have been faring worse than non-vegan ones. Some vegan businesses have recently closed in St. Louis for personal reasons rather than failing in the market, she told me.

This is part of the natural life cycle of independent restaurants — many disappear within a few years, and even highly successful ones eventually run their course. US cities had many vegan restaurants open in the 2000s and 2010s, so we might now be seeing a wave of closures that reflects the aging of that cohort. 

Preliminary results shared with Vox from a 2026 survey of the global vegan restaurant industry, by the nonprofit Vegan Hospitality, also complicate the idea that plant-based restaurants are being killed off because of waning demand for vegan food. In responses from about 59 vegan restaurants (a self-selected group, to be sure), mostly in the US and Mexico, roughly four in five said they’d still choose to be fully vegan if they were opening today. Of 13 businesses that were closing or had been sold, six said that being vegan actually helped them, and four said it made no meaningful difference.

And there’s some tension between the “death of veganism” hypothesis and what may be one of the biggest forces now disadvantaging dedicated vegan restaurants: the widespread adoption of plant-based options on omnivorous restaurant menus. That it’s now easier to be vegan at mainstream establishments is “unquestionable,” Anger said. He viewed Mad Rabbit’s competitors as not just fully plant-based businesses, but any restaurant that offers “more than two or three” vegan options; it was located just a block away from one of Madison’s best-regarded restaurants, a Laotian place with several very good plant-based offerings.

Likewise, Michael Fifelski, general manager of Red Sushi in downtown Madison, which has a solid list of vegan options, told me, “Our vegetarian and vegan rolls actually are quite popular” — a foundational part of the menu. There can be a real advantage to simply letting vegan food blend in — Amanda Byrd, the manager of Everly, an eclectic, globally inspired restaurant in Madison, told me that its top dish, a butternut squash and forbidden rice curry, is incidentally plant-based. In many cases, “if you de-emphasize the vegan statement, but the dish happens to be vegan,” it will sell better, Claire Conaghan of the food industry research firm Datassential said.

Though nothing compares, for me, to the feeling of total alignment that comes with dining at an all-vegan restaurant, there is also something affirming about seeing plant-based food finally taken seriously by the wider culture — and vegan dishes surviving on their own merits alongside everything else on the menu.

Do vegan restaurants still matter?

In a world where you can find a satisfying vegan entrée at Chipotle or Taco Bell or your local brewpub, are fully vegan restaurants still needed? What purpose do they serve?

The most fundamental problem beneath the downturn in vegan businesses is simply that the vegan population does not seem to be growing much at all. Polling on the question is messy and often inconsistent, but according to Gallup’s 2026 survey, 2 percent of Americans call themselves vegan, the same figure as in 2012, when the firm first started asking the question. If expanding the number of people who abstain from animal products remains an important goal (a point debated within the animal movement, though I think dietary change still matters a great deal), then which is more likely to move that objective forward: vegan restaurants, or an abundance of vegan options at omnivorous ones? Which does more to increase the number of plant-based meals consumed rather than animal-based ones and generate excitement about vegan food?  

I put those questions to Seth Ariel Green, a research scientist at Stanford’s Humane and Sustainable Food Lab, who writes the Substack “Regression to the Meat.” He’s one of the most intellectually honest researchers anywhere on meat reduction. His answer, via email, is that we don’t really know: “I have no idea how to weigh the pros and cons of, when I’m choosing between meals, 1) signaling to the world that vegan businesses are viable or 2) signaling to a particular business that their vegan options are viable. That’s a hard problem!” (It might be “a microeconomic structural equation modeling paper waiting to be written,” he added.)

Reducing prevailing levels of meat consumption even a tiny bit, much less convincing people to become vegan, is really, maddeningly hard, as Green has written. One frequently cited obstacle to growing the animal rights movement — its “central unsolved problem,” as one movement leader recently put it — is that it lacks much in the way of an in-person social world and sense of community. Vegan restaurants alone can’t fix that, of course, but they are among the few physical institutions the movement has. At their best, they provide a space where a private dietary choice can be reinforced by a shared sense of identity — a place to run into someone you already know or meet someone new, at a speaker event or social mixer. These spontaneous, embodied connections made Mad Rabbit such a warm presence in my life, and its final days all the more melancholy.

That function may be especially useful when plant-based restaurants are rooted in traditions people already belong to — cultural, religious, or otherwise — and help them view veganism as continuous with an identity they already have rather than as something alien to it. As Green has suggested, “let’s tap into pre-existing identities, explain how plant-based diets are consistent with them, and then take folks somewhere to enjoy convenient, delicious plant-based food together.” 

On the other hand, plant-based options at omnivorous establishments matter for almost the opposite reason. People often struggle to stay vegan because eating differently isolates them from non-vegan friends and family; restaurants that can accommodate mixed-diet social groups help remove that social penalty. These options also need a customer base — if no one orders them, they’re unlikely to remain on menus. 

I’m enough of a weirdo that I try to almost exclusively support plant-based restaurants whenever I eat out. I desperately want them to survive, and at the end of the day, no one is more invested in advancing the craft of plant-based cooking than vegan restaurants themselves.

Not everyone needs to be like me — in a world where almost all people still eat animal products, a healthy ecosystem needs both places built entirely around veganism and those where plant-based food is woven into broader food culture. It needs, most of all, excellent vegan food, wherever it might be found. And now that veganism has made at least a small breach into mainstream dining, vegan restaurants still offer something their meat-serving counterparts cannot. They’re like miniature utopias where the normal order of things is inverted and, for the length of a meal, we can see what a future without animal exploitation would look like. 

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Todd Waller wasn’t expecting to spend the latter half of his 30s living with roommates. But in late 2022, following a breakup with his girlfriend, he needed to find a new place to live, quickly. 

A social worker based in the Atlanta metro, Waller started googling “efficiency apartments” and stumbled onto an ad for PadSplit, a company founded in 2017 that lets property owners rent out individual furnished bedrooms in single-family homes by the week. “It said I could get approved right away and move in tomorrow,” he recalled. There was no security deposit required.

All of a sudden, Waller found himself living with six other people and able to save a lot of money. His rent was just $180 per week, or less than $800 per month. Though he earned a decent salary, he never really had anything left over after all his bills were paid, and the new financial breathing room made the tradeoff of housemates feel worth it.

After a while, Waller decided he would be willing to upgrade to a nicer PadSplit unit, one with more amenities but still with roommates. Now he pays $1,250 a month to live on one side of a 2,000-square-foot home, with access to his own private bathroom, a private entrance, and a renovated kitchen. Three other people live on the other side of the house, and he rarely interacts with them.

“My house is awesome; I pay $500 less a month than I would if I were renting [a place of my own] without roommates, and I just was able to buy a new car,” he told me. He knows one day he’ll move somewhere else and perhaps even buy his own home, but he likes that he feels he can make that decision comfortably at his own pace.

With rents outpacing wages in most of the country, legislators are increasingly looking at co-living — sometimes called house-sharing or adult dorm rooms — as an overlooked piece of America’s housing stock. Zillow counts roughly 21 million “empty nest households” — or homes where older residents living with no children have at least two extra bedrooms. Some lawmakers want to make it easier for those homeowners to rent them out, which could put workers closer to their jobs and help seniors stay in houses they can no longer afford alone. Others are eyeing a different kind of vacancy: Post-pandemic remote work has left about a fifth of American office space empty, and there’s growing interest in turning some of it into apartments. 

Many advocates for people experiencing homelessness also argue that co-living is a needed solution, something that could help people going through emergencies avoid the scary slide into shelter living, especially models where you can move in almost immediately and without a deposit. PadSplit surveyed its renters in December and found a population that mostly works (83 percent were employed) and mostly hadn’t been to college. The median income was $32,500.

That co-living needs advocates at all is a legacy of the last century. Renting a single room in a boarding house or residential hotel was once an ordinary way to live in an American city, but in the decades after World War II those rooms became shorthand for poverty and vice, and cities responded by banning new ones and paying landlords to get rid of the old. Half a century later, many people still see sharing space with strangers as a last resort, or feel embarrassed about having roommates past a certain age. And discriminatory zoning codes written in that era are still on the books in most communities, enforcing traditional nuclear family arrangements when it comes to single-family housing, by defining “family” as people related by blood, marriage, or adoption. Those rules can be wielded against home-sharing, and against specific renters neighbors want to keep out.

But these longstanding barriers are starting to finally give. Doubling up with people you aren’t related to is less unusual than it used to be. Between 2017 and 2022, the number of households sharing space with nonrelatives grew by more than 500,000. Lawmakers desperate for anything that adds more housing supply also seem less picky about where it comes from. Companies like PadSplit are putting private capital behind the model, and a wave of new laws and litigation — much of it led by conservative legal groups arguing on property-rights grounds — is making it harder for cities to tell homeowners who can and cannot sleep in their spare rooms. 

For the first time since cities banned cheap rooms, the people trying to bring them back have the momentum, and the next couple of years will go a long way toward deciding whether co-living stays a niche workaround for people like Waller or becomes something a lot more people are able to consider.

The return of SROs

At the turn of the 20th century, as American cities swelled, immigrants, day laborers, and factory workers crowded into downtowns looking for somewhere cheap and temporary to sleep. A small room could be rented by the day, the week, or however long someone needed it. Some “boarded” in private homes while others took beds in bottom-rung hotels known as flophouses. These arrangements varied widely, but became broadly known as single-room occupancies (SROs).

The turn against them came after World War II, as middle-class white families decamped for roomy new houses in the suburbs, and SROs grew more closely associated with shoddy housing for the poor and the deviant. New York and other cities started banning SRO construction in the 1950s. By the 1970s, SROs were a regular media villain, even as they still housed hundreds of thousands of people, including the mentally ill who had been turned out by the closing of state asylums. Cities started to offer landlords incentives to convert their SROs into luxury rentals. Between the mid-1970s and the 1990s, roughly a million of these affordable market-rate units disappeared from the market across the country.

The idea that perhaps cities made a mistake in banning these lower-cost housing options has been simmering in urbanist policy circles for the last 15 years, particularly as the homelessness crisis has gotten worse. The Furman Center at NYU argued in 2018 that reintroducing SROs could help address the housing shortage. The architecture critic Karrie Jacobs argued in 2021 that cities had blamed a kind of housing for problems that belonged to the people living in it. “The notion took hold that if you eliminated the housing, the marginal people would simply vanish,” she wrote in Curbed.

Still, lawmakers have dragged their feet on actually making it easier to rent these kinds of units again, and until recently the people pushing for it had little to show beyond op-eds and white papers. What’s different now is that the fight has moved out of the world of policy papers and into places where it can produce actual results, including a lawsuit that could reach the Supreme Court.

Suing over who counts as family

In early 2022, a home-sharing startup called HomeRoom was renting out two houses in Shawnee, Kansas, a suburb of Kansas City. The company rented rooms one at a time to unrelated adults who wanted cheaper housing, and at a local city council meeting that year, Shawnee’s community development director asked whether the city should support such arrangements in single-family neighborhoods at all. Two months later, the council passed an ordinance banning “co-living groups,” which it defined as four or more unrelated adults sharing a home. 

Under the ordinance, if even one adult in a house wasn’t related to the others by blood, marriage, or adoption, the whole household counted as unrelated.

While the new law forced HomeRoom to evict its tenants, it also put Val French, a Shawnee homeowner, in a bad situation. She lived with her husband, their two adult sons, and one son’s girlfriend. Because the girlfriend was related to no one, the house was now deemed in violation of the city’s occupancy rules. Her son and his girlfriend had to move out, and French couldn’t rent the empty room to anyone else.

French and HomeRoom sued in federal court in May 2023, with assistance from the libertarian Pacific Legal Foundation. They argued that their right to choose who they live with is protected under the 14th Amendment, but they ran into legal precedent from a 1974 Supreme Court case, Village of Belle Terre v. Boraas, which upheld a Long Island village’s nearly identical rule against six college students sharing a house.

The decision came down in the same years cities were clearing out their SROs, and it has given local governments cover to decide who counts as a family ever since.

A federal judge dismissed the Shawnee suit in September 2023, citing Belle Terre, and this past April the US Court of Appeals for the 10th Circuit upheld the dismissal. A few months later, the Pacific Legal Foundation (PLF) petitioned the US Supreme Court to hear the case and reconsider Belle Terre once and for all. The precedent has already frayed in places — state courts in California, Michigan, New Jersey, and New York have struck down local “unrelated occupants” limits under their own laws — but it still governs everywhere else. 

There is “a fundamental liberty right to choose household living companions — whether as an articulation of the right of intimate association or independently — that is deeply rooted in American history and tradition,” PLF’s lead attorney on the case, David Deerson, told me. 

The Supreme Court hears only about 1 percent of the cases it’s asked to take, and even if it took this one, the plaintiffs would be asking a conservative majority to recognize a new constitutional right, which that majority has spent the past few years insisting courts should almost never do. 

Deerson’s argument is aimed at that skepticism, though. When the Supreme Court overturned Roe v. Wade in 2022, it held that an unwritten right counts only if it is “deeply rooted in history and tradition.” Deerson and his allies are arguing that living with people you aren’t related to qualifies as such because, for most of American history, boarding houses and lodgers were typical staples of family life. Belle Terre is also a short opinion written by William O. Douglas, a liberal justice whose legacy has little connection to today’s conservative justices. 

The legislative front

A Supreme Court reversal would be the cleanest fix for co-living, but advocates aren’t waiting on it. State legislatures have already shown they’ll act: Iowa barred cities from enforcing relationship-based occupancy limits in 2017, Oregon and Washington followed in 2021, and in 2024, Colorado lawmakers passed a law prohibiting cities from restricting how many unrelated roommates can live under one roof absent a clear health or safety reason. 

The Pacific Legal Foundation worked on that last bill too, and has since turned it into model legislation for other states. They colloquially call it the “Golden Girls bill” since occupancy caps like these would have prevented the four unrelated women of the hit 1980s sitcom from sharing a house. 

This year Pennsylvania lawmakers introduced their own version, with supporters citing not private property rights but the potential to ease the state’s affordable housing shortage. As legislators considered the proposal, Pacific Legal Foundation published research showing that nine of the 10 most populous cities in Pennsylvania capped the number of unrelated adults who could live together. The state House passed the Golden Girls bill this summer, though the Pennsylvania Senate version has not yet received a vote. 

The objection lawmakers hear most is the same one that animated Belle Terre — that lifting occupancy caps could turn quiet, orderly, neighborhood homes into de facto frat houses. That college partying concern killed Connecticut’s proposed Golden Girls bill this year. While the bill cleared the state Senate, it never got a vote in the House, amid reported concerns from the speaker about college students moving into wealthy neighborhoods. “What if a neighbor is unhappy about four unrelated people who are 19 years old or 22 years old living in the house?” state House Speaker Matt Ritter asked in an interview with the Connecticut Mirror. 

Pennsylvania’s sponsors tried to head off those fears by amending the bill to exclude protections where someone is enrolled at a college or university. In other words, the law would have covered Blanche, Dorothy, Rose, and Sophia from Golden Girls unless one of them signed up for a class at their community college.

Nevertheless, advocates are expanding their push. Jim Manley, state policy director for the Pacific Legal Foundation, told me he expects Texas, Florida, Pennsylvania, North Carolina, Rhode Island and Utah to take up new versions of the legislation in 2027.

And occupancy caps aren’t the only co-living target. Sam Hooper, a lawyer who has been lobbying state legislatures to re-legalize SROs, and his former colleagues at the Institute for Justice are now focused on the ROOM Act, model legislation that would bar cities from restricting SROs and other co-living arrangements, including rules that make it hard to convert offices into apartments. A version was first introduced in Rhode Island earlier this year. 

For Meagan Forbes, Institute for Justice’s director of legislation, the goal is for co-living to be treated like any other form of housing. “Other local laws can regulate things like noise and fire safety, but current regulations just go way too overboard in preventing this kind of housing,” she told me. 

Hooper, who drafted the ROOM Act, says he wanted to “take a massive sledgehammer” to existing restrictions. The resistance he runs into isn’t only the frat-house worry, but older cultural fears that SROs would recreate the poor tenement conditions of the early 20th century. “I think there’s this real problem of letting the perfect be the enemy of the good in housing policy,” he told me. “People accuse us of wanting people to live in undignified housing, but they just struggle to understand that it can be a perfectly fine option for many people at different points in their life.” Hooper credits his own London co-living experience in his 20s with introducing him to some of his best friends and his wife. 

Even so, he cited a broad political coalition backing him up, from property rights champions in conservative states to Democrats and progressive YIMBYs drawn to the housing justice and homelessness angles. There are business leaders interested in workforce housing, he said, and he noted that the AARP testified for the ROOM Act in Rhode Island. “I’m hopeful we’ll be able to keep this bipartisan coalition that hasn’t succumbed to the culture wars,” Hooper added.

Not every co-living proposal is about removing rules. DC’s Senior Co-Living Program Establishment Act, also nicknamed the Golden Girls bill, would pay senior homeowners $300 a month to rent a room to another senior, plus up to $2,500 for home modifications. 

The 21st Century ROAD to Housing Act, the federal housing package that became law in July, doesn’t touch occupancy rules. But it does fund a pilot program for converting vacant commercial buildings into housing, which could make adult dorm office conversions easier.

The demand question

While momentum for co-living is real, demand is also complicated. Americans are doubling up more than they were before the pandemic — about 8.2 million households in 2024, up 4.3 percent since 2019, according to analysis shared by Zillow. Yet the share made up of unrelated adults living together actually fell slightly, by roughly 50,000 households, while homes shared with couples or families grew by nearly 400,000. In other words, when Americans need to save on rent, they still mostly turn to people they already know.

PadSplit is betting that changes. Atticus LeBlanc recently announced his company is expanding into New York, Chicago, and San Francisco, three of the most expensive rental markets in the country.

“Does that mean things have gotten more desperate, that it’s forcing this cultural acceptance?” he asked me in an interview. “I think there’s certainly an argument to be made there. But you could just as easily make the argument that, holy cow, we are really, really wasteful with space.”

Hi readers! Shayla Love here, science journalist and longtime fan of Your Mileage May Vary. I’m honored to be subbing for Sigal Samuel while she’s out on parental leave. I’m diving into your questions as a way to help understand human nature and our choices through multiple lenses: philosophical, psychological, and beyond. Please send in any emotional, body/brain, sociological, perceptual, or other kind of life quandaries you might have.

My best friend confessed his love for me one year ago and I rejected him because I was unhappily in love with another man, and I was never really physically attracted to my best friend. He was devastated. I am happy our friendship survived.

Over a year later, I find myself thinking about how it would be like to be in a relationship with my best friend. He is the only man who ever showed me genuine love and support, and I wonder what if I try…maybe I will fall in love with him. However, I am concerned about hurting his feelings again. Is it selfish of me wanting to try this love out because it promises security and appreciation?

Dear Fanning the Flame,

I can’t blame you for being curious about the common “friends to lovers” storyline. It’s often portrayed as the best kind of pairing: Two people have the foundation of their friendship plus a newfound love; the romantic relationship is like a soaring addition to an existing sturdy house. 

But real life is not always like the movies, and it sounds to me like you haven’t actually had an awakening of desire for your friend. In fact, it’s the opposite: He once expressed feelings for you, and you confronted a lack of physical attraction for this person. Now you’re wondering if it would be possible for you to fall in love if you tried. I think you’d agree that your timing is suspect. After a breakup, it’s common and understandable to seek out comfort and intimacy. Still, I detect a philosophical streak in your question beyond the issue of whether or not this would simply be a rebound. 

If your friend has always appreciated you, made you feel safe, and loves you — could that be a form of love that’s better than what you had in your last relationship? Maybe that is what love is.

Is it? Over a long night of drinking some 2,400 years ago, one group of thinkers allegedly debated the true nature of love, as Greek philosopher Plato describes in The Symposium. 

Aristophanes, a playwright, tells a story that most closely aligns with the love we see in the rom-coms of today. He said that humans used to be larger creatures with four arms and four legs. After annoying the gods, Zeus cuts all the humans in half, creating the two-limbed bodies we have today. The result is that people wander the world looking for the one person who used to literally complete them. If you followed Aristophanes’s fable, you shouldn’t try to be with your friend unless you felt that deep longing that one has when meeting their other half. 

The rest of the dinner party companions have more circumspect ideas. Phaedrus, a Greek aristocrat, thought that true love inspired people to become the best possible version of themselves. Pausanias, a military man, thought that love driven only by attraction to someone’s body was “vulgar love”, and that “noble love” was the love of someone’s values. Eryximachus, a doctor, asserts that love is also about moderation, and it needs order, much in the way the natural world does. Finally, Socrates says that even if you start out with physical infatuation, you can eventually transcend that and end up loving wisdom itself, the highest form of love. As I read it, the men are grappling with how to make love make sense, while acknowledging that it can make us lustful and impulsive. Shouldn’t its best manifestations instead be practical and virtuous?   

You could easily justify trying to date your friend with these theories that try to wrangle and tame love. For example, if your friend inspires you to be the best version of yourself, you could decide that’s enough to go for it. You could also decide that because you admire your friend’s character, and not his body, that’s a noble love, and better than the vulgar love of attraction. 

German philosopher Arthur Schopenhauer wrote in his 19th-century essay “The Metaphysics of Sexual Love” that he distrusted the feeling of being desperately in love. He considered romantic love to be a biological drive disguised as a real emotion — one whose goal is to trick us into procreating. You could even see your lack of attraction as an indication that you’re able to act more rationally, and not be deceived by that cunning trickster, passion. 

I know you’ve recently gone through a breakup, but I hope you can feel how bleak these views can become: to see love only as the window dressing for the propagation of a species, or as just a bridge to the love of wisdom. 

This cynicism has other consequences. Wondering if you could redefine love in a relationship with your friend isn’t like a wine-fueled dinner party bouncing around thought experiments. It involves your best friend and his own feelings too, and could risk not only hurting him, but also robbing him of a better romantic partner. 

For Simone de Beauvoir, the 20th-century existential philosopher, the most important aspect of life was freedom: We are technically free to do whatever we want, and it’s the choices we make with that freedom that determine our authenticity, or lack of it. De Beauvoir worried about forms of love that stole freedom from other people. In narcissistic love, she wrote in The Second Sex, a partner doesn’t love the other person, but loves the fact that the other loves them. It’s a relationship built on the self-interest of one of its members. 

I want to gently point out that it sounds like there may be aspects of the narcissistic relationship in your dilemma. While it may be intriguing to consider what it’s like to date a friend, you don’t seem to be as romantically interested so much as you are interested in his interest in and support of you. Actually involving yourself in such a dynamic could take his freedom, as well as your own capacity to learn from your break-up, then find a partner you’re genuinely drawn to for their own merits.  

I’m not saying friendship isn’t an important ingredient in love. Many of the most successful, very long-term partners I know have developed a deep friendship with one another. This friendship helps them stay kind to each other and have fun over many years when work, health, or stress can interrupt more passionate times of connection. But those same couples also had the undeniable spark of attraction at the start of their relationships too. They didn’t have to try. Sometimes they tried not to feel as strongly as they did, and still weren’t able to stop. 

Even in cases when a relationship first launches platonically, if something more is there, the undeniable, reciprocal pull tends to emerge soon thereafter. In H.G. Wells’ 1911 novel, The New Machiavelli, which was largely based on a real-life affair Wells had, he writes about a college graduate called Richard who meets a young woman, Isabel. The two become friends and are entranced with each other’s minds. But they quickly start to notice more between them, despite trying to push such thoughts away.

They fail at this attempt. Richard has a moment of realization, when he turns to look at Isabel’s face one day. “And something — an infinite tenderness, stabbed me,” Wells wrote. “It was a keen physical feeling, like nothing I had ever felt before. …From that time forth I knew I loved Isabel beyond measure.” I think you owe it to yourself, and your friend, to pursue connections that have this quality, especially at the start. 

You should also make room for and appreciate your friendship. If it never becomes romantic, that doesn’t make it a lesser relationship. The couples therapist, Esther Perel, calls friendships their own kind of love story. She once described a simple exercise to help appreciate that bond. Take a few minutes and think about a friend who isn’t a family member or romantic partner. “Recall a time when that friend reflected you back to yourself, created space for joy, or helped you remember who you are,” Perel suggests. Then, send a message to that friend about that moment, and thank them. 

Having a good friend by your side in the aftermath of a breakup is a gift. Work on maintaining and nurturing that friendship, and make sure you spend some time helping him with his life too. Don’t fixate on whether you should attempt to fall in love. The truth is, for better or for worse, if you love him, you won’t have to try.

Bonus: What I’m reading

• I’ve always been interested in the history of love, by which I mean the differences over time in how love has been expressed and discussed. William Reddy, a historian of emotion, has an excellent book called The Making of Romantic Love; you can also check out a syllabus for a class at Duke University he taught on the subject. 
• For a deeper dive (and refresher!) on Plato’s Symposium, I found that there was no better person to turn to than Melvyn Bragg and his guests on the BBC In Our Time episode on the philosophy of love. 
• Arranged marriages are an interesting window into understanding the growth of love. Mansi Choksi’s nonfiction book, The Newlyweds, follows three couples in India who attempt to marry for love; here’s an excerpt that was published in Harper’s Magazine. 

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.