British police faces criticism from civil liberties groups over their treatment of anti-monarchy protesters.

The British monarch arrives in Belfast, leading the last leg of the mourning for his mother in the four parts of the UK.

A decade into her optometry career, Marina Su began noticing something unusual about the kids in her New York City practice. More of them were requiring glasses, and at younger and younger ages. Many of these kids had parents who had perfect vision and who were baffled by the decline in their children’s eyesight. Frankly, Su couldn’t explain it either.

In optometry school, she had been taught—as American textbooks had been teaching for decades—that nearsightedness, or myopia, is a genetic condition. Having one parent with myopia doubles the odds that a kid will need glasses. Having two parents with myopia quintuples them. Over the years, she did indeed diagnose lots of nearsighted kids with nearsighted parents. These parents, she told me, would sigh in recognition: Oh no, not them too. But something was changing. A generation of children was suddenly seeing worse than their parents. Su remembers asking herself, as she saw more and more young patients with bad eyesight that seemed to have come out of nowhere: “If it’s only genetics, then why are these kids also getting myopic?”

What she noticed in her New York office a few years ago has in fact been happening around the world. In East and Southeast Asia, where this shift is most dramatic, the proportion of teenagers and young adults with myopia has jumped from roughly a quarter to more than 80 percent in just over half a century. In China, myopia is so prevalent that it has become a national-security concern: The military is worried about recruiting enough sharp-eyed pilots from among the country’s 1.4 billion people. Recent pandemic lockdowns seem to have made eyesight among Chinese children even worse.

For years, many experts dismissed the rising myopia rates in Asia as an aberration. They argued that Asians are genetically predisposed to myopia and nitpicked the methodology of studies conducted there. But eventually the scope of the problem and the speed of change became impossible to deny.

In the U.S., 42 percent of 12-to-54-year-olds were nearsighted in the early 2000s—the last time a national survey of myopia was conducted—up from a quarter in the 1970s. Though more recent large-scale surveys are not available, when I asked eye doctors around the U.S. if they were seeing more nearsighted kids, the answers were: “Absolutely.” “Yes.” “No question about it.”

In Europe as well, young adults are more likely to need glasses for distance vision than their parents or grandparents are now. Some of the lowest rates of myopia are in developing countries in Africa and South America. But where Asia was once seen as an outlier, it’s now considered a harbinger. If current trends continue, one study estimates, half of the world’s population will be myopic by 2050.

The consequences of this trend are more dire than a surge in bespectacled kids. Nearsighted eyes become prone to serious problems like glaucoma and retinal detachment in middle age, conditions that can in turn cause permanent blindness. The risks start small but rise exponentially with higher prescriptions. The younger myopia starts, the worse the outlook. In 2019, the American Academy of Ophthalmology convened a task force to recognize myopia as an urgent global-health problem. As Michael Repka, an ophthalmology professor at Johns Hopkins University and the AAO’s medical director for government affairs, told me, “You’re trying to head off an epidemic of blindness that’s decades down the road.”

The cause of this remarkable deterioration in our vision may seem obvious: You need only look around to see countless kids absorbed in phones and tablets and laptops. And you wouldn’t be the first to conclude that staring at something inches from your face is bad for distance vision. Four centuries ago, the German astronomer Johannes Kepler blamed his own poor eyesight, in part, on all the hours he spent studying. Historically, British doctors have found myopia to be much more common among Oxford students than among military recruits, and in “more rigorous” town schools than in rural ones. A late-19th-century ophthalmology handbook even suggested treating myopia with a change of air and avoidance of all work with the eyes—“a sea voyage if possible.”

By the early 20th century, experts were coalescing around the idea that myopia was caused by “near work,” which might include reading and writing—or, these days, watching TV and scrolling through Instagram. In China, officials have become so alarmed that they’ve proposed large-scale social changes to curb myopia in children. Written exams are now limited before third grade, and video games are restricted. One elementary school reportedly installed metal bars on its desks to prevent kids from leaning in too close to their schoolwork.

Spend too much time scrutinizing text or images right in front of you, the logic goes, and your eyes become nearsighted. “Long ago, humans were hunters and gatherers,” says Liandra Jung, an optometrist in the Bay Area. We relied on our sharp distance vision to track prey and find ripe fruit. Now our modern lives are close-up and indoors. “To get food, we forage by getting Uber Eats.”

This is a pleasingly intuitive explanation, but it has been surprisingly difficult to prove. “For every study that shows an effect of near work on myopia, there’s another study that doesn’t,” says Thomas Aller, an optometrist in San Bruno, California. Adding up the number of hours spent in front of a book or screen does not seem to explain the onset or progression of nearsightedness.

A number of theories have rushed to fill this confusing vacuum. Maybe the data in the studies are wrong—participants didn’t record their hours of near work accurately. Maybe the total duration of near work is less important than whether it’s interrupted by short breaks. Maybe it’s not near work itself that ruins eyes but the fact that it deprives kids of time outdoors. Scientists who argue for the importance of the outdoors are further subdivided into two camps: those who believe that bright sunlight promotes proper eye growth versus those who believe that wide-open spaces do.

Something about modern life is destroying our ability to see far away, but what?

Asking this question will plunge you into a thicket of scientific rivalries—which is what happened when I asked Christine Wildsoet, an optometry professor at UC Berkeley, about the biological plausibility of these myopia theories. Over the course of two hours, she paused repeatedly to note that the next part was contentious. “I’m not sure which controversy we’re up to,” she said at one point. (It was No. 4, and there were still three more to come.) But, she also noted, these theories are essentially two sides of the same coin: Anyone who does too much near work is also not spending much time outside. Whichever theory is true, you can draw the same practical conclusion about what’s best for kids’ vision: less time hunched over screens, more time on outdoor activities.

By now, scientists have moved past the faulty assumption that myopia is purely genetic. That idea took hold in the ’60s, when studies of twins showed that identical twins had more similar patterns of myopia than fraternal ones, and persisted in the academic world for decades. DNA does indeed play a role in myopia, but the tricky factor here is that identical twins don’t just share the same genes; they’re exposed to many of the same environmental stimuli, too.

Glasses, contacts, and laser surgery all help nearsighted people see better. But none of these fixes corrects the underlying anatomical problem of myopia. Whereas a healthy eye is shaped almost like an orb, a nearsighted one is more like an olive. To slow the progression of myopia, we would have to stop the elongation of the eyeball.

Which we already know how to do. Treatments to slow the progression of myopia—called “myopia control” or “myopia management”—exist. They’re just not widely known in America.

Over the past two decades, eye doctors—mostly in Asia—have discovered that special lenses and eye drops can slow the progression of nearsightedness in children. Maria Liu, a myopia researcher who grew up in Beijing, told me that she first became interested in nearsightedness as a teenager, when she began watching classmates at her school for gifted children get glasses one by one. In this intensely competitive academic environment, she remembers spending the hours of 6:30 a.m. to 10 p.m. on schoolwork, virtually all indoors. By the time she finished university, nearly all of her fellow students needed glasses, and she did too.

Years later, when she started an ophthalmology residency in China, she met many young patients who wore orthokeratology lenses—also known as OrthoK—a type of overnight contact lens that temporarily alters the way light enters the eye by reshaping the clear front layer of the eyeball, thus improving vision during the day. Liu noticed, anecdotally, that those who wore OrthoK seemed to have better vision down the line than those who wore glasses. Could long-term use of the lenses somehow prevent elongation of the eye, thus impeding myopia’s progression? It turns out that other scientists and doctors across Asia were noticing the same trend. In 2004, a randomized controlled study in Hong Kong of OrthoK confirmed Liu’s hunch.

By then, Liu had moved to the U.S., and she soon began a doctoral program in vision science at Berkeley to study myopia. Her classmates, she recalls, were tackling exotic-sounding topics such as gene therapy and retinal transplants and wondered why she was studying “something that’s so boring.” She ended up working in Wildsoet’s lab, researching the development of myopia in young chick eyes.

In humans, the majority of babies are born farsighted. Our eyes start slightly too short, and they grow in childhood to the right length, then stop. This process has been finely calibrated over millions of years of evolution. But when the environmental signals don’t match what the eye has evolved to expect—whether that’s due to too much near work, not enough outdoor time, some combination of the two, or another factor—the eye just keeps growing. This process is irreversible. “You can’t make a longer eyeball shorter,” Liu said. But you can interrupt growth by counteracting these faulty signals, which is what myopia control is designed to do.

When Liu became a professor at Berkeley after receiving her Ph.D., she started envisioning a myopia-control clinic—the first of its kind in the U.S.—that could bridge the gap between research and practice. By then, she knew that many doctors in China were already successfully using OrthoK for myopia control.

Photo-illustration by Vanessa Saba. Sources: Nick Dolding / Getty; Tina Caunt / EyeEm / Getty.

The school administration was skeptical. Liu says that the clinical director didn’t see how the clinic would benefit optometry students, or how it could attract enough patients to be worthwhile financially. But in 2013, Liu started it anyway, as a one-woman operation. She began seeing patients on Sundays in borrowed exam rooms with no extra pay and without relinquishing any of her teaching or clinical duties. Within months, her schedule was full. The Berkeley Myopia Control Clinic now runs four days a week and has 1,000 active patients—some of whom drive hours through Bay Area traffic to get there. Liu was one of the only people at the school who anticipated the clinic’s massive success. Jung, who is also an assistant clinical professor at Berkeley, told me that Liu’s knowledge of the latest myopia-control treatments made it feel like she came “from the future.”

When I arrived at the clinic at 8 a.m. on a Saturday morning this past spring—an hour at which the rest of the campus was still quiet—it was already filling up with optometry students and residents who work there as part of their training. Liu, who is petite with neat, wavy hair, moved through the clinic with frightful efficiency. One moment she was examining eyes, the next talking down a parent whose son’s contact-lens shipment had gone missing, the next warning staffers about a malfunctioning printer.

The clinic offers three different treatments: OrthoK, multifocal soft contact lenses, and atropine eye drops. The first two both work by tweaking how light enters the eye, producing a signal for the eyeball to stop lengthening. Atropine, in contrast, is a drug that seems to chemically alter the growth pathway of the eye when used at low doses. (It also dilates the pupil; Cleopatra reportedly used it to make her eyes more beautiful.) These treatments slow myopia progression on average by about 50 percent. The original clinical trials validating them were mostly conducted in Asia starting in the mid-2000s. And the American Optometric Association’s evidence-based committee published a report advising its members on how to use myopia control last year. Until quite recently, though, none of these treatments had been approved by the FDA for myopia control. Any optometrists who wanted to offer them had to go off label. And any patient who wanted to use them had to find the right doctor.

[Yascha Mounk: The great American eye-exam scam]

It’s not a coincidence that Liu’s clinic found early success in the Bay Area, which has a large Asian population. Eye doctors I spoke with in multiple cities across the U.S. said it was usually Asian parents who came in asking for myopia control. The parents I met at the clinic skewed Asian and, on that Saturday, particularly Chinese—first-generation immigrants who speak Mandarin seek Liu out on the days she is personally in the clinic. Many of them heard about myopia control from fellow immigrants or friends in Asia. George Tsai, whose 8-year-old son was at the clinic for an OrthoK appointment, told me that his wife, who grew up in China, had learned of myopia control through WeChat, the messaging app popular in the country and among the Chinese diaspora.

Liu has a second phone, which she uses to manage three WeChat groups full of parents with kids in myopia control across North America. The questions flood in day and night. “First thing in the morning, I look at this WeChat group. Who has lost a lens? Who has red eyes? Who has other problems?” she said. “And again, before I go to bed.” She started the first group with a parent of one of her patients. When it hit the maximum number of members allowed on WeChat, they created a second, and then a third. The groups now contain a total of 1,500 parents.

In general, Liu told me, Asian parents tend to be a lot more motivated because myopia “is much better perceived or accepted as a disease in Asian culture.” I know this firsthand, as the child of Chinese immigrants. Distressed about my worsening vision in elementary school, my mother would regularly admonish me, standing my pencil case upright to measure the distance between my head and my desk. She also made me do eye exercises developed in China, which I was vindicated to finally learn, in the course of reporting this story, do not work. This was the late ’90s, when there really was nothing to be done about myopia progression. But in the parents I met at the Berkeley clinic, I saw the same determination I once saw in my own. They had uprooted their lives and come to a foreign country and now here they were, hoping to bestow upon their kids any advantage, any edge that modern science could give.

There is another reason that the Bay Area, with its high median income, has been fertile ground for myopia control: The treatments are expensive. Many of the parents I met at the clinic were engineers or doctors. At Berkeley, OrthoK costs more than $450 for one pair of lenses, plus $1,600 for the initial fitting, not including the fees for several follow-up appointments a year. Soft contact lenses can run from several hundred to more than $1,000 a year. And a year’s supply of atropine eye drops costs hundreds of dollars. Kids are typically in myopia control until their mid-teens to early 20s. Vision insurance does not cover any of these treatments.

Multinational eye-care companies now see myopia control as a hot potential market. They’re vying for FDA approval of new lenses and improved formulations of atropine, which can be patented rather than sold as a cheaper generic. The business case is obvious: If half of the world is myopic by 2050, that’s a huge pool of would-be customers. “How often do you have an opportunity to have an impact on a condition that will affect one out of two people? There’s nothing else on the planet that I’m aware of,” says Joe Rappon, the former chief medical officer of SightGlass Vision, a small California company whose myopia-control technology was jointly acquired by the eye-care giants CooperVision and Essilor.

In November 2019, the FDA green-lighted the first—and currently only—treatment specifically designed to slow the progression of myopia in the U.S., a soft contact lens from CooperVision called MiSight. Many more treatments, though, are in trials in the U.S., including several types of spectacles that tweak the way light enters the eye in order to slow its growth. Some are already on the market in Europe and Canada.

Once those glasses get approved in the U.S., “that’s going to open the floodgates of myopia management,” Barry Eiden, an optometrist in Deerfield, Illinois, told me. The earlier you can start slowing myopia progression in kids, the better the outcome, he explained, but parents sometimes balk at the idea of putting drugs or contacts into the eyes of their young children. They don’t have the same problem with glasses.

In the future, Liu told me, she hopes FDA approvals will spur vision insurance to cover myopia control at least partially, making the treatments affordable to more parents. Meanwhile, CooperVision has already revved up its MiSight marketing machine. It’s targeting exactly the parents you would expect: In my own Brooklyn neighborhood of Park Slope, where you regularly see toddlers in $1,000-plus Uppababy strollers, an optometry shop recently hung a big banner advertising MiSight with two smiling kids. An optometrist in downtown San Francisco told me that parents who have seen MiSight’s ads are now coming into her office asking for it by name. The word-of-mouth era of myopia control is ending; the mass-advertising era is beginning.

Within the optometry business, myopia control often gets compared to braces—another treatment for which middle- and upper-class parents who want the best for their kids will dutifully shell out thousands of dollars. This comparison feels apt in a different way, too. Braces are also a modern solution to a relatively modern affliction. The teeth of cavemen, anthropologists have marveled, were incredibly straight. Crooked teeth appear in the archaeological record only when our ancestors transitioned from chewing raw meat and vegetables to eating cooked and processed grains. Our jaws are now smaller and weaker from disuse, our teeth more crowded and crooked. Today, braces are the way we retrofit our ill-adapted bodies for contemporary life.

We may not know exactly how ogling screens all day and spending so much time indoors are affecting us, or which is doing more damage, but we do know that myopia is a clear consequence of living at odds with our biology. The optometrists I spoke with all said they try to push better vision habits, such as limiting screen time and playing outside. But this only goes so far. Today, taking a phone away from a teenager may be no more practical than feeding a toddler a raw hunter-gatherer diet.

So this is where we’ve ended up, for those of us who can even afford it: adding chemicals and putting pieces of plastic in our eyes every day, in hopes of tricking them back to their natural state.

This article appears in the October 2022 print edition with the headline “The Myopia Generation.”

Let me explain something about me: When I was 12, I started having panic attacks, brought on by fears that I couldn’t shake, even though I knew they were irrational. I was terrified, for example, that I’d become depressed—but I’d never been depressed before, and didn’t feel depressed. My junior high school devoted a series of assemblies to warning us budding teenagers that we were entering the most dangerous years of our lives, now ripe targets for cutting, suicide, eating disorders, overdoses, AIDS, and fatal car accidents. I would spend hours, even days, worrying that one of these things might be coming for me. My mind seemed to spin out of control—I couldn’t stop fixating, I couldn’t calm down, and I couldn’t understand what was happening.

Finding language to describe suffering of any kind is hard, but eventually, fearing I was going irreversibly insane, I tried—first for my mother, then for a doctor. Soon I was told there was a name for my particular distress: obsessive-compulsive disorder. Receiving this news at 13 was both relieving and shattering. (And surprising. There had been no assembly suggesting we watch out for anxiety disorders.) With the diagnosis came explanations and context for what I had not been able to interpret, as well as a body of scientific knowledge about treatment. Still, OCD can be an upsetting diagnosis, partly because according to current psychiatric understanding, it’s a chronic illness. You don’t typically get cured. You “learn to manage it” and, like most chronic conditions, it ebbs and flows based on a variety of factors. I felt horror at being indelibly marked and feared that I’d never get back to “my old self.” Who was I now?

[Read: Can you cure mental illness? Two centuries of trying says no.]

Rachel Aviv begins her nonfiction debut, Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, with the story of her own childhood introduction to psychiatry—briefer and more unusual than mine. At 6, she tells us, she abruptly stopped eating. She refused to say the names of food, “because pronouncing the words felt like the equivalent of eating,” and refused to say the number eight, because it sounded like ate. That year, she was admitted to the eating-disorders unit at Children’s Hospital of Michigan, thought to be the youngest person on record to be diagnosed with anorexia. Her doctors were perplexed, speculating that her anorexia might be related to the stress of her parents’ divorce. Aviv didn’t understand her diagnosis, its implications, or its cultural associations—she couldn’t even spell it. “I had a diseas called anexexia,” she wrote in her diary two years later.

In the ward, she was guided by older girls, from whom she learned the conventions of the disorder. “I hadn’t known that exercise had anything to do with body weight, but I began doing jumping jacks with Carrie and Hava at night.” She refused to sit down after the girls taught her the phrase couch potato. But eventually Aviv ate because she’d been forbidden to see or speak to her parents unless she did. “My goals realigned.” She was discharged from the hospital after six weeks, and assimilated back into her old life, eventually consenting to sit down with the rest of her class at school. The illness lifted as mysteriously as it had descended. From here, she suggests, she went back to a normal, healthy life.

“To use the terms of the historian Joan Jacobs Brumberg, who has written eloquently about the genesis of eating disorders, I was ‘recruited’ for anorexia, but the illness never became a ‘career,’ ” Aviv writes. “It didn’t provide the language with which I came to understand myself.” She proposes that she recovered because she was too young at the time of her illness to decipher or internalize the cultural and psychiatric narratives that attend it. She had no “insight,” a term used by psychiatrists to describe the quality of being self-aware and rational regarding one’s illness. Typically, insight is crucial to a good prognosis: If you have insight, you have what doctors would call the “correct attitude to a morbid change in oneself,” as a 1934 paper in The British Journal of Medical Psychology put it. But Aviv, pointing out that a correct attitude to a morbid change “depends on culture, race, ethnicity, and faith,” supplies a different, more acerbic definition of insight: “the degree to which a patient agrees with his or her doctor’s interpretation.”

Being an “insightful” patient in the traditional sense demands accepting the diagnostic categories and language on offer, she writes. (Failure to correctly perform insight can also play a role in the decision to institutionalize a person without their consent.) And insight, Aviv argues, has its dangers. Adopting a dictated narrative about your mind can change your outcomes, for better and worse. “I wasn’t bound to any particular story about the role of illness in my life,” she writes with relief. “There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.”

As a writer who has reported on medicine, education, and criminal justice for The New Yorker since 2011, Aviv reanimates this early chapter of her life to introduce the collection of essays that follow: five profiles of people whose stories defy or complicate psychiatric models of understanding the mind. Aviv is skeptical of psychiatric diagnosis and the language that accompanies it not because she’s fundamentally anti-psychiatry but because psychiatry is a limited and constantly shifting discipline, deeply influenced by the foibles and fashions of culture. More broadly, her interest is in the parts of existence that William James called the “unclassified residuum,” which frustrates scientists whose desire, he wrote, is “a closed and completed system of truth.”

[From the December 2018 issue: Jordan Kisner on Lucia Berlin’s harrowing, radiant fiction]

Each of the people Aviv profiles offers evidence of a different shortcoming of Western psychiatry. Ray is a ruminative depressive who was institutionalized in 1979. Because his illness coincided with a sea change within modern psychiatry, he was offered two very different explanations—and treatments—for what ailed him. One approach endorsed introspective therapy to promote “understanding” of the fundamental personal and social maladjustments producing his distress; the other, corresponding with the rise of the “chemical imbalance” theory of mental illness, proposed that his depression was a natural, biochemical phenomenon, and required psychopharmacology. Ray had begun, medically speaking, as a man with burdensome personal flaws, and emerged a man with bad neurochemistry. “Who is Ray Osheroff, now?” he wrote, late in life, still miserable.

Then there is Bapu, a young Indian woman who in the 1960s experienced a spiritual awakening and became convinced that she had been chosen to “immerse myself in the ocean of devotion,” as she wrote in her journal. She spent hours a day in her prayer room, began dressing and living like a Hindu ascetic, and repeatedly tried to leave her husband and children to live in a monastery. She believed she was a bride of Krishna’s. Bapu’s husband took her to a Catholic psychiatrist trained in Western approaches, who pronounced her schizophrenic. She insisted that she was simply joining a millennia-old tradition of Hindu mystics.

Bapu refers to herself as a madwoman or a lunatic more than a dozen times in her journals, but only sometimes with despair. She saw her alienation from society as proof of her insight. Her inner world had come to feel more substantial than the reality to which her family was bound. The saints she admired had also ruptured ties with family and devoted their lives to phenomena that others could neither see nor touch. Ramakrishna, a nineteenth-century mystic, told his devotees that madness was a mark of devotion and should never be mocked.

Bapu lived for many years on the streets, suffering both physically and psychically, but “she drew from a rich tradition that gave her anguish purpose and structure.” Aviv asks: Whose version of Bapu’s story should be the authoritative one?

The bleakest of the case studies is Naomi, a young Black American who grew up in the 1980s and ’90s in a Chicago housing project that a Housing Authority official described at the time as a “hell hole.” The grinding poverty and violence of her childhood gave way to the grinding poverty of her adulthood: As a teenager, she lived in a shelter with her newborn, but became a teacher’s assistant and went to community college at night. She loved to read and to write music, and after joining a writing group began searching for Black-women-centered histories of American racism, poverty, and police brutality. “She felt debilitated by the historical resonances of her own story,” Aviv writes. “She suddenly had language to describe the kind of pain that had haunted her family for generations.”

Naomi’s grief was all-consuming. She became depressed, and then—after a traumatic childbirth experience—psychotic; a year later, she leaped off a bridge after dropping her twin sons into the water below, believing she was saving them from a life of thwarted potential and unjust suffering. Her subsequent journey through the legal and medical systems, which failed her spectacularly, was complicated by the fact that her delusions were rooted in something so absolutely real and grimly central to her experience. “She wants to convert people into not being racist and accepting her people,” a doctor noted in Naomi’s chart during one emergency-room visit. In some contexts, Naomi’s complaints were described as “bizarre,” evidence of her incapacity—in others, as “astute observations about the society in which she lived.” Which responses to racism are pathological, and according to whom, and when?

[Thomas Insel: What American mental-health care is missing]

One of the pleasures of this book is its resistance to a clear and comforting verdict, its desire to dwell in unknowing. At every step, Aviv is nuanced and perceptive, probing cultural differences and alert to ambiguity, always filling in the fine-grain details. Extracting a remarkable amount of information from archival material as well as living interview subjects, she brings all of these people to life, even the two whom she never met. I zipped through each essay—propelled by curiosity—yet needed to take breaks between them, both to recover from the intensity of the human experience described and to sit with the implications of the argument Aviv is building, which suggests that it may be more harmful than helpful to see yourself the way doctors see you.

As I read, I found myself with a lingering unease about Aviv’s own relationship to her broader subject, sensing more complication there than she initially allows. She presents herself at the outset as someone who was spared a lifelong struggle with mental illness because she was just too young to become ensnarled in what the philosopher Ian Hacking calls the “looping effect,” when a diagnosis becomes a self-fulfilling prophecy. A new diagnosis can change “the space of possibilities for personhood,” he writes. Unlike the girls Aviv met when she was 6, some of whom never recovered, she is able to study this process rather than live it.

Did Aviv escape an external narrative quite as cleanly as she wants to believe? We are left to wonder until her final essay, in which she wrestles with this question directly. “Laura” tells the story of a young woman who was put on a string of medications in adolescence, none of which seemed to significantly ease her misery, a failure that led to additional medications in various combinations. Here, more explicitly than in her portrait of Ray, Aviv joins an existing discourse about psychopharmacology, raising by now familiar concerns about the overmedication of Americans, and the impulse to treat regular human unhappiness as pathological. And here, she introduces her own fraught relationship with Lexapro.

Aviv started medication in her late 20s, as her writing career was getting under way, to assuage social anxiety and ambient feelings of inadequacy. Her first six months on Lexapro was, she thought, the best period of her life. Her social anxiety vanished. She also felt somehow intrinsically different—more playful, more loving, more engaged in the world. This recalled a telling moment from her childhood diary: “I had some thing that was a siknis its cald anexorea. I had anexorea because I want to be someone better than me.” This central issue—wanting “to be someone better than me”—seemed neither produced by her pediatric brush with diagnosis nor helped by it. She may have escaped a “career” of illness, but this feeling stayed, until Lexapro.

Soon Aviv became disconcerted that so many of her female friends were also taking Lexapro and loving it. “These more and more seem like Make The Ambitious Ladies More Tolerable Pills,” a friend wrote, echoing her suspicion that the medication was more fad than necessity. But Aviv’s attempts to quit didn’t go well—stopping the medication brought on terrible depression (which can be a passing withdrawal effect of some antidepressants), and she always started her dose again. A couple of years later, still on Lexapro, she decided she wanted to be a mother. Two weeks after going off the medication upon learning she was pregnant (as is sometimes advised), she was immobilized and quietly imagining a miscarriage. Her doctor grew alarmed and suggested she resume the medication. She did, and three weeks later, she writes, “I felt connected again to my reasons for having a baby.”

Aviv tries to take stock: What to make of the enormous hold Lexapro now seemed to have on her life, despite her belief that she’d avoided an illness “career”? She describes growing confused about her “baseline self.” What if she is not the achieving, albeit anxious, person she’d been before Lexapro, the identity she’d embraced as “true,” but “the more dysfunctional self that had occasionally resurfaced—most visibly when I was six and hospitalized”? Aviv is negotiating a complicated formulation here. First, she assumes a “baseline self,” a concept that makes intuitive sense but also stands in tension with the evidence she’s offered throughout her essays that the “self” can be determined or altered by external factors. Then she makes a distinction between her “baseline self,” which is functional, and the “more dysfunctional self” that sometimes surfaces. Where did this narrative come from? What is the self? Who gets to say? “To continue as the person I’d become I needed a drug,” she writes after more than a decade on Lexapro. “I wanted my children to remember the version of me that took Lexapro.” “On 7.5 milligrams I’m a better family member,” she tells Laura about her decision not to lower her dose. Who is Rachel now?

The existence of this book—and Aviv’s career as a journalist who frequently investigates the depths of human suffering, whether among refugee children who sink into coma-like trances or senior citizens taken from their homes and denied autonomy—indicates unfinished business of the generative sort. She’s drawn to the disorienting terrain of shifting self-knowledge, alert to the trauma of having one’s agency stripped by an outside authority or an imposed narrative. Still, she doesn’t argue for pure self-determination. As I read, I kept returning to Aviv’s early diary entry, “Here let me explain something about me. I had a diseas called anexexia.” A second moment from the same era also stuck with me. She writes that when she first arrived on the ward, she asked one of the older girls there over and over, “Do you think I’m weird?”

This feels like the core human impulse that Aviv is attempting to parse. Every person in Strangers to Ourselves writes to understand their mind. Ray spends decades on an autobiography; Bapu has a kind of graphomania, sometimes scrawling diaries on the walls; Naomi writes songs, a novel, and a memoir; Laura has a blog; Aviv gets access to the many journals kept by Hava, one of the girls she met in the hospital. When we become strangers to ourselves, we are compelled to narrativize. And then we need to know what others make of that story, how they understand us, so that we can understand ourselves. The question “Who am I now?,” while directed at the self, cannot be answered only by the self. It requires traversing between the meaning we make inside ourselves and the meaning we encounter in community. Aviv’s subjects, she writes,

described their psychological experiences with deep self-awareness, but they also needed others to confirm whether what they were feeling was real. It didn’t matter whether they believed they were married to God or saving the world from racism—they still looked to authorities (mystics for Bapu, doctors for others) to tell them how and why they were feeling this way. Their distress took a form that was created in dialogue with others, a process that altered the path of their suffering and their identities too.

Approved insight, the kind that informs “correct” narratives, exerts real and lasting power, whether damaging (Aviv’s focus) or healing, as is often the case. But Aviv is more preoccupied with insight in the philosophical sense—finding order and meaning in one’s own story—which is anything but straightforward or static. I am not the person I feared I would become after my diagnosis at 13, and the diagnostic language and medication I was offered at that time allowed me, paradoxically, to feel less defined by my experience of anxiety. Still, I have an ongoing, sometimes uneasy relationship with diagnostic categories and with medication—a relationship that necessarily changes as I change. Aviv reminds us that Who am I now? is less a momentary question than a koan that suffuses every life, an invitation to revisit and revise the conundrum, whoever you are and whether or not you have a diagnosis. All of Aviv’s subjects, herself included, live at the mercy of social and medical constructions, and yet strive to shape and reshape their irreducible, protean selves. It is the most human drama. It doesn’t seem weird at all.

This article appears in the October 2022 print edition with the headline “The Diagnosis Trap.”

America is in the grips of two kinds of child-pornography problems. The first involves the production of child pornography itself—the abuse of children photographed, filmed, and monetized. The second involves the remarkably early age at which children are now exposed to pornography, when they start to see the images that shape their minds and hearts.

Both have profound costs. The terrible toll of child sexual abuse requires little explanation. Many girls and boys who have survived abuse carry the consequences for a lifetime, and because of the almost endless ability of porn consumers to find, download, and upload the same images, survivors can be traumatized again and again.

The consequences of childhood sexual exposure—while in no way comparable to the trauma of those exploited—are also becoming clear. Women and men are reporting that their relationships are twisted and distorted by early exposure to porn, and that’s contributing to an immense amount of pain, exploitation, and heartbreak.

But our nation doesn’t have to consent to child sexual exploitation or child sexual exposure as terrible but inevitable “costs of freedom.” Our culture and our government possess tools to deal with these problems, and those tools are consistent with the First Amendment. The challenge is in doing so with enough creativity and pugnacity to take on a ubiquitous, resilient industry.

Child sexual abuse may be (almost) universally reviled, but it is also widely consumed, including on some mainstream porn websites. A survey of recent media investigations reveals some rather staggering scandals. Investigations of the popular porn sites OnlyFans and xHamster have uncovered thoroughly inadequate controls on child pornography. A Twitter plan to allow users to sell OnlyFans-style porn subscriptions floundered when an internal study determined that “Twitter cannot accurately detect child sexual exploitation and non-consensual nudity at scale.”

Most notably, in 2020, The New York Times’ Nick Kristof wrote a searing story called “The Children of Pornhub” that highlighted how remarkably easy it was to find child pornography on Pornhub and described the high cost of abuse to the young girls who survived it. More recently, one of the young women Kristof profiled, Serena Fleites, filed a lawsuit against MindGeek (the company that owns Pornhub) and Visa, claiming that both companies had violated the Trafficking Victims Protection Reauthorization Act—which grants trafficking victims a private right of action against traffickers and against beneficiaries of trafficking ventures—by knowingly taking part in the “monetization of child porn.”

Fleites’s allegations make for tough reading. “MindGeek,” she claims, “employed a barebones team of as few as 6 but never more than about 30 untrained, minimum wage contractors to monitor the millions of daily uploads.” Even more alarming, she alleged that moderators were paid bonuses based on the number of posts they approved, not the number of posts they rejected. As the judge in her case noted, “Such an incentive structure suggests that content moderation was not the goal.”

Using children to make porn is plainly abusive. Permitting children to see porn may not create the same kind of trauma, but it has profound negative effects nonetheless. Last September Michelle Goldberg wrote an important column for The New York Times that contained this exchange from the feminist philosopher Amia Srinivasan’s book, The Right to Sex.

In a class at the University of Oxford, Srinivasan writes, she asked, “Could it be that pornography doesn’t merely depict the subordination of women, but actually makes it real?”

Her students said yes, she wrote. Srinivasan asked a follow-up: “Does porn bear responsibility for the objectification of women, for the marginalization of women, for sexual violence against women?”

According to Srinivasan, they said “yes to all of it.”

Pornography is warping the minds and hearts of young men, as many writers, both here in The Atlantic and elsewhere across our culture, have noted. It can create wildly unrealistic expectations of sexual performance, and—in the worst cases—it can lead men to believe that women expect or even enjoy degrading or violent sexual practices. Young women already know this; they need only look to their own experience and the experience of their friends.

It’s easy to see why porn can have this effect, especially on young minds. Many porn sites are full of depictions of dominating, abusive behavior. A survey of news reports and court documents detailing the contents of porn sites reveals much that is disturbing. “Barely legal” videos are deliberately filmed to make it appear as if grown men are having sex with young teens, and many of the allegedly “barely legal” videos aren’t legal at all. Videos depicting real or simulated rape and assault proliferate online, and even pornography that clearly depicts adult, consenting performers portrays sex that is utterly alien from the experiences of most couples.

[Read: Is porn culture to be feared?]

Moreover, the costs of porn are not borne only by women—though women are the principal victims of a form of “entertainment” that seems virtually lab-engineered to attract the male gaze. Many young men don’t have the slightest clue as to what “normal” sexual activity looks like, and they feel a pressure to perform like the performers they’ve watched for years. They expect women to like what female porn stars seem to like. And thus they place impossible expectations on themselves and their partners.

A memorable 2018 Atlantic cover story on America’s “sex recession”—the decline of young people having sex—discussed widespread availability of pornography as one of the culprits. Young men are replacing sexual intimacy with masturbation, and that is resulting in a cascade of negative academic, social, and sexual consequences.

Yet that’s far from the only cost of early male exposure to pornography. In many cases, it starts a process of character deformation in teen boys. Because parents disapprove of their kids viewing porn, boys learn to cover their tracks. Some grow practiced in deception, and they carry this pattern of deception into adult relationships—where they shield porn habits from their partner.

Countless marriages have been rocked by revelations that the husband watches pornography secretly and compulsively. In many of those cases, it’s not just the pornography that wounds the spouse; it’s the deception.

Thus here we are, in 2022, with a growing bipartisan, secular, and religious consensus that both childhood sexual abuse and childhood sexual exposure are creating or contributing to a series of cultural crises. And that leads us to a question: What can be done?

There is no substitute for parental vigilance, of course, but talk to even the most diligent parents and you’ll learn that they often feel helpless, for good reason. There are so many methods for avoiding parental controls—especially when many children are far more tech-savvy than their parents—that parents despair of shielding their children from the images they simply shouldn’t see.

Moreover, maximalist legal positions—such as banning pornography altogether—will go nowhere, for the simple reason that even if political majorities wanted to ban porn, the First Amendment wouldn’t permit it.

We know this because it’s already been tried: In the early 1980s, an effort to ban porn grew out of an unusual but long-standing consensus between religious conservatives and progressive feminists on this issue. Many religious conservatives have always viewed pornography as inherently immoral. A number of second-wave feminists, led by Catharine MacKinnon and Andrea Dworkin, also viewed it as discriminatory. Porn, they argued, exploited and subjugated women.

And so, in a little-remembered episode of American legal history, MacKinnon and Dworkin worked with social conservatives in the city of Indianapolis to write an ordinance that banned porn. “Pornography,” the ordninance stated, “is a systematic practice of exploitation and subordination based on sex which differentially harms women.” It was deemed “central in creating and maintaining sex as a basis for discrimination.”

The legal theory was creative. It tied pornography to then-nascent legal doctrines expanding definitions of sex discrimination. But it got wiped out in court. A federal trial judge struck it down. Then the federal Court of Appeals for the Seventh Circuit struck it down, with Judge Frank Easterbrook writing the majority opinion. Then, lest there be any doubt about the outcome, in 1986 the Supreme Court summarily affirmed the Seventh Circuit, without full briefing and without oral argument.

Eleven years later, the Supreme Court made its point yet again. The Communications Decency Act, written at the dawn of the internet, tried to regulate children’s access to porn by criminalizing the “knowing” sending or displaying of certain kinds of pornographic images to a person under 18.

In Reno v. ACLU, the Supreme Court struck down the law’s age provisions, noting that there were a number of technical challenges to requiring age screening, and that age limitations “must inevitably curtail a significant amount of adult communication on the Internet.” In other words, the burdens placed on websites to police the age of their users would necessarily suppress the expression of constitutionally protected speech among adults.

Between the two cases, the legal difficulties were clear. First, outright bans on porn won’t survive constitutional review, and second, even otherwise-constitutional age restrictions (children do not possess a constitutional right to view porn) won’t pass judicial review if the cost of compliance excessively burdens protected speech by adults, to adults.

But this case law does not render our culture—or our government—helpless. Companies such as Visa, Mastercard, and Discover could choose to block consumers from using their credit cards to make purchases on Pornhub, as they did after Kristof’s story was published in the Times. (Visa later reinstated payments on Mindgeek sites that it said “offer professionally produced adult studio content that is subject to requirements designed to ensure compliance with the law.”)

Mastercard also announced that it would require “clear, unambiguous and documented consent” from all people depicted in pornographic content on all adult sites that use it for payment processing.

Each and every company that helps monetize pornographic content—including each and every major credit-card company—should impose the same rule. For those who fret about activist corporate overreach, remember that sharing child pornography, revenge porn, or other sex-abuse material is not a constitutionally protected activity and indeed is already prohibited by  a number of federal or state criminal and civil statutes.

All of this is to say that corporate action to demand accountability and responsibility from pornographic websites isn’t suppressing legal commercial activity; it’s deterring the intentional and negligent distribution of illegal images.

There’s now an additional legal incentive for credit-card companies and other financial-services companies to impose strict standards on porn sites. In July, a federal district-court judge refused to dismiss Serena Fleites’s lawsuit against MindGeek and Visa. The court noted that “the emotional trauma that Plaintiff suffered flows directly from MindGeek’s monetization of her videos and the steps that MindGeek took to maximize that monetization.”

Moreover, the court detailed MindGeek’s “astonishingly strong” response after Visa’s reaction to Kristof’s story, which included removing 10 million videos from Pornhub. MindGeek was far more responsive to Visa than it allegedly was to even victims who complained about abusive material on its sites.

Shortly after the ruling, Visa and Mastercard suspended the use of their cards for ad purchases on MindGeek and Pornhub. Visa’s CEO and chairman, Al Kelly, said that the company strongly disagreed with the court’s ruling, but that it “created new uncertainty” about the role of MindGeek’s advertising, and that Visa cards can’t be used to purchase advertising on any MindGeek accounts.

This should be the beginning, not the end, of corporate responsibility. Financial-services companies should choose to do business only with those entities that rigorously age-gate their content. The United Kingdom is currently considering imposing a legal obligation on porn providers to block minors from their sites.

The British government doesn’t operate under the same kind of constitutional free-speech constraints as the American government does, and so it has greater legal freedom to impose restrictions on the porn industry. But that doesn’t mean that American private actors can’t learn from the British model.

Nor does it mean that American governments should rule out making another attempt at technically feasible age-gating. The Supreme Court’s prior decisions depended a great deal on the technical impossibility of age-gating without substantially burdening adult access to constitutionally protected material. They did not grant minors a constitutional right of access to pornography.

[From the August 1966 issue: The obscenity business]

Thus the question of age-gating may well be every bit as technical as it is legal. Ease the technical challenge, and you’ll likely cross the constitutional hurdle.

In addition, as Fleites’s case indicates, the prospect of using private rights of action to inhibit irresponsible conduct remains. In fact, as of October 1, victims of the “unauthorized dissemination of private, intimate images of both adults and children” will have access to a new federal civil cause of action.

Another model for limiting online pornography’s reach while respecting constitutional constraints exists, and it comes from decades of legislative efforts to mitigate the effects of offline porn. Beginning in the 1970s, courts began empowering local governments to regulate the locations of adult businesses through the “secondary-effects doctrine.”

For example, in Young v. American Mini Theatres, the Supreme Court upheld a Detroit “anti-skid row” ordinance, which prohibited adult businesses from being located close together in the same neighborhood. Writing for the majority, Justice John Paul Stevens noted that the city had concluded that a “concentration of ‘adult’ movie theaters causes the area to deteriorate and become a focus of crime, effects which are not attributable to theaters showing other types of films. It is this secondary effect which these zoning ordinances attempt to avoid, not the dissemination of ‘offensive’ speech.”

In 1986, the Court reaffirmed this reasoning in City of Renton v. Playtime Theatres, which upheld a city zoning ordinance that prevented adult businesses “from locating within 1,000 feet of any residential zone, single- or multiple-family dwelling, church, park, or school.” Each of these prohibited areas represent places where children live, learn, and pray.

There’s no doubt that the secondary-effects doctrine has burdened the adult-entertainment industry. It has not, however, come close to prohibiting it. Similarly, internet regulation aimed at the secondary effects of adult entertainment—accessibility by children and the inclusion of abusive material—should be constitutional even if it imposes additional burdens on porn sites, as long as those burdens are not so onerous that they, to quote Reno v. ACLU, “curtail a significant amount of adult communication” online.

Pornography is a multibillion-dollar business that directly profits both from child abuse and from sales of sexual images to young children. Child sex abuse destroys lives. Childhood sexual exposure has warped the marriages and intimate relationships of an entire generation of Americans. It is not too much to ask American culture, American corporations, and American governments to respond. The Constitution does not require us to sacrifice childhood innocence on the altar of adult lust.

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