How To Address the Opioid Crisis Without Gunboat Diplomacy

 

The United States is currently suffering through the self-inflicted crisis of electing an authoritarian administration.  Civil, legal, international, and diplomatic standards are routinely ignored and there seems to be no clear overriding strategy other than promulgating the autocracy.   271,000 government employees were fired, many leading experts in fields that ran counter to the autocratic myths, but most were loyal career government employees dedicated to serve the public.  USAID – a government agency providing technical assistance and medical care in the developing world since 1961 was officially shut down by the Trump administration in 2025.  USAID was credited with saving 92 million lives over 20 years and there is currently a tracker in place that estimates how many people will die as a result of the closure.  It is clear the Trump administration is not afraid to be directly responsible for the deaths of tens of thousands if not millions of people.  It might fit their American first narrative if there was any possible benefit to Americans.  Their political calculus apparently ignores any goodwill effects of helping people and a national image unlike the usual totalitarian regimes.

Trump’s version of the War on Drugs, is smaller in scale but probably much more deadly.  Trump began sinking boats in the Caribbean and the Pacific Ocean that he alleged were carrying drugs in September 2025.  Since then, 35 vessels were struck or sunk killing 123 people (1).  There is ongoing debate that this is not standard drug interdiction where drug smugglers are stopped by the Coast Guard, arrested, and stand trial.  This is unlawful killing of suspected drug smugglers where the public is supposed to accept that the alleged intelligence about whether they were smuggling drugs is accurate.  Given this administration’s honesty track record there is no way that should be accepted at face value.  The Coast Guard’s own statistics suggests that 25% of the vessels they board for the same reason are not carrying drugs. Even if they were this is essentially executing people without due process for what are non-capital crimes in the US.

In addition to the strikes that are seen as criminal there have been 2 incidents suggesting additional war crimes.  In the first, survivors of the first strike were killed while they were swimming in the water.  In the second, a strike was made by a plane disguised as a civilian plane.  According to the Geneva Convention it is a war crime to feign protected status and then attempt to kill, capture, or injure an adversary.  This is known as perfidy and it is accepted by the US.  Like most activity from this administration there appears to be no clear rationale for all this activity and despite the outcry over potential war crimes – the actions continue unabated.

I had plenty of experience teaching diverse groups of students about the opioid epidemic from about 2008 to 2020.   Overdose deaths were a proxy for the epidemic.  The initial part of that curve was due to excessive prescribing that was associated with a pain as the fifth vital sign initiative.  There were excessive and escalating prescriptions for the treatment of chronic pain.  In many cases there were diversions of these drug supplies for non-prescription use.  In some cases, there were pill mills that specialized in writing opioid prescriptions in great numbers.  They resembled medical practices from the turn of the 20^th century that maintained people in addiction rather than treating any specific medical problems. As more prescription opioids were diverted it was more cost effective to purchase heroin and that was the first significant change in consumed opioid composition.  By 2014 synthetic opioids (fentanyl and carfentanyl)  were introduced into this landscape.  They had much higher potency than the usual prescription opioids and that led to more drug overdoses.  Countermeasures were introduced including intranasal naloxone and fentanyl test kits.  These are effective measures if available but there is some misunderstanding by the public, who sees opioid users as risk averse.  They are not risk averse but both countermeasures are useful in saving lives.  The most effective life saving measure is MOUD or medication for opioid use disorder including buprenorphine, methadone, and naltrexone.

That brings me to a paper on the sudden reduction in overdose deaths beginning in mid-2023 and extending into 2025 in both the US and Canada.  During that time the overdose death rates dropped by 30%(3).  The graph of that reduction is shown below.  The data is a combination of confirmed data by the CDC and provisional counts and projections by NCHS for the last two years.  It is very similar to the graphs generated by the authors in their report.

 

 The authors used a novel approach to investigate the idea that supply shock accounts for the decrease in overdose deaths.  During treatment it is common for people using non-prescription controlled substances to report shortages and changes in the drug supply as well as price changes to their treatment providers.  The authors used the number of drug seizures and opioid concentration estimates of those seizures to estimate fentanyl shortages.  They also searched a popular social media site (Reddit) for any mention of the term fentanyl or a reasonable facsimile and drought or shortage or a facsimile.  The Reddit data was compromised from January to July of 2024 by moderation on the basis that these posts about fentanyl shortages violated terms of use.

Both groups of indicators of decreased drug supply (drug seizures and concentration and social media posts indicating a drug shortage) correlated with a drop in drug overdose deaths.  By the end of 2024 the opioid overdose death rates and concentrations has fallen by about 30% (see graph).  The original paper plots both fentanyl concentration in pills and powders as well as death rates).

What caused these drops?  The authors suggest several possibilities.  First, China acted against the manufacture and sale of fentanyl and the precursors starting in late 2023. That included online platforms.  There was a meeting between President Biden and Xi in November 2023 that focused on law enforcement cooperation in this area.  The authors suggest this is a low-cost opportunity for China to get leverage in negotiations with the US. Second, US drug interventions in Mexico may have reduced the supply, but the authors point out that the DEA would have paradoxically claimed no credit in their reporting but did credit the lack of precursors from China.  These factors are strong arguments for supply chain disruption as a cause of the drop in opioid overdose deaths.  

Could this be a generational effect?  From a demographic standpoint, the 25-plus year opioid epidemic represents an entire generation.  The succeeding generation has seen the toll of these drugs as both mortality and morbidity.  The younger generation has been noted to have some sober initiatives and they are consuming less alcohol than their predecessors. Is it possible that this subcultural movement is extended to other intoxicants?  The 0-25 year age group typically has the lowest number of overdose deaths and by itself is unlikely to account for the decrease.

The authors suggest three implications of their paper.  First, that dealer level interdiction on the street may not be necessary to reduce drug trafficking.  Presumably that intervention has been constant over the course of the recorded data and it has had minimal impact. It is also high risk and places certain demographic groups at higher risk.  Second, this may be a transient effect.  Drug traffickers can adapt as noted by the difference in how fentanyl makes it to the streets in the US compared to Canada.  Finally, if this was in fact the effect of diplomacy those efforts should be increased rather than decreased. India is a source of precursors and in some cases direct to consumer shipments of controlled substances.  Diplomatic efforts could yield further disruptions in the supply chain and less problems with opioids on the streets of the US.       

There is now a fourth implication and that is that gunboat diplomacy and the questionable use of the US military against boats suspected of carrying drugs is unnecessary.  It also highlights that the Executive order to declare war on cartels was also unnecessary.  There was a substantial drop in overdose deaths before any of these measures was employed and it may be an indication that diplomacy is the way forward.  If I was a conspiracy theorist, I would suggest that Trump wants to get credit for the drop in fentanyl trafficking that occurred in the Biden administration.  According to the authors of this paper we do not know if this is a long-term trend or not. Since most fentanyl trafficking does not originate in Venezuela or the countries surrounding the targeted areas it is unlikely to have a big effect.  

That 30% decrease in mortality cannot be ignored and a closer examination of the Biden negotiations is warranted.

 

 

 

George Dawson, MD, DFAPA

References:

1:  Watson B, Peniston B.  The D Brief: ‘Perfidy’ in boat strike?; Pentagon’s new AI plan; Venezuela’s broken air defenses; Quantum space cameras; And a bit more.  Defense One.  January 13, 2026.  https://www.defenseone.com/threats/2026/01/the-d-brief-january-13-2026/410643/

2:  Tait R. Killing of survivors sparks outrage – but entire US ‘drug boat’ war is legally shaky.  The Guardian.  December 4, 2025.  https://www.theguardian.com/us-news/2025/dec/04/venezuela-boat-strikes-legality-hegseth

3:  Vangelov K, Humphreys K, Caulkins JP, Pollack H, Pardo B, Reuter P. Did the illicit fentanyl trade experience a supply shock? Science. 2026 Jan 8;391(6781):134-136. doi: 10.1126/science.aea6130. Epub 2026 Jan 8. PMID: 41505547.

Graphics:

1:  Lead graphic is from the CDC and is in the public domain: https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

2:  The graph of fatal overdose deaths per year shows the number of fatal opioid overdose deaths in the United States from 2000 to 2025.  The data from 2000 to 2023 consists of final and reported figures from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA). The figures for 2024 and 2025 are based on provisional counts and projections released by the CDC's National Center for Health Statistics (NCHS) as of January 2026.

3:  Graphics 2 and 3 were designed with the assistance of Google Gemini.

Why Equal Opportunity for Women Is Not “Woke”

 

I encountered two media events in the last couple of days that I thought I would respond to.  The first was an interview of Dana White talking about why there is no such thing as toxic masculinity and that you can’t be too masculine.  The second was the Trump-Hegseth lecture to the commanders of the armed forces and how there would now be male performance standards and grooming standards for members of the armed forces that were consistent with the new warrior ethos. President Trump also made an irresponsible comment about nuclear weapons that I will only say was not strategic or realistic.  He seemed to imply that because we have more of these weapons and they are more modern we could intimidate other nuclear powers and win a war.  I hope that I have been clear on this blog that in even a limited nuclear war whether you are close to the explosions and fallout or not – all of humanity loses.  By loses I mean up to and including extinction of all humans.

As I was watching the Dana White clip my first thought was: “Toxic masculinity is watching two guys inflict brain damage on one another.”  I remember watching him comment early in his career about how people never get injured badly in these fights despite being knocked out by punches, kicks, and chokes. Fighters have died in boxing matches and mixed martial arts competition (MMA) but apparently not in White’s ultimate fighting championship (UFC) competitions.  Despite that distinction it is just not realistic to think there are not injuries from these sudden accelerations and decelerations to the brain in any combat sports.  All it takes is repetitive nonconcussive impacts (1).

Like most of these complex subjects – masculinity and femininity all depend on your definitions.  And in academics the definitions may come down to your field.  My initial attempt at trying to research it yielded a steady stream of papers from the fields of post modern philosophy and literature, gender studies, and English literature.  A Medline search was more productive but still vague. I narrowed it down from 19,266 references (masculinity) to 333 (masculinity AND definition) to 93 (masculinity AND definition AND review). Even then the results are sparse since they include many references to medical disorders that may be masculinizing or feminizing. 

The overall process or how we arrived at stereotype of masculine or feminine is rarely discussed.  It is usually just assumed that the universe of human traits, attributes, and behaviors segregate neatly into two categories based on biological sex. These stereotypes come into play in some assessments like the Minnesota Multiphasic Personality Inventory (MMPI).  Scale 5 on that assessment is the Masculinity-Femininity scale.  It contains subscales Mf2 Stereotypic Feminine Interests and MF3 Denial of Stereotypic Masculine Interests.  High scores on the MF2 scale indicate and interest in stereotypical occupational and pastime interests.  High score on the Mf3 scale indicate a denial of stereotypical masculine occupations and interests.  Examples of masculine occupations include a forest ranger or a building contractor). The examples of feminine occupations include librarian or nurse.  Some sources state this scale is not usually interpreted in current use and it was originally intended for use with occupational interest. From the examples given – many of us know men and women working in occupations in opposition to what used to be considered stereotypically masculine or feminine (eg. women park rangers and men nurses).

A relevant dimension that I have not seen investigated in any systematic way is how societal conventions have affected masculinity and femininity stereotypes.  In a patriarchal society, where women have less access to jobs that are dominated by men – it will appear that they chose work based on their preferences. The change in the distribution of men and women in the work environment has changed dramatically in the past 40 years. When I started in medical school there were specialties where women were actively discriminated against and their numbers were naturally low. In psychiatry – I have never worked in a department where there were fewer women than men.  That includes jobs where heavy physical work predominates. All things equal – women have demonstrated that they can perform as well in jobs that men do.  That includes professional sports.  In this previous post – I pointed out the landmark district court ruling that expanded women’s access to high school sports with the result being highly skilled professional sports teams.

This wholescale integration of women into all aspects of society has been overwhelmingly positive.  The obvious rational argument is that no society can afford to eliminate the intellectual, creative, and physical resource of half of their population without suffering.  The proof of that is in what has happened so far. More high caliber workers and researchers and overall a much more productive society.  If there has been a downside – I have missed it.  Feel free to let me know about it in the comments below.

There has been a predictable political reaction to the integration of women in the workplace. Forty years ago, the family model was the husband was the breadwinner and the wife was expected to be the homemaker.  If a woman dared to get hired into a predominately male workplace – they were criticized for taking a job from a man. Their choice was to brave that criticism or take a traditionally female job where compensation was less. There are social and political forces out there today that think that 40-year-old model was the best one.  They do not see women in the workplace as a tremendous asset, only a detriment.  That often extends to women not being seen as physical or intellectual equals or having the same basic problem as men needing to generate income for families.  The end result of that bias is a male-centric society operating on male gender stereotypes.    

Dated masculine-feminine stereotyping also works against men.  Here is an example.  Sam wants to bring one of his college professors home for a visit.  He lives in a scenic part of the state and his professor said he would like to see it.  He is concerned about how his professor will be perceived by his largely blue-collar family and friends.  He confides in another friend at college: “I am worried that my professor’s vocabulary, style, and articulation will not be accepted.  I am really worried they will think he is gay and he is not.”  This brief example points to common stereotypes used by subcultures and some of the associated problems.  In this case, the subculture demands that men exercise a very limited male stereotype and if they move too far outside of that they will be criticized or not tolerated.

Common criticism of the concept of toxic masculinity is that it is not well defined, it can be stigmatizing, and the outcomes of people who have it are not well studied.  Considering all the possible traits, attributes, and vocations it is easy to imagine that a sample of men with relatively homogeneous toxic masculinity might be difficult to find.

Some authors have attempted a definition.  Sanders, et al (3) use a dimensional approach across 5 categories: masculine superiority, domination and desire, gender rigidity, emotional restriction, and repressed suffering. The researchers came up with a 35-item scale consisting of statements that subjects disagreed or agreed with on a 5-point scale.  The entire scale is available at reference 2.  A few examples of the test statements:

6. People are attracted to men who dominate others

7. Muscles are indicators of masculinity

10. Men are superior to women

11. Gender and sex are the same thing

15. Men cheating on their partner is natural

 The only aggression noted in the scale is sexual aggression in the statement: “Men can’t rape women because consent isn’t a real thing.”  There are no statements about verbal or physical aggression. The authors conclude the scale has adequate psychometric properties but it appears form the references that it was not widely adopted. 

Rather than define toxic masculinity in terms of what it is – a better approach may be to define it in terms of what it is not. I suggest the following:

1:  Acceptance of women as equals in every possible way – entitled to the same rights, independence, and privileges as men in society.  I am sure that most people agree with this on paper – but in many applications this statement is still difficult to implement.

2:  Refusal to accept the stereotype that women and the physical appearance of woman are primarily for the sexual interest and satisfaction of men.  This is commonly referred to as objectifying women, and despite an equality revolution in the 1970s it still permeates most aspects of American society. As far as I can tell there has been no initiative to educate boys at an early age about this bias and how it can affect their sexual behavior. We are counting on men to become self-enlightened at some point in their lives.

3:  Aggression against women as either physical or verbal forms of aggression is never acceptable. Aggression in general and the potential for aggression including the use of firearms is identified by some as a masculine trait. Aggression against women is a complex construct because in many cases it involves seeing a woman as the exclusive property of a man.   

4:  All people must be accepted and not discriminated against based on masculine or feminine stereotypes.  This is more complicated than it seems. My example of the professor in a blue-collar world is one – but there are many more. It includes the idea that gender is not necessarily equivalent to biological sex.

Coming around to the introductory paragraph.  Dana White’s comment about how “you can’t be too masculine” requires context and definition.  He provided neither. If he includes encouraging people to beat people up – even if they are consenting adults and doing it as a job then I would disagree.  I notice his standard argument is that he has improved the medical and safety standards of the UFC so that nobody has died (there have been fatalities in both mixed martial arts (MMA) and professional boxing). I would not agree. Most men are not UFC fighters and don’t get into physical altercations at all.  Prevalence surveys suggest that 30-40% of adolescent males get into fights (versus 20% of females), 1/3 of adult males get into fights, 1/3 may be at risk for intimate partner violence, and about 10% of male homicides are preceded by a fight.  Substance use and intoxication are frequent correlates.  I am personally aware of 5 cases where bar fights resulted in death.  In all cases the victim was struck just once.  All these prevalence studies also investigate aggression from women and the numbers are lower but substantial.

It may be easier for some people to see aggression as a male trait pushing into a zone of toxic masculinity.  There are too many complicating factors to make that statement.  I would suggest that an attitude of needing to settle disputes no matter how trivial with physical violence or using physical violence to intimidate people or take advantage of them crosses that line.  In that case – aggression is overvalued beyond any societal norm.     

In terms of classification – masculinity stereotypes are qualitative rather than quantitative categories.  Nobody is measuring them in terms of quantity and the same thing applies at the biological level.  Testosterone levels have a cutoff between normal and deficient and is age adjusted. Having more testosterone does not make you more masculine but it may cause side effects. The same might be said of any psychological construct of toxic masculinity.

There has been a good response to the awkward Hegseth lecture from retired Generals and women who served as officers, pilots, and in special forces. The consensus of that sample at this point is that the lecture was an insult to women in the military (as well as the assembled officers) because they perform as well as the men and did not get any special considerations for promotion or placement in combat ready positions.  There has been a pattern of regulations that prevented women from serving in combat or special forces that seems to be implemented on an arbitrary basis. The women who qualified and served are proof that they can do that work like they have done every other kind of work in modern society.  There was also a suggestion that without women, enlistment quotas would not be met.  Beyond these comments there are many references on women in the military and in combat positions by country and policy.  It is not like this is a novel consideration.

These same generals pointed out why the officers in the room at that lecture would not be saying anything.  Military protocol is that they must defer to civilian authority and cannot question it.  They also pointed out the exception that they cannot follow illegal orders.  The retired generals all said this is why Trump’s comments about deploying the military in cities and using the military against civilians was wrong. 

What is the real difference between men and women fighter pilots and combat veterans? Just a Y chromosome. That’s it and there is nothing "woke" about it.

 

George Dawson, MD, DFAPA

Supplementary 1:  What about Fuck Around and Find Out (FAFO) messaging? 

This blurb from Hegseth:

“That's why pacifism is so naive and dangerous. It ignores human nature and it ignores human history. Either you protect your people and your sovereignty or you will be subservient to something or someone. It's a truth as old as time.

And since waging war is so costly in blood and treasure, we owe our republic a military that will win any war we choose or any war that is thrust upon us. Should our enemies choose foolishly to challenge us, they will be crushed by the violence, precision and ferocity of the War Department. In other words, to our enemies, FAFO.”

If you are naïve to hep Internet slang (like I am) – you might have had to look up FAFO (like I did).  As noted in the above sentence – it is aggressive language.  The type of language you can see expressed in the road rage incidents of any real crime TV show. It is not the longstanding peace through strength position that the US has taken with previous administrations.  When you spend more on your military than the next 10 countries in the world and have a large standing military it could be construed as the language of a bully trying to provoke someone into unwise action. I am sure that I could provide some quotes from Sun Tzu that would make more strategic sense.  I am also sure that is why his line fell flat with military officers who are scholars in this area.

It is not the first time the FAFO rhetoric has been used by the Trump administration. Eight months ago Trump posted a photo of himself dressed like a gangster in front of an FAFO sign on his social media.  It was a message to Columbia after they refused to receive 2 airplanes carrying deported immigrants. Trump apparently threatened tariffs and visa bans. 

In keeping with the one of the overall themes of this post – is this form of symbolism and verbal aggression toxic masculinity?  If you consider gangsters and verbal aggression to be a masculine trait – then yes, it is.  

Supplementary 2:

Commentary from retired Generals on the Hegseth speech.  All links are to transcripts or videos.

Retired Brigadier General Ty Seidule:  Retired Army brigadier calls Hegseth and Trump's military meeting 'an insult'. Link

Retired Lt. Gen. Mark Hertling:  A Retired General Blasted Trump And Pete Hegseth For Their "Insulting" And "Offensive" Remarks To Military Leaders.  Link and Link

Retired Major General Randy Manner:  Major General Takes on Trumps “Enemy Within” Comment Link

Retired Army Gen. Barry McCaffrey: Comments on Trump Hegseth  Link

Retired U.S. Army Major General Mark MacCarley: Link

Retired Lt. Gen. Russel Honoré:  Retired general criticizes Trump and Hegseth’s new military standards.  Link

Retired Lt. Gen. Ben Hodges: Link

Ret. General Wesley Clark: “A lot of the rhetoric that came out struck me as culture wars stuff.”  Link

Former Army Vice Chief of Staff Gen.  Peter Chiarelli (Ret) on This Week:  Link

CHIARELLI: "No, there's nothing unlawful about what he said. Nothing whatsoever. I'm concerned about what I considered an attack on women, and the fact that -- that there are -- there are people who say that women have been let into different combat fields and cannot meet the standards. I just don't believe that's true. I know when the Army opened up the Ranger program, the standards did not change at all. Not at all. And the fact of the matter is on today's battlefield, everybody's in combat. Everybody's in combat. We found that out in Iraq. The minute you set foot from Kuwait into Iraq, you went into harm's way. And we needed medics. And many of our women -- many of our women were assigned to medical units. So, we had to pull them out and send them up with convoys. And they did amazing."

Retired Lt. General Ben Hodges:  Face the Nation  Link

MARGARET BRENNAN: I want to pick – pick up where we left off with Senator Duckworth, who is a Purple Heart recipient for her time serving this country in combat.  Men and women have different basic fitness standards. The secretary, in his remarks at Quantico, said women – or he suggested women were being given a pass or were held to lower standards for fitness requirements. Do you think his change to the, quote/unquote, "male standard" is necessary?

LIEUTENANT GENERAL BEN HODGES: I think this is completely unnecessary. I have 38 years in the Army, and we've served with women in all sorts of different environments and deployments. And I never had a case where a female soldier was not able to do what she had to do. So, this is a – seems to me an unnecessary, almost a medieval approach that doesn't reflect the requirements that we have for women and men who are intelligent, able to operate in a modern battlefield environment.

Ret. Colonel Don Christensen:  “His speech directly attacked the values of many of the senior officers and enlisted members in the audience, and I would expect many of them to demonstrate their disgust by retiring,” Don Christensen, a retired Air Force colonel and former military lawyer who watched the speech, said of Hegseth.  Link

Retired General Tim Haugh:  Commenting on cybersecurity and being fired by Trump for being "disloyal":  60 Minutes Transcript.

Major General (Ret.) William Enyart:  On appropriate uses of the National Guard.  Link

References:

1:  Daneshvar DH, Nair ES, Baucom ZH, et al. Leveraging football accelerometer data to quantify associations between repetitive head impacts and chronic traumatic encephalopathy in males. Nat Commun. 2023 Jun 20;14(1):3470. doi: 10.1038/s41467-023-39183-0. PMID: 37340004; PMCID: PMC10281995.

2:  Graham JR. The MMPI – a Practical Guide. 2^nd ed.  Oxford, England: Oxford University Press, 1987:  136-139.

3:  Sanders SM, Garcia-Aguilera C, Borgogna NC, Sy JR, Comoglio G, Schultz OA, Goldman J. The Toxic Masculinity Scale: Development and Initial Validation. Behavioral Sciences. 2024 Nov 14;14(11):1096.

 

Graphics Credit:

Wikimedia Commons:  English: Corporal Brandy Bates, a team member with Female Engagement Team 8 and native of Ann Arbor, Mich., walks around the corner of a mud wall while supporting soldiers from the Afghan National Army’s 215th Corps and U.S. Marines with Lima Company, 3rd Battalion, 7th Marine Regiment, during a recent foot patrol through the village of Tughay, Sangin district, Helmand province. The FET supports 3/7 by bridging the cultural gap and interacting with the local Afghan women.

This image was released by the United States Marine Corps with the ID 111206-M-GF563-025 posted on December 15, 2011.

https://commons.wikimedia.org/wiki/File:Female_Engagement_Team_builds_trust,_rapport_with_women_in_Sangin_111206-M-GF563-025.jpg

 

 

The FDA and the Trump Formulary or What Separates Physicians from Politicians

 

 The difference between politicians and physicians was on full display at President Trump and HHS Secretary Robert Kennedy press conference several days ago.   It was hyped as an important announcement about autism for a month. They announced that Tylenol (acetaminophen or APAP hereafter) was a cause of autism.  In the associated hyperbole – Trump shouted not to take Tylenol and suggested that pregnant women should "tough it out".  That even though fever alone is a risk factor for complications of pregnancy and there are no safer analgesics.  Kennedy suggested that this was somehow “transparency” about science at the FDA, CDC, and HHS, praised their cooperation and suggested that past research was somehow flawed because of a focus on genetics.

The news media had a field day with the press conference.  Twenty-four-hour news channels were playing it every half hour. Controversy rather than accuracy is how they get views. What better way to describe science as pushback on the Trump Kennedy statements.  Real science is now pushing back against political rhetoric that claims to have essentially replaced the scientific method.  It is a case study in political black and white thinking versus the probabilistic thinking of medicine and science.

The purpose of this post is to look at the science and the rhetoric around this conference. Acetaminophen (APAP) has been FDA approved since 1951.  The first Tylenol product was an elixir for children marketed in 1955.   It was approved as an over-the-counter medication in 1960 using an FDA monograph procedure that allowed drugs to be grandfathered in if they were in general use prior to the stricter regulations that began in the 1970s. These monographs are updated with new information including risks in pregnancy. 

The Trump-Kennedy Autism Press Conference (TKAC) suggests that physicians may not be aware of APAP toxicity as much as they should be.  The reality is that physicians are highly aware of that problem. As interns, most physicians are involved in treating APAP overdoses and preventing severe hepatotoxicity and death. APAP toxicity is the second leading cause of liver transplantation worldwide. Only half of the overdoses are intentional with the remainder either accidental (due to mixing APAP containing products or not following the directions) or taking APAP with alcohol use, alcoholic liver disease, liver disease, nutritional compromise, or herbal supplements. It is critical that APAP toxicity is recognized as soon as possible to prevent irreversible liver damage and death.  It is the reason why OTC bottles of APAP have the following warnings:

On the warning for pregnant or breast-feeding women, the FDA has risk categories in the approved labelling.  APAP is listed as a Category C drug defined as shown in the slide below.  In 2015 the FDA stopped using the category system and started using the Pregnancy and Lactation Labeling Rule (PLLR) – a more detailed narrative form. Despite a letter to physicians from the FDA on the APAP in pregnancy issue and the standard advice physicians have used for years I can find no new FDA package insert and no detailed PLLR language from that agency. 

This post will discuss these issues is to look at the history, rhetoric, and epidemiology in this post and then depending on how much information I think is relevant to post on the genetics, pathophysiology, and toxicology of autism in subsequent posts.  I will touch on a few of those points here to address the rhetoric.

The TKAC conference characterized autism as a “crisis” and cited an unexplained increase in the prevalence of autism over the past 20 years.  By unexplained I mean they were taking it at face value as a real increase rather than reading the research and what those authors had to say about the reasons. The reality of the prevalence numbers and the design of these studies need to be examined. I have previously posted that variation in prevalence estimates for psychiatric disorders depends a lot on methodology.  That includes the study design, how the subjects are recruited, the assessments used to make the diagnoses, and the data analysis.  There are also cultural effects over time on the same culture and in comparisons of different international cultures.

In the United States there has been a marked increase in awareness of autism.  That awareness has increased significantly with the advent of the DSM 5 autism spectrum disorder diagnosis.  It is common to hear people declare that they think that either they or someone they know “is on the spectrum.”  That includes celebrities.  Increased awareness can increase early identification programs that can increase the prevalence.  The expansion in prevalence also reflects the inclusion of people with less severe symptoms.  An example comes from the ADDM CDC study that looks at autism prevalence between selected states.  Cases are identified through educational and medical records.  California had the highest 4- and 8-year-old autism rates of any state and it was thought to be due to a program that trained hundreds of pediatricians to identify cases early and refer them to local centers for intervention.    

The diagnostic criteria for autism have also evolved as shown in the diagram below.  From very few criteria applied to more disabled populations (Kanner, Rutter) to more elaborate criteria that went from a syndrome (DSM-IV) to a spectrum (DSM 5) encompassing milder forms of the disorder (7,8). That expectedly increases the prevalence of the disorder.  The smaller graphic illustrates that 3 DSM-IV syndromes were collapsed into a DSM 5 autism spectrum disorder.  I am on record that the term spectrum makes no biological sense to me.  It is merely a convenient way that humans have to deal with very complicated biological processes.  In this case nosological convenience has blurred the boundary between people with mild forms of the disorder and no disorder.  The DSM deals with that like it does with all disorders by including a necessary significant impairment in functioning term.

Very few prevalence studies look at cross sections of all the patients with that diagnosis in the community (12). In acute care psychiatry it is common to see 50- to 70-year-old adults in crisis situations because the parents they were living with have been hospitalized or died. These same people will not be in a medical or educational database with the studied diagnoses and will not be counted in those prevalence estimates.  I have been able to locate only one study (12) showing that using the same criteria at the same point in time - the prevalence of autism in the older population is the same as it is in the younger population.

Another consideration of prevalence is that is the diagnosis of autism is not an easy one.  It assumes the clinician has expertise in making the diagnosis and has adequate time to gather and consider all the necessary information. A recent paper points out significant age related differences in diagnosis suggesting that most people with autism in England (59-72%) are older and undiagnosed (13). A paper by Fusar-Poli et al (14) highlights typical errors of misdiagnosis, the lag between first presentation and the accurate diagnosis, and reasons behind those misdiagnoses in a large sample of people presenting to specialty clinics for a diagnosis of autism spectrum disorder (ASD). That same paper begins with a vignette of a middle-aged man living in the community with some assistance to illustrate how autism can present in the older undiagnosed population.    

An interesting footnote about criteria. Like all psychiatric disorders at one point in time only psychological causes were considered as etiologies for the disease.  In the case of autism it was the refrigerator mother hypothesis.  Cold, distant mothers were considered the cause of autism.  Folstein and Rutter’s 1977 genetic study of autism helped to reverse that line of thinking and bring the likely cause back to genetics and biology.  

That biological cause was a focus of criticism in the TKAC conference.  Secretary Kennedy went on record stating that genetic research is unproductive and produces no “actionable” information.  Throughout most of my career the same was said about Huntington’s Disease.  When the genetic tests for Huntington’s came on the scene, we used them like everyone else but there was still not much optimism about an effective treatment that addressed the pathophysiology of the disorder. All of that may have changed a few days ago when a report about a therapy for Huntington’s (10) that may slow progression was made public. (9) There are currently several papers about the potential for using gene therapy for autism and other developmental disorders(11).

With all the criticism of current research at this news conference a couple of major actionable research discoveries were not covered.  The first are studies that show paternal and maternal age are risk factors for autism in offspring (14-21).  Increasing age of the father and mother are both risk factors for offspring with autism.  Paternal age greater than 50 years old doubles the risk of a child with autism compared with 20-29 yr old fathers. (20).  Spontaneous mutations in DNA are a likely mechanism but several others are hypothesized.

DNA effects would also suggest that environmental factors leading to mutations may be important.  The work done at the NIH (22-25) on this issue was not mentioned at all. One of the researchers in this area announced that her lab was terminated by the Trump administration.  She was working on the effect of environmental toxins on parental DNA and her research showed an effect for maternal solvent exposure, pesticide exposure and low fatty acid intake, and occupational exposures to phenols, ethylene oxide and pharmaceuticals.  All these exposures are actionable by a government interested in protecting people from environmental and occupational toxic exposures.

Coming back to the rhetoric of the TKAC conference the overall goals seem clear – to persuade the American people that there is a crisis, that politicians rather than scientists are best equipped to solve that crisis, and that politicians can give you medical advice but at the same time you should consult with your physician.  This is typical authoritarian rhetoric and if you really believe it – there is no longer any need for science or medicine. The “crisis” in terms of increased prevalence is explainable by broadened diagnostic criteria, inclusion of less severely disabled individuals, and increased awareness. The statement about the toxicity of acetaminophen is also exaggerated since in the end – despite the President declaring that nobody should use acetaminophen – both he and the HHS Secretary walked those statements back to the current recommendations to “consult your physician.”  The criticism about the lack of actionable research suggests a lack of awareness of what has been done – including work by government scientists who were fired by this administration.  I have illustrated this with a small fraction of the autism research that is currently out there.

As a final preliminary comment – politics and rhetoric occur both inside and outside of medicine.  I have seen similar statements made by researchers over the years that in the end did not pan out.  They did not pan out because those hypotheses were exhaustively investigated and disproven by other researchers attempting to replicate that research.  There is no similar political process. In medicine especially in some epidemiological research - a clear answer at the margins is often not possible. That is why medical treatment does not guarantee a result and involves a detailed informed consent discussion of potential risks and benefits.  In politics - all it takes for a new hypothesis is somebody winning an election.  And when that happens it is more likely to be a declaration than a hypothesis.

Do the American people really want to make health care decisions based on who won an election?    

 

George Dawson, MD, DFAPA

Supplementary:  An interview with the study author was released today and it can be accessed on the JAMA web site:  https://jamanetwork.com/journals/jama/fullarticle/2839562

The reference is:  Schweitzer K. Acetaminophen Use in Pregnancy—Study Author Explains the Data. JAMA. Published online September 29, 2025. doi:10.1001/jama.2025.19345

 

References:

1: Rosen NE, Lord C, Volkmar FR. The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. J Autism Dev Disord. 2021 Dec;51(12):4253-4270. doi: 10.1007/s10803-021-04904-1. Epub 2021 Feb 24. PMID: 33624215; PMCID: PMC8531066.

2: Brugha TS, McManus S, Bankart J, Scott F, Purdon S, Smith J, Bebbington P, Jenkins R, Meltzer H. Epidemiology of autism spectrum disorders in adults in the community in England. Arch Gen Psychiatry. 2011 May;68(5):459-65. doi: 10.1001/archgenpsychiatry.2011.38. PMID: 21536975.

3: Kanner L. Autistic disturbances of affective contact. Nervous child. 1943 Apr;2(3):217-50.

4: Folstein S, Rutter M. Infantile autism: a genetic study of 21 twin pairs. J Child Psychol Psychiatry. 1977 Sep;18(4):297-321. doi: 10.1111/j.1469-7610.1977.tb00443.x. PMID: 562353.

5: Murphy D, Glaser K, Hayward H, et al. Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan. Southampton (UK): NIHR Journals Library; 2018 Jun. (Programme Grants for Applied Research, No. 6.2.) Chapter 17, Improving outcomes through better diagnosis: the effects of changes in DSM-V on clinical diagnosis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518676/

6: Shaw KA, Williams S, Patrick ME, et al. Prevalence and Early Identification of Autism Spectrum Disorder Among Children Aged 4 and 8 Years — Autism and Developmental Disabilities Monitoring Network, 16 Sites, United States, 2022. MMWR Surveill Summ 2025;74(No. SS-2):1–22. DOI: http://dx.doi.org/10.15585/mmwr.ss7402a1.

7: Arvidsson O, Gillberg C, Lichtenstein P, Lundström S. Secular changes in the symptom level of clinically diagnosed autism. J Child Psychol Psychiatry. 2018 Jul;59(7):744-751. doi: 10.1111/jcpp.12864. Epub 2018 Jan 29. PMID: 29377119.

8: Avlund SH, Thomsen PH, Schendel D, Jørgensen M, Clausen L. Time Trends in Diagnostics and Clinical Features of Young Children Referred on Suspicion of Autism: A Population-Based Clinical Cohort Study, 2000-2010. J Autism Dev Disord. 2021 Feb;51(2):444-458. doi: 10.1007/s10803-020-04555-8. PMID: 32474837.

9: Tabrizi SJ, Flower MD, Ross CA, Wild EJ. Huntington disease: new insights into molecular pathogenesis and therapeutic opportunities. Nature Reviews Neurology. 2020 Oct;16(10):529-46.

10: Kaiser J.  In a first, a gene therapy seems to slow Huntington disease.  Science, September 24,2025.  doi:10.1126/science.zbkgxvm

11: Sahin M, Sur M. Genes, circuits, and precision therapies for autism and related neurodevelopmental disorders. Science. 2015 Nov 20;350(6263):10.1126/science.aab3897 aab3897. doi: 10.1126/science.aab3897. Epub 2015 Oct 15. PMID: 26472761; PMCID: PMC4739545.

12:  Brugha TS, McManus S, Bankart J, Scott F, Purdon S, Smith J, Bebbington P, Jenkins R, Meltzer H. Epidemiology of autism spectrum disorders in adults in the community in England. Arch Gen Psychiatry. 2011 May;68(5):459-65. doi: 10.1001/archgenpsychiatry.2011.38. PMID: 21536975.

13: O'Nions E, Petersen I, Buckman JEJ, Charlton R, Cooper C, Corbett A, Happé F, Manthorpe J, Richards M, Saunders R, Zanker C, Mandy W, Stott J. Autism in England: assessing underdiagnosis in a population-based cohort study of prospectively collected primary care data. Lancet Reg Health Eur. 2023 Apr 3;29:100626. doi: 10.1016/j.lanepe.2023.100626. PMID: 37090088; PMCID: PMC10114511. 

14:  Fusar-Poli L, Brondino N, Politi P, Aguglia E. Missed diagnoses and misdiagnoses of adults with autism spectrum disorder. Eur Arch Psychiatry Clin Neurosci. 2022 Mar;272(2):187-198. doi: 10.1007/s00406-020-01189-w. Epub 2020 Sep 6. PMID: 32892291; PMCID: PMC8866369.

15: Hultman, C. M., Sandin, S., Levine, S. Z., Lichtenstein, P., & Reichenberg, A. (2011). Advancing paternal age and risk of autism: New evidence from a population-based study and a meta-analysis of epidemiological studies. Molecular Psychiatry, 16(12), 1203–1212. https://doi.org/10.1038/mp.2010.121

16: S. E. W. Sandin et al., "Autism risk associated with parental age and with increasing parental age difference in a population-based cohort of 5,766,794 children," Molecular Psychiatry, 2015

17: Wu, S., Wu, F., Ding, Y., Hou, J., Bi, J., & Zhang, Z. (2017). Advanced parental age and autism risk in children: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 135(1), 29–41. https://doi.org/10.1111/acps.12666

18: Reichenberg, A., Gross, R., Weiser, M., Bresnahan, M., Silverman, J., Harlap, S., Rabinowitz, J., Shulman, C., Malaspina, D., Lubin, G., Knobler, H. Y., Davidson, M., & Susser, E. (2006). Advancing paternal age and autism. Archives of General Psychiatry, 63(9), 1026–1032. https://doi.org/10.1001/archpsyc.63.9.1026

19: Wood, K. A., & Goriely, A. (2022). The impact of paternal age on new mutations and disease in the next generation. Fertility and Sterility, 118(6), 1001–1012. https://doi.org/10.1016/j.fertnstert.2022.

20: McGrath, J. J., Petersen, L., Agerbo, E., Mors, O., Mortensen, P. B., & Pedersen, C. B. (2014). A comprehensive assessment of parental age and psychiatric disorders. JAMA Psychiatry, 71(3), 301–309. https://doi.org/10.1001/jamapsychiatry.20

21: Sandin, S., Hultman, C. M., Kolevzon, A., Gross, R., MacCabe, J. H., & Reichenberg, A. (2012). Advancing maternal age is associated with increasing risk for autism: A review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 51(5), 477–486.e1. https://doi.org/10.1016/j.jaac.2012.02.018

22: Ye Q, Apsley AT, Hastings WJ, Etzel L, Newschaffer C, Shalev I. Parental age at birth, telomere length, and autism spectrum disorders in the UK Biobank cohort. Autism Res. 2024 Nov;17(11):2223-2231. doi: 10.1002/aur.3258. Epub 2024 Oct 30. PMID: 39474987.

23: McCanlies EC, Gu JK, Ma CC, Sanderson WT, Ludeña-Rodriguez YJ, Hertz-Picciotto I. The effects of parental occupational exposures on autism spectrum disorder severity and skills in cognitive and adaptive domains in children with autism spectrum disorder. Int J Hyg Environ Health. 2025 Jul;268:114613. doi: 10.1016/j.ijheh.2025.114613. Epub 2025 Jun 28. PMID: 40582232; PMCID: PMC12415903.

24: McCanlies EC, Gu JK, Kashon M, Yucesoy B, Ma CC, Sanderson WT, Kim K, Ludeña-Rodriguez YJ, Hertz-Picciotto I. Parental occupational exposure to solvents and autism spectrum disorder: An exploratory look at gene-environment interactions. Environ Res. 2023 Jul 1;228:115769. doi: 10.1016/j.envres.2023.115769. Epub 2023 Mar 31. PMID: 37004853; PMCID: PMC10273405.

25: McCanlies EC, Ma CC, Gu JK, Fekedulegn D, Sanderson WT, Ludeña-Rodriguez YJ, Hertz-Picciotto I. The CHARGE study: an assessment of parental occupational exposures and autism spectrum disorder. Occup Environ Med. 2019 Sep;76(9):644-651. doi: 10.1136/oemed-2018-105395. Epub 2019 Jun 27. PMID: 31248991.

26: Schmidt RJ, Kogan V, Shelton JF, Delwiche L, Hansen RL, Ozonoff S, Ma CC, McCanlies EC, Bennett DH, Hertz-Picciotto I, Tancredi DJ, Volk HE. Combined Prenatal Pesticide Exposure and Folic Acid Intake in Relation to Autism Spectrum Disorder. Environ Health Perspect. 2017 Sep 8;125(9):097007. doi: 10.1289/EHP604. PMID: 28934093; PMCID: PMC5915192.

27: Pernia S, DeMaagd G. The New Pregnancy and Lactation Labeling Rule. P T. 2016 Nov;41(11):713-715. PMID: 27904304; PMCID: PMC5083079.

28:  Sheikh J, Allotey J, Sobhy S, Plana MN, Martinez-Barros H, Naidu H, Junaid F, Sofat R, Mol BW, Kenny LC, Gladstone M, Teede H, Zamora J, Thangaratinam S. Maternal paracetamol (acetaminophen) use during pregnancy and risk of autism spectrum disorder and attention deficit/hyperactivity disorder in offspring: umbrella review of systematic reviews. BMJ. 2025 Nov 9;391:e088141. doi: 10.1136/bmj-2025-088141. PMID: 41207796.

29:  Morris, S., Hill, S., Brugha, T., McManus, S. (Eds.). (2025). Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. NHS England. DOI: 10.13140/RG.2.2.24367.39840

"Autism (examined using ADOS) has remained stable in prevalence since 2007, at about one in a hundred adults (0.8%)."

30:  D'Antonio F,  Flacco, ME, Valle LD, Prasad S, Manzoli L, Samara A, Khalil A.  Prenatal paracetamol exposure and child neurodevelopment: a systematic review and meta-analysis.  Lancet Obstetrics, Gynaecology, and Women's Health.  Jan 16, 2026.  Online (open access):  https://www.thelancet.com/journals/lanogw/article/PIIS3050-5038(25)00211-0/fulltext

Reference Credit:

h/t to Tyler Black, MD @tylerblack32 for reference 12.

Graphics Credit

1:  DSM-IV and DSM 5 graphics are from the respective DSMs copyrighted by the American Psychiatric Association and reproduced here only for educational purposes.  

2:  FDA package insert information is reproduced here and considered in the public domain.

3:  The detailed ADDM graphic of ASD prevalence by state is form the Mortality and Morbidity Weekly Report (MMWR) (see reference 6 and is in the public domain).

4:  Lipak GS.  The epidemiology of autism.  In:  Textbook of Psychiatric Epidemiology. 3rd ed.  Tsuang MT, Tohen M, Jones PB (eds).  Wiley-Blackwell. Oxford, UK.  2011, p. 475.  

Reference for lead graphic - licensed from publisher.  

Commentary on the Trump Kennedy Press Conference Commentaries with time points in the transcript: 

1:  Trump at 4:43

“Which is basically commonly known as Tylenol during pregnancy and can be associated with a very increased risk of autism. So taking Tylenol is not good. All right, I'll say it; it's not good. For this reason they are strongly recommending that women limit Tylenol use during pregnancy unless medically necessary. That's, for instance, in cases of extremely high fever that you feel you can't tough it out; you can't do it. I guess there's that. It's a small number of cases, I think. But if you can't tough it out, if you can't do it, that's what you're going to have to do. You'll take a Tylenol, but it'll be very sparingly. It can be something that's very dangerous to the woman's health. In other words, a fever that's very, very dangerous and ideally a doctor's decision because I think you shouldn't take it, and you”

Trump simultaneously skirts the issue of the potential dangers of acetaminophen in pregnancy while walking back that recommendation to the current package insert statement (see graphic above). 

2:  Trump at 36:59

“I understand it's maybe 10% of the women that are pregnant would perhaps be forced to use it, and that would mean you just can't tough it out. No matter what you do, you can't tough it out. So that's up to you and your doctor.”

Trump seems to confuse the analgesic effect of acetaminophen with the antipyretic effects important to prevent complications of pregnancy.  

3:  Trump at 40:12

“Don't take Tylenol. Don't give Tylenol to the baby after the baby's born. Every time the baby gets a shot, the baby goes, gets a shot, they say, "Here, take a couple of Tylenol." I've heard that for years. Take Tylenol. Don't take Tylenol, don't have your baby take Tylenol. Now, Tylenol is fine for people that aren't pregnant, that aren't in the situation that we're talking about one very specific situation. If you're pregnant, don't take Tylenol. When you have your baby, don't give your baby Tylenol at all unless it's absolutely necessary. Don't do it.”

Trump clearly states not to take acetaminophen if you are pregnant - with no package insert qualifier. He also suggests that it is dangerous for infants. 

4:  Trump at 44:03

“And the other things I told you about, just… The word, tough it out. It's easy for me to say tough it out. But sometimes in life with a lot of other things, you have to tough it out also. Don't take Tylenol. Don't give Tylenol to the baby. When the baby's born, they throw it at you, "Here, give them a couple of Tylenol." They give them a shot. They give them a vaccine. And every time they give them a vaccine, they throw in Tylenol. And some of these babies they're long born, and all of a sudden they're gone. And it doesn't hurt not to do it. It doesn't hurt. There's no downside. There's no downside at all.”

Trump persists with his "tough it out" message missing the point of acetaminophen use in pregnancy.  He also suggests that vaccinations lead to more acetaminophen use in infants. 

5:  Kennedy at 14:10

“NIH research teams are currently testing multiple hypotheses with no area off-limits. We promise transparency as we uncover the potential causes and treatments, and we will notify the public regularly of our progress. Today we are announcing two important findings from our autism work that are vital for parents to know as they make these decisions. First, HHS will act on acetaminophen. The FDA is responding to clinical and laboratory studies that suggest a potential association between acetaminophen used during pregnancy and adverse neurodevelopmental outcomes, including later diagnosis for ADHD and autism. Scientists have proposed biological mechanisms linking prenatal acetaminophen exposure to altered brain development. We have also evaluated the contrary studies that show no association. Today, the FDA will issue a physician's notice about the risk of acetaminophen during pregnancy and begin the process to initiate a safety label change. HHS will launch a nationwide public service campaign to inform families and protect public health.”

No mention of the research program cancelled by the Trump administration as noted above. Not clear who he means when he talks about "we" evaluating studies.  Does he mean him and Trump?  Is there anybody left at NIH, CDC, HHS who can do those evaluations?

6:  Kennedy at 15:28

“The FDA also recognized that acetaminophen is often the only tool for fevers and pain in pregnancy, as other alternatives have well-documented adverse effects. HHS wants, therefore, to encourage clinicians to exercise their best judgment and use of acetaminophen for fevers and pain in pregnancy by prescribing the lowest effective dose for the shortest necessary duration and only when treatment is required. Furthermore, thanks also to the politicization of science. The safety of acetaminophen against the risk of neurodevelopmental disorders in young children has never been validated.”

Kennedy takes credit for the longstanding advice on the package insert of acetaminophen - namely discuss with your physician. 

7:  Kennedy at 52:13

"But also it's just common sense, because you're only seeing this in people who are under 50 years of age. If it were better recognition or diagnosis, you'd see it in 70-year-old men. I've never seen this happening in people my age. I've never seen a case of full-blown autism, and that means profound autism, I want to be very careful, head banging, stimming, toe walking, nonverbal, non-toilet trained. I've never in my life seen a 70-year-old man who looks like that. You're only seeing it in kids. It's an epidemic"

Kennedy simultaneously displays his lack of knowledge about the historical development of the autism diagnosis (DSM-IV restricted age of onset to 3 years) and perpetuates a stereotype of a person with severe developmental disabilities who would typically require institutional care.  There are many older individuals with ASD living in the community - some may be your neighbors. And as noted in the above post - the expansion in prevalence has occurred primarily due to milder cases that were included in new diagnostic criteria.

Existential Threats....

 

Mapping Existential Threats in the Medical Literature

 

I heard President Trump and several right-wing politicians complaining about the term “existential threat” in the press the other day.  Some of the clips were a few months old but the overall message was first – “I didn’t know what it means”, second – the people using the term (in this case former President Biden discussing climate change) don’t know what it means, and third you are an elitist if you use the term because the average family in American does not use the term and you should learn to talk like them.  Like most statements uttered by the current President and his unquestioning party I found it rhetorical, not useful, and decided to see what the medical literature said.  This is what I found.

On PubMed, there are 248 references to the term dating back to 1979.  As seen in the table most of the scenarios listed like climate change, COVID and other pandemics (in this case HIV), diseases, antibiotic resistance, artificial intelligence, and other threats to life are the commonest threats listed in medical literature.  By definition, an existential threat puts the future of some group (humanity, specified individuals) or person at risk.  The worst-case scenario is an extinction event like the Cretaceous-Paleogene (K-Pg extinction) event that occurred 66 million years ago.  That was caused by an asteroid strike and it led to the extinction of non-avian dinosaurs and 75% of all plant and animal species. 

The tables contain existential threats to humanity, many subgroups including physicians and the afflicted, school and businesses, other animals, and plants, as well as ecosystems.  It also includes the psychological component where the perceived threat is experienced as a threat to existence, but more at a symbolic level.  Yalom’s text (1) on existential psychotherapy breaks those threats down to death anxiety, freedom, isolation, and meaninglessness.  Other psychoanalytical writers point out that existential crises are more likely to occur at various points in human development.  In psychiatric practice it is common to see people experiencing crises in these areas across all settings.  Existential crises can exist at the level of group or individual psychology depending on the nature and scope of the threat. Some scientists hypothesize that we are currently in the midst an extinction event.  They describe this as the sixth mass extinction event and verify it by estimating the number of vertebrate species that have gone extinct and compare it to previous mass extinctions (3).  Human culture is a critical factor in this extinction and the conclusion are a massive effort is needed to head off this event and much of that effort needs to be directed at reducing overconsumption, transitioning to environmentally friendly technologies, and an equitable path to those transitions (2).  These authors point out obstacles to these changes including most people being unaware of the changes required to prevent ecosystem damage by human culture, the scope of the problem, and the necessary solution of scaling back human impact – both the scale and processes.

The political use of the term “existential threat” has been applied to the Trump administration and this is probably why Trump himself is trying to spin the term in his favor. He is focused on blaming the opposition party, but at this point it goes far beyond the Democrats.  The non-partisan Bulletin of the Atomic Scientists has posted that the well know extreme budget cuts of the administration pose an existential threat to the next generation of scientists. Various publications around the world have written about Trump as an existential threat to democracy, the American economy, former American allies, Social Security, freedom, black Americans, American colleges and universities, public health, science, and critical international food and medical aid.  In many of these areas the facts are clear.  I can think of no better example than USAID and the PEPFAR program.  Just defunding those programs could lead to as many as 14 million deaths if none of these changes are reversed by the courts.  

Paranoid people do not do well with existential threats.  They lack the ability to assign probabilities. They cannot see a car on the street and just see it as another car.  They get the idea that all cars or all red cars are threats to them. The defined threat may be elaborated as surveillance by Homeland Security to being attacked by microwaves being transmitted from these cars.  In some cases, everything is seen as a threat.  The anxiety is real but the threat assessment is wrong.

If you do not know what an existential crisis is – you should.  Most students in the US start reading existential themed literature in middle school and early high school.  The average person needs to know at what level the threat exists (personal, group, civilization-wide) and what can be done about it.  That means that it makes sense to break down the specific threat, adequately assess it, and not leave it hanging there as ill-defined.  For example, nuclear war, a massive asteroid collision, and climate change threaten all human, animal, and plant life on the planet.  Not being able to get a job in an area where you were trained in college or losing your first significant relationship can be existential crises at an individual level.  That can be life changing at a personal level and the good news is most people find their way back on track with the help of family, friends, and the occasional therapist. 

The outcomes of existential threats can lead to unexpected action.  When I was in college, one of my jobs was working in the local public library.  It was a multi-county library and the main part of my work consisted of mailing out books and films to all the co-operating libraries. One day the chief librarian came in and told me it was now my job to dismantle the fall-out shelter in the basement.  The year was 1972 just 10 years after the Cuban Missile Crisis. The library had two Fallout Shelter signs like the one at the top of this post.  I went down into the basement and found about 100 steel drums.  They were all about 30-gallon capacity. According to the instructions on the side they were supposed to be used for water storage.  When empty they were supposed to be used as latrines.  None of them contained water.  I guess the planners thought there would be time after a nuclear attack to fill them all. When I asked my boss what I was supposed to do with the drums he said:” I don’t care just get them out of here.”  I took them back to my neighborhood and handed them out to anyone who wanted them.  Apart from the steel drums there was no food or medical supplies.  Just a very large room full of steel drums.

It took me a long time to figure out what happened to the fallout shelters and how they went from a national priority to complete disrepair and abandonment in a decade.  The only explanation is that the planners knew there would be no survivors. A few groups here and there would survive the blast and radiation but nobody would survive the nuclear winter.  Even a limited nuclear exchange kicks enough dust up into the atmosphere that makes food production impossible. That marks the end of humanity – the ultimate existential crisis.

Shouldn’t the man with the power to end civilization quickly or slowly know something about this?  Shouldn’t everyone know the real existential threats we are facing?  Shouldn't we all be facing these threats realistically instead of denying they exist or pretending that we can survive them?

 

George Dawson, MD, DFAPA

 

References:

1:  Yalom ID.  Existential Psychotherapy.  Basic Books.  New York, 1980.

2:  Dirzo R, Ceballos G, Ehrlich PR. Circling the drain: the extinction crisis and the future of humanity. Philos Trans R Soc Lond B Biol Sci. 2022 Aug 15;377(1857):20210378. doi: 10.1098/rstb.2021.0378. Epub 2022 Jun 27. PMID: 35757873; PMCID: PMC9237743.

3: G. Ceballos, P. R. Ehrlich, A. D. Barnosky, A. García, R. M. Pringle, T. M. Palmer.  Accelerated modern human–induced species losses: Entering the sixth mass extinction. Sci. Adv. 1, e1400253 (2015).

Supplementary:

I thought I would list a few references to existential crisis as they occur:

Ford L.  Seymour Hersh Issues Grave Warning in Venice: “Trump Wants to Be Commander of America — He Wants to Not Have Another Election”  The Hollywood Reporter.  August 29, 2025.

https://www.yahoo.com/news/articles/seymour-hersh-issues-grave-warning-111210675.html

“There’s still integrity in America right now but as somebody said recently, we’re in existential crisis right now. And the president is a man who wants to be here for life. He wants to be commander of America. My belief is that’s his absolute sole mission. He wants to not have another election, because under the Constitution he cannot…. That’s what he’s going to be doing for the next three years.”