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I hesitate to speak for other Never Trumpers, but we’ve gotten used to losing, haven’t we? In three consecutive presidential elections, our doughty gang of dissidents has failed spectacularly in its attempts to shake Donald Trump’s grip on the GOP. At this year’s Republican National Convention—that great festival of Trumpian celebration—Never Trump Republicanism was invisible, for the second convention in a row. Never Trump writers and pundits have frequently contributed to national media outlets (including here in The Atlantic), but in the GOP itself, the group has been derided and purged.
Now some Never Trumpers are finding a place elsewhere: Last night in Wisconsin, I was invited to moderate a discussion between the Democratic nominee for president, Kamala Harris, and her new ally Liz Cheney. The two had spent the day on a campaign tour through the so-called blue-wall states of Pennsylvania, Michigan, and Wisconsin. Seeing them together felt surreal: As I said at the event, Harris and Cheney make an odd couple—and their alliance is a sign of a not-at-all-normal election. It also marks a crucial shift in the focus of the Democratic case. When Harris launched her campaign this summer, she leaned heavily into a message of joy and good vibes. Her vice-presidential pick, Governor Tim Walz, rose to prominence by calling the Trumpists “weird,” rather than an existential menace, as Joe Biden had argued during his campaign. But then the polls tightened, and Harris brought in Liz Cheney.
It’s worth taking a moment to reflect on how unlikely this development is. Among many Democratic voters, the name Cheney is radioactive, going back to the years of her father’s vice presidency; Liz Cheney herself spent years as a fierce right-wing ideological warrior and party loyalist, rising to the leadership ranks of the House GOP. Cheney was not an original Never Trumper. Unlike those of us who have been publicly expressing our concern since he came down the golden escalator in 2015, Cheney says she voted for Trump twice, and in Congress, she backed his administration more than 90 percent of the time. Then came January 6. Although her disillusionment with Trump had obviously been festering for some time, the insurrection led to Cheney’s full-throated denunciation. Her willingness to sacrifice her standing with the party and her seat in Congress made her a symbol of principled GOP resistance. Her role as vice chair of the Select Committee to investigate the January 6 attack on the Capitol made her the most famous Never Trumper in the country.
And there she was Monday night with a Democrat she had once denounced as a dangerous radical. The usual alignments of right and left and Democrat and Republican simply don’t apply anymore, because Donald Trump poses a unique danger to the entire American order. “We’ve never faced a threat like this before,” Cheney said, “and I think it’s so important for people to realize this republic only survives if we protect it, and that means putting partisan politics aside and standing up for the Constitution and for what’s right and loving our country.”
This is what Never Trumpers have been shouting into the GOP void for the past nine years. And in the last two weeks of the campaign, Harris and her team have decided to make it their closing argument. Although Harris now frequently refers to Trump as “an unserious man,” she also warns that the “consequences” of his return to power are “brutally serious.” Sounding that alarm also has meant reaching out to the battered remnants of the Never Trump movement. (Bulwark’s publisher, Sarah Longwell—a leading figure of the Never Trump movement—moderated the Harris-Cheney event in Pennsylvania.) Why the Never Trumpers? Because they have been making the case for years that voting against Trump isn’t a betrayal of party principles. They are particularly well positioned to argue that it isn’t necessary to embrace Democratic policies to vote for Harris, because the stakes are so much higher than mere party politics. And that’s an argument that Harris is now trying to make to swing voters. The question is, will that argument actually persuade these voters in the way Harris hopes it will?
The majority of Republican voters across the country will vote for Trump, and Cheney’s involvement is unlikely to move many of them. Harris also faces challenges in persuading conservative voters to overlook her past stances on issues such as transgender health care, the Green New Deal, and immigration. Meanwhile, the largest known group of undecideds is unsure about voting at all.
But this election could come down to a sliver of a percent, and the Harris campaign has decided to make a concerted play for disillusioned and discarded Republican voters in places like Waukesha County, where we met Monday night. In April’s GOP presidential primary, Nikki Haley won about 14 percent of the vote in Waukesha County. Some of those voters were in the audience Monday when Cheney made it clear to them that voting for a Democrat was okay because Trump should never be allowed in any office of public trust again. Perhaps her words will give a few Republican voters the cover they need to make a decision that might feel like a betrayal but is in fact an act of loyalty to country above all.
The Israeli military said that one of its air strikes in early October killed Hashem Safieddine, a top Hezbollah leader who was a potential successor to Hezbollah’s recently assassinated longtime leader. Hezbollah did not immediately respond to the claim.
A federal judge ordered Rudy Giuliani, a former Trump lawyer and former mayor of New York City, to turn over his New York apartment and his valuable personal items to the two Georgia election workers he defamed.
A federal appeals court upheld the conviction of Couy Griffin, the Cowboys for Trump leader who was found guilty of a trespassing charge that was used against many other January 6 defendants.
Evening Read
Chelsey Hauge-Zavaleta at home with her children in Santa Cruz, California Jenna Garrett for The Atlantic
This Influencer Says You Can’t Parent Too Gently
By Olga Khazan
The kids held it together pretty well until right after gymnastics. At the end of a long day that included school, a chaotic playdate, and a mostly ignored lunch of sandwiches, the parenting coach Chelsey Hauge-Zavaleta picked up her twins from the tumbling gym around 5:30. The two 8-year-olds joined their 6-year-old sister inside Chelsey’s silver minivan.
Chelsey, an energetic 41-year-old, promotes gentle parenting, a philosophy in which prioritizing a good relationship with your kid trumps getting them to obey you. I was tagging along with her family for a few days to see how her strategy—stay calm, name emotions, don’t punish kids for acting out—works in practice.
Marvel. No one knows how big pumpkins can get, Yasmin Tayag writes. Now the 3,000-pound mark is within sight.
Debate. Apparently a whole-grain, seed-coated loaf of bread counts as an ultra-processed food, just like Twinkies, Coke, and sugary cereals, Nicholas Florko writes.
In September, Secret Service agents apprehended a man carrying an AK-47-style gun near Donald Trump’s Palm Beach golf course—in an apparent attempt, the FBI concluded, to assassinate the former president. To some, the thwarted violence was a bleak testament to the times: one more reminder that politics, when approached as an endless war, will come with collateral damage. To Elon Musk, however, it was an opportunity. The billionaire, treating his control of X as a means of owning the libs, gave the Palm Beach news a MAGA-friendly twist. “And no one is even trying to assassinate Biden/Kamala,” Musk wrote on the platform, punctuating the line with a thinking-face emoji.
Musk was wrong—authorities have arrested several people for death threats made against the president and vice president—and he eventually deleted the post. But he did not apologize for the mistake. Instead, earlier this month, Musk used an appearance on Tucker Carlson’s X-based show as a chance to workshop the line. “Nobody’s even bothering to try to kill Kamala,” Musk told Carlson, “because it’s pointless. What do you achieve?”
At this, both men guffawed. Musk, having found an appreciative audience, kept going, finding new ways to suggest that the vice president was not worth the trouble of assassinating. Carlson’s reply: “That’s hilarious.”
First as tragedy, then as farce, the adage goes. If only the old order still applied. Not that long ago, public figures such as Carlson and Musk might have been embarrassed to be seen using political violence as a punch line. But embarrassment, these days, is a partisan affliction. It can ail only the soft, the sincere—the people willing to be caught caring in public. The brand of politics that Musk and Carlson practice is swaggering and provocative and, as a result, entirely devoid of shame. And so the two men, wielding their mockery, make a show of each chortle and smirk. They may consider their delight to be defiant—a rebuke to the humorless masses who see the violence and not the lol—but it is not defiant. It is banal. This is the way of things now. The tragedy and the farce, the menace that winks, the joke that threatens, the emoji that cries with joy and the one that simply cries: They bleed together, all of them. Irony storms the Capitol. Cynicism reigns.
Trump, that louche comedian, is partially to blame. His humor—some of it crude, some of it cruel, most of it treating politics and the people who engage in them as the butt of an endless joke—is more than a performance. It is also permission. Musk and Carlson laughed at the thought of Harris’s death both because they wanted to and because they knew they could. Trump and his crowbar will come for every Overton window. Now no claim is too much. No joke is too soon. Deportations, assassinations, the casual suggestion that America is due for its own version of Kristallnacht: Invoked as ideas and implications, they might be threats. They might be omens. For Trump and the many who humor him, though, they’re simply material—fodder for jokes in a set that never ends.
“Not The Onion,” people might warn one another on social media, as they share the video of Trump’s nearly 40-minute attempt to turn a town hall into a one-man dance party. “Beyond parody,” they might moan, as J. D. Vance spreads racist lies about immigrants snatching and eating their neighbors’ pets. The disclaimers are hardly necessary. Americans, whatever their political convictions, have become accustomed to politics that read as dark comedy—and to politicians who commit fully to the bit. These leaders don’t merely lie or misspeak or make light of life and death. To them, leadership itself is a joke. They’re trolling one another. They’re trolling us. They’ve made mischief a mandate.
Call it the trolligarchy—and have no doubt that its regime is inescapable. Trump says that if reelected he’ll be a dictator on “day one” and then insists that he’s only joking. Under Musk, X’s email for press inquiries auto-responds to reporters’ questions with a poop emoji. Marjorie Taylor Greene, who won a congressional seat in Georgia by turning trolling into a campaign strategy, has been using the House bill-amendment process as an opportunity for cheap acts of score-settling. In a proposed amendment to a bill meant to allocate funding to aid Ukraine as it defends itself against Russia’s invasion, she stipulated, among other things, that any colleague who voted for it would be conscripted into Ukraine’s military.
“Messaging bills” may be fairly common among politicians seeking new ways to rack up political points. And Greene’s amendment was roundly defeated. Her stunt, though, wrote tragedy and farce into the congressional record. Roll Call, reporting on it, quoted social-media posts from Matt Glassman, an analyst at Georgetown University’s Government Affairs Institute. There have “always been chucklehead Members of the House,” Glassman wrote of Greene’s antics. “But the prominence of many of the chuckleheads in the GOP and the ever-increasing general level of chucklehead behavior worries me.”
Life under the trolligarchy requires constant acts of micro-translation: Did she mean it? Was he joking? Were they lying? The lulz, as a result, can be exhausting. The scholar Dannagal Goldthwaite Young, analyzing fMRI studies that illustrate how the brain processes jokes, argues that humor can impose a cognitive tax. Jokes, for all their delights, ask more of their audiences than other forms of discourse do: They require more split-second parsing, more energy, more work. And a troll is a joke unhinged—which makes it extra taxing. Its terms are particularly murky. Its claims are especially suspect. Under its influence, the old categories fail. Nihilism takes over. Fatigue sets in. Sincerity and irony, like stars whose centers cannot hold, collapse into each other.
Humor is an age-old political tradition—Common Sense, the pamphlet that persuaded many Americans to become revolutionaries, was powerful in part because it was often quite funny—but trolling, as a mode of political engagement, is not comedy. It is its antithesis. Nazis of both the past and present have tried to hide in plain sight by characterizing their racism as merely ironic. As The New Yorker’s Emily Nussbaum wrote in a 2017 essay, jokes deployed as rhetoric played a crucial role in helping Trump win the presidency.
Since then, the trolling has only intensified. But it has also become—in a twist that can read as a cosmic kind of troll—ever more banal. In 2008, The New York Times published “The Trolls Among Us,” a lengthy introduction to a subculture that was then emerging from the dark recesses of the internet. The article is remarkably prescient. It treats trolling as a novelty but frames it as a new moral problem. It parses the cruelty that has become a standard feature of online engagement. But it was also written when trolls’ power was relatively contained. Trolling, today, having slipped the surly bonds of 4chan, is no longer subculture. It is culture.
Many trolls of the early internet hid behind pseudonyms and anonymity; they largely performed for one another rather than for a mass audience. But trolling, as a political style, demands credit for the chaos it sows. Trump, the “troll in chief,” channels that status as brand identity. He will happily lie, his followers know; maybe he’ll lie on their behalf. He will trick his opponents. He will set traps. He will reveal his rivals’ foolishness. He will humiliate them. That old Times article captured one of the abiding ironies of this brave new mode of digital engagement. Trolling may manifest as pranks. But many practitioners insist that their hijinks have ethical ends. Trolls claim to be puncturing pieties, saving the sanctimonious from themselves. They’re righting social wrongs as they subject “elites” to a barrage of corrective humiliations meant to reveal empathy and equality and other such values as nothing more than smug little lies.
Trolling, in that way, can be self-rationalizing, and therefore particularly powerful when its logic comes for our politics. Trump once gave a speech in the rain and then bragged about the sun shining down on his performance. His bravado was propaganda in its most basic and recognizable form—overt, insistent, blunt. It did what propaganda typically will, imposing its preferred reality onto the one that actually exists. But the lie was also so casual, so basic, so fundamentally absurd—even the heavens, Trump says, will do his bidding—that it barely registered as propaganda at all.
Trump came of age as a public figure in the 1980s, long before irony was alleged to have died—a time, on the contrary, when cynicism had become cultural currency. It was a period when earnestness, or at least the appearance of it, was curdling into a liability. Trump has taken the irony-infused assumptions of those years and used them as tools of power. His lies invade and destroy, trampling the truths that stand in their way with casual, cunning brutality. But Trump’s jokes can be similarly, if more subtly, ruinous. A troll reserves the right, always, to be kidding—even about matters of life and death.
That attitude, once it takes hold of the body politic, spreads rapidly. People talk about “irony poisoning” because irony, in the end, has so few antidotes. Greene’s attempt to troll her colleagues as they determined aid to Ukraine led to several more proposed amendments—this time from Jared Moskowitz, a Democratic representative from Florida. One proposed to appoint Greene as “Vladimir Putin’s Special Envoy to the United States Congress.” Another suggested renaming Greene’s office for Neville Chamberlain, the British prime minister who is widely denigrated for his appeasement of Hitler.
Recommending that a congressional office be called the Neville Chamberlain Room may not be a great joke; it’s even worse, though, as a mode of government. Democracy is an earnest enterprise: It requires us—challenges us—to care. It assumes that people will disagree, about the small things and the big ones. It further assumes that they will settle differences through acts of debate. But cynicism makes argument impossible. “How do you fight an enemy who’s just kidding?” Nussbaum asked in her 2017 essay, and the question still has no good answer. The old insult comic remains onstage, serving up the same routine to a crowd that cackles and roars. He’ll roast anyone in his path. He’ll soak up the applause. He’ll trust that, in all the levity, people will miss the obvious: When the comedy keeps punching down, anyone can become the butt of the joke.
The twinge begins in the afternoon: toes. At my desk, toes, itching. Toes, toes, toes.
I don’t normally think about my toes. But as I commute home in a crowded subway car, my feet are burning, and I cannot reach them. Even if I could, what would I do with my sneakers? My ankles are itchy too. But I’m wearing jeans, which are difficult to scratch through, unless you have a fork or something similarly rigid and sharp. I contemplate getting off at the next stop, finding a spot on a bench, removing my shoes, and scratching for a while. But I need to get home. Growing desperate, I scrape at my scalp, which is not itchy. This somehow quiets things down.
I am full of these kinds of tricks. A lot of folks, if you tell them you’re itchy, will recommend a specific brand of lotion. I hate these people. My husband made me a T-shirt that reads yes, I have tried lotions. They do not work. No, not that one either. Zen types will tell you to accept the itch, to meditate on it, as you might do if you were in pain. These people have no idea what they are talking about. Watching someone scratch makes you itchy; worrying about something pruritogenic, like a tick crawling on you, makes you itchy; focusing on how itchy you are when you are itchy makes you itchier. The trick, if you are itchy, is to not think about it, using those ancient psychological tricks disfavored in today’s therapeutic environments: avoidance, deflection, compartmentalization, denial.
Cruelest of all are the people who tell you not to scratch. They have a point, I admit. Scratching spurs cells in your immune system to secrete the hormone histamine, which makes you itchy; in this way, scratching leads to itching just as itching leads to scratching. But if you itch like I itch, like a lot of people itch, there’s no not scratching. It would be like telling someone to stop sneezing or not to pee. “I never tell people not to scratch,” Gil Yosipovitch, a dermatologist at the University of Miami Miller School of Medicine known as “the godfather of itch,” told me, something I found enormously validating.
No, the techniques that work are the techniques that work. During the day, I pace. Overnight, when the itching intensifies, I balance frozen bags of corn on my legs or dunk myself in a cold bath. I apply menthol, whose cold-tingle overrides the hot-tingle for a while. I jerk my hair or pinch myself with the edges of my nails or dig a diabetic lancet into my stomach. And I scratch.
My body bears the evidence. Right now I am not itchy—well, I am mildly itchy, because writing about being itchy makes me itchy—yet my feet and legs are covered in patches of thick, lichenified skin. This spring, I dug a bloody hole into the inside of my cheek with my teeth. I’ve taken out patches of my scalp, shredded the edge of my belly button, and more than once, desperate to get to an itch inside of me, abraded the walls of my vagina.
During my first pregnancy, when the itching began, it was so unrelenting and extreme that I begged for a surgeon to amputate my limbs; during the second, my doctor induced labor early to stop it. Still, I ended up hallucinating because I was so sleep-deprived. Now I have long spells when I feel normal. Until something happens; I wish I knew what. I get brain-fogged, blowing deadlines, struggling to remember to-dos, failing to understand how anyone eats dinner at 8 p.m., sleeping only to wake up tired. And I get itchy. Maybe it will last forever, I think. It stops. And then it starts again.
One in five people will experience chronic itch in their lifetime, often caused by cancer, a skin condition, liver or kidney disease, or a medication such as an opiate. (Mine is caused by a rare disease called primary biliary cholangitis, or PBC.) The itching is the corporeal equivalent of a car alarm, a constant, obnoxious, and shrill reminder that you are in a body: I’m here, I’m here, I’m here. It is associated with elevated levels of stress, anxiety, and depression; causes sleep deprivation; and intensifies suicidal ideation. In one study, the average patient with chronic itch said they would give up 13 percent of their lifespan to stop it.
Yet itching is taken less seriously than its cousin in misery, pain. Physicians often dismiss it or ignore it entirely. Not that they could treat it effectively if they wanted to, in many cases. There are scores of FDA-approved medications for chronic pain, from ibuprofen to fentanyl. There are no medications approved for chronic itch. “Pain has so much more research, in terms of our understanding of the pathophysiology and drug development. There’s so much more compassion from doctors and family members,” Shawn Kwatra of the University of Maryland School of Medicine told me. Itch, he added, “is just not respected.”
Perhaps doctors do not respect it because, until recently, they did not really understand it. Only in the late aughts did scientists establish that itch is a sensation distinct from pain and begin figuring out the physiology of chronic itch. And only in the past decade did researchers find drugs that resolve it. “We’re having all these breakthroughs,” Kwatra said, ticking off a list of medications, pathways, proteins, and techniques. “We’re in a golden age.”
Once left to suffer through their commutes and to ice their shins with frozen vegetables, millions of Americans are finding relief in their medicine cabinet. For them, science is finally scratching that itch. Still, so far, none of those treatments works on me.
Itching is one of those tautological sensations, like hunger or thirst, characterized by the action that resolves it. The classic definition, the one still used in medical textbooks, comes from a 17th-century German physician: “an unpleasant sensation that provokes the desire to scratch.” Physicians today classify it in a few ways. Itching can be acute, or it can be chronic, lasting for more than six weeks. It can be exogenous, caused by a bug bite or a drug, or endogenous, generated from within. It can be a problem of the skin, the brain and nervous system, the liver, the kidneys.
Most itching is acute and exogenous. This kind of itch, scientists understand pretty well. In simplified terms, poison ivy or laundry detergent irritates the skin and spurs the body’s immune system to react; immune cells secrete histamine, which activates the nervous system; the brain hallucinates itch into being; the person starts to scratch. The episode ends when the offending irritant is gone and the body heals. Usually medicine can vanquish the itch by quieting a person’s immune response (as steroids do) or blocking histamine from arousing the nervous system (as antihistamines do).
Yet some people itch for no clear reason, for months or even years. And many itching spells do not respond to steroids or antihistamines. This kind of itch, until recently, posed some “fundamental, basic science questions,” Diana Bautista, a neuroscientist at UC Berkeley, told me. Scientists had little idea what was happening.
In the 1800s, physicians were studying the nervous system, trying to figure out how the body is capable of feeling such an astonishing panoply of sensations. Researchers found that tiny patches of skin respond to specific stimuli: You might feel a needle prick at one spot, but feel nothing a hair’s breadth away. This indicated that the body has different nerve circuits for different sensations: hot, warm, cold, cool, crushing, stabbing. (Migratory birds have receptors in their eyes that detect the world’s magnetic field.) The brain synthesizes signals from nerve endings and broadcasts what it senses with obscene specificity: the kiss of a raindrop, the crack of an electric shock.
In the 1920s, a German physiologist noted that when researchers poked a pain point on the skin, itch often followed ouch. This led scientists to believe that the sensations shared the same nervous-system circuits, with the brain interpreting weak messages of pain as itch. This became known as the “intensity theory”—itchis pain, below some threshold—and it became the “canonical view,” Brian Kim, a dermatologist at the Icahn School of Medicine at Mount Sinai, told me.
It never made much sense. If you catch your finger in a door, the stinging sensation does not dissipate into itch as the swelling goes down. That the body might have different circuitries for itch and pain seemed plausible for other reasons, too. “If you take 10 patients experiencing pain and give them morphine, probably all of them will feel better. If you take 10 patients with chronic itch and you give them morphine, none of them would,” Kim said. “That tells you right there.” Moreover, pain alleviates itch. It interrupts it. That is, in part, why you scratch: The pain creates the pleasure of relief. “The behavioral output is very different,” Bautista told me. “If you encounter poison ivy or get a bug bite, you don’t try to avoid the injury. You attack it. But with pain, you withdraw; you have these protective reflexes.”
Many scientists preferred an alternative theory: that itch had its own dedicated “labeled line” within the body. It took until 2007 for neuroscientists to uncover an itch-specific circuitry that many had long suspected was there. Mice genetically engineered to lack a specific receptor, scientists found, felt “thermal, mechanical, inflammatory, and neuropathic pain,” but not itch.
Since then, neuroscientists have refined and complicated their understanding of how things work—in particular, extending their understanding of what amplifies or overrides itch and the relationship between the pain and itch circuitries. And doctors have come to understand itch as a disease in and of itself.
And a curious disease, at that. In any given year, one epidemiological survey found, chronic itch afflicts 16 percent of the general adult population, making it half as common as chronic pain. Yet there are scores of American medical centers dedicated to treating pain and none for itch. On Facebook, I found hundreds of peer-support groups for people with chronic pain. For chronic itch, I found just one, dedicated to sufferers of the miserable dermatological condition prurigo nodularis.
Millions of us are scratching alone, a social reality with deep physiological roots. Itching is isolating. The touch of another person can be unbearable. When I get really itchy at night, I build a pillow wall between myself and my cuddle-enthusiast husband, so he does not accidentally wake me up, kickstart the itch-scratch cycle, and mechanically increase our chance of divorce. Studies also show that itch is both contagious and repellent. In the 1990s, scientists in Germany rigged up cameras in a lecture hall and filmed members of the public who came to watch a talk on pruritus. Inevitably, people in the crowd began scratching themselves. Yet people reflexively move away from others who are itching, and toward those in pain.
At best, scratching yourself is like chewing with your mouth open, embarrassing and undignified. At worst, it broadcasts uncleanliness, infestation, derangement, and disease, raising the specter of bedbugs, scabies, chicken pox, roseola, gonorrhea, insanity, and who knows what else. In ancient times, people believed that lice were a form of godly punishment: They generated spontaneously in a person’s flesh, tunneled their way out, and consumed their host, thus transfiguring them into bugs. Plato is one of many historical figures accused by his haters of being so lousy, literally, that it killed him. And maybe it did. An extreme lice infestation can cause a person to die from a blood infection or anemia.
At least the ancients grasped how miserable being itchy can be. In 1365, a scabies-ridden Petrarch complained to Boccaccio that his hands could not hold a pen, as “they serve only to scratch and scrape.” In Dante’s Inferno, itching is meted out as a punishment to alchemists in the eighthring of hell. Murderers in the seventh ring, including Attila the Hun, get a mere eternal dunk in a boiling river of blood.
In my experience, people do not meet an itchy person and grasp that they might be beyond the boiling river. (The physician and journalist Atul Gawande wrote about a patient who scratched all the way through her skull into her brain.) The stigma and the dismissal compound the body horror. When I explain that I itch, and at some point might start itching and never stop, many people respond with a nervous giggle or incredulousness. One of my dumb lines on it involves being a distant relative of a participant—to be clear, an accuser—in the Salem witch trials. Who knew that curses work so well!
Itch is a curse, an eldritch one. At night, I sometimes feel crumbs or sand on my sheets, go to brush the grit off, and find the bed clean. One day, I was rummaging around in a basement and felt a spider drop onto my shoulder from the ceiling. I felt that same, vivid sensation a hundred times more over the next few days. The inside of my body itches, like I have bug bites on my intestines and my lungs. I swear that I can feel the floss-thin electric fibers under my skin, pinging their signals back and forth.
The worst is when I need the itch to stop and I cannot get it to stop, not by dunking myself in ice water or abrading myself with a fork or stabbing myself with a needle or taking so much Benadryl that I brown out. It generates the fight-or-flight response; it feels like being trapped. I don’t know; maybe it is akin to drowning.
My chronic itch might be a disease unto itself, but it is also a symptom. At some point in my early 30s, my immune system erred and started to destroy the cells lining the small bile ducts in my liver. This inflamed them, obstructing the flow of sticky green bile into my digestive system. The ducts are now developing lattices of scar tissue, which will spread through my liver, perhaps resulting in cirrhosis, perhaps resulting in death.
Primary biliary cholangitis is degenerative and incurable, and was until recently considered fatal. The prognosis was radically improved by the discovery that a hundred-year-old drug used to dissolve gallstones slows its progression, reducing inflammation and making bile secretion easier. But a minority of people do not respond to the medication. I am one of them.
PBC is generally slow moving. Science keeps advancing; my doctors have me on an off-label drug that seems to be working. Still, I am sick, and I always will be. I feel fine much of the time. The dissonance is weird, as is the disease. What am I supposed to do with the knowledge of my illness? Am I at the end of the healthy part of my life, at the beginning of the dying part?
I am stuck with questions I cannot answer, trying to ignore them, all the while reminded of them over and over again, itchy.
Some answers, however, are coming. Having found nerve circuits dedicated to itch, scientists also began finding receptors triggered by substances other than histamine, thus unlocking the secrets of chronic itch. “We know more about the neural circuits that allow you to experience this sensation, regardless of cause,” Bautista told me. “We know more about inflammatory mediators and how they activate the circuits. We know more about triggers and priming the immune system and priming the nervous system.”
I asked a number of experts to help me understand chronic itch in the same way I understood acute itch—to show me an itch map. “It’s complicated,” Kwatra told me. “Complicated,” Kim agreed. “Complex,” said Xinzhong Dong of Johns Hopkins. The issue is that there’s not really a map for chronic itch. There are multiple itch maps, many body circuits going haywire in many ways.
Still, Dong gave me one example. The drug chloroquine “works really well to kill malaria,” he explained. But chloroquine can cause extreme itchiness in people with dark skin tones. “The phenomenon is not an allergic reaction,” Dong told me; and antihistamines do not ease it. In 2009, his lab figured it out: In highly simplified terms, melanin holds chloroquine in the skin, and chloroquine lights up an itch receptor.
Because there is no single map for chronic itch, there is no “big itch switch that you can turn off reliably with a drug,” Kim told me. “I’m not so convinced that it is even doable.” (Dong thought that it probably is. It just might cause debilitating side effects or even kill the itchy person in the process.) Still, there are lots of smaller itch switches, and researchers are figuring out how to flip them, one by one.
These include a pair of cytokines called interleukin 4 and interleukin 13. When a person encounters an allergen, the body secretes these chemical messengers to rev up the immune system. Yet the messengers also spur the body to produce itch-related cytokines and make the nervous system more sensitive to them. In 2017, the FDA approved a drug called Dupixent, which blocks the pair of cytokines, to treat atopic dermatitis, a form of eczema; the agency later approved it for asthma, laryngitis, and other inflammatory conditions (at a retail cost of $59,000 a year).
Michael McDaniel found a single open blister on his bicep when he was traveling in Europe in 2013. Within a few days, he told me, a crackling, bleeding rash had engulfed his upper extremities, oozing a honey-colored liquid. His knuckles were so swollen that his hands stiffened.
Back in the United States one miserable week after his trip, he saw a dermatologist, who diagnosed him with atopic dermatitis. Nothing McDaniel tried—steroids, bathing in diluted bleach, avoiding cigarette smoke and dryer sheets, praying to any god who would listen—ended his misery. He bled through socks and shirts. He hid his hands in photographs. “I was able to get my symptoms to a manageable baseline,” he told me. “It wasn’t really manageable, though. I just got used to it.”
McDaniel muddled through this circle of hell for seven years, until his dermatologist gave him an infusion of Dupixent. Twenty-four hours later, “my skin was the calmest it had been since my symptoms appeared,” McDaniel told me. The drug was a “miracle.”
Numerous drugs similar to Dupixent have been found over the past seven years to work on chronic itch, and physicians are refining techniques such as nerve blocks and ketamine infusions. But finding treatments for itching that is not related to an immune response has proved harder. Progress is throttled by the relatively small number of researchers working on itch, and the limited sums Big Pharma is willing to pump into drug development and trials. Plus, treatment options do not readily translate into treatment; a lot of folks are still being told to try Benadryl, even if all it does is make them groggy.
When I saw my hepatologist in August, that’s exactly what he suggested. The drug would help to quell the itching caused by my scratching, at a minimum, and help me sleep.
“I hate Benadryl,” I snapped. (Maybe I need a new T-shirt.) He suggested Zyrtec or Claritin.
As I continued to press for more options, he reviewed my bloodwork. My liver enzymes were still high. He suggested more tests, a biopsy. And he said we could start trialing drugs to manage my symptoms better. SSRIs, used to treat depression, sometimes ease itch in patients with PBC. Opioid antagonists, used to treat heroin overdoses, sometimes do the same. Cholestyramine, which soaks up bile acid (a known pruritogen), could work. Maybe UVB phototherapy. Maybe a cream charged with fatty acids that activate the endocannabinoid system. Maybe rifampin, an antibiotic.
These ragtag off-label treatment options reflect the fact that physicians have not yet figured out PBC’s itch map. Some patients just itch and itch and itch and it never ends. I once asked my old hepatologist what she would do if that happened to me. “Transplant your liver,” she told me, not even looking up from her computer.
This was not a comforting answer. Organ transplantation is a lifesaving miracle, but a saved life is not an easy one. Recovery from a liver transplant takes at least a year. Grafts die, not infrequently. Many patients never heal fully. The five-year survival rate is 14 percentage points lower for PBC patients with liver transplants than it is for PBC patients who respond to the standard treatment and do not need one.
When I shared this prognosis with my mother, she responded, “You better start being nice to your siblings!” (I would rather die.) When I broke it to my husband, he paused a beat before saying he might go call his therapist.
Would I rather just live with the itch? How would I do it? I could not find a support group for the chronically itchy. But I did find two people with PBC who were willing to share their experiences with me. Carol Davis is a retired kindergarten teacher. More than a decade ago, she started itching “like crazy,” she told me. “It would wake me up in the night.” A doctor diagnosed her with PBC; like me, she itches on and off, and doctors have never found a set of drugs to quell her itch without causing miserable side effects.
I asked her how she has dealt with it, not in terms of doctors and drugs and lotions but in a more cosmic sense. “When you’re at the end of your lifespan, you just have the mindset: These things are going to happen,” Davis told me. “If I had been younger, like you, it might have been more scary.” Then she ticked off a list of things she looks forward to: games of Farkle, Bible study, going to the gym, seeing her friends from her sorority, spending time with her husband of 54 years. She got out of her head, she meant. And when she found herself back there, itching or afraid or in pain, she told me, “I don’t dwell on myself. I don’t ask the Lord to make me well. I dwell on Him!”
Gail Fisher is 84 “and a half,” she told me, and a harpist, gardener, and motor-home enthusiast. She lives alone in rural Effingham County, Illinois. Her PBC has developed into cirrhosis, and she also has arthritis and thyroid disease. The itching drives her nuts sometimes too, she told me. But she does not dwell on it either. “Gosh, don’t worry about it,” she said. “You don’t know what tomorrow is going to bring anyway!”
When the itch is at its worst—not a bodily sensation but an existential blight, not a force begging for resignation but one driving a person to madness—that’s easier said than done. Still, I knew that following Davis’s and Fisher’s advice would do me more good than lotion or Benadryl ever has.
There is something ironic about the fact that, of all the countries in the Middle East, Iran is the one that now finds itself on the brink of war with Israel. Iran is not one of the 22 Arab states party to the decades-long Arab-Israeli conflict. Its population, unlike those of many Arab countries, harbors little anti-Israel sentiment. During the past year, mass rallies in support of the Palestinians have taken place in cities all over the world: Baghdad, Sanaa, New York, and Madrid, to name only a few. Nothing like this has happened at scale in Tehran—when Iranians really protest en masse, they tend to do so against their own regime and its obsession with Israel.
Alas, wars are waged by governments, not peoples. And because the regime ruling Iran has long made hostility toward Israel central to its identity, Iran now faces a direct confrontation with the Jewish state, regardless of whether most Iranians want such a war. For the country’s opposition, the prospect has occasioned a divide—between those who fear that the next round of fighting will be a costly setback to their efforts and those who cautiously hope that it will shake something loose.
In the first camp are many Iranian dissidents, both inside and outside the country, who loudly protested Iran’s missile attacks on Israel in April and October. Now they are also opposed to an Israeli counterattack on Iran: All-out war between the two countries, these activists say, would be a disaster in both humanitarian and political terms, making life worse for ordinary Iranians without weakening the Islamic Republic.
Narges Mohammadi, the Nobel Peace Prize laureate and human-rights advocate imprisoned in Tehran, and Atena Daemi, an activist who recently fled Iran after years in prison, have issued statements decrying a potential war. Mohammad Habibi, the spokesperson for Iran’s teachers’ union, wrote on X that he opposed “any war”; he added that he considered Hezbollah and Hamas terrorists, and Israeli Prime Minister Benjamin Netanyahu a war criminal. Sadegh Zibakalam, an outspoken political-science professor at the University of Tehran, has repeatedly criticized the Iranian regime’s declared goal of destroying Israel.
The position of this part of the Iranian opposition is friendly neither to Iranian aggression against Israel nor to Israeli strikes on Iran, on the grounds that such hostilities are most likely to preserve the power of the current regime. An Israeli attack on the Iranian oil industry would just collapse the country’s infrastructure and immiserate its people, Hossein Yazdi, a social-democratic activist and former political prisoner in Tehran, told me, and attacking the country’s nuclear sites could bring about a humanitarian disaster. Politically, Yazdi said, an Iran-Israel war would have terrible consequences. “Iranians are the least Islamist people in this region,” Yazdi says. “They are mostly secular and friendly to the West. But a war can make fanatics out of people and give a new lease on life to the Islamic Republic.”
Many of the regime’s most vociferous opponents in exile think along similar lines. Hamed Esmaeilion, a 47-year-old novelist based in Toronto, has emerged as a major voice for Iran’s secular democratic opposition in recent years. His wife and 9-year-old daughter were among the passengers on PS752, the Ukrainian airliner downed by the Iranian regime under suspicious circumstances in January 2020. Esmaeilion became renowned for his advocacy on behalf of those victims’ families. He published a statement on October 5, a few days after Iran’s latest missile attacks on Israel, calling for opposition both to the Iranian regime and to the “fundamentalist government of Israel, which ignores international treaties and kills many civilians.”
By spelling this out, Esmaeilion was speaking to another group of Iranians who oppose their government: those who favor a war with Israel, or at least regard it as a potentially useful lever for toppling the regime. I encountered such sentiments among many Iranians I talked with—and sometimes in surprising quarters. A mid-level manager at a government ministry told me, “We are in limbo now. If Israel attacks, things can be done with the regime once and for all.” I spoke with some Iranians who said they just hoped that an Israeli attack would hurt the regime leaders and not ordinary people, and some who fantasized that a military confrontation with Israel would lead to a mass uprising that would finally end the regime.
Some in this camp, though not all, support the leadership aspirations of Reza Pahlavi, who was Iran’s crown prince before his father was overthrown in the 1979 revolution. Pahlavi and his supporters have drawn close to Donald Trump and other elements of the international right. In April 2023, the Iranian royal visited Israel and met with Netanyahu. Some of Pahlavi’s supporters work for hawkish Washington, D.C., outfits, such as the Foundation for the Defense of Democracies, and Pahlavi spoke at the National Conservatism conference, held in July in Washington. Last month, he was a keynote speaker at the Israeli American Council’s annual summit in D.C., alongside Trump.
Pahlavi has long vocally opposed military attacks on Iran. But in the days after Iran’s October 1 missile barrage against Israel, when an Israeli retaliation seemed imminent, Pahlavi published a video message that some took to be an implicit invitation. He called on the people of the region not to fear chaos if Iran’s regime should collapse. “We will not allow a power vacuum,” he promised, pledging that “patriotic Iranians” would replace the regime.
In the days that followed, Pahlavi clarified that he still opposed war. “We have seen diplomacy fail, and war is not a solution,” he told Fox News on October 16. The West must “invest in the Iranian people,” Pahlavi added, meaning that it should “abandon the policy of appeasement” and exert “maximum pressure on the regime” while also giving “maximum support” to the Iranian people to organize themselves.
Cameron Khansarinia is a well-known Pahlavi supporter and the vice president of a Washington-based Iranian American organization that backs the Iranian royal. I asked Khansarinia whether he supported an Israeli attack on Iran. He said that he disagreed with the “framing of the question.” He told me that he hoped “no innocent Iranians are injured in Israel’s inevitable retaliation,” and that he supported Pahlavi’s policy of “maximum pressure” alongside “maximum support” for Iranians. Khansarinia pointed to Israel’s killing of Hamas and Hezbollah leaders in recent weeks as an effective means of putting pressure on the Iranian regime while supporting the people.
I even spoke with an Iranian socialist activist in Washington who has come to support both Pahlavi and Israel’s war (a very unusual stance within his corner of the opposition): Farhad Moradi, who arrived in the United States as a refugee a few years ago, told me that Israel should avoid attacking Iran’s nuclear sites or port infrastructure, because doing so wouldn’t help ordinary Iranians or weaken the regime politically. But he did support Israel hitting military sites or assassinating regime figures.
Esmaeilion, the novelist and spokesperson for the passengers killed on the Ukraine-bound flight, worries that those who embrace the possibility of war with Israel do so based on delusions about what both war and regime change really entail. Iranians need a “revolution” to bring down their regime, he said in his statement—not a foreign conflict. And doing battle with Israel could be terribly costly. “The current Israeli government has shown that it’s not really committed to international law,” he told me. “Many innocent people have died. If a broad war breaks out between Iran and Israel, many more innocents will die. The regime will also use people as human shields and cannon fodder.”
Esmaeilion is of the generation that can vividly remember the Iran-Iraq War of 1980–88. Many of his novels are set during that conflict, which killed as many as half a million people. The talk of potential Israeli attacks on Iranian infrastructure recalls very specific traumas. “My father worked at the Kermanshah refinery when it was bombed on July 24, 1986,” he said. “He lost six of his colleagues there. Three days later, my uncle was killed when Iraq bombed the aluminum works in Arak. Many of my relatives died at the front in that war. What remained was pain and suffering for many years to follow. War can be terrible.”
Esmaeilion agrees with Hossein Yazdi, the activist in Tehran, that a war with Israel risks strengthening the regime. The opposition is fractious, and the Islamic Republic could use war as a pretext to clamp down on fragile networks that need shoring up: “We must organize our forces, bring about strikes and uprisings and finish this nightmare of a regime once and for all,” he told me. “A war will hurt this process.”
The divisions within the Iranian opposition are deep and often rancorous. Yazdi told me that he found Pahlavi’s intervention ominous. “It’s very scary for the prime minister of Israel to meet with a fugitive Iranian prince,” he told me. Many Iranians will even back the current regime if the alternative is an Israeli-backed restoration of the fallen monarchy, he said. Last year, Esmaeilion joined an anti-regime coalition that included Pahlavi and others, including the U.S.-based women’s-rights activist Masih Alinejad—but the effort collapsed in less than a month over disagreements about Iran’s future.
In the end, debates among Iranian dissidents over the desirability of an Israeli attack matter only so much. The Iranian opposition does not get to decide what Israel will do. It is watching events, not shaping them—and until and unless it gets organized, that will be true within Iran as well.
Under normal circumstances, you would not expect a crowd of regular Americans—even those engaged enough to go to a political rally—to recognize an assistant secretary of health and human services. But the crowd at Donald Trump’s appearance earlier this month at the Santander Arena, in Reading, Pennsylvania, started booing as soon as Rachel Levine’s image appeared on the Jumbotron.
That’s because Levine is the highest-profile transgender official in the Biden administration, and she has become a public face of the American left’s support for medical gender transition by minors. Having heard the Reading crowd’s ugly, full-throated reaction to Levine’s mere image, I understand why the prospect of a second Trump term might alarm transgender Americans—or the parents of gender-nonconforming children. I also more clearly understand Trump’s strategy: to rile up voters over positions that he thinks the Democrats won’t dare defend.
Back in 2016, the Republican presidential nominee portrayed himself as a moderate on trans rights, saying that Caitlyn Jenner was welcome to use whatever bathroom she wanted to at Trump Tower. But Trump’s rhetoric has become steadily more inflammatory, and his positions have hardened. Many commentators have nevertheless been surprised by the ferocity of Republican attacks on this issue. In 2022, the party’s efforts to exploit trans-rights controversies for electoral gain repelled more voters than they attracted, and recent polling in three swing states shows that more than half of respondents agreed that “society should accept transgender people as having the gender they identify with.”
Yet polls have also detected considerable public skepticism on three specific points: gender-related medical interventions for minors, the incarceration of trans women in women’s jails, and trans women’s participation in female sports. In Pennsylvania, one attack ad is on repeat throughout prime-time television. It ends: “Kamala’s for they/them; President Trump is for you.” The Republicans have spent $17 million on ads like this, according to NPR. “Republicans see an issue that can break through, especially with Trump voters who’ve been supporting Democratic candidates for Senate,” Semafor’s Dave Weigel wrote recently.
Trump has always used his audiences as an editor, refining his talking points based on the raw feedback of boos and cheers. At the rally in Reading, the image of Levine—pictured in the admiral’s uniform she wears as head of the U.S. Public Health Service Commissioned Corps—was part of a montage dedicated to condemning what Trump called the “woke military.” This video juxtaposed clips from Stanley Kubrick’s Full Metal Jacket—meant to represent good old-fashioned military discipline—with more recent footage of drag queens lip-synching to Kylie Minogue’s “Padam Padam.” Never mind that Full Metal Jacket is an anti-war film showing how sustained brutalization corrodes the soul.
This video is part of Republicans’ larger argument that their opponents are big-city elitists who have attempted to change the culture by imposing radical policies from above and then refused to defend them when challenged—and instead called anyone who disagreed a bigot. Many on the left see transgender acceptance as the next frontier of the civil-rights movement and favor far-reaching efforts to uproot discrimination. Yet activists and their supporters have waved away genuinely complex questions: Some claim, despite the available evidence from most sports, that biological males have no athletic advantage over females—perhaps because this is an easier argument to make than saying that the inclusion of trans women should outweigh any question of fairness to their competitors.
Others default to the idea that underage medical transition is “lifesaving” and therefore cannot be questioned—even though systematic evidence reviews by several European countries found a dearth of goodresearch to support that assertion. According to emails unsealed earlier this year in an Alabama court case, Levine successfully urged the influential World Professional Association for Transgender Health to eliminate minimum-age guidelines for gender-transition hormones and surgeries.
The Republicans are using trans issues as a symbol of “wokeness” more generally—what conservatives paint as a rejection of common sense, and as a top-down imposition of alienating values by fiat. In right-wing online echo chambers, Minnesota Governor Tim Walz is known as “Tampon Tim” for signing a state law calling for menstrual products to be placed in both girls’ and boys’ bathrooms. Throughout the speeches in Trump’s Reading event, talk of “men playing in women’s sports” and an exhortation to “keep men out of women’s sports” reliably drew the biggest cheers of the night. (Dave McCormick, the Republican candidate for Senate, brought up the issue, as did Trump himself.) The former president’s 90-minute speech had an extended riff on underage transition—and how schools might avoid telling parents about their child’s shifting gender. “How about this—pushing transgender ideology onto minor children?” Trump said, in an abrupt segue from a bit about fracking. “How about that one? Your child goes to school, and they take your child. It was a he, comes back as a she. And they do it, often without parental consent.”
Lines like this would not succeed without containing at least a kernel of truth. Under the policies of many districts, students can change their pronouns at school and use the bathroom of their chosen gender without their parents’ knowledge. A recent California law prohibits districts from requiring that parents be informed. In the presidential debate, many commentators laughed at the bizarre phrasing of Trump’s claim that Kamala Harris “wants to do transgender operations on illegal aliens that are in prison.” But the charge was basically true: While running for the 2020 Democratic nomination, Harris replied “Yes” to an ACLU questionnaire that asked her if she would use “executive authority to ensure that transgender and non-binary people who rely on the state for medical care—including those in prison and immigration detention—will have access to comprehensive treatment associated with gender transition, including all necessary surgical care.”
This year, Harris has mostly avoided such issues. She has tacitly moved her position from the left toward the center without explaining the shift or answering whether she believes she was previously wrong—a microcosm of her campaign in general.
As with abortion, a compromise position on gender exists that would satisfy a plurality of voters. Essentially: Let people live however makes them happy, but be cautious about medicalizing children and insist on fair competition in female sports. But Harris has been unwilling or unable to articulate it, and candidates in downballot races have followed her lead. You can see why: Even as polls suggest that many voters are morehesitant than the median Democratic activist, any backsliding by candidates from the progressive line alienates influential LGBTQ groups. In Texas, the Democrat candidate for Senate, Colin Allred, has faced such a barrage of ads about female sports from the Ted Cruz campaign that he cut his own spot in response. “Let me be clear; I don’t want boys playing girls’ sports,” Allred says in the clip. The LGBTQ publication The Advocatewrote this up as him having “embraced far-right language around gender identity.”
Like Allred, the Harris campaign has realized, belatedly, that silence is hurting the candidate’s cause. When the vice president was interviewed by Bret Baier on Fox News last week, she made sure to raise a New York Times story about how the Trump administration had also offered taxpayer-funded gender medicine in prisons. “I will follow the law,” Harris said. “And it’s a law that Donald Trump actually followed.”
Is that enough to neutralize the attacks? Seems unlikely: The Republican ads have not disappeared from the airwaves, because they bolster the party’s broader theme that Harris is more radical than she pretends to be. Which is the real Kamala Harris—the tough prosecutor of the 2010s or the ultraprogressive candidate of 2019 and 2020?
Presumably her campaign believes that every day spent talking about gender medicine for teens is one not spent discussing Trump’s mental fitness or disdain for democratic norms. In the absence of her articulating a compromise position, however, the Republicans are defining the contours of the debate in ways that could prove fateful—for Harris, for trans people, and for the country as a whole.
