The investigation comes at a time when the Tennessee state government has been proposing a barrage of legislation to limit access to healthcare for trans people. On July 8, a ban on gender-affirming care for minors went into effect. A block on the ban by a federal district judge was temporarily overturned by the Sixth Circuit Court of Appeals, a higher federal court, in a split decision after an appeal by Tennessee Attorney General Jonathan Skrmetti.

In such a hostile atmosphere, Skrmetti’s demands for records from the Vanderbilt’s Clinic for Transgender Health have alarmed patients.

Chris Sanders, executive director at Tennessee Equality Project, an LGBTQ advocacy organization, told me that the parents of young trans people have expressed fears that their children might be targeted. “When you’re a parent intent on defending your child, this looks like danger coming down the road,” said Sanders. 

States with aggressive anti-trans laws like Texas and Florida have been seeking large swathes of data on trans people. In the wake of the VUMC revelations, people are asking if Tennessee is taking a similar path. 

In September 2022, VUMC battled claims on social media, including by conservative politicians and religious leaders, that their gender-affirming care services were morally and legally objectionable and amounted to “money-making schemes.” Nashville, due in part to the VUMC clinic, has been seen as a haven for people seeking gender-affirming options in Tennessee. In response to allegations of illegal conduct, Attorney General Skrmetti said he would “use the full scope of his authority to ensure compliance with Tennessee law.” 

VUMC was required by law to turn over records to Skrmetti’s office. In response to a request for comment, the Tennessee Attorney General’s office directed me to its statement on June 21: “This investigation is directed solely at VUMC and related providers and not at patients or their families. The records have been and will continue to be held in the strictest confidence, as is our standard practice and required by law. This same process happens in dozens of billing fraud investigations every year.”

But on social media, many feared that Skrmetti’s data sweep was a gross violation of the 1996 Health Insurance Portability and Accountability Act and that VUMC could have done more to protect confidential information. In one tweet, a person who said VUMC had shared their data and that they were “terrified” claimed to have “challenged it with a HIPAA violation report.” In another tweet, containing a news clip from Nashville’s WKRN station in which the mother of a trans teen says she felt betrayed by the VUMC, several of the comments suggested VUMC had committed a HIPAA violation.

Jolynn Dellinger, senior lecturing fellow on privacy law and policy at Duke University School of Law, says that while HIPAA “is a pretty good law it’s widely misunderstood.” It only applies, she told me, “to a very small number of covered entities. The vast majority of health data is not covered by HIPAA.” 

As VUMC is a hospital, HIPAA does in fact protect its patient records, conversations with healthcare providers, and billing information. This means that the information cannot be shared without consent, but exceptions are made for law enforcement requests such as subpoenas and court orders. In this instance, a VUMC spokesman told reporters, the Tennessee Attorney General had the necessary legal authority to obtain the data.   

According to Dellinger, laws that are looking to criminalize access to gender-affirming care and abortion care leave the door open for authorities to seek people’s health data. On June 16, attorneys general from 19 states, including Tennessee, signed a letter addressed to the Secretary of Health and Human Services voicing their objection to a proposed expansion of HIPAA protections that would prevent states from exploiting their authority to fish for data. The dissenting attorneys general insist that the rule change “would unlawfully interfere with States’ authority to enforce their laws, and does not serve any legitimate need.” While focused on access to abortion, the complaints of Republican-governed states apply equally to those seeking gender-affirming care. 

Laws that restrict bodily autonomy, whether it is access to gender-affirming care or abortion, leave people vulnerable to a set of threats from state authorities that very much include demands for digital data.

Dellinger fears that laws that criminalize access to health care disincentivize people from seeking the care they need because they feel they can’t trust their doctor or that their medical records will be seized. Dellinger also said, “Once criminalization comes into play, privacy risks grow.” In their letter, the 19 state attorneys general argue that HIPAA recognizes that “privacy interests must be balanced against the ‘public interest in using identifiable health information for vital public and private purposes.’” 

Despite Tennessee Attorney General Skrmetti’s assertion that the VUMC patients’ records will be held in the “strictest” confidence, it is unclear how long that data will be held by authorities and whether it will continue to hold the data even after its investigation is complete. For now, though, Tennessee has taken another step in the legislative war that it appears to be waging against healthcare for trans people.

The decision this month by the Sixth Circuit Court of Appeals is the first time a federal court has overturned a block on the banning of gender-affirming treatment. Courts have unanimously blocked such bans, points out the American Civil Liberties Union, in Arkansas, Florida, Indiana, Alabama and Kentucky. In a statement, the ACLU’s Tennessee chapter described the court’s decision as a “heartbreaking development for thousands of transgender youth, their doctors, and their families.”

Since 2015, reported the Washington Post, “Tennessee has enacted at least 14 laws that restrict LGBTQ rights — the most in the nation in that time frame.” On June 22, a federal judge dismissed a lawsuit filed by a group of trans women from Tennessee who wanted the right to change the designated sex on their birth certificates. 

“It’s hard to exist as a transgender person in Tennessee at this moment,” said Jaime Combs, one of the plaintiffs. And now the state is asking the trans people whose rights it seeks to restrict to trust it with their data.

The post Why trans people can’t trust Tennessee with their data appeared first on Coda Story.

At barely 16, Milo is the proud holder of a Florida learner’s permit, a state-issued driving permit. He has just finished 10th grade. His favorite class is journalism. He enjoys roller skating with friends. Milo is also transgender.

He glances in the rearview mirror as we drive away from Common Ground Books, Tallahassee's only LGBTQ and feminist bookstore. The family, whose names we’ve changed to protect their privacy, bought half a dozen books to help pass the time on an upcoming road trip, most of them science and historical fiction.

The city is small. In less than 10 minutes, we pull into an empty parking lot next to a complex of sports fields and tennis courts that belong to Milo’s high school. The grounds are quiet — summer break has just begun. He points to an empty red running track on the perimeter of a football field, down the hill from the main school building. 

“That one dude, who’s doing everything wrong, is like right there.” He’s talking about Florida Governor Ron DeSantis, who lives just five minutes away. DeSantis often runs the track early in the morning while his security detail waits nearby.

In a few days’ time, Milo and his family will load up their car and say goodbye to Tallahassee, Florida, the only place their family has ever called home. They will begin the aforementioned road trip: a 1,200-mile journey to Connecticut, where they are hoping to build a new life, far away from the scorched-earth anti-trans laws that have become a hallmark of the DeSantis administration.

Milo is one of an estimated 16,000 transgender teenagers in the state who have become prime targets of DeSantis’ campaign to ensure, in his words, that Florida becomes a place “where woke goes to die.” Along with restricting access to gender-affirming healthcare for transgender people, his administration has placed legal limits on what can be taught in schools, which books can stay on the shelves of public libraries and which bathrooms people can use.

The American Academy of Pediatrics has urged legislators to protect young transgender people’s ability to receive “comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space.” The American Medical Association has written that gender-affirming care is medically necessary and that it can “improve the physical and mental health of transgender and gender-diverse people.” But Florida’s legislature still approved Senate Bill 254, a law that prohibits healthcare providers from administering gender-affirming care to anyone who receives health insurance through Medicaid, and for all people under 18, except for those who had already started treatment before the law was enacted. The policy went into effect in May 2023.

After the families of three transgender teens took the state to court, a federal judge issued an injunction that blocked the law from affecting the plaintiffs in the case beginning on June 6, 2023. While the case has yet to be decided, the judge wrote that Florida’s law likely runs afoul of constitutional protections against identity-based discrimination. 

But for now, state officials say the law remains in effect for everyone but the plaintiffs, and uncertainty prevails. Healthcare providers are unsure of what treatments they can offer. The fear of losing medical licenses or even facing felony charges has led clinics to turn transgender patients away. Some have shut down altogether, leaving young transgender Floridians with nowhere to turn. For many, the costs of seeking care out-of-state are simply too prohibitive. Milo is one of the lucky ones.

“I am just flying under the radar. I know other trans people at school who didn't transition as early as I did,” Milo told me when we met last month in Tallahassee. “I consider myself incredibly lucky to have the parents and the health care that I do.” 

Milo came out as transgender when he was still in elementary school. Having supportive parents who were able to work together with his doctors made a huge difference, he told me.

Milo’s doctor became a critical figure in their lives. “He really helped us a lot,” his mother Beverly said. “He was one of the only people I found here in town that would adhere to the time frame that we wanted in terms of medical intervention.”

With careful guidance from his doctor, Milo began taking testosterone when he was 13. Since Florida’s law has an exception for those already receiving gender-affirming care, it doesn't affect Milo directly, at least for now. But with some providers declining to serve transgender patients and others discontinuing their practices altogether, his parents worried that Milo’s ability to get adequate healthcare could still be in jeopardy.

For Milo’s family, an early sign of trouble came in June 2022, when Florida Surgeon General Joseph Ladapo wrote a letter to the state medical board arguing that there was a lack of medical evidence showing that gender-affirming treatments could be beneficial for young people grappling with gender dysphoria. Ladapo insisted that the leading medical guidance from organizations including the American Academy of Pediatrics followed a “preferred political ideology instead of the highest level of generally accepted medical science.”

“We didn't see a course forward that would allow us to keep our promise,” said Beverly, Milo's mom. “When we started this whole journey, we said, ‘We will do whatever it takes for you.’ We didn't feel that was any longer going to be possible in Florida.”

Legal actions targeting education also put the family on notice. Milo recalled a moment when his younger sister came home in the middle of the semester with a note from her biology teacher, explaining that students would no longer be required to read “The Immortal Life of Henrietta Lacks.” This award-winning study on racist policies and practices in medical research in the U.S. became optional after Florida began vetting all school curricula and library books to ensure they’re free of pornography and “race-based teachings.”

Soon after, DeSantis signed an expansion of the Parental Rights in Education Bill, the so-called ‘Don't Say Gay’ law, which prevents teachers from discussing ideas related to gender and sexual identity at any grade level. The law is set to go into effect this summer. Another law, also passed before the close of this year’s legislative session, will prohibit trans people from using public bathrooms consistent with their gender identity.

Senate Bill 254 was born out of a recommendation issued by the state's medical board that had similar parameters — it advised doctors to deny minors access to puberty-blocking medications or hormones. The recommendation was an unusual move for the medical board, a group of state-appointed experts that has traditionally overseen the administration of licensing for physicians in the state and periodically issued recommendations to healthcare providers on public health-related issues, like the Covid-19 pandemic. The board has gone so far as to call itself “vociferously apolitical.” But an investigation by the Tampa Bay Times revealed that Governor DeSantis handpicked eight of the 14 board members, all of whom donated money to his gubernatorial campaign.

WUSF Public Media’s Health News Florida revealed that members of the American College of Pediatricians — an innocuous-sounding organization that the Southern Poverty Law Center has designated as a hate group — were paid tens of thousands of dollars by the DeSantis administration to provide “expert” reports, witness testimony and talking points discrediting the science behind gender-affirming care.

The medical board recommendation process constituted a unique route to banning gender-affirming care. Instead of starting out at the legislative level, DeSantis took advantage of the supermajority within his state to push his agenda through the executive branch. He then went on to codify the medical board recommendations with Senate Bill 254, officially banning gender-affirming care for minors and for anyone receiving health insurance through Medicaid.

The Republican supermajority in the Florida legislature, and at various levels of state and local government, has been in place for decades. Milo’s dad said it is wearing down people who are advocating for the rights of trans people. 

“It looks like an intentional undoing of democracy when they're not listening to their constituents,” he told me. He wonders if the next election will bring more people out to vote and elect people willing to engage with public testimony rather than toeing the party line.

“DeSantis, more than anything, has really taken advantage of gubernatorial power that no one has in the past,” said Charles Barrilleaux, a political science professor at Florida State University. For him, the governor's power shifted in the 1990s under Jeb Bush’s administration. And with the help of redistricting, Republicans gained more substantial control in local government. 

When you combine a supermajority with a politically ambitious governor, the voices of those who don't agree with the government get drowned out. “Political competition matters, and when you don't have competition because of districting, you don't have representation of your own ideas,” said Barrilleaux.

State Senator Shevrin Jones has spoken out against the abundance of anti-LGBTQ legislation pushed through in Florida this year. As a Democrat, Jones is a minority in Florida’s Senate and has voted against adopting the gender-affirming care ban. In a January 2023 NPR interview, he said, “Florida is just the testing ground, but people across the country should be concerned that legislatures and governors across the country are going to do exactly what Florida is doing.”

For Milo’s mom, the onslaught of legislation further solidified the family’s decision to leave the state.

“You think to yourself, ‘Do I really need to uproot my whole family? Did I need to put my kids through all of this? Do we really need to change jobs to get new insurance? Did we really need to sell our house? Do we really need to spend all our savings on a new house? Is it really necessary?’” she said. “And then, something new happens every day, so I'm so glad we're moving.”

The possibility of these kinds of laws spreading across the country was not lost on Milo’s family. When it came time to decide where to move, they struggled. Hostile legislation was constantly popping up around the country, especially in states with predominantly Republican legislatures. They started looking north. Maryland was safe but surrounded by less-certain places. California felt too far away. Other states looked like they were hanging in the balance, one election away from tipping toward transphobic policies. Eventually, they decided on Connecticut, where they also had some family. They chose a house in a quiet suburb, near the home of Milo’s cousins.

Milo and his parents talked to me about the immense privilege they had in being able to move their family. The move depended on job flexibility and on the sheer financial capital required to uproot and resettle in a more expensive state.

While I was in Tallahassee, I met others whose lives and families were directly affected by the law but who were not in a position to leave. Fenix Moon, a trans man and a visual artist, originally from Orlando, was one of them.

“I do want to go, but I can’t right now,” he told me. “Right now I’m on a one-year lease. I'm just getting stable from the pandemic exactly three years ago,” he said, alluding to financial burdens.

He told me his brother had begged him to leave Florida, fearful of what the legislation would mean for Moon’s health. What would make it possible for him to go?

“If I could wave a magic wand, if I had all the money, I'd probably go to New York,” he said. “I feel like that community would protect me,” he said. 

Moon sees leaving Florida as a powerful political choice too. “We shouldn't sacrifice our health and our bodies, when in reality, the greatest pushback would be to relocate, if that is the case, and be stronger, and fight from wherever we are, right where we have the most strength,” Moon said. 

When people decide to leave a city, they take social and economic capital with them. “We're losing a lot of talent, we're losing a lot of people who contributed a lot to their local communities. We're losing people in all kinds of fields,” said Melinda Stanwood, who teaches government classes at the Tallahassee Community College. 

Stanwood has two trans children. Her son, who is in his twenties, had to scramble to find a new doctor after his long-time provider at a Tallahassee Planned Parenthood clinic stopped serving transgender patients earlier this year. For now, both children plan to stay in Florida. But Stanwood is worried for them and has been vocal on the issue. “That strength that you have in the community, the diversity of support is being eroded gradually,” she said.

It's hard to know exactly how many families are leaving, but Rick Minor, a Leon County commissioner, suspects that the numbers are rising.

“I do think it’s gonna have an impact in terms of bringing new businesses into the state that are looking for markets that are diverse and thriving,” Minor said.

He believes that Tallahassee can be an attractive place for businesses because it is home to several universities with diverse populations and lots of young people. But he says that’s not enough to convince businesses to come: “The types of communities like the one we have here in Tallahassee also exist in other states that don't have these policies being passed.”

When I asked Milo what he'll miss most when he leaves, he talked about his friends. 

“I have a whole group of friends that I didn't have last year. Last year, I was a freshman, so I was still building everything,” said Milo. “Now, I'm a sophomore, so I have stuff already put in place, and I don't want to leave that.”

“It's hard to see that as a parent and to know that you're changing those friendships that could have been richer if you had stayed. But we can't continue here,” Beverly told me. “Friendships won't be enough for what he needs.”

Milo’s school itself holds a lot of traditions for the family. His mother and grandmother are alumni. From where he sits in his math class, if he looks out the window, he can even see the building where his parents got married.

But the school also sits just a 15-minute walk from the state capitol and the governor's mansion. DeSantis’ physical proximity to their community is “kind of crazy,” Milo told me.

“If Florida wasn't being Florida, then I would stay here for sure,” Milo said. “But Connecticut is going to be safer ultimately.”

At school, Milo has never told his classmates or teachers that he is transgender. But during the past semester, Milo slowly started coming out to more friends. “I want to be honest with them because I've known them for a while, and I don't want to have to lie to them about why I'm moving because I care about them,” he said.

His parents tread even more carefully. “In some cases, I said, we have to leave Florida. It's a family issue. And I left it at that,” Phil told me. But, when it comes to their family and others familiar with Milo and his trans identity, Phil found that he didn't have to explain much.

“I just said, I'm leaving Florida, and universally the response from everyone was, ‘I don't blame you.’ Every single person said the exact same thing,” Phil said.

Toward the end of the school year, with moving day looming, Milo wanted to enjoy his last days doing what he loves best. Going skating, hanging out in parks and walking around Railroad Square, the city’s small, mural-covered arts district. When I asked what he was looking forward to about the move, he talked about his hope for getting more involved in the school community at his new school. 

“My focus is just like finding a social group,” Milo said. “As far as school, I have always had pretty good grades. But I just want to find a good friend group and join the newspaper at my new school.”

In spite of all that the past year has brought, Milo is optimistic about what the future holds for him.

“There will be new places, new people, and a new culture. I'm curious about up north, apprehensive and excited,” he told me. “I’m not going to stop being me if I move, right?”

The post Fleeing Florida appeared first on Coda Story.

Policymakers who pushed for the law say it will help protect kids from mental health issues and other risks that can arise from viewing certain kinds of material online. But what counts as “harmful,” exactly? The law is aimed at pornography, but it extends to virtually any commercial website with content that does not have “literary, artistic, political or scientific” value for minors and that makes up more than a third of all material on that site. With the law now in effect this month, anyone in Utah can sue violators if a minor accesses content on their website. Nonprofit-run sites, search engines and news-gathering organizations are exempt from liability.

Utah passed another law earlier this year to regulate minors’ access to social media platforms, which requires teens to get parental consent to use the platforms and prohibits them from using such platforms between 10:30 p.m. and 6:30 a.m. Research has shown that social media can be harmful to the mental health of young people. But age verification and time curfews might not be the best solutions to the problems that lawmakers have trained their focus on.

Heidi Tandy, a lawyer and First Amendment speech researcher, says it’s worrying that policymakers don’t consider kids’ rights. “It's very clear that there is a sliding scale of First Amendment rights for those under the age of 18,” Tandy told me.

On Twitter, Electronic Frontier Foundation researcher Jason Kelley pointed out that while politicians tend to frame these laws as protection for children, they apply to everyone under the age of 18. He warned against “lumping in 10 year olds with seventeen year olds who can work, apply for emancipation, and drive.” Older teens are much more likely to seek out sexual content online — and have legitimate reasons to do so — than kids who are just nine or 10 years old.

Kelley suggested that the Utah law might end up pushing well past pornography to cover things like sexual education materials or fiction that includes sexual themes.

“The goal is often not just to remove or block what most of us would consider adult content, but go beyond that,” he told me. Kelley says advocates have “a certain reasonable fear that larger swaths of sites would be swept up in the law.”

“You've seen that, with definitions of what’s considered pornography or adult content in places like Florida, they're removing books from libraries,” Kelley said, referring to recent legislation targeting books that are considered “sexually explicit” or that deal with gender identity, sexuality and related subjects.

Experts and adult film industry voices have also noted that these restrictions could send teens toward more obscure sites that parents or policymakers might not be aware of. This is a key argument that Pornhub makes, the Canada-based adult content site that consistently ranks among the most popular websites in the world. Earlier this month, Pornhub blocked access to videos on its site for all users based in Utah to show its opposition to the law. People in Utah who tried accessing the site were instead redirected to a video featuring adult film actress Cherie DeVille explaining the company’s objections to the law. Among other things, she noted that it could lead teens to sites with no protections against videos depicting things like sexual violence or child abuse.

There’s good reason to believe that rules like the one in Utah will soon spread to much of the U.S. The state of Louisiana was the first ever to implement this type of age verification law. A raft of similarly-worded age verification bills, what Kelley calls “copycat laws,” have been introduced in six states so far this year. All of these policies ostensibly require websites to introduce technical mechanisms for checking a user’s age before they can access that site’s content. Although the Louisiana law provides special guidance on this, Utah hasn’t established a standard for how sites should digitally verify a user’s age.

How should websites card their users, exactly? Utah recently implemented a pilot project for making driver’s licenses accessible on a mobile device that comes with an annual subscription cost. A digital ID works in tandem with a state's motor vehicle administration, so it can be considered a valid form of identification for buying alcohol or other age-restricted products.

Louisiana, meanwhile, requires sites to use “commercial age verification systems.” And there’s a burgeoning industry waiting to serve sites in states with these requirements. Third-party services like FaceTec and Yoti offer biometrics-driven age verification software that websites can pay for, but this software can be costly to buy and maintain, making it difficult for small businesses to comply with the law.

All of the solutions on the table thus far raise significant concerns about the privacy of young people’s data. As Coda has reported in the past, using biometrics to verify someone’s identity or assess their age often requires sites to hold troves of personal data that can become vulnerable to breaches or even targeted abuse, harming users in the near term or for years ahead.

“People who want age verification laws have the best interest of teenagers at heart,” Tandy told me. But, she said, “I don't think they're thinking through the privacy ramifications of what they're asking for.”

The post Utah’s online porn law puts teens’ digital rights at risk appeared first on Coda Story.

In the U.S., one special breed of telehealth companies tends to focus on “wellness” issues common among people in their 20s and 30s: Companies like Cerebral, Hims & Hers, Keeps and Mindbloom offer a quick path to prescription medications for anxiety, depression, sexual health and skin-related issues. They also tend to feature a sleek, Instagram-friendly aesthetic.

Hims, launched in 2017, uses the tagline: “Telehealth for a healthy, handsome you.” For years, I’d noticed ads for Hers, its sister brand, dotting my social media feeds and featuring on the walls of subway cars. I finally visited the Hers website and found a banner stretched across the homepage: “Anxiety treatment, no insurance required. START YOUR FREE ASSESSMENT,” it read. Curious to learn more, I clicked on the link.

After a short intake assessment, the platform told me to wait for a provider evaluation that would also take place entirely online. If prescribed, the medication would be delivered to my door, as soon as possible. In the meantime, I could browse the site to see what kinds of drugs they prescribe. Brand names like Lexapro, Wellbutrin and Zoloft float across the sections for medication featuring the website’s calming, sage-green color palette. The site also sells health and sex-adjacent products like melatonin gummies (to help you “get the sleep of your dreams”) and USB-rechargeable vibrators (because “life’s too short for boring sex”). The familiar shopping cart icon in the upper right corner of the site reinforced the idea that I was here to buy something, not to seek a professional medical consultation.

It felt almost too easy. I didn’t see it through — I see a regular doctor at a regular brick-and-mortar clinic. But it left me wondering how other people might understand — or misunderstand — what the service really offers. Hims & Hers and companies like it often adopt the language of telehealth that we see coming from established healthcare providers, a practice that might give consumers the impression that the company has their best interests at heart. But these companies aren’t regulated in the same way that traditional healthcare providers are. And they are out to make money. In the first half of 2021 alone, venture capitalists invested nearly $15 billion into digital health companies.

In the eyes of Dr. Adrianne Fugh-Berman, a pharmacology researcher at Georgetown University, “there's real telehealth and there's fake telehealth.” Real telehealth, she explained, was an asset during the worst periods of the pandemic. And for years, it has helped people with limited mobility, or those who live in far-flung places, get access to specialist clinicians who tend to work in big city hospitals.

But then there are fake telehealth outfits, which Fugh-Berman described as “companies who are really just bypassing clinicians to provide drugs to patients.” 

“There's a prescriber involved,” she said, and that clinician does provide some level of safety. But she cautioned that they ultimately answer to the telehealth company, not to a traditional medical institution. “Their job is to prescribe you drugs,” said Fugh-Berman. If they deny a lot of people drugs, “they are not going to keep that job.” 

In traditional healthcare, patients typically see a primary care provider who can recommend treatment, medication or otherwise, with their full health status and history in mind. Although traditional healthcare institutions have been caught bending to the interests of big pharma — a major factor in the U.S. opioid crisis — there are regulatory measures in place to prevent this. New-fangled telehealth companies do not have the same guardrails.

Fugh-Berman runs Georgetown's PharmedOut program, a project to help educate healthcare professionals on pharmaceutical marketing practices. According to PharmedOut's resources, companies that use direct-to-consumer advertising are not subject to FDA regulations if they provide “disease awareness,” even though these sorts of campaigns can “lead to the overuse of marginally effective or potentially dangerous drugs for minor conditions.” PharmedOut warns that this practice can harm public health, especially as more companies rely on social media ads to get in front of potential customers.

Although it’s rare, plenty of the antidepressants that these companies prescribe can cause serotonin syndrome, a serious and potentially fatal response. The anxiety drug propranolol, described by Hims & Hers as a medication that can help you ace “a public speaking engagement, interview, or audition,” can trigger asthma attacks for people with the disease. Last year, Bloomberg investigated the telehealth company Cerebral, which focuses on mental health treatment, and found that patients were prescribed medications that led to complications and even death from overdoses. In short, the actual health risks that these companies might present for consumers are real.

Then there’s the matter of the telehealth companies’ business model. Alongside payments for the services they provide, companies like Hims & Hers also collect a good deal of customer data. We all know what it’s like to be asked to consent to the terms of service of data privacy agreements. They’re incredibly long, written in legalese and impossible to negotiate with. If you want the service, you select “I agree” and hope for the best.

The mere fact that these companies deal with people’s health data might make customers think that it will be covered by HIPAA, the U.S. federal law that requires healthcare and insurance providers to protect sensitive health information from being disclosed without patient consent. But just because you’re sharing your health data does not mean it’s protected. In fact, Hims & Hers’ privacy policy mentions that it is not a “covered entity” under HIPAA. This suggests that the company is collecting demographic data and medical information, as well as images and messages, all on behalf of the diagnosing providers and with no guarantee of privacy protection under U.S. law. We asked Hims & Hers for more information about their business and how they handle customer data but did not receive a response prior to publication.

What happens to your data after it is collected? Researchers have shown that it can be bought and sold by third-party data brokers. Last year, The Markup reported that private information about the medications prescribed through telehealth services (Hims & Hers was among those they tested) had been shared with Big Tech companies like Meta, Google and Snapchat. This data is often used to improve ad-targeting and prompt customers to purchase even more products or services based on their browsing habits. But it could be used or abused in other ways, too.

The lack of HIPAA oversight over some telehealth companies is a concern for Keith Porcaro, who researches law and technology at Duke University. He explained that these kinds of companies can get around privacy protections that traditional healthcare companies would otherwise be subject to and said that regulations need to catch up with the market.

“Companies like this are changing people's expectations about healthcare,” he said. “There's an assumption, especially if you talk to doctors, that there's sort of one model of getting care: You go to your doctor and rely on doctors for everything. Putting doctor shortages aside, there’s a lot of evidence that says that most people take care of most of their health problems on their own,” Porcaro told me.

Bypassing traditional healthcare routes in favor of for-profit, start-up companies may be making consumers more vulnerable to medical misinformation. Influenced by a growing self-care movement that has popularized the idea that “you know your situation best,” consumers increasingly turn to these companies. 

Porcaro puts some of this on people’s legitimate “mistrust of the medical establishment,” based on their negative experiences with traditional healthcare. In a 2022 Pew research study on race and disparities in healthcare, more than 70% of Black female respondents between the ages of 18 and 49 said that they had had a negative experience with healthcare providers, ranging from pain they reported not being taken seriously to being treated with less respect than other patients. The same report found that most Black Americans were skeptical of “medical researchers when it comes to issues of openness and accountability” and suspected that misconduct in medical research remains just as likely to happen today as in the past. Long-standing stigma may drive prospective patients to seek alternative routes to healthcare. But people looking for quick solutions might be willing to accept help from just about anyone. 

“People who are going to services like this, especially mental health or addiction treatment, are vulnerable,” Porcaro said. And they’re not just vulnerable to misinformation, he said, “they're vulnerable to actual harm.”

The convenience and branding of telehealth start-ups may have plenty of appeal for Gen Zers and people with legitimate reservations about the medical establishment. But they come with some serious trade-offs that could affect your health data — and your health itself.

CORRECTION [05/15/2023 11:08 AM EDT]: The original version of this story said Duke University lawyer and technologist Keith Porcaro. Keith Porcaro researches law and technology at Duke University.

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"Everybody is in a kind of chaos right now,” said Joseph Knoll, a nurse practitioner and the CEO of Spektrum Health, a community-based health center located in central Florida that specializes in medical and mental health services for the LGBTQ community and beyond. He told me that the new rules leave healthcare professionals who provide this care “feeling helpless.”

Doctors and other practitioners who violate the ban could lose their medical license and be hit with hefty fines. Many are even considering leaving the state, given the uncertainty of future restrictions on their practice. Part of the dismay comes from feeling that the deck has been unfairly stacked. Local news outlets have reported that Florida Governor Ron DeSantis appointed all the members of the “vociferously apolitical” Board of Medicine, several of whom made contributions to his campaign totaling $80,000. DeSantis is reportedly considering running for president in 2024 and gender-affirming care is an issue that many conservative lawmakers have been pushing across the country.

Florida is now one of 10 or more states that have passed similar legislation. In Utah, the state passed a law at the beginning of the year to ban any healthcare professional from providing any gender-affirming treatments to minors or face a felony charge. In February, South Dakota passed a similar law for minors in which medical professionals providing such treatments stood to lose their licenses. Georgia followed in March. And just days ago, West Virginia enacted a ban on gender-affirming therapies, though it made exceptions for teenagers considered to be at risk for self-harm or suicide. 

Florida, unlike the other states, initially chose not to take a legislative route, instead moving ahead via state medical boards. A bill, though, is currently making its way through the Florida House of Representatives to codify the ban on gender-affirming care. This bill also includes a ban on changing the sex as recorded on a birth certificate, prohibits health insurance providers from covering any treatments related to youth transitioning and prohibits organizations that provide transition-related healthcare to minors from receiving public funds. 

Already, this has led to clinics shutting down preemptively. Outlets reported that the Johns Hopkins All Children Hospital in St. Petersburg and Nicklaus Children's Hospital in Miami, among others, stopped accepting new patients into programs that provided hormones or puberty blockers well before the law went into effect. The fear of prosecution leaves few providers still offering these services.

With clinics closing and the high potential consequences for providing care, medical professionals are increasingly forced to choose between staying in an environment that makes it challenging to provide the necessary medical care to their patients or leaving to continue practicing elsewhere. 

"Our primary service line is gender affirming treatment,” Knoll, the Spektrum Health CEO, told me, “but we're a community healthcare clinic that does primary care as well." He says he is now faced with the choice of abandoning all patients because his clinic’s survival is at stake. “Gender affirming treatment represents somewhere between 50% and 60% of our services,” he said. “Obviously, our biggest concern is the care of people that need to access our services, but we have to be realistic. We don't have room in our budget to have half of our revenue gone."

He told me he’s heard of colleagues who are taking the option to leave Florida. The consideration weighs heavily for his transgender staff members. "For them to stay in the state of Florida,” Knoll said, “they have to accept the lack of access to health care while working at a healthcare organization. I mean, it's nonsense." 

Nurse practitioners like Knoll play an essential role in this equation. They can prescribe medication, promote disease prevention and diagnose common ailments, often providing this care directly in clinical settings. In 2020, Florida passed a law that grants nurse practitioners full authority to autonomously practice primary care. Losing these healthcare professionals drastically affects the communities they serve. 

Vernon Langford, the president of the Florida Association of Nurse Practitioners, wrote in an email that the state has "a bad shortage of healthcare professionals now and it is not getting better anytime soon.” It’s hard to know exactly how many medical professionals are leaving and what their exact reasons are for doing so, but a 2021 report for the Florida Hospital Association estimates that the state will face a shortage of nearly 6,000 primary care physicians by 2035. The lack of physicians makes it difficult for all patients seeking care in Florida, especially those in rural areas. Additionally, more care providers will be needed as the population increases and ages. A state facing significant shortages in care needs to be able to attract and retain talent. 

The new rules are not helping. Langford said Florida needed to remove barriers to accessing care, not create additional hurdles. "The culture wars have seeped into healthcare,” he said, which introduces more restrictions for the work of nurse practitioners. There has been an increase, he added, “in the desire to relocate to states that have more favorable practice environments.” 

As bans and restrictions on gender-affirming spread around the country, perhaps the only option left for patients who need this care is to file legal challenges. Four anonymous transgender minors sued the state this month, arguing that the medical bans “violate the Equal Protection Clause of the Fourteenth Amendment” and should, as unconstitutional legislation, be thrown out. “It is,” Langford told me, “a very sad thing to see when vulnerable populations are being targeted."

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In many places, meteorologists on the local news are local celebrities, seen as trusted interpreters of the data provided by the National Weather Service, friendly personalities and loyal community boosters. Even in today’s sharply divided, partisan America, they are not usually seen as divisive figures.

No longer.

A vocal opposition has formed against TV weather forecasters and the science of meteorology.

Former political candidates have conjured claims that last October’s devastating Hurricane Ian was engineered by the "Deep State" to destroy Republican governor Ron DeSantis' reputation. Many in Florida’s Tampa region prepared for the landfall of Hurricane Ian, which, models had predicted, would hit their area. But storm path models rapidly evolved in the run-up to the hurricane, sparking spurious allegations from two Republican candidates: DeAnna Lorraine, who ran for election to the U.S. House in 2020, and Lauren Witzke, who campaigned for a U.S. Senate seat in Delaware. They claimed that the hurricane was, in fact, a political instrument targeting opponents of vaccine mandates and anti-transgender legislation — baseless and absurd claims that gained currency on social media, especially among some Republican supporters.

Weather manipulation conspiracies have been around for decades. One of the most durable has been the chemtrails theory, which holds that the U.S. government manipulates the weather for nefarious reasons by releasing chemicals into the atmosphere from aircraft. Chemtrail conspiracists often mistake the trails of water vapor expelled by airplanes flying overhead for chemicals.

This conspiracy has been re-upped many times in recent years, especially during moments of uncertainty or social panic, such as during the outbreak of the Covid-19 pandemic. Chemtrail conspiracists often share the same messaging as other conspiracy theorists, like adherents of the “Great Replacement Theory.” Researchers have estimated that between 30% and 40% of Americans believe in elements of the chemtrails conspiracy.  

Adverse weather events like the latest catastrophic hurricane, heatwave or winter storm energize conspiracists. Many cite local weather to bolster their claims of climate change denial. 

"Weather is your mood, the climate is your personality. It's easy to conflate the two, if you don't understand the difference," said Dennis Mersereau, a weather journalist in Reidsville, North Carolina. "It's hard for folks to separate daily weather from long-term climate patterns, especially now that we're feeling the effects of climate change's influence on extreme weather."

Weaponizing weather has made meteorologists a target, and not only in the United States. 

Meteorologists in Sweden had faced backlash ahead of the country’s general elections last year because of a "misleading image" that falsely claimed to show proof of "climate hysteria." Screengrabs of weather forecasts are being manipulated to show weather patterns and temperatures that allegedly prove that climate change is not real. 

In Hungary, two meteorologists were fired over forecasts, ultimately inaccurate, that put a damper on patriotic celebrations, part of the government’s general crackdown on media in the country. 

In response, meteorologists have felt the need to get political themselves. A German meteorologist has centered climate change in his weather reports to counter growing climate change denial. “TV meteorologists, unlike news reporters, can demonstrate this connection in a way that's far more immediate and accessible," he told Politico Europe.

As climate change transforms coastlines, consumes forests and upends hundreds of millions of lives, it follows that the local weather report has become a cultural and political warzone. Added to their predictions of precipitation and reporting on snowfall measurements, meteorologists have begun to develop a televised discourse on climate change in an effort to combat climate misinformation. 

"Meteorologists are the most visible scientists in our daily lives. They're on television every day, and their forecasts are omnipresent whenever you hop online. That visibility makes them an easy target for someone looking to vent their rage," said Mersereau, the weather journalist.

And because climate change denialism has been linked to other forms of online extremism, meteorologists have a unique role in being able to bring familiar credibility to combat misinformation for a local audience. 

"Once you believe that even nature itself is under the control of a shadowy cabal, it gets easier to see how someone falls into the really dangerous stuff," said Mersereau.

"We've done a lot of work with TV meteorologists on understanding their audience," said Bernadette Placky, the chief meteorologist at Climate Central. "People's views on climate change do tend to be more aligned with politics than they do with science and education."

Climate Central provides resources for meteorologists to help educate their local audiences on matters of climate change. They collaborate with meteorologists abroad since these issues can also be transnational. 

It wasn’t that long ago that the majority of meteorologists had trouble believing in the human causes of climate change. In a research paper published in 2017, surveys of TV weathercasters suggested that “weathercasters’ views of climate change may be rapidly evolving.” The paper found that “in contrast to prior surveys, which found many weathercasters who were unconvinced of climate change, newer results show that approximately 80% of weathercasters are convinced of human-caused climate change. A majority of weathercasters now indicate that climate change has altered the weather in their media markets over the past 50 years, and many feel there have also been harmful impacts to water resources, agriculture, transportation resources, and human health.”

American audiences have also continued to shift, according to reports from the Climate Change Communication program at the Yale School of the Environment. The number of people who are “alarmed” by climate change is increasing, while those grouped as “dismissive” have trended downward. 

The challenge for meteorologists is to tease out the distinctions between everyday weather and long-term climate patterns, while still preparing their audience for the next extreme weather event. The outlook looks cloudy, with a strong possibility of storms ahead.

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The fallout from the war in Ukraine

This year, we have been tracking how propaganda around this war has been weaponized in Europe and around the world, particularly in Africa. In our weekly newsletter Disinfo Matters, we’ve stayed on the story of Russian wartime disinformation, such as the Kremlin’s use of social media to spread its narratives. We have also highlighted how Ukrainians have turned to photography and music, among other things, to mourn the Russian invasion, to express defiance and to point toward a brighter future. A major development has been the extensive, even unprecedented, use of technology like killer robots and drones in a war otherwise characterized by grinding, wearying ground battles in which heavily outnumbered Ukrainian forces have managed to force Russia to retreat from some occupied territories. While the story of the Russian invasion has been one of boots on the ground, including Russia calling up its reserves, an extraordinary and dystopic subplot is how this war, as one of our writers noted, is “serving as a testing ground for cutting edge, but unproven, technology.” Sign up here for the newsletter we are launching in 2023 that will be entirely dedicated to covering the global fallout from the war in Ukraine.  

Rewriting history

2022 has been marked by governments and regimes around the world seeking to influence, inflect and even entirely rewrite their national histories. Some of this has taken the form of quite literally rewriting school textbooks to reflect political trends and ideologies. One of our Big Ideas dove deep into revisionist agendas in Poland, Spain, the Channel Islands, Northern Ireland and Lithuania. In each of these places, uncomfortable questions are being asked about national identity. 

How, for instance, should Poland reflect on its wartime history? A right-wing government is using the country’s National Institute of Remembrance to spin a nationalist narrative about Polish heroism in the face of Nazi atrocities. It embraces and promotes a vision of Polish resistance, of ethnic Poles helping the country’s Jewish community, while refusing to countenance a serious conversation on Polish collaboration in Nazi crimes. Collaboration is also a taboo topic of conversation in Alderney, one of the Channel Islands occupied by the Nazis where they built concentration camps. Nazi crimes on British soil have been buried far into the recesses of the national memory but, some historians argue, it’s time to revive those memories. 

A simmering, resentful silence continues to hold in parts of Northern Ireland over the Troubles, decades after the Good Friday Agreement. Is it possible to simply draw a line under the violence without also finding a way for people to be told the truth, to grieve together and to move forward without burying the past? This is a question that echoes in Spain's Valley of the Fallen, where a national pact of forgetting has failed to erase the cataclysmic violence of the Spanish Civil War. People still want answers, even as others claim answers are no longer possible or too politicized. Meanwhile, the politicization of medieval symbols has created rifts between Lithuanians and Belarusians, as each nation clings to versions of its distant history as guides to present-day national identities.  

Cross-border repression 

Governments reaching across borders to harass and persecute their own citizens, whether digitally or physically, is an increasingly prevalent phenomenon that scholars label transnational repression. Some of the worst offenders include China, Turkey, Saudi Arabia and Iran. We have written about the few Uyghur journalists and translators who are able to tell their stories about the harassment they have suffered in Xinjiang. Surveillance tactics and censorship have made it difficult for members of the Uyghur diaspora to speak out against the atrocities of the Chinese authorities both within and outside China’s borders. Just months ago, the FBI indicted men it said had been helping Chinese authorities to execute a campaign to force political dissidents living in the United States to return to China. So alarmed are some members of Congress that they have introduced a new bill to jail those convicted of helping authoritarian regimes to attack dissidents based in the U.S. for up to 10 years. While this would be a significant deterrent and a recognition of the threat certain regimes pose to their own citizens abroad, questions remain about enforcement and sincerity when the United States’ close political relationships with countries such as Saudi Arabia come under pressure. This is a theme that Coda will devote much of its energy to reporting on as 2023 unfolds. 

Climate denial and pseudohealth

The ongoing Russian aggression in Ukraine and the resulting energy crisis are contributing hugely to climate anxieties, as European countries desperate for alternative energy relationships ignore their commitments to combating climate change by signing deals to exploit natural gas resources in Africa. Shifts to sustainable forms of transportation in the U.K. have stirred up virulent online debates over environmental policies. Shortages of medicines at the center of TikTok trends, such as diabetes pills touted as miracle weight loss aids, are affecting patients who are struggling to access their regular medication. Meanwhile in India, the government’s ideological priorities mean that it is pushing Ayurvedic medicines that have been insufficiently tested as a “natural” homegrown alternative to Western science. In the United States, radical anti-trans actions have been a focus of Coda’s coverage, including bomb threats to children's hospitals. Legislation passed in states like Florida have underscored attempts to push harmful rhetoric on transgender issues, rather than paying attention to experts or, indeed, trans people. 

The age of nostalgia

Our latest Big Idea series takes on our “infatuation with a mythologized history.” The series ranges widely. In Cambodia, the Vietnamese, rather than the Khmer Rouge who ruled Cambodia at the time, are blamed for the genocide of nearly two million people. In California, grieving the losses wrought by climate change revives the term “solastalgia” — the desolation felt by those who see their homes ripped away before their eyes. In Hungary, a right-wing government rejects the Europeanization of Hungary in favor of tracing its roots to a glorious, imperial Turkic past. And in Kuwait, the globalization of the 1990s was a way of life, rather than a trendy academic term, until the Iraqis invaded and forced Kuwaitis and expats alike to wrestle with questions of identity and home. Nostalgia for an imagined past, a somehow superior past, has contributed significantly to what we might also describe as an age of anger, a period in which countries around the world have become increasingly fractious and divided. Nostalgia has distorted the way in which we look at ourselves — our history and our present. It is a theme that threads through and connects many of the issues we cover at Coda and will continue to cover over the next year.

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Alberta was the site of many of the mass protests over the summer: “Freedom Convoys” stretched over parts of southern Alberta along the border with the United States, blockaded cross-border commerce and occupied the streets of Canada’s capital, Ottawa. Hundreds of truckers traveled from across the country to protest vaccine mandates in front of the parliament building. To many in Canada, the protests highlighted the cultural and ideological differences between the western prairie provinces and the more populated, urban provinces in Canada’s east. 

The Freedom Convoy that shut down the border with the U.S. was full of people from Alberta. The blockades lasted for several weeks as the anti-government protests challenged vaccine mandates and other Covid safety restrictions. Those who joined the demonstrations frequently slipped into extremist far-right narratives and promoted conspiracy theories. 

Conspiracy theorists have latched on to spreading scientific misinformation. Doubts about vaccine efficacy are commonly circulated through social media, and potential Covid cures like ivermectin, which scientific research does not support, are promoted. Agence France-Presse's fact-checking bureau found a fire hose of false claims online suggesting that more vaccinated people were hospitalized in Canada than those who were unvaccinated — a claim unsupported by data from Health Canada.

In this still-simmering political cauldron, the new premier of Alberta’s government announced that people unvaccinated against Covid confront the most discrimination in the state.

Shortly after taking office last month, Danielle Smith declared at her first press conference that unvaccinated people are the state’s most vulnerable, having already come up with a plan to amend the Alberta Human Rights Act to codify protections for those who allegedly have been discriminated against for being unvaccinated against Covid. (She ultimately backtracked when leaders from groups experiencing discrimination protested her remarks.)

The new premier, the equivalent of a state governor, has previously come under fire for sharing unproven claims about the virus on Twitter during the early days of the pandemic. Smith became the leader of the Wildrose party in 2009. The party is unique to Alberta with a platform that has sought to revamp healthcare delivery with more privatized options and reign in provincial spending, hoping to appeal to populist voters. Her previous position as a radio talk show host allowed her to broadcast views that promoted pseudoscience and cures for Covid frequently touted by former President Donald Trump.

Overall, Canada consistently ranks as having one of the most highly educated populations in the world. Nationally, support for vaccines is high. But while 88% of the Canadian population has received at least one dose, Alberta has the lowest number of doses administered per 100,000 people to date compared to the other prairie provinces.

Alberta is well known for its “western alienation” — a kind of jilted, strained relationship with other parts of Canada. A feeling of limited representation in the federal government and an economic reliance on natural resources has yielded a sense of apartness from the rest of Canada.

This apartness is rooted in Alberta’s history. In the 19th century, many Americans heading west settled in the vast Canadian province, bringing with them a strident individualism and deeply entrenched political populism, rejecting government reach into private lives. The number of Americans arriving in Alberta, mainly from the rural American Midwest, quickly outpaced British settlers and even native-born Canadians.

Whether due to the stress of the pandemic, opportunism from populist politicians or the forces still at work from its settler colonial history, Alberta’s apartness now may be intensifying. 

Doctors in Alberta have warned that it is becoming more common for patients to refuse blood transfusions from Covid-vaccinated donors, and they worry that this could develop into the next form of widespread protest. Timothy Caulfield, a professor in the Faculty of Law and School of Public Health at the University of Alberta, believes this trend is driven by misinformation, which is causing patients to refuse to consent to blood transfusions if the blood comes from a donor who had received the Covid vaccine. 

Damaging myths surrounding blood purity cost countless human lives during the 20th century, and centering Covid vaccine opposition around the transfusion of blood would be a remarkable new chapter for the vaccine hesitancy movement. 

In the 20th century, a fear of contaminated blood was a vehicle for anti-Black racism. The false notion that drops of blood could contain racial purity was a widespread belief in the U.S. and swaths of Europe. The Canadian Red Cross oversaw the blood donation process for five decades, from the mid-1940s to the late 1990s. The program, originating in wartime, had a history of racially segregating blood for American and British white soldiers. 

Fear of blood contamination has historically impacted marginalized communities. Earlier this year, after three decades, Canada removed the ban on donated blood from men who have sex with men. The ban came out of longstanding concerns about HIV transmission in the donated blood supply following the HIV/AIDS crisis of the 1980s. It was slowly dialed back as testing requirements became more comprehensive and donation supply demands increased.

Dr. Nathan Lachowsky, a public health professor at the University of Victoria, cited “a variety of screening questions that have excluded specific groups from blood donation, including men who have sex with men, certain Black African communities, people who inject drugs, and sex workers.” He believes that while the screening questions have evolved, “rarely has there been acknowledgment or apology for ways in which the blood system has propagated stigma and discrimination against these groups."

The general public has questioned the integrity of Canada's blood donation system in the past. A scandal in the 1990s led to thousands acquiring HIV and hepatitis C through blood transfusions, which prompted investigations into the system. Subsequently, a nonprofit health organization, Canadian Blood Services, took over the processing of blood donations with stringent health protocols. 

"This system failure led to a national inquiry and the current blood donation system we have today in Canada,” said Dr. Lachowsky, which created a sense of distrust. 

Nevertheless, Canada’s public healthcare system, which shielded the country from outsized effects of contracting Covid and minimized vaccine hesitancy, should also minimize an outbreak of fear over “contaminated” vaccinated blood, said Dr. Davinder Sidhu, a transfusion specialist physician from the University of Calgary.

"Based on the Canadian universal healthcare model, there is just a presumption [that] the system will be here to take care of people if they get sick. The fear of significant financial pressures and costs don't exist like in the U.S. medical healthcare model. And so, people may be more cavalier with their health," said Dr. Sidhu. 

According to Dr. Sidhu, the requests for directed donations from unvaccinated donor groups is particularly surprising because Canada is known for its safe blood system. "Directed donations are more common in parts of the world where the blood supply is less well tested or deemed dangerous due to other circulating transfusion-transmitted diseases," he said.

A spokesperson for the Canadian Blood Services said in a statement: "Our ultimate priority is the health of the patient. Health Canada has not recommended or imposed any restriction on the use of the approved Covid-19 vaccines and blood donation. This is because the blood of donors who have received non-live vaccines does not pose a risk to patients who receive a blood transfusion."

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Last month, the website Dall:E (named after the Spanish artist Dali, and the Pixar character Wall-E, from the eponymous 2008 movie), announced that users were creating over two million AI generated images per day. The site added that it had fine-tuned its filters to reject violent or sexual content or other images that violate its policies.

But given the ease of access and increased sophistication of text-image generators, many experts predict that it won’t be long before the technology becomes yet another weapon in the arsenal of those looking to spread disinformation and propaganda. The technology already raises serious questions about copyright and the commercial use of artificially generated images.

Getty Images, for instance, unlike some of its competitors, banned the sale of AI generated illustrations on its site in September because of uncertainty around the legality of such images, while also announcing a partnership with a site that uses similar technology to enable the substantial and creative editing of existing images. The difference being emphasized here is that between image generation and image editing, even if the effect of the editing is to create an entirely different image.

In a recently released report, Democracy Reporting International observed that this “combination of a text model and a synthetic image creator raises the prospect that we will see a shift in disinformation strategies, moving from manipulation of existing content to the creation of new realities.” For the researchers the application of AI technology goes “beyond the manipulation of existing media” to the “production of fully synthetic content… eventually allowing for the quick and easy generation of fake visual evidence as a direct complement to false (news) narratives.”

Another significant concern, say critics, is that the AI technology will continue to reproduce stereotypes and biases that already exist within our society as it pulls from existing images online when it generates pictorial responses to textual commands. This would make it easier for those who want to create visual “evidence” to display alongside falsified narratives targeting marginalized communities.

Democracy Reporting International does offer recommendations on how to prepare for and respond to the growing mass of AI-created content. It argues that widespread digital literacy is essential if people are to recognize false narratives and disinformation. The researchers also suggest prebunking, that is being proactive in countering falsified images and text, rather than to merely react. 

I spoke with Beatriz Almeida Saab, co-author of the report, about the threat text-image generators represent and how best to mitigate potential damage. This conversation has been edited for length and clarity. 

While preparing the report, what came up unexpectedly for you in your research?

The threat is not the technology itself, but the access to this technology. Because the technology to manipulate media has always been there, it's just a matter of how easy and fast you can do this. Plus, we've seen that people believe in much less sophisticated manners of manipulation. Our whole point is that it will get to the point where malicious actors will have easy access to this and it will be effortless. This kind of technology is open access meaning it's available for everybody. There's no regulation in place, meaning that if we are not discussing it at a policy level, how will we be prepared to see the consequences?

What would be your nightmare scenario with text-to-image generation?

A malicious actor creates a false headline, builds a story around it, and uses artificial intelligence (AI), specifically text-to-image generation models, to create an image that perfectly supports their false narrative, manufacturing realistic fake evidence. Consequently, this false narrative is harder to verify and debunk, so people will not change their minds as a shred of fake evidence supports the story, and there is no room for questioning an image. 

How does text-to-image generation differ from “deep fakes” that already exist? 

Deep fakes are typically used as an umbrella description of all forms of audio-visual manipulation — video, audio, or both. They are highly sophisticated manipulations using AI-driven technology, enabling those aiming to spread disinformation to make it seem that someone said or did something that they did not or that an event took place that never actually occurred. The main difference between deep fakes and text-prompt generated images is that deep fakes refer to sophisticated manipulations of existing audio-visual content. Text-to-image creation is novel as it moves from manipulating pre-existing media to the entire generation of new media, to the creation of an image that reflects the desired reality. 

Who is most directly impacted by the implementation of this technology? What responsibility do people on the frontlines of this new tech have?

On one level, everyone is impacted. The way we consume information, images, and everything online will change. We need to learn how to discern what is true from what is false online, which is very hard. A researcher we interviewed for the report pointed out that your brain will already process information just by consuming it, whether it's true or not. Your subconscious will process it, and it will stay with you. It also impacts what we call provenance technology stakeholders, who can detect media authenticity. So it impacts the way you debunk. It affects the way you fact check. It involves all these stakeholders because creating fake evidence to support a false narrative is very serious. 

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A feature of the hearing has been Trump’s apparent willingness to knowingly spread falsehoods and misinformation on social media, fomenting anger and unrest among his supporters. In a taped interview played before the investigating committee at the second hearing, Richard Donoghue, former Acting Attorney General in the last weeks of the Trump administration, said, “this gets back to the point that there were so many of these allegations that when you gave him a very direct answer on one of them, he wouldn't fight us on it, but he would move on to another allegation.” These other allegations, according to Donoghue, included such conspiracy theory fodder as “dead people are voting,” or “Indians are getting paid to vote.” Trump meant, Donoghue clarified, “people on Native American reservations.” 

The hearing offers detailed evidence of the lingering half-life of misinformation, no matter how many times the lies are debunked. I spoke with Jared Holt, a social media and extremist activities researcher and fellow at Atlantic Council, about how conspiracy theorists are responding to the latest hearing on the Capitol Hill riots investigation on social media. This conversation has been edited for length and clarity.

Has surprising misinformation popped up on social media among far-right groups you monitor as the hearings continue?

Much of what I've seen has been what I expected to see, including the re-litigating of conspiracy theories about the events of that day, such as claims that federal law enforcement set up or entrapped Trump supporters. A lot of what we're also seeing is smear campaigns of the witnesses testifying and committee members involved. There's lots of right-wing criticism of Liz Cheney specifically.

How might extremist use of social media continue to affect midterm elections?

I'm getting the impression that many of the Democrats' plans for midterm elections are to try first to make this assertion that the Republican Party is an insurrectionist party and link their candidates to January 6. Additionally, candidates and their supporters will find themselves in a position where they're continuing this seemingly never-ending attempt at revisionist history around the events of January 6, shifting away from the idea that it was an attack on the democratic process.

While the hearings look to uncover what led to the events of January 6, the Department of Justice is also trying to prosecute those who breached the Capitol. This includes members affiliated with the Proud Boys, a far-right group. Similar groups have recently disrupted Pride events in several states using social media to find their targets. Are they all part of the same conversation?

Groups like the Proud Boys, before January 6, were using social media to coordinate very openly. Now that many of their top guys have been busted by the police, it has changed a bit. For some groups, their online presence uses alternative social media platforms. Groups like the Patriot Front have been banned from the mainstream ones for quite some time. Their goal online is to try to project this intimidating image of themselves. The connecting line from the wake of January 6 and the arrests that have followed is the extra scrutiny they face operating on those mainstream tech platforms. Many of these groups underwent a series of adaptations meant to help them persist through those challenges to get over those roadblocks. For example, you're starting to see software picking up the methods that some of the harder groups have used to evade detection.

What are those ways that you're seeing that they're using to evade detection?

A method used is decentralization, which we've seen across the extremist movement since January 6. These groups are abandoning these national-scale hierarchies in favor of more autonomous state chapters and local chapters. Additionally, they've kind of decentralized targets of protest and targets of harassment. For example, it's not just all guns blazing on Washington D.C. instead, it's, you know, your Proud Boys chapter going out to health board meetings and intimidating the people on that board. These groups are also creating parallel systems on the internet for people to use, which I don't think will ever catch on. The mainstream social and marketing platforms are way too convenient.

What do people tend to get wrong when they think about extremist groups using these platforms?

The internet doesn't make extremism. Political extremism has existed since the early days of this country and will probably continue in some form or another. But the internet has been utilized to reach more people with less effort. They can do it very quickly, and if they are careful, they can do it anonymously. It's not just an internet problem but indicative of a certain amount of social disorder within the U.S. that is not being adequately addressed.

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An umbrella term has emerged to describe how governments are locating their citizens across national borders: “transnational repression.” In a recent example in the United States, as a federal indictment outlined, the government of Iran targeted Iranian-American journalist Masih Alinejad, coercing her relatives and using surveillance tactics to attempt to kidnap and transport her to a country that would cooperate with her extradition to Iran.

In another recent case, a U.S. citizen was arrested on charges of spying on Uyghur and Tibetan activists with the aim of silencing their criticism of the Chinese government. Transnational repression has been especially trained on Uyghurs and journalists.

Combating transnational repression is different from counterterrorism efforts, Isabel Linzer, a Freedom House analyst specializing in transnational repression, told me. “If we're able to raise more awareness among security officials who work on counterterrorism, who engage with refugees and asylum seekers, then maybe you can catch instances or risk of transnational repression before they occur.”

In a recently released report, Freedom House found that in more than half of the cases of transnational repression, accusations of terrorism or extremism were cited to justify state-sponsored attacks across borders, allowing the abuse of another country’s security procedures to carry out campaigns of harassment and intimidation. 

Freedom House urged democratic governments to end the impunity enjoyed by perpetrators such as China, Rwanda, Russia, Algeria, Belarus, and Nigeria, and limit their opportunities to target exiles. The question for national security experts is how. Rebekah Robinson discussed options with Javed Ali, an associate professor of practice from the Ford School of Public Policy at the University of Michigan, in a conversation that has been edited for length and clarity.

How in your work within counterterrorism and national security have you encountered instances of transnational repression? 

From a U.S. perspective, the number one actor on that list was the Iranian government. There have been times over the 40-year stretch when the Iranians have tried to launch terrorist attacks or assassinations against political opponents or dissidents. But the best example that caught a lot of people by surprise, and I was in government when it happened, was in 2011. The Iranians tried to basically sponsor an assassination attack against the Saudi ambassador in Washington. They didn't care; the attack would have happened in daylight in Washington, DC. There's been media reporting that the Iranian government has likewise thought about other similar types of attacks here in the United States. 

Many victims of transnational repression have been under surveillance and targeted by cyber attacks. When is this espionage? Should it be considered part of terrorism? 

When you look at the use of cyber tools to stalk, harass, bully, and collect intelligence, that wouldn't be, at least from a U.S. perspective, considered something that falls within the counterterrorism domain. But if foreign government intelligence services are using these cyber tools to go after dissident targets or opposition targets here in the United States, I would think that would fall amore in the counterintelligence world. And that is the question: what laws have been broken that could potentially build a case against one of these foreign intelligence actors or services? 

Are there ways that you can take these national security strategies to address these instances of transnational repression, or are they separate?

They're separate but related because you're trying to build an integrated strategy that brings all these different tools to limit their ability to conduct harm against us, either at home or abroad. When it comes to these kinds of operations in the U.S., we haven't seen the Chinese, the Russians, or the North Koreans try to engage in lethal assassination attacks. You're blending the counterintelligence world with cybersecurity, at times terrorism. Then you're trying to come up with a multi-tiered approach to limit these countries' ability to project their influence here in the United States. I think more of this is in the cyber world and less so in the physical world, although I don't think that's the case overseas; like, look at what the Russians have done in England twice.

Is there a deterrent that you think maybe deters Russia from carrying out these attacks on U.S. soil?

Well, I think deterrence might actually be lower now. All bets are off with Ukraine. So, I think we're in a somewhat unusual moment where the risk-taking calculus for Russia for lethal operations here might even be higher than it was in the past. We're in a different phase of conflict with Russia now. And, as things get more dire for Russia and Putin, they're not going to change the strategic balance, but they can send a message. 

Do you see that there might be a landscape shift to embolden repressive governments to take on lethal tactics in the U.S.?

I think the lethal part is still the lowest probability because it engenders the highest consequences. But the cyber world now makes it a more wide-open playing field for these repressive governments to go after targets here.

Are there policy deterrents?  

Yeah, there's a range of policy tools. You can use a naming and shaming sort of tactic. You can add more sanctions. You can do things on the diplomatic side and build pressure campaigns. With some governments, that may not really change their behavior, but you're trying to do the best you can. 

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