The N.B.A. Is Choosing Hoops Over Human Rights in Abu Dhabi

Todd Golden preached for Florida fans to let “due process” take its course before judging the allegations levied against him in a Title IX complaint.  The Gators men’s basketball coach was on the sideline for Monday’s 86-62 win over Grambling State, his first public appearance since The Independent Florida Alligator reported that the university was...

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The news came four years ago, at the end of a casual phone call. Bill’s family had always thought it was a freak coincidence that his father and grandfather both had ALS. But at the end of a catch-up, Bill’s brother revealed that he had a diagnosis too. The familial trend, it turned out, was linked to a genetic mutation. That meant Bill might also be at risk for the disease.An ALS specialist ordered Bill a DNA test. While he waited for results, he applied for long-term-care insurance. If he ever developed ALS, Bill told me, he wanted to ensure that the care he would need as his nerve cells died and muscles atrophied wouldn’t strain the family finances. When Bill found out he had the mutation, he shared the news with his insurance agent, who dealt him another blow: “I don’t expect you to be approved,” he remembers her saying.Bill doesn’t have ALS. He’s a healthy 60-year-old man who spends his weekends building his dream home by hand. A recent study of mutations like his suggests that his genetics increase his chances of developing ALS by about 25 percent, on average. Most ALS cases aren’t genetic at all. And yet, Bill felt like he was being treated as if he was already sick. (Bill asked to be identified by his first name only, because he hasn’t disclosed his situation to his employer and worried about facing blowback at work too.)What happened to Bill, and to dozens of other people whose experiences have been documented by disease advocates and on social media, is perfectly legal. Gaps in the United States’ genetic-nondiscrimination law mean that life, long-term-care, and disability insurers can obligate their customers to disclose genetic risk factors for disease and deny them coverage (or hike prices) based on the resulting information. It doesn’t matter whether those customers found out about their mutations from a doctor-ordered test or a 23andMe kit. For decades, researchers have feared that people might be targeted over their DNA, but they weren’t sure how often it was happening. Now at least a handful of Americans are experiencing what they argue is a form of discrimination. And as more people get their genomes sequenced—and researchers learn to glean even more information from the results—a growing number of people may find themselves similarly targeted.When scientists were mapping the immense complexity of the human genome around the turn of the 21st century, many thought that most diseases would eventually be traced to individual genes. Consequently, researchers worried that people might, for example, get fired because of their genetics; around the same time, a federal research lab was sued by its employees for conducting genetic tests for sickle-cell disease on prospective hires without their explicit consent. In 2008, the Genetic Information Nondiscrimination Act (GINA) was signed into law, ensuring that employers couldn’t decide to hire or fire you, and health insurers couldn’t decide whether to issue a policy, based on DNA. But lawmakers carved out a host of exceptions. Insurers offering life, long-term-care, or disability insurance could take DNA into account. Too many high-risk people in an insurance pool, they argued, could raise prices for everyone. Those exceptions are why an insurer was able to deny Bill a long-term-care policy.[Read: The loopholes in the law prohibiting genetic discrimination]Cases like Bill’s are exactly what critics of the consumer-genetic-testing industry feared when millions of people began spitting into test tubes. These cases have never been tallied up or well documented. But I found plenty of examples by canvassing disease-advocacy organizations and social-media communities for ALS, breast cancer, and Huntington’s disease. Lisa Schlager, the vice president of public policy at the hereditary-cancer advocacy group FORCE, told me she is collecting accounts of discrimination in life, long-term-care, and disability insurance to assess the extent of the problem; so far, she has about 40. A man Schlager connected me with, whose genetic condition, Lynch syndrome, increases the risk for several cancers, had his life-insurance premium increased and coverage decreased; several other providers denied him a policy altogether. Kelly Kashmer, a 42-year-old South Carolina resident, told me she was denied life insurance in 2013 after learning that she had a harmful version of the BRCA2 gene. One woman I found via Reddit told me she had never tested her own DNA, but showed me documents that demonstrate she was still denied policies—because, she said, her mom had a concerning gene. (Some of the people I spoke with, like Bill, requested not to be identified in order to protect their medical privacy.)Studies have shown that people seek out additional insurance when they have increased genetic odds of becoming ill or dying. “Life insurers carefully evaluate each applicant’s health, determining premiums and coverage based on life expectancy,” Jan Graeber, a senior health actuary for the American Council of Life Insurers, said in a statement. “This process ensures fairness for both current and future policyholders while supporting the company’s long-term financial stability.” But it also means people might avoid seeking out potentially lifesaving health information. Research has consistently found that concerns about discrimination are one of the most cited reasons that people avoid taking DNA tests.For some genetically linked diseases, such as ALS and Huntington’s disease, knowing you have a harmful mutation does not enable you to prevent the potential onset of disease. Sometimes, though, knowing about a mutation can decrease odds of severe illness or death. BRCA mutations, for example, give someone as much as an 85 percent chance of developing breast cancer, but evidence shows that testing women for the mutations has helped reduce the rate of cancer deaths by encouraging screenings and prophylactic surgeries that could catch or prevent disease. Kashmer told me that her first screening after she discovered her BRCA2 mutation revealed that she already had breast cancer; had she not sought a genetic test, she may have gotten a policy, but would have been a much worse bet for the insurer. She’s now been cancer-free for 11 years, but she said she hasn’t bothered to apply for a policy again.[Read: Remember that DNA you gave 23andMe?]Even employers, which must adhere to GINA, might soon be able to hire or fire based on certain genetic risk factors. Laura Hercher, a genetic counselor and director of research at the Sarah Lawrence College Human Genetics Program, told me that some researchers are now arguing that having two copies of the APOE4 mutation, which gives people about a 60 percent chance of developing Alzheimer’s, is equivalent to a Stage Zero of the disease. If having a gene is considered equivalent to a diagnosis, do GINA’s protections still apply? The Affordable Care Act prevents health insurers from discriminating based on preexisting conditions, but not employers and other types of insurers. (The ACA may change dramatically under the coming Trump presidency anyway.) And the Americans With Disabilities Act might not apply to the gray area between what might be viewed as an early manifestation of a disease and the stage when it’s considered a disability. FORCE and other advocacy groups—including the ALS Association and the Michael J. Fox Foundation—as well as members of the National Society of Genetic Counselors, are working in a few states to pass laws that close gaps left by GINA, as Florida did in 2020, but so far they have been mostly unsuccessful.Genetic testing has only just become common enough in the U.S. that insurers might bother asking about it, Hercher said. Recently, groups like Schlager’s have been hearing more and more anecdotes. “People are so worried about genetic discrimination that they are failing to sign up for research studies or declining medically recommended care because of the concerns of what could happen to their insurance,” Anya Prince, a professor at the University of Iowa College of Law, told me. Carolyn Applegate, a genetic counselor in Maryland, told me that when patients come to her worried about a hereditary disease, she typically advises them to line up all the extra coverage they might need first—then hand over their DNA to a lab.So far, these unintended consequences of genetic testing seem to be manifesting for people with risk for rare diseases linked to single genes, which, combined, affect about 6 percent of the global population, according to one estimate. But the leading killers—heart disease, diabetes, and the like—are influenced by a yet unknown number of genes, along with lifestyle and environmental factors, such as diet, stress, and air quality. Researchers have tried to make sense of this complex interplay of genes through polygenic risk scores, which use statistical modeling to predict that someone has, say, a slightly elevated chance of developing Alzeheimer’s. Many experts think these scores have limited predictive power, but “in the future, genetic tests will be even more predictive and even more helpful and even more out there,” Prince said. Already, if you look deep enough, almost everyone’s genome registers some risk.[Read: What happens when you’re convinced you have bad genes]In aggregate, such information can be valuable to companies, Nicholas Papageorge, a professor of economics at Johns Hopkins University, told me. Insurers want to sell policies at as high a price as possible while also reducing their exposure; knowing even a little bit more about someone’s odds of one day developing a debilitating or deadly disease might help one company win out over the competition. As long as the predictions embedded in polygenic risk scores come true at least a small percentage of the time, they could help insurers make more targeted decisions about who to cover and what to charge them. As we learn more about what genes mean for everyone’s health, insurance companies could use that information to dictate coverage for ever more people.Bill still doesn’t know whether he will ever develop ALS. The average age of onset is 40 to 60, but many people don’t show symptoms until well into their 70s. Without long-term-care insurance, Bill might not be able to afford full-time nursing care if he someday needs it. People who do develop ALS become unable to walk or talk or chew as the disease progresses. “Moving people to the bathroom, changing the sheets, changing the bedpans,” Bill said—“I dread the thought of burdening my wife with all of those things.”Cases like Bill’s could soon become more common. Because scientists’ understanding of the human genome is still evolving, no one can predict all of the potential consequences of decoding it. As more information is mined from the genome, interest in its secrets is sure to grow beyond risk-averse insurers. If consumer-facing DNA-testing companies such as 23andMe change their long-standing privacy policies, go bankrupt, or are sold to unscrupulous buyers, more companies could have access to individuals’ genetic risk profiles too. (23andMe told me that it does not share customer data with insurance companies and its CEO has said she is not currently open to third-party acquisition offers.) Papageorge told me he could imagine, say, scammers targeting people at risk for Alzheimer’s, just as they often target older people who may fall for a ploy out of confusion. All of us have glitches somewhere in our genome—the question is who will take advantage of that information.

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Americans are the No. 1 consumers of toilet paper in the world. | Javier Zayas Photography/Getty Images It’s a truism that everything’s bigger in America — just look at the cars and houses. But perhaps nowhere is the virtue of bigger is better more bizarrely apparent than how toilet paper is sold. Wander into the bathroom products aisle at the supermarket and you’ve entered a topsy-turvy world where numbers shape-shift. A pack of 18 mega toilet paper rolls, for example, magically transforms into 90 “regular” ones. The labeling emphasizes this greater number in large font, lest you foolishly think 18 simply equals 18. Another pack might insist that 12 even-thicker rolls of toilet paper are the equivalent of 96 normal rolls. The advertising is clear: You’re getting a lot of toilet paper. That should be good news, since if there’s one rule of thumb everyone should live by, it’s never run out of TP. We saw anxiety around this eventuality reach new heights in the early days of the pandemic, when crowds of people fought to snap up as much toilet paper as they could, leading to a shortage and extreme price gouging. Americans’ enormous vehicles and palatial abodes may in fact exist in service of conveying and storing gigantic bulk packs of this bathroom essential. There’s some irony, then, that for all the trumpeting of gargantuan sizes, toilet paper rolls are generally getting smaller. It’s a key example of the trend of manufacturers charging the same price (or even slightly more) for less product that’s been dubbed “shrinkflation.” It makes it more difficult than ever to figure out if you’re getting ripped off. None of the three major toilet paper manufacturers Vox reached out to responded to a request for comment. “I really can’t think of any other category that’s as confusing as toilet paper,” says Neil Saunders, managing director of retail at the consulting firm GlobalData. With dubious numerical claims about how much a “mega” roll is really worth, brands can promote the perception of value without actually having to show their work. Figuring out the price per toilet paper sheet is a hassle, but it would show how much more expensive the product has become. “The consumer wouldn’t like that, so they all keep it a bit opaque,” Saunders says. Get ready for some back-of-the-toilet-paper math The most glaring issue plaguing the toilet paper industry is a lack of standardization. Double, triple, and mega rolls are imprecise descriptors that vary by brand; they are not measurement units. In fine print, toilet paper packaging will often admit that these sizes are relative to the “regular” roll — sometimes they mean their own brand’s regular size, but other times, it’s against a competitor’s one-ply regular. Unsurprisingly, the so-called standard size has no consistency, either. Charmin’s regular roll has 55 two-ply sheets, for example, but it’s often hard to even find the regular size of a brand’s toilet paper in stores. The mega roll is often advertised as having four times as many sheets as the mythical “regular” it’s being compared to, which means that Cottonelle’s idea of a regular roll contains 61 sheets, Quilted Northern’s an awkward 73.75 sheets, and Angel Soft’s 80 sheets. But even these are perplexing figures since many real-life standard toilet paper rolls contain more than 100 sheets. The sheets-per-roll ratio is also subject to change depending on whether you’re looking at single-ply, two-ply, or three-ply. (Not to make your brain hurt more, but sheet dimensions vary too.) The mega roll is just one size out of many that brands offer, all with slightly different naming conventions. Cottonelle sells mega, family mega, or super mega, while Charmin now offers the mega-XXL and even the “forever roll,” which is so big you need a standalone holder. There appears to be no limit to the jumbofication of toilet paper jargon.  All this renders comparison shopping far more challenging than it is for the average household product. Making matters worse, there’s no single consistent method of unit pricing for toilet paper. Some retailers, like Walmart, Amazon, and Target, show the price per 100 sheets, but then you still have to factor in the variation in sheets per roll for each brand. Walgreens shows price per sheet, while Home Depot displays a pretty unhelpful price per roll. Irregular unit price labeling is a problem for many consumer products, according to Chuck Bell, programs director of advocacy at Consumer Reports. Unit pricing is “only mandated directly in nine states,” Bell says, while 10 others have voluntarily taken it up. “It’s hard to compare products online for value for money.” It’s no wonder people have taken matters into their own hands. In late 2018, a California man named Victor Ly launched a “Toilet Paper Value Calculator” that crunches the number of rolls, sheets per roll, and any discounts that apply. Ly told Wirecutter in 2022 that a good deal was probably around 0.253 cents per sheet. While there’s no longer a toilet paper shortage or people panic-buying pallets of them — though the impulse to do so lingers — it’s a much more expensive commodity today than before the pandemic, especially now that we’re a few years out from a period of high inflation. A report from consumer watchdog Public Interest Research Group noted that, before the pandemic, a pack of 36 Charmin Ultra Soft rolls cost $30.95 on Amazon. At time of writing, the same pack costs $59 on the site. (In December 2020, it was selling for as high as $114.99.) Most name-brand toilet paper today far exceeds Ly’s price threshold. A 30-pack of Charmin Ultra Strong mega rolls breaks down to 0.5 cents per sheet, though a 36-pack of Scott 1000 toilet paper is about 0.083 cents per sheet. Kirkland’s 30-pack of toilet paper, selling for $23.49 at time of writing, works out to 0.206 cents per sheet. The cost of making toilet paper may have gone up in recent years, according to the Los Angeles Times, due to a slowdown in lumber production (there’s less available wood pulp, which is what most toilet paper is made of). Combine that with the fact that, as journalist Will Oremus reported in a piece about the pandemic toilet paper shortage, more people are working remotely today, reducing the time spent in office bathrooms. It means that the average consumer is using more toilet paper at home, cringing at how much their budget for bathroom products has gone up.  Shrinkflation strikes – again Toilet paper manufacturers have come up with a way to keep prices roughly the same, though — at least at a quick glance. The same pack of toilet paper you buy every month might only be more expensive upon close scrutiny of the fine print, when you realize each roll is made up of fewer sheets. A recent analysis by loan marketplace LendingTree showed that toilet paper was among the top offenders among products whose size or volume had shrunk since 2019 or 2020. A pack of 12 mega rolls from Angel Soft went from 429 sheets per roll to 320 — essentially shrinking by a quarter — but at least the price went down by 15 percent too. Charmin Ultra Strong mega rolls, on the other hand, shrank by 15 percent while the price increased by 11 percent. This isn’t a new strategy that only toilet paper makers are employing. People have been complaining about product shrinkage for years; a Consumer Reports article from 2015 compared toilet paper rolls from top brands, showing that some had reduced by over 20 percent. The reason, manufacturers claimed at the time, was that better paper quality meant that people could use less of it. An older Charmin regular roll had 82 sheets versus just 55 today. Edgar Dworsky, a former consumer protection lawyer, has been tracking this shady practice — which he calls “downsizing” — for decades on his websites, MousePrint.org and ConsumerWorld.org. “I remember back in the 1960s when my Mounds candy bar used to be two ounces and became one point something or other,” he tells Vox. He notes that old Charmin toilet paper had as many as 650 sheets in a single-ply roll; its mega-XXL today has just 440 sheets. An older Charmin regular roll had 82 sheets versus just 55 today. The playbook is to shrink the current roll size, then invent a new tier (with a more ridiculous name) that can be priced higher. Consumer brands “are in the business of making you think you’re getting more,” Dworsky says. “It’s all a name game, it’s all a numbers game, and if you’re just oblivious to it, you’re going to get snookered.” How to avoid flushing money down the toilet Toilet paper is marketed both as a value product, where you’re getting four rolls for the price of one, and a weirdly indulgent luxury at the same time. It’s something meant to be quickly disposed of, literally flushed away, yet commercials for toilet paper are almost always focusing on its delightful, cushiony softness or a special “quilted” or “diamond weave” texture that adds a premium feel to the product. There’s scented toilet paper, and even toilet paper with colorful patterns. One of Quilted Northern’s April Fool’s Day ads pokes fun at the excessive promotional style of its own industry, proclaiming a “return” to hand-crafted, artisanal toilet paper. Ultimately, this is because we spend so much time with it, and in such an intimate way, so such bells and whistles do matter to some of us. “There’s obviously some people [who], for medical reasons, like to have really soft toilet paper,” Saunders says. “Some people just like extra strong toilet paper.” For others, it’s a pure bang-for-buck play, where they might just gravitate toward the pack with the most rolls (which isn’t necessarily the best value).  The range of options, from one-ply sparseness to lilac-scented plushness, isn’t the problem. It’s that it’s so hard to disentangle the value you’re actually getting. As Dworsky notes, consumers could bring a scale to weigh packs of toilet paper every time they go to the store, but then what can you do about it? You still have to buy one of the #ShrinkFlated options, and it’s not an area where we’re spoiled for choice. While there are plenty of different versions that a single brand offers, just three manufacturers — Procter & Gamble, Kimberly-Clark, and Georgia-Pacific — make up some 80 percent of the bathroom tissue market. One could switch to commercial-grade toilet paper, which is much cheaper but is of (ahem) crappier quality. Where consumer toilet paper is soft, perhaps infused with lotion, often embossed with a delightful little pattern, the stuff we see in public restrooms is stiff and so thin that it breaks apart if you so much as look at it. Still, a 12-pack of commercial toilet paper at Home Depot is about $34 at time of writing, and one roll is about 700 feet long. Assuming that a square of consumer-grade toilet paper is about 4 inches long, a 440-sheet Charmin mega-XXL roll would still be under 147 feet.  Lawmakers and President Joe Biden have wagged their fingers at corporations for shrinkflation and have even introduced a bill attempting to ban the practice, though neither Dworsky nor Bell thinks it’s likely to become law. But more transparency around product sizes, more consistent unit price labels, or even requiring a consumer notice when there’s a change in size would go a long way to help shoppers. Last year, in the lead-up to price negotiations with suppliers, French grocery chain Carrefour started attaching labels next to packaged foods and drinks that had gotten smaller.  What’s certain is that the deceptive, confusing accounting of toilet paper rolls shouldn’t be the norm — and, in fact, it appears to be mostly a North American tradition. While other countries do also sell “mega” rolls, there’s no fiddly math on the packaging insisting that a dozen rolls are somehow more than that. Toilet paper is no small matter, especially for Americans. Per capita, the US is the No. 1 consumer of it in the world, each American using about 141 rolls per year as of 2018. A Consumer Reports buying guide once compared the annual usage to the length of 23 football fields. One way to avoid the frustrating morass of counting rolls and sheets is to opt out of the game altogether. “I switched to a bidet 10 years ago,” Dworsky says.

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Private investigator Steve Ridge believes the mysterious disappearance of Iowa news anchor Jodi Huisentruit was a crime of "jealousy" and "passion."

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Welcome to the golden age of STI prevention. Sure, condoms are still an effective strategy for lowering the risk of sexually transmitted infections (STIs) — but now, they’re just one of a smorgasbord of strategies for decreasing your chances of catching an infection spread by sex.  That includes vaccines to lower your risk of certain STIs, and medications you can take to prevent infection — some with the ease of a morning-after pill, and many that can be mailed to your home after an online telehealth visit. It also includes new STI tests that people can take in their homes, with results available either instantly or within days to enable quick and discreet testing and treatment. In a world where getting sexual health care sometimes feels fraught with judgment, these new methods offer a level of discretion and convenience that feels nothing short of revolutionary. In-person care is still best for getting the most comprehensive and personalized evaluation and education, and we’ve got guidance on how to find that kind of care here. But even sexual health care clinicians recognize it’s annoying — or worse — to go to the doctor sometimes.  “Inconvenience — whether it’s cost, or travel, or parking, or taking off work, or other competing demands — is probably a big factor in why people aren’t necessarily engaged in … sexual health care that they might otherwise benefit from,” says Douglas Krakower, an infectious disease doctor and HIV prevention researcher at Harvard Medical School. Stigma — that shameful sense that people who know you have an STI look down on you, whether real or imagined — also sometimes prevents people from getting high-quality sexual health care in person.  The bottom line: People often prefer sexual health care that involves as few other humans as possible. Now, there are more ways to get that than ever. Not everyone gets to benefit equally from these advances. Some come with hefty out-of-pocket price tags or are still out of reach for pregnant or likely-to-be-pregnant people. Still, the changes represent a leap forward in an area of health care that needs as much help as it can get. Here’s what’s out there. You can greatly reduce your risk of HIV, syphilis, gonorrhea, chlamydia, and more  STIs include a range of bacteria and viruses that cause unpleasant genital symptoms, threaten your ability to have pleasurable sex, and may endanger your ability to have healthy children. Barrier protections like internal and external condoms are still the best (and usually cheapest) way to protect yourself from STIs.  However, if you anticipate having sex without condoms, there are now lots of other ways to prevent STIs. Vaccines have come a long way and several can prevent STIs, including HPV (a cause of genital warts and cervical cancer), mpox, and hepatitis A and B. Recent studies also suggest being vaccinated against meningitis can offer some gonorrhea protection, especially among gay men and the people they have sex with. There are also pills and injectable medications that can greatly reduce the risk a sexual partner will infect you with HIV, syphilis, gonorrhea, or chlamydia. HIV prevention is available in a few forms: as a daily oral or every-two-months injectable medication you take before sex (called PrEP, for pre-exposure prophylaxis), or as a month-long regimen of oral medicines you take immediately after sex. The latter option, called PEP, for post-exposure prophylaxis, has to be started within 72 hours of exposure to be effective. Both options work by entering the body’s cells and preventing HIV from replicating inside them. A smorgasbord of new STI prevention options PrEP, a daily oral or every-two-months injectable HIV-prevention medication you take before sex PEP, a month-long course of oral HIV-prevention medication you take after sex DoxyPEP, a morning-after pill to prevent syphilis, gonorrhea, and chlamydia infections Home-based testing for chlamydia and gonorrhea, syphilis, HIV, and other STIs (click here for free resources; some direct-to-consumer options are listed here) Vaccines for HPV, mpox, hepatitis A and B  There’s even more progress to come in this area: An every-six-months injectable drug for preventing HIV infection called lenacapavir has shown huge promise in preventing HIV infections in both women and trans and nonbinary people and could be available for US use as soon as late 2025. Krakower says an oral option isn’t far behind. Syphilis has been rising explosively in the US for the past few years, affecting gay men and the people they have sex with as well as heterosexual men and women, especially those whose sexual partners include sex workers and people who inject drugs. The trend has huge stakes: Women can spread syphilis to their pregnancies, leading to serious illness or death in their newborns.  Earlier this year, the Centers for Disease Control and Prevention released guidelines for using doxyPEP, a morning-after pill to prevent syphilis infection. This breakthrough strategy involves taking the antibiotic doxycycline the morning after sex — and because this medication also fights other germs, doxyPEP also reduces gonorrhea and chlamydia transmission. The problem is that doxycycline’s effects on pregnancy are unclear, but there’s suspicion they’re not good. Many clinicians are therefore hesitant to prescribe it to younger patients in their care. Still, because congenital syphilis has become such a dire national emergency, scientists are seeking ways doxyPEP can protect pregnant people and their fetuses. One focus is getting more men who have sex with men and women to use doxyPEP; another approach may involve prescribing the drug to women at high risk of syphilis infection. In a Japanese study of female sex workers, this strategy led to plummeting syphilis and chlamydia rates. You can get at-home testing for a range of STIs  It used to be that if you’d had unprotected sex with a new partner or had unusual genital symptoms — like painful urination, funky discharge, or skin changes like a bump, ulcer, or rash — you’d have to jump through a lot of hoops to figure out whether you had an STI. You would start by visiting a clinic or emergency room; getting your parts swabbed by a clinician (or peeing in a cup or getting blood drawn); waiting for a lab to process those results; waiting for the doctor’s office to communicate those results to you; going back to the clinic for medicine or picking it up at a pharmacy; and then potentially going back again to be retested once treatment was done.  Now, a variety of new testing options allows clinics to get test results within hours for a range of STIs. Once these get adopted broadly by clinics and emergency rooms, it’ll be a lot easier for people to get testing and treatment all in the space of one health care visit. Hopefully, that will lower the number of people who get diagnosed with an STI but never get treated for it. Another huge step forward: New tests now enable people to do most or all of the STI testing and treatment process at home, online, or through the mail — without a doctor or another clinician having to get involved. “Agency is what home testing gets people,” says Yuka Manabe, an infectious disease doctor at Johns Hopkins School of Medicine who leads the home-based HIV and STI testing program, I Want the Kit.  The FDA has only approved a handful of these tests, and they’re not perfect. For example, the only FDA-approved test that screens for chlamydia and gonorrhea with home-based sample collection is the Simple 2 test —  it’s only approved to test samples from penises and vaginas. That means the test can’t be used to diagnose throat and rectal infections, which are more common in men exposed through oral or anal sex with other men. So while the Simple 2 is a great choice for people who engage only in heterosexual sex, it leaves out gay men and people they have sex with.  Another important innovation is the First to Know Syphilis Test, which can detect within minutes syphilis-fighting antibodies in blood samples collected at home with a simple skin prick. The FDA approved the test in August. However, it has a catch: The test doesn’t distinguish between new syphilis infections and old, already-treated infections. That means people who’ve had syphilis before can’t use the test to rule out a new infection. It’s worth noting that home-use HIV tests have been FDA-approved for more than a decade, although they also require follow-up testing for positive results. Just because these tests are FDA-approved doesn’t guarantee they are covered by insurance; you can check with your insurer to find out what it will cost you. If it’s not covered, it’s worth checking to see if you live in a part of the country where free HIV, gonorrhea and chlamydia, or trichomonas test kits are available (the American Sexual Health Association lists free HIV and STI home test kit resources).   Most of this testing would be free or low-cost if you got it in person, says Elizabeth Finley, the senior director of communications and programs at the National Coalition of STD Directors. “There’s some equity implications” in the reality that higher-income people can afford to pay out of pocket for the convenience of home-based testing, while lower-income people often cannot, she says. Choosing a test is just the beginning An array of companies have created home-based STI tests that haven’t yet been approved by the FDA, including ones for hepatitis B and C, which are often overlooked. Non-approval doesn’t mean a test is garbage — it just makes it harder to be certain that it’s effective at doing what you want it to do. “There are no real guardrails for the companies in terms of the quality they have to offer to customers,” Finley says. “The tests have to work, but I’m not sure customers are fully informed about, if they see a test available on social media, ‘Is this a good one? Is this a bad one?’” The appeal of these tests is strong for people who hate having someone else get their genital sample. Many of them have you pee in a cup, pinprick your own finger and blot blood on a card, or swab a range of body parts at home (including your vagina or penis, your butt, or your throat), then mail that sample to a lab that runs the usual tests on it, which can be retrieved in an online portal.  Home testing kits also often make an end-run around the process of getting to a brick-and-mortar clinic to figure out next steps or pick up medication. Many use a telehealth platform to connect people who test positive for an STI with clinicians, who can provide counseling, suggest ways to get partners tested, and mail some medications directly to patients.  Curing many STIs requires one or more antibiotic injections, and experts sometimes recommend additional evaluation after a diagnosis. Both of these scenarios require an in-person visit with a clinician. If you test positive for one of these STIs, your test company’s telehealth provider should direct you to a clinic where you can see an in-person clinician. Giving people the option of self-directed sexual health care isn’t just good for people’s sense of autonomy — it’s also a sensible response to impending health worker shortages. Out of concern for an inadequate global supply of clinicians, the World Health Organization has recently recommended a range of self-care interventions for people all over the world, among them many of the latest innovations in STI self-sampling and testing.  It’s about time, Manabe says: “We’re not trusting the public enough.”

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