Editor's Note: There’s no denying a small percentage of hospitalized Covid patients experience complications — sometimes quite severe — following their recovery. But the mystery of “long Covid,” as defined in terms of huge fractions of the population that were never hospitalized experiencing persistent “debilitating” symptoms with no known basis in medical reality poses many interesting questions. With men experiencing markedly higher rates of severe Covid symptoms and Covid morbidity, why has the phenomena of “long Covid” impacted nearly twice as many women? Why does the phenomena of “long Covid” far more greatly impact people with a history of anxiety? And why, among the LGBTQ, do gay men and lesbians experience the phenomena of “long Covid” roughly on par with their straight counterparts, while the rates among bisexuals are nearly twice as high?

A fascinating Sunday morning mystery. River Page explores.

-Solana

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In the Spring of 2021, it seemed like the pandemic was about to end. Some people didn't want it to — we saw them online and in grocery stores, glaring at the unmasked behind their N95s, and the press wrote stories about them. A few months later, in July, "long Covid" was added as a recognized condition that could result in a disability under the Americans with Disabilities Act. For Covid long haulers, the pandemic never ended and never will. They constitute an emerging protected class, and one with few barriers to entry. 

The CDC's own webpage for healthcare providers on the subject makes this clear: "Objective laboratory or imaging findings should not be used as the only measure or assessment of a patient's well-being; normal laboratory or imaging findings do not invalidate the existence, severity, or importance of a patient's post-COVID symptoms or conditions." Many long Covid symptoms are invisible, vague and subjective. For example, fatigue, mood changes and "brain fog." These symptoms are lumped in with the rarer physical, and objectively observable respiratory conditions suffered by some patients after infection. Almost nothing is required to receive a diagnosis, not even proof that one was previously infected with Covid, according to the CDC: 

A positive SARS-CoV-2 viral test (i.e., nucleic acid amplification test (NAAT) or antigen test) or serologic (antibody) test can help assess for current or previous infection; however, these laboratory tests are not required to establish a diagnosis of post-COVID conditions. SARS-CoV-2 RT-PCR and antigen testing are not 100% sensitive. Further, testing capacity was limited early in the pandemic so some infected and recovered persons had no opportunity to obtain laboratory confirmation of SARS-CoV-2 infection. Finally, some patients who develop post-COVID conditions were asymptomatic with their acute infection and would not have had a reason to be tested.

While it's true that no test is 100 percent accurate, research indicates that antibody tests administered three weeks after the onset of symptoms are accurate 88 to 93 percent of the time. The use of such tests was the basis of this French study of over 26,000 people, which found that "persistent physical symptoms after COVID-19 infection may be associated more with the belief in having been infected with SARS-CoV-2 than with having laboratory-confirmed COVID-19 infection." In other words, people have "long Covid" because they think they do. This study serves as a damning retort to the CDC's guidance, which essentially advocates for doctors to acquiesce to a patient's self-diagnosis regardless of any observable information which might contradict it. This position rests behind a barely concealed ideological pretext. According to disability activist Jessica Baker:

“Hypochondriac" has become the new "hysteria" in dismissing oftentimes disabled women when they bring up legitimate concerns. The hypochondriac stereotype creates frustrating and life-threatening experiences for disabled people. Disabled people tend to have extensive knowledge about their medical conditions, such as what treatments they need and what tests are required in order to treat their condition. When they have to argue over their diagnoses in order to get proper treatment, as doctors think they are exhibiting hypochondriac tendencies due to this extensive knowledge, this delay holds the potential for life-altering consequences and even death.

Although there are undoubtedly specific situations where patient self-education and self-advocacy are essential — when dealing with rare diseases, for example — the truth is, some people are actually predisposed toward hypochondria. The initial, society-wide panic over Covid, and subsequent headlines like "You Might Have Long Covid and Not Even Know It," have created a perfect storm for hypochondriacs, a fact the medical establishment is remiss to talk about for fear of seeming dismissive. For those actually experiencing debilitating effects as a result of Covid, a number which is certainly less than the 15 percent of the population the CDC currently estimates, this "believe all patients" approach will likely do for them what "believe all women" did for rape victims: nothing at best and active harm at worst.

But the CDC's ideological approach to long Covid doesn't end with its promotion of physician credulity. If the pandemic never ended for the perpetually tired and "brain-fogged," the Summer of Floyd never ended for the CDC. Speaking to the racial demographics of long Covid, the CDC talks out of both sides of its mouth, saying that:

People who belong to racial and ethnic minority populations have experienced a higher burden of COVID-19—partly because of structural racism and longstanding disparities in social determinants of health—which has led to a higher incidence of post-COVID conditions in some of these same populations.

But also that:

...people from racial and ethnic minority groups are disproportionately affected by some chronic conditions that have characterized post-COVID conditions, new or worsening symptoms from these conditions might not be recognized as post-COVID conditions, leading to underestimation of post-COVID conditions prevalence in these populations.

Essentially, the CDC's line on long Covid is that it's somehow worse for racial minorities, whether they can prove it or not. For the record, they aren't proving it, at least through their own data, which shows that blacks and asians, as a percentage of all adults, experience lower rates of long Covid than whites, hispanics, and those from "Other/Multiple Races." That hispanics experience the highest rates is interesting, but one suspects that given the extreme heterogeneity of that group: racially, economically, and politically, they’re probably not the minorities the CDC is looking for. As a South Florida resident, I can assure you that many of the hispanics here are no less white, wealthy, or politically connected than the bands of resentful Yankee boomers marauding day-drunk around the strip malls, flip-flops slapping against the soles of their feet, exposed toenails chipped and yellow as the linoleum in the house up north they sold to a Chinese LLC, huffing and grunting as they buy handbags and scratch-offs and yappy little dogs until the day they finally get what they want, and their ungrateful children bury them on a credit card.

Whatever story the government wants to tell about long Covid and "systemic racism" — a word that people use when they want to discuss entrenched black poverty specifically, and the problems which spring from it — in America, it isn't supported by their own data; hence, I assume, the caveat about underestimation. Instead, the data show remarkable divergences along the lines of sex, gender identity, and sexual orientation. Women report long Covid more than men, trans people more than cisgender people, and bisexuals more than heterosexuals or homosexuals. Why?

That more women and trans people suffer from long Covid might be a statistic ripe for liberal pontification on the plight of both, and cloying explanations as to how "systemic" oppression has magically transubstantiated into long Covid in the body like the Catholic eucharist. But the disproportionate number of bisexuals who report experiencing long Covid — over 20 percent of them in the CDC's latest testing phase — throws a wrench into any potential social justice narratives that might arise from this data. 

Meanwhile, gays and lesbians reported experiencing long Covid at similar levels as straight people. Homophobia certainly does not affect bisexuals any more than gays or lesbians, especially since many bisexuals participate fully in heterosexual life. As a cohort, bisexuals' chief complaint is that they suffer "bi erasure." According to the self-appointed LGBT spokespeople over at GLAAD, examples of bi erasure include saying, "It’s a phase," and "Assuming that a bisexual person is heterosexual if with a different-sex partner or homosexual if with a same-sex person." The first is not unique to bisexuals. Most adult gays and lesbians alive today were probably told it was "just a phase" at some point in their early years. The solution to the second "problem" requires assuming every person you meet is a bisexual until they explicitly tell you otherwise, a deranged and narcissistic request which, in practice, would ironically lead to the same "erasure" bisexual activists claim is so oppressive, for both heterosexuals and homosexuals alike. This barely meets the level of a microaggression. There are no systemic social issues within this community which might lead to a higher incidence of long Covid. There has to be some other reason.

So what is it, then?

Perhaps it is the same thing that's led to the overrepresentation of trans people and women among long Covid sufferers, as well as the suspiciously high numbers overall, for all groups: pre-existing mental health problems.

One 2022 study with a largely female sample found that “depression anxiety, perceived stress, loneliness and worry about Covid-19 were prospectively associated with a 1.3 to 1.5 fold increased risk of self-reported post-Covid-19 conditions, as well as increased risk of daily life impairment related to post-Covid-19 conditions." In other words, people who had mental and emotional problems before Covid infection are more likely to report having long Covid and say that it affected their daily life more than those who were mentally well before the infection. Another study, published the same year, yielded similar results. In this study, long Covid patients showed no difference on a variety of biomarkers, including general inflammation, autoimmunity, heart inflammation, kidney and liver function, blood levels, brain injury, etc., when compared to the control group of people who had never been infected. Essentially, the bodies of people who said they had long Covid were in no better or worse shape than those who never had Covid at all. In terms of risk factors, anxiety disorder was second only to diabetes. Like the CDC, this study also found that women were more likely to say they had long Covid.

Streets are saying women be crazy (pretend it's 2014), and science says that's true, at least in comparison to men. According to the National Institute of Mental Health, generalized anxiety disorder affects women more than men, 3.4 to 1.9 percent, respectively. Research also suggests that, more specifically to health anxiety, women also have greater hypochondriacal tendencies than men, with the exception of cardiophobia. Women are also just more mentally ill than men overall. A 2016 study found that a staggering 20.7 percent of women aged 16 and over had a common mental disorder, compared to 13.2 percent of men — two suspiciously high numbers that are hard to believe have occurred as a result of nature or a relatively stable and prosperous society. Perhaps in the West it is our prosperity, or decadence even, which has led to the medicalization of unpleasant but nevertheless normal feelings like nervousness and sadness or attributes we once attributed to normal variation in personality like shyness or hyperactivity. Conflating social ineptitude or even just plain awkwardness with autism has become commonplace — a conflation I’ve been guilty as anyone of making, usually off the cuff. Similarly, former virtues like curiosity and studiousness have become symptoms of the disorder, turning intelligence for all but the most socially sophisticated into a pitiable medical condition. Now, our brightest minds have been placed with the profoundly disabled on a contrived “autism spectrum” whose scope has expanded so widely and frivolously that it now serves as the most imposing monument to mediocrity ever constructed in Western civilization. Perhaps it’s possible for some that, as with long-covid, the mere belief that one is suffering from depression, an anxiety disorder, autism, ADHD, etc., represents a driving force.

Trans people are much more likely to suffer anxiety and other forms of mental illness as well. For example, one Swedish study found that transgender individuals were six times more likely to have a mood or anxiety disorder than the general population, three times as likely to be prescribed an antidepressant, and six times more likely to attempt suicide. Some of this might be due to social stigma, as is often argued, but rates of mental illness this high certainly can't all be due to that, particularly in one of the most secular and progressive societies in Europe. Nor were these individuals lacking access to healthcare. The dataset covered the entire population of Sweden, which has a state-run, universal healthcare system. 

Evidence suggests bisexuals are also more mentally ill than most people, even gays and lesbians. A 2019 Hong Kong study found that "[b]isexual individuals showed higher levels of depressive and anxiety symptoms than lesbians and gay men." The researchers claim: "Structural equation modeling showed that, compared with lesbians and gay men, bisexual individuals were more likely to report identity uncertainty, conceal their sexual orientation, and have a weaker sense of connection to the LGBT community, which were in turn associated with greater affective symptoms and poorer mental well-being." These problems, which, along with so-called "bi-erasure" are all the same thing: insecurity — which is the actual chief neurosis of the bisexual community and one that they have no one but themselves to blame for. The bisexual's insatiable need for validation is an embarrassment for those of us who do just fine without it. My marriage to another man has gracefully limited the number of occasions in which I find it relevant to disclose that I belong to a community of people who view the legitimacy of their sexual relationships and attractions as contingent upon the perceptions of others. 

It's also worth noting that women, who we've already established are more likely to suffer from mental illness than men, are also much more likely to identify as bisexual. Of course, all lesbians are women, but they are "different than other girls," as anyone who spends any time around them and is willing to be honest with themselves would admit. They are paradigms of grit and nous. They carry themselves with an air that alludes to most people. Bisexual women, particularly those who primarily date men, which is to say most of them, are far more similar to heterosexual women than to lesbians. 

The association between mental illness and so-called long Covid is difficult to ignore. In many of the studies I cited, mental illness was portrayed as a "risk factor" for long Covid. The legitimacy of the long Covid diagnosis is rarely questioned. That's not to say that people don't experience the "invisible" symptoms they describe. People can psych themselves into anything. But affirming the self-diagnoses of anxious people who literally think themselves sick seems unwise and declaring them disabled — a protected class — functions as an incentive. This has implications for the labor market, welfare spending, and the social fabric. While researching for this article, I was struck with a legion of visions about the future of America, each more stupid than the last. Most recently, long lines — late Soviet style — of mentally ill bisexual women at the social security office, their chorus of murmuring complaints about "brain fog" drowned out by the Animal Crossing theme music radiating from their Nintendo Switches. If I'm wrong and most of the long Covid afflicted bisexuals are male, will this country suffer shortages of line cooks, bad DJs, and Dominican barbers? It's too soon to tell. Until then, doctors would be wise to focus on people who left Covid wards in oxygen tanks rather than those who just need to snap out of it.

-River Page