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In this week's Rich Girl Roundup, Katie and Henah answer the one prompt they often receive as two childless women: "Please run the numbers on childcare." Tune in to hear them run through the average budget and costs to set aside for various forms of childcare, as well as Katie's impassioned diatribe about the state of care work in the US.

Rich Girl Roundup is Money with Katie's weekly segment where Katie and her Executive Producer Henah answer your burning money questions. Each month, we'll put out a call for questions on her Instagram (@moneywithkatie). New episodes every week.

Our show is a production of Morning Brew and is produced by Henah Velez and Katie Gatti Tassin, with our audio engineering and sound design from Nick Torres. Devin Emery is our Chief Content Officer and additional fact checking comes from Kate Brandt.

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Mentioned in the Episode

• Data on childcare across 47 states (Census.gov)

• Nanny costs (Babylist)

• Au pair costs (Go Au Pair)

• Cost-benefit analysis of on-site childcare for employers (Benefits Pro)

• Childcare costs pay for themselves with on-site childcare (Boston Consulting Group)

• OECD countries’ spending on childcare vs. the US (NY Times)

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Katie:

Welcome back Rich People to the Rich Girl Roundup weekly discussion of The Money with Katie Show. As always, I'm your host, Katie Gatti Tassin, and every Monday my executive producer, Henah and I talk through listener questions and interesting stories and just kind of the more casual end of financial topics right after a quick break.

Before we get into it. This week's upcoming main episode is about something we alluded to in a previous Rich Girl Roundup, money dysmorphia aka when your perception does not align with your financial reality, I think it's going to be incredibly, incredibly resonant.

So, okay, onto today's roundup. Henah, what are we talking about today?

Henah:

This week's question came from so many people over the years begging us to look into the costs of childcare. So as two childless people, baby, we are back.

Katie:

We back.

Henah:

We're looking at the state of care work in the US, and if you don't live in the US, lucky you, bless you for this specific question.

Katie:

Usually we're like, if you don't live in the US, so sorry. This time we're like, wow, must be nice.

Henah:

Must be so nice. So we're going to look at how people are making it work in the US as best we can. So I'm going to caveat this in the beginning that I pulled a lot of numbers from the internet and I used as much as I could for national averages. However, every time we've ever talked about this, someone will be like, that's not at all close to what I'm paying, or that's vastly under what—

Katie:

I saw a tweet that this reminds me…

Henah:

Oh no.

Katie:

Oh my God, I wrote it down, it cracked me up. Next time you get that, I'm like, send back, “my apologies for not considering your extremely niche situation in my tweet about myself.”

Henah:

Well, in this case, fair, but I know that the numbers wildly differ and so I know it depends on how many kids you have, where you live, the accessibility or demand in your area. So I guess I just want to caveat all of this by saying we are using national averages here. So please do not write me a really mean email. I am baby.

Katie:

Big shout out to Henah for pulling literally all of the data. Thank you for this episode to save me from the Googling. I am going to do my part today by bringing vibes.

Henah:

The chronic case of bad vibes that you mentioned in a previous episode?

Katie:

Those were the bad vibes leaving my body. No, only good vibes left, only good vibes left. So where should we start? Should we ground ourselves in the data first and then get into the vibes? What do you think?

Henah:

I think the data first. I know that you have a diatribe about care work in the US and as excited as I am to hear it…

Katie:

Everyone's like, Katie, we've heard the rant. We don't need to hear the rant again. We…

Henah:

We got it.

Katie:

Yes you do.

Henah:

It's never too much. So I wanted to run the numbers between stay at home parents, childcare, like traditional childcare, nannying and nanny shares, au pairs, and intergenerational living with your parents where you would just need additional space in your home kind of thing. We could go into other things like friends living together and childcare co-ops, babysitting exchanges, nonprofit programs. But for this, I'm just going to stick with kind of the general numbers. So with me so far?

Katie:

I am, and I know we've talked about this essay before that “We Live in a Society” essay, but we had mentioned in the past that it went kind of viral on Instagram and how that was really cool to see the reception and how much it resonated with people. This idea that when you are paying for everything you need, it kind of introduces this unnecessary level of isolation and stress into your life and how community is the antidote. Someone had shared it and was like, there are so many times that I want to post like, hey, does anyone want to come over for an hour this morning and sit with my baby while they watch Bluey and I'll make you a latte so that I can take a nap. And she'll be like, I just always feel so nervous to ask for help. I don't want to be an imposition.

And I'm also afraid of nobody answering and feeling even more lonely that no one wants to do this. And it a broke my heart. I had the exact same reaction you did, but it also feels so resonant for a conversation about childcare. The fact that people feel that mothers feel that isolated in caring for their kids, that they're like, please come over so I can nap for 40 minutes and I will make you a coffee and you can literally just sit on my couch and scroll on your phone. I'm like, God, it is bleak, man. It is really bleak.

Henah:

I will tell any friend who's listening, even if I don't know you, I guess I'll offer, if you're local to Atlanta, I'm happy to help. I struggle when I can't sleep eight hours a night, and so I cannot even imagine what new parents are going through, and so I just have all of the empathy for them. But it's a great example of feeling alone in all of this.

Katie:

I also think that sometimes—we were just with my nieces and nephews, I think I'm going to guess, I mean, I don't want to generalize, but sometimes I think that parents of young kids, because they're so entrenched in the caretaking aspect, they might forget that there are a lot of childless people who want to be around little kids. I love being around my nieces and nephews. I'm like, can I watch them? Can I take them with me somewhere? Can we go do something together? I am obsessed with them.

So it is not an imposition at all. If they were to be like, Hey, can you come over for the afternoon so I can go run errands? I would be like, thank you. I want to see them and spend time with them. And being around little kids is something that I think a lot there are. I'm not going to put that on everybody. I know there are a lot of adults that don't like children, but I think there are a lot of childless people that really like being around little kids.

Henah:

I'm scared of children, but I feel that way about dogs. But I'll say one of my best friends, she just had her second baby and I offered because I didn't want her to have to ask. I said, why don't I fly up to Pittsburgh and spend a week so that you have time? And so we were trying to figure out if that could work, but it was just one of those things where sometimes I think they really appreciate you just stepping up if you have the time and bandwidth rather than having to wait for them to ask when they feel like they're on their last leg.

Katie:

That's a really good point actually.

Henah:

I'm going to be like, Katie, I need to sleep. Can you fly into Atlanta? Thanks.

Katie:

Sorry. So I know I've derailed us, but—

Henah:

No, no, I think this is all valuable because I think it gets to this larger point of it takes a village to raise a child, and we often leave American parents kind of just like, you're on your own, kid.

Katie:

Literally you're on your own kid.

Henah:

For this example, let's maybe run with a two income household of $150,000. So we're talking about after taxes probably $108k a year, so about $9,000 in take home pay. And this is obviously assuming they're not making retirement contributions, they don't have to pay a hundred percent of their own medical benefits, et cetera, et cetera. So again, I know again that we're caveating this. So I looked at the average costs of childcare, which from Census.gov that across 47 states, the numbers range from a single child from $4,800 to $15,400. The first one for school aged home-based care and the second for infant center based care in larger counties.

Katie:

So $15,000 for infant based center care was the average.

Henah:

That was the range, yeah. From $4,800 to $15,000. Essentially what I did is I averaged all of those numbers and adjusted it for 2024 dollars and I got $11,700. Again, I know this is not perfect math, but that's kind of that…We'll say $12,000 probably is the easiest way to run it. Yeah.

Katie:

A thousand bucks a month, a thousand bucks a month per kid. Yeah,

Henah:

So that's probably on the cheaper end. And then you have the higher, I took a slightly higher number and I said, okay, if you do about $25,000 or $18,000, some of those higher numbers, if you have more than one kid, we're talking $1,500 a month, $2,000 a month. So if you have a $9,000 budget every month, that ranges between 10% and 20%. A little bit more than 20% of your take home pay. You following me so far?

Katie:

I am, yeah.

Henah:

Okay, cool. So the next thing I looked at was the average cost of nannying. So according to Babylist, the average is around $17.50 an hour, but it can be as high as $23 in New York City. And so it's about $35,000 a year. So it could be lower if you do a live-in nanny or you do a nanny share, which I have friends who do nanny shares, but at an annual average around $35-$36,000, that's $3,000 a month. And at a $9,000 budget, that's almost a third of your take home pay, which kind of reaffirms for me that the nanny is definitely the most expensive option. But the other one that people don't often talk about as much that I've seen is the au pair option. And so per a source called Go Au Pair, that's usually around $20,000 and they live with you. So you would also need obviously a room or space for them to live.

And so that averages out to about $1,600 a month to about 18% of your $9k budget. So we got 10 to 20% when you're going to traditional daycare, 30% or more for a nanny or 18% for an au pair. The thing with the au pair that I want to point out is that there's some ethical concerns. I have family members who use an au pair and they love them. They've built really loving, long lasting relationships, but it can also be considered sort of like indentured servitude at a certain point. They used another term that I don't think applies here, but basically that they're overworked and over exploited for the amount of money that they make and they don't have time off. So I think this obviously depends, but I want to mention that.

Katie:

Particularly if you're looking at it as a low cost option. If something is low cost to you that seems like it is below market value, you're like, well, who is bearing that cost then? Is this a win-win? Or…

Henah:

I know that we can obviously talk about the effects of this on women of color who were put in childcare positions and daycare workers and all of that, so we could talk about that.

But the other two scenarios that I looked at are living with parents or friends, which would obviously be free, but it would have upfront costs like having the space in your home or buying a home together.

Or just becoming a stay-at-home parent, which would be a loss of your monthly and annual pay. So you would have to essentially cut 50% of your budget out to become a stay at home parent. And so if you have one kid and you're between 10% for daycare or 50% stay at home, it might make sense that you continue to work. But when you have two or three kids, the math is really going to change.

Katie:

Depends on your situation. Yeah. Okay. May I introduce some vibes? Permission to vibe?

Henah:

Permission. Granted scared, but permission granted.

Katie:

I have a few thoughts about this and why I think conversations about the costs of and dynamics around caring for others in the US is very challenging. We often talk about the decision to either stay in the workforce or leave not just in the financial sense, but as though one choice is morally better than the other. As in you are a traitor to feminist working women everywhere if you choose to be a stay at home mom, so you should keep working. Or you're not a good mom if you don't now devote your entire life to your kid, now that you have one.

And I think that we see this double speak around this issue where you'll hear, oh, things that basically imply being a stay-at-home parent is both this underutilization of your potential as a person because it's not producing anything that capitalism recognizes as valuable, which is a problem in and of itself with how we view and value the work of caring for one another, and that it's this privilege that a lot of people don't have access to because most families required two incomes to live comfortably. So you get this almost caricature of stay at home moms as being very affluent and kind of, I don't want to say lazy, but there is sometimes this caricature of like, oh, it's such a privilege that you're home. Well, it's like, well, is it good or is it bad? You kind of hear it construed in both ways, right?

Henah:

Is it work or is it not? Yeah.

Katie:

And I think that there's two things that come up for me. A, it's not that care work is not valuable, it's that it is not presently valued.

Henah:

Wait, wait, wait. Say that again. Say that again. That's so good.

Katie:

It's not that care work is not valuable, it's that it is not valued.

And because it is not valued, people in society whose time is perceived to be less valuable are the ones that do it, women, people of color, and then the low pay or no pay is justified by going, oh, well, the work isn't really that valuable. So it's like circular. It's like a self-fulfilling prophecy and not for nothing. It's probably worth stating explicitly that money is not the only way that you can be remunerated for your work.

Value comes in many forms, but if we're talking specifically about labor, we really have to parse that reality from am I driving value in other ways and is this a fair exchange of value or am I being exploited for someone else's benefit? And I think in the US, you can really make the argument that the position that our policymakers put parents in is to the vast benefit of corporations and to the detriment of parents. Whether you choose to stay home or you choose to stay in the workforce, you are being put in a very, very difficult position. Like Paco said, our culture is almost downright hostile to parents.

Henah:

On that note about companies, I actually looked into onsite childcare as well…

Katie:

Ooh. Go off.

Henah:

I know. Plot twist. So obviously if you wanted to get a little more radical, we could look at universal childcare, onsite childcare, and so universal childcare, I remember we had done this in a previous episode, I believe it costs $70 billion or so to provide, which obviously is a lot of money, but it's something that the US could feasibly relatively easily afford.

Katie:

Reallocate some things.

Henah:

And so the other option that I looked into is the onsite childcare. And so I found a Boston Consulting Group study that came out earlier this year that actually said that childcare benefits deliver returns of up to 425% of their cost for companies across the US. And so they studied five different companies that were across different industries, company sizes, employee mixes, benefit types, and they saw that this 425% ROI was possible through all of them. And that retaining as few as 1% of eligible employees because of childcare benefits can cover the cost of offering them in the first place. And so when you take also the intangible effects into account, the case for offering benefits grows even further. And so I say that, to say yes, it is not possible to have at all as we've sort of said in our current American landscape, but I do think this would make it a lot easier and a lot better for parents and companies and productivity for coming from a capitalist standpoint to look into something like this. And there are companies that are doing it and doing it really well.

Katie:

It's a really interesting note. It feels like the middle ground. It kind of feels like the compromise. Okay, well, if you want all of our wellbeing to be tied to our corporate overlords the way we've decided healthcare should work in this country, then they should provide childcare too. It's like, is that the perfect solution? Is that the most efficient solution? No, but keep going. Yeah, put your money where your mouth is. Oh my goodness.

Henah:

I also found a New York Times analysis of OECD data that was published in 2021, and I couldn't help but laugh. I felt really sad, but I couldn't really help but laugh. It said that the US spends roughly $500 a year per child on early childhood care compared to, you want to guess the number for the average OECD country?

Katie:

What? Like $10,000?

Henah:

$14,000.

Katie:

Oh, sick. Love it. Great. Amazing.

Henah:

So we spend $13,500 less than the average OECD country to provide early childhood care. When I say that we're on our own…

Katie:

Yeah, they really do not give a fuck. So I also think that there's an element here of how people often make this decision and how it can code differently across class lines. I think we talk about it across gender lines a lot, but that phrase, that's like what's classy if you're rich, but if you're poor day drinking, no, wow, that just threw me off. I was not expecting that. You get a very different tenor depending on the perception of you as a person and your class status and whatnot, though I do think you see that logic regardless. I follow this astronaut. Oh, nice. And I see people comment on her videos all the time. Yeah, who's taking care of your kids on missions? Oh my God. And I'm like, when are people going to her partner? Her spouse is taking care of them.

But you only see that directed at women, which this is not news, this is not a novel point, but I do think that when people are making this decision in their own lives, the extent to which your career is gratifying and interesting to you and a part of your identity more broadly is necessarily going to shape how you feel about these trade-offs and the circumstances that are going to allow you personally to be the person that you want to be in your life.

And in this world, it's not cut and dry. My biggest gripe though, with the way that we talk about this I think is twofold. One is that we often always place the burden kind of inadvertently on, alright, women, you got to figure it out, make it work. You're the ones that have to renegotiate your terms with career and family division. But the other thing that kind of bothers me is I even saw this viral reel yesterday where this woman was like, I used to be this high powered executive. I made $200,000 a year. I had nannies, I had cleaners, I had this, I had that. And now I'm a stay at home mom and I do it all myself. And I can tell you it is so much better. I'm irreplaceable now. My company replaced me on my maternity leave or something like that. I wasn't irreplaceable at my company.

And that narrative drives me crazy because I see no issue whatsoever with anyone choosing to be a stay-at-home parent if that is what's best for them and the culture and the economics of their household. I just have a problem with framing it as though this is a women's issue of like, oh, well, I was replaceable in this company, but I'm not replaceable in my family. It's like, no, this is a labor issue. This is a workplace issue.

First of all, if you were discriminated against for being pregnant or a mother, that's illegal for starters. Secondly, when companies treat women badly, the answer isn’t like, well, I guess they shouldn't work. But the problem that you have is not with feminist progress. Your problem is with shitty working conditions and eroded protections for labor and a national corporate culture that is driven by ruthless blind profit hunger, and you're just perceiving that as a problem specific to women in the workforce.

Henah:
These are the vibes she was talking about, everybody. These are the vibes.

Katie:

It drives me nuts. It's such a pervasive argument that's like, I used to have it all. And now I just stay home with my kids and it's amazing and it's so much better. It's like, well, yeah, I'm sure it is better because your company was shitty to you. But the answer is not sending all women back into their homes or perpetrating this idea that the workplace is no place for women. It's holding people in power accountable and reprioritizing labor power.

Henah:

Ooh. Okay.

Katie:

Having a successful career is not about being irreplaceable. Literally nobody is irreplaceable in any job. And yes, that includes caretaking. Irreplaceability is not the point.

Henah:

I 100% agree with you. I think it's interesting because in my own life I have never had the yearning to be a stay-at-home parent Jovanni would love to be a stay-at-home parent. That is his dream. And so I'm like, you enjoy, you do that as much as you want, but I will be working. And so it's really nice to have that freedom and autonomy to decide if I want to do that.

Katie:

That is a really good point too, because to add a more positive note, I just saw some data the other day that millennial partnerships are actually way more egalitarian. Millennial men are doing a lot more than their fathers and their father’s fathers’ fathers did. So we are absolutely going in the right direction. I don't want to imply that things are getting worse. I don't think that that's really the case, but I just think the way that we talk about these things is so tricky, but so important.

Henah:

Yeah. I mean, there's layers upon layers here, and I feel like we've circled all of them over the years, but it's interesting to me that we are two childless women and we are aware of all these things. I cannot imagine the rage I will feel when…

Katie:

You actually are in that boat? Yeah.

Henah:

But on that note, I would love to just talk quickly about sort of what have you seen in your own personal life with childcare? For me, intergenerational living is really prominent. So I grew up with my grandparents in my home. I never had a babysitter or a nanny, and it worked really beautifully. I had an amazing relationship with my grandparents. I have friends who are doing nanny shares. I have families who they've done pairs as I talked about. So what have you kind of seen as the norm or most common options?

Katie:

So the examples that I've personally witnessed as an adult come from my brothers and sisters-in-Law, all of whom have nannies who come over daily to watch their kids. So their situation at a high level: Each couple has two kids and all four parents work. In one set of parents, they're both doctors and then the other, they're both lawyers. They have demanding jobs and stressful jobs. In both scenarios, the older child is about to be in school, so they're about to just have one at home during the workday…

Henah:

When you say they're going to drop down to one, have they shared whether they would move out of the nannying now that it's just one or if they would continue?

Katie:

So when I was talking to one parent, they mentioned looking into a nanny share now that they will just have one that's kind of at home all day. But in this instance, you can probably connect the dots here if we're talking about people that are doctors and lawyers, both adults and both couples are earning a living that is far more conducive to staying in the workforce and just paying for in-home care than leaving the workforce and having one of them staying home.

I also, anecdotally talking to the mother specifically, there's one conversation that jumps out at me. I remember after her second kid was born, I was like, oh, are you thinking about, are either of you thinking about staying home or is that on your radar? What do you want to do? And she was like, oh my god, I would go crazy. I have to work. I really like work. And so that's where I say, I think the way that you feel about your career and the extent to which it is satisfying to you is a huge factor here. Even beyond just the money. It's like, what do I want to be doing all day?

It is interesting. I really enjoy talking to…my husband's family's huge. He has three older siblings and then four step siblings. And so they pretty much all have children except for us. And so it's really nice to get to pick their brain. They all have two kids. It's wild. So we have lots of little cousins running around, but it's fun to get to ask them like, hey, what's it like? What's hard? How do you guys negotiate the labor in your own home? How do you get help? But for the most part, I mostly see nannies. Honestly.

Henah:

I feel like a telling example is that my mom is one of 11 children, and I know, so I have a lot of aunts and uncles and nearly all of them except maybe one moved to the states or Australia or the UK, and all of them only have two to three kids.

And I feel like that is a testament to when you have 11 kids, it's kind of like an ecosystem of a household of the oldest sibling becomes a de facto parent, and they take care of the younger with, that kind of situation, and you just can't do that again in the US with the cost of living or lack of childcare options. It's interesting the way that people have also defaulted to two kids because they don't want their single kid to be lonely. Sorry, Katie, but also they don't want to have four or five kids, but also people aren't having kids at all now. So who knows?

Katie:

Oh my God, that's so funny.

Henah:

I have a curve ball for this week's money story, and it came in response to you asking players, do you want to change the game? It was in an email where you had said, this is a status quo. Do we want to keep it the status quo? Do you want to play the game? And somebody responded and they said, abso-f’ing-lutely.

And they wrote about this because they own and operate an early childhood education program, which is a daycare center in preschool. So they've been doing this for almost 15 years. And she said, the math ain't mathin’.

And so early childhood educators in the state of Iowa, which is where she lives, earn just over $10 an hour while parents pay thousands of dollars for the care of their precious offspring. So where then does the money go, most of the time? But for her childhood and education center, they said our average employee makes more than double the industry standard in our state.

They have access to health, vision, and dental, and they have a laundry list of employer paid benefits that don't exist in the childcare world. So she included paid time off, sick leave, paid holidays, paid snow days, life insurance, short-term disability with maternity leave, hospital indemnity insurance accident and critical illness insurance, a simple IRA with a 3% match tuition reimbursement, paid bereavement leave, which like amazing, paid jury duty, WAGES participation, which is a stipend of up to $9,000 a year that they can earn for staying in early education.

And she said, and guess what? We're not satisfied. We are still searching for money because she said, we have several of our staff who have declined wage increases in order to remain eligible for updates to the WAGES program. If they do that, then they cannot take advantage of the $9,000 stipend. So our staff, most of whom have a college degree stay here because they can afford to.

But she's closed by saying, unpopular opinion in that there is a childcare crisis, but it may not be the crisis people think it is. The actual crisis is often greedy people taking advantage of less educated and marginalized people. And then she said, cheers to never being like them, even if it means that I'll never personally be rich.

And I have a lot of admiration for this person and what they're doing, because the way they're doing it obviously sounds so ethical and intentional, but it really kind of adds that layer of when we spend this money, who are we giving the money to? Is it the right amount of money? Are they being exploited? Do they have fair wages? Are they having decent benefits? So I'm curious if you have anything you wanted to add there.

Katie:

Well, the discrepancy between what childcare costs and what workers are paid has always seemed really strange to me. My understanding is that there's a lot of regulatory and compliance stuff in place that impacts wages to the extent that in order to be, I don't know if the term is licensed, but in order to be operating in good legal standing, you have to have one caretaker for a certain amount of kids. There has to be, to your point, yeah, good ratios.

But I've always kind of heard that kind passed off as like, oh, the regulations are so crazy that it is so expensive to run a daycare center that the wages have to be low. I look at that and I go, I dunno if I really buy that. I dunno if I really buy, but you've got 15 kids or 20 kids that are all paying $2,000, $3,000 a month and you have to pay $10 an hour. It doesn't really make sense to me. But I haven't looked into it enough to know where the money is actually going.

Henah:

So I asked them, I said, are you okay if I share this story, I'll remove any identifying info? And they said, yes, that'd be fine. You have my permission, but be prepared for backlash because this industry really enjoys their message that they only have 1% to 2% margins at best.

And I won't pretend that there weren't hurdles along the way and that we're only in a better position because we did receive federal support during Covid, and we are locked in at a 3% interest rate, which is not someone else's startup story right now.

But when she was showing the math, because she has children of her own, she's saying most people are paying between $13,000 and $17,000 in her area per child per year. So if you have a ratio of 12 students in one classroom, that's $150,000 per year. So if you're only getting paid $10 an hour, where's the rest of it going? So I don't know, just kind of food for thought on the larger question that I thought was interesting.

Katie:

I'm glad you brought that in. I think it is interesting. I mean, I know rent's expensive. I know that there are operating costs associated with running, but to her point about be prepared for backlash because the 1% to 2% margin is a pretty strong talking point. I just don't know enough. I've never seen the books. I've never seen someone go, oh yeah, look.

But I think the problem is in the pudding in a sense. If we're talking about margins, it's like, well, who is profiting? Who pulling the strings is making the money off this? It's not actually, it's putting capital at work, but it's not actually working themselves. Who has to profit? Why does it have to be profitable? Why does carer have to be profitable? Kind of the same thing we get into with financialization of healthcare. Why does this have to be a transaction that someone is making a profit on? Why can't it just be something that we know everyone needs? And so we should be trying to provide it in the most efficient way possible.

Henah:

Katie, when do you turn 35? 2029. Katie for President 2032.

Katie:

Listen, I don't know. Shit, I'm just here to complain. Okay. I told you I'm bringing vibes. I'm complaining, I'm ranting. I'm bringing vibes. That's really as a childless woman, all I have to offer you. But I hope there's some vicarious venting happening that if you are a working parent or a stay-at-home parent, and it all feels confusing and shitty, that there are two childless women out there who understand and agree.

But that is all for this week's Rich Girl Roundup. So we'll see you on Wednesday to talk about money dysmorphia.