Dept. of False Equivalence

Have you ever been in a conversation with someone who had a good point to make, but went so over the top that they lost you anyway?  Someone who, if they’d kept their arguments reasonable and their criticisms balanced, might have swayed some opinions, but whose rhetoric got so unhinged that they probably did more harm than good to their cause?  (Not so long ago a wise friend wrote a parable along those lines with regard to our political culture.)  You know the type, right?  People who should maybe let other people do the talking for them, because they just completely lose their shit and make things worse?

So it is with Paul Campos and the subject of obesity.  The man has some good points to make, but he makes them so badly and so vociferously that he loses people who might otherwise nod in agreement with what he’s trying to say.

Behold his essay in Salon, “Anti-obesity: The new homophobia,” a heaping helping of facepalm:

“Homosexuality” and “obesity” are both diseases invented around the turn of the previous century. Prior to that time, being sexually attracted to someone of the same gender or having a larger than average body were, to the extent they were thought of as social problems, considered moral rather than medical issues: That is, they were seen as manifestations of morally problematic appetites, rather than disease states.

The same medical establishment that pathologized same-sex sexual attraction and larger bodies also offered up cures for these newly discovered diseases. Those who deviated from social norms were assured that, with the help of medical science, homosexuals and the obese could become “normal,” that is, heterosexual and thin.

In the latter half of the 20th century these frames were challenged by gay rights and fat rights advocates. Within these movements, the words “gay” and “fat” had similar purposes. They were intended to depathologize what medicine called “homosexuality” and “obesity,” by asserting that different sexual orientations and body sizes were both inevitable and largely unalterable, and that being gay or fat was not a disease.

Campos is trying to make the point that same-sex attraction and being overweight are equivalent in that they are unfairly pathologized, and that both are innate and immutable characteristics.  I think there is a kernel of something good in there, though to what degree being overweight is innate and immutable is unclear.  Certainly it raises the question that, if obesity is something that is inevitable, why have the rates of obesity risen within the United States so sharply within the past few decades?  It is implausible to posit that something intrinsic in Americans changed within that span of time, though what precise factor(s) account for the change is a subject of much contentious debate.  If being overweight is an innate characteristic of those who are obese, why are there so many more of them now?

Leaving aside the rather blithe way Campos conflates society’s views about homosexuality and obesity before the turn of the last century (and, let’s face it, today), he seems to imply that the medicalization of these “conditions” happened within some kind of vacuum.  In reality, of course, medicine was merely one part of a culture that, as a whole, stigmatized both of these issues.  By offering “cures” for homosexuality, doctors were misguidedly trying to help patients conform to social norms.  The difference with obesity is that doctors aren’t trying to “cure” it because society believes fat people are perverts (like they did and still to a great degree do with gay people), but because being overweight leads to a whole host of health problems.  The only reason to “fix” homosexuality is that society says that there is something wrong with being gay per se.  The reason to try to help obese people lose weight is that they will be far less likely to suffer from numerous life-shortening illnesses.  They are not equivalent goals.

Indeed, the most striking parallel between attempts to turn gay people into straight people and efforts to turn fat people into thin people is that both almost invariably fail. The long-term success rate of such attempts is extremely low. When it comes to the various forms of conversion therapy, the medical establishment now acknowledges this. This acknowledgment, in turn, has helped medical authorities recognize that it does not make sense to label “homosexuality” a disease, and that therapy for same-sex sexual attraction is both unnecessary and more likely to do harm than good.

But when it comes to fat, the fear and disgust elicited in this culture by fat bodies (reminiscent of the reactions elicited traditionally by same-sex sexual relations) prevents the public health establishment from recognizing that the various “cures” it advocates for “obesity” have been demonstrated again and again to be every bit as ineffective as conversion therapy has been shown to be for “homosexuality.”

Here Campos makes his best point, and the one that I agree with.  Indeed, I have already expressed sympathy for the argument he is making.  It is incredibly hard for overweight people to lose weight effectively and sustainably, and I think both the medical community and society as a whole are far too glib and dismissive of that reality.  Treating overweight people as moral failures is appalling, and the overwhelming majority of non-surgical obesity cures are woefully unsuccessful, at least in the long term.  If he had stuck with this point, he would have been far more convincing.  But he doesn’t.

The pathologizing of gay and fat bodies springs ultimately from the same cultural source: the desire to ground moral and aesthetic disapproval in the supposedly objective discourse of science and health. It is true that fat people are at a higher risk for certain diseases (although the extent to which higher weight correlates with increased mortality and morbidity is greatly exaggerated). But trying to, for example, lessen the prevalence of diabetes by eliminating “obesity” makes no more sense than trying to lessen the prevalence of HIV infection by eliminating “homosexuality.”

ARGH!  No!

The moral and aesthetic disapproval for gayness was the only reason it was pathologized.  It was pathologized long before the advent of HIV, and remains pathologized in large segments of America and beyond completely independent of the AIDS crisis.  Medicine tried to change homosexuals because society said being homosexual was wrong, not because it was a risk factor for some other undesirable outcome.  “Curing” homosexuality was an end unto itself, and a wrong one.

The reasons for trying to “cure” obesity are related to health and wellness.  The medical community is trying to prevent numerous illnesses and infirmities that are related to obesity, not because of moral disapproval but because being overweight makes people sicker and can significantly worsen their quality of life.  Or at least that should be its reason for addressing the issue.  I would be a fool to deny that fat people are stigmatized, and that there is a tremendous degree of shame and humiliation that is foisted on them by an unkind society.  I agree without hesitation that treating the overweight as unworthy of dignity and respect is a disgrace, and insofar as physicians’ interactions with their overweight patients are informed by similar attitudes they should be ashamed of themselves.

But there are real problems that being overweight can lead to.  Campos links to his own article under “greatly exaggerated” above, and it does raise questions about confounding factors in predicting the exact degree that obesity affects the morbidity and mortality of patients.  But it takes no effort whatsoever to find a huge body of evidence linking obesity to numerous illnesses that worsen and shorten people’s lives.  I suppose it is Campos’s prerogative to dismiss this body of evidence as flawed or overblown, but all I can say in response is that I dissent.  Obesity makes people less healthy in the long run, and helping patients be as healthy as possible is what doctors are meant to be about.

Are there lots of great points that Campos has buried in his piece?  Yes.  Obese people are treated with contempt by a judgmental society that is largely ignorant of how genuinely hard it is for people to lose weight sustainably.  Medical intervention has been largely unsuccessful at mitigating this difficulty.  Insofar as a morally judgmental attitude informs the way that physicians treat their obese patients, they should redirect their attention to the health problems their patients face, not to a misguided focus on willpower or strength of character.  I am on board with all of that.

But medicine’s specious “treatment” of homosexuality was predicated on the belief that to be homosexual was wrong and perverted.  Remove that belief and the need to “treat” homosexuals evaporates.  But even if we remove any moral judgment from our view of overweight patients, that won’t make them any less likely to develop osteoarthritis in their knees or suffer from coronary heart disease.  It is outcomes such as those that medicine seeks to prevent, and why it continues to try to find effect ways of combating obesity.  That Campos cannot appreciate these distinctions makes his polemic a failure.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I’ve found many advocates are often the worst at advocating. The more passionate they are the more likely they are a poor advocate. True Believers are the worst and usually scare me even when i agree with them. Campos usually writes well about obesity issues, but i agree he has using a flawed analogy.

    • Campos usually writes well about obesity issues,

      Hmmm, I’d have to disagree. Campos writes terribly in a way pretty much designed to antagonize and make people look at one another and circle their ears. It’s just that he happens to be more right on the subject than the vast majority of people who actually comment on it.

      • Disagree??? Well it will have to be pistols at dawn then.

        He would be what i would call a passionate advocate though, for better or worse.

  2. Well, I am obese.

    I’m working on losing the weight – when my sister died from breast cancer in ’05 I weighed about 370 pounds.

    I’m down to 300 now. I still have a ways to go – I’d like to be about 180 again.

    I don’t want a diet ‘fix’, I don’t want a surgery ‘fix’ – those don’t treat the bottom issue – changing the lifestyle I lead.

    Despite being morbidly obese, (which carries risks I am well aware of) – I don’t have the typical ‘problems’ associated with it. I’m no longer asthmatic (work induced – 2nd hand smoke, although cats/dogs can trigger allergies), I don’t have high blood pressure, I don’t have high cholesterol, etc.

    I have made alterations to my lifestyle which I continue to improve. I have made changes to what I eat – to be healthier. While I’m not exercising as much as I should, I make the effort to take the stairs rather than the elevator, I make myself walk longer distances instead of taking the bus, etc. And I use my bicycle to get a liter of milk or two from the store rather than taking the car.

    It’s small steps – but those are what I need to slim down. I will still enjoy an ice cream on occasion, etc – because that’s part of enjoying life – being able to treat yourself to things like that. I was never the ‘sit on the couch and stuff my face with chocolate’ person – a nasty sports injury my junior year of high school pretty much sidelined me for most of that year – and then subsequent reinjury over time stole my mobility from me. It’s hard to exercise when you can’t. But surgery in 2004 fixed that and my weight is on its way down. It might take me 10 years to get there, but I’m fine with that.

    • Thanks for sharing your experience, Darwy. I wish you well on your gradual path to better health. It’s long been my belief that a slow process of steadily-accumulating lifestyle changes is a more effective and sustainable approach to health than any more radical intervention.

      Where I think Campos is strongest is in trying to get the focus off weight per se and onto fitness and other factors. Being physically active and eating healthier foods is probably more important than being “thin.”

      • Well a lot of people don’t understand that I could NOT exercise until I fixed my knee. I could not extend my right leg with ANY force behind it, or it would hyperextend upwards.

        When I went for an eval regarding my candidacy for surgery, the surgeon flat out asked me, “How the HELL did you manage to walk in here?” I had zero ACL left, and tears in the PCL. He said this as he (essentially) sat on my foot while moving my lower leg roughly an inch and a half away from my kneecap and then from side to side.

        When I originally injured it, I was given 3 potential options for ‘fixing’ it. The first was to have an artificial ligament inserted – but it would need to be tightened/adjusted and/or replaced regularly.

        That wasn’t a feasible option.

        The second option was donor tissue. This was around the same time the scandal broke regarding donated tissue/bone/etc being harvested from ineligible ‘donors’ – people who had died of leukemia, etc.

        I wasn’t taking that option, either.

        The third option was to do nothing and wait until the science caught up to my needs. So that’s what I did.

        Granted, I kept skiing, playing softball, karate, bicycling, etc… and reinjuring it. As my mobility slowly decreased my weight increased. It’s an evil cycle.

        I knew it was time to get it fixed when I could feel my quads nearly spasming in an attempt to hold my leg in a ‘natural’ position over the knee. I could feel the leg slipping out of place going up or down stairs, and each time I put my foot down to walk.

  3. Speaking to the broader point – I was always uncomfortable with the gay mariage movement comparing itself to the civil rights movement of the 1960s. It seemed like a bridge too far. But that was the gold standard for movements so they went for it.

    I look at the fact that other ‘movements’ are comparing themselves to gay rights as a sort of moral victory for gay rights folks. Maybe they are the new gold standard.

  4. Yes, that’s an article that isn’t going to convince anyone who doesn’t already agree with its author.

    Obesity is an actual problem. It’s not something that people should be encouraged to embrace any more than excessive thinness is (there are pro-anorexia communities online. The world is screwed up). The medical challenge is to remember not to conflate “fat” with unhealthy eating and exercise patterns and “thin” with healthy ones. I exercise occasionally, eat tons of junk food, and am lucky to have a good enough metabolism to still stay fairly thin. There are probably plenty of overweight people who exercise more, eat better, and are healthier than I am. But I suspect that if I went for a check-up, the doctor would be less focused on my eating and exercise habits than they would be for someone who was clearly overweight (I may be wrong about this, though).

    We need to distinguish between health problems that are the direct result of obesity – damage to the body caused by it carrying around too much weight – and health problems that are the result of poor eating habits and lack of exercise. For the latter, the focus should be on changing behaviour regardless of whether the changed behaviour manages to make a person thin.

  5. “Certainly it raises the question that, if obesity is something that is inevitable, why have the rates of obesity risen within the United States so sharply within the past few decades? ”

    I think what Campos would say is that, just as with homosexuality, there was heavy social pressure to Be Like Everyone Else, and everyone else was thin. And that inside every thin person was a fat person waiting to get out.

  6. I think the original author has a point. I know that it is hard to believe that obese People are naturally that way. First off, the medical idea that a five and a half foot woman should way 125 pounds is a farce. The actuarial tables indicating proper weight are based on life insurance. Since the fatter people don’t get that kind of life insurance, the statistics are biased and skewed towards the thin. The fact is that thin people are more likely to die from infections then people who are simply fat. Most people who are overweight are within sixty pounds of their goal weight. These people probably do not eat the fruits and veggies that they should and are eating to much meat which are the true factors leading to diabetes. Red meat and proccessed sugars white bread are killing everyone in our society. On to obese people. Folks who are over sixty pounds over weight, the truly obese, are naturally obese but that doesn’t mean they must be immobile and eat the prominent meat, fat, sugar, salt based died of the majority. It is the diet that is deadly leading to diabetes ace coronary artery disease. Obese vegans and vegetarians do not get diabetes. They ALSO don’t have cardiovascular disease or cancers in access of the general population. But when you mix our nasty diet with lack of exercise then you get very unhealthy obese people and unhealthy everyone else. Being fat and being obese are two different things. I am obese. I weighed as little as 150 pounds during my adult hood which required a maintenance diet of 1400 callories coupled with one to two hours of intense daily exercise. It was simply not sustainable for life. I gave up the starvation side of it and worked out one to two hours daily, I swam one mile of the butterfly and one mile of freestyle daily–without stopping. When I went to the doctor no matter the reason I was told to lose weight. That is simple bias. It is possible to be obese and healthy but everyone needs to eat a better diet and exercise. I have two very thin siblings both of whom are in horrible health. Now I have an endless pool, eat a mostly vegetarian diet, and have stand up desks to discourage sitting more than a short time. I am still obese. I think you are wrong about obesity and health issues. You just can’t see through the biased science. Meat and processed foods lead to diabetes. Meat and accumulation of carcinogens leads to cancer. A cultural over consumption of salt leads to high blood pressure. Universal lack of exercise exacerbates the phenomenon. Oh and as a final note. Obese, and otherwise heavier women, are more fertile than thin women. Much much more fertile. Humans are getting fatter everywhere. Mammals are also getting fat everywhere from a new virus which appeared in the 80s but that is a side factor.

    • Hello, Jack.

      I do not think you read my post very carefully. (You also make some rather startling medical claims, which I am going to just leave alone.) Allow me to restate my point, which you seem to have missed. Insofar as Campos raises legitimate concerns about how obesity is viewed by the medical community, he loses his reader’s sympathy when he conflates those concerns with other, unrelated cultural biases.

      Whether or not obesity itself is the cause of the health problems typically associated with it, or if it is a sedentary lifestyle combined with an unhealthy diet, is an important question. However, given that the typical approach to obesity management is to recommend more physical activity and modify diet in a healthier direction, and that these approaches often prove unsustainable, it does become a question about distinctions without differences. Campos doesn’t help his cause with pieces like this in any case.

  7. Hm. Anytime I read about obesity, I think of a (female) friend of mine. She’s overweight, yes.

    She also has PCOS. The treatment for which used to be “lose weight”. I’ve seen her exercise, I’ve seen her diet, I’ve seen her exert more ‘willpower’ on that than any of the gym rats I know.

    Yet it was like hitting a wall. To get the same results as anyone else, the poor girl’s calorie intake and exercise schedules had to be insane. Some people could manage it, I’m sure. Not 100% if anyone with a full time job could, though.

    Then she got diagnosed and treated. Glucaphage and birth control pills, I believe. (PCOS is apparently a lovely little reinforcing cycle of insulin insensitivety and out-of-whack hormones. The hormones screwed up her body’s ability to regulate blood sugar, which made the hormones worse, which made the blood sugar issues worse…the end result was someone whose body was basically designed to convert food to fat).

    Treatment? She lost 20% of her body weight in less than a year. At the time she was in grad school, so she didn’t even bother to alter her diet or exercise plan. I’m not sure she was following one.

    It stayed off, oh, a good four or five years AFTER she stopped treatment. She’s started back up, after what I understand was a real chewing out by her gyno about, you know, “not bothering to see a doctor for six years”.

    The end result — I personally watched a woman whose body was so screwed up by nature that the only way she could have been “in good shape” would have been to exercise like the most obsessed gym rat and diet like an anorexic. But a simple pair of medications to unwind that nasty cycle — one she was more or less born with, I understand — and she moved from unhealthy to healthy over a period of a few months.

    And I bet strangers judged her. Just like, well, I tended to. I realize “I’m not fat, I have a glandular condition” is practically a joke. I know there are obese people out there who are that way because of poor choices.

    But I know for a fact that there are those who aren’t. And between her and a few other friends (one of whose weight issues were like Dawry’s — he started losing weight as soon as he got a knee replacement) to know that, you know what? Sometimes it’s true.

    So I try not to judge anymore.

    • Morat20, thanks for the kind words.

      It isn’t an easy path, and it isn’t as simple as a lot of people seem to think it is. I watch my calories (I eat 1500 along with watching the ratio of fat/fiber/protein) and try to fit in ‘just 5 more minutes’ of whatever exercise I can manage for the day. Sometimes it’s getting off the bus one (or tw0 – if I have the time) stops before my ‘usual’ stop.

      I know people judge me. Anytime I eat lunch, people look to see what I’m eating. They look at me if I drink a diet soda. They look at me if I get a small ice cream cone in 100 degree weather. I’ve gone from a size 32 to a size 26. I want to get back to a 13/14, and I’ll be happy.

      I’ll never be ‘thin’ – my body structure won’t allow for it (I wear women’s size 11 shoes and I can palm basketballs) – so I know that I”ll never be ‘normal’ weight with the BMI index (only 5’6). But I’m ok with that, too. I’ll be smaller, wiser and hopefully healthier.

      That’s all that matters.

    • Glucaphage and birth control pills, I believe.

      I hope she doesn’t expect her insurance to pay for those.

  8. LOL. All I was trying to say is that some folks are fit and fat by providing examples; being fat is their natural state. They are not unhealthy but biased against by doctors. In other words, some folks are born to be fat just like some folks are born to be gay. Sure some people choose to be fat by consuming massive amounts of food, and some folks have hormonal problems causing them to be fat, which can also be inherited or from illness/injury. Body size is every bit an inherited trait.

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