I received the following e-mail from a blog reader who is a certified sex therapist. Her question is one that I hear from and about therapists of all specialties so I thought I would answer it here. (The quote may be a bit triggering, you can skip the indented text to skip the possible triggering language.)
I’m currently a board-certified sex therapist. My clinical “home” is AASECT – the American Association of Sex Educators, Counselors and Therapists – who do fabulous work and push the envelope mightily when it comes to healthy sexuality. My other clinical home is a local listserve. But there are occasions when these two homes can feel like jails – and being part of a small town community and a small, collegial association means that I’ve been reluctant to take on my colleagues despite occasional, and horrendous, comments that are made, clinicians who make a practice out of weight loss therapy, and awful comments linking obesity and health, and obesity and sexuality.
The frequent comments on both listserves concerning obesity are so distressing – and I’m enraged that folks are practicing so unethically. Here’s one from today…. ” We all know Obesity exists and I don’t see this diagnosis in the DSM. Addiction is prevalent in our society. There are individuals eating too much, gambling too much, drinking too much, shopping and spending too much. All to fill a void or manage emotions.” People who would consider themselves evidence-based clinicians freely throw around screwed up commentary about fatness and I have so far just sat back fuming. I’m struggling both personally and ideologically with this as an issue, and can’t figure out how to proceed to take on my colleagues. I regularly post your blog posts on my center’s Facebook page, cut and paste comments from your blog and put them on my personal FB page to “train” my friends in HAES thinking – but haven’t figured out how to address the issue of my colleagues and their fucked-up thinking. Part of this is that if I piss off people locally, I’ll be ostracized from my local clinical home – a big rural landmass, not many people. My business depends on referrals from local doctors, psychiatrists and other therapists.
I’m rambling – and this in itself will tell you how distressed I am. I don’t know how to address this or where to start.
Let’s talk about the actual issues first and then we’ll talk about the politics.
There are two errors that are likely to be committed here. The first is the same weight/health conflation and stereotyping that we talk about all the time, the second is an issue that when all you have is a hammer, every problem looks like a nail.
I talk a lot about the fact that obesity is not a physical health diagnosis – it’s simply a ratio of weight and height. By the same token, body size is not a mental health diagnosis. While it’s possible that someone’s body weight may be related to an issue such as binge eating disorder, someone’s body size never ever constitutes a mental health diagnosis.
The people who practice weight loss therapy are engaging in the same mistakes as medical doctors who prescribe weight loss. I find it even more unconscionable coming from a purported mental health specialist who should know better than to set people up for failure and then blame them when they fail (since they are obviously harboring the delusion that they can help people achieve long-term weight loss despite a complete lack of evidence to corroborate the theory and a ton of evidence that people are likely to end up less healthy than when they started from both physical and mental health perspectives.)
In my experience, people who push the idea that obesity should be in the DSM as a diagnosis come in three basic varieties. There are well-intentioned people who want to make sure that everyone who does need mental illness treatment gets that treatment and so try to get it covered by insurance in every way possible. There are people who have bought into the stereotypes and misinformation about fat people and are simply tragically misguided. Finally, there are people who look at us and see dollar signs. Eating Disorder Treatment centers and weight loss practices can be lucrative for-profit businesses, and if obesity is considered a diagnosis then that’s a whole lot more potential customers for them (and just like the diet industry, their solution will lead to weight cycling which leads to repeat clients.)
This is a very simple concept: the belief that you can determine anything based on how someone looks (other than how they look) – is stereotyping at best and, when it’s for the purpose of making a mental or physical health diagnosis it constitutes malpractice. Period. Often when dealing with people of size this behavior is engaged in by people, like therapists, who we really wish knew better – and/or who know better for every group except us.
One issue that can happen with health care practitioners is that their specialty becomes a hammer, so every problem they see is a nail. Remember when Doctor Oz tried to claim that every fat person has heart problems because every fat person on whom he had performed cardiovascular surgery had heart problems? Obviously this logic is flawed because people with good hearts don’t get their chests cracked (and every thin person he performs surgery on also has heart problems, but he does not assume that all thin people have heart problems.)
This is what sometimes happens with therapists – every person of size they see has issues with food. Of course that’s because those people come to them because their practice specializes in helping people who have issues with food. Still, therapists are human and can lose perspective and they are inundated with the same incorrect information about health and weight as everyone else. I once witnessed a conversation where someone tried to explain to a binge eating disorder specialist that I did not have binge eating disorder. Her response was that she was certain that I had BED because, in her experience, people don’t get to be my size without having an eating disorder. The statement is true but the conclusion is false – her experience is completely colored by the fact that it is made up of people who sought her out for her claim that she has expertise is dealing with eating disorders, and I happen to look like those people.
With sex therapists, my biggest concern is a scenario in which someone comes to the therapist because their sex life is being affected by body shame brought on by a culture of fat hatred. If the therapists assumes that their body size indicates a mental illness, then they will become part of the bullying culture, engage in victim blaming, and attempt to solve social stigma by trying to get the stigmatized person to change, rather than helping the person acknowledge and cope with the unfair stigma with which they have to deal. The cure for social stigma is not weight loss. The cure for social stigma is ending social stigma.
Bottom line: There are fat people who have under-eating disorders, there are thin people who have over eating-disorders. There are fat people who have very healthy relationships with food and their are “normal weight” people who have very unhealthy relationships with food. As far as I’m concerned, trying to make a mental health diagnosis by looking at someone indicates gross incompetence.
So those are the basic responses, now let’s quickly talk politics.
There’s not an easy answer here. Each person who wants to fight fat oppression has to decide what/if they are willing to risk to do it. It’s entirely your decision and any decision that you make will be valid. The truth is that in order to succeed at ending fat oppression and weight bullying, many people will have to risk something. Some people will have to risk everything – that’s the nature of revolution – but that person doesn’t have to be you.
Once you decide what you want to risk you can choose what method you think will be likely to succeed and be within your risk tolerance – anything from full on confrontation to doing nothing.
One thing that I’ve found can be successful in a situation where less confrontation is called for, is making the point in the form of a question attached to research – for example: “I was reading this paper by Linda Bacon and Lucy Aphramor that seems well-researched and talks about the lack of research on weight loss efficacy. I know that you offer weight loss in your practice, can you help me understand how your philosophy differs?”
“I wanted to get your thoughts on this – I read a lot of blogs written by people of size and one of the things they talk about is their frustration with health professionals making a snap diagnosis based on their body size. They say that it’s stereotyping, that it ignores the fact that mental illnesses have many diagnostic criteria and that body size alone does not constitute a diagnosis, ignores the fact that there are people of all shapes and sizes who experience disordered eating and people of all shapes and sizes who have healthy relationships with food, and that it’s disrespectful to them since they are the best witnesses to their own experience. What do you think?”
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