Map of life expectancy at birth from Global Education Project.

Thursday, January 27, 2005

Weird, bizarre, and very, very strange

I.e., "abnormal." I referred in the post on disease and illness to the concept of abnormality. Much of our limited time here on earth is wasted in people talking past each other because the normal/abnormal dichotomy refers to two -- or perhaps three -- quite different categories of meaning.

The first sense of "normal" refers to typicality, being somewhere close (exactly how close is problematic) to the average. When we refer to people being of normal height, or normal IQ, that's essentially what we mean. In these instances, we might want to be abnormal -- to be unusually tall or have an unusually high IQ.

The second sense refers to what is considered good, approved or condoned. To a physician, "normal" weight doesn't mean average or typical weight, because in the U.S., the average person is thought to weigh too much. When a physician makes a judgment that a person is too fat, it based on a belief (quite well supported, in my opinion) that having too much body fat greatly increases the risk of unpleasant consequences, including arthritis, type 2 diabetes, heart disease, and premature death.

Unfortunately, there are other bases for considering a personal characteristic not good or not condoned than simple pragmatic concerns about the possible consequences. These include moral disapproval or social devaluation. People who are "too fat" must endure ridicule, humiliation, moral condemnation as gluttunous or undisciplined. They may suffer professional or social disadvantages. I think that this is why some fat people contest the medical view that obesity is unhealthy. They are conflating that judgment with the social stigma they must endure. If we could effectively separate these two very different kinds of judgments, we could simultaneously campaign against the hurtful, irrational stigmatization of overweight while working to find ways to reduce its incidence and help people to lose weight.

Obesity can be thought of as a kind of psychological disorder, as it is related to behavior, although simple caloric imbalance per se has not been given a psychiatric label. But in the area of psychiatric diagnosis the confusion about the various senses of "abnormal" (or "deviant," a synonym which shares the same multiplicity of meanings) is particularly likely to cause problems.

In the area of sexuality, because there are so many different parameters and also because our knowledge is limited, it is really impossible to define "normal" in terms of what is typical or average. Homosexuality used to be a disease. It is no longer, although it is still undoubtedly somewhat atypical. But while it is not a disease, it is condemned by many people, as we know. A friend of mine has argued that Borderline Personality Disorder (a horribly named condition to which I referred earlier) is comparable to homosexuality in that its labelling as a disease is based on a social construct of what is right or normal. I do not agree with him about that, but he is a very smart guy and the existence of such an intellectually respectable viewpoint does prove that psychiatric labelling is of questionable ontological status. (That's a fancy way of saying that its relationship to reality is contestable.) Antisocial Personality Disorder is a more telling example, because sociopaths aren't necessarily unhappy and don't necessarily think there is anything wrong with themselves or their lives (although the less intelligent and less resourceful ones may spend time in jail). We call them diseased because other people don't like their behavior.

So what is health? What is disease? What is illness? Who decides?

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