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Notes -
Gender dysphoria and its similarities to more general body dysphoria
So consider the /r/loseit subreddit. There are a ton of people on there who hate their appearance and would like it to be different. Consider also the community of people who get plastic surgery.
Hating your body is a very universal human experience! An experience that sucks! The interesting thing here is how the different types of "hating your body" are perceived radically differently by wider society. As in:
(1) Consensus is that weight-based body dysphoria is reasonable and you should fix it by dieting. (It can also be fixed by medication-- semaglutide/tirzepatide, in particular-- but this has not achieved widespread social acceptance.) There is also a fat-acceptance movement, but this is niche and is discouraged by obesity being comorbid with a ton of medical issues.
(2) Consensus is that age-based and (more broadly) ugliness-based body dysphoria is something you should just get over instead of addressing directly. Plastic surgery exists, but it does not have widespread social acceptance, and it is socially acceptable to make fun of women whose plastic surgeries are bad enough to be noticeable.
The common line of "cosmetic surgery won't make you feel better about yourself" is contradicted by pretty clear evidence on average; a cursory google scholar search gets us https://academic.oup.com/asj/article/25/3/263/227685 , which claims the following:
(3) Gender dysphoria has, of course, gotten a huge amount of play in the media since addressing it optimally requires surgery and hormones in adolescence, when we mostly accept that people have not yet reached their full capacity for judgement. Plus, even in rich countries bio-engineering has not reached nearly the place it would need to in order to make neogenitalia function properly, or for "passing" to be easy for transitioners.
Is the current push for social acceptance of gender-based body modification something that will spread into other kinds of artificial body modification, such as plastic surgery for appearance or medications for weight loss?
I certainly hope so!
These 3 things all have different causes of "not liking how you look," different proposed interventions, and different consequences for those interventions.
Being overweight is mostly the result of being exposed to and embracing an environment unlike the one we evolved in, with easy access to high-calorie foods and reduced need to engage in physical activity. It has a lot of negative medical consequences. It should be no surprise, nor considered unexpected, to not want to be in this state. The process of losing weight is mostly eating a more normal amount of calories and engaging in physical activity, which are both entirely "natural" (in the sense of reflecting the evolutionary environment) and which have positive medical consequences even aside from losing weight. I think calling this "dysphoria" in the same vein as obesity is equivocation and not useful in understanding what's going on.
Age-based appearance change is "natural" (expected, typical, whatever) and thus the only interventions available, other than partial mitigation by the same kind of healthy living mentioned above, rely on modern technology. There might be some negative effects of age which can be mitigated this way (like improving vision by tightening the skin around the eyes) but mostly cosmetic surgery to change appearance has little effect on physical health.
I don't know much about the history of gender dysphoria, but a description like "feeling like you're in the wrong sex body" indicates that something is going wrong. It's weird to use language "not working properly" in an evolutionary context, because evolution does not have purpose. However, if we can say that a complex brain does something which improves fitness, then the brain operating in this way is probably not doing that, like how a brain that hallucinates is not improving the fitness of the organism its in. There are ways to affect one's appearance (breast binding, hair, clothes, etc.) but sex-change surgery or manipulating hormones is very new, it's a pretty serious and irreversible intervention, and it certainly doesn't reliably solve all of the relevant issues (not even appearance, reliably).
Worth pointing out that diet and exercise alone have extremely poor intent-to-treat efficacy, generally between 2% and 4% of body weight as measured by most studies. For instance, see https://www.nature.com/articles/0803015 . Medication dramatically improves weight successfully lost (see also: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183)
I'm aware that the studies don't show huge effect sizes, but I'm also skeptical of their quality. For example "intention to treat" does not mean the subjects actually adjusted their diet and exercise as much as intended. That people are bad at following the interventions is certainly relevant information to have, but it doesn't mean that diet and exercise aren't relevant, just that people are bad at sticking to these sorts of changes.
Some other limitations to interpreting results like this:
The included studies range in duration from 10 to 52 weeks, average 33, and the meta-analysis reports an average of 13kg or 28 pounds lost with diet and exercise combined. In my mind, that's quite good. It's certainly much more than 4% of body weight. I don't expect these changes produce immediate results; most people who are obese have been slowly adding fat and weight for man years, and it takes time for them to become healthy.
Drop-out rate of included studies ranges from 15-25%.
Out of the included studies, 1 was male-only, 3 were female-only, and 2 had both. So 28 pounds is an even larger relative reduction.
You're definitely right that diet-and-exercise studies include a huge range of effect sizes. I'm not 100% certain how to interpret this; my suspicion is that there's a hidden intervention sliding scale between "doctor says to you, with gravitas, 'eat healthier'" and "nutritionist locks you in a box and hand-feeds you kale that they calorie-counted themselves." And meta-analyses do a poor job differentiating between these, including the one I linked.
I would expect that more dramatic effects combined with heavier fadeout of results is a natural indicator that a particular study is doing an unsustainably aggressive intervention; in the meta-analysis, it indicated that in both diet-only and diet-and-exercise groups everyone regained about half the weight after a year. Which still does leave 14 pounds, and that isn't anything to sneeze at.
You are also right that there are two ways of doing these studies-- "as prescribed" and "intent-to-treat", and as-prescribed results will always show much better effect sizes than intent-to-treat results. In a sense, intent-to-treat isn't measuring the results of the treatment as much as it is measuring the results of prescribing the treatment. And as-prescribed, diet and exercise will always be 100% effective at inducing any amount of weight loss almost by definition. Hard to beat that, really.
But on the other hand... I kinda figure that intent-to-treat is a fairer representation of real life? In the sense that in real life people don't have the option of getting locked in the nutritionist-box indefinitely. And if two treatments are both effective as-prescribed, but the first one has much worse intent-to-treat efficacy, I want the second treatment.
Sure, but that wasn't the point I was making. The point I was making is that obesity is caused, in the first place, by poor diet and lack of exercise.
Yeah, sorry, went on a bit of a tangent there. Anyway.
I feel a lot of skepticism about bad diet and exercise habits being the primary causal drivers of obesity, since on a personal level I know some people who struggle to lose weight in spite of vigorous and frequent exercise and a diet heavy in foods traditionally considered healthy.
I expect that genetics has a hell of a lot to do with whether somebody becomes fat or not, and that "well you probably have bad diet and exercise habits" is a close-to-hand explanation that is both extremely difficult to falsify and which satisfies our instincts toward the Just World Hypothesis. There might also be chemical contaminants involved.
There might be some sort of interaction between genes and environment, where some people are more susceptible to modern lifestyles causing obesity. But the obesity rate has increased rapidly across many countries, so whatever it is, is not wholly genetic.
(Not sure if you got the chemical contaminant hypothesis from Slime Mold Time Mold, but apparently a lot of their claims are not well supported.
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