What Shouldn't Have Made The Cut

Fair warning: This is an essay written by a man who is very angry about something that he saw written on the internet. I'm so annoyed that I've linked to an archive version, because the original really, really doesn't deserve the ad money. Ideally, this is an essay on a topic that should have The Last Psychiatry come running out of retirement: it's got more narcissism than a mirrored pond with a floating corpse in it. But he's busy writing about porn (which is a secret, mystical way of writing about everything except porn), so you'll have to settle for me.

I'll front-load the biases. I'm a psychiatric resident. I have treatment-resistant depression and ADHD, both of which I've been in treatment for longer than is dignified, neither of which a kind observer would call well-controlled, and both of which I'm routinely more up-to-date on than is the case for the average disease I'm asked to tackle, my stake being personal. The joke in the trade is that psychiatrists are the least mentally well specialty in medicine. I'm in no rush to falsify this.

This is relevant because I have, with embarrassing regularity, looked at my own behaviour, recognised that it was neither fair nor defensible, and then gone on doing it anyway. Depression plus ADHD is a hell of a cocktail; you get the insight free of charge and the follow-through at reserved-box-seat prices. I've been a worse friend than I meant to be (quite often). I've (very rarely) cancelled on people for reasons that would not survive five minutes of cross-examination. I'll do it again before the year is out. Pretending otherwise would be a lie, and not an interesting one. Pretending that I'm a bad person would be an even bigger lie, and one that I am fortunately not depressed enough to claim, at least while believing it. It's up to you to decide if that's interesting or not.

What I have never done, and what I think marks the bright line between person with a mental illness and person who has discovered a useful new weapon, is convert the failures into publishable wisdom. I have not written a two-thousand-word first-person essay in which my therapist's working hypothesis became the universal ethics of friendship. I have not torched a relationship, sat down the following Monday to compose a well-crafted treatise explaining why the torching was in fact an act of moral seriousness, sold the treatise to The Cut, and then watched the magazine commission an illustrator to make the fire look photogenic.

Sophia Ortega has. The kicker, the thing that turns this from a sad piece into a contemptible one, is that she has done it in a manner that reveals, paragraph by paragraph, that she knows exactly what she is doing.

Wegoy Is Great, Actually

Wegovy is semaglutide at 2.4 mg, a GLP-1 receptor agonist in a drug class that has been in clinical use for roughly two decades. It is approved for chronic weight management. Since March 2024 it is also approved for reducing the risk of cardiovascular death, heart attack, and stroke in adults with established cardiovascular disease. The trial that earned it the second indication, SELECT, enrolled 17,604 patients and produced a 20% reduction in major adverse cardiovascular events and a 19% reduction in all-cause mortality against placebo. These are numbers pharmaceutical companies light cigars over. Across the broader GLP-1 class, the emerging literature01375-3/fulltext) on neurodegenerative disease, inflammatory disease, and addictive behaviours keeps getting better, not worse. Hey, I know you've probably read Scott's piece on the topic, so I'll stop belabouring the point. On a more personal note:

My mother is severely diabetic, and was close to non-alcoholic fatty liver turning into outright cirrhosis because of it. I was resigned to eventually donating mine, if she needed it, but I was fortunate enough to find out about semaglutide before it was cool (or particularly cheap). I badgered her into seeing an actual endocrinologist who did end up prescribing it to her, and I've very recently looked at her blood work and felt outright awe at the night and day difference. In a very real sense, I might have bought my mother - the lady I love the most - at least a decade of healthy life. I'm suitably proud of that.

I've been on it myself, albeit mostly electively. A certain antidepressant that is notorious for temporary somnolence and permanent weight gain had deleterious effects on me. The semaglutide helped. It didn't save my life, but considering the savings on takeout, it definitely earned its keep.

What I'm getting at is that the stigma around these drugs is a public-health problem, and essays like Ortega's exist to shore it up.

None of this appears in her piece. It cannot, because the essay runs on the axiom that Wegovy is not a pharmaceutical but an ideological artefact, diet culture concentrated into a pen-shaped delivery device. Her friend, whose name we are never given and whose medical reasoning is never sought, is not a patient being treated for a condition. She is a woman making a statement, a bad one, with her body. The whole piece rests on that reframe. Take it away and the headline becomes "Losing My Friend Over Her Statin," and your features editor at The Cut is politely asking whether you've considered a different angle.

Arbiter of Trouble

The scene, briefly. Ortega is alone in her friend's apartment, dog-sitting. The same friend who literally let her crash at her place for ages, after she fell on hard times. She has opened the refrigerator for reasons she declines to explain. She has found a box of Wegovy. She has read the label closely enough to note the typographic choices. Her first thought, she tells us in print, is that it might be for the dog. Four paragraphs later she clarifies, still in print, that no, the dog was not on Wegovy.

(I must admit that I found this bleakly funny: she's a decent writer, a fact I acknowledge after fending off accusations of the same. Good joke, and to be honest, my older lab could do with a diet.)

What she does next is text the friend from inside the friend's kitchen: "wegovy… You're not in trouble but what is going on."

The second clause is where the essay lives. You're not in trouble. That is not the voice of a friend. That is not even the voice of a hurt friend. It is the voice of a parent addressing a teenager caught with something in the bedside drawer. It presumes a reporting relationship, an authority gradient, an adult-to-child asymmetry of standing. Ortega has moved physically into her friend's apartment for the afternoon and then moved psychologically into her mother's chair. From that chair she graciously declines to escalate, thereby confirming that escalation was on the table. She weaponizes her “restraint”, and then reneges on that stance the moment it becomes convenient to do so.

Look: Two grown women. Prescription medication in the owner's own home, in a box with the owner's name on it. No reasonable frame in which Ortega is the aggrieved party. The text pretends there is one, and the pretence is the point. "You're not in trouble" is a social-control move, the kind of sentence you deploy when you want to extract a confession without having earned the standing to demand one. And it works, because the friend confesses.

She comes home. She apologises. She laughs nervously. "I can't believe you found out." "You're the one who really couldn't find out." A woman is apologising to her houseguest for the contents of her own refrigerator, and the houseguest is permitting her to do so. No functioning member of the writing staff at The Cut appears to have flagged the inversion, though I'm going to force myself to be kind and admit that editorial staff aren't there to enforce ethical standards first and foremost. In psych we would call it incongruous affect. The grown adult is being infantilised, she is accepting the frame, and the one holding the reins is writing it up for money.

On the walk home, Ortega has "a brief but violent fantasy about breaking and entering her doctor's office." This goes into the essay the way another writer might note that she stopped for coffee. No flinches, no expression of regret. In a psychiatric assessment this sentence generates follow-up questions. The fantasy is not about confronting her friend, or processing her own distress, or throwing a plate at a wall. It is about committing a crime against a third party, a physician she has never met, whose only offence is having prescribed a drug Ortega disapproves of to a patient Ortega does not own. I'm not diagnosing her with anything, my armchair’s arm rest doesn't reach quite that far, but goddamn.

The Extension

Two-thirds in, the line the rest of the piece is organised around: "At the end of the day, it's her body and her choice, but it's hard when she feels like an extension of myself."

A forty-something writer in a flagship women's magazine, describing her adult friend's body as a prosthesis of her own. In print. Under her byline. Without the grace to be embarrassed. The disclaimers on either side ("her body, her choice," "in many ways I'm being a baby") aren't hedging. They constitute structural adhesive, applied to keep the thing in the middle from falling off the page. The but is load-bearing to a degree rarely seen outside a Jenga tower in its last three moves.

The more I look at this rhetorical chokeslam, the more I see the ever inflammatory “your body, my choice.” Used by a woman, on another woman, one who has been nothing but kind to her. I'm impressed at the verbal and ethical judo here, the typical man could never.

Once you see the line, the rest collapses into diagnostic clarity. The friend's pharmacy is Ortega's business because the friend's body is, by Ortega's theory, Ortega's body. The friend's secret is a betrayal because one does not conceal one's medication from one's own limbs. The book club cannot be attended because the drug in the friend's bloodstream is, by the transitive property of narcissism, in Ortega's. The doctor who wrote the prescription did so without Ortega's consent, which is how a person ends up casually describing a breaking-and-entering fantasy as if reporting on the weather.

Earlier in the essay, Ortega praises a "favourite ex-boyfriend" who used to sweep hotel rooms for bathroom scales before she arrived and hide any he found. She calls this "a remarkably loving gesture." Loving gesture? Quite possibly, but it was also a chore. The man she dated most fondly was the man most willing to do her unpaid environmental services work, which tells you something you need to know about the going rate of admission to her inner circle. The friend was running the same errand, less demonstratively, by hiding the Wegovy in the back of the fridge. When caught, she apologised, because that was the arrangement. Proximity to Ortega is staff work. The pay is access. Her friends come to her; she does not come to them.

(It hurts to say all of this, since, in a vacuum, the near and dear ones of someone suffering from mental illness deserve praise for accommodating them. The problem is that the person they're accommodating is a psychic vampire, one who's proud of her fangs. One who says her dietary habits save her money on crimson lip gloss.)

The Actual Grievance

Strip off the diet-culture wrapper and the piece is not about Wegovy. It is about the collapse of a status differential Ortega had been quietly banking for years.

Before the fridge incident, she was the Recovered One: the woman at the table who had Done The Work, the visible survivor with the hard-earned appetite and the moral high ground. Her friend, under the unwritten terms of the arrangement, was meant to stay in her current body, eat her current food, and applaud Ortega's ascension from the respectful distance of someone who had not earned any of it. The Wegovy violated the treaty. Her friend, by taking it, was choosing her own exit from a body she did not want to be in, through a route that did not require Ortega's framework, Ortega's therapist, or Ortega's permission. Worse, the route was working. The friend was getting healthier and getting thinner, and she was doing it without any of the elaborate suffering Ortega had been obliged to perform for her own recovery.

This is unbearable to Ortega in a way she cannot bring herself to say out loud, so she does not. She says "diet culture" instead, which performs the same function but sounds nicer in print. It has the particular virtue of reclassifying what is actually envy, along with the collapse of a status arrangement she depended on, as principled ideological opposition to a medical technology she has not bothered to understand.

This is what people gesture at when they talk about the increasing weaponization of therapy-speak. The assumption that if you can glibly articulate your problems - and the meta-knowledge that you know you have a problem - well, that's a free pass to keep on taking the same shit in a different toilet.

The Miranda July detail clinches the diagnosis. The book is All Fours, described by Ortega herself as "about a woman rediscovering her body as a vessel for pleasure and choosing to indulge her appetites, no matter the mess." She had dog-eared the copy. She was excited. She bailed on the discussion because her friend, the host, was on a medication that happened to affect appetite. The structure of that preference is the thesis. A book about a woman choosing to indulge cannot be discussed in the presence of a woman who, at the direction of her physician, has chosen not to. The theology Ortega has constructed around appetite accommodates exactly one appetite. Hers. Every other body in her vicinity is a set piece in the ongoing production of her recovery, and any body that steps out of its blocking receives a two-thousand-word writeup in a national magazine.

Self Awareness Only Goes So Far

Now the part I am actually qualified to be angry about.

Ortega knows. You can watch her knowing in real time. She tells the friend, on the couch, seconds into the confrontation: "I'm the worst person for this." She tells the reader, in the back half of the piece: "in many ways, I'm being a baby." She writes "I don't fault my friend for any of this. Of course I don't," and then spends the rest of the essay faulting her friend for all of it. Of course is a tell. Nobody opens with of course about a thing they actually believe; the phrase is a pre-emptive defence against a charge the speaker anticipates.

The temptation in the face of this running commentary is to treat it as mitigation. She admits she's being unreasonable, so give her credit; she's trying. I disagree, and I disagree on clinical and moral grounds. Unexamined cruelty is the easiest thing in the world to forgive. Unexamined cruelty doesn't know what it's doing; you can educate it, walk away from it, or wait it out. Examined cruelty is a worse animal. Examined cruelty has looked at itself, filed an incident report, stamped the report acknowledged, and carried on.

It is a pattern I see often in my own patient population, and occasionally in myself. A subtype of well-read patient presents with what I might call epistemic fluency and behavioural paralysis. They have the vocabulary. They can name their attachment style at intake. They can list their defences. They cannot, under any circumstances, alter a single thing they actually do. The vocabulary, in practice, is deployed to pre-empt challenge. "I know I'm being avoidant" is not, in these patients, a first step toward being less avoidant; it is a ritual phrase that, once pronounced, buys another week of avoidance. The therapist's job in such cases is less to increase insight than to stop rewarding the performance of it.

Ortega, in prose, is one of these patients. "I'm being a baby" is not a sincere confession. It is a plea entered to the lesser charge, filed so the greater charge never has to see the jury. The lesser charge is "unreasonable behaviour." The greater charge, not prosecuted, is "systematically dismantled a close friendship because the friend sought medical care for a chronic metabolic condition, and then sold a two-thousand-word account of the dismantling to a national magazine, in which the friend appears only as a device for the author's self-knowledge." She's wry enough to cop guilty to the jaywalking, while making money selling the movie rights to the arson and murder. The piece is structured so the jury votes on the first count and goes home. Ortega, if you read her carefully, has been practising this structure her whole life. It is, I suspect, how she has survived. It is also why everyone around her is exhausted. I'm exhausted too, even with the benefit of an ocean in the way. That's being on the internet for you.

There is a rule I try to keep, even when it costs me something: being kind to the cruel is a form of cruelty to the kind. Every editor, every reader, every friend who has ever seen Ortega self-deprecate her way out of accountability and let her off on the strength of it is, in some small degree, responsible for the essay. She has been trained, by decades of credit for the self-deprecation alone, to believe that seeing herself clearly is interchangeable with acting decently. It is not. She has demonstrated as much on the page. The decent actions available to her were: say nothing, go to her therapist, feel her feelings in private the way the rest of us are obliged to when our friends make choices we would not make. She took none of them. She took the essay.

The Least Painful Breakup

There is one line in the piece that, read properly, should have made the editor spike the draft and call someone. It is: "Of all my breakups, this has been the least painful, not because our love was platonic, but because it was an act of self-protection."

The least painful.

By Ortega's own telling, earlier and at length, this was one of the closest friendships of her life. They had been mistaken for each other. Same birthday, two days apart. Same shoe size. Same clogs. Same block. Cats traded between apartments. They had lived together, for months, when Ortega had nowhere else to go and her friend took her in at cost to her own living arrangement. On Ortega's own accounting, the loss of this woman hurt less than a standard-issue romantic breakup.

The mechanism is in the construction. Self-protection is an anaesthetic. It converts grief into hygiene. You are not mourning a person you loved; you are maintaining your recovery, which is a virtue, which means the grief does not count as loss but as evidence of having done the hard work. That recoding is the product the essay sells, to its readers and, more importantly, to its author. Ortega is not mourning her friend. She is metabolising her. The friendship has been digested into two thousand words of marketable, viral content; and I use “viral” here as pejoratively as I would for HIV. The byproduct is the neurochemical warmth of having passed a moral test; the friend, who by every line of evidence in the text continued being kind throughout, does not get to leave the story on her own terms. She is left. She is then written up. She is then illustrated. And the months she spent nauseated on a new injectable, adjusting to a real drug in a real body, are recycled as "your poor body" jokes in the text thread her ex-friend reproduces for copy.

This is cannibalism with better vocabulary. The friend, in addition to the condition she was treating and the nausea she was enduring, has been eaten for content. That the eating was performed with visible self-awareness on the author's part does not diminish the eating. It may in fact be the worst part of it. Ortega knows what she is doing. She is doing it anyway. She is being paid.

A Friend You Need, But Clearly Don't Deserve

I find it worth saying (because the essay works hard to obscure it) that the friend is the only adult in this story. She has a medical condition. She sought medical care for it. She kept the decision private because she correctly identified that her closest friend would react poorly. She continued being a good friend through the fallout. When caught, she apologised for something she did not need to apologise for. When refused at book club, she said "That makes me very sad but I do understand," and meant it. She did not publish a rebuttal. She did not leak the group chat. She did not, as far as we know, write an essay of her own, though she would have had a much easier time of it than I am having.

She is going to be fine. She has a doctor, a prescription, a new book club waiting for her, and, if the small constituency of strangers already rooting for her online is representative, more public sympathy than her former friend is going to enjoy once this piece ages another week. She is going to feel better. She is going to live longer. With the benefit of hindsight, I'm confident that she'll understand that Ortega did her a favor by amputating her from her life. It's not often that a tumor is courteous enough to wield the scalpel for you. Her only sin was too much kindness, and hey, maybe Ortega does have redeeming qualities that aren't being mildly amusing at her best.

The Genre/The Ennablers

The magazine. The Cut has spent the past fifteen years optimising a pipeline for converting the private distress of youngish women into engagement-ready first-person confession. Laura Bennett called this out at Slate back in 2015, and the diagnostic has aged well. Writer produces confession. Editor commissions illustration. Magazine publishes under a "First Person" banner that encourages the writer to mistake herself for Joan Didion. Reader comes away with the impression that she has read wisdom rather than symptom. Writer, if she's any good at it, gets a second commission. The subject of the confession, if there is one, gets nothing.

The extra cost in this particular case is that Ortega's piece makes a real contribution to a real public-health stigma. GLP-1 prescribing is already somewhat constrained by shame, by the residual suspicion that taking a drug for one's weight is somehow beneath taking a drug for one's blood pressure. An essay in a major women's magazine reframing a friend's use of one as a contamination too toxic to remain in the room with is not a neutral act of personal expression. It is, among other things, a nudge in the direction of less care for more people who need it. The author's distress does not exempt the piece from that cost, and neither does her byline.

I do not expect that Ortega considered any of this. I am quite confident her editor didn't. A competent editor (or at least a decent human being), when handed a draft in which the author narrates her own active relapse ("my own eating turned feral in a way it hadn't for years") in the same piece that presents the friendship-ending as mature self-care, would have asked: is this a piece, or a cry for help. A kind editor would have said: this is beautifully written, and I think we shouldn't run it, and I think you should talk to your therapist about the parts of it that scared me. They did neither. They ran it. They got the engagement they paid her for.

End of Line

Ortega's closing line is the one sentence in the essay that earns its keep without argument: "Hunger is the body's announcement that it is alive and wants to stay that way." It is true, and well put. Her body made that announcement, unheard, for thirteen years into a room that had been soundproofed by her illness, and she has earned, at a cost I would not pretend to comprehend fully, the right to hear it now. I am glad she can. I hope she keeps hearing it for as long as she is given.

Her friend's body made the same announcement. The words it used were slightly different. It said it was tired. It said it was at risk. It said, through a physician whom Ortega has never met and has fantasised about burglarising, that there was a medication for this. Ortega could not hear the announcement, because she had decided, before the refrigerator was ever opened, that the medication belonged to a category she would not tolerate in the room. She is entitled to make that decision for herself. What she is not entitled to do is have the decision laundered into ethics by her magazine and delivered to the rest of us as instruction. What she is absolutely not entitled to do, is to expect that her behavior goes by unnoticed and unchecked. Consider me a reluctant contributor to a very small shitstorm. I would not normally write this essay, but I believe that the clade of personal-essay writers who make a living off commodifying the lives of others are willingly shrugging off most of what privacy I'd normally feel they're entitled to.

There is a rule of thumb in my line of work that I will gift, unasked, to any reader who got this far: if your recovery requires other people to orient their bodies around your triggers, your recovery is not going well. It is, more plausibly, a protection racket with your illness as the enforcement arm. I stress that this is a rule of thumb, and probably not even a very straight thumb - if you're a recovering alcoholic, then you have every right to ask your buddies not to call you out for a pub crawl. If you're in recovery from anorexia, then you have every right to get mad if your old Tumblr buddies DM you thinspo. But there's a limit to that, and one that's… abundantly clear, by this point. So I hope, or at least I'm too tired to continue litigating it. There is no bright line between day and night, but if you're breaking your nose on unseen foliage, then you might want to wait for dawn.

Ortega has written a few thousand words acknowledging as much and framing the acknowledgement as personal growth. The friend understood, and let her go. The editor understood, and ran it anyway. The last participant in the chain with any leverage at all is the reader, and the appropriate response from that reader is not sympathy, and not outrage, and not virality. It is the sentence the friend was too gracious to say out loud, and that someone owes Ortega on her behalf: none of this was ever any of your business. It never will be. And she is not going to apologise for the contents of her own fridge ever again.

The last thing I want to see, as someone weighed down by invisible chains, is someone else wrapping them around perfectly manicured fists and using them as a cudgel. Sorry, I know I'm angry. I can only hope I am reasonably angry, and if not, that you don't hold it against me too hard. See, self-awareness. If you're going to hand out points for that after I've argued against feeding the beast that bites you, you won't resent the odd nibble.