Fighting Weight Stigma by Ending Weight Pathologization - Part 2

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In part 1 we started discussing the study “Working toward eradicating weight stigma by combating pathologization: A qualitative pilot study using direct contact and narrative medicine” by Rachel Fox, Kelly Park, Rowan Hildebrand-Chupp, and Anne T. Vo.

We discussed the issues with existing weight stigma research and the approach that this study is taking. Today we’ll take a look at the study and its findings. Again, thank you so much to Rachel Fox for reviewing this before it was published!

To start with, this is a qualitative study, which means that rather than testing hypotheses to understand the relationship between variables, it instead is focused on understanding an experience in the context of the real world through the use of interviews and observations. It’s also a pilot study which means that it is an intentionally small study, conducted to determine whether a larger study may be warranted.

The study matched 4 first- and second-year medical students with 2 fat community members who had “self-reported experiencing weight-based discrimination from a healthcare provider” and” were recruited from California-based fat activist Facebook groups and word-of-mouth in the online fat community.” In order to assess their attitudes toward fat people, Fat Phobia Scale—Short Form (Bacon et al., 2001)

The intervention involved participants meeting for two hours once per week for five weeks. During the meeting that week’s text was read out loud followed by a facilitated 45 minute discussion of the literary aspects of the writing including “genre, tone, diction, and use of figurative language.” The discussion was followed by five minutes of writing in response to a prompt from the facilitator after which the participants were encouraged to read what they had written and “If they invited feedback, other participants discussed the literary components of their response and what elements of the writing were impactful.” The study authors explain:

We chose texts that specifically dealt with experiences of being fat rather than unrelated literary works or didactic medical information. Thus, while analyzing and interpreting how these texts make their meaning, participants also had the indirect opportunity to think about the nuances and complexities of living a fat life. By focusing on language and grammar, they did not have to evaluate the story’s utility or veracity, but they had the chance to think deeply about it in community with the other participants. Since there was no right or wrong or didactic information to take away, these discussions were designed to encourage participants to show up and engage with one another in their full, multidimensional humanity.

After the first workshop, participants were given an assignment to write about “a time you witnessed, participated in, or experienced fatphobia in a clinical encounter.” Each week they would be asked to write about the same topic in a different style. During future meetings they would break into groups of three (2 med students and 1 community member,) and discuss the writing.

At the end of the fifth and final session they engaged in a full group reflection for ten minutes (without the facilitators present) using discussion prompts about  “what they were going to take away from the workshops”  and “if they had any final reflections for each other. “

One week after the final workshop separate focus groups were conducted with the med students and the fat community members. They were asked four questions about their “general understanding of weight stigma in healthcare and in broader society,”  five questions about their “reactions to the use of narrative methods for addressing weight stigma,” three questions about “the usefulness of direct contact and collaboration” and five questions about “ideas for overcoming weight stigma in healthcare.” The medical students were asked six more questions about “the relevance of narrative medicine to their formal medical curriculum.”

The focus group data found that the “workshops created an opportunity for medical students to think critically about the causes and consequences of the pathologization of fat people. When asked to define fatphobia and speculate on why it exists, the medical students provided broad, complex definitions that acknowledged interpersonal (misunderstanding, discomfort), social (stereotyping, negative media portrayals), and structural (medicine as “normalized” for thin, White, male bodies) discrimination against fat people. These definitions show an understanding that weight stigma does not simply depend on the idea that weight is individually controllable, but rather that it is upheld in many realms of life, including medicine. Medical students also specifically cited how assumptions that all fat people are unhealthy, and the medical authority invoked in those assumptions, perpetuate the stigmatization of fat people. One student unpacked how the word overweight “implies that there’s a normal weight,” which contributes to stigma, while another discussed the “extra power dynamic” between an HCP and a fat person, explaining how an HCP claiming that all fat people are diseased comes across as “more factual and more conclusive, which could definitely lead to more shame” about being fat. Medical students also reflected on how the pathologization of fat people can prevent them from receiving adequate medical care. One student commented on how their curriculum encouraged them to make quick judgments about fat people’s ill health through the use of mnemonics like “fat, forty, female [in reference to gallbladder diseases].” This student drew an explicit connection between the use of such phrases and the way diagnostic shortcuts discourage HCPs from soliciting fat people’s individual stories and medical histories. Another student recounted stories from the community members about how their medical issues were overlooked by doctors because of their weight. The medical students felt that their curriculum encouraged them to define fat people by their fatness and thus prescribe weight loss as “the solution for every disease or illness.” However, they also recognized that there “seems to be a lot of distrust with what fat patients might say,” so even if fat people try to tell their own stories, their experiences may be discounted.”

For their part, the medical students both valued the opportunity to learn from the lived experience of fat people, and recognized the emotional labor that involved. The study authors point out that “When a group is dehumanized, their perceived capacity to suffer can be minimized” and that the students’ recognition of the courage and difficulty of sharing these stories speaks to their recognition of “the community members as agential (choosing to participate in the study) and generous (giving their time and insight to the medical students), two qualities that can be minimized in the process of dehumanization.”

One medical student said, in part “I think before the workshop, I underestimated how much every community member had heard the same thing from every doctor they saw. Even if every doctor had good intentions when they said, “maybe you should exercise,” [the community members] had already heard it so many times before that it just became white noise. I think I would want to keep that in mind whenever I talk to patients…” The study authors point out that this student’s recognition of fat people’s individuality suggests an investment “in the particularity—and thus the humanity—of fat people, including their future fat patients.”

Both students and community members acknowledged that the narrative, collaborative workshop increased their empathy for each other and the authors point out the importance of considering both the experiences of the medical student and the community members for mutual benefit and according to the principles of research justice.

Overall they explain that

Our qualitative findings suggest that our intervention created the depathologizing, humanizing, and empathetic interactions that we theorized are important for eradicating weight stigma. Using direct contact structured by narrative medicine workshops, we formed a small space where the power of medical authority was temporarily undermined, as evidenced by the way that the medical students reflected critically on their training and respected the expertise of the community members about their lived experience.

They acknowledge the limitations of the study including the small size (and thus the limited applicability of any pre and post quantitative measures, the fact that qualitative findings may be specific to the study participants and not extrapolatable, the fact that their participants were medical students rather than fully-trained practicing providers, perhaps minimizing the power imbalance between them and the community members, and finally issues with recruitment, drop-outs, and diversity, )and they provide recommendations for addressing these limitations in future work.

They point out again that “All weight stigma interventions must begin from the premise that fatness is not pathological. Anything less is merely perpetuating the oppression of fat people at the hands of the institution of medicine,” they end by saying “weight stigma research should treat fat people the way that fat people would be treated in a world without weight stigma.”

I couldn’t agree more and I’m so grateful for this work!

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.