Reducing Stigma by Ending the Pathologizing of Fatness - Part 1

Studying the Studies

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When I talk and write about weight stigma (which I do frequently!) I often say/write some version of “you can’t reduce weight stigma while being invested in anti-fatness.” By this I mean, you can’t be invested in pathologizing fatness, calling the existence of fat people an “epidemic,” eradicating fat people from the world and preventing more fat people from existing… and also reduce weight stigma, since all of those things are expressions of weight stigma that create additional weight stigma. Unfortunately, the weight loss industry is counting on us (and by us I mean the general public, the healthcare industry, and anyone they can convince) believing that the same people who are willing to risk our lives and quality of life to make us thin are also the world’s leading experts in ending weight stigma. It seems ridiculous on its face, but it is a massive issue and we are at a tipping point wherein the weight loss industry is trying to co-opt decades of anti-weight stigma work by fat activists and weight-neutral health advocates in order to make “anti-weight stigma” about selling weight loss, using their massive profits to center themselves as the experts.

That’s why I was thrilled to learn of a study by Rachel Fox, Kelly Park, Rowan Hildebrand-Chupp, and Anne T. Vo called “Working toward eradicating weight stigma by combating pathologization: A qualitative pilot study using direct contact and narrative medicine.”

Thanks to Rachel Fox for reviewing my draft prior to publication!

They begin by pointing out that weight stigma is ubiquitous in every area of healthcare, including during the training of healthcare providers even though there is plenty of evidence demonstrating the negative consequences of weight stigma on patients. They also explain that the current methods being used to reduce stigma are minimally effective at best. The goals of their study were to utilize fat studies research to “construct a new theoretical framework for understanding weight stigma centered around the concept of pathologization [and] develop a new normative framework centered around the goal of eradicating weight stigma, and design and qualitatively assess an alternative weight stigma intervention.”

They define stigma using Link and Phelan’s definition that stigma exists “when elements of labeling, stereotyping, separating, status loss, and discrimination co-occur in a power situation that allows these processes to unfold.” By the definition fatness is “selected and deemed salient (labeling,)” then fatness is “linked to a set of undesirable characteristics (stereotyping).” Through this process, fat people come to be seen as “a homogenized, negative outgroup that is seen as fundamentally different from the ingroup (separating).” The final result is that fat people as a group are “devalued, rejected, and excluded from many realms of life; they experience a ‘general downward placement’ in status hierarchies and face internalized, interpersonal, and structural discrimination.” The study authors point out that “Every step of this process relies on the relative distribution of social, economic, and political power.”

They point out that one source of power that creates stigma is the healthcare system and explain that studies since 1975 point out that the pathologization of fatness – turning simply living in a higher-weight body into a “disease” is a source of stigma and can make people’s size the “most important thing” about them, thus “reducing their humanity to bodily deviance and creating stigma.”

Unfortunately many of the current weight stigma researchers come from a perspective of pathologizing higher-weight bodies and thus fail to examine (or even mention) the ways in which pathologizing fatness can create stigma, an issue I wrote about in detail here.

The study authors explain that most weight stigma reduction interventions focus on shifting the “blame” for being higher-weight from the patient to “structural or biological causes.”  Given that pathologization of fatness drives stigma and is not addressed (and is, in fact, supported) in these interventions, they are not successful in dismantling weight stigma.

Another intervention strategy involves attempting to create empathy for fat people which the study authors explain asks those involved to “’put themselves in a fat person’s shoes’ through techniques such as exposure to first-person narratives, roleplaying, imagination, and experience simulation.” These interventions fail on multiple levels, both by focusing on the perceived negative parts of being fat and by failing to question the pathologizing of fatness. As the study explains “because pathologization involves dehumanizing fat people by reducing them to their disease category, empathy-based interventions that do not challenge pathologization will encourage their participants to empathize with a dehumanized figure. In other words, existing empathy-based interventions have failed to produce meaningful reductions in weight stigma because they have promoted a form of dehumanizing empathy.”

They point to a particularly egregious example in which participants read a first-person narrative about the difficulties a fat person faces trying to lose weight. This, of course, reinforces that pathologization of fatness and makes the entire focus of a fat person’s experience an attempt to not be fat (which, I would point out, could be avoided by simply not telling fat people to engage in almost certainly doomed-to-fail weight loss interventions.) This research and research like it “ask participants to empathize with an already deeply negative and stigmatizing understanding of fatness.” (I’ll also point out that this view of fatness reflects the beliefs of the typically thin people who conduct this kind of research.) This “intervention yielded ‘somewhat pessimistic findings” in which increased empathy did not produce a corresponding reduction in weight bias.” It is unsurprising to me that conducting “empathy training” from the perspective that being fat is a disease that makes peoples’ lives difficult would not decrease (and, may well increase) training participants investment in stigmatizing (and eradicating) fatness.

At this point I want to be very clear that there is no shame in having a disease, and there should be no stigma attached. That said, simply existing in a higher-weight body does not qualify as a disease and the weight-loss-industry-driven defining of fatness as a disease is rooted in weight stigma and creates a call to eradicate existing fat people through unnecessary so-called “treatments” that risk their lives and quality of life, and produce billions in profits.

Next the study authors take on the horrifying practice of attempting to reduce weight stigma by having thin people wear fat suits which, the authors explain, fail in multiple ways as they “do not actually simulate the experience of being fat, they homogenize fat people because participants generalize their experiences in a fat suit to the experience of “being fat,” they implicitly value the momentary, false experience of being in a fat suit over the lived experience of fat people, and they do not appear to be effective.” In fact, they go on, research has shown that they can actually increase weight stigma among participants “Because the donning of fat suits produces dehumanizing empathy, it is more likely to be stigmatizing than destigmatizing.”

Finally, they examine anti-weight stigma interventions that rest in the direct contact hypothesis – the idea that “stigma can be reduced through direct interactions between members of different groups.” In one incredibly ill-conceived example, medical students were paired with people awaiting weight loss surgery. (Pairing students in a healthcare system that suggests that it’s worth risking fat people’s lives and quality of life to make them thin with fat people who have decided to risk their lives and quality of life with weight loss surgery is what, to me, makes this a particularly ridiculous study design.) The study authors explain that, while the study did change the students’ attitudes about the controllability of weight through behavior-based interventions, “it also reinforced students’ perceptions of fat people as diseased and convinced them that fat people need more drastic treatment (i.e., surgery instead of low-calorie diets) It did not humanize fat people.”

I exhibit no surprise.

Acknowledging the failure of weight stigma reduction methods that do not seek to dismantle the pathologizing of fatness, the study authors point out that, from a fat studies approach, a “deep, normative shift in existing research goals and practices” is needed. They continue that rather than a goal of simply producing a “statistically significant reduction in some measure of stigmatizing beliefs or attitudes” the goal should be “to eradicate weight stigma entirely by using interventions that undermine stigma and aspire to manifest a world without it.” They are clear that this doesn’t mean that each single intervention must completely end weight stigma, or that the goal should just be a larger reduction in whatever measure of stigmatizing beliefs is being used. “Rather, it means that all interventions should be designed such that they help bring about a world without weight stigma, meaning that even interventions focused on interpersonal interactions can and should still challenge the underlying foundations of weight stigma. Any efforts to reduce weight stigma should be depathologizing and humanizing.”

This will, of course, require a shift in research. Specifically, the authors explain “According to the principles of research justice (Cooper, 2013), interventions designed to eradicate stigma should (a) involve collaboration with members of the stigmatized community, (b) create situations where stigmatized groups are respected and can benefit both directly and indirectly from participation, and c) make findings accessible to stigmatized groups.”

The study is based on the idea that direct contact interventions can fit into these principles. But any kind of direct contact does not, evidenced by the fact that healthcare providers interact with fat patients frequently, but still stigmatize them. The study authors “believe that leveling the power asymmetry between HCPs and fat people is crucial for weight stigma interventions. Direct contact interventions should create the opportunity for mutual vulnerability and mutual benefit between HCPs and fat people. If pathologization depends on the power of medical authority, a depathologizing weight stigma intervention must create situations that take HCPs out of the expert role, empower fat people to speak from their own expertise, and thereby make space for HCPs and fat people to interact on equal terms.”

In Part 2 we’ll take a look at their study and what they found!

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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.