Understanding Weight Stigma in Healthcare Practice

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Weight Stigma impacts fat people’s healthcare at every level. Let’s start with what weight stigma is with, as always, a reminder that I am not in charge of defining things for all of fat-kind, this is just how I think about it. Also, a reminder that weight stigma is rooted in, and inextricable from, racism and anti-Blackness, and I urge you to read Da’Shaun Harrison’s Belly of the Beast and Dr. Sabrina Strings’ Fearing the Black Body to learn more about this.

To me, weight stigma is any belief that a thinner body is better than a fatter body – whether that means a belief that thinner bodies are healthier and/or more attractive and/or more deserving of accommodation etc.

Where weight stigma is about beliefs (both individual and societal) weight bias is about the action of treating fat people differently.

As always, weight stigma and bias can harm people of all sizes, but they do more harm to those at higher weights and/or with multiple marginalized identities.

There are general basic forms:

Extrinsic/Explicit/Conscious

This is conscious weight stigma and bias - the person is aware that they have negative beliefs about fat people and is purposefully acting on them. A few examples would be a healthcare practitioner who holds negative stereotypes about fat people and states them out loud (to patients and/or colleagues/coworkers,) or who insists that they shame fat patients ‘for their own good," or who believes that suffering and pain as weight loss intervention side effects are acceptable because fat people deserve to suffer.

Intrinsic/Implicit/Subconscious

This is subconscious weight stigma and bias. In this case the person has bought into stereotypes and negative beliefs about higher-weight people and is operating from them without being conscious that it is happening.

Internalized:

This occurs when a higher-weight person internalizes negative beliefs about their own body. It often causes them to participate in their own oppression and the oppression of other fat people. An example of this would be a fat person who thinks that they shouldn’t expect that a hospital has beds, gowns, and other equipment that fits them.

Structural:

This occurs when things that fat people need (everything from chairs, to blood pressure cuffs, to research, best practices, restaurant booths etc.) are created/purchased based on thin bodies and/or to the specific exclusion of fat bodies.

In healthcare, we see all of these forms of weight stigma and bias, often layered upon each other and, for those with multiple marginalized identities, layered with intersectional stigma and bias as well (using Kimberlé Crenshaw’s framework for intersectionality.)

Research

Often research for things like interventions, pharmaceuticals, tools, techniques, and best practices don’t include higher-weight people. This leads to inequalities in healthcare access and treatment. Often the negative ramifications of these inequalities are then blamed on fat bodies, rather than on the inequalities at the source. For example, when there was a fear that, like previous vaccines, the COVID-19 vaccine would not be tested on fat people and would subsequently be found to be less effective, supposedly respectable news outlets went to great lengths to blame fat people for this.

Examples of this include everything from emergency contraception, to vaccines and vaccine protocols and more and, of course, fat people aren’t the only people who are left out of research. Research that is based on the most privileged people (despite the fact that we know extrapolation to other populations from that research is far from accurate) is a problem that should have been solved long ago.

Practitioner Bias

Research tells us that many healthcare practitioners have high levels of both implicit and explicit bias. This is certainly an expected outcome of a society rife with weight stigma, a medical education that teaches healthcare practitioners to see fat patients as walking, talking pathologies, and a system that wasn’t built and/or stocked to accommodate fat people. This also often creates more work for healthcare workers who are typically actively encouraged to blame the fat patients for existing, rather than the system for not accommodating them.

I’ve been speaking about these things to healthcare practitioners as well as advocating for fat patients and helping them advocate for themselves since 2009, and I have met many, many practitioners who are well-meaning and simply deeply miseducated. I have met many practitioners who have made changes in response to data (whether it was from me or another source,) and I have met practitioners who are fully fat affirming and weight-neutral in their practice. That said, I have also met, heard about (and personally had appointments with) practitioners who are actively, proudly, anti-fat. Who treat fat patients badly and then brag about it. Who truly don’t believe that fat people deserve healthcare unless and until we become thin. I want to acknowledge that because I think too many people are quick to blame the system for all of the weight stigma or suggest that all HCPs are doing the best that they can. That ends up gaslighting people whose experiences are with HCPs who are mistreating their patients because they are operating from extrinsic weight stigma and bias.  

Also, we can’t lose sight of the fact that even practitioners who are well-meaning are still harming higher-weight patients. So while I believe that intent matters (someone accidentally pushing me and someone purposefully pushing me are two different things) we can’t forget that impact is still the most important thing. I have a guide here to red flags for weight stigma in a healthcare practitioner.

Lack of Accommodation

Lack of accommodation happens anytime a fat person doesn’t have the same access to healthcare that a thin patient does. This can begin with chairs in the waiting room. If a waiting room doesn’t have armless chairs and/or love seats then fat patients aren’t able to sit or be comfortable in the way that thin patients are. This intersects with ableism for fat people who have injuries, disabilities, limited mobility or in any way want/need to be able to sit. The chair problem can also occur in the examination room. Then there are things like gowns and blood pressure cuffs, diagnostic equipment like MRIs and CT scans,  surgical beds and tools, hospital equipment, braces, compression garments, durable medical equipment and more. Again, the negative outcomes from these failures to include and accommodate fat patients often get blamed on the patients for existing, rather than (correctly) on a medical system that knows fat people exist but still fails to accommodate them.

Again, this is not an exhaustive list. I also want to acknowledge BMI limits here - BMI limits for healthcare procedures are a complicated area of weight stigma and I am working on a series about this specifically that will be separate from this series.

In general, if you are trying to explain weight stigma in healthcare to someone, I have a quick guide here.  

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More Research

For a full bank of research, check out 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 Harrisons Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.