Weight Stigma In Practice - The Gynecologist Should Not Be A BYOS Party

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Over the years that I’ve been writing and talking about the ways in which weight stigma shows up in healthcare, I’ve heard from many higher weight people who went for their annual visit to the gynecologist, only to be told that the doctor/practice doesn’t have the correct size speculum to examine them.

In some cases, the person was simply told outright that they couldn’t be helped (often prompting them to e-mail me to see if I knew of any options.)

In other cases, the doctor went ahead with the exam, but made notes about how the “patient’s body” made the exam lower quality. This is problematic in multiple ways. For one thing, the patient’s body isn’t the problem - the tools and best practices that aren’t created for fat* bodies (and thus give fat people subpar treatment,) are the problem. Second, there are techniques that can be used to improve viewing, including putting a condom with the end cut off over the speculum. This is an option that is used for people of all sizes and, in the cases of people who contacted me about this, wasn’t offered. Finally, rather than simply documenting that a patient was given subpar care, and trying to excuse it by placing the blame on the patient for existing, ideally the notes would mention a lack of ability to provide this patient equitable care, and follow up would be done by the practitioner to see what can be done to solve this problem for this patient and other patients in the future.

Then there several who were told that a speculum that would accommodate them existed, and that if they wanted to purchase one (one doctor suggested Amazon.com!) they could bring it in for an exam. In one case the doctor even refused to refund the patient’s co-pay, since they “should never have expected” that they could be accommodated….

With a speculum.

At the gynecologist.

For a pre-scheduled pap smear.

This is blatant weight stigma and it should be completely unacceptable. It’s not just specula – thought that feels like a particularly awful aberration since going to the gynecologist is such a stressful situation to begin with, and putting off the visit or getting subpar treatment can mean delaying or missing, among other things, a cancer diagnosis. But it’s also blood pressure cuffs, knee braces, higher weight capacity beds and chairs, longer needles for vaccinations, and on and on and on. It’s research, tools, and best practices that were NOT created to accommodate bodies of all sizes.

This arises from a healthcare system (including the education/medical school system, insurance companies, healthcare executives etc.) and those with a profit interest in selling weight loss, who all too often teach/encourage everyone within the system to consider fat patients to be inconveniences who don’t deserve full access to ethical, evidence-based healthcare unless and until they become thin patients. Which means that well-intentioned practitioners are often operating from unexamined implicit and explicit weight bias that was ingrained in them during their education and training, and that gets reinforced during their continuing ed and by authority figures, employers, and colleagues.

When fat patients aren’t accommodated in some cases the needed medical equipment doesn’t exist – larger size knee braces, for example, may need to be custom made. (And that’ s absolutely unacceptable since it is a known fact that fat people do exist, and that many have knees.) But if that’s the situation, then the brace should be custom made, and the patient shouldn’t be asked to pay more because of a lack of accommodation and equitable care.

But in many cases, the items absolutely exist but the healthcare facility has simply chosen not to provide them for fat patients. This is, obviously, inconsistent with any belief in “doing no harm” or anything resembling a community health practice. (And I’ll point out that often these decisions are not made at the practitioner level, but that doesn’t preclude practitioner pushback.)

Plenty of fat patients have been pushed to participate in humiliating “routine” weigh-ins at every visit under the insistence that it is “medically necessary” (spoiler alert: It’s almost never medically necessary, but that’s a subject for a different newsletter) only to find that their healthcare practitioner can’t even take an accurate blood pressure because those in power haven’t bothered to spring for the properly sized cuff and/or the person taking the blood pressure insists on using an improperly-sized cuff.

Size discrimination by medical facilities should not be allowed. Patients of all sizes should be able to sit and lie down as necessary for their care. They should be able to get an accurate blood pressure reading – something that is as basic as basic gets when it comes to medical care. Not bothering to have appropriately sized needles shouldn’t be a barrier to vaccine efficacy. A visit to the gynecologist should not be a BYOS (Bring Your Own Speculum) party.

People, including and especially within healthcare, can be incredibly quick to point out how being higher weight is correlated with poorer health outcomes, without mentioning the fact that (along with enduring weight stigma and weight cycling) fat patients don’t have anything approaching equal access to ethical, competent, stigma-free care. And of course this does the most harms to those at the highest weights and is compounded for those who are subject to other oppression and bigotry in healthcare including racism, transphobia, homophobia, misogyny et al.)

Fat patients deserve the same care that thinner patients get, and we shouldn’t accept any justification or excuse for anything less.

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*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’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.