This past week I had the opportunity to attend the third annual Weight Stigma Conference (WSC) in Reykjavik, Iceland. I lived Tweeted throughout, as did some others, so if you’re interested in seeing the social media from the conference I recommend checking out the #StigmaConf2015 hashtag on Twitter. A few people asked if I would blog about the conference, and I’m more than happy to do so! If you’re not a fan of conference recap blogs, stay tuned for our regular Science of EDs programming soon.
Overall, I thought this conference was fantastic. Though it was not a conference strictly geared toward eating disorders, weight stigma is not helpful for anyone in any kind of body and engaging in any kind of behaviours around food and exercise. It oversimplifies complex issues, makes body management a personal issue with strong political stakes, and reduces eating disorders and obesity to a binary position, which is clearly problematic: people of all shapes and sizes have eating disorders, and people of all shapes and sizes do not have eating disorders.
This extraordinarily simple-seeming note is surprisingly not well recognized. People continue to act as though they can tell what a person is like, how they eat and exercise (and/or don’t eat and don’t exercise) based on a split-second evaluation of their body. This is socially problematic, but also medically dangerous, as presenters shared.
Medicalization and Fatness
Keynote talks touched on how the framing of fatness can promote blame and stigma, even when well-intended. In the wake of the classification of obesity as a disease by the American Medical Association, looking at the impact of a medical framing of fatness is particularly important. Abigail Saguy from UCLA, author of What’s Wrong With Fat, spoke about the different ways fatness is framed. A medical framing of fatness is perpetuated in both medical settings and in society more broadly: for example, every time people use the term “obesity,” they are taking up a medical frame.
Coupled with a public health framing of fatness as a problem in need of a solution, this idea of needing to “cure” fat people places those in larger bodies in the position of being continually scrutinized pretty much wherever they go, from the mall to the doctor’s office. Saguy suggested that instead of presenting fatness as a medical issue, we use a social justice framing to explore how weight stigma actually worsens health and acts as a barrier to healthcare. She did note, however, that it is much harder for this framing to gain a foothold- those in favor of this framing tend to have less social and economic capital (that is, fewer means to support this perspective) than proponents of the medical frame.
Daniel Goldberg from the Brody School of Medicine also spoke about medicalization, using his bioethicist and historian lens to explore medicalization of fatness. As Goldberg noted, medicalization is far from new, and is extremely complex. One of the complexities of medicalization, he reflected, is that people themselves may seek medicalization and diagnosis in order to get help for something that is distressing them.
We see this in eating disorders, too: think about how hard (if not impossible) it is to get treatment if you do not have a diagnosis. Regardless of whether you see diagnostic practice as positive or negative, it can’t be denied that in order to receive healthcare under our current systems, you’ll need to somehow “prove” that you have the condition for which you are seeking treatment. Of course, this can be problematic: it places those who less easily fit the diagnosis or who are marginalized to “prove” they are sick enough to get help.
Thinking about fatness, medicalization may be intended to remove blame from the individual by suggesting that the suffering is a medical condition. It might be leveraged as a way of making what is described as a “contested illness” (eating disorders have also been labeled contested- see this article by Easter, 2014) more legitimate in the eyes of medicine and science, which act as arbiters of truth in our society. However, not everyone who is fat is suffering. Not everyone who is fat desires a clinical label, even if some do. While perhaps well-intentioned and rooted in the desire to help, suggesting that all those who are in larger bodies are sick is incredibly stigmatizing.
Medicalization surfaced in concurrent session talks as well. For example, Astridur Stefansdottir commented on how medicalization and individualizing (i.e. suggesting that those who have larger bodies are somehow responsible for producing that kind of body and should also be responsibility for “fixing” their bodies) is yet another method of social control. Crystal Hoyt spoke about how the AMA’s classification of obesity as a disease may decrease blame of people for “causing their own fatness” but also reduces fatness to a solely medical phenomenon and increases certain stereotypes about what a fat person can do and be.
One of the most interesting things about the discussions of good intentions going awry was the tension this brought up about organizations that aim to reduce weight stigma while also referring to the “obesity epidemic.” Ragen Chastain, another keynote speaker and author of the blog Dances With Fat voiced concern about this approach, noting that it can be read as: don’t stigmatize fat people, but assume that all fat people have an inner, better, healthier thin person waiting to get out.
I think this is a really tricky point. On the one hand, I think it is a step in the right direction for large obesity prevention groups to get on board with the message that, as Chastain said, “you can’t hate people healthy.” At the same time, I also get a conflicted feeling about this eradication narrative, because it still presumes that all fat people want to “get skinny.”
I, like other speakers at the conference, wonder about the limits of anti-weight stigma efforts that take place in our dominant paradigm (neoliberal, individual-responsibility-and-success-oriented frame). At the same time, as I’ve mentioned in my eating disorder prevention posts, I’m not prepared to ask mainstream organizations to stop moving in the right direction because I disagree with the underlying message and lack of challenge to the status quo. I just believe we need to continue to rabble rouse as we move things in the direction of a new paradigm that would be systemically designed to support a wider diversity of bodies and even definitions of health.
We Need a Paradigm Shift
Along these lines, another key theme that emerged was that we are not getting anywhere by trying to move within our current paradigm. To support change in how we see fatness and treat people in all bodies with respect, we need a paradigm shift.
Why do we need a paradigm shift that would move us toward social justice and away from weight stigma? Well, besides just generally needing to respect people, we might think about what happens when we shame and stigmatize those in larger bodies. Notably, speakers shared convincing data to complicate what is presented as a linear link between fatness and mortality. Angela Meadows, founder of the conference and the site Never Diet Again, presented extremely compelling studies that reveal that the relationship between fat and death is far, far more complex than what is reported in the media (for more, see these studies: Locher et al., 2007; Nyholm et al., 2005; Engeland et al., 2003). Instead, weight discrimination and stigma is associated with higher mortality; for example, Angelina Sutin spoke about “the fatality of stigma” (there are also studies supporting this, including these recent ones by Phelan et al., 2015a, 2015b).
Ragen Chastain’s keynote talk also underscored the medical irresponsibility of making assumptions about a person’s exercise and eating habits based on an observation of their size. Drawing on Rebecca Puhl’s research indicating that many (up to 50%) doctors found their larger patients “awkward, ugly and unlikely to comply with treatment” and strong case examples, Chastain highlighted how common it is for fat people to present to the doctor with a medical complaint unrelated to their size and be greeted with “you need to lose X pounds.”
Chastain’s talk brought home the idea that medical assessment practices that focus on judging health by the proxy of size are incredibly irresponsible. Thinking about how people of all sizes can have healthy or disordered relationships with food (see this post about a recent Lebow et al article about restrictive eating disorders at any size, for example), how is it ok for a doctor to prescribe weight loss or dieting to someone without ever asking what they eat or how they exercise? Perhaps more startling still, speakers shared data and stories about how medical care for fat people is often made contingent on their agreement to engage in weight loss practices.
So what might a paradigm shift look like? We can take some cues from those who advocate an anti-oppression, social justice orientation frame. This means seriously rethinking what health is and how to get there. It means:
- Questioning the “regimes of truth” Bridgette Rickett spoke about in her talk, where she also highlighted how we reproduce dominant discourses on health in our everyday talk
- Considering how these discourses about fatness are not only gendered, as Saguy and others described, but classed and serve to reinscribe boundaries around class, as Maxine Woolhouse noted
- Looking at the ableist tone often held in talk about exercise: there are many reasons why people may not exercise in the expected way ranging from using a wheelchair to feeling emotionally or physically unsafe in environments built to shame, stigmatize, and exclude
- Recognizing that stigma is something that people do, as Daniel Goldberg reminded us
- Challenging neoliberal standards of perfection, success, and continual self-improvement that Lucy Thompson spoke about in her paper on how people using proana websites talk about their eating disorders
- Evaluating personal biases about weight and size, especially in educational contexts, as Sarah Nutter and Angela Alberga reflected in their talk about fat pedagogy; considering that teachers and students each bring their own bodily histories into the classroom
It means, quite simply, cultural and social revolution. Of course, nobody suggested that this would be easy. Changing representations is no easy task- this was also illustrated in a talk that stirred up a lot of emotion in the room at the conference. Films intended to be subversive were received as re-inscribing the problematic assumptions about fatness that the conference sought to challenge. To me, this speaks to just how ingrained our ideas about bodies and size are- again, even the best of intentions can go awry because we are all a part of a context that neither celebrates diverse bodies nor provides mechanisms for speaking back to dominant culture.
This post is getting incredibly long and I haven’t managed to deliver on my promise to write more about Lucy Thompson’s work on neoliberalism and the culture of self-improvement in relation to eating disorders. Though the paper is not published yet, I promise that I will prepare a blog post specifically on the subject of neoliberalism and eating disorders including references to that and other work in this vein (though I won’t write about my own, because that feels just a little too self-serving ;).
For now, I’ll close on this: weight stigma is not just about fat bodies. Weight stigma is about people’s right to be treated as human beings. To combat weight stigma, we need to focus on social justice and work intersectionality to consider how marginalization and oppression build and combine along lines of gender, race, class, ability, size, and more. We need to open up space for more bodies to fit, which involves not just injecting representations into a problematic sociocultural and political economic context, but changing the context and the terms of our conversations. It’s nothing short of a revolution.