Working Through Weight Stigma

What thoughts come to mind when you hear the word “stigma”? Perhaps shame, guilt, or moral impurity.

Now, what thoughts come to mind when you hear the words “overweight” or “obese”?

For many traditionally trained clinicians, similar words might come to mind. Both clients and clinicians have been taught for years that weight relates to someone’s value as a human. 

Weight stigma has a way of showing up in healthcare, our communities, and the conversations we have with each other.

The more we learn about our own thoughts and biases towards people in larger bodies, the more we can be role models to others to change the conversation about weight stigma and healthcare.

You might be thinking, “But what about people who are in much smaller bodies? They must also face weight stigma.”

People in smaller bodies absolutely face challenges, which I don’t want to diminish. However, this article is written with the knowledge that people in larger bodies do not fit the current cultural ideal the way those in smaller bodies do.

What is weight stigma?

Weight stigma is weight bias in action. It’s the thoughts about people in larger bodies that get turned into hurtful words, spaces that aren’t accommodating, and policies that actively work against them. On an individual level, people in larger bodies often have to navigate a world that wasn’t physically made for them. Think about seats on public transportation, booths at restaurants, and theater seats. 

Then there’s the experience of going to the doctor, which can be a stressful—or even traumatic—experience. People in doctor’s offices are often weighed in not-private areas, and may face snide comments from doctors who assume whatever reason the individual came in for could be cured by losing weight. And these comments are often made without any effort to learn what health behaviors the individual is already doing, or what they’ve tried in the past. 

Weight bias is often perpetuated under the guise of “concern for your health”—but when was the last time you were motivated by scare tactics or threats? Weight stigma is more dangerous to health than the actual weight. It can lead to people canceling medical appointments for fear that their concerns won’t be taken seriously, depression and anxiety, and sometimes substance use to cope with internalized shame.  

The dangers of weight stigma in healthcare

Weight stigma in healthcare has a long history. Much of the billing requirements, guidelines for procedures, and diagnoses in the healthcare field are related to body mass index (BMI)—which is flawed science. It’s based on 1800s rhetoric from a mathematician who studied European males, and it doesn’t account for anything other than the height and weight. That means it doesn’t account for age, sex, muscle mass, or fat mass. And because these other factors aren’t taken into account, some conditions go undiagnosed. 

People of all shapes and sizes can have anorexia nervosa, bulimia nervosa, or binge eating disorder. However, if someone doesn’t fit the image that comes to mind when thinking about anorexia—which is usually a thin white woman—their disordered eating is often dismissed. As mental health clinicians, we can work with primary care doctors and other specialists to share our concerns about our clients and any disordered eating patterns we may notice in the course of our work with them. However, it’s dangerous if clinicians don’t address their own weight bias first, as they may not take larger clients as seriously or think they’re as willing to do the work inside and outside of sessions.    

Let’s imagine someone is at the doctor’s office, and they request to not be weighed for their own mental health. Aside from the pushback they may receive that “this is needed for the chart,” there might be the sentiment that if someone doesn’t want to be weighed, then they will decline all medical procedures too, because it makes them uncomfortable and ashamed. 

While any procedure can be declined due to personal autonomy and consent, this is where false equivalence comes in—associating two items as equal that could never be equal, like apples and oranges. For example, a health concern like high blood pressure is something that can be modified with nutrition, movement, and medication. But there’s not a single valid, long-term study showing that weight responds in the same way. Because of the way the body resists all attempts at starvation, it’s a false equivalence to assume that someone’s weight could be as easily modified as their blood pressure.  

Helping clients in your office and out in the world

With the body positive and acceptance movement, some people are reclaiming the word “fat” to be a neutral descriptor like “short” or “tall.” Others are taking it a step further to mean strong, powerful, and beautiful. However, not everyone is comfortable with fat as a descriptor because of the shame it has been tied to for so long. It’s important to ask clients what wording they prefer, and check in periodically if their choice continues to feel right. We can also decrease our use of the words like “overweight” and “obese,” because they’re tied to the flawed BMI that assumes there is a “normal” weight for everyone. 

To work with clients in larger bodies, make sure your office has appropriate seating, which may mean chairs without armrests or couches. Consider adding that information to your website, as well as mentioning if there are stairs or elevators to your office. In regards to the work that you do together, increasing their confidence for their life outside of your sessions can be a good place to start. That could be working to increase their confidence in or acceptance of their bodies, or it could mean helping them feel ready and confident to decline to be weighed at the doctor. 

Clients have the right to decline to be weighed, which might be something they aren’t aware of. If there’s a weight threshold for a medication, you can help your clients prepare to ask for something called a “blind weigh,” in which they turn around so they can’t see the scale and ask not to be told the number. There’s also been a recent movement of “Don’t weigh” cards, which can be handy if clients don’t want to be weighed but aren’t quite comfortable having that conversation with their doctor or nurse. 

​​These are all options that doctor’s offices are increasingly receptive to, but clients often don’t know they’re available, or how to take advantage of them. We can help our clients combat weight stigma in healthcare by helping them advocate for themselves in those situations. 

The deeper layers of weight stigma

Weight stigma, just like other types of stigma and bias, is influenced by different privileges and intersectionalities.  This means that a person’s experience can be made better—or far worse—by those influences. People in larger bodies who are also part of marginalized communities, such as people of color, members of the LGBTIA+ community, and  disabled people are even more likely to have eating disorders overlooked by their providers. Limited access to healthcare, fear of seeking treatment, and the assumption that only affluent white women develop eating disorders are just some of the factors that make it difficult for other groups to access the care they need.

As clinicians, we must be aware of this disparity and listen when marginalized individuals voice their concerns. As we broaden our knowledge and awareness through the lenses of cultural competence and humility, we’re on our way to seeing and being the change for our clients. And by doing so, we can start to ensure that healthcare is more respectful and compassionate for everyone. 

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