Medical Bigotry Is Harming Fat People
As a result of enduring fatphobia within health care, a number of patients are forced to choose between enduring weight-shaming or avoiding the doctor entirely. The lose-lose binary is unacceptable.
After getting her period at age 9, Melissa Sinclair experienced chronic menstrual pain so severe, she routinely missed one to two days of school per month; later, she had to work from home the same number of days for the same reason. As an adult in her thirties, copious amounts of research led her to believe she likely had endometriosis, a chronic health condition that affects an estimated 10 percent of people with vaginas worldwide and occurs when tissue grows outside the lining of the uterus. There is no known cure, but one of the most effective and common treatments for the excruciating pain endometriosis can bring is laparoscopic surgery to remove or destroy the excess tissue.
Sinclair, now 35, was thrilled when, in 2022, she snagged an appointment with one of the most respected physicians in the field: a world-renowned surgeon and researcher who has written multiple books, is the head of a celebrity-endorsed endometriosis foundation, and whose initial consult, not covered by insurance, costs $1,000. She was so relieved at the prospect of a life without pain, she didn’t even really mind the fee or five-month wait it took to see the doctor after a phone consultation with a nurse, who told her that it absolutely sounded like she had endometriosis.
Sinclair is a close friend, and I know the details of her story intimately because right after the appointment, she came to my apartment, hysterical.
“The first thing the doctor says to me is, ‘How long have you been this way?’” Sinclair didn’t understand what “this way” meant, so she asked the doctor to clarify: “How long have you been this big?” she recalls him asking. “Because you're pretty big.”
Sinclair, a photo director who currently lives in California, has spent most of her life on and off diets. Shortly before her visit with this doctor, she underwent both outpatient and residential eating disorder treatment, and received a diagnosis of binge eating disorder and atypical anorexia (an inherently problematic term that refers to someone who has anorexia but is not thin). “I probably told him that I had been in eating disorder treatment like three or four times during the conversation,” Sinclair says. “And I went into my mental health, and how I had been to treatment before for depression and suicidality, and had to be on medical leave from work.”
When she told the doctor that she’d once lost 100 pounds on the extreme-low-calorie HCG diet, she remembers his responses as being, “Wow, that's really good,” and, “Well, how suicidal were you when you lost 100 pounds?” She says he also told her that she was very pretty, which might have been intended as a compliment, or encouragement to lose weight (as in, “You’ll be even prettier thin!”), or both—but is actually sexual harassment.
After the doctor performed a vaginal ultrasound, he told her that she was indeed a candidate for exploratory laparoscopy and excision surgery. But, he would operate only if she had weight-loss surgery first. She left with two business cards: one for a bariatric surgeon and one for a psychiatrist. The latter, the doctor said, was because he thought she needed “to do some work on the fact that you're okay with being in this body and being so unhealthy.”
A great deal of Sinclair’s eating disorder treatment had been dedicated to getting to a place of feeling okay in her body.
As a fat person, I long thought I had two options when it came to medical care: endure weight shaming or avoid the doctor completely. The first often led to the second, like when a doctor took a look at the number on the scale and asked me, “Do you like eating cake?”
In recent years, as I’ve gotten out of the diet cycle and started educating myself about fat liberation and positivity, there’s been comfort in meeting other people who have long faced the same lose-lose binary. But Sinclair’s story revealed that there was also a third potential outcome of going to the doctor: outright abuse followed by denial of care.
“It’s fatphobia,” Alexis Conason, PsyD, Certified Eating Disorder Specialist Supervisor (CEDS-S), clinical psychologist, and author of The Diet-Free Revolution, tells me after I relay Sinclair’s story to her. From 2007 to 2018, Dr. Conason maintained a research position at the New York Obesity Nutrition Research Center at Mount Sinai St. Luke’s Hospital in affiliation with Columbia University, with a focus on psychological outcomes following bariatric weight-loss surgery. “It doesn't make sense that you would be cleared to get bariatric surgery, but for something that you actually are struggling with, you can't get surgery for that.”
The problem, as Dr. Conason sees it, is systemic and patriarchal: It’s like a doctor is saying, “You don't have the capacity to make that decision, but I can make the decision for you,” she says. And in the case of bariatric surgery, that decision might further compromise health, as the procedure is connected to a number of complications, including anastomotic leaks, stenosis, bleeding, venous thromboembolism, and more.
Says Dr. Conason, “It's really a kind of paternalistic system that is taking away people's autonomy and their ability to make their own decisions. We don't want to be in the driver's seat of all of our medical decisions, but to be providing someone in a larger body with a totally different level of care than someone in a thinner body [is] discrimination."
Nearly 70 percent of medical students hold preferences for thin people, 74 percent believe that obesity is caused by ignorance, and nearly 30 percent classified fat people as lazy.
In her book, Dr. Conason cites multiples studies that outline the harm anti-fat medical bias does: She writes that nearly 70 percent of women in bigger bodies have experienced weight stigma at their doctor’s office at least once, more than half have experienced multiple stigmatizing experiences, and most doctors believe fat patients to be dishonest, unintelligent, and ugly. Nearly 70 percent of medical students hold preferences for thin people, 74 percent believe that obesity is caused by ignorance, and nearly 30 percent classified fat people as lazy.
Jennifer Gaudiani, MD, founder of the Gaudiani Clinic, carries the credential CEDS-S and Fellow in the Academy for Eating Disorders (FAED). She has a similar take: “The theory [for denying certain types of surgery] is that people in bigger bodies may have more anesthetic complications and may have more healing complications and perhaps infectious risks. Both of those may be true. However, that is the patient's risk to choose or not choose, not the doctors’ to make the patriarchal choice whether or not [the patient] can receive a procedure.”
Michael Champeau, MD, FASA, and president of the American Society of Anesthesiologists, points to various ways that anesthesiologists can make surgery safer for patients in bigger bodies. For example, “The first thing we usually do with a patient is to start an IV, and sometimes it can be very difficult to find the veins [with a bigger patient],” he says. “But there are now these devices that use ultrasound...that you can put over an arm or hand and give you sort of a view of what's going on below the skin so you can see where the bands are. So that has helped dramatically over the last five to 10 years.”
He also points to surgeries that require intubation. With patients in bigger bodies, “it can be harder to see [and so harder to place] that breathing tube. There's more tissue around the airway, so that when you look in there, things tend to just sort of collapse and you don't see the structures as clearly,” he says. “There's a new device that has a video camera in the tip and you put that into the patient's mouth, and that gives you a very clear view of down in the back of the throat.” In addition, during surgeries that require the Trendelenburg or supine position—like laparoscopic endometriosis surgery—a patient in a bigger body in a steep Trendelenburg can face ventilator complications. But Dr. Champeau points to research being done in the field to mitigate risk there, too.
What became clear from talking to Dr. Champeau is that there are options, and even if they don’t pan out, having a medical professional explain those options and why they may or may not work for a particular body goes a very long way in terms of humanity and dignity—certainly farther than “I won’t operate on you until you lose weight.”
Dr. Gaudiani, or Dr. G., as her patients call her, sees a mutually beneficial reason for some doctors to deny fat patients care: “The unbelievably lucrative and extensive bariatric surgery realm, where apparently as long as the physician feels that the surgery is worthy enough—in that it is going to cure fatness—the surgeon is willing to take on and the anesthesiologist is willing to take on the risks of a vastly more complex surgery and healing process…As long as they believe that the outcome is worth it, they are willing to take those risks. That is a reduction of autonomous choice that is unacceptable and unethical.” In other words: Risk is worthy if the outcome is making the patient thinner, but that’s not necessarily the case if the outcome is alleviating a fat person’s pain.
She offers the following analogy: “Surgeons may look at two different cohorts and say, ‘Oh, it looks like thinner people do better postoperatively than fatter people.’ That's like saying, 40-year-olds who go in for lung transplant surgery do better than 80-year-olds, therefore, the 80-year-olds should go ahead and get on losing 40 years.’ No, that's just not how it works. These are two completely different things—you can't make one out of the other. That's not scientific.”
And the implications of those judgment calls that doctors make are far-reaching in the harm that they can do: A conservative anesthesiologist might use a patient's body mass index (BMI) as a reason to refuse gender-affirming surgery, or even egg freezing and retrieval, says Dr. G.
At the Gaudiani Clinic, Dr. G. and her team are “passionately pro-autonomy and pro-body-choice, anti-diet, and fat-positive—not just weight-inclusive, but fat-positive,” she says. “I see the profound harm done by physicians, to people in all body sizes, because of the pervasive universal experience of weight stigma, which we not only were socialized to as physicians, but then trained in and reinforced constantly and then subsequently in our practices.”
Krista Miranda, 46, is a queer lifelong dancer who is disabled, chronically ill (she has back and hip pain, migraines), and has an eating disorder history. She currently lives in a bigger body. When new symptoms—intense sickness and weakness after workouts—sent her in search of a diagnosis in spring 2019, she had trouble getting any answer beyond “lose weight.”
“My first rheumatologist just looked at me and told me to lose weight. No exam,” she says. “She just looked at me and was like, ‘Your pain is from your weight.’” As a movement practitioner who has taught Pilates and Gyrotonics, Miranda says she knew the assessment was wrong: “I have been very in tune with my body my whole life. I’ve got a good brain. I’m telling you: This is not it.”
In fact, her worst symptoms started when she was in the process of losing weight. Eventually, Miranda was diagnosed with orthostatic hypertension, which makes movement—especially the kind encouraged by a doctor who wants her patient to drop pounds—dangerous, possibly even stroke-causing. And yet, a doctor told her—based on looking at her and nothing else—that losing weight was the key to the enigma of her pain.
Fatima Cody Stanford, MD, an obesity-medicine physician scientist and associate professor of medicine and pediatrics at Harvard Medical School, sees medical discrimination and fat-bias clear as day. Dr. Stanford believes that obesity is a genetic condition, and that someone eating nutrient-rich foods could still end up fat.
She recalls a recent encounter with a surgeon at the Emerging Leaders Forum reception at the National Academies of Science. Says Dr. Stanford, “He's like, you're always talking about obesity not being the person's fault, but you know, they just need to stop eating McDonald's.’ I said, ‘It sounds like you’re not listening to your patients.’...He was so entrenched in his bias.”
“If you come in and you have an ax in the middle of your head right between your glasses, and I'm like, 'You know, let's talk about your weight,' and you're like, ‘Okay, but can we get the ax out of my head?’”—Fatima Cody Stanford, MD
When a patient exists in multiple marginalized identities, that bias increases exponentially: “For example,” says Dr. Stanford, “if you're a Black woman with obesity, imagine what that is like.”
Dr. Stanford cites one particular example of the harm doctors can do when they are quick to ascribe their patients’ ailments to weight: “I have a lot of patients that come in to me that need a joint replacement or something” and the orthopedic surgeon will not operate until the person loses weight. “They usually throw out some arbitrary number that’s nowhere in the literature,” Dr. Stanford says of the surgeon’s instructions. A recent patient in need of hip surgery was sent to Dr. Stanford and told to lose 15 to 20 percent of their body weight. The patient had bariatric surgery, lost the weight, and still had hip pain.
"They had a cancer growing in their hip,” says Dr. Stanford, but, she says, nobody knew because the referring physician had never examined the patient. “That person ended up losing significant mobility, almost losing their life because the doctor in question, also a prominent individual—usually these are my white male colleagues—did not examine.” If he had, he could have caught the cancer sooner. She likens it to this situation: “If you come in and you have an ax in the middle of your head right between your glasses, and I'm like, 'You know, let's talk about your weight,' and you're like, ‘Okay, but can we get the ax out of my head?’”
So, what are people in bigger bodies supposed to do to get the care they need and deserve in a system that is often fatphobic?
For one thing, we must realize that even though their literal job is to help people medically, doctors are human beings, and like all human beings, they have biases. That is not an excuse, but a warning: Just because a doctor has a fancy medical degree on their wall does not mean that they understand the totality of your experience or that they won’t make suggestions that are harmful. And because, according to all the doctors with whom I spoke, medical schools do not currently make a point to teach fat-positive care, individual doctors have to take it upon themselves to self-educate (and first they have to want to).
At One Medical, a national membership-based primary care practice, such education is intrinsic in patient care. Natasha Bhuyan, MD, a One Medical primary care physician (PCP) in Phoenix, echoes the importance of the same kind of care Drs. Guadiani and Conason point to: patient-directed, autonomous and holistic. “We've really changed our model; we focus on this weight-inclusive approach and its understanding that weight is not the end all, be all…and that was actually driven by a lot of our clinicians. We did recognize they didn't have this kind of training before,” she says. “For some people, it certainly is a novel concept,” she says of the One Medical way of doing things, like following accepted-language guidelines, not weighing patients unless they want that, and not automatically looking to weight as a factor in someone’s health.
“We bring the evidence that shows there is bias and stigma. So, for example, we've pulled studies that do show people with a higher BMI get less time with their clinicians, like there's something going on in other parts of the health-care system where clinicians are rushing them out the door," says Dr. Bhuyan. "There are also studies that show people with a higher BMI will get offered less pain medication. It's really hard to dispute; the evidence plainly states there is bias and stigma against people with a higher BMI and our health care system.”
And though she regrets that patients have to make up for the deficits of fat-positive education at the medical-school level and beyond, Dr. Bhuyan thinks that their increasing willingness to speak up may be what ultimately changes the field. “We are seeing more and more patients in this country speaking out and saying, 'I have had such terrible experiences with the health-care system. It's got to be better.' And so because there's an outcry from patients, I see that that is influencing the health-care system, and how we approach this conversation.”
Avoiding doctors without biases or financial conflicts of interest (something Dr. Conason cites in her book as a problem) is crucial for patients to receive necessary care, but not easy. Right now, the weight-neutral health space functions mostly like a whisper network or clearinghouse, with crowd-sourced Google Docs in place of a centralized resource maintained by the medical establishment. You Just Need to Lose Weight author and Maintenance Phase podcast host Aubrey Gordon has one; there’s another for patients in New York and New Jersey; there’s another one that combines as many as are available.
This is all great news, because these lists are populated by people who not only need them but are also in the position to give honest feedback. The problem is that they are, by nature, works in progress, incredibly subjective, and not a centralized directory from a medical source.
The Association for Size Diversity and Health (ASDAH) has a sparsely populated provider list that is mainly made up of nutritional therapists, weight-neutral personal trainers, and other non-medical providers. The website Bare currently has 255 providers in its national database of self-designated fat-friendly doctors, which is also promising, but 255 providers for 50 states plus the District of Columbia isn’t much.
Another way for people who are fat to protect themselves is to employ a health advocate to screen doctors. “I feel very privileged and lucky because I have an amazing registered dietitian, who is an incredible advocate for me,” says Sinclair.
After the traumatic experience with the endometriosis doctor, “I told her what happened, and she was furious. Without even asking me she was like, ‘This is what we will do from now on. You will find a doctor, and I will call them, and I will basically screen them to make sure that you don't walk into a situation like you just walked into.” Sinclair says she feels lucky, because it turned out the next two doctors her dietitian screened also had a BMI requirement for surgery. (The good news is that Sinclair avoided retraumatization. The terrible news is that she still has not found a doctor who will treat her.)
A doctor cannot look at a fat person and determine that they are unhealthy any more than they can look at a thin person and determine that they are healthy.
All of the tools of empowerment available to you either take means, confidence, or both, and the playing field is not level. It also takes believing that you are worthy of being treated fairly and compassionately. If you cannot employ a medical advocate like an RD, I (speaking from experience) highly recommend bringing along a mouthy friend to doctor’s appointments, so that if things go off the rails and you freeze, the loyal representative by your side will do the talking (or yelling) for you.
As another tool of empowerment, Miranda refuses to be weighed. I, not quite as bold yet, acquiesce to being weighed, but do so standing backward on the scale, with a request that the nurse not say my weight out loud. Dr. Stanford points to a series of “Don’t Weigh Me” cards produced by More-Love.org, an online resource founded in 2016 to support parents who have kids with eating disorders. The cards are for individuals who have found the words to stand up for themselves but are not yet able to articulate them verbally.
If you exist in a bigger body and need medical attention, the most important thing to remember and remind yourself is that a doctor cannot look at a fat person and determine that they are unhealthy any more than they can look at a thin person and determine that they are healthy. This is a fact, despite what the doctor standing in front of you may be telling you. “We’re caught in a cultural delusion that our weight determines our health,” says Dr. Conason.
Says Dr. Bhuyan, “People should feel empowered to interview their PCP. They should meet their PCP and say, ‘Tell me how you approach health care. Tell me how you would approach these situations’…And if it's not the care that you want, then you can find another PCP and definitely feel empowered to do so.”
You do not have to see doctors you don’t like. You do not have to change your body in order to be worthy of treatment. And here’s hoping someday soon, you will not have to choose between bad care and no care at all.