Fat folks in the U.S. are continually reminded of how others view our bodies. This is no less true when we seek medical care. The fear of mistreatment and being seen only as a fat person often mean that fat folks are hesitant to seek medical treatment at all. Leaving us to wonder – are poor outcomes amongst fat folks due to being fat or due to delaying medical care based on experiences of medical fatphobia.

A Note About the Word “Fat”

I have chosen to use the word “fat” throughout this post as a neutral descriptor of larger bodies. It is a word that I, along with many others, have worked to reclaim. Some people might prefer varying descriptors, and that is just fine.

Some words that I avoid using include “overweight” and “obese.” These are terms that are utilized in the context of the BMI (read on for more about that) and are representative of medical fatphobia. “Overweight” implies there is some perfect weight for a person, and that an arbitrary scale can determine that. The word “obese” comes from Latin, and literally means “to eat oneself fat.” Since we know through research that genetics play a much larger role than eating habits in our body size, this is an inaccurate term.

Some Examples of Medical Fatphobia

BMI – Body Mass Index

If you’ve been to a doctor in the last 30 years, you’ve likely heard the term BMI, or body mass index. You may have even been given a summary of your visit that had your BMI number boldly printed near the top. But what is BMI?

What we now know as the BMI was originally known as the Quetelet Index. It was created in the early 1800s by a man with the last name Quetelet. He was an astronomer and mathematician (not a medical provider). He wanted a mathematical way to figure out the size of the average man.

This value that the U.S. medical system relies on as an indicator of health was never meant to tell us anything about health. It was a way to look at averages of white, European men. So, if you’re not a white, European man the scale doesn’t even apply to you!

The BMI was adopted by the U.S. medical system in the 1970s because insurance companies needed a quick, numerical system to determine folks’ health (and therefore the price for insurance). So, they chose a system that has nothing to do with health at all!

Then, in 1998, the National Institutes for Health lowered the threshold for what’s considered “overweight.” Overnight, almost 30 million Americans found themselves now in the “overweight” category, despite the fact that nothing about their size or health changed.

This brief history of the BMI demonstrates how anti-fat bias permeates our medical system.

Prescribing Surgery Before Allowing Surgery

I have heard and read many, many stories of folks who were denied life-enhancing surgeries based on their weight. These surgeries include joint replacements, removal of ovarian cysts, and a variety of other procedures.

What is the recommendation often given to these folks for whom the needed surgery is deemed too dangerous?

Another surgery. Directly after being informed that they are not eligible for the surgery they need due to the impact surgery could have on their body or fears related to putting them under anesthesia, they are recommended bariatric surgery so they can lose weight and be eligible for the surgery they need. Now, there are many varieties of bariatric surgery. However, I believe they all involve being put under anesthesia. They involve removing and/or rerouting healthy organs in a way that puts one’s body into a permanent state of malnutrition. They require a lifetime of commitment to daily supplements and restrictive food and liquid intake. And, as with all other weight loss interventions, we still don’t have evidence that they are effective long-term (i.e. that a majority of folks keep the weight off 5 years later).

Make it make sense that someone is denied surgery until they get a different surgery. This is anti-fat bias and medical fatphobia in a nutshell.

Lack of Inclusive Medical Equipment

MRI machines, scales, medical gowns / coverings, blood pressure cuffs – all these things are available in sizes that accommodate a wide range of bodies. I believe that medical offices, especially those affiliated with large-scale hospitals, should have access to inclusive medical equipment. Generally, the person scheduling your procedure has access to your records and can see your height and weight there. This information can help them ensure the appropriate equipment is provided on the day of your appointment. In cases that involve expensive machinery like MRIs, if the location doesn’t have access to one appropriate for your body, they can help locate a provider who is able to meet your needs and communicate that information in a way that is not blaming toward you for the size/shape of your body.

I’ve had a few personal experiences in this arena. Issues with the blood pressure cuff are exasperating to me. The nurse can see my arm when they are preparing to take my blood pressure. My arm is large, I happen to be a person genetically predisposed to fat upper arms. I’m aware I need the larger cuff. The nurse can see that I’m going to need the larger cuff. Oftentimes, the larger cuff is sitting right beside the regular cuff. Yet, the nurse attempts to wrap the regular cuff around my upper arm and causes excruciating pain as the cuff squeezes and inevitably pops off. Sometimes the nurse continues to attempt with the smaller cuff, moving it to my forearm with equally bad results. We may eventually get around to using the larger cuff – the one that should’ve been used in the first place – and the reading is high. Surprise, surprise – I have some health-related anxiety, my arm has been squeezed to the point of pain twice, and I’m feeling like a troublesome patient (even though it’s not my fault they are refusing to use the appropriate equipment). Of course, my blood pressure is high at that point!

Yet, this high reading is attributed to my body size. And I get a lecture about weight loss. Exasperating, I tell you!

For years, I didn’t know that I could ask for the larger cuff. I thought I just had to go with the providers decision. Now, I know that I can ask. Sometimes the provider honors the request. But sometimes they will still say something like, “Let’s just try this one first.” Interactions like these require a lot of emotional energy, and this is just the initial vitals being taken. These are the things that can lead to fat folks avoiding medical appointments altogether. Our requests are denied and our complaints are met with directives to lose weight.

Personal Experiences of Medical Fatphobia

Puberty came early for me. At the age of 12, I was my adult height, had gained the typical 40-ish pounds associated with puberty, and met all the markers for being toward the end of that transition. I was larger than my peers, and I have experienced size discrimination since that time. In fact, my first memory of medical fatphobia (though I didn’t have that term at the time) was at age 12. My provider commented on the increase in my weight, not mentioning I had also grown 5 inches in a year, and said, “You’re just gonna have to start eating like a bird.” I was already barely eating one meal per day, but because of my size was being told to eat even less!

The medical fatphobia has continued into the present, and I recognize it more easily now. Here are a few examples from the past 20 years:

• My menstrual cycle has always been irregular. Through my teens and 20s, I was repeatedly told that if I lost weight it would become regular. Yet, even when I did lose a large amount of weight, it was never regular. There is a hormonal reason for the irregularity, but only my weight was the focus.
• In my late 20s, I experienced intense back pain caused by a slipped disc that was the result of a car accident. The chiropractor knew the history and the cause of the problem, yet each appointment included a mini-lecture about losing weight.
• I was struggling with an active eating disorder in my early 30s which ultimately led to triple digit weight loss. This weight change was celebrated by every provider I saw during that time. No one asked me about the behaviors that were contributing to this drastic weight change. No one assessed for an eating disorder. Everyone just congratulated me because my body was getting smaller. (As a side note, I have since experienced multiple health issues related to the behaviors of that time period. Not a single medical provider has celebrated my recovery because I recovered into a larger body.)
• A few years ago, I was working as a counselor in a setting that also had psychiatrists. I had recently had a foot surgery and was using a walking boot. One of the psychiatrists, a colleague and not my medical provider, commented in passing, “Bet they told you to lose some weight and you wouldn’t have issues with your feet.” What? No one asked for your input. You are not my doctor. This is not even your area of specialty. And my issue was related to a bone deformity present since birth.
• Back in 2019, I went to urgent care for treatment of a sinus infection. I received a 20 minute talking to about my weight and all the ways I needed to change my diet. I guess thin people don’t get sinus infections???
• And just last week, I was at a check-up with a provider with whom I have discussed being in recovery from an eating disorder. I don’t weigh myself because it’s not good for my mental health, and I don’t look when they weigh me at the doctor’s office. But apparently I had lost a few pounds. The provider proceeded to congratulate me and ask me what other goals I was going to set for weight loss, with no consideration of my eating disorder history.

What Can I Do?

For thin folks…

You have likely never had these types of experiences. Maybe you didn’t even know this type of thing occurred until reading this post. Yet you have the power to be an amazing advocate for fat folks. See, it is often easier to advocate for needs we don’t personally experience because it takes less emotional labor from us. For example, I happen to use the pronouns that match what people typically assume based on my presentation. It takes little to no emotional labor for me to include my pronouns in introductions and email signatures, yet that is a way that I can advocate for and indicate safety to folks who may be more likely to experience discrimination based on their pronouns.

Here are some ideas for how you, as a thin person, can advocate for fat folks in medical settings:

• Pay attention to the seating in the waiting area and patient rooms. Are there chairs that are wider and/or that have no arms? If so, offer some praise to the practice for providing more inclusive seating. If not, mention that you noticed and would love to see more inclusive seating in their office.
• Decline to be weighed. There are very few reasons that a weigh-in is medically necessary. The most common are for medication dosing or tracking pregnancy. Many people don’t know they can decline to be weighed unless medically necessary. And it’s helpful if fat folks aren’t the only ones pushing back against this oft-unnecessary step. Even if your weight is needed as a medical necessity, you can decline to be told the number.
• Ask about the availability of medical equipment for people of various sizes. Getting your blood pressure taken? Inquire if they have larger cuffs for folks who may need them. Having a mammogram? Ask of they offer various sizes of cover-ups to meet the needs of various sizes of people.

For fat folks…

You have likely resonated with this post. Perhaps you even found yourself nodding your head as you related to a particular example.

Here are a few ways you can combat medical fatphobia:

• Speak up! Ask for the blood pressure cuff that fits. Tell the nurse you do not want to be weighed and/or do not want to know your weight. Ask for the larger gown, and let the medical practice know it’s their role to provide necessary items for ALL patients.
• Bring along an advocate. It may be helpful to have someone you trust accompany you to your appointment and be your voice when the emotional labor is too much for you. This person can communicate the need for appropriate equipment, and refocus a conversation that may veer down the weight loss trail.
• Ask the provider how they would treat your issue in a person with a smaller body. For example, with my sinus infection mentioned above, I could’ve said, “What would you prescribe for a thin person who came in with these same symptoms?”

For medical providers…

You are in the driver’s seat of helping to combat many aspects of medical fatphobia. I recognize there are certain things you have to document, especially if health insurance is paying for a patient’s services. I also know there are ways you can provide the necessary documentation while not subjecting the person in front of you to anti-fat bias and rhetoric.

Here are some ideas you may want to implement:

• Ensure your office has a variety of seating, including wider chairs, chairs with no arms, and even higher chairs that may help with mobility issues.
• Ask for a patient’s consent before taking their weight. If getting a weight is truly medically necessary, let the patient know why and give them the option of not seeing or being told the number.
• Have appropriate medical equipment available and use it without making a fuss. When you see that I am fat, just give me the larger gown. Go ahead and grab the larger blood pressure cuff once you’ve seen the size of my upper arm.
• Don’t assume weight loss in larger patients is positive. If you must comment on weight, be curious. Leave space to learn what’s been going on with the person that may factor into weight change.
• Ask yourself, “What would I suggest for this same ailment in someone who was thin?” Then, ask yourself why that’s not what you’re suggesting for the fat patient in front of you.

Medical Fatphobia and Mental Health

Dealing with fear of anti-fat bias prior to every medical appointment takes a toll on one’s mental health. I hope this post makes more folks aware of the prevalance of medical fatphobia. I also hope that some of the suggestions in how to combat medical fatphobia are useful and used.

If you are dealing with the effects of medical fatphobia or of existing in a larger body, you may benefit from working with a mental health professional who seeks to combat fatphobia (both internally and externally). I work with clients in NC from a HAES-aligned perspective, meaning that I believe health is much more than weight and that health-related behaviors should be available to all who desire to access them. I offer a free video consult to prospective clients to determine if we are a good fit to work together. You can contact me and schedule a free consult by completing this form.

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Michelle F. Moseley is a Licensed Mental Health Counselor in NC and a Registered Telehealth Provider in FL. She believes ALL people deserve respect, compassion, and access to mental and physical healthcare. Michelle specializes in working with survivors of religious trauma and with those who have body image concerns, finding there is frequent overlap in these areas. You can learn more about Michelle by visiting her website at MichelleFMoseley.com or following her on Instagram – @therapy_with_michelle