Recognizing Institutionalized Weight Bias

Recognizing Institutionalized Weight Bias

By Janell Mensinger, PhD, FAED

“It is inherently dangerous to be a fat woman in the eating disorders world.”

These powerful and somewhat jarring words were relayed to me in a conversation with Chevese Turner, then founder and CEO of the former Binge Eating Disorder Association (now integrated into the National Eating Disorders Association). I am beginning this commentary with that particular statement because, before writing anything at all, I want to underscore the fact that there is a pure lack of safety (yes, SAFETY—one of our very basic needs) for people in larger bodies in the health care community, and this very much includes the eating disorders profession. While this conversation occurred many years ago, I carry the message with me every day in my work as an eating disorder professional. I am eternally grateful for the profound insights Chevese—and many other advocates, teachers, scholars, and clinicians from the Health at Every Size^® (HAES^®) community—has given me about the issues of the structural weight stigma in our community. Know that I stand on their wise shoulders as I write this.

For any readers who may be questioning the accuracy of the opening statement, I challenge you to observe the body sizes of your colleagues the next time you find yourself at an eating disorders conference or a gathering of eating disorders professionals. Compare this to a representative sample of our population, and undoubtedly, it will be clear to you that our field is drastically askew from the population parameters. For the scientists in the audience, it would be true even if we matched them by education and other demographic characteristics to minimize some confounding variables. Some might argue that this is not due to fat phobia in our field, but rather because the field tends to draw many people who have lived experience with disordered eating. Before you allow that explanation to justify why you are surrounded by thin white women at the majority of your eating disorder events, think about this statistic from a recent epidemiological study: Individuals with a BMI over 30 have a 12-fold increased probability of disordered eating compared with their peers with a BMI less than 25 (Hilbert et al., 2012, and there are multiple studies showing very similar figures regarding prevalence of eating disorders and weight status). Now ask yourself, where is this representation—not just among those who show up at conferences, but in the field as a whole? (Not to mention the representation of folks with black and brown skin—but that is a whole other needed commentary…) When we truly take in the body sizes of the majority of our peers at eating disorder conferences, it is ever apparent that it must be inherently dangerous to show up in a fat¹ body. Let this brief diatribe, that will only scratch the very surface of the nature of the issues at hand, help you recognize the amount of work we have to do in order to change this.

________________________________________

¹To be consistent with the size acceptance movement and the preferred language of critical weight studies, I use the words fat, larger-bodied, higher weight, and higher BMI as non-pejorative descriptors for a body that has been marginalized and oppressed for much of the past century. Notably, these terms do not connote anything about a person’s medical condition or an ideal weight against which to compare it as optimal.

***********

When I was initially asked to write this article on weight stigma for the Gürze/Salucore Eating Disorders Resource Catalogue, I began to reflect on the content of that conversation with Chevese (as well as many others I have had with fellow members of the HAES^® community and advocates for fat acceptance). Honestly, my first thought was, Should I be the one writing about this? To allay my anxiety, I reminded myself of my professional qualifications: I have conducted research studies, reviewed journal articles, participated in expert panels, and read many hundreds of scientific papers on the topic of weight stigma. This hesitation was not about a lack of qualifications or passion about this topic. I have gained all of this experience through my personal and professional commitments to educate people about the harmful effects of weight stigma. And yet, when I sat down to write this article, I began questioning how readers would respond to someone who has never been the target of anti-fat prejudice writing it.

Ultimately, I decided to move forward with writing this article because I have never been the target of anti-fat prejudice. I am a thin, white, cisgender woman with education, employment, health care access, food, and housing security. I shouldbe the one writing this article. Some might ask, why? The efforts of educating others about weight stigma should not be on those with more marginalized identities. I also recognize there is the reality that part of why I am given opportunities to use my voice like this is because of my privilege, and when possible, I try to center the voices of my more marginalized peers. It should not be the case that we repeatedly see thin, white cis-women (and men) given platforms in the eating disorder field, and that is what happened here. For readers who felt irritated by this, know that I see and hear you, and you have a right to your anger. The complexity grows, because at the same time, we must aid people in understanding the often-hidden depths of weight stigma, and, again, it should not fall on those who have been most impacted by it to do the unpaid labor of educating. Thus, while I have not been the direct target of anti-fat bias, I have intentionally and carefully listened, learned, and educated myself in the multilayered structural systems of bias we uphold in our culture. Consequently, I appreciate the profound impact institutionalized weight bias (not to mention other systems-level “isms”) has on people. Furthermore, as a scientist, I know that weight bias is ubiquitous and pervasive in every sector of our society, and it is responsible for a multitude of health disparities that the dominant weight-normative paradigm continues to attribute to weight alone. Weight is not the health problem to be fixed; institutionalized weight bias is.

*********

Therefore, if you have privilege, do not ignore it, disown it, or look for your own hardships—despite how difficult it may be to avoid doing this. Instead, please leverage your privilege to uplift and empower those with less privilege. Please recognize that being aware of your privilege does not negate your lived experience. What it means is that you have an awareness that your privileged identities allow you to navigate the world more easily. If you are in a thin body, you may have lived with tremendous body hatred; that is real and valid. And you are not treated poorly in every sector of our culture because of your thin body. If you do not have the lived experience of being in a higher-weight body, you have a responsibility and obligation to educate yourself about the ways weight bias shows up. You need to be aware of how spaces are set up to preclude higher-weight people from accessing them. Notice how tables are set up in restaurants and how chairs are arranged in conference rooms, and imagine navigating those spaces in a fat body. Would you feel comfortable and welcomed? Consider going to a conference and having the airline lose your luggage and how stressful that can be (it has happened to so many of us!). Now imagine that there aren’t stores that are easily accessible that have clothes available in your size and how that would add to your already stressful situation. Think of traveling on the airplane to the conference, sitting in the waiting room in your doctor’s office, or going into your therapist’s office and finding that none of the seating is made to fit your body. These biases are woven into the fabric of our everyday living, and many of us do not ever think about how these things impact people in larger bodies.

As eating disorder professionals, I urge us to work together to undo the harmful messages and the structural biases. Unquestionably, our effectiveness will multiply when our voices unite. This is especially important when there is clear and present danger to young and vulnerable people. When we allow and perpetuate an ideology that continuously develops and funds programs in efforts to eliminate, minimize, or prevent the very existence of certain bodies, we are engaging in what Sonya Renee Taylor calls “body terrorism” (please read her book The Body Is Not an Apology). Simply put: All bodies have the right to exist with dignity and respect, and by no means should we consider bodies, implicitly or explicitly, problems in need of prevention, minimization, or elimination. We are the problem—our culture, our institutions, and our systems that oppress and allow us to maintain the status quo. Reflect on what you can do to disrupt the status quo. Every effort matters.

***************

In closing, I invite you to join me in solidarity for liberating all bodies from the anti-fat diet culture that has had us in a life-threatening stranglehold for well over half a century. It is no secret to this audience that people are dying every day from eating disorders. While science has demonstrated that there is a genetic etiology, let’s not mistake the ways that diet culture and weight stigma contribute to the development of eating disorders. In fact, my new research shows that of those who have the privilege of actually making it to higher levels of care (only a small minority of eating disorder cases), nearly one in five attribute anti-fat sentiments to the onset of their eating disorder. These individuals initiate care being more weight suppressed and with more severe eating disorders. It is time to put an end to this by using our vast knowledge as a community to collectively identify insidious diets in whatever new alluring cloak they are wearing and work together to push back (e.g., stopping the harm of the Kurbo app). For many eating disorder professionals, body liberation for all may feel like a higher calling; for others, it might feel like a professional duty. Wherever you stand, let us work together to make it a universally adopted ethical obligation as professionals, caregivers, and advocates. Thank you for reading.

For more information and resources on understanding and identifying structural weight bias, consider joining the Association for Size Diversity and Health at www.sizediversityandhealth.com.

Acknowledgments: I cannot express enough how much appreciation and respect I have for my brilliant colleagues and friends from the fat acceptance community who have educated me over the years since I began this work. Also, a specific thank you to Rachel Millner for providing comments on an earlier draft of this article

10 simple questions to recognize your own weight biases as a clinician in the ED field:

• Have you ever promised a client with anorexia during the weight restoration phase of their treatment that you would not let them get fat? 

This is weight bias. 

• When you meet a client with a larger body for the first time, do you assume they struggle with binge eating? 

This is weight bias.

• When someone with a larger body identifies as fat, do you consider them “brave,” and do you struggle to describe them in this way?

This is weight bias.

• When a fat client with BED comes to residential treatment and has been on a stable meal plan for weeks with no weight loss, do you assume they may be sneaking food?

This is weight bias.

• When you hear about a colleague’s client who has lost significant weight and needs a higher level of care for medical stabilization, do you assume their BMI is “low” (i.e., using the traditional medical definition of <18.5 kg/m²)?

This is weight bias.

• Do you think Health at Every Size^® is a wonderful approach, but draw the line at a certain BMI point?  

This is weight bias.

• Do you ever use the words obese or obesity to describe a person’s body or BMI? 

This is weight bias.

• Of all the terms associated with the size acceptance movement in the eating disorder field, do you prefer the term body positivity and feel that the idea of fat liberation seems somewhat “over the top” or “too radical” to you?  

This is weight bias.

• Do you prescribe exercise more readily to your “atypical” anorexia patients and weigh them with less careful attention as they restore their health and weight from severe dietary restriction and weight suppression?

This is weight bias.

• Do you maintain a rigid and calorie-restricted diet in order to control your own weight? 

Yes, this, too, is weight bias.    

About the author:

Dr. Janell Mensinger has a PhD in health psychology and completed NIMH-funded post-doctoral training fellowship in biostatistics. She is an Associate Research Professor in the Fitzpatrick College of Nursing at Villanova University where she serves as a statistician and a research collaborator for her faculty peers. She also leads a research program on weight stigma in eating disorders. Broadly speaking, her research is focused on health disparities and uses a social justice-oriented framework. More specifically, her work seeks to better understand how eating disorders are identified, diagnosed, treated, and prevented in individuals with marginalized and oppressed identities.