Weight Bias Is a Social Justice Issue

Weight Bias Is a Social Justice Issue 

By Erin Harrop, LICSW, PhD & Shira Rosenbluth, LCSW

Over the years, many theories have been formulated to explain why someone might develop an eating disorder. Most people will agree that eating disorders are multifactorial and stem from biological, environmental, and psychological factors. Within these paradigms, we might talk about eating disorders as responses to various experiences (e.g., trauma, other triggers) and personality traits (e.g., over/under-controlled, perfectionism) in individuals with specific vulnerabilities (e.g., genetic, environmental). These theories of eating disorder etiology largely rely on “individualized paradigms”—we look at the individual and examine their specific risk factors, experiences, and biology. What are the traits, choices, behaviors, and individual situations that led to the development of this eating disorder?

The -isms

As social work clinicians, we view human suffering through a slightly different lens. In addition to considering individual factors, we also examine “systemic” factors. Systemic factors are phenomena that function within systems, according to the needs and values of that system. Within systems, when bias exists in an environment, it often seeps into all facets of functioning in that environment. As such, systemic factors can be pernicious, ubiquitous, and difficult to identify; they are often unconscious or unrecognized by participants in the system, yet they influence the system all the same. This systemic-level discrimination then gets reflected in institutional, political, and social interactions. For example, in societies where males are valued (however unconsciously) more than females, this bias seeps into the societal system, leading to the development of policies and environments that produce gender pay gaps “unintentionally,” with masculine jobs receiving higher pay than feminine jobs, resulting in women being less financially stable or secure, particularly if they are not partnered with a man. 

This type of systemic bias manifests in multiple types of systems-level discrimination, generally coined as “the -isms” (e.g., sexism, racism, ageism, ableism, healthism, weightism, and sizeism, in addition to transphobia, homophobia, and xenophobia). A common factor among all these systemic forms of discrimination is when you are in the system, it is hard to recognize the system. As a result, many systemic issues are misinterpreted as individual shortcomings. 

While discussions of the -isms are beginning to happen with more frequency, these conversations are often left out of the eating disorders community. In addition, even when conversations about the -isms do occur, weightism (the systematic valuing of bodies that are thinner compared to fatter) is often left out of the conversation. This is particularly noteworthy within the eating disorders community, since a hallmark symptom of eating disorders has to do with fat phobia, fear of weight gain and “undue influence” of weight.

What Do Weight Stigma and Fat Phobia Look Like?

We live in a world where thin people are terrified of becoming fat and fat people know that their bodies are everyone’s worst nightmare. Even the word fat has taken on a disparaging meaning (Paine, 2021), though some body liberation advocates are reclaiming the word as a neutral descriptor (Meadows & Daníelsdóttir, 2016). Fat people are paid less than their thinner counterparts (Puhl & Heuer, 2009), are often denied medical care, may not have access to travel or clothes that fit them, and don’t have equal rights because of their size (Tomiyama et al., 2018). Nearly everything we consume via the media portrays fat people as the butt of the joke. We rarely see representations of people in larger bodies who are happy and loved, or where the entire plotline isn’t a mockery of their weight. 

The harsh realities and consequences of weight stigma make it clear that fearing fatness is not an inherently pathological phenomenon, as long as fat bodies are systematically ridiculed, devalued, and harmed by societal stigma with predictable regularity. When stigma is this harmful, fearing aspects of our identity that put us at risk of experiencing deep harm may function as a form of self-preservation. Of course weight stigma is a contributing factor to eating disorders in a world where fat people are denied basic rights!

Weight Stigma Is an Intersectional Phenomenon

It’s also important to note here that no one stigma exists within a vacuum. The other identities that we hold influence how we experience weight stigma. For example, women experience weight stigma differently than men; nonbinary people experience weight stigma differently still. Other identity intersections (e.g., racism, ableism) also affect people’s experience of weight stigma, with weight stigma often exacerbating (or being used as a substitute for) other forms of societal discrimination (Strings, 2019). Thus, looking at weight stigma intersectionality (Crenshaw, 2017) is imperative.

Weight Stigma and Eating Disorders

The proportion of eating disorder patients with low weight is generally less than those with “normal” or higher weight, according to current body mass index standards. However, the proportion of thin patients in higher levels of care for eating disorders is much higher. For example, one recent review found that although atypical anorexia was more commonly found in community samples (compared to low-weight anorexia), low-weight anorexia was more common in treatment studies (Harrop et al., 2021). 

There are many potential reasons for this. As in the case of systemic discrimination, weight bias is built into our medical, diagnostic, and insurance systems. We find weight stigma within eating disorder diagnoses, and insurance companies often deny people treatment because of their weight. Research has shown that people with atypical anorexia experience severe medical complications at rates equivalent to those of patients with low-weight anorexia nervosa (Peebles et al., 2010; Sawyer et al., 2016). However, likely because of weight bias, we associate anorexia with patients in thin bodies, and providers (including eating disorder providers) often dismiss eating disorder behaviors in fat patients because the patients don’t “look ill” (Harrop, 2019; Harrop, 2020).

Further, in a world where most people still believe the myth that eating disorders only affect thin white women, a person who is Black, queer, fat, or any other marginalized identity may not recognize that they could have an eating disorder or try to seek help. Alternatively, a person in a larger body might be encouraged to incorporate a dangerous diet into their life and be praised for weight loss, even when it’s at the expense of their health (Sim et al., 2013).

Weight stigma also shows up in the everyday experiences of eating disorder care (Harrop, 2019). Treatment centers often don’t have towels, chairs, or blood pressure cuffs that fit clients in larger bodies. Treatment centers and outpatient dietitians often put larger clients on restrictive meal plans, despite the fact that those clients are malnourished, never giving the client the opportunity to truly heal their body and mind. It is common practice for therapists to reassure clients, saying, “Don’t worry, we’d never make you get fat,” which reinforces the idea that being fat is the worst thing a person could be. When a client says, “I’d rather die than be fat,” in group therapy, rarely does someone gently point out to the client how awful it might be for a person in a larger body to hear that their body is more frightening than death. Generally, as a result of systemic norms and eating disorder stereotypes, eating disorder treatment has been designed with thin white patients in mind. 

Healing from an Eating Disorder and Weight Stigma

Everyone in our thin- and fitness-obsessed culture is affected by an environment that villainizes fatness. When it comes to eating disorders specifically, internalized fat phobia (i.e., a fear of weight gain or the belief that one is inherently less good or worthy because of their weight) is a common hallmark. Further, it is often these obsessions around body weight and shape that bolster feelings of shame, obsession, and suffering, as well as the triggering of eating disorder behaviors. To address the harm and suffering of the eating disorder mindset, clinicians must take a systemic approach in addition to an individual approach. We cannot prescribe individual solutions to solve the pathologies of society (e.g., weight discrimination). 

While we can commit to taking collective action as eating disorder professionals to resist weight stigma in society to the best of our abilities, we are likely a long way off from solving the problems of modern intersectional discrimination. How, then, should we approach treatment of eating disorders and the problem of the pervasiveness of weight stigma? We suspect that we must begin by helping our patients recognize that their bodies are not the problem; societal discrimination is. We must help them confront the fact that although attempting to avoid discrimination is understandable and even logical (through efforts at weight loss, disordered eating, and other eating-disordered behaviors), these efforts result in a life-threatening eating disorder that reduces quality of life. We can attempt to help clients see through the veil of societal weight stigma to transform these fat-phobic beliefs at their core—and we can do this difficult work in our own lives as well. We can offer our patients a nuanced view of how body privilege and oppression manifest within society, their families, and our eating disorder treatment systems. And we can insist, with all the power from our positionality as providers, that all bodies are good bodies and deserving of rest, nourishment, gentle touch, and care. 

About the authors:

Erin Harrop, LICSW, PhD, is an assistant professor at University of Denver and a licensed medical social worker. Erin’s research focuses on eating disorders, weight stigma, adolescent health behaviors, and patient-provider communication. Their dissertation featured a mixed-methods longitudinal study of individuals with atypical anorexia. They approach their research and clinical work from an intersectional social-justice-informed, fat liberation, and Health at Every Size® lens. Erin’s clinical work also involves trainings at the provider level, introducing interprofessional clinicians to weight-inclusive practices that honor patients’ unique intersecting identities. 

Shira Rosenbluth, LCSW, is a licensed clinical social worker in New York City. She has a passion for helping people feel their best in their body at any size and specializes in the treatment of disordered eating, eating disorders, and body image dissatisfaction using a weight-neutral approach. Her story has been featured in Healthline, NEDA, Dazed, Health, Medium, The Food Psych Podcast and PCOS and Food Peace Podcast. She’s also the author of a popular body positive style blog and has over 80,000 followers on Instagram.

References:

Crenshaw, K. W. (2017). On intersectionality: Essential writings. The New Press.

Harrop, E. N. (2019). Typical-atypical interactions: One patient’s experience of weight bias in an inpatient eating disorder treatment setting. Women & Therapy, 42(1-2), 45-58.

Harrop, E. (2020). “Maybe I really am too fat to have an eating disorder”: A mixed methods study of weight stigma and healthcare experiences in a diverse sample of patients with atypical anorexia (Doctoral dissertation).

Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders, 54(8), 1328-1357.

Meadows, A., & Daníelsdóttir, S. (2016). What’s in a word? On weight stigma and terminology. Frontiers in Psychology, 7, 1527.

Paine, E. A. (2021). “Fat broken arm syndrome”: Negotiating risk, stigma, and weight bias in LGBTQ healthcare. Social Science & Medicine, 270, 113609.

Peebles, R., Hardy, K. K., Wilson, J. L., & Lock, J. D. (2010). Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics, 125(5), e1193-e1201.

Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941.

Sawyer, S. M., Whitelaw, M., Le Grange, D., Yeo, M., & Hughes, E. K. (2016). Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics, 137(4).

Sim, L. A., Lebow, J., & Billings, M. (2013). Eating disorders in adolescents with a history of obesity. Pediatrics, 132(4), e1026-e1030.

Strings, S. (2019). Fearing the black body: The racial origins of fat phobia. New York University Press.

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity “epidemic” and harms health. BMC Medicine, 16(1), 1-6.

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