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Weight, What? How Fatphobia Impacts Reproductive Care

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September 29, 2020

uterusCartoon of a Uterus.

Fatphobia, the institutional bias against plus-size bodies, is rampant in the way we view ourselves and each other. Popular culture depicts the slim woman, (size 6 at most) as normal, despite sizes 16-18 being the true average women’s size in the US. Anyone outside this cultural norm or skinniness is deemed undesirable—as literally taking up too much space in society. This can be seen in the othering and separation of plus size clothing or models, the cultural obsession with dieting and weight loss products, and the fetishization or degradation of fat women on social media. Everywhere we look, we are flooded with false messaging telling us that to be fat is to be different and unwanted.

Fatphobia is perhaps at its most harmful when it influences healthcare. Weight bias in medicine is a well-recognized phenomenon. Fat people of all genders frequently report dissatisfaction with their experiences with medical providers, often resulting in avoiding seeking medical attention at all. Doctors tend to hyperfocus on their weight regardless of other medical complaints raised by the patient. Rather than taking a holistic approach to a fat patient’s overall health, too many doctors perpetuate internalized and institutional fatphobia by pushing weight loss as a cure-all despite the complex social, cultural, and genetic factors that impact weight. 

cartoon of doctor taking a patient's measurements

Cartoon of a doctor taking measurements of a patient.

The effects of this bias can most readily be seen in the area of reproductive healthcare. From birth control to medical conditions, reproductive care is researched, developed, and provided primarily with thin individuals in mind. The morning-after pill, for example, is alleged to not work for individuals over 176 pounds, even though the average american woman weighs 166 pounds. A survey of 1,300 physicians found that 17% were reluctant to perform a pelvic exam on a “very obese” person. Due to this anti-fat stigma, fat individuals are less likely to receive preventative healthcare or cancer screenings – particularly Pap smears and mammograms – despite being more likely than thin individuals to develop and die from cancer. 

Every individual has a base right to reproduction. Fat individuals, however, are not always able to exercise this right in the same manner as thin individuals. Half of the 20 largest fertility clinics in the United States refuse to perform in-vitro fertilization on individuals who are extremely or severely “obese” as determined by BMI. Doctors often push fat pregnant people towards C-sections rather than vaginal births, warn of dangerous conditions such as preeclampsia or gestational diabetes, or encourage weight loss during pregnancy. This advice is given despite the fact that the majority of fat pregnant people give birth without complications. These individuals are hyper-scrutinized based on the assumption that their weight will inherently present a risk to the pregnant person, regardless of the actual status of their health. Their innate ability to reproduce is brought into question, unfairly, due to their weight. 

Like most axes of oppression in America, fatphobia intersects neatly with America’s other forms of bigotry. Fatness has historically been linked to Blackness, with society’s revulsion towards both coalescing in an aggressive form of racism, classism, and fatphobia. Black people do tend to weigh more than white people, but rather than being due to accused innate laziness or a lack of self-control within the Black community, variances in body composition and bone density are to thank for the difference. Additionally, Black people are more likely to live in poverty than white individuals, resulting in decreased access to fresh food, decreased access to preventative healthcare, and increased size.

Another example of the intersection of fatphobia and racism is the continued reliance on BMI despite it’s racist and patriarchal origins. BMI, or body mass index, was invented nearly 200 years ago by Adolphe Quetelet, a Belgian academic who was not a medical provider. Quetelet based BMI on measurements of French and Scottish subjects, therefore accounting solely for the Western European phenotype of whiteness, let alone the variances found in other races. BMI made a resurgence in the 1970s as medical providers searched for an effective metric with which to measure weight and obesity rates. Again, this project found subjects primarily from white, western countries, though Japan and South Africa were also included. BMI is still used as a health metric to this day despite recent studies confirming that BMI correctly identifies “obesity” in less than 50% of cases. 

statue of Adolphe Quetelet

Statue of Adolphe Quetelet.

The “science” of BMI is inherently rooted in a view of healthcare and medicine that centers the white experience. By continuing to use a system that fails to account for the normal variations found in racially diverse individuals, healthcare perpetuates a form of “scientific” anti-Blackness and fatphobia. The usage of BMI presents further problems in terms of reproductive care when BMI is used as a metric to diagnose conditions such as PCOS or to monitor the effects of medications like birth control. 

In order to be impactful, reproductive justice must be intersectional. Fat individuals of color experience barriers that their white counterparts do not. While fatphobia impacts all individuals regardless of weight, the historic anti-Blackness and classism of BMI and diet culture have direct effects on the accessibility and equitableness of reproductive healthcare. Fat individuals are routinely denied their autonomy in terms of their sexual health. Fat people, and especially fat people of color, deserve our attention and advocacy. We must all do our part to center fat voices and combat fatphobia in ourselves, our lives, and our healthcare. 

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