The first time I went to see a doctor about debilitating abdominal pain, I was about 14 years old. In the emergency room, doubled over in pain, my mother squeezing my hand, I described my symptoms to the doctor – awful pain in my lower abdomen, nausea, vomiting, and diarrhea that lasted weeks at a time. Persistent, recurring gastrointestinal distress that left me in so much pain and discomfort that I often missed school.
After the requisite blood and urine tests, but no ultrasound or MRI, the doctor told me I had IBS-D. He asked how much exercise I got, how often I ate fast food, and how much junk food I ate each day. When my mother told him that I was fairly active, that we ate mostly home-cooked meals, and that junk food was a rarity in our house, the doctor gave us such a skeptical and judgmental glare that we nearly wilted. At the pace of an auctioneer, he rattled off the diet and lifestyle changes I’d need to make to control my gastrointestinal symptoms. At the top of the list of recommendations – lose weight.
‘A heavy remaining stigma’
That wasn’t my first experience with medical weight stigma and it definitely wasn’t my last. When medical professionals develop strong biases against fat people – and research shows that the vast majority of medical professionals are biased against fat people – it changes the way they interact with and the level of care they give fat people.
Dr. Jennifer Gunsaullus, a sociologist and sexpert who specializes in the relationship between body image and sex, explained, “We have a societal perception that if somebody has a higher body weight, that any problem they have is because of that. And it's definitely a heavy remaining stigma. Almost like an acceptable stigma we have in our society.”
This stigma causes medical professionals to make assumptions about fat people’s diets, exercise habits, and overall health habits based entirely on their body size. It leads them to assume that being “overweight” or “obese” is at the root of all their medical problems, even when there’s no logical connection. These assumptions push medical professionals to recommend weight loss even when there’s no evidence it will resolve the medical issue they’re supposed to be treating.
And when fat patients repeatedly fail to lose weight, medical professionals assume they’re not trying hard enough or following medical advice. They label fat patients “non-compliant” and “difficult.” All of this bias leads medical professionals to provide subpar care to fat folks.
“Folks get treated sometimes in very blunt and rude and harmful ways. Very much treated like the person has a character flaw, and it's an individual weakness,” Dr. Gunsaullus told me.
This is such a common experience for fat people that it’s been dubbed “Fat Broken Arm Syndrome” – a fat person goes to the doctor with a broken arm and the doctor recommends weight loss. When Ragen Chastain, a fat activist, writer, and speaker, went to the doctor for strep throat, the doctor told her to lose weight. The same thing happened when she went to another doctor for a broken toe, and it happened again when she sought care for a separated shoulder. One doctor told fat writer and activist Aubrey Gordon that losing weight that losing weight should be part of her recovery from an ear infection.
For the next 13 years, I had similar experiences as I tried to figure out why I was plagued by horrendous GI issues and pelvic pain. The IBS-D diagnosis was confirmed multiple times over, as was the recommendation to lose weight. As I intensified my efforts at dieting, diets turned into an obsession, which morphed into anorexia and exercise bulimia.
When I lost over 75 pounds in the most unhealthy ways possible, I found out just how differently medical professionals treat thin people. Tests and scans doctors had never bothered with before were ordered. Eventually, I was diagnosed with endometriosis, a chronic reproductive disease that causes severe pelvic pain, abnormal menstrual cycles, and, for some people, severe GI symptoms. The doctor who diagnosed me said she suspected I’d had endometriosis since shortly after I got my first period. But because of medical weight stigma, not a single doctor could see that until I was thin.
‘You get tired of everything being about your weight’
When I spoke to Nicola Salmon, a fat fertility coach and author based in the UK, about her experiences seeking treatment for irregular periods, she shared stories eerily similar to mine. Salmon’s concerns about her period were dismissed for three more years before she was finally diagnosed with polycystic ovarian syndrome (PCOS) at 16. The doctor who diagnosed Salmon gave her almost no information about how to manage PCOS other than… you’ve probably guessed already: “Lose weight.”
“I took away, ‘My body's the problem. I'm broken…’ So that informed how I spent my time in my twenties,” Salmon told me. “It seriously impacted my self-esteem. I thought there was something wrong with me… So I thought I had to make myself smaller. I spent a lot of time dieting… It really did impact how I saw myself, how I was in sexual relationships, how I looked after my own health, my reproductive health, my general health.”
My own experiences seeking treatment for a chronic reproductive disease mirrored Salmon’s. After struggling with anorexia and exercise bulimia for almost a decade, I finally got treatment. As soon as I began eating and stopped exercising for 3 hours a day six days a week, I started gaining weight. Rapidly. Within six months, I was fat again.
Regardless of how many times I stressed that I was in treatment for multiple eating disorders, the doctor managing my endometriosis insisted that a “healthy diet” and “weight management” were essential components of managing the symptoms of endometriosis. She explained that since fat cells store estrogen, I would probably experience more severe symptoms because endometriosis is an estrogen-dominant disease.
At the time, I didn’t know that none of what she was telling me was evidence-based. Though the relationship between body fat, estrogen levels, and endometriosis has been the subject of several studies, none of these studies have found conclusive evidence that estrogen stored in fat cells contributes to the development of endometriosis or worsens symptoms. In fact, endometriosis is less common in fat people and more common in thinner people, and there’s no evidence that weight loss improves endometriosis.
But she was the doctor, the expert. I was just the “non-compliant” patient who couldn’t follow my doctor’s instructions because I didn’t know how to lose weight without triggering the eating disorders that still haunted every corner of my mind. So, I stopped going to that doctor. And like Salmon, I pretty much stopped seeking medical care at all for a while.
Dr. Gunsaullus told me this is a common and completely understandable reaction to medical weight stigma.
“You're avoiding healthcare professionals and avoiding fear of judgment from them,” she explained. “You get tired of everything being about your weight… As humans, it is really, really hard to be vulnerable and ask questions for our wellbeing… If we're pretty sure somebody's just going to immediately judge us or shame us, we're probably going to avoid those conversations.”
Unfortunately, this means that many fat folks don’t get the regular preventative healthcare they need, especially when it comes to their sexual and reproductive health. Many fat people only seek medical care for their sexual or reproductive health when they absolutely have to, like when they have chronic, debilitating symptoms, like Salmon and I did, or when they’re trying to get pregnant.
‘I'm going to need to diet now because we want to start to grow our family’
Salmon spent most of her twenties believing two things – she would never get pregnant on her own because of her PCOS diagnosis and that fact, along with her fat body, meant that she would probably never find a long-term partner. But she did. And after a few years, they decided to have children.
Her first thought was, “I'm going to need to diet now because we want to start to grow our family, and so of course I'm going to need to make myself smaller.”
Salmon’s reaction makes sense given that the common wisdom in fertility medicine is that being fat makes getting pregnant more difficult. Most fat people are told they need to lose weight before they should even try to conceive. They’re also told that it will take them a long time to conceive, even though research has shown that, on average, it takes fat folks only fat folks only one to two months longer to conceive than thinner folks.
While it may take some fat folks longer to conceive, that wasn’t the case for me, and it wasn’t the case for Salmon either. We both got pregnant very easily, even though, according to everything we’d ever been told, our reproductive diseases and our fatness should have made it very hard to conceive. But the joy and surprise of conceiving easily was overshadowed by the horrible medical weight stigma we experienced during our pregnancies.
In obstetrics, fatness is viewed as a risk factor for all sorts of pregnancy and childbirth complications. There is evidence to support this. Multiple studies have found that fat birthing parents are at higher risk for miscarriage, stillbirth, gestational diabetes, high blood pressure, and preeclampsia. Fat birthing parents are also at higher risk for childbirth complications like induction of labor, stalled labor, and emergency cesarean sections due to the baby being stuck or stalled labor. Babies carried by fat birthing parents are more likely to have fetal anomalies, birth defects, and need admission to the neonatal intensive care unit (NICU) after birth.
However, this evidence doesn’t tell the whole story. The studies examining pregnancy and birthing complications in fat folks only show that being fat is associated with these complications. No evidence shows fatness is the root cause of these complications, all of which could be caused by underlying medical conditions.
Some of these complications can also result from chronic stress, and the evidence that chronic stress can cause physical illness is clear. Newer research into the physical and psychological impacts of weight stigma shows that a lifetime of dealing with weight stigma can cause chronic stress. So, the complications that fat birthing parents experience may actually be a product of the weight stigma they face during their pregnancies.
Additionally, the research into pregnancy and birthing complications in fat folks doesn’t examine how weight stigma impacted their pregnancies. One study of 501 women in the US found that 64.9% of them experienced weight stigma during their pregnancy. The same study concluded that the negative impact weight stigma had on birthing parents’ mental health was associated with poor maternal health outcomes.
The bottom line is that we don’t have a complete picture of why fat birthing parents experience more complications during pregnancy and childbirth. Yet, medical professionals still assume that fat birthing parents will have more health issues, and in my experience, as well as Salmon’s, this assumption comes out in the awful way they treat their patients.
I was sick 24 hours a day during my first trimester. Morning sickness is a misnomer, by the way. Because of this, I lost weight instead of gaining weight. When I asked my providers if they were concerned, they told me that because of my “high weight at conception” it was actually fine if I didn’t gain any weight at all during pregnancy, even though I was growing an entire human.
Of course, I did eventually gain weight, like everyone does during pregnancy, and was treated to constant lectures about how I needed to watch my weight, limit my sugar intake, and “eat healthy” to ensure the baby didn’t get too big. Because if the baby was too big, I wouldn’t be able to give birth vaginally. More than once, I was told that my weight put me at high risk for a C-section.
Every time I went for a checkup, the doctors were shocked when my blood pressure was normal, even though I told them repeatedly that I’d never had high blood pressure. I was told several times that I was at high risk for gestational diabetes, and when my test came back negative, my providers couldn’t hide their disbelief. Whenever I had an ultrasound, providers commented on how my belly fat made the scan difficult, then gave me a half-hearted apology when I winced as they jammed the ultrasound wand into my stomach.
When I presented my birthing plan to my medical team, which specified that I wanted a natural birth with as few interventions as possible, they told me that likely wouldn’t be possible because my body put me at risk for complications.
I did, in fact, have multiple birthing complications, but none of them had anything to do with my fatness. My son was stuck, not because he was too big, but because he was trying to make his way out behind my pelvis. I had dangerously abnormal contractions and didn’t dilate properly, so I did need a C-section. Not because I was fat, but because my little guy got some bad directions and took a wrong turn.
If I were a participant in one of those studies on birthing complications, my experience would contribute to the narrative that fat people are at higher risk for birthing complications, even though my complications had nothing to do with my fatness.
Salmon’s experience was similarly horrible. Early on in her first pregnancy, Salmon was told that her pregnancy was “high-risk,” even though none of her early exams revealed any health problems for her or the fetus.
“The only thing that they had that was an indicator of this ‘high risk’ was my body,” Salmon told me.
That label changed her entire experience of pregnancy. All of her providers expected something to go wrong. When Salmon took the gestational diabetes test and it came back negative, her doctors forced her to take the test again. Salmon was told that she wouldn’t be able to have a home birth or a water birth because her body made it too risky. Like me, she was told that her baby would probably be too big and it would get stuck because she was fat.
Of course, all these negative expectations from her providers made Salmon terrified that something horrible would happen.
“The experience that’s portrayed about pregnancy, about this wonderful time that you're growing a human, it just felt… Yeah, I didn't enjoy it because of all that negative expectation,” Salmon told me. “I spent that whole time just feeling so anxious, hating myself because I'd put myself in this position [by being fat], and it was awful.”
On top of the constant anxiety and self-hatred, Salmon had to deal with the outright disdain her providers showed toward her fat body at every appointment.
“[They looked] almost disgusted that they had to touch my body and just… that sense of ‘I've got to deal with the fat person,’” Salmon recounted. “It was somehow more difficult or made their job harder.”
Despite all the negative expectations, both of Salmon’s pregnancies and birthing experiences were relatively easy and complication-free. But Salmon wasn’t allowed to give birth the way she wanted.
During her first birth, her providers insisted that because her pregnancy was high risk – a label she only got because of her weight – she had to be continuously monitored. So, she had to stay in bed for the entirety of her labor. With her second child, she wanted a water birth, but during labor, she was moved to a room without a birthing tub. When she asked why, she was told not to worry about it.
“People experience this every single day,” Salmon said. “Being denied their body autonomy, not given appropriate consent through procedures being gaslit… It's totally taking away that ability to choose what you want for your own experiences.”
Now, Salmon is the one ensuring that people do have the pregnancy and birthing experiences they want. In her practice as a fat fertility coach, she educates people about medical weight stigma and teaches them how to advocate for themselves. Salmon also puts a lot of work into public education about fatness and fertility, including debunking weight stigma-driven myths like the ones we both heard from our medical providers.
‘That leaves out so many people and so many differences’
Though the impact of medical weight stigma is most obvious in the way medical professionals interact with fat patients, it’s not just a problem of biased providers. Medical weight stigma is a systemic problem that exists at all levels of the healthcare system.
When the American Medical Association classified obesity as a disease in 2013, they formally solidified the idea that fatness is a medical problem that needs a medical solution. And research has shown that’s not always the case. Yes, fatness is associated with certain medical conditions, but research has yet to prove that fatness causes any of those medical conditions.
Many fat people are perfectly healthy according to the most commonly evaluated markers of health – blood pressure, cholesterol, and blood sugar levels. But since obesity is a disease, fat people are automatically considered unhealthy, regardless of their actual health status.
The classification of fat people as “unhealthy” has major impacts on medical research. A review of 201 clinical drug trials approved in 2022 found that many clinical trials exclude fat people. Clinical trials that didn’t outright exclude fat folks often didn’t include a proportionate number of fat participants compared to thin participants. So, a lot of the medications currently on the market are never tested on fat people.
“So much about our medical research and our research on anything around sex and medicine and bodies has so much been just this sort of mainstream standard male model,” Dr. Gunsaullus told me. “And that leaves out so many people and so many differences… There are differences by gender and age and by weight, hormonal differences that can have massive impact on folks.”
Dr. Caroline Apovian, a researcher at Brigham and Women’s Hospital in Boston, told The Associated Press that participants in clinical trials are often volunteers, and fat people are less likely to volunteer. Though researchers don’t know exactly why that is, I’d guess it has something to do with avoiding medical weight stigma. Additionally, clinical trials often exclude people with chronic medical conditions, and fat people are more likely to have chronic medical conditions for reasons that may or may not have to do with their weight. And, perhaps most importantly, the Food and Drug Administration (FDA) doesn’t require that medications be tested on fat patients.
Dr. Gunsaullus added that many pharmaceutical companies only include “healthy” participants, which automatically excludes fat folks.
“They've got a lot of money behind things and they've got investors and they're trying to get things to get FDA approval, and so they make the population as predictable as possible.”
Excluding fat people from clinical trials creates significant problems, especially in the realm of sexual health. The most common example is that birth control pills and emergency contraceptives are less effective for fat people. Some researchers believe that these medications could be effective for fat folks with adjusted dosages, but without the data from clinical trials to back that up, doctors are reluctant to prescribe different dosages.
Salmon told me, “It's the same for fertility medications… It doesn't work as well for us as in we just need more of it in order for it to work at the same capacity.”
She added that with something as complex as fertility treatments, the reduced effectiveness of the hormones can derail the entire, expensive process.
Salmon has also been investigating the effectiveness of at-home pregnancy tests for fat folks, and her anecdotal evidence uncovered a troubling issue.
“A lot of the reference ranges that have been created don't take into account fat people,” she explained. “When you pee on a pregnancy test, there's a range and it will show up a different color when it hits that specific range, but often our results can be lower… It seems like, ‘Oh, well, you'll just get a positive test later.’ But it's got so much wider implications than that… It might be impacting their fertility treatments… which then could have implications on their pregnancy. It's also abortion care. If people don't know that pregnancy tests don't work at a particular point, then possibly they'll test it's negative. They'll stop thinking about that, and then they won't get abortion care that they might need.”
So much of our sexual health is centered on medications and testing – birth control, emergency contraceptives, fertility treatments, and hormone tests, including pregnancy and ovulation tests – yet medical professionals and researchers know so little about how these medications and tests work on fat bodies. And as long as medical research excludes fat bodies, fat folks will never have the same level of control over their healthcare as thin folks.
‘We are all deserving of evidence-based, equitable and safe healthcare’
The cornerstone of sex positivity and activism for sexual freedom is bodily autonomy, the assertion that we all have the undeniable right to make our own choices about our bodies. If we believe in sex positivity, if we want to be activists for sexual freedom, then we also need to be activists for fat liberation.
The way the healthcare system is built right now, fat people do not have access to bodily autonomy. They don’t have the unbiased, evidence-based information required to give them that autonomy. And even when they do, the majority of the medical professionals they interact with refuse to acknowledge the unbiased, evidence-based fact that fatness is not a medical issue that needs a medical solution.
It doesn’t have to be this way.
We can build a system where fat people have the same access to, as Salmon put it, “evidence-based, equitable, and safe healthcare.” It will take a lot of work, and a lot of unlearning, but we can do it.
I’ll leave you with Salmon and Gunsaullus’ visions for fat-positive sexual healthcare:
“It is about centering fat people and about centering the most marginalized fat people,” Salmon said. “So really basing all of our care around what are the most marginalized folks in our communities need, and making sure that the care is equitable. So the people who need more care get more care. We are all deserving of evidence-based, equitable and safe healthcare, and [the ability] to access that without shame, without judgment.”
“It would start with compassion,” Gunsaullus told me. “It would start with healthcare practitioners reflecting on their own stigmas and assumptions and tying that to their reflections and assumptions around sexual health and sexual wellbeing. And what hangups do they have around that? What assumptions do they have? What judgments do they have? Because if we don't own them for ourselves and work through them, we can inadvertently show that judgment and stigma to others, and that will shut folks down… And fundamentally, what is the most important thing in providing care to another human is to see them as a human and just being kind.”
